LIBRARY OF THE University of California. GTF"T OF^ Received ^'f-To^cuo- 1^ ^ '^9^.- Accession No. ^ ^77-3 - Class No, ^ Tf^ERXmEHT OF HEMORRHOIDS •flflD OTHER IIon-J|alignant l(ectal Di?ea?e? BY W. p. AONKVV, Nl.D. [SECOND KDITION. PUBIvISHBD BY R. R. PATTERSON, 429 MONTGOMERY STREET, SAN FRANCISCO, CAL. 1S91 . 6f773 Entered according to Act of Congress, in the year 1891, by W. P. Agnew, M. D,, in the office of the Librarian of Congress at Washington. g;^ »| Hvi«,/^- INTRODUCTORY. In preparing this hand-book, the object will be to give in plain and comprehensive language, as briefly as possible and with little dis- cussion, a few general rules, which, if even approximately observed, can but lead to success in the treatment of ail non-malignant rectal diseases commonly known, and for which the general practitioner will not infrequently be called upon for relief. Hemorrhoids, being by far the most common among this class of ailments in private practice, and the greatest bone of contention rela- tive to the best manner of effecting a radical cure, will take prece- dence in our consideration, and receive the attention that their im- portance and dignity justfy- merit. It is an indisputable fact that until within the past few years, an operation for the radical cure of hemorrhoids was considered so for- midable an undertaking, that their treatment, outside of palliative measures, was almost entirely eschewed by the general practitioner. "No fact is better known to the profession," says Dr. S. S. Turner, U. S. Army, "than that nearly all men, doctors not excepted, will suffer more than the pain and inconvenience of a thousand operations, rather than undergo an operation for removal by any of the meth- ods in vogue. The fame of some specialists who are distant enough to 'lend enchantment to the view,' will generally induce people of large means when life has become something of a burden, to place themselves under their care and take what they offer; but unfor- tunately, piles are not limited to people of large means. The great- er number of sufferers must take what the general practitioner can give and will not take the cutting and crushing operations until compelled by dire necessity, and are only too glad of a less heroic 4 INTRODUCTORY. alternative which offers them hope of relief. For this body of suf- ferers, the operation by carbolic acid injection offers a means of re- lief to which they will readily submit. In a sufficient number and variety of cases to justify me in having an opinion upon the ques- tion, of its merits, I have never met with anything which I have re- gretted." When AUingham, Matthews, Kelsey, Andrews and others uttered their pronunciamento in favor of their choice of operations and against other methods, it was done, no doubt, with firm belief and honest intent, and in strict accordance with the inability of these gentlemen to understand, "that the opinions of mere men, however venerable by age, are but a sandy base. The people of the present time are not given to echo the sentiments of a master. Nature's laws and nature's facts alone are able to stand the rigid scrutiny to which the sentiments of men, in physical science, are now so unre- servedly exposed." Concerning the relative merits of the "so-called" more scientific methods of cure advocated by the above named and other leading specialists, known as the operation by circular excision, the clamp and cautery, the ligature — the following quotations appear signifi- cant: Of the circular excision, Dr. S. S. Turner says: "Mr. Whitehead's operation is so self-evidently 'bloody, tedious, and difficult,' that no general practitioner and few specialists will care to undertake it. No amount of assertion by Mr. Whitehead in favor of its simplicity will deceive any one who has studied anatom5^" Of the clamp and cautery, with its attendant pain and sizzling of human flesh, dangers of an immediate or a severe secondary hem- orrhage, extensive sloughing or stricture by contraction of tissue, AUingham says : "In my opinion, this has little to recommend it. As far as my most careful researches have led me to a conclusion, it is quite six times as fatal as the ligature properly and dexterously ap- plied. In one hundred and ninety-five cases operated on by me by means of the clamp and cautery, I have had two deaths." Of the ligature. Dr. F. L. Haynes says, "I have frequently made INTRODUCTORY. 5 AUingham's ligature operation. It is easy and effectual, but fol- lowed by retention of urine and great pain, lasting in some cases seven days. One of my cases died from lock-jaw, and a similar re- sult followed in a case in the Episcopal Hospital of Philadelphia. The great objection to this and other operations is that they are operations and involve the use of ether and rest in bed. Do we pos- sess in carbolic acid a safe, speedy and painless cure for hem- orrhoids?" With the foregoing stubborn and uncompromising facts relating to the old methods' treatment confronting us on the one hand, and a full appreciation of the superiority, the simplicity, the safety and certainty of the treatment by carbolic acid injection commending itself to us on the other, no further explanation will be required nor is an apology deemed necessary for the adoption and recom- mendation of the latter method of cure; and an effort is made in this little publication to point out iii an easily understood and a practical way, what has been acquired by personal observation and experience, and all in all, believed to be the best manner of applying this truly scientific and greatly superior method, — a method, the discovery of which, I feel prepared to say, marks an epoch in the history of medicine unrivaled in advancement by the treatment of any other disease or class of diseases to which the human family is subject. The treatment of hemorrhoids by carbolic acid injection has not been placed before the profession upon a practical and scientific ba- sis, nor has it been fairly represented; but on the contrary is ham- pered by undue prejudice and misunderstanding, and made respon- sible for the results of the many and various kinds of injection com- pounds, in the hands of the ignorant and inexperienced and in diverse and unfavorable conditions for treatment. A review of the literature of the subject in support of the method, shows that it is a product principally of the unlettered, and is not overburdened with theory nor replete in scientific deductions. Of the few books and pamphlets that have been published, including the "Secret Systems" of the itinerants, none have come to my notice that give a rationale of the principles involved in the process of cure, 6 INTRODUCTORY. nor complete instructions in the technique of an operation and the management of a case generally. These drawbacks, together with a diversity of opinion concerning the different combinations and strengths of carbolic acid to be used, with reported accidents in some instances, and failure to cure in others, all of which have been magnified and enlarged upon by the old methods' writers and specialists to a degree of intimidation, have not favored the general adoption of this easily acquired and successful plan of treatment, in an apparently doubtful and un- settled state. More might be said here in explanation of the slow progress of a thing of true worth and merit would time and space permit, but suf- fice it to say that the dignity of physic and surgery, and the educa- tion and skepticisms of the laity, demand that something more than petty contentions and professional bickerings hinder the employ- ment of a method in the treatment of a disease, where the results and comparisons are so unmistakable. The successful treatment of hemorrhoids naturally leads to the investigation and treatment of other forms of rectal trouble, by vir- tue of the close relationship existing between the different kinds of diseases affecting the rectum, one disease of this organ often being mistaken from the subjective symptoms for another; therefore, all non-malignant rectal diseases have received a fair share of notice in the present volume, giving the most improved and rational plans of treatment to date, which, it is hoped, will the better enable the ethical ph3'sician to forestall and root out the itinerant and advertis- ing local specialist, as well as to compete with his wide-awake fel- low practitioner, and in this way retain his own clientele, secure the fees arising therefrom and maintain his social standing and dignity in the community in which he resides. "There is no organ," says Dr. S. T. Yount, "that is so prone to become diseased as the rectum. There is no class of cases so little understood and treated as rectal diseases. There are no diseases so annoying and painful, and at the same time producing such dire re- INTRODUCTORY. 7 suits on the general system, directly and reflexly, as rectal diseases. For years Rectal Surgery has been principally in the hands of itin- erants, whose remorseless greed for money has caused them to treat for revenue only, and to play the vampire on all who fall into their clutches. It is high time for the general practitioner to gather up all the information possible, in order to be able to treat all patients suffering from rectal disease, and thereby drive the itinerants back to their previous occupation of tilling the soil." Nowhere in medical lore do we find suitable instructions whereby the beginner may knowingly and intelligently engage in a rectal ex- amination — what to expect, where and how to find it, and how to pursue each succeeding step in applying the treatment after a diag- nosis has been reached. Writers either presume too much on the part of those who have not had experience, or, are so habituated to the use of general anaesthesia in accomplishing the objects sought, that milder means have been seriously neglected. Finding many, otherwise well informed practitioners at a great disadvantage in this respect, was one of the leading incentives that resulted in the preparation of the following few pages. HEMORRHOIDS The division of hemorrhoids into internal and external, is naturally suggested by their observation and study, and clearly defined by designating all hemorrhoidal tumors or- iginating above and within the grasp of the external sphinc- ter as internal, while those situated external to, or outside of, the external sphincter, when this muscle is closed and the bowel not protruded, are external. The statement that hemorrhoids are nothing more nor less than a varicosed condition of the rectal vessels, is true only in so far as it is applicable to their incipient stage of formation. The first tissue change that takes place leading to the development of a hemorrhoid, is the dilitation, stretch- ing, or bulging out, as it were, of the coats of one of the hemorrhoidal veins, venules or arterioles, at its weakest and least protected part, forming a bulb or sac-like protuber- ance beneath the mucous membrane or skin, and superin- ducing an infiltration and a thickening of the cellular tissue in connection w4th the vessel. The causes remaining in operation, this sac-like protuberance becomes more en- larged, painful and inflamed, from a continuous pressure of blood within its walls and other irritating influences with- out, until relieved by palliative treatment or the unaided e£forts of nature. lo HEMORRHOIDS. After the immediate exciting causes have been removed, the sac shrivels, or contracts, but is left somewhat enlarged and its walls thickened, holding possibly a clot of blood within its cavity or some having been forced out through a breach, producing an extravasation. Successive attacks will so change the walls and surrounding structure of the sac by hyperaemia and the deposition of plastic material, that in time it becomes an organized mass, or tumor, made up of fibrous and spongy connective tissue, and sustained by a complete circulatory system of small arteries, veins and capillaries, quite unlike its primitive state of development, and varies in kind, shape and locality according to the causes and peculiarities belonging to each individual case. Fully developed hemorrhoids are, therefore, something more than varicosities; they are thoroughly organized tumors. There are three distinct varieties of internal hemorrhoids, which have been appropriately named, from certain well marked features characterizing each, as the capillary, the arterial, and the venous, and all may be present in the same person. Tun CAPII.I.ARY HEjMORRHoiD is a Small, flat slightly elevated, raspberry-looking growth, having a thin, delicate covering, and a spongy, bleeding surface, with a capacity for yielding, compared with its insignificant size, large quantities of arterial blood on the slightest provocation. Indeed this kind of pile may appear as nothing more than an obscure efflorescent patch, with the one symptom of daily hemorrhage, either little or much. In structure it consists principally of a congeries of hypertrophic capil- HEMORRHOIDS. " laries, bound together with spongy connective tissue, re- sembling that of an arterial naevus, and is not painful and does not prolapse, unless accompanied by other larger tumors or a weakened condition of the bowel. By the application of caustics, powerful astringents and the lapse of time, the delicate mucous membrane covering the capillary hemorrhoid becomes firmer, smooth and shiny, at the same time the capillary net-work disappears beneath, arresting the bleeding from the surface, the vessels feeding the growth enlarge and extend, the connective tissue be- comes more abundant by the exudation of plastic lymph, and, in accordance with the theory of the development of hemorrhoids generally, a fully formed arterial hemorrhoid may be evolved from one of the capillary variety. Thk arteriaIv hemorrhoid is a bright red, strawberry- like, sensitive, vascular tumor of a pronounced arterial type, with the arteries and veins freely anastomosing and is particularly the irritable pile, subject to erosion, prolapse and hemorrhage. In common with the first variety, it seems to arise entirely on the arterial side of the circulation, and may take its origin independently or proceed from the capillary tumor by a process of change as described in the preceding paragraph. The artery entering the base at the upper part of an arterial hemorrhoid may be large, and felt to pulsate with as much force as the radial. The arterial pile sometimes tends to a peculiar sort of a spontaneous cure by a slow hardening process, which begins at its apex by an obliteration of the vessels from a contrac- tion and a solidification of the fibrous tissue, leaving a hard, 12 HEMORRHOIDS. incompressible, pyramidal-shaped substance, flattened from above downward, projecting toward the opposite side of the bowel, which it may prod during a motion, and is wholly destitute of circulation. This relic might with propriety be called a horny papilla. A tumor in which this process has been only partially completed, is called an indurated pile. Other forms of internal hemorrhoids may undergo a similar degenerative change by ultimately subsiding into an indo- lent state, persisting as hard, shot-like tumors containing clotted blood. The clot occasionally undergoes a calcareous change and becomes converted into a phleobite, or vein stone. Capillary. Arterial. Venous. Fig. I. — Varieties of Internal Hemorrhoids. (Typical tumors.) The: venous hemorrhoid is the passive tumor, variable in size, shape and texture, with the venous element largely predominating, giving it a bluish and a sluggish appear- ance. It may be a small, round, smooth tumor, or a large undulating oblong mass extending entirely across the bow- el, is not prone to bleed, nor sensitive unless inflamed or strangulated by the action of the sphincters, and is certain- ly by far the most common variety. This is the form of hemorrhoid that results from an obstruction to the circula- tion of the liver and abdominal viscera, such as bilious tem- HEMORRHOIDS. H peraments and spirit drinkers get, likewise women who have borne many children or who have an enlarged or retroverted uterus. The mucous membrane covering the venous hemorrhoid becomes tough and fibrous from exposure and chronicity, and sometimes looks whitish, or it may become thinned and sensitive by a partial transformation of the tumor to one of an arterial character. It seems hardly possible that a purely venous hemorrhoid can be evolved from a capillary or an arterial tumor, but it is not difficult to understand how a venous tumor can be changed, by a partial displacement of the venules by arterioles, and partake largely of the features belonging to the arterial type. I would remark, en passant, thdt the first two varieties of internal hemorrhoids, being the more delicate in structure, are rapidly cured by the operation of carbolic acid injection. The division of hemorrhoids into internal and external, is fully in conformity with the disposition of the hemorrhoid- al veins into two distinct systems, the one internal and the other external. The internal hemorrhoidal system compri- ses the superior hemorrhoidal veins alone, which are the veins exclusively implicated in the formation of internal hemorrhoids. These veins have their origin in about a dozen "little sacs or pools" of blood, arranged in a circular form around the extremity of the rectum, at the upper bor- der of the external sphincter, and which vary in size, in the normal state, from a wheat grain to that of a small pea. As the primitive branches of the superior hemorrhoidal veins take their departure from the "little sacs or pools" of 14 HEMORRHOIDS. blood, to which allusion is made, they ascend in parallel and flexuous lines for a short distance, then enlarge, cumu- V.H.E P. r Fig. 2.— The three sets of hemorrhoidal veins. (Xfter Duret.) P. P., skin. SpB., Exterior sphincter. Sp.I . Interior sphincter. V.H.E., Inferior Hemorrhoidal veins. H.M., Middle Hemorrhoidal veins. H.I. , Superior Hemorrhoidal veins. M.cl., muscular tunic. M.q., mucous membrane dissected up and cutaway below. HEMORRHOIDS. I5 late and anastomose, and encircle the upper margin of the internal sphincter, and later unite to form the five or six large veins which abruptly perforate the wall of the bowel between three or four inches from the verge of the anus. Continuing on the outer surface, these five or six large veins form three or four venous trunks, which ascend on the sides and posterior aspect of the rectum, and enter the inferior mesenteric vein. Thus the blood is returned from the rec- tum, but not the anus, through the superior hemorrhoidal veins to the inferior mesenteric vein, thence through the splenic vein and vena porte to the liver. None of these veins have valves. **Verneuil has laid stress upon the fact," says Kelsey, "that where the internal or superior haemorrhoidal veins perforate the rectal wall from within outward, they pass through 'muscular button-holes' surrounded by no fibrous tissue and having, therefore, the power of contracting round the vein, closing its calibre, and preventing the return of the blood to the liver. In this anatomical arrangement he believes he has found the active cause of internal haemor- rhoids." Admitting the existence of the "button-hole" apertures through the muscular wall of the rectum, Allingham demurs to the theory advanced by Verneuil, that they obstruct, by contraction, the return of the blood from the lower portion of the rectum ; but on the contrary, infers that they play the part of valves and really support the column of blood to the liver, and prevent regurgitation in congested states of that organ. i6 r HEMORRHOIDS. The external hemorrhoidal system comprises both the middle and inferior hemorrhoidal veins, which are the veins solely concerned in the origin of external hemorrhoids. The middle hemorrhoidal veins arise by a net-work, or plex- iform arrangement of minute vessels surrounding the ex- ternal sphincter, and terminate in the internal iliac. Some of the rudimentary branches of this plexus perforate the upper border of the external sphincter and anastomose with the primitive branches of the superior, or internal hemor- rhoidal veins, by connecting with the "little sacs or pools" of blood before mentioned. The inferior hemorrhoidal veins take their origin by a similar plexiform arrangement situ- ated between the skin and the inferior border of the external sphincter, and empty into the internal iliac by first joining the pudic. The two sets, anastomosing, make up the anal venous circulation and return the blood through the iliacs to the vena cava ascendens, and to the heart. We see from this brief review of anatomy, that the blood returned by the internal hemorrhoidal system, circu- lates through the liver, while that returned by the external hemorrhoidal system does not, except, possibly, an inconsid- erable amount which may reach it through small branches of the inferior mesenteric vein, that inosculate with the internal iliac, and also through a slight anastomosis of rudimentary branches of the two systems. A regurgitation of blood through a few small inosculatory vessels (branches of the inferior mesenteric) into a large, freely coursing and expanding vessel (internal iliac), would hardly be sufficient to occlude the large vessel and thereby f OF Tnn; ^ ^NIVEHSITY HEMORRHOIDS. if ^^ obstruct its branches (external hemorrhoidal system), which are provided with valves, reaching as far back as the begin- ning of these branches. Therefore, a stagnation of the por- tal circulation could not materially affect the external hem- orrhoidal system, and hence external hemorrhoids cannot reasonably be attributed to an affection of the liver. It fol- lows, then, excluding local causes and assuming the disease to be constitutional, that internal hemorrhoids are produced by a disturbance involving the visceral venous system, and that external hemorrhoids arise from a disturbance implica- ting the general venous system. KxTKRNAiy HEMORRHOIDS always originate as venous tu- mors, and make their appearance primarily in two ways: the one by a simple circumscribed dilitation of the vessel, causing an infiltration and a thickening of the surrounding tissue; the other by a condition in which the dilitation has been followed by a rupture of the vessel, allowing extravasation with infiltration, which may lead on to inflammation and suppuration, or the clot may absorb and the tumor disappear altogether or result in an external cutaneous tag, subject to irritation, oedema, itching and induration. An external hemorrhoid may be a bluish, a purplish, or a pinkish looking tumor, smooth, globose and unilocular; or it may be uneven and irregular in outline and multilocular, having two or more sacs or ruptured venulae. It sometimes happens that a single hemorrhoidal tumor forms on one side of the anus measuring an inch and a quarter in length, kidne5^-shaped, and having a pallid or whitish appearing surface. The distended or ruptured vessel, in recent i8 HEMORRHOIDS. cases, is often plainly visible through a translucent skin. The quickest way to relieve the pain and tension and free the clot in a newly formed external hemorrhoid, is by incision. First inject carefully into the substance of the tu- mor, a few drops of a five per cent, solution of cocaine, and then, transfixing its base with a small, sharp, curved bis- toury which has been previously dipped in pure, liquified carbolic acid, cut outward, the incision being in the direc- tion of the radiating folds of the anus, and press out the clot. This procedure is allowable when the pain is very annoying, the tumor small and the patient not altogether averse to the slight amount of cutting required ; otherwise, palliate by making hot water applications and afterward treat by injection. The causes of hemorrhoids are manifold and often obscure. In general, they may be given as anything which hinders or obstructs the return flow of blood from the lower part of the rectum and anus, or anything producing an excessive flow to these parts through the arteries which supply them. Hence, sedentary life, luxurious habits, occupations which require much standing, disorders of the alimentary canal and liver, straining, constipation, excesses etc., are circumstances favorable to the promotion of hemorrhoids; while bilious temperaments and a hereditary tendency operate as predis- posing causes. It matters not what form of tumor presents itself for treat- ment, whether of the capillary variety, distinguishable in being of small size, flat or sessile, made up of the terminal branches ot the arteries, the beginning of the veins and the HEMORRHOIDS. 19 capillaries which join them, punctated, granular surface with thin covering and likely to bleed on the least provoca- tion; or the arterial hemorrhoid with the arteries and veins freely anastomosing, larger, and presenting the glazed ap- pearance of a very ripe strawberry, liable to inflammation, erosion, prolapse, and hemorrhage ; or the venous hemor- rhoid, hard or soft, not very sensitive, blue and sluggish, which Kelsey says may result from either of the other two varieties or arise de 7iovo and h\Q&& per saltum ; or any form of external hemorrhoid, cutaneous tag or like redundant tissue, each is treated alike and with like good results by the operation of carbolic acid injection and the use of the combination herein recommended. # EXAMINATION. After obtaining something of a history of the case, you will have ascertained whether or not there is an inordinate protrusion at stool, its nature and if it has to be replaced. In the latter event the patient is directed to go to the closet or use a commode and make an effort to strain out the bowel. If not successful, use an injection of warm water, or select a time immediately after the usual hour for evacu- ation, which, if it occurs early in the day, may be deferred by the will power of the patient to a later hour. This will bring to view any and all large hemorrhoids lo- cated on the upper margin of the internal sphincter, as well as those situated between the sphincters, they being caught in the grasp and button-holed -like by the external muscle. Should the prolapse not be sufficiently great nor the piles sufficiently large to be thus caught and held out for inspec- 20 HEMORRHOIDS. tion, let the patient lie on either side, with knees drawn up, and instruct him to strain down and extrude the parts as much as possible, assisting by gently pulling down and everting, with the thumbs, the mucous membrane at the verge of the anus. It is always better to precede with an in- jection of warm water, which may not only unload the rec- tum and give the patient greater confidence in the effort to extrude the parts, but will wash away the mucous and re- tained feces in and about the sphincters. When the ex- amination has been carried to this point and no satisfactory cause found to explain the trouble complained of, the finger and speculum will be required to complete the diagnosis. The finger is of little use in diagnosing small, soft hem- orrhoids that form on the upper margin of the internal sphincter and lie back in the rectal pouch, being hinder- ed by the pressure of the muscles and a like feeling imparted by the bowel. Bear in mind that you need not look for hemorrhoids higher up than the upper margin of the internal sphincter, a distance of not more than an inch from the verge of the anus (called the hemorrhoidal inch), and if of any appreciable size, they will always show at stool. Where to look, what to look for, and how to find it, are questions which often con- front the beginner, and it will not be out of place here to firmly impress the following rule: See all that can be seen and treat all that can be treated without the aid of a specu- lum. DIAGNOSIS. There is not much probability of confounding hemor- HEMORRHOIDS, 21 rhoidal tumors with any other abnormality in the vicinity of the rectum. The different varieties of internal hemor- rhoids, a description of which has already been given, may confuse; but, as before stated, no discrimnation is necessary in applying the treatment for the purpose of effecting a radi- cal cure, the one great object lo be attained. Where sever- al distinct tumors exist, they are usually arranged in a row Fig. 4. Internal hemorrhoids prolapsed and held out by the constriction of the sphincter. J. Junction of skin with mucous membrane. E. Evert- ed bowel. on either side, not up and down, but antero-posteriorly, with the long diameter of each tumor at its base, corresponding to the antero-posterior diameter, or, if the muscles were dilated, to the circumference of the rectum. 22 HEMORRHOIDS. If situated on the upper margin of the internal sphincter, there ma}^ be several isolated tumors thus arranged on one side, while they may have all coalesced or originally have formed into one continuous hemorrhoidal mass on the op- posite side, Fig. 4 ; or there may be one continuous hem- orrhoidal mass on either side, separated only by an anterior and posterior commissure, Fig. 5. In some instances when the bowel is prolapsed and constricted by the external mus- cle, the branches of the superior hemorrhoidal veins that anastomose and encircle the upper part of the internal sphincter, may be so dilated and distended as to present an unsightly appearance, reminding the anatomist of the circle of Willis ; at the same time a few capillary or sessile tumors may be seen studded around at diflferent points. The arrangement of internal hemorrhoids in double rows on a side, the one being half an inch or more above the other, is mentioned by Henry Smith, and denied by Curling; the latter claiming that the arrangement in the one or two specimens in the Museum of the Royal College of Surgeons, cited by Henry Smith, showing that the tumors may be disposed in this manner, is due to the mode of preparing the specimens for inspection. I am inclined to the belief of Curling, having never seen duplicate rows on a side; but have found a hemorrhoidal mass seated upon the upper half of the hemorrhoidal inch, and one or two arterial and ex- quisitely sensitive piles attached below, just within the anus. Figure 5 would exhibit a case of this kind were the bowel replaced and the tumors shown in their normal position. There can be no mistake in discriminating between a HEMORRHOIDS. . 23 large hemorrhoid and the bowel; but to distinguish a small, blanched, venous hemorrhoid, located on the upper margin of the internal sphincter from a prolapsed, or a saggened portion of the bowel, when looking through a speculum, is more difficult. The bowel presents a more smooth and continuous surface, while the hemorrhoid is -more uneven and irregular, fills with blood by titillation and bleeds free- ly when scratched. There is a species of the capillary hemorrhoid which, in some instances, may be quite obscure and perplexing, for the reason that the hypertrophic capillaries forming it appear to be very little raised above the mucous surface, and if it be situated anteriorly and at the upper part of the hemorrhoi- dal inch, is liable to escape detection. Other causes being eliminated as an explanation for the presence of blood at stool will establish its identity; and diligent search will lo- cate an irregular scarlet patch, which readily yields to treat- ment, and in this way the diagnosis be confirmed. The white pile {Jiemorrhoide bla7iche), of Professor Richet of the Hotel Dieu, Paris, so called because it does not dis- charge blood like ordinary internal hemorrhoids, but a sero- mucous fluid, is explained by the professor as merely a transformation of the ordinary pile by a hypertrophy of the papillary bodies of the mucous membrane, and the incessant discharge, which acts as perniciously as bleeding, is nothing more than metamorphosed blood. Sometimes a victim of hemorrhoids will call and make the statement that his piles have come down and are hang- ing out. On inspection, a large fold of mucous membrane, 24 HEMORRHOIDS. caused by rectal engorgement, will be seen protruding on one side of the anus, that has been mistaken by physicians for a hemorrhoidal tumor; but the tumor will be found im- mediately above and possibly on the opposite side. A nipple-shaped protusion, consisting of a thickened con- dition of the mucous membrane, forming rather a sharp, sometimes notched, cedematous looking lip, extending across the anus on one or both sides, and which has been occasioned by localized inflammation from repeated attacks of small, irritable piles in proximity above, may likewise be mistaken by the inexperienced physician as well as pa- tients themselves, for true hemorrhoidal tumors. In some cases of hemorrhoids of long standing, where there is a weakened condition and a lack of sensibility of the mucous membrane, and a want of tone in the sphincter muscles, a falling or a partial prolapse of the tumors occurs from the slightest engorgement of the rectal veSvSels, with little more than ordinary inconvenience to the patient ; also in more recent cases, the tumors may remain in a state of prolapse during the acute stage of an attack, without becom- ing altogether intolerable; but a prolapse of hemorrhoids followed by a strangulation of the tumors from a tonic spasm of the sphincters, is quite another phase of the disease and fortunately an exceptional one. Reduction may be effected when called to a patient suffer- ing from prolapsed hemorrhoids and is unable to return them, by placing him in the genu-pectoral position to allow the intestines to gravitate toward the chest, thus producing a sort of suction, supporting the pelvis, while in this position, HEMORRHOIDS. 25 by means of three or four large pillows; then, after having first brushed over the constricted mass a five per cent, sol- ution of cocaine, smear with vaseline, and insert one finger into the rectum, and with the other hand attempt to empty the tumors of a portion of their superfluous blood by gentle FIG. 5. Prolapsed internal hemorrhoids, showing a continuous hemorrhoi- dal mass on either side, an arterial pile on the left, all completely eradicated by two operations. pressure; finally make an effort to push the protrusion through the sphincters en masse, or roll in one side at a time. If un- successful, make hot applications to the exterior and inject 26 HEMORRHOIDS. into the rectum a quantity of hot water, and, after the water has been expelled, apply taxis as before. Some recommend that a bladder of ice be kept on the parts an hour before at- tempting to replace the mass ; but if the ice be allowed to re- main too long there is danger of sphacelation of the tumors. From polypi, hemorrhoids may be distinguished by their spongy like texture, history, shape, color, manner of ar- rangement, and being easy to bleed when scratched, and more painful. Polypi are considered as a hypertrophy of the normal elements of the mucous membrane and the sub- mucous connective tissue. If originating principally from the former, they are soft; if from the latter, hard and fibrous, are generally pedunculated, or club-shaped, sometimes grow rapidly, not painful unless within the graspof the sphincter, may arise entirely above the sphincters, and are rarely of a glandular, villous, or bleeding surface. Should a mistake be made and a polypus thoroughly injected, the result would be nothing more than a permanent removal of the offending growth. The external hemorrhoid does not elicit the thought nor command the dignity of its neighbor, the internal pile, but usually makes itself known more forcibly m its incipient stage of formation, caused by the dilitation of a venule of one of the inferior hemorrhoidal veins, producing an in- filtration, or possibly a rupture of the vessel follows allow- ing extravasation with infiltration, etc., conditions that were named in speaking of the development of external hemorrhoids. On pulling down the mucous membrane at the verge of the anus, sometimes a slight fulness or bulb- HEMORRHOIDS. 27 ous-like expansion of an exposed part of a superficiatvein, or probably one of the "little globose sacs or pools" of blood heretofore described, in a state of repletion, will be seen, and should not be mistaken by the novice for an in- cipient hemorrhoid. TREATMENT. In the treatment of hemorrhoids by carbolic acid injection, there are certain rules and minor details to be observed be- fore, during and after the operation, which, if strictly fol- lowed, will greatly facilitate the ease and success of the treatment and materially abbreviate the time in effecting a cure. It is quite common for those afflicted with hemorrhoids to call for treatment while suifering from an attack, or at the time they experience the first symptoms which usually pre- cede an attack, constituting what the older writers called the hemorrhoidal effort. This is not a favorable time to op- erate on account of the engorged condition of the rectal vessels and the irritability of the mucus membrane. First, reduce all local congestion and inflammation by palliative' measures, such as hot water douches, injections into the rectum of equal parts of Fl. Bxt. Hamamelis and Pinus Canadensis (dark) in a little water, or water and glycerine, should the latter be not repelled by an irritated bowel. At the same time open up the portal circulation by the use of equal parts of sulphur and cream of tartar, a teaspoonful in syrup or mixed with sugar, once or twice a day for a few days, or any other suitable means to put the bowel and piles at rest. Often patients will know what will relieve them of 28 HEMORRHOIDS. an attack of piles better than the physician, inasmuch as what relieves one will sometimes aggravate another. In all cases of large growths, whether the patient is in a comparative state of ease or not, a similar preparatory treat- ment before the operation will shrinken the tumors and lessen the tendency to local congestion and pain. Sulphur should not be taken within two or three days prior to an operation, since it continues its action about that length of time after dosage; but the bowels should be sufficiently evacuated previously by any agreeable cathartic or hy flush- ing the colon, to enable them to be held for four days afterward. This will be unnecessary in the treatment of small growths. When the bowels are already in a soluble condition, the compound sulphur tablet, together with the Hamamelis and Pinus Canadensis, will be found, as a rule, all that is neces- sary to fit the patient for the operation. Should pain or a feeling of uneasiness suggest the use of an anodyne, a sixth of a grain of morphia should be added to each half-teaspoon- ful of the combined extracts and thrown into the rectum, twice a day, after the rectal douche. A hollow cocoa but- ter suppository holding twenty minims, is a convenient ve- hicle to carry the extracts and morphia, and introduced into the rectum will almost instantly relieve the unpleasant sensation characterizing a mild attack of internal hemor- rhoids. The previous evacuation of the bowels by flushing the colon, has the advantage over catharsis, in that it does not disturb -the digestive tract, and admits of no possible chance of engorging the rectal vessels or irritating the mu- HEMORRHOIDS. 29 cous membrane, and is a means always at hand, is simple, easily and quickly performed and does not delay the opera- tion more than thirty minutes ; nor has it the uncertainty of continuing its action beyond the appointed hour or opera- ting at an inopportune moment, like many purgative medi- cines. I always adopt this method of unloading the bowels when the gravity of the case demands that no motion take place within the prescribed limit of four days after an opera- tion. The same course should be pursued to expose the tumors for the operation, that was named under the head of exami- nation. In some instances, where the tumors are not very large but exceedingly irritable (arterial), it may be quite difhcult, even though the bowel be partially prolapsed, to expose them sufficiently to perform a good operation with- out the use of a speculum. In such cases, paint the pro- trusion with a 5 per cent, solution of cocaine and allow the patient to sit for a few moments over a vessel containing a small quantity of steaming hot water. This will engorge the tumors, relax the parts and materially aid in handling them. The spongy structure of hemorrhoids gives them a power of erectility not generally known, resembling, to a certain extent, that of the corpus spongiosum of the penis, and is a property they possess that is capable of being utilized in their treatment, by handling or titillating the tumors, when it is desirable to make them stand out more prominently to view. As a precautionary measure in all operations on hem- orrhoids by injection^ to prevent the medicine from extending 30 HEMORRHOIDS. too deeply into the tissue of the gut by gravity, or the over- flow from running down on the outside of the pile and over the bowel, let the patient lie on the side opposite the tu- mor to be treated, so that the preparation will gravitate to the apex rather than its base of attachment. Smear vaseline on the lower side of the bowel and anus, and over any piles that may be exposed on the lower side, that side being in a position to catch the smallest quantity of the carbolic acid solution that may drop from the hem- orrhoidal needle at the time of the injection of the tumor above, or escape from the place of puncture after the needle has been withdrawn. As a further protection, pack or hold absorbent cotton underneath the tumor to be operated upon. If the tumor be small and partly obscured, the end of the finger may be held back of it to act as a counterforce while introducing the needle, or a double spring, slide tenaculum SHARE. smvix . FIG. 6. — Greene's Double Tenaculum. may be used to pull and hold it down for the same purpose, being careful not to remove the tenaculum when once ap- plied until after the operation, as the least prick or scratch of a hemorrhoid will cause a free flow of blood and greatly hinder the sight when it is desirable to watch the action of the injection compound. Should any portion of the injection compound fall on the muco-cutaneous surface, unless the latter be heavily coated with vaseline or protected with absorbent cotton, it will HEMORRHOIDS. 31 excoriate and probably cause a great deal more pain and soreness than the operation itself. In operating through a speculum such risk is avoided by the sides and floor of the instrument, which afford a protection to the surrounding parts; that is, if the precaution regarding position when operating be duly observed, to wit: Always operate with the tumor pendent, or with its attachment on the upper side. FORMULA. Make a glycerite of tannin in the proportion of 4 drachms (Squibb's) tannic acid to i oz. (Price's) glycerine. When the solution is complete, add 2 drachms each of (Squibb's) salicylic acid and borax (Sod. Bibor.), putting in the salicy- lic acid first; stir over a lamp, using a glass rod and a porcelain dish, until dissolved, being careful not to burn. If any dirt or sediment be seen, it had better be strained now through a piece of wet cheese cloth, while yet hot, into a two-ounce vial. Select a No. i grade of carbolic acid, say Calvert's, and barely liquify it by distilled water. Pour ^ ounce and 15 minims of the liquified carbolic acid into a clean graduate, and add a sufficient quantity of the glycerite of the salicyl- ate of borax and tannin, previousl}^ made, to make the preparation measure one ounce and no more. Give of the carbolic acid full measurement. The addition of the extra 15 minims of the acid to the half-ounce, in making the ounce combination, compensates for the water that has been used to liquify the acid, lessens the consisten- cy of the preparation a trifle and makes it fully 50 per cent. 32 HBMORRHOIDS. of pure carbolic acid ; in which strength the preparation, I think, acts better and is less painful, particularly in the more fibrously organized hemorrhoids. Should equal parts of the crystalized carbolic acid (liqui- fied by warmth) and the glyceride of the salicylate of borax and tannin be combined, the preparation will be found rather too heavy for convenience. It must be remembered that the carbolic acid exhausts its strength as soon as it unites with the tissues, and also that its action is restricted by the tannic acid, and that it does not take hold of the tis- sues the same as when combined with a less astringent and less consistent fluid. When the acid and the glyceride are combined, a floccu- lent precipitate will be noticed, which should all clear up within two or three days; otherwise, something will be found wrong, either in the purity of the chemicals used or the manner of combining them. Too much importance cannot be attached to the purity of the ingredients entering into this preparation, as any- thing unnecessarily irritating should be scrupulouslj^ avoid- ed. I have tried synthetic carbolic acid and found the odor of tar decidedly stronger, and believe it much more acrid and irritating than the commoner preparations ; neither can I see that anything is gained in using vegetable glycerine. Inject froin 3 to 30 minims or more, according to the size of the tumor. There is no rule by which the quantity can be accurately gauged before the operation; this can only be approximated by judgment. The object is to in- OF THR HEMORRHOIDS. 33 ject a sufficient quantity to permeate the entire substance of the tumor, its texture being much more spongy than the surrounding tissue, but not enough to extend beyond its base of attachment. Here is where many make a mistake in the injection of hemorrhoids. Some are prone to use too much of the solu- tion employed, even though it be weak, and apply it too deeply, reaching to and destroying the muscular coat of the bowel by inflammatory action, causing prolonged pain, deep sloughing, etc.; while others use too little, which may act as a foreign body or local irritant, producing a central slough and a slow breaking down of the disturbed growth. Fig. 7. Section of hemorrhoid showing internal spongy structure. 'Bsniarch.) A tumor, properly operated upon by injection, cannot in- flame for the obvious reason that the inflammatory process does not take place in a tissue destitute of circulation. The theory of cure by carbolic acid injection, is by strangulating the circulation, the same in effect as a ligature, with the advantages of the immediate caiiterant, local micssthetic, antiphlogistic and antiseptic properties of carbolic acid. The base of attachment of the tumor heals, while the dead tissue, 34 HEMORRHOIDS. which is rendered non-inflammatory and antiseptic, dis- integrates and is thrown off" at the expiration of three or four days ; a process that fortifies against secondary hemorrhage. There is a medium ground to be taken in regard to the quantity as well as the strength of carbolic acid to be used, with a little room for variation on either side ; yet there must, in point of reason and fact, be a limit somewhere. Should a little more be used than is necessary to permeate the entire substance of the tumor, the result will not be dis- astrous, but may excite a little more local disturbance and pain. On the other hand, should a little less be used, the oper- ation will be equally as effective, and is probably the better side to err upon provided the discrimination be not carried too far. A similar dilemma respecting the strength, confronts us. After trying the weaker solutions and watching their effects, I have concluded that the solution should contain not les^ than fifty per cent, of pure carbolic. acid combined with the glyceride of the salicylate of borax and tannin, the latter in such proportions as to produce an immediate astringent ef- fect. Tannic acid not only keeps the carbolic acid within limits by its non-irritating astringent effect, but of itself combines with a certain portion of the albumen of the blood and other tissue, forming an insoluble albumenoid. The salicylic acid and borax original with Dr. Q. A. Shuford of Tyler, Texas, give the preparation more consistency and seem to lessen the irritative properties of the carbolic acid and otherwise act beneficially. A weak, thin, watery solution, aside from doing poor HKMORRHOlDS. 35 work, is much more liable to dijGfuse itself and be carried into the circulation like a hypodermic of morphia, than a solution sufficiently strong to act as a cauterant, destroying the tissue, forming a tough, compact and an insoluble co- agulum and thereby strangulating the circulation at once. A solution, weak or strong, when deposited to any depth beneath the surface, surrounded by live tissue and a free circulation, will of necessity excite pain, inflammation and a slough, the same as a splinter in the flesh unless the solution should be so weak that absorption take place, in which event it would become locally inert. The properties of car- bolic acid being non-inflammatory in their nature, will often, where a small quantity of the diluted acid is used, excite an adhesive inflammation and produce a contraction of and an induration in a tumor, by destroying the capillaries where applied, and would be a very desirable way to cure hemor- rhoids were such effects uniform and permanent. Care should be taken, when operating on external hem- orrhoids, to see that quite a goodly portion of the cutaneous surface, especially at the summit of the tumor, is affected by the carbolic acid solution applied inside the capsule ; otherwise the integument will become inflamed in order to let out the interior coagulum, which I have often seen come out on the third day intact, and in one unbroken cystic- looking mass. Fig. 9. The same rule obtains regarding internal hemorrhoids having thick, unyielding coats. The covering of a hemorrhoidal tumor is the most fibrous portion and is least affected by the injection compound; consequently it is always advisable, after withdrawing the 36 HEMORRHOIDS. needle when operating on piles of any considerable size, to deposit one or two drops of the preparation in three or four places about the apex of the tumor, to be sure of thor- oughly cauterizing the more dense tissue of its integument, which otherwise might inflame and create unnecessary pain and suffering. Also feel over the surface of the tumor for any soft places that may not have been permeated by the injection fluid, and if any be found, treat them in a similar manner. FIG. 8. :fig. 9. External hemorrhoid before Three days after operation operation by injection. with coagulum still attached. Puncture the tumor at the most accessible point, prefera- bly about midway between its base and apex, carrying the point of the needle to the center of the tumor, if it be globe shaped, or equi-distant from side to side, if it be elongated, with the face or opening of the needle toward the apex. Be sure the needle is inserted beyond the proximal end of its opening, which is not always observable in treating small growths, but may be tested by forcing the piston of the syringe a little, and, if the end should not be sufficiently. HEMORRHOIDS. 37 buried the medicine will show around on the outside. The capillary hemorrhoid and other small tumors are to be punctured at their base and the injection made from behind or beneath the mucous membrane. Inject the first few drops the same as you would a hypo- dermic of morphia, then slow^ly, drop by drop, watching its action by the change of color produced on the surface of the pile. This change of color is quite marked with hemorrhoids of a delicate covering, less so with those pos- sessed of more tough and fibrous coats. Hold the needle in position a moment, and if the quantity injected does not appear sufiicient, turn back a few rounds the nut on the piston with which you have previously gauged approxi- mately the quantity to be injected, and throw in more. Puncture large elongated tumors in two, three, four or more places. The compound takes effect slowly by virtue of its astringency and the con- sistency of the fluid, and no doubt extends some farther than is always apparent at the time of the operation. Withdraw the FlT^io.-Diagram showing needle carefully. It may be place of puncture ; tumor pen- necessary to force out a few ^^ ' drops of the preparation at the point of entrance, for the pur- pose of sealing up the puncture to prevent the escape of blood and medicine together, which, however, never amounts to much. If, after withdrawing the needle, some of the injec- tion fluid runs out, unmixed with blood, take it up with ab- sorbent cotton, as it indicates that the quantity at that 38 HEMORRHOIDS. particular part is superfluous. Now dry the surface of the tumor with absorbent cotton, bathe the adjacent tissue with dilute acetic acid, (see antidote to the local effects of carbolic acid in appendix), smear the entire protrusion with vaseline and return it within the bowel. A tumor, properly operated upon by injection, immedi- ately becomes hard. There are septa, forming compartments in elongated growths, which do not permit the medicine to pass through readily, and if a soft section be noticed, it has not been penetrated, although it will doubtless break down with the general mass ; yet it will break down with less struggle and pain by receiving a few drops of the carbolic acid solution for the reasons already given. I have seen a liberal injection into the middle one of three tumors con- nected and arranged in a row, so penetrate those on either side that a single reddish column-like fragment appeared afterward on the extreme outsides (Figs, ii and 12). FIG. II. FIG. 12. Three internal hemorrhoids be- After a liberal injection into fore operation. the middle tumor. Large hemorrhoids must not be exposed too long after the operation, since there is always more or less swelling pro- duced around the tumor by the stoppage of the circulation and the presence of a foreign body. Return first the side not operated upon, then the other, and if the tumor has HEMORRHOIDS. 39 considerable length, let it go in endwise. The patient can often return the protrusion with least pain. A little practice will enable any one to see the simplicity of the entire procedure. If you should make a mistake, when operating through a speculum, and deposit the whole charge into a fold or saggened portion of the bowel, do not be alarmed, as it will only tighten, or shorten the bowel a little on that side and be a little more painful and longer in healing. Injection into internal hemorrhoids is not painful to any degree ; therefore if the patient complains much, you may suspect that you are invading the tissue of the bowel. With some, the injection into external hemorrhoids is quite painful at the first contact of the medicine, but immediately thereafter, subsides. When the tumor is very sensitive, ex- ternal or internal, precede by a hypodermic of from three to five minims of a five per cent, solution of cocaine. Intro- duce the needle point barely underneath the covering of the growth, and force out one drop. This will anaesthetize enough to allow further penetration, when another drop may be thrown in. By this time you can approach the in- terior to a sufficient depth to inject from three to five drops more, and anaesthesia will be immediate and complete. There need be no fear from cocaine absorption, since the carbolic acid compound will catch and hold the cocaine all within the body of the tumor before it can be absorbed and enter the general circulation. From one to two hours after an operation, the carbolic acid loses its local anaesthetic effect, and what I have called the after-pain, commences, caused by the presence of a for- 40 HEMORRHOIDS. eign body acting on the peripheral nerve at a point where the line of demarkation forms. This pain varies in intensity with the sensibility of the patient and surface of attachment of the tumor or tumors. Some will not complain at all, saying the discomfort is not as great as the suffering from an attack of piles ; while others will make considerable fuss, requiring an opium and belladonna suppository: R Opii Pulv. Optim. gr. xij Kxt. Bellad. gr. iv 01. Theobrom. 3 iij M. et Ft. Sup. No. xij. Sig. Introduce one every hour or two as occasion re- quires. The after-pain does not continue longer than twelve or fourteen hours unless aggravated by undue exercise or other similar causes, being replaced by a feeling of soreness, which is sometimes reflected down the limb or up to the bladder. The treatment after the operation should be markedly palliative, — hot water sponge compresses to the anus, hot water sitz-baths, and hot poultices together with opium and belladonna suppositories pro re nata^ are great as long as there is pain and a feeling of soreness. If the extent of the operation requires constipation of the bowels, enemas should be dispensed with until after the expiration of four days ; then injections of hot slippery elm water, flaxseed tea, or corn starch as prepared for stiffening clothes, may be used, as well as a soothing suppository : HEMORRHOIDS. 4i R Bism. Subnit. lodoformi a a 3 j Opii Pulv. gr. v-x Ext. Belladon. gr. v 01. Eucalypti gtt. vj Ol. Theobrom. 3 iiss 01. Olivae gtt. x M. et. Ft. Sup. No. xii. The oil of eucalyptus will almost completely disguise the odor of iodoform. In old persons or those who lack sufficient vitality to quickly heal a broken surface, coat the surface with bis- muth, bismuth and oxide of zinc ointment, oxide of zinc powder, resin cerate, phenol sodique, eucalyptol, etc.; in- creasing the potency of the agent as the soreness disap- pears. Eucalyptol in the proportion of ^ dr. or more to i oz. oxide of zinc ointment containing a small quantity of stramonium or opium and belladonna, is a sovereign remedy to stimulate healthy granulations after a broken surface has lost its freshness or has acquired some age. Anything that excites and keeps up pain, is hurtful. Severe, continuous and prolonged pain is an indication that the changes are not going on in a satisfactory manner. It should always be subdued as much as possible. Supposito- ries containing glycerine, castor oil, or anything productive of much pain should be wholly discarded. Temporary sympathetic paralysis of the bladder or spas- modic stricture of the urethra, may occur, being relieved by hip baths, hot water applications over the bladder and 42 HEMORRHOIDS. to the perineum, or by the catheter. The latter is very sel- dom required and cannot be introduced until after the urethral spasm has been relaxed. Enjoin as little straining as possible. In many of the worst cases, in otherwise healthy persons, the holding of the bowels will be mentioned as being the greatest difficulty encountered during the entire course of the treatment. A little flatus will some- times produce an annoying titillation of the muscles. It has been suggested that a small tube be introduced at such times for relief. A certain amount of moisture begins to exude the second day after the operation, particularly noticeable from exter- nal hemorrhoids, and a peculiar smell emanates when the coagulum is thrown off. These should not be interpreted as suppuration. It would be unreasonable to suppose that all cases will behave alike. The local and constitutional disturbance will, of course, depend upon the size or surface of attach- ment of the tumor or tumors and the nervous and physical condition of the patient. It is best to require patients to be quiet a few days, even though they do not complain, after an operation on large hemorrhoids or when more than one of small size have been taken. The operation may be performed at the office or the resi- dence of the patient, as suits the circumstances and gravity of the case. Inasmuch as there is no particular strain on a patient during an operation, and the after-pain, even should it become severe, does not begin for one or two hours afterward nor culminate inside of eight or ten, HEMORRHOIDS. 43 patients may be allowed to travel some distance after the operation, provided they do not indulge in much walking. In persons enjoying average health, with internal hemor- rhoids located on both sides, take one side at a time, mak- ing two operations of the treatment. In a case like Figure 4, not an uncommon form, it will be better to operate on all the five smaller tumors first, while they are exposed and kept out by the aid of the large one on the opposite side. Should the large growth be taken first, it may be impossible for the patient to hold the bowel down sufficiently afterward to operate on any one of the five small ones, and a speculum will be called into use ; this will prolong the treatment, as few will submit to the operation on all five tumors through the slot of a speculum at one sitting. Small, isolated piles can be treated singly, and the patients allowed to go about their business. It is in the manage- ment of these bad cases, in which the patients know the im- portance, prepare and lie up for treatment, that we should endeavor to bring about as quick results as possible ; these cases in which the patients have been great sufferers, and possibly the operation on one small tumor would so arouse the others that the suffering would be as much, if not more than if all the tumors had been operated upon at the same time. Not unfrequently the piles on the opposite side of the bowel that have been left for a second operation, will set up a local disturbance and create more pain and suffering than those on the side treated ; especially may you look for such alarm if you allow any of the injection compound 44 HEMORRHOIDS. to fall on their unprotected surface. A patient once observ- ingly remarked that it must be a peculiar kind of medicine that caused pain when brought in contact with the outside of a pile, but none when applied to the interior. As regards pain, it might be briefly stated that little can be done in the vicinity of the rectum, it matters not what strength of carbolic acid be used or plan of treatment adopted, without causing more or less discomfort in all cases, amounting to actual pain and suffering for a brief period in others, not at the time of the operation, for that in itself is practically painless, but during the process of cure. This is not surprising when considering the extreme sensibility of the parts, and the amount of tissue involved and actually removed by a radical operation ; yet it is no greater in the majority of instances, when the preparation is sufficiently strong to produce a decided effect, and not as great in extremely irritable pileSy as that caused by the periodical squirting in of a few drops of carbolic acid and water, extending over a period of weeks and even months , that is not safe, certain, nor otherwise satisfactorj^ and often brings discredit upon a process which, if properly understood and rationally applied, has no approach to com- parison with any other method of cure. Some physicians fear to use anything stronger than a little carbolized water and gl3^cerine, lest they produce carbolic acid poison, embolism or a slough. This is a mistake ; the dangers they seek to avoid are coupled with such uncertain and illogical practice. HEMORRHOIDS. 45 Dr. K. H. Dorland, Chicago, 111., says : "When a com- pact coagulum is formed and the muscular layer of the bowel is not touched by the styptic, it is impossible to do harm, all the learned theory to the contrary, notwithstand- ing. A weak solution forms Uttle globules in a tumor and we can imagine one so small as to be carried into the circu- lation." Dr. F. ly. Haynes, Los Angeles, Cal., reports a series of fifteen cases of hemorrhoids, ranging from a mild to a more or less severe type of the disease, which was treated by weak solutions of carbolic acid with anything but gratifying re- sults. In the first five cases, single injections of five minims each of a two per cent, solution of carbolic acid, were em- ployed at intervals of ten days. The pain following some of the injections lasted from two to three days, and in one case there was sloughing of the tumors and a cure, but the pain was intolerable, and crural phlebitis, starting in the veins near the sloughing tumors, set in immediately, which kept the patient in bed for two months and seriously endan- gered life. The remaining ten cases were treated by the injection of five minims of a 5 per cent, solution of carbolic acid, in glycerine and water {a la Kelsey), at intervals often days or longer, and were more satisfactory ; but there was more or less pain in some instances and sloughing, with relapses and failures to cure in others. The fifteenth case is note- worthy from the fact that, in the treatment of this patient, the doctor inaugurated a radical and almost an unaccount- able change in the strength of the acid, for one prejudiced .'-'' ' _ \ J r< /\ /^^ OF THE UNIVERSITY 46 he;morrhoids. by "the literature of the subject" against strong solutions. He says : "After twenty-five sittings (250 days) in which a five per cent, solution was used, two small but annoying tumors remained. These were constricted separately at their base by the wire of a nasal snare, and pure crystalized carbolic acid (liquified by warmth) was injected into each till the mass turned white;" then the startling announce- ment comes that the result w^as a cure with but slight in- convenience, and that two other cases similarly treated were equally satisfactory. This impartial report of fifteen consecutive cases, by one biased in favor of the weaker solutions, may be fairly con- sidered as a good representation of the stereotyped five- minim injection of the weaker solutions, advocated by some writers and those who claim to be able to cure piles without causing pain or detention from business. A review of the series shows that a small per cent, of the milder cases was cured, after an indefinite length of time, by contraction of the tumors with little inconvenience, but some relapsed; that others were cured by inflammation and sloughing, with a great deal of pain and inconvenience ; while others were little affected by the treatment. Dr. Howard Crutcher, Chicago, writes me that he often uses the pure acid in the injection of hemorrhoids and never less than 80 per cent., and that he has operated on as many as eight tumors at one time, using 160 drops of pure carbolic acid therefor, with no evil results whatever. This goes far to prove that there is no danger of carbolic acid poison in the use of strong solutions. HEMORRHOIDS. 47 To effect a safe, speedy and a radical cure, it is desirable to get rid of the tumor bodily, not by shrinking, or contrac- tion, leaving a hard, or an indurated prominence, subject to resuscitation and a return of the old malady, nor by inflam- matory destruction ; but by a separation of the spongy and vascular growth from the normal tissue of the body, the FIG. 13. Syringe, needle and flexible silver canula. same as if it were dissected from its remotest attachments. This is obtained by putting a sufficient quantity of the prep- aration recommended just where you want it,*and such re- sults will invariably follow. I have seen internal hemor- rhoids become so friable about the third day after an opera- tion, that they could be crumbled off similar to a piece of 48 HEMORRHOIDS. cheese. The preparation can be relied upon to extend just as far as you put it and no farther, and will remove as much of the tissue as permeated. It will extend farther into and permeate more readily the structure of a pile than the sound tissue, because the former is much more spongy and cellular, which allows the preparation to be easily forced and diffused throughout its integrity (Fig. 7). A pile properly operated upon by injection should appear the next day after the op- eration perfectly dead, as if boiled or cooked, and of a leaden color, varying somewhat with the amount of blood it con- tained and the thickness of the capsule. NEEDLE AND SYRINGE. The size and shape of a hemorrhoidal needle are of no little importance in doing neat and effective work. The needle should be fitted with a screw to gauge the depth of insertion, and the point made of gold or platinum, with FIG. 14. FIG. 15. Desirable shape. Undesirable shape. rather a short face or opening Fig. 14, and not over one- thirty-second of an inch in diameter. The calibre of the needle should be sufficiently large to let the preparation pass through with moderate freedom. A common hypo- dermic needle would be utterly useless. A common glass barrel, metal bound, hypdermic syringe is all that is needed. It should be provided with side han- dles. Draw the medicine into the syringe before screwing HKMORRHOIDS. 49 on the needle, force out the air and gauge the nut on the piston for about as many minims as it is thought will be re- quired. When a syringe is not kept in constant use, the piston will dry out and stick to the barrel. This is remedied by set- ting the nut on the piston when laying the syringe away, so that the piston will not go quite to the bottom of the barrel. When it is desired to use the sjTinge, screw back the nut, say sixteenth of an inch, then with the thumb on the piston handle and finger on the cap at the other end, press together, thus freeing the piston. A heavy, open face watch glass with a center facet, is a good receptacle for the injection compound before drawing it up into the syringe. ACCIDENTS. MARGINAIy SWKlylyING AND ABSCESS. A marginal swelling followed by aii abscess, appearing the third or fourth day after an operation, is produced by excessive irritation. I have never seen it occur except when the patient disobeyed instructions and exercised in- ordinately. One instance, in a case of long standing, where the piles occupied both sides of the rectum between the sphincters, I operated on both sides and injected the car- bolic acid solution into every tumor at one sitting, enjoining rest and quiet. The patient afterward rode a long distance and walked a half-mile, which caused an unusual amount of pain and soreness ; and not content with this he took a dose ' of castor oil on the third day, when a very painful marginal!/ 50 HEMORRHOIDS. swelling occurred. Being a strong man up to this time he had used no palliative measures whatever, and only then informed me of his suffering. Hot water and a sponge soon 'eased the pain and a superficial abscess developed, which iDroke in two places, both external, and no doubt would liave left a small, sub-cutaneous fistula. The skin between the two openings, w^hich did not involve any muscular tis- sue, was cocainized and slit up and a good recovery followed. According to my observation and belief, piles situated just above the verge and in proximity to the network, or plexus of nerves surrounding the anus, are more prone to cause a marginal swelling than others, particularly if improperly operated upon and an irritating quality of carbolic acid be used. It might also be stated that pain varies in intensity as it approaches the verge of the anus, one of the most acutely sensitive surfaces of the body. A small, sensitive pile not larger than a salmon egg, and S I. position of sphincters, situated within the grasp of I/. Hilton's white line. N. nerve. . ^ -^ . the external sphincter, will keep up a titillation and contraction of the muscle, sufficient to disturb and put ill at ease the entire animal economy. Fig, i6. — Diagram showing nerve supply of anus. (Hilton.) M. Mu- cous membrane. C. Skin, S. E. HEMORRHOIDS. 51 A swelling, or lump, which often appears immediately after the injection of piles of any considerable size just above the verge, is of no consequence and will subside within a few days. A similar swelling sometimes results from a severe attack of internal hemorrhoids, which some speak of as the developing of an external pile ; but I do not see that such formations are anything more than marginal swellings, caused by the irritation above. SECONDARY HEMORRHAGE. About the time the tumor is thrown off, from three to four days, and sometimes la4;er, before the healing stir- face becomes strong, or should the portal circulation become obstructed and the hemorrhoidal vessels congested, secon- dary hemorrhage may rarely occur. It is easily controlled by the use of Monsel's Salt, to which a little morphia should be added to lessen pain which may be produced by the styptic power and irritant eflfect of the iron. The iron and morphia may be conveyed to the ruptured vessel iii a small piece of wet absorbent cotton, and held there by the end of the finger until the hemorrhage ceases. A few minutes will usually suffice to control the bleeding; the cotton being allowed to remain in place after the finger has been with- drawn. Knowing where you operated will be a guide to the place of application. The injection of a strong solution of tannic acid will be sufficient in mild cases. In extremely bad cases — hemorrhagic diathesis — the in- troduction into the rectum of a piece of ammonio-ferric alum, which has been smoothed and shaped to the size of a large suppository and lubricated with vaseline, will quickly 52 HEJMORRHOIDS. form a coagulum. Ten drops or more of the Fl. Kxt. of opium (aqueous) may be thrown into the rectum after the suppository has been inserted. To as many of the profession as do not know its value, I desire, at a risk of pardon for the digression, to call attention to the ' 'alum plug' ' for controlling uterine hemor- rhage after an abortion or a miscarriage. A chunk of com- mon alum is shaved down to the size of a hen's egg. A hole is made through its center for the purpose of retaining a stout cord, which is used to remove the plug from the vagina after it has remained there over night. The vagina is then to be irrigated once or twice a day by an anti-sep- tic solution as is usual in such cases. No one who has a knowledge and makes proper use of the "alum plug," need go to a case of uterine hemorrhage with "fear and trembling." It is reliable and harmless. I have never known a secondary hemorrhage following carbolic acid injection amount to anything more than an easily controlled venous hemorrhage. I am inclined to think that a tendency toward secondary hemorrhage would be increased when a pile breaks down from a partial injection, leaving the vessels unprotected in places, or from an injec- tion too deeply into the substance of the bowel ; yet, I have seen all these conditions time and again without the slight- est indication of hemorrhage, CARBOI.IC ACID POISON AND EMBOLUS. With a fifty per cent, solution of carbolic acid and the combination given, carbolic acid poison and embolus are entirely out of the question. The only danger of embolus HEMORRHOIDS. 53 lies in the too sparing use of a weak solution of carbolic acid, injected slowly into the unobstructed calibre of a coursing vein; while a strong solution quickly and gener- ously applied would destroy the tissue and obliterate the vessel as effectually as the hot iron. In relation to embolus and ulceration following the in- jection of hemorrhoids, Kelsey says: "As for embolus I can see no more reason why the clot formed in this way should become detached and pass into the general circula- tion, than should the clot formed on the proximal side of the ligature. In my own practice, as I have said, the re- sults have been uniformly satisfactory, and when ulceration has been produced I have found it no more difficult to man- age than that which follows the detachment of the ligature." SLOUGHING. The extensive sloughing concerning which I have heard so much, I have never experienced, and am unable to conceive of such an occurrence, except it be in a low state of vitality, which would fare no better under any other kind of an operation; but can imagine how a pile would slough if a few drops of carbolic acid were deposited in its center or deeply into its base, leaving the apex and the greater portion of the growth with a free circulation, a condition that would most surely induce prolonged pain and suffering. A weak solution taking effect in the interstices of the most tender part of a hemorrhoid, but not sufficiently strong to attack the more fibrous portion, would doubtless result in in- flammation and a slough. A pile with a thin, delicate cov- ering and a delicate internal structure can be cured by an 54 HEMORRHOIDS. injection of water, while those of a tougher and more fibrous character would only be exasperated by such annoying treatment and behave in a bad manner. In looking over the comments of Kelsey, Andrews and others regarding the injection of hemorrhoids, it appears quite evident that they have not given the subject scientific study. It would seem that representative men and authori- ties, after a knowledge of the brilliant results following the treatment in many cases, attended by accidents and failures to cure in others, would seek to know and try to obviate the cause or causes of these unexplained irregularities; but they never improved upon the method in its primitive and undeveloped state, yet seemed willing to magnify and enlarge upon all the accidents and complications arising from and following the indiscriminate use of all sorts of injection compounds, in the hands of the ignorant and inexperienced and in diverse and unfavorable conditions for treatment. How about the old methods? Only a few months since my attention was attracted to a gentleman of prominence, in middle life, strong body and good habit, who had been operated upon for the removal of piles by ligature. He was seven months in recovering, during which time two fistulas developed. I do not mention this case as an isolated one, because we all know that excessive and prolonged pain, (causing in some instances lock-jaw and death), retention of urine, sloughing and stricture by contraction of tissue, ab- scess, fissure, fistula, intractable ulceration, hemorrhage (immediate or secondary), great and lasting prostration and slow recoveries, (saying nothing about the dangers and in- HEMORRHOIDS. 55 conveniences of anaesthesia), are not uncommon when the old methods are practiced. There are no tenable objections to the traatment of* hemorrhoids by carbolic acid injection, rationally and scientifically applied, which cannot be equally urged against the more heroic plans of treatment advocated and generally adopted; but there are many serious and unavoid- able drawbacks inherent in the latter methods of cure, which are wholly and incontrovertibly absent in the former method. The behavior of a bad case of hemorrhoids after injection, is similar, in many respects, to that after an operation by the ligature, the thermo-cautery, crushing, etc.; except that the local and constitutional disturbance is of shorter duration and is less marked, with none of the after conse- quences which not infrequently complicate recoveries, wherk the harsher means have been employed. In many cases of hemorrhoids, and in fact it may be said^ in the majority of instances, not more than two or three ac- cessible, medium sized tumors can be found, and w^hicli, having been a source of great annoyance to the patient, lead him or her to believe that his or her case is a bad one. Such persons are not likely to suffer much inconvenience from any radical plan of treatment that may be adopted, and no dou^t it is the result of this class of cases that lends great en- couragement to the old methods' operations. When Kelsey, after having deposited five drops of a car- bolic acid solution in the center of a large tumor, observed it looking dark, angry and inflamed from the intrusion of a. .36 HEMORRHOIDS. foreign substance, that would have been a fitting moment for the injection of a sufficient quantity of carbolic acid to have pervaded the entire structure, and in sufficient strength to have thoroughly cauterized the mass, and thereby have stopped the circulation and checked the inflammatory action at once, and then to have followed up the procedure by the liberal application of hot water and a sponge. The method that I adopt and recommend for the removal of hemorrhoids, not only does the work more neatly than the more heroic measures in vogue, but robs the patient of the terrors of etherization, as well as the dreaded conse- quences incumbent upon and more or less inseparable from operations of violence, in a peculiarly organized and sensi- tive locality; and, as Dr. B. F. Hoyt of New York says: "There is not a hemorrhoidal case possible but what can be 'Obliterated by this means; and I am at a loss to explain why so many cling to methods that carry so much havoc and suffering. If every college in the land would have this subject demonstrated by men of experience and learning, all other methods would soon lose recognition." I shall not take up time and space in enumerating cases, "but will briefly mention three of quite recent date and of more than common interest on account of some of their as- sociated history. Manuel L — , aged 41, capitalist, had arranged his business affairs and prepared for the possible results of a ligature 'Operation. All being in readiness, he was placed on the operating table by a prominent surgeon, who, upon exam- ination, found the hemorrhoids to look so formidable in ap- HEMORRHOIDS. 57 pearance that he, the surgeon, refused to proceed further, stating that the operation might prove fatal. On the gen- tleman's first visit to me, he was asked to use the commode and strain out the piles. This having been done, a large, continuous hemorrhoidal mass was seen encircling nearly one-half the bowel on one side, with five distinct and typical tumors on the other, similar to Fig. 4. He was directed to lie on the operating chair with the large growth on the up- per side, and about 30 minims of the .carbolic acid prepara- tion were injected in three different places into the mass, the protrusion returned and the bowels constipated for four days, after which the bowels were moved by an enema of slippery elm water, when not a vestige of the growth could be seen, and there was no pain produced by the motion. He put his hand back to replace the bowel, as he had been accustomed for the past eight years, and found the pro- trusion gone, whereupon he said if this had occurred in the day of miracles, he would think one had been performed. One operation was required for the remaining five tumors, and both piles and prolapus were cured by tv/o operations. In fact, the small tumors should have been taken first, when the opportunity to get at them was much better. The only inconvenience suffered was from an effort to hold the bowels and the after-pain ; the latter not being severe but lasting about fourteen hours, during which time an opium and belladonna suppository was introduced every two or three hours. He stated that he was just getting over an attack of La Grippe and had been purged pretty freely ; con- sequently the bowels were not evacuated previous to the 58 HKMORRHOIDS. Operation, but a liquid diet was advised for the first three days afterward. George P — , aged 37, druggist, had a continuous hemor- rhoidal mass occupying both sides of the bowel when pro- lapsed, being separated only by an anterior and a posterior commissure. Glaring fibrous bands seemed to bind down the enlargements in places, presenting anything but an in- viting case. He also had an arterial hemorrhoid attached just above the verge, constantly hanging out and exciting the external sphincter, and which looked like and was about as large as a medium sized strawberry, being irritable and eroded. The history of the case and the ungainly appearance of the protrusion induced me to have it photographed. It is approximately represented in Fig. 5 which does not^ however, show the fibrous bands. The patient was placed on the side opposite the larger mass, and injections made into the mass at four different points. The bowels were constipated for four days afterward by the occasional intro- duction of an opium suppository and then moved by enema, when the man was overjoyed on having no pain at stool and finding no protrusion on the side that had been treated. The next operation took the mass on the other side to- gether with the strawberry growth, and the case was dis- charged, cured of piles and prolapsus. Both of these gentlemen had been told time and again that the carbolic acid treatment was ineffectual and dangerous. One ex-army surgeon and college professor said he would not attempt any of the heroic operations in the second case, HEMORRHOIDS. 59 as there was too much tissue involved; that he would agree to treat it only by making local applications twice a week; further, he wo-uld not promise any results inside often months, asking twenty dollars per month. He would not swerve from his opinion and could not say that a perman- ent cure would then be effected. Mrs. Jane D — , nearly 80, afflicted many years, had con- sulted fifteen different physicians, all of whom refused any- thing more than temporary relief because of extreme age, she, having always been considered delicate, with cataract now forming in both eyes; said she would be satisfied if she could live not more than two years after a cure. The tumors were ''old bronzed veterans," tough and un- yielding. One side was taken at a time, and although con- fined to the bed mostly for the first seven or eight days after each operation, she could get out and in at any time without assistance. She had no constitutional disturbance, never missed a meal and was able to get up and down stains inside of eight days after the second and last operation, un- attended. The dead piles embraced by the coagula were much long er in separating from the bowel, and their base of attach- ment longer in healing than in average cases. Hot water sponge compresses together with opium suppositories were used frequently for the first twenty-four hours, then oc- casionally for the next three days, after which hot water irrigations and iodoform suppositories; and later an ointment of bismuth, eucalyptol and oxide of zinc was used. An oc- casional dose of sulphur and pot. bitart. was given and the 6o HEMORRHOIDS. bowels moved by flushing the colon, which was resorted to but twice. In this case the edges of the thickened, calloused mucous membrane of the bowel where it joined the hemorrhoids, appeared te be so cartilaginous in places, that I expected hard ridges would be left; but they all disappeared and softened down by the use of eucalyptol and stramonium ointment. At one point a small polypus sprang up, which withered from the injection of a few drops of pure carbolic acid. The lady could not repress her feelings of emotion, in ex- pressing gratitude for the services rendered, but gave way and freel}^ cried. Although in rather poor circumstances, she did not think a charge of fifty dollars sufficient and afterward returned, saying that she felt that she could not die happ3^ unless I was better paid, and insisted upon my taking another "twenty." RESUME. Do not operate during an attack of piles. Operate with the tumor, or tumors on the upper side. Handle the parts with extreme gentleness and deliberation. See all that can be seen and treat all that can be treated without the aid of a speculum. Protect the under parts from excoriation by waste and overflow of medicine. HEMORRHOIDS, 6l Evacuate the bowels previously and constipate them for four days after an operation on large growths, or when several small tumors are taken at one time. Hot water applied to the anus by means of a large, soft sponge, early and often, is indispensable and unequaled for the relief of pain, swelling and soreness. To be effective,, it should be applied as hot as can be borne. Wait until the soreness disappears before performing a second operation. This will require from one to two weeks,, according to the extent of the first operation and the phys- ical condition of the patient. Take great pains and care to perform a neat operation. A certain amount of ingenuity and tact is required, which, unfortunately, all do not possess. If a bungling job be made, the bowel punctured, the solution injected into only one side of a pile, and the surfaces excoriated, do not attri- bute an unnecessary amount of pain and suffering to the preparation used or the method employed. As a general alterative and curative agent in maoy dis- eases, and particularly to relieve and prevent hemorrhoidal congestion in rectal troubles, sulphur in small doses, per- sisted in for some time, probably has no equal. The niost convenient form for administration is that of a palatable tablet (Wyeth & Co.) containing 5 grains with 2 grains of cream of tartar. A reference to the learned articles on the physiological and therapeutical uses of sulphur, by Dr. John V. Shoemaker, published in the Dietetic Gazette, Sir Alfred B. Garod in \X\^ Lancet, and in Ringer's hand-book of ther- apeutics, will be amply repaid. 62 HEMORRHOIDS. RElyAPSES. A recurrence of hemorrhoids after treatment and an ap- parent cure by carbolic acid injection, is one of the strongest points adduced by the opponents of the metjiod. It is need- less to say, to those who have had experiences, that the argument is valid only in so far as it applies to the sequences of the treatment by the weaker solutions. It will be conceded that many cures are effected by the *'high dilutionists," which remain permanent; it will also be admitted that many cases yield to various kinds of local applications and cease troubling thereafter, and that some tend to a spontaneous cure. Evidently such results are con- fined to that class of cases in which the hemorrhoidal struct- ure is delicate, and the predisposing and exciting causes are not overly potent. Hemorrhoids, well organized and largely made up of fibrous tissue, are not curable except by recourse to some sort of a radical operation ; although they may be shrunken and rendered more or less passive, by palliative measures, in some instances, for an indefinite length of time. The same causes operating, some hold that relapses will and often do occur after the removal of hemorrhoids by any of the operations known to the profession. This statement is certainly not borne out by reason and observation. A radical operation, by which I am to be understood as an immediate or a timely removal of the tumor in substance, either destroys the vessel upon which the tumor forms or HEMORRHOIDS. 63 by which it is sustained, or the coats of the vessel become so thickened and strengthened by inflammatory action lead- ing to hyperplasia, that relapses do not occur. Personally, I have not been able to find a single authen- ticated case in which there has been a return ot hemorrhoids at the same place, or upon the same part of the hemor- rhoidal vein or veins, from which they had been once prop- erly removed. Persons who were suffering from a return of hemorrhoids, after they had submitted to the knife or ligature some years before and pronounced cured of the disease, have made application to me for treatment, in none of whom could be seen the slightest tendency toward a re- newal of the growths at the seat of the operation. Tumors were found on the opposite side or on both sides of the bowel, with an intervening space, showing the extent of the operation which had been performed and had included all of the tumors found at that time. The conclusions that I have reached, after carefully weighing all the evidence in my possession relative to the probability and frequency of relapses, are : 1. That the more chronic the case, the less is there a likelihood to a return of the disease. 2. That young or middle aged people who have only partially developed the hemorrhoidal tendency, are more prone to a return than others. 3. That relapses so seldom occur after any of the radical operations have been performed, and never at the original seat of the disease, that they may be considered wholly as an ex parte matter. 64 HEMORRHOIDS. 4. That hemorrhoids first develop on the weakest and least protected part of the hemorrhoidal vessels, varying in kind, shape, and locality, according to the causes and peculiarities belonging to each individual case ; and when once eradicated do not reform, in consequence of the struc- tural changes brought about by the operation as before explained. Women suffering from a tripartite disease of the rectum, uterus, and bladder or urethra, or simply uterine displace- ment and internal hemorrhoids, are not benefited, according to Allingham, by an operation for the relief of the latter; not that the operation of itself proves a failure or that re- lapses follow, but a proctitis is set up, the parts remain sore, ulcerate and refuse to heal, and a feeling of discomfort and uneasiness is constantly experienced. These statements, coming from good authority, are well worthy of notice ; although it would hardly be possible to conceive of a bad case of hemorrhoids in connection with other diseases, in which the patient could not be benefited by eliminating the hemorrhoidal part of the complication, par- ticularly where the hemorrhoids seemed paramount and were the greatest source of annoyance ; otherwise, the other troubles complained of would first attract attention and treatment, making the hemorrhoids of only secondary im- portance. In chronic cases of uterine displacement causing little in- convenience, the rectal vessels accommodate themselves to. the change, and the circulation becomes so well restored that the displacement cannot be looked upon as a barrier '^ TNIVERSIT^ HEMORRHOIDS. 65 sufficiently strong to contra-ihdicate an operation for the re- lief of internal hemorrhoids in women afflicted by the two conjoined ailments. This neutral state of the malposed uterus in its relation to the rectum, may be known by the exhibition of periodical outbursts of the hemorrhoidal dis- ease, followed by intervals of complete rest, the same as we see in the behavior of hemorrhoids generally. The operation alluded to by Mr. AUingham, of course, means the ligature, and presupposes the divulsion of the sphincters and the strangulation of all the tumors at the same time, while under the influence of general anaesthesia, a procedure which, by its very nature, must excite a high degree of rectal engorgement and inflammation; whereas the operation by carbolic acid injection may be conveniently limited to one tumor or to all on one side of the bowel, according to the circumstances of the case, and in this way the treatment may be so varied and divided as to greatly modify and control the local disturbance. RECTAL EXAMINATION. The first step to be taken in making an examination of the rectum, when disease of this organ is present or sus- pected, will be to obtain a history of the case as given by the patient, supplemented by questions which naturally suggest themselves. This will furnish an approximate idea of what might be looked for, but the patient's interpretation ivill often b® found quite erroneous and misleading. Should there be an undue protrusion at stool, pursue the same course that is recommended for the examination of internal he.morrhoids. If protrusion be absent, direct the patient to lie on the side, with knees drawn up, separate the buttocks and inspect the anus, or, in other words, all that 4s presented to view externally at the terminal orifice of the Tectum. Now draw down and evert the mucous membrane at the verge of the anus with the thumbs, asking the patient at the same time to extrude the parts as much as possible. This will enable you to. see all there is half an inch or more above the entrance. Next, anoint the finger, pass it in gentl}^ and examine all the surface limited by the sphincters, a distance upwards of not over an inch, being careful lest you be deceived by the mobility of the tissue, when introducing the finger, and a small marginal growth, which may have formed, be carried up and appear as one of internal origin. Any one familiar with vaginal examinations can detect a RECTAL EXAMINATION. 67 rough or a broken mucous membrane, an indurated spot or prominence as soon as touched. Next, feel aboye the in- ternal sphincter, keeping in mind the anatomy of the parts; turn the finger slowly, posteriorly, you can hook it behind the muscle. Here is sit- uated the bottom or floor of the rectum which forms a cul-de-sac (Fig. 17). By asking the pa- tient to strain down mod- erately, its surface will be thrown up against the end of the finger and in this manner properly ex- plored. A digital examination reveals, in the normal state, a soft, velvety, un- broken mucous mem- brane, the parts pliable and yielding, with no re- flex excitability of the sphincters. The position and sensibility of the ute- rus should be noted in the female, and size of the prostate gland in the male of advanced years. The first three or three and a half inches of the rectum can be brought within reach of the finger. Explorations Fig. 17. — Lateral section of rectum; normal curve. R. Rectal pouch. C. ad- de-sac of the rectum. E. S. External sphincter. I.S. Internal sphincter. H. Hilton's white Inie. P. Position of pros- tate gland. 68 . RECTAL EXAMINATION. farther up will require a rectal sound and a long tubular speculum. Ninety-nine one-hundredths of all rectal ailments, it is safe to say, are found within the first two inches- Therefore, few general practitioners will ever be called upon to treat anything beyond the reach of the finger or the scope of a common speculum. All hemorrhoids of any appreciable size or other tumor- ous growths in the same vicinity, will show at defecation and can be treated while the parts are extruded. All abrasions, ulcerations, indurations, etc, are discoverable by the sense of touch. Hence, it will be seen that the uses of the speculum are narrowed down to a few in number; namely, in that of bringing to view, for observation and treatment, diseased surfaces previously located and small, soft hemorrhoids and other minor affections which may have es- caped detection by a careful digital examination. Then, in view of the foregoing facts and in consideration of the anatoi^iical formation of the parts, (the rectum being a collapsable tube, highly sensitive and extremely difficult of accessibility, quite unlike the vaginal canal, which is closed at one end, more capacious and dilatable, and designed by nature to be approached from the exterior), a speculum should be so constructed as to not only be easy of intro- duction and withdrawal, but to exclude all the surface ex- cept a limited portion, and to permit the greatest possible amount of available light to fall on the exposed part shown in situ. The greatest barrier to the successful use of a speculum, is the unruly external sphincter and the excessive mobility RECTAL EXAMINATION. 69 of the mucous and muco-cutaneous surfaces. The upper margin of the external sphincter terminates beneath the Fig. 18. — Position for operating or making a rectal examination. Engraving kindly furnished by Sharp & Smith, Chicago. It is unnecessary for a lady to disrobe herself for examination, or suffer immoderate exposure. A cloth cover should be used, when a lad}^ patient is placed on the chair, the same as in gynaecological practice. junction of the skin with the mucous membrane, which place also marks the beginning of the internal sphincter 70 - RECTAL BXAMINyflON. and its junction with the external muscle by a more dense connective tissue, sometimes appearing as a white Hne at the muco-cutaneous junction, called the white line of Hilton. According to Dr. Andrews, Hiltoja has demonstrated that the locality where the two muscles join by the intervention of this fibrous ring forming the anal verge, the junction of the skin and mucous membrane, and the exit of the branches of the pudic nerve, is identical. The internal sphincter is a collection of the circular fibres of the muscular coat of the bowel, about five-eighths of an inch in width, and constitutes in reality the terminus of the gut ; for the external sphincter is a thin band of distinct and separate muscular fibres, elliptical in shape, between three and four inches from its anterior to its posterior ex- tremity, and expands out around the margin of the anus like the flaring end of a trumpet, with its superficial layer in close relation to the skin which it draws down in radiating folds. With this understanding of the anatomical relations, it will be seen that the external muscle contributes so slightly to the length of the canal, that it might be considered wholly on the outside, where it guards closely the entrance and is nowise concerned in an examination with a speculum except as a feature of incumbrance. To correct an erroneous idea that there is any consider- able depression or space intervening between the muscles, we mean, when we say between the sphincters, the distance bounded by the fibrous ring uniting the two muscles below and the upper portion of the internal muscle above. More simplified, we mean all the surface included between the RECTAL EXAMINATION. , yr upper margin of the internal sphincter and its junction with. the external muscle at the anal verge. All examinations with a speculum should be preceded by an enema of warm water to wash aw^ay the mucous and re- tained feces in and about the sphincters. Let the patient- lie on either side and direct him to turn partially on the- chest, with knees drawn up, the one uppermost more firmly - flexed on the abdomen, and hips so elevated or turned that the speculum, when introduced, points or inclines down- ward and admits of strong natural light to fall in parallel rays to its axis. The most suitable position for making an examination of the rectum with a speculum, is in reality that of Sims ; his. position being adaptable to the right as well as the left side. Figure i8 does not show it accurately. The upper hij> should be thrown over a little more and the patient allowed to recline more directly upon the chest and abdomen, per- mitting the weight of the intestines to fall upon the front wall of the abdomen, and thus taking their weight off ther pelvis. The light is always better on the lower side of the: interior of the speculum when introduced, and consequently the patient is directed to lie for treatment on the same side with the disease after the disease has been located, except during the injection of hemorrhoids. Warm the speculum by dry heat over a single blast kero- sene stove, where gas or other means are not convenient. A suitable kerosene stove is an indispensable adjunct to an office for heating instruments, water, etc., causing no smelly and leaving no deposit of soot on the bottom of vessels as is 72 RECTAL EXAMINATION. often left by gas or alcohol. Use white vaseline as a lubri- cant; everything that tends to whiteness helps the sight. The vaseline may be squeezed from a tin-foil tube and the "finger not soiled in preparing the speculum for insertion. To prevent the loose tissue from rolling up and being pushed in with the speculum at the time of its introduction, Fig. 19. — A suitable Kerosene Stove for office use. Engraving furnished b^jr Wiester & Co , dealers, opposite Palace Hotel, S. F. the patient may assist by holding the upper buttock away and by straining down moderately, while the physician in- troduces- the instrument with one hand and retracts the lower buttock with the other. In operating or making ap- plications through a speculum, the hand of the patient can t>e further and desirably utilized in retaining the speculum RECTAL EXAMINATION. 73 in place, thereby giving tbe operator the freedom of both hands. Introduce the speculum slowly, giving the muscles time to relax, bearing in mind that all movements about the rectum and anus mu?t be extremely easy and gentle. For the first inch the speculum should be directed, or pointed toward the navel of the patient, then toward the hollow of the sacrum. The proximal end of the slot of the speculum must be carried and kept above the external sphincter during the examination. It matters not what kind of a speculum is being used, the value of the instrument will Fig. 2b. — Author's Rectal Speculum. greatly depend upon its power to hold this muscle out of the way. When examining above the internal sphincter, especially posteriorly, where the bottom or floor of the rectum forms a cul-de-sac, direct the patient to strain down a little. This effort will throw the mucous membrane out into the specu- lum, and at the same time spread out and smooth its sur face. In looking through a speculum this cul-de-sac of the rectum sometimes appears as a vacancy behind the internal sphincter, and has been mistaken and treated as an ulcer 74 RRCTAIv EXAMINATION. cavity. It often contains a liberal supply of mucous. The finger will first have ascertained, however, whether or not there be any need to view the mucous membrane of the cul- de-sac. In making examinations of the rectum and diagnosing rectal disease, as with other parts and organs of the body where disease is not well marked or is merely suspected, a knowledge of the normal conditions is necessary before de- termining the abnormal. A healthy mucous membrane above the sphincters when viewed through the slot of a speculum, often appears more or less flabb}^ and redundant, and has been mistaken by the inexperienced eye for diseased tissue. The normal rectal mucous membrane varies in color from an amber or straw to a light pink, and may be of a bluish or leaden color as it approaches the anus. Should you not be sure of your diagnosis, or should the examination not ba altogether satisfactory, prescribe a placebo and ask the patient to call again for further examination, and make a study of the case. FIBULA. Fistula in the recto-anal region so far exceeds that in any other locality, that the unqualified use of the term imme- diately points to the lower extremity of the rectum, as being the seat of the affection, and. to those who have given this part of the physical organism special study, the word calls to mind a local condition of disease that is anything but agreeable or an easy one to manage. In point of frequency fistula is next akin to hemorrhoids, but a much less desirable complaint to treat. Allingham states that the number of cases occuring in hospital practice is greater ; that two-thirds of all the cases operated upon of the in-patients at St. Mark's Hospital, London, were fistula, the most frequent cause assigned being abscess. A failure of the abcess to heal, leaving a sinus or sinuses, is ex- plained by the presence of loose areolar tissue and fat, ex- cessive mobility of the parts by the action of the sphincters, respiration, coughing and sneezing, and a strumous diathesis. In consequence of an occasional failure of the muscles to regain their power after division by tlie knife, elastic liga- ture or galvano-cautery wire in the treatment of fistula, leav- ing the subject in a pitiable state of incontinence of feces, which has resulted, in several well authenticated cases, in suicide, new and rational methods have been devised for the relief of this very troublesome and unpleasant affection. Kelsey says: 'A permanent incontinence of feces is al- 76 FI^STUIvA. ways considered- by the patient a very poor exchange for fistula, which was causing comparatively little suffering and annoyance." From the fact that such a deplorable condition does some- times follow complete section of the sphincters, and that we have no means of knowing previously when it may or may not occur, I submit the question to all thinking, conscien- tious and painstaking physicians: Should we not seek the adoption of any efiicient means of treatment, whereby such risk is wholly avoided? About the first of March, 1890, Daniel Mc — , aged 35, who a few months before had been operated upon by a reputable surgeon for a simple, uncomplicated fistula, sought my ac- quaintance, exhibited his condition and related his experi- ences. The fistula, which originated from a small abscess, had its internal opening between the sphincters, the external scarce- ly an inch outside the anus, and was not of long standing. The operation consisted in a division of the external muscle with the greater portion of the internal. He was put on a liquid diet, his bowels confined for fifteen days, and he was kept in a recumbent posture. The incision was slow in healing, nearly four months; his health, which was formerly good, became alter the operation very much impaired; the external sphincter had lost its power altogether and the internal muscle was greatly weakened — conditions which necessitated the wear- ing of a clout whenever the bowels became a trifle loose, and he lived in constant fear of soiHng himself by allowing the FISTULA, 77 escapement of the least quantity of flatus. The time lost, the money expended, and the unfortunate condition in which he found himself eight months after the operation, so thorough- ly embittered him against the cutting process, that he spared no pains and lost no opportunity to influence every one with whom he became acquainted, against all such heroic and uncertain measures. Since preparing my first edition about one year ago, two cases have come under my observation in which muscu- lar section had been practiced for the cure of fistula, after which the incision refused to heal properly, leaving a small lateral sinus dis- charging into the gaping cicatrix together with a loss of function of the external sphincter. Both of these conditions occurred in gentle- men of temperate habits, who were in the prime of life and in whom could be traced no consti- tutional taint. One of these gentlemen was suffering from frequent at- tacks of gastro-intestinal irritation, which he assured me had never troubled him before the operation. Food passed through the bowels partially digested and vomiting some- times occurred while walking on the street. He was ad- vised to regain lost health before having anything done to the remaining small sinus. After the lapse of some months, I incidentally made inquiry of one of his acquaintances con- FiG. 21.— Varieties of Fistula. (Gosselin.) 78 FISTUIvA. cerning his welfare, and was pained to learn that he had quite recently died from the effects of the gastro-intestinal irritation, all of which dated back to the time of the opera- tion, which had been performed nearly one year and a half before for the relief of fistula. I now believe that the di- gestive trouble was solely a reflex from the resulting procti- tis and the irritation in and about the sphincters. For the purpose of obviating these very unsatisfactory and highly objectionable results, we have a choice of any one or all of three different methods ; viz., treatment by in- jection, treatment with the fistulatome and treatment by galvano-cautery as practiced by Dr. Shotwell, who, fully appreciating the dangers of muscular section, has hit upon a plan both new and commendable. The subcutaneous or sub-mucous fistula can be cocain- ized and slit up with a pair of scissors, and the tract cleansed and cauterized with a solution of carbolic acid, a compara- tively trivial affair ; but the external and the internal blind, the complete, the complete with diverticula, etc., are varieties which call forth a decidedly greater amount of in- genuity and thought in bringing them to a successful issue. An abscess cavity, leading to the formation of a permanent fistula, in time usually contracts down to a narrow chan- nel lined with accidental tissue. The horse-shoe variety, which partly encircles the bowel and may have several diverticula; and possibly more than one external opening, is not common ; neither is the internal blind ; the simple, complete, sub-muscular fistula being by far the most com- mon variety. FISTULA. 79 The treatment by injection, sometimes classified as a "non-operative method," has been so successful in the hands of many, that it is stoutly affirmed that any case cur- able by the usual heroic methods is equally curable by this method. Different preparations have been used, chief of all being carbolic acid, ranging in strength from 50 percent, up. In adopting the carbolic acid treatment, probably the bet- ter wa\^ after preparing the sinus, will be to use an 80 per cent, solution the first time and subsequently a 50 per cent. solution ; protecting the parts from excoriation by any suit- able unguent and absorbent cotton ; hot water compresses to relieve pain and reduce swelling ; eucalyptol, calendula, campbo-phenique, etc., in the interim. Judgment will be SHARP b SHI-^H Fig. 22. — Flexible Silver Canula. required in not making too many irritant applications and granulation thus hindered for want of rest. The object is to destroy the pyogenic membrane by the cauterizing effect of the acid and get up a granulating car- bolic acid sore. It may be necessary to evacuate the bowels previously and at intervals of every three or four days after- ward, by flushing the colon, and to use an opium and bella- donna suppository for a time to give the muscles rest, or resort in extreme cases to divulsion. The sinus must have constant, free external drainage until the healing process is complete. For the purpose of keeping the external orifice open, AUingham recommends the introduction of the small 8o FISTULA. end of a bone collar button with a hole drilled through its center for drainage. As a preliminary step the external orifice should be well dilated with a laminaria tent or other appropriate means, and the fistulous tract explored with a common probe and thor- oughly cleansed with hot water introduced through a flexible silver canula. The canula is also used for the injection of a 5 or ID per cent, solution of cocaine to obtund the sensibility before the injection of the acid. After the fistula has b?en suitably prepared for the re- ception of the acid, the silver canula attached to a hypoder- mic syringe charged with the acid, is passed up into the tract, the finger inserted into the rectum and the end held over the internal opening, if the fistula be complete, to pre- vent the acid from escaping into the bowel. The canula is then slowly withdrawn and the acid gently forced out of the syringe at the same time. The residual acid is allowed to remain in the fistulous tract for a few moments ; the tract is then pressed by the finger and syringed out with a weak solution of acetic acid and injected with oil. Once in two or three weeks is sufficient to repeat the injection of the car- bolic acid should more than one application be required ; often one application of a strong solution will be found suf- ficient to effect a cure. Indeed, the examination of a fistu- lous tract with a probe will sometimes .set up the requisite amount gf inflammation necessary to obliterate the sinus. " Concerning the carbolic acid treatment, Allingham says: "Since the publication of my last edition I have cured many patients by dilitation of the sphincters and the use of the FISTULA. 8i bone stud and carbolic acid. One practical point I would mention. The further the external aperture is from the sphincter the more likelihood is there that the sinus will heal. This is shown as well in the cases of spontaneous cure as in my own successes. You must always enjoin rest after a strong application, and watch that not too much inflammation be set up." Some prefer Mar- chand's peroxide of hydrogen, full strength, to carbol- ic acid in the treat- ment of fistula by inj ection. It is used in a similar manner to that of carbolic acid. As an application in the after-treat- ment of fistula, par- ticularly in condi- tions in which there is much secretion or in which the tissue seems to melt away, the oil of eucalyptus has an established reputation for its beneficial effects. It may be combined with any of the petroleum products in the proportion of i dr. to I oz. An ointnient made by incorporating a strong tincture of calendula with a selected base and used in a simple form or in combination, has favor among eclectic phj sicians. Dr. Wm. Bpdenhamer, in Medical Record^ in giving the Fig. 23 with diverticula. Section of Horse-Shoe Fistula" (Andrews. ) 82 FISTULA. indications in the treatment of simple fistulae, says : '* The chief indication in patients otherwise healthy, is to destroy the accidental tissue which lines their internal surface, which, when accomplished, modifies the condition of their parieties, and together with enlarging the orifices of the pas- sages and complete drainage, decidedly favors granulation, cicatrization, obliteration and cure. This may be effected by means of various escharotics, some in the form of fluids, as injections, and others in the solid form. " I have sucessfully treated quite a number of cases of simple and superficial anal and rectal fistulae, in which there existed one or more straight or slightly curved fistulous tracks, by means of probes of silver or copper eight inches long and of different sizes. The silver probe may be coated with the nitrate of silver by dipping it several times in the fused salt, and introduced the whole length of the track, or the copper probe may be coated with the nitrate of cop- per by dipping it in nitric acid, and introduced like the former. A choice can thus be had between the nitrate of silver and the nitrate of copper. I have had the most suc- cess with the latter. "When a silver and a copper probe are dipped in nitric acid and introduced together into a fistulous passage, the caustic effect is greatly increased, and if suffered to remain in too long would destroy the tissues with which they were in contact. This is the ejfect of the galvanic action set up by the contact of the copper and silver probes with the acid acting upon them." Among the milder means recommended for the cure of FISTULA. 83 fistula, the following offers itself as being extremely simple : " Fistula in ano may be cured by forcibly dilating the sinus and applying sulphate of copper wrapped in loose cotton and pushed to the bottom of the sinus and allowed to remain and dry by slow process. It ex- cites a healing action on the inner extremity of the sinus. In this way healthy granulations are built up from the bottom and by degrees they push the cotton plug out and the whole track of the fistula is obliterated."' I would suggest that a little morphia be combined with the pow- dered sulphate of copper, since it produces some pain, last- ing an hour or more after the pledget of cotton holding it has been inserted. The fistulatome shown in Fig. 24, is a contrivance which is perhaps destined to take the lead in the treatment of fis- < ^ ■■■ ' cai Fir. 24. — Fistulatome with blades extended. tula generally. It is so constructed that the fine cutting blades close on themselves, while the instrument, which is flexible and probe pointed, is being introduced, but imme- diately open on withdrawal and thus catch up and cut through the fistulous membrane. Who the inventor of this clever devise is, I have been un- able to ascertain, having seen the invention claimed by three different physicians, one of whom speaks of curing 76 per cent, of all cases treated by one operation; that is by draw- ing the fistulatome through the track once. Cases of long 84 FISTULA. standing require that the instrument should be turned at right angles and drawn through the second time, and possi- bly repeated later on, and a tenotome employed to scarify any remaining indolent sinus. It will be readily seen, however, that a fistula with a side pocket, branch, or diverticulum, would hardly be reached by this method; although the blades are so formed that they draw the membrane of a dilatable pouch to them from the sides. In such cases a little ingenuity would be required in finding these diverticula, for the purpose of scarifying them with a tenotome. The preparation of the sinus and the after- treatment are the same as already mentioned. In relation to treatment, Andrews says: ''The truth is, that anal fistulse have a natural tendency to recovery, and are held back from it mainly by two things: 1. "The unfavorable effect of the undrained septic fluids within the sac. 2. "The tightness of the external opening, which pre- vents free drainage and keeps the sac distended with this putrid pus. "It is demonstrated by Dr. Mathews on the one hand and by the experiments of quacks on the other, that by control- ing these two conditions, many cases will heal spontaneous- ly. It follows that among the thousands of patients sub- jected to cutting operations by surgeons for this disease, there are many who might be cured by much milder means." Shotwell's operation consists in straightening out of the fis- tulous track with a steel probe, having an eye at its distal end, which is carried entirely within the bowel whether the FISTULA. 85 fistula is complete or not. He next pierces the solid struc- ture about three-eights of an inch farther from the anus with a lance-pointed probe also having an eye near its end, parallel with the first probe, until its end is seen penetrating the bowel a little beyond. The eyes of the probes are then threaded with the oppo- site ends -of a No. 24 platinum wire about ten inches in length, and both probes withdrawn, leaving the wire in situ, forming a loop; both ends are now secured to an electrode, the current turned on and the loop drawn through the par- tition, lyittle, if any, dressing is required, but the bowels must be kept locked up for at least a week. This of course involves the use of general anaesthesia. A word to the beginner, in the prevention and detection of fistula : Since abscess is the most prolific source, proper attention to the abscess by poulticing, early lancing, the sinus washed with hot, heavily carbolized water, allowed free drainage, the bowels evacuated, constipated and the muscles put at rest for a few days, will doubtless be success- ful in forestalling its almost certain fistulous sequence. Dr. Hoyt strongly recommends divulsion of the sphinc- ters, immediately after opening the abscess, as an unfailing remedy in preventing fistula. Annoyance by itching, a slight discharge and soreness at times in a circumscribed spot, with a previous history of ab- scess, might be considered a sure sign of fistula ; but the patient may give the same symptoms with no knowledge of previous abscess, or any other cause pointing to the for- mation of a fistula; yet, on inspection, a small opening with S6 UIvCBR AND STRICTURE. pouty lips, or a closed cicatrical depression not much larger than a pin-head, will be found. This is the external ring or opening of a fistula, and if closed, may resist the introduc- tion of a probe sufficiently to create the belief that no sinus exists. ULCER AND STRICTURE. A solution of continuity, varying from a slight abrasion of the mucous membrane to a marked degree of destruction of tissue, comes within the scope and meaning of rectal ulcer. A deep seated, non malignant type of rectal ulceration, complicated with stricture, fistula, etc., is not so very com- mon and seldom met with outside of hospital practice. The less serious and more simple varieties, such as may be productive of considerable systemic disturbance through reflex excitability, without attracting much, if any attention locally, are the forms most frequently seen by the general practitioner. With few excieptions, rectal ulcer is insidious in its na- ture; in some instances passing on to the stage of stricture, which alone may be the first symptom to cause alarm, as the following two recent cases will illustrate. Mr. C , aged 33, married, applied for the treatment of hemorrhoids. He stated that the only inconvenience suf- fered was from constipation; that the piles did not come out and were never very sore, but he had seen a little bloody ULCER AND STRICTURK. 87 mucous at times and had a constant desire to go to stool; a free evacuation and relief being obtained only after the feces were made liquid by the injection of warm water. On the introduction of the finger I found about one-inch and a half from the anus, an annular stricture which almost entirely occluded the bowel, with ulcera- tion and nodular deposits below. Closer inquiry elicited the fact that the stools were not much larger in circumference than a lead pencil. He had noticed the trouble not more than two months before. There was a previous history of chancroid at the age of 19, with no constitutional symptoms. The other case was that of a young man of about 35, clerk, who complained of morning diarrhoea and a constant dis- charge at the anus, which necessitated the wearing of a clout. His physician, a col- lege professor, diagnosed hemorrhoids, prescribed ointment and had removed two or three small condylomata for piles, and thought that the cure would be complete when all were removed. The morning diarrhcea and the annoying discharge con- Rental Bougies. tinned, and he was advised, not by his physician, however, to see a specialist. 88 UI.CBR AND STRICTURE. A short history of the case being given to nie, the patient was informed that his symptoms were those of rectal ulcer. A digital examination revealed an ulcer occupying the en- tire surface of the bowel limited by the sphincters, with stricture involving the posterior half of the upper margin of the internal sphincter. Further inquiry developed the fact that there was a previous history of syphilis, which was contracted in early manhood. It is claimed that organic stricture does occur without previous ulceration by interstitial deposit and thickening, and ulceration follows ; but this must be considered excep- tional. The ulcerative process usually precedes, and through efforts at repair, cicatrical bands are thrown out, producing a narrowing and contraction of the canal, either in places or throughout the circumference of the bowel. Electrolysis may be tried for the relief of stricture before resorting to the usual methods of breaking it up by forced dilitation. If divulsion be decided upon, it should be com- plete at one operation. Should the fibrous bands be strong and unyielding, nicking their edges with a probe pointed bistoury is advantageous. The persistent use of bougies will be found necessary for a long time after divulsion. On account of severe hemorrhage and other untoward symptoms likely to follow a complete division of the stricture, the galvano-cautery is decidedly preferable to the common proctotomy knife. A duplicature of the peritoneum, which varies with different subjects and comes down within three and one-half to one and one-half inches of the anus anteri- orly, should not be lost sight of in operations ou the rectiuw. UI^CER AND STRICTURE. 89 Dr. Joseph M. Mathews, in the address on surgery deliv- ered before the American Medical Association at Washing- ton, May, 1 89 1, formulates some very interesting and reason- able conclusions on the pathology and treatment of rectal stricture. He says that the common seat of stricture is within the reach of the finger, and it is the rarest thing that one is found in the movable gut. He does not favor colot- omy except as a dernier resort, and when the stricture (non- malignant) is located in the sigmoid flexure, or in the movable part of the bowel. He then prefers the lumbar operation. Dr. Mathews recommends forced dilitation in fibrous stricture when this alone would appear sufficient ; otherwise he is quite partial to incision. Of the two operations rec- ommended, internal and external posterior linear proctotomy, he much prefers the internal. He says : "I cannot believe that the internal incision is as dangerous as it is represented to be by some authors. My plan is to introduce a three or four valve speculum, and after dilating sufficiently for the purpose, a long, sharp knife is used to divide the constrictions of fibrous tissue down to a healthy base — not only in the median line, but in several places around the circumference of the gut. I then place a tampon, through which I have inserted a metalic tube for drainage and the escape of gases. This tampon is aseptic, and usually dusted with powdered persulphate of iron. On the fourth. day it is removed, and the i^^tiirn irrigated with a mercuric solution. ''Jfth.e Qperation is c(Qn^ effectually, I Uciye neyer s.eeti^ 90 ULCKR AND STRICTURE. the necessity of employing bougies afterward, for the pur- pose of dilitation. Patients are averse to their use, and they do not accomplish the good claimed for them. My objection to the external operation, although I have prac- ticed it often, is that to divide the sphincters, where all the tissues are in a diseased condition, invites non-union, and incontinence is nearly certain to follow." Stricture is mostly of syphilitic origin. Of the seventy cases tabulated by AUingham, ten of the number were found in men and sixty in women, showing a great predominence in the latter, and none were more than three inches above the rectal orifice. It is not an easy matter to diagnose between the advanced stages of non-malignant rectal ulcer and cancer. Both may be accompanied by tender condylomatous growths, or flaps of skin outside the anus, bathed with an ichorous fluid. The characteristic, unremitting pain of cancer may be absent in its formative stage, and in this respect insidious in its approach, the same as non-malignant ulcer. AUingham speaks of a very rare species of rectal ulcer, which he terms rodent or lupoid, that is superficial, does not implicate the surrounding parts, is devoid of hard edges and surface, is very painful, and was only cured by complete extirpation. I have intentionally omitted the early symptoms and course of rectal ulcer for the purpose of giving audience to Dr. A. C. Hall, who, in a communication to a medical journal, writes the following lucid description: "Rectal ulcer is a more common disease than is generally ULCER AND STRICTURE. 91 supposed. Unfortunately the symptons are generally ob- scure, and the patient suiBfers but very little, if any pain, and consequently consults his physician for some of the re- flex symptoms, rather than for the initial disease itself; and very often these reflex symptoms are vainly treated till the patient and physician are both thoroue^hly disgusted and disheartened. There is one maxim which every physician should always bear in mind, and that is, always suspect rectal ulcer 171 every case of protracted or chronic diarrhoea. I have reports from eighty-six pension surgeons, in which they es- timate that they have examined two thousand cases, where chronic diarrhoea was the alleged cause of disability in ap- plicants for pensions. Of these two thousand cases of chronic diarrhoea, eighty-seven per cent, had rectal ulcer, and fully ninety per cent, of those who claimed chronic diar- rhoea as their disability and who had no ulceration were re- jected, because their proofs of the disease, aside from the ulceration were too meagre. Thus the strongest and most prominent sympton of rectal ulcer is chronic diarrhoea. "The diarrhoea is generally more troublesome in the morn- ing. The patient often on arising feels an urgent desire to go to stool. This act is often very unsatisfactory, for he passes very little feces and a great deal of wind. Occasion- ally these small stools are covered with a jelly-like, or white of an Q^^g substance, or the motion may be only a jelly-like mucus, with no feces. There is generally more or less ten- esmus, or a disagreeable feeling, as if the rectum was imper- fectly evacuated. Sometimes the patient will be compelled to go out two or three times before breakfast, and he may in 9i UlvCER AND STRICTURE. the later attempts to have a stool, pass lumpy or scybalous feces, covered with mucus, and often streaked with blood. There sometimes exists, as a symptom of rectal ulcer, a de- sire to go to stool when cold drinks are taken. But gener- ally the diarrhoea and tenesmus subside soon after breakfast, and the patient has no more trouble until the next morning. A great many, or I might say a majority of those suifering from rectal ulcer, consult the physician for some symptom or other that suggests anything else but the rectum, but by close questioning and following up the symptoms, one can soon tell whether they are reflex or otherwise. "In cases of rectal ulcer of long standing, there is always more or less cachexia, or peculiar waxy, sallow, unhealthy complexion, which sometimes alone points significantly towards the disease. "There is often more or less enlargement of the liver and spleen, especially the spleen. **In advanced ca»es, the diarrhoea comes on at night as well as morning, and defecation is accompanied with pain and griping. Another almost characteristic sign of rectal ulceration is alternating diarrhoea and constipation. The bowels remain constipated for a considerable while, then diarrhoea supervenes, and is accompanied by severe and ex- cruciating colicky pains and often nausea. Persons subject to chronic diarrhoea always dread to take a physic to relieve a temporarily constipated state, for it will almost invariably put them to bed. ^'In extreme cases, infiltration and thickening of the sub- mucous and muscular coats supervene, as a result of nature's ULCER AND STRICTURE. 93 effort to repair the lost tissue. This thickening may be so extensive as to threaten and actually produce stricture. It will often convert the rectum into a passive tube, through which feces and fluids trickle, the patient having little or no control over the sphincters. "The passage of hardened feces and the pressure of internal hemorrhoids and polypi are the most common causes of rec- tal ulceration. The lodgment of foreign bodies, such as fish bones, cherry stones and plum seeds that have been swallowed, and which act as irritants and produce ulceration. "In women the presure of the foetal head on the rectum during childbirth is a frequent cause of ulceration, likewise the pressure of a misplaced uterus. "On examination, by meang of a speculum, the ulceration will be found about an inch or an inch and a half from the anus, generally on the posterior wall, but often on the an- terior wall. "When the ulcer is on the anterior wall, there is more or less irritability of the bladder, and seminal emissions or im- potency. The ulcer itself may be round, oval or elongated, radiating or following the columns of Morgagni. The ulcer may present ragged, interrupted elevated edges, or they may be sharp cut and regular, as though cut with a sharp punch. The edges are sometimes hard and gristly, or may be soft and have no elevation above the surrounding tissues. The surface of the ulcer is often clean, and healthy looking granulations may be seen, or the ulcerated surface may be loosely covered with a greyish, grumous scum, that is offen- sive and decidedly unhealthy for the patient. Underneath 94 UIXER AND STRICTURE. this scum there is often found an ulcerated spot, that is ap- parently lifeless, and will require much attention, locally and constitutionally, to prevent its rapid extension. In this form of rectal ulcer there is always more or less marked cachexia. It is the indolent ulcer, occasioned by the grad- ual breaking down of the tissues, that produces the grave constitutional disturbances and death. It is the small, round, or oval ulcer, with elevated, hardened edges, that produces the many and various reflex nervous symptoms, which are misleading: and troublesome.' In all cases of rectal ulcer of any considerable gravity, absolute rest, both of the parts and the body, is to be main- tained. A complete^destruction of the diseased surface by carbolic acid, and hot water irrigations in conjunction with a liquid diet, are the first things to be thought of in adopting a course of treatment. Convert the ulcer into a carbolic acid sore and use an iodoform, bismuth and eucalyptol suppository. Should other local measures be required, treat the surface of the ulcer in a similar manner to that recommended for healing a fissure. Caution must be exercised lest the healing pro- cess be delayed by making stimulating applications too fre- FISSURE. 95 quently; rest and surface protection being two of the most prominent factors concerned in the treatment. In the more extensive forms of rectal ulceration, constitu- tional treatment is of paramount importance. I•-'> s Fig. 33. — Represents figure 30, showing reticulated arrangement under post mortem relaxation. C.C.C. Columnae recti. S. Sacculi Hornei. P.P. Papillae. (Andrews.) Rectal pockets are doubtless a duplicature of the mucous membrane, forming cul-de-sacs with their mouths looking upward. They are removed through a speculum by raising the outer wall with a blunt hook, and by excising it with a pair of scissors, or, better, by slitting the wall through Fig. 34. — Author's Knife-hook for slitting down pockets. its center with a knife, and carbolic acid applied to the remain- ing flaps. ■ One at a time treated in this way will cause no inconvenience or detention from business. Papillae may be seen in four different forms: One, a white, flat, or sessile process, resembling the half of a split RECTAL POCKETS AND PAPILLA. I07 pea, but not quite so large; another, a small, white, rather stiff projection sometimes seen on the side of a large pocket; the third, a slender, perfectly flexible, worm-like vegetation, possessed of a white, or transparent top; and the fourth, a white, fibrous, paramydal shaped substance, flattened from above downward; Figs. 3 1 and 32. They appear to spring out of the mucous membrane similar to a polypus, and can be raised with a tenaculum and snipped off at their base with little loss of blood and trifling pain. ''The usual location of pockets and papillae," says Pro- fessor Pratt, ''is at a point about an inch from the anus, at the upper margin of the internal sphincter, where the large distended pouch of the middle portion of the rectum is abruptly puckered down to the narrow limits of its last inch. SNARPaSMITH CHICACO Fig. 34. — lyong Tenaculum. "These pockets are curious formations, and have received very little attention from writers upon rectal disease, and they have been almost entirely overlooked by anatomists, as well as pathologists. Whether they belong to the anatomy or not, I am unable to state with any certainty, but I know for certain, however, that they are not always present. I know also that they can almost always be found in cases of old, deep-seated, chronic diseases, and that the removal of these pockets in this class of cases is followed by the most happy results. "When these pockets are present, they always occasion a io8 RECTAL POCKETS AND PAPILLA. spasmodic contraction of the sphincter ani, a condition which is most frequently observed in those cases that are developing some deep-seated constitutional disease. Their removal in this class of cases is invariably attended by more or less improvement of the patient's general condition and circulation. Fig. 35. — Pratt's curved scissors. "In form and character these pockets may be long and narrow channels, and ulcerated at the bottom; short (cul- de-sacs) or broad-mouthed and pointed at the bottom. These pockets create a great amount of irritation to the nervous system. No matter what shape, condition or location they may be in, by reflex irritation they produce a long train of nervous symptoms that cannot be remedied until they (the pockets) are removed. SHARP ft SMITH CNICA50 Fig. 36. — Long blunt hook. ''Papillae are conical processes of mucous membrane, of variable size, shape and location. They have no relation- ship with rectal pockets, for they very frequently exist in- dependently of them. *'I look upon these conditions as being the most mischiev- ous of rectal disorders, because they always occasion a tonic RKCTAt POCKETS AND PAPILLA. I09 spasm of the internal sphincter, and this alone makes exces- sive demands upon the powers of the sympathetic nerve. They are common in all forms of chronic disease. I know of no reason why these conditions, which I have described, should have been so long overlooked and their importance have remained unappreciated. "Unless it be that their presence is Unattended by local symptoms, and hence they have failed to attract the atten- tion of either patient or the physician. But in view of the fact that they occur in so many chronic conditions, and the additional fact that marked benefit almost invariably follows their removal, I insist upon it that no obstinate case of chronic disease has been properly examined until their pres- ence or absence has been ascertained. The most happy and the most marvelous results that I have ever seen in the prac- tice of medicine and surgery have followed the removal of pockets and papillae, and in thus bringing them to your no- tice, I do so in the confident belief that a proper apprecia- tion of their importance on your part will add materially to your resources in battling with disease, and in helping those who apply to you for relief." PRURITUS ANI. Excluding all discoverable local causes whereby the pres- ence of this obstinate aflfection may be explained, such as piles, ulcer, fistula, oxyuris vermicularis, eczema margina- tum, etc., and take the disease unalloyed, or as it may exist in a state pure and simple, and assure a patient thus afflict- ed that he can be quickly and permanently cured, would not only be presuming too much, but would be stepping be- yond the legitimate bounds of all past recorded experiences. To furnish something of an idea to those who are not already familiar with this apparently trivial yet rebellious complaint, I here quote the language of Dr, Hoyt, who uses words somewhat extravagantly in the beginning of his remarks, but seemingly palliates his feelings later on with lotio niger. He says: "With what anguish its unhappy victims battle through innumerable sleepless nights, fighting this demon of so-called local epilepsy, with its long array of itching, burning, exuding, corroding, exhausting, and blasphem- ing characteristics, as though they had been brewed by the chemistry of hell. The whole organization becomes a chaotic discord, the disposition is cruelly warped, the counte- nance Shows a sad picture of living woe, the carriage is nearly lost to all laws of equilibrium, and the complete being merges into a throbbing phantom of despair, trembling upon the very threshold of idolized suicide. PRURITUS ANI. Ill "Of course I speak of the most aggravated cases, instances that seldom occur within the experiences of general practi- tioners. Wherefore, then, these phenomena? What is the mighty influence that yields so much distress, as all these objective symptoms are but an appearance outflowered by some subtle and specific force. The meager literature upon this subject hobbles upon the crutches of hypothetical infer- ences, telling you perhaps it is capillary congestion or chronic proctitis, or neurotic hyparaesthesia or eczema, or malaria, suggesting a panoramic array of remedial agencies all unsatisfactory, thereby confessing to a sad condition of helpless empiricism. "My comprehensioa of this subject compels me to endorse the parasitic theory, though it may excite your disapproval, and perhaps your ridicule, yet it can be easily verified by directing your management towards the destruction of the parasite, when all symptoms will disappear. Mercury is quoted as nearly a specific for the annihilation of these marauders, and the very best method of administration is by using Lotio Niger. "Thrice daily the patient should relax the respiration of the cutaneous surface by the free application of hot water, just as hot as it can be comfortably endured. Then imme- diately afterwards while the skin is made absorbent by the action of the liquid heat, it should be saturated with this medicine in the most thorough manner. Within three days time the itching will be reduced fifty per cent., but the complete result is attained only after a continued use of from four to eight weeks. 112 PRURITUS ANI. "In many cases there will remain points or patches where the agent does not seem to act, and to these I usually apply the regular unguentum hydrargyri. Avoid all soaps and ointments except as above stated, thereby preventing the obstruction to absorption of the remedy as it has to enter the pores of the skin in order to act upon these energetic enemies that hold their victims under such a terrible bond- age." It is characteristic of pruritus for the paroxysms of itching to come on mostly after the patient gets warm in bed, at Fig. 37. — Thickened condition of the skin in pruritus. (Ksmarch.) which time the annoyance may be further increased by a moisture or an exudation about the anus. In long standing cases, the skin about the anus becomes thickened and horny in texture, and loses its pigment and elas- ticity. Sometimes portions of the radiating folds of the skin will become so hypertrophied and elongated, from the effects of gouging and scratching, that they look like and are often improperly called external piles. J l^ave successfully remQve4 these hypertrophic formatio^s Op PRURITUS ANI. by the same process adopted for the cure of hemorrhoids. They go through similar changes after being treated by injection, and open up a cavity surrounded by a ragged, thick, calloused skin, which, after first being cocainized, can ba trimmed off with a pair of scissors. If there should be several large tabs I do not operate on all at one sitting. In the treatment of pruritus ani, a thorough search for a local cause and its removal, if any be found, will find a lasting reward in the results obtained. Of the obscure local causes, perhaps animal and vegetable parasites are the most difficult to find. The injection into the rectum of a decoction of quassia bark or lime water and carbolic acid, will be efficacious in dislodging the oxyuris vermicularis, which may or may not be seen, like small pieces of white thread lodged between the anal folds. For the vegetable parasites, tricophyton, etc., (microscop- ical) sulphurous acid ranging in strength from 50 per cent, up, is an old and tried remedy. Immoderate eating, drink- ing coffee, and smoking excites the itching with some. Whenever it is decided that no dietary or local trouble can be found as an assignable cause, and that the disease is purely neurotic in character, we commence to grope in the darkness for remedies. What relieves one will not another ; and what relieves for a time may lose its effect altogether. Hot water compresses, a little short of scalding, are good for relief and act well as an intercurrent remedy. Among the remedies highly recommended are linseed oil, thuja occidentalis, carbolic acid, citrine ointment^ oil of cade, am- mojiiated mercury, oxide of zinc, compound tincture of green 114 PRURITUS ANI soap, black wash, and galvanism. The anode is placed over the perineum and base of the scrotum and the cathode against the anus or within the grasp of the sphincters ; claimed to be a specific. Nerve stretching by divulsion of the sphincter muscles is also recommended. Formulae : R Ung. Citrini 3ij Balsam. Peru 7> jss Acid. Carbol. gr. XX Sulphuris Z iij Cerat. Simp, vell^anolii i ,lj Misce. R Hyd. Chlor. Mit. 9 iv Adipis .^j Misce. Said to be a specific for pruritus ani or R Hyd. Chlor. Mit. .^j Balsam. Peru .^ iss Acid. Carbol. gr. XX Lanolini .Ij Misce. . R Ol. Cadini .^j Acid. Salicyl. gr. XV Ung. Zinci Oxidi q. s. ft. l\ Misce. (Kelsey.) PRURITUS ANI. 115 H Saponi viridis ^ 01. Cadini } a a § j Alcohol. J Misce. K lyiq. Carbon. Detergentis (Wright's), Glycerinse a a ^j Zinci Oxidi *) Calamini Prep. j. a a 5 ss Sulphuris Precip. j Aquae Purae 1 vj Misce, (Allingham.) R Jlydrarg. Ammouiati 9 j Benzoinini Pulv. gr. xx Lanolin i "^ j M. et Sig. Apply once or twice a day or as oc- casion requires. (Waugh.) Am moniated mercury is equal if not superior to any other remedy we have for the relief of puritus ani. It has served me in one of the most inveterate cases; a case of many years standing and which had been almost abandoned as hopeless. DIVULSION. Forced dilitation of the sphincter muscles at the terminus of the rectum as a means of relief and cure for certain forms of rectal trouble, although a much abused and somewhat barbarous practice, has positive and undoubted merits. It is only justified, however, in peculiar and isolated cases. The wholesale stretching of the sphincters is certainly to be deprecated as unscientific, illogical, and without the ad- vantages or benefits claimed for it by rattling and noisy fanatics. Divulsion injudiciously employed, may be fol- lowed by very undesirable sequelae and a long and tedious recovery, and thereby excite adverse and unending criticism. The case of a lady recently came under my observation, who, although in average health, complained a little as many women do and thought she was troubled with hem- orrhoids. Through the advice of her physician, a college professor, she submitted to the operation of stretching the sphincters on general principles. Irritability of the rectum followed, with soreness and continued pain. Finally two large sympathetic buboes developed, which suppurated, and were slow in healing. This happened a little over a year ago, I am reliably informed, and she has not yet fully re- covered. A number of cases have come to my notice in which stretching was practiced for the cure of piles, imaginary DIVULSION. 117 Spasmodic stricture of the rectum, etc., without the least benefit, except, possibly, that accruing to the physician. A young married man, foreman of a printing office, com- plained at times of slight pain in the region of the liver. /v. Fig. 38.— Graduated Rectal Dilators. (Pratt's.) His physician, an editor of a medical journal, made an ex- amination of the rectum with a speculum and informed him ii8 DIVULSION. that it would be necessary for the preservation of his health, to undergo the operation of stretching the sphincters. The day was appointed and the hour set for the operation, which, fortunately for the young man was ''nipped in the bud " by the physicians' arriving a little late, and through the advice of a friend he embraced the opportunity and came to my office for an examination. His bowels were regular, there was no history of rectal disease nor the least sign of any, nor was there a shadow of an excuse for an operation. The cases in which divulsion seems to be of greatest ben- efit, are found mostly among women of a peculiar high nervous tension or organization, in which the muscles have become hypertrophied from repeated spasm, and constipa- tion results from ineffectual efforts to expel the feces. In such cases forced dilitation is followed by the most satisfac- tory results. In a paper read before the New York Medical Society upon the subject of rectal diseases, Dr. K. F. Hoyt illus- trates the temperament to which reference is made by giv- ing the history of two interesting cases of hypertrophy of the sphincters successfully treated by him by means of divulsion. He says : "In April, 18S2, there walked into my office a lady of about thirty-three years of age, hand- some, rich, married, and in good general health. She pro- ceeded to tell her story, and a '^tale she did unfold," relating experiences she had had with nearly all the available phys- icians here and in Brooklyn, telling of many operations en- dured, mentioning a galaxy of remedies she had tested, enumerating a wilderness of pains, and still suffering. She DIVULSION. 119 concluded her pathological auto-biography by boldly stating that if I should promise to do her any good, she would think me either a knave or a fool, as she had consulted gentlemen that knew all that was known upon this subject, and without result. I replied by politely asking her to promptly walk out into the street. Do you know, returning impudence for impudence commanded her confidence at once, and she came down from her lofty pinnacle of egotism and proceeded to compromise our differences. She was one of those fine cultured women, highly educated, gifted with a large ability to enjoy or suffer, possessing a disposition that was at times a perfect flower-garden of angelic loveliness, magnetic, poetic, aesthetic, just the kind of a woman to ensnare the sentiment of any large-souled man, until she had unloaded in his presence one of her cyclonic waves of pyrotechnical temper, and then he would hate her. All this proves that the most unsystematic of all systems is the ner- vous system. The local condition as manifested by her descriptive language, was one of almost constant tenesmus, delicate soreness, and an inability to have a natural move- ment of the bowels, which was only accomplished by taking a large amount of compound licorice root upon retiring, which responded the following morning, leaving the patient so exhausted that she had to remain in bed all that day ; and this had been going on for fifteen years. By forcing the function about three times weekly could she only realize any comfort at all. Upon examination I found a sensitive spasmodic sphincter muscle, with its correlative condition of engorged sub- I20 DIVULSION. mucus tissue. It was tissue of this character that had been excised under the mistaken impression of being hemor- rhoids. Only in women of such fiery and eccentric temper- aments have I ever found this particular manifestation, and that is the reason I elaborate her peculiarities so minutely, as it is safe to suspect a spasmodic sphincter wherever a high strung nervous woman tells of having obstinate consti- pation attended with great exhaustion subsequent to a movement. The slightest effort to exercise any extrusive force would cause the muscle to spasmodically contract, and thus it had misbehaved for all this time, obstinately refusing to surrender, and would have held to its wayward career until now, had not its conceit been overcome by dilitation, and in two days' time the woman was well and remains so to the present date. Another attractive specimen of necessity for dilitation was the case of a lady about fifty years of age, in good general health, and very nervous. About four years since she called upon me and related experiences arising from her condition, experiences realized in nearly every capital of the whole world, and varied enough in detail to form the sub- ject matter of a Rider Haggard novel. Upon examination I discovered a hypertrophied sphincter muscle, so extens- ively thickened that it was impossible to have a natural movement of the bowels. For about twenty years, and by the advice of a physician in Rome, she had introduced into the rectum every night upon retiring, about eight inches of a large Roman candle, such as are used in the cathedrals there, and during the following morning the relaxation had DIVUI.SION. 121 been so accomplished as to allow the movement after this taper had been withdrawn. The muscle was promptly dilated and from that time she discontinued the Roman expedient, gained greatly in general health and has been a much happier woman ever since." Divulsion should be accomplished with the patient lying on the side and under the most profound anaethesia. Rec- tal dilators, which distribute the force evenly all around, may first be employed, then the thumbs, or the thumb of right hand and index finger of the left, or two fingers of each hand, to completely paralyze the muscles. The pro- cess should be slow and gentle, and caution excercised lest the tissue give way from the application of undue force. Local causes should always be sought, and excluded if practical, before heroic measures are adopted for the relief of spasmodic sphincter. There are instances where tight- ness of the sphincters exists, superinducing constipation, etc., not traceable to any appreciable cause. These cases may be relieved without the aid of general anaesthesia, by grad- uated dilators or rectal bougies, accomplishing little at a time, daily or tri-weekly. When constipation depends upon inertia or a lack of ex- pulsive power of the rectum, I think moderate dilitation advisable and decidedly beneficial. A circumscribed irritation of any portion of the mucous membrane within the sphincters, is often found to be suf- ficient by reflex action, to keep the bowels soluble while the irritation lasts. This fact is evidenced by a looseness of the bowels sometimes following the removal of rectal 122 RECTAL POLYPI. pockets and papillae, the injection of small hemorrhoids, the presence of ulcer, applications to fissure, and the ap- plication to the mucous membrane of boric acid as recom- mended by Dr. Herr Flatau of Berlin, for chronic consti- pation due to torpor of the colon. RECTAL POLYPI. These innocent growths can be successfully removed, when within reach and most of them are, without the lOvSS of blood or the infliction of pain, by carbolic acid injection to act as a stypic and deaden the sensibility, while the scissors are used to sever their connection with the bowel. A polypus is a benign tumor springing from the mucous and sub-mucous con- nective tissue, ranging in size from a wheat grain, when seen early, to that of a wal- nut, and is hard or soft in proportion to the relative amount of fibrous substance or glandular mucous tissue entering into its formation. The hard, or fibrous polypus, is made up largely of the sub-mucous connective Fig. 39. -Fibrous tissue. It is variable but mostly club- fu^'rcS'^extimi- ^baped, and has a whitish looking surface ty. (Andrews.) which never bleeds and is principally found in adult life. It is not so large as the soft, or mucous poly- pus incident to childhood, which is more rounded and ses- RECTAL POLYPI. 123 sile,with a short, thick stem, and which possesses a straw- berry-like surface that easily bleeds. Some maintain that the true fibrous polypus takes in muscular fibres of the rectum, has a well defined peduncle an inch or more in length, which is always attached above the sphincters and is a rare growth ; that it seldom pro- trudes ; but when the peduncle becomes sufficiently length- ened to allow of protrusion, it causes pain, irritation and spasm, and may set up ulcer of the bowel. The discharge from this va- riety is ichorous and foul smelling. The villous or hairy polypus, found only in adults and old persons, is so named on account of the papillae of the surface being multiplied and elongated, giving it a hairy appear- ance. They are of a red color and Fig. 4o.^oft polypus, bleed easily when touched,and are (E^smarch,) very uncommon. While the peduncle is a characteristic feature of polypi, it is not to be understood that all are attached to the rectal wall in this manner. Some grow out directly by means of a broad base and are pyramidal in shape. Fig. 27 shows one ot this sort. When first noticed, the nature of the two growths represented in that figure was somewhat uncertain, but all doubts were soon dispelled, by observing them double in size within two weeks time. After removal they were found to be hollow centrally with elliptical and concentric layers of fibrous tissue respectively. The stem of a polypus [24 RECTAIv POLYPI. contains a central artery, the pulsation of which, in some in- stances, can be distinctly felt. The fibrous polypus is the variety most frequently seen, and, being more hard and dense in its composition than hemorrhoids, is not readily permeated by the injection com- pound ; neither can the hemorrhoi- dal needle be used with any advan- tage. Therefore, a small hypoder- mic needle is selected and a 95 per cent, solution of carbolic acid. This strength of carbolic acid is not only a powerful stypic and cauterant, but its fluidity permits it to be forced throughout the fibrous structure with ease. The action of the acid should extend fully to the base of the polypus, which is then clipped off a little outside of the line. The stump goes through similar changes to that of hemorrhoids after injection. In long or pedunculated polypi, it will only be necessary to apply the acid at their base suffi- ciently to intercept the circulation, before excision. A little cocaine may first be used, if the parts are very sensitive, and the same precaution should be taken with re- gard to the protection of the adjacent and surrounding parts from the excoriating effect of the carbolic acid, as recommended when operating on hemorrhoids. Fig. 41.— Villous poly pus. (Esmarch.) PROCTITIS. Inflammation of the rectum, like other phlegmasiae, may arise traumatically or idiopathically; by contiguity of structure or continuity of surface. The acute symptoms are very much like those of acute dysentery, which disease, in my opinion, nearly always extends to the rectum, caus- ing the characteristic symptoms of weight, tenesmus and straining at stool. Irritable rectum in the absence of diarrhoea is diagnostic of the complaint. The bladder and prostate gland may be affected through sympathy, and colicky pain be reflected to the small intestines or stomach. In the more chronic forms, constipation, tenderness and the cul-de-sac partially filled with mucous are distinguishing features. Carbolized hot water irrigation, prepared hot corn starch, slippery elm water, bismuth, etc., together with supposi- tories of iodoform, bismuth and opium ; or bismuth, opium, belladonna and calomel, will be found serviceable in the acute stage. About a half-tumblerful of a saturated solu- tion of chlorate of potash, injected slowly into the rectum and retained for ten or fifteen minutes, is said to effect a cure by one or two applications. Chronic proctitis, also called irritable rectum, and some- times rectal catarrh, with symptoms that might be expected to emanate from a disease of the mucous membrane, rarely 126 . FLUSHING THE COLON. amounting to a diffuse thickening of the rectal walls, is treated similarly, except less palliative. Combinations of eucalyptol, iodoform and bismuth in the form of a supposi- tory are indicated. An ointment of eucalyptol >^ dr., ox- ide of zinc I dr. to vaseline i oz., is highly recommended after the rectal douche. Some physicians hold that chronic inflammation of the rectum is a disease of more frequent occurrence than all other rectal diseases combined, and equally as pernicious, causing many functional and even organic troubles through reflex action. FLUSHING- THE COLON. I have always been loath to admit the value of a thing which did not originally come from an authoritative source. A little retrospective medicine, however, is sufficient to teach any of us that many important discoveries have been made without the free will and full consent of " acknowl- edged authorities;" and that it is not positively necessary for progressive physicians first to obtain their permission before being allowed to think and act for themselves. Flushing the colon is a discovery of intrinsic worth, brought to notice in an irregular way, and has its place as a remedial agent with which every physician should be- come familiar. If you doubt its efficacy, and want a fiee evac- uation of the bowels without taking physic, lie on the back and with a bulb-syringe inject slowly into the rectum one- half-gallon or more of hot water, allowing the water time to FLUSHING THE COLON. 127 pass into the colon, and you will get it inside of fifteen minutes. I have often been amused by the copious evacuations produced by the flushing process ; they being not unlike those produced by an active cathartic. This means of un- loading a torpid colon will certainly be looked upon as a boon to those who find it necessary to relieve themselves Fig. 42. — Flushing the Colon, every three or four days by catharsis. I do not find that the bowels are left inactive after a flushing, in fact they seem to be left in a soluble condition and will probably move the next day of their own accord ; the column of fecal matter from the small intestines being allowed to descend. A small portion of the water usually remains in the ascending colon after the general evacuation has taken place, and will either be expelled by way of the rectum some minutes later or be absorbed and pass off through the kidneys. I do not see that Dr. A. W. Hall, who claims in his 128 FLUSHING THE COLON. health pamphlet to be the father of the process, and whose name bears the titles of Ph.D. and lyl^.D., and consequently deserving of the respect of an educated man, makes out a clear case in defense of his " New Hygienic Treatment " as a life-giving principle, either in health or disease. His argument is certainly unphysiological, and we are left to infer that nature has been derelict in the construction of man, which he has been instrumental in supplementing. If he were to confine himself to disease alone, his reasoning would appear more plausible ; but he holds that persons enjoying good health, with no physical ailment whatever, should wash out the colon ; that in the adoption of this practice as a hygienic measure, health will be preserved and the body fortified against the inroad of general systemic dis- ease, youth maintained, the old limbered and rejuvenated, and life prolonged to an average of one hundred years. The theory advanced in support of these rather extrava- gant claims is, that the flushing process carries away all deleterious and excrementitious matter, which otherwise would become absorbed, and that it eliminates from the in- gesta, calcifying, or earthy substances, which are not re- quired after the prime of life has been reached and are thenceforth stiffening to muscles and joint. No doubt Dr. Hall has been greatly benefited by flush- ing the colon, as also have many others, which offers some apology for the enthusiasm and interest he manifests in the "new revelation;" but we shall be compelled to look to others for the pathological conditions in which it will be found of greatest service. FIvUSHING THE COLON. 129 Respecting the colon itself, there are two very diverse conditions, with their concomitant symptoms, in which flushing will be found of great benefit ; the one a diseased condition of the mucous membrane, of a chronic dysenteric or an ulcerative character ; the other, a sluggishness or tor- pidity of the bowel belonging to a constipated habit. The easiest, simplest and most efficient manner of practicing the flushings, according to my experience, is b}^ assuming the position shown in the cut. A piece of oil-cloth, rubber- cloth or a newspaper may be used to protect the carpet. One or both feet are allowed to rest on the floor, by which the hips can be raised by the slightest exertion for a few moments, any time it is desirable to hold and hasten the water down the incline ; or the hips may be elevated by means of a pad for the same purpose. Beginners should use a common bulb syringe with water rather hot, varying in quantity as they become accustomed to the process, from a quart to a gallon or more. A bulb- ful may be squeezed out slowly, with intervals between, giving the water time to pass out of the rectum into the colon. On regaining the erect posture, if the rectum be loaded with feces or distended with water, the desire to ex- pel its contents may be irresistible, especially if air has passed through the syringe ; although a little practice will enable any one to exert great control over him or herself in this respect. Dr. F. H. Ktheridge (Trans. Chicago Med. Soc.) gives a number of cases of impacted colon, in which daily flushings, extending over a period of from one to three months in 130 FivUSHING THE COLON. each case, were followed by the most grateful results. This, too, after the persistent use of drugs had almost hopelessly- failed to afford even temporary relief. Without segregating the cases mentioned in his report, some were dyspepsia, characterized by anorexia, acid and bitter eructations, bad taste in the mouth, gaseous dis- tention, gastric weight and pain. In other cases the most prominent symptoms were cephalalgia, chills, vertigo, chloasmic spots, muddy sclerotics and complexion^ insomnia, ennui, eczema, psoriasis, and dysuria. He says : "Daily movements of the bowels are no sort of a sign that the colon is not impacted ; in fact, the worst cases of costiveness that we ever see are those in which daily movements of the bowels occur. The diagnosis of fecal accumulations is facilitated by inquiring as to the color of the daily discharges. A black or a very dark green color almost always indicates that the feces are ancient. Prompt discharge of food refuse is indicated by more or less yellow color. It would be interesting to inquire why fresh feces are yellow and ancient feces are dark. "Absorption of the feces from the colon leads to a great many different symptoms ; among others, anaemia, with its results, sallow or yellow complexion, with its chloasmic spots, furred tongue, foul breath, and muddy sclerotics. Such, patients have digestive fermentations to torment them, resulting in flatulent distention encroaches on the cav- ity of the chest and in excessive cases may cause short and rapid breathing, irregular heart action, disturbed circu- lation in the brain, with vertigo and headache. An over- ^tUSHING THE COLON. 13I distended caecum, or sigmoid flexure, from pressure, may- produce dropsy, numbness or cramps in the right or left lower extremity. "I have often questioned whether chloasmic spots were not due to fecal absorption. These spots are pigmentary matter deposited under the skin. It is a physiological fact that all pigments originate in the liver. In a condition of health their abnormal deposit we never see. It is only when the patient is not well, in some way, that these spots are noticed. They are infinitely more common in women than in men. It is easy to see that their sedentary life is more apt to lead in them to the fiUing of the colon. Absorption from the colon produces a poisoned blood, which in turn deranges every organ of the body, among others the liver. It is possible that the action of light, as in photographs, contributes in some way to precipitate the deposits of these chloasmic spots, because we see them chiefly upon the parts of the body exposed to light. ^ ^ ^ ^ 5|C ^> 5j^ "The use of a long rectal tube is unnecessary. The patient should be placed in a genu-pectoral position, the shoulders thus being lower than the hips. The water will be made to descend while anatomically ascending the intestines. Patients can be made to receive from one to six pints of water in this position without the slightest trouble. One of the effects of the water is to distend the colon, thus pressing away the walls of the loculi from the accumu- lations that fall into the current of water and are passed out while the water is leaving the intestine. The patient will 152 FLUSHING THE COIvON. oftentimes complain of severe tormina, checking the current of water for a few seconds, and will be followed by complete relief. The presence of such a strange foreign body in the intestine as hot water in many cases excites prodigious peristaltic activity, thus producing the tormina. Plain hot water is all that is necessary to use ; the water should be hot ; cold water or tepid water will not do. It will pro- duce great suffering. One patient took the flushings for a fortnight, returning vowed she would never use any more because they produced such terrific cramps. Upon inquiry it was found that she was using tepid water. The subse- quent use of hot water by her was never followed by a cramp. Upon many patients this large amount of water acts as a vigorous diuretic. Where patients suffer as well from renal insufficiency, I am in the habit of telling them to use a pint or a pint and a half of hot water after the flush- ing has passed away, and to lie upon the back with hips elevated for half an hour. Thus retaining the water, it will act as a powerful diuretic. Some patients can administer this flushing with greatest ease, while others will develop a most phenomenal awkwardness. I generally advise patients, who are at all awkward about using these flushings," to kneel in the bath-tub." RECTAL REFLEXES. The lower end of the rectum is richly supplied with both sensory and sympathetic nerves ; the sensory greatly pre- dominating at the verge of the anus, making it one of the most acutely sensitive surfaces of the body. In ascending, the sensory nerves gradually give place to the sympathetic, until little sensibility is imparted by the touch three inches from the entrance, in a normal condition. This accounts for the hidden cause of so many reflexes, having their seat of origin from lesions an inch or more above the anus, where the sensibility is not always suffi- ciently great to attract attention. It is claimed that obscure rectal disorders may so under- mine the nervous system by reflex irritation, allowing the inroad of general systemic disease, that many die yearly from them as the primary cause, without ever knowing the source and origin of the fatal malady ; that migratory pain, headaches, dyspepsia, sleeplessness, palpitations, sexual weakness, nervousness, despondency, irritability, and a general breaking down ot the system, may all be caused by a small ulcer or other irritation of the rectum, which has passed unnoticed by either physician or patient. Nearly every physician is familiar with the white ring around the mouth, extending along the alae of the nose, produced by the presence of pin worms in the rectum, or a 134 RKCTAI, REFLEXES, fatal lock-jaw caused by a broken off needle or rusty nail in the foot. Such illustrations alone are sufficient to demon- strate conclusively the power of this dynamical disturbance, called reflex action. **In all pathological conditions," says Professor Pratt, surgical or medical, which linger persistently in spite of all efforts at removal, from the delicate derangements of the brain substance that induce insanity, and the various forms of neurasthenia, to the great variety of morbid changes re- peatedly found in the coarser structures of the body, there will invariably be found more or less irritation of the rectum, or the orifices of the sexual system, or both." While there is doubtless unwarrantable exaggeration con- cerning rectal reflexes by some, there are many unpar- donable oversights by others. A case was reported in the Medical Record in which all preparations were made to operate for organic stricture of the urethra, which, per- chance, proved to be a reflex from a small rectal fissure and was purely of a spasmodic nature. When the fissure was cured the spasm ceased. A case of roaring in the right ear was relieved by the cure of a fistula, says Dr. Rorick, who also speaks of two other similar cases. A very remarkable case occurred in my own practice in which the right testicle had been enlarged to the ordinary size of a well developed case of orchitis for some years, and had resisted all manner of treatment, the enlargement com- pletely disappeared after the removal of hemorrhoids. The case of hemorrhoids, which was one of the worst I ever saw, is represented on page 25. RECTAIy REFLEXES. I35 Another case was that of a merchant, who suffered fre- quently from a sensation of drawing and weight in the back of the head and neck. When these attacks came on, his memory became so badly impaired that he was rendered unfit for the transaction of business. He noticed during the attacks that there was a feeling of heaviness in the rec- tum, swelling and tightness of the sphincters and a lack of expulsive power at stool. Examination revealed several pockets and papillae of the variety shown in Fig. 31, which was taken from this case. I have not been apprised of any return of the trouble since an operation for the removal of these abnormalities. As evidence that physicians should be a little more vig- ilant in the observation and study of rectal reflexes, the case of a very talented and influential lady of this State may be appropriately instanced. Her general health had been greatly impaired for a long time, with unexplained and repeated outbursts of sickness. Several prominent physicians were consulted, to whom she called attention to a little uneasiness, at times, in the rectum with an irritable bladder. They all examined the rectum, in their way, and ridiculed the idea of local disease, but went on treating the reflex symptoms with nothing more than temporary relief. The successes of a local specialist in the treatment of hemorrhoids by the Brinkerhoff" system, whose ignorance of anatomy was such that he denominated the sphincters "dispenser" muscles, induced her to pay him a visit. He found a well defined superficial rectal ulcer and exhibited it to one of the previously named doubting physicians. The 136 CONDYLOMATA. ulcer was quickly healed and the lad,v restored to health. She became so enthused over the result, that she took up the study of rectal diseases for the benefit of others, as a missionary, so to speak ; and it is needless to say that the physicians who failed to detect the cause of her trouble did not reap any of the emoluments of her labors, but there were several irregular practitioners who were ready listeners and took in some handsome fees as a reward. Her motto, true to a grateful nature, was "to praise the bridge that car- ries you over." CONDYLOMATA. Condyloma, from kondulos Gr, a ''knot," or ''tubercle," may be applied to any small, hard tumor, flap, tab of flesh or wart-like excrescence about the anus, whether of syphilitic or non-syphilitic origin. They may take the form of one of the radiating folds of skin at the anus, or be flattened transversly by the pressuie of the buttocks. They generally consist of a hypertrophy of the skin from localized inflammation or irritation, and sometimes continue to grow after the cause has been re- moved. A cutaneous tag as a relic of an external hemorrhoid, after it has lost its identity and become dense in structure, is properly a condyloma ; also a warty vegetation developed from the papillary layer of the derma. Certain forms of condy- lomata are pathognomonic of ulceration and other serious CONDYIvOMATA. 137 changes going on above ; the discharge at the anus produc- ing these fleshy tags. Some writers prefer to limit the meaning of the word to certain varieties of growths about the anus. But it appears less liable to confuse, to use it in a literal and a generic sense; making the varieties associated with their causes qualifying terms ; as, syphilitic, non-syphilitic, warty, can- cerous, innocent, etc. The objection to cocainizing condylomatous growths of any size and excising them, is the annoyance from the bleeding that sometimes follows, which will often break through a heavy crust of Monsels' salt. The prettiest way to remove them is by galvano-cautery. When electricity is not at hand, carbolic acid injection is equally as effective. It may be necessary, where the skin is thick and horny in texture, to afterwards trim off the remaining ragged edges with the scissors. Small condylomatous growths as well as small external hemorrhoids, can be easily removed by first injecting into their base a few drops of a 5 per cent, solution of cocaine, and then splitting them from base to apex with a sharp- pointed bistoury which has been previously dipped in liquified carbolic acid. Each half may be similarly treated and thus the growth quartered, allowing it to perish with less struggle. NEURALGIA. Neuralgia of the rectum as a clinical entity is rare indeed. Mention ' is made here simply in acknowledgment of the affection, having met with but one case and that in a very nervous and delicate lady, who maintained that she was cursed with a rectal ulcer. In obedience to this idea her physician had examined the rectum under general anaesthesia, and found what he called a rectal ulcer at a point where the uterine cervix rests on the rectum. His diagnosis was, no doubt, founded upon her belief and as an apology for the examination and treat- ment resorted to, which put her to bed for six weeks. There were no symptoms of rectal ulcer, other than pain, and no lesion found by a digital examination or seen through a speculum. She insisted on taking chloroform and a more thorough examination made. This was done without revealing anything more than what had already been ascertained, and the diagnosis of neuralgia confirmed. Pain continued, periodical or irregular, in the absence of mechanical pressure (uterine) or structural lesion in the region of the sphincters or higher up, is diagnostic. If alone in the sphincters dilitation may be sufficient ; when higher up, constitutional treatment with galvanism is ad- vised. APPENDIX CARBOLIC ACID. Aside from the established reputation of carbolic acid in aseptic and antiseptic surgery, it being preferable to bichlor- ide of mercury because of the danger from absorption of the latter and its damaging effect to instruments, and aside from the wide range of usefulness of carbolic acid in the treatment of rectal diseases, it has other uses which make it worthy of special mention. The cauterant, local anaesthetic, antiphlogistic and anti- septic properties of carbolic acid are not found combined in any other single remedical agent, and are properties which explain, I think, its superiority over any other remedy for many of the purposes for which it is recommended. Carbolic acid is fast saperceding iodine for the radical cure [of hydrocele. The chief claims are its certainty of action, entire freedom from pain and mild inflammatory action. All liquid is first drawn off through an aspirating needle and about 30 minims of carbolic acid (full strength) is injected into the sac. The first effect is to cause swelling, which soon subsides. In fifty cases operated upon by Prof. John A. Wyeth, only two cases were not cured by the first injection. T40 CARBOLIC ACID. Dr. D. D. Bramble, Cincinnati, Ohio,. recommends the in- jection of pure carbolic acid for the cure of "housemaid's knee." "Housemaid's knee" is an enlargement of the pre- patellar bursa from a thickening of the tissue of the bursal sac or an accumulation of fluid within the sac, caused by- pressure from kneeling, etc. After a failure to cure by the usual plans of treatment — rest, stimulating lotions, counter- irritations, iodine, seton, tapping and injection of iodine, — Dr. Bramble, reasoning from the successful use of carbolic acid in the treatment of hydrocele, injected into the bursal sac, 15 minims of pure carbolic acid with the result of a cure in every case. The injection of two or three drops of carbolic acid into the center of a boil, is said to abort the boil in every in- stance. A fellon may be lanced without causing pain, by first dipping the finger in a 50 or 75 per cent, solution of carbolic acid and waiting from three-fourths to one hour. Antidotes : — It is claimed that any of the soluble sul- phates will ccmpletely antidote an over dose of carbolic acid, forming a. harmless compound (a sulpho-carbolate). Acetic acid is an antidote to the immediate local effects of carbolic acid and will almost entirely destroy its odor. The power of acetic acid to neutralize to a great extent the im- mediate action of carbolic acid and lessen the characteristic numbness" and tingling sensation which it produces, was ac- cidently discovered by a physician in one of the New York hospitals. A test of this antidotive property of acetic acid may be harmlessly made by pouring over the finger a 95 COCAINB. 14I: per cent, solution of carbolic acid and then washing it off with (U. S. P.) acetic acid. Kxperiment may develop some valuable points in making combinations of acetic and carbolic acids. I have concluded to begin a series of experiments by adding one or two drops of the officinal acetic acid, to ten of the carbolic acid solution for the injection of hemorrhoids. Anything in combination that will lessen or control for twelve or fourteen hours, the quite severe pain which sometimes follows the in- jection of carbolic acid into hemorrhoids, will remove the only valid objection to the treatment by injection. I regret that I am unable to give to the profession the result of such experiments, having conceived the idea but a short time be- fore going to press. COCAINE. The use of cocaine for the purpose of producing local an- aesthesia in the treatment of diseases of the rectum and anus, renders painless and makes easy many little oper- ations, which could otherwise be performed only with ex treme difficulty. The alarming toxical effects w^hich sometimes, though rarely, follow the injection of even the smallest quantity of a solution of cocaine into the tissue, have caused the utmost caution to be exercised in relation to its employment. For the prevention of these toxic effects, Dr. Gluck recom- mends the addition of a few drops of phenol (carbolic acid) to the solution, claiming, after a year's trial, that the so- 14^ COCAINE. lution will not only be preserved and its ansesthetic'action increased, but that no evil consequences need be feared from cocaine absorption. Also that there is an absence of con- gestive reaction, and the solution is rendered asceptic. His formula is : R Phenol gtt. ij Distilled water .^ j Shake until the solution is perfect and then add cocaine, gr. X ; makes a little over i6 per cent, solution. I always add a small quantity of carbolic acid to my cocaine solutions, and have never been chagrined by, nor called upon to combat, any of the toxical effects of the drug ; but thought it due more to good luck and caution than any- thing else. A five per cent, solution is sufficiently strong for hypodermic injection to produce complete and immediate anaesthesia. li Cocain. hydrochlor. gr. vj Aquae Dest. 3 ij Acid Carbol. gtt. iv M. Makes a 5 per cent, solution. For surface anaesthesia, a strong solution acts better ; first, by rapidity of action, lessening the probability of ab- sorption and saving time ; second, by the effects being more profound. The addition of a few drops of acetic acid to the solution, saponifies any oily matter that may be clinging to the surface and allows the cocaine to take effect more readily. B Cocain. hydrochlor. gr. xij-xviij Aquae Dest. .^ij f nNIVERSIT" ASPIRATING HEMORRHOIDS. 143 Acid. Carbol. gtt. iv Acid. Acetici gtt. v M. Makes a 10 or 15 per cent, solution. The unfavorable action of cocaine on the heart is anti- doted by the inhalation of nitrite of amyl. ASPIRATING HEMORRHOIDS. The treatment of hemorrhoids by first clamping the tumor at its base between the blades of a bi-valve or a tri-valve speculum, puncturing it at the most dependent part with an aspirating needle and drawing off the blood, and then in- jecting into the ex-sanguinated sac some coagulent, is theo- retically good but certainly wanting in practical value. The plan must have originated from a conception that all piles were simple sacs, isolated and having a well defined pedicle, an error which the eight thousand credulous physicians who purchased "outfits" at ten dollars apiece, have doubtless learned ere this. One traveling salesman in- formed me that he had sold in the United States eight thousand outfits for treating hemorrhoids by the aspirating process, and that he had accumulated enough money to re- tire from the business. When told that his treatment existed principally in theory and had little practical value, he stated that the idea was a new one and appeared plaus- ible, that the aspirating needle and syringe together with a tri-valve speculum, met with ready sale. FORMULA FOR Tun HYPODERMIC TREATMENT OF HEMORRHOIDS. Dr. Shuford. R . Sod^ Bibor. Acidi Salicyl. a a 3 i Glycerinae ^ i Acidi Carbolici 3 iii Misce. Inject from 3 to 5 drops into small tumors and from 8 to 10 or more in large ones. The advantages claimed by Dr. Shuford for his combination are, that it is comparatively painless, causes no accidents and is eminent- ly successful ; that the hypertrophic tissue atrophies and is thrown off, leaving a smooth, healthy mucous membrane. A physician informs me that he has used the above combination with good results in a number of cases ; but in three instances it in- flamed the tumor and created considerable pain, which prolonged the treatment, and in one instance the tumor was inflamed, and, using his expression, "ploughed its way out," which confined the patient to his room for five weeks. Of the milder solutions I would give it the preference. Dr. Green. (A traveling pile doctor.) R Acidi Carbolici 5 i Creosoti gtt. x r Acidi Hydrocyan. gtt i Olei Olivse 5 i , Mix and unite by heat in a water bath. Inject enough to turn the tumor an ashen grey color. The creosote and hydrocyanic acid are nothing more than rubbish i» Dr. Green's formula. FORMULA. 145 Rorick. Brinkerhoff. Largest piles, Medium piles, Small piles, *An unnecessary irritant. Powell. R Acidi Carbolici 40 per cent. Fl. Ext. Ergotse 15 " Glycerin 3e 15 " Aquae Dest. 30 " Misce. Inject from 2 to 10 drops. R Acidi Carbolici s j Olei Olivse I v Zinci Chloridi * gr. viij Misce. 8 minims. 4 to 8 2 to 3 " R Acid. Carbol. (crystals)gr. xiij Tr. Thujae (Homoeop.) .^ j ,^ ss 2 drops. Aq. Dest. q. s. ut ft. Misce. Inject from 4 to Overall. R Acid. Carbol. Fl. Ext. Ergotae 01. Olivae a a Misce. Inject from 3 to 8 drops. For Fistula (Overall). Irritate the canal with a probe and inject into it a 95 per cent, solution of carbolic acid. Wash out the rectum after each stool with warm water, and at bed time inject into the rectum white Pinus Canad. i dr. to 2 oz. of w^arm water. The injection of the acid is to be repeated every two or three weeks un'il a cure is effected. 146 FORMIIIv.^i. For Fistula (Powell). Irritate the canal with a probe and inject into it Sanders' eucalyptus, full strength. The next day inject a 75 per cent, solution of carbolic acid. For Ulceration (Powell). R 01. Eucalypti (Sanders'.) ^ iij Phoenol Sodique z iv Glycerinse ^ ij Misce. Sig. Apply from two to four times a week. For Ulceration (Powell). R 01. Eucalypti ^i Zinci Oxidi ^ ij Vase 1 in i | iss 01. Theobrom. ^ ss Misce. EXPLANATORY. All engravings representing diseased conditions in this book, that are not otherwise accredited, are taken from observations of the author. For the purpose of convenience and brevity in preparing liter- ature on the subject of the injection methods, there seems to be a need for the illiterate use of different forms of the word "inject," to express a state or condition instead of action. Such usage has been adopted in a few places in the general text. TYPOGRAPHICAL ERRORS. Page 80, Irad for tracA-. " 107, paraniydal for pyramidal, " 115 Benzoinmi Pulv. for Beiizoini Pulv. " 139, reined ical agent for remedial agent. " 142, rendered asceptic for rendered aseptic. INDEX. Abscess 49' 75 Allingham 4, 14, 64, 75, 80 Andrews . 54, 84, 104 Brinkerhoff 145 Carbolic Acid 139 Cocaine 141 Condylomata 136 Crutclier 46 Divulsion 116 Borland 45 Etheridge 129 Fissure 95 Fistula 75 Flushing the Colon 126 Hall 90,127 Haynes 4, 45 Hemorrhoids 9 Varieties of 10 Examination of 19 Diagnosis of 20 Strangulation of 24 Treatment of 27 Treatment by Aspiration . . . .^ 143 Relapses of 62 148 INDEX. Cases Reported 45, 56 Accidents 49 Carbolic Acid Poison and Embolus 52 Marginal Swelling and Abscess 49 Secondary Hemoirhage 51 Sloughing 53 Hoyt 56, 1 10, 1 18 Kelsey 15. 53. 55, 75 Mathews 84, 89 Neuralgia 138 Overall , 145 Polypus 122 Powell 145 Pratt 107, 134 Proctitis 125 Prolapsus Recti . . 102 Pruritus Ani no Rectal Pockets and Papillae 104 Rectal Reflexes 133 Rectum 67 Resume 60 Rorick 145 Shuford 34i 144 Shotwell 78 Sphincter Muscles 67, 70 Needle and Syringe 48 Turner 3 Ulcer and Stricture 86 Yount 6 RETURN TO the circulation desk of any University of California Library or to the NORTHERN REGIONAL LIBRARY FACILITY BIdg. 400, Richmond Field Station University of California Richmond, CA 94804-4698 ALL BOOKS MAY BE RECALLED AFTER 7 DAYS • 2-month loans may be renewed by calling (510)642-6753 • 1-year loans may be recharged by bringing books to NRLF • Renewals and recharges may be made 4 days prior to due date. DUE AS STAMPED BELOW DEC 8 1998 AUG 18 2000 12,000(11/95)