il?' -^ 'M •).> ■•%< I -nmcn PERKINS LIBRARY Dulte UnLverslty Rare Books ^^ I TREATISE "^"' Ta^^, ff": ^^^ MALPORJIATIONS, INJURIES, AND DISEASES RECTUM AND ANUS. ILLUSTRATED WITH PLATES. GEORGE BUSHE, M. D. FORMERLY PROFKSSOKOF ANaTOMV ANU FHVSIOLOoV, ETC. NEW-YORK: FRENCH & ADLARD, 46 BROADWAY. MDCCCXXXVIL Entered according to the Act of Congress of the United States of America, in the year eighteen hundred and thirty seven by George Bcshe, m. d., in the Clerk's Office of the District Court of the United States, for the Southern District of New-York. Ti^T&T TO DOCTOR JOSEPH SKEY, M. D., ' INSPECTOR OP BRITISH MILITARY HOSPITALS, &C., &C., &C. Dear Sir, Were I desirous to dedicate this work to one deservedly eminent m his profession, and who, at the same time, is no less remarkable for his scholarship, than scientific attainments, and proficiency in the fine arts, tliere is none that I could select with more propriety than your, self. But it is not on account of these distinctions, that 1 have taken the liberty of prefixing your name to this volume,— nor is it to repay past favours ; but as a token of regard, inspired by a long'ob- servation of your conduct as Princrpal Medical Officer, and by the genuine acts of kindness and charity you were wont invariably to extend to the invalid soldier, widow, and orphan, the humanizing effect of which has ever been warmly lauded and acknowledged by those who, like myself, had the good fortune to serve under you. Now that, after upwards of thirty years arduous service in war^and peace, in various quarters of the globe, you are about to retire, having completed the prescribed term, may you long live to enjoy the esteem, of all good men, and reap those advantages which accrue from a highly cultivated mind, genuine benevolence, and a well spent life, is the ardent wish of your obedient and faithful servant, GEORGE BIJSHE. 58 V/ a Iker- street, Aew-York, December 1st, 183(). ADVERTISEMENT. I SHALL make but few prefatory remarks respecting this work, and these shall be short. Many years ago, I was induced to pay particular attention to the diseases of the rectum and anus, in con- sequence of their frequency, and the diversity of opinion which prevailed in relation to their nature and treatment. My opportunities for investigating them have been ample, and I may safely say, that I spared neither time, trouble, nor expense, in endeavouring to arr'ive at just conclusions. In the compilation of my researches, I have aimed at simplicity and conciseness, at the same time that I have been careful to omit nothing of importance. I regret that a few oversights have occurred in correcting the proofs, such as ilius for" ileus, pubes for pubis, my for any, and in some instan- ces want of precision in punctuation. For such mistakes I claim the reader's indulgence, which I am sure he will grant me, when I inform him that, this book has been in the press for more than a year, in consequence of my inability, from the pressure of business, and declining health, to correct the proofs, some of which, I have been compelled to trust to others. Finally, I am far from being insensible to still more serious defects in my performance; but, should it go through another edition, and I am spared to superintend it, 1 shall endeavour to correct them to the best of my abilities, and add any new information I may be able to obtain. 58 Walker-street, Neio-York, December Is/, 1836. 4v65'?-S Digitized by the Internet Arciiive in 2011 witii funding from Duke University Libraries http://www.arcliive.org/details/treatiseonmalforOObusli CONTENTS. PAGE. Anatomv of the Rectum, 9 Functions of the Rectum, 23 Malformations of the Rectum and Anus, 37 Foreign bodies in the Rectum, 57 Laceration of the Rectum, G9 Inflammation of the Rectum, 87 Inflammation and Excoriation of the Anus, 93 Inflammation of the Rectum and Anus, arising from the application of Gonorrhceal Matter 97 Fissure of the Anus, 99, Neuralgia of the Extremity of the Rectum, Ill Spasmodic Contraction of the Sphincter Ani, 119 Ulceration of the Rectum, 131 Venereal Ulceration of the Rectum, 143 Affections called Hemorrhoidal, 145 Enlargement of the Hemorrhoidal Veins, 197 Prolapsus of the Rectum, 201 Relaxation of the Anus, • 213 .Relaxation of the Rectum, with Invagination of the Mucous Membrane, 215 Itching of the Anus 219 Excrescences about the Anus, 223 Polypi of the Rectum 227 Abscess near the Anus, • 231 Fistula in Ano, •. . 247 Contraction of the Anus, • 257 Stricture of the Rectum, 263 Carcinomatous Degeneration of the Rectum 289 CHAPTER I. ANATOMY OF THE RECTUM. Name. The last portion of the intestinal canal has been improperly denominated the rectum, for we shall presently see that it is curved. Form. Cylindrical, except at its lower part, immediately above the external sphincter, where it is considerably^ dilated and flattened from before backward, constituting what is called its pouch. Size. Superiorly, it is continuous with the sig- moid flexure of the colon, extending from that part of the psoas muscles, opposite the inferior border of the body of the last lumbar vertebra, on the left side, to the anus.* Direction. In the adult, it descends for five or six inches, occasionally undergoing slight lateral inflections, and gradually passing from left to right until it arrives at the median line.f Then, bending obliquely forward and downward for three inches, * In some rare instances the position of the abdominal viscera is reversed and, in such cases, the rectum would of course commence on the right side. t When the rectum is greatly distended it forces off the bladder to the right side. 2 10 ANATOMY OF THE RECTUM. it turns backward and downward for one inch or one inch and a half, thus completing its course.* Structure. Like the hollow abdominal viscera, it consists of three tunics, viz., peritoneal, muscular, and mucous. The peritoneum is reflected from the posterior surface of the bladder in the male, and from the upper and back part of the vagina in the female, on the anterior surface of the rectum. In this way a cul de sac is formed, bounded by two folds, one on either side, only remarkable when the rectum is empty, and consequently very improperly deno- minated its posterior ligaments. It then passes off from the sides of the rectum in an oblique direction, extending from behind forward, and from above downward, to the walls of the pelvis. Finally, after having covered the rectum, the laminae from either side unite and form the meso-rectum, by which it is connected to the sacrum. This process is about four inches in length, continuous with the iliac meso-colon, and gradually becoming narrow, ter- minates in a point opposite the junction of the third and fourth bones of the sacrum. The hemorrhoi- dal vessels and nerves, together with loose cellular tissue, are contained between its layers. In some instances it does not exist, the peritoneum passing directly from the posterior and lateral parts of the * In tiip foetus, the greater part of it is lodged in the alxlominal cavity, In cojisequonce of the imperfect devclopcmcnt of the pelvis. ANATOMY OF THE RECTUM. 11 rectum to the sacrum ; while in others, it is so small as to be obliterated by the distension of this intestine. Thus we see that the peritoneal coat is but par- tial, covering the rectum anteriorly for five or six, laterally four or five, and posteriorly three or four inches. Such, however, is not always the case, for the distension of the bladder and uterus, as well as the developement of tumours, have a tendency to diminish this tunic. Occasionally, an adipose lamina is deposited beneath it, embracing the anterior and lateral parts of the intestine ; but more commonly its free surface is furnished with fatty appendages, opposite the base of the sacrum. The muscular coat is of a deeper colour, and much more thick and strong than in the other por- tions of the large intestine. It consists of two las- ers of fibres, the external being longitudinal, while the internal are circular. The longitudinal fibres are partly prolongations of the three bands from the colon ; but, in addition to these, which are of a hghter colour, there are others perfectly indepen- dent of such a source, and entirely peculiar to the rectum. Taken together, these fibres are parallel, investing every part of the bowel, but more nume- rous on its anterior and posterior walls.* They are * The distribution of the longitudinal fibres in parallel striae prevents the intestine being thrown into partial pouches, as the colon ; however, when its walls collapse, it is marked by transverse depressions, so that equality of sur- face pertains only to its distended state. 12 ANATOMY OF THE RECTUM. most remarkable in the three upper fourths, being smaller, less apparent, and confounded with the levatores ani, in the inferior fourth, disappearing a few lines above the anus.* The circular fibres are neither particularly strong nor numerous, except near the anus, where they assume a deeper colour, and are so congregated as to form a fleshy flattened ring, from four to ten or more lines wide, and two thick, constituting what is termed the internal sphincter, which has a slight attachment to the central point of the perineum.f The mucous tunic is more thick and vascular than in any other portion of the large intestine, but does not at all merit the appellation pajJillaris, and scarcely that of mllosa ; for its villosities are * Dr. Horner, when treating of the anatomy of the rectum, says, " At the anus an arrangement of the muscular coat prevails, which, as far as I know, has not been heretofore attended to by anatomists. The longitudinal fibres having got to the lower margin of the internal sphincter, turn under this mar- gin, between it and the external sphincter, and then ascend upwards for an inch or two in contact with the mucous coat, into which they are finally inserted. This connexion must have obviously much influence in the pro- trusions of the mucous coat which sometimes take place." Anat. vol. II., p. 36, 37., Phila. 1826. As I have had no opportunity since I read the above in Mr. H.'s treatise, of examining the rectum post-mortem, I am, of course, unwilling to admit his description into my text ; yet, as this gentleman's opinion is entitled to every attention, I have thought proper to insert it in the form of a note, so that others may ascertain whether it be corrrect. t H. Cloquet says, " Les secondes, (the circular fibres) existent presque seules dans son tiers inferieur et pr^s de I'anus." Traite d'Anatomie, tome ii., p. 351. Paris, 1828. If by this method of speech he means to convey the idea that they are not to be found in the middle third, I must protest against his accuracy, having constantly observed them in the middle third, though pale, sparse and sppnrnted by considerable intervals. ANATOMY OF THE RECTUM. 13 • very small, and not sufficiently numerous to give a character to this membrane. It contains many mucous follicles, whose mouths are distinct and stand well out, having generally a direction down- wards. This membrane is connected with the mus- cular tunic by lax cellular tissue. Superiorly, it is smooth, and when empty, in consequence of its great amplitude, is thrown into oblique and trans- verse folds, which, however, do not assume any regular form or arrangement.* Inferiorly, it forms * Mr. Houston, of Dublin, who is very justly esteemed an excellent practical anatomist, published in 1830, an essay in the fifth volume of the Dublin Hospital Reports, in which he describes a valvular arrangement of the mucous mem- brane of the rectum. Having for several years had the intention of writing a treatise on the diseases of the rectum, I made repeated examinations of this intestine with great care, but without observing any other condition of the mucous membrane than that described in the text. However, after perusing the essay above alluded to, I again resumed my investigations, which only assured me of the correctness of my previous examinations, though I chose recent subjects, and allowed the intestine to remain in situ. I declare nothing can be more remote from my mind than a disposition to cavil ; yet I cannot help remarking in this place, that veritable valves, containing muscular fibres too, ought not to be obliterated by the removal of the bowel, and should be found at any period previous to decomposition. It occurred to me, and I think reasonably, that valves capable of supporting the weight of the fecal matter, ought to be pretty firm, and consequently dis- tinguishable in the living body. I must say, that after the most careful exami- nations, I have not been able to detect them in a single instance. I have, however, frequently met with accidental folds, produced by the partial contrac' tion of the bowel. A proof that they were accidental is aflforded by the fact, that, in the same subject, I have found them on diiferent days to occupy differ- ent situations, and in no instance could they have performed the office of valves, being unresisting, and easily displaced by the extremity of the finger. With all due deference to Mr. H., I would beg to remark, that his misap- prehension of this piece of anatomy has arisen from his methods of investiga- tion : — one, by filling the intestine with alcohol, and then opening it ; the other. 14 ANATOMY OF THE RECTUM. vertical duplications which contain cellular tissue ;* and thus supported, these duj)lications project for- ward, so as, according to JMorgagni, to merit the appellation of pillars.f They are of variable length, by inflation and drying. In tlie first, the accidental folds are rendered perma- nent by the induration resulting from the action of the aJcohoi ; while in the second, the projections resembling valves are produced by the angles formed by the settling of the intestine during'the process of desiccation. Before I finish this note, I ought to mention that a few other anatomists have spoken of the existence of valves in the lower extremity of the rectum. Thus Morgagni (De Sedibus et Causis Morbonam) says lie found valves in two subjects, situated about an inch above the anus, in one of a circular, and in the other of a cnicial form. Portal says, " Mais on remarque h. son extremity inferieure pres de I'anus, divers replis de sa lame interne, lesquels forment des «speces de valvules rangees it. peu pres circulairement. Ghsson, qui les a recon- nues, les nomment les valvules semi-lunaires. La membrane interne qui con- stitue ces replis se relache et se prolonge quelquefois au point de former un bourlet qui s'oppose h. la sortie des excrements." (Anat. Medical.) This is ■only in keeping with the rest of Portal's anatomical writing, bearing evidence that he did not investigate the subject witli his eyes and hands ; but preferred associating, as it were, the truths ascertained by some with the glaring blun- ders committed by others. In the passage quoted, he evidently alludes to the semi-lunar folds described in the text ; — Ijut how they can become so relaxed and prolonged as to form UJi bmirlet, sufficiently large to oppose the passage of the feces, is beyond all credence. Boyer too has asserted, " Cluelque- fois, mais rarement, au lieu des replis semi-lunaires dont il vient d'etre parle, on trouve de v€ritables valvuels qui bouchent en quelque sort I'extremite infe- rieure du rectum." (Traite d' Anatomic, tome iv., p. 377. Paris, 1815.) If there be such cases, they must be very uncommon. It is to be regretted that Boyer has been so general and superficial. Is it not reasonable to suppose that the authority of Morgagni led him into error 1 This is my own opinion, and is derived from the fact of his having touched the matter so lightly, and at the same time quoted the cases from Morgagni. * I cannot agree with Boyer when he says, " EUes fortifies par quelques fibres chamues." (Op. cit.) t Some anatomists suppose that these pillars result from the contraction of the extremity of the gut. This, however, is not the case ; for, though dimi- nished when the mucous membrane is extended, they are not obliterated. ANATOMY OF THE RECTUM. 15 thicker near the anus, where they terminate in rounded extremities, and are from four to twelve in number. Between these folds there are others, generally not very numerous, but always most remarkable opposite the lower border of the inter- nal sphincter, of a semilunar form, usually trans- verse, though sometimes oblique, w^th their free edges turned upward, thus forming narrow, semi- lunar lacunae, the orifices of which are directed u J) wards toward the cavity of the intestine.* The arteries of the rectum may be divided into * In 1820 Ribes published a paper, in which he says, " J'ai infructueuse- ment cherch^ les rcphs senii-lunaires plus ou moins niembreux que Ton a pnS- tendu y exister, et dont le bord flottaiit est derige de bas en haut, du c6t^ de la cavitd de I'intestin." (Re\'ue M^dicale, tome i., p. 180.) In 1826, in another paper, he holds the following language : " J'avais long-temps infructueuse- ment cherche les replis semi-lunaires plus ou moius nombreux que Ton avait dit y exister; dans ces derniers temps, je les ai recontres sur plusieurs cadu- vres ; j'ai trouve un sujet qui avait quatre depressions, et chacune d'elles etait garnie d'un petit repli membraneux en fonne de valvule mince ; sur d'autres individus, je n'en ai observe que trois , ces replis avaient une forme semi-Iu- naire ; le bord flottant etait derige en haut, du cote de la cavit^ de I'intestine, il etait legerement concave. Le bord adherent 6tait convexe, derig^ en bas, et se trouvait tout-Ji-fait i la partie inferieure de I'intestin et presque i I'endroit oil la peau s'unit k la tunique interne du rectimi, de maniere que le bord su- perieur et flottant etait tout au plus h. la hauteur de trois ou quatre lignes de la marge de I'anus, ces replis ^taient formes par la membrane interne de I'intestine." (Memoirs de la Societe Medicale d'emulation de Paris, tome ix., p. 107.) It appears very odd how any anatomist could have experienced so much difficulty in finding these folds. For my own part, I have always been able, in my lec- tures and dissections, to verify the concise description of Winslow, who says, " Towards the circumference of the inner margin of the anus, they form little bags or semilunar lacunse, the openings of which are turned upward, toward the cavity of the intestine." (Anatomy by Douglas, vol. ii., p. 194. Edin- burgh, 1772.) 16 ANATOMY OF THE RECTUM. three classes. The lirst or superior are derived from the inferior mesenteric ; the second or middle from the hypogastric ; and the third or inferior from the internal pudic. After the inferior mesen- teric has furnished the left colic and sigmoid arte- ries, it divides into two branches, called the supe- rior hemorrhoidal. These vessels course along the posterior surface of the rectum, are at first superficial, but soon become concealed in the lon- gitudinal fibres, giving off laterally a great number of branches which anastomose on the anterior sur- face of the rectum, not only with each other, but also with the middle and inferior hemorrhoidal arteries. The middle hemorrhoidal arteries do not always exist, especially in the male subject, and vary in size, number and origin, being one, two, or three in number, on each side, of a size propor- tionate to their number ; and, instead of arising from the side of the hypogastric, may come off from the ischiatic or internal pudic arteries. They take an oblique course downward, behind the bladder in the male, and the vagina in the female, applied to the rectum, on the anterior surface of which they divide into twigs, anastomosing with the superior and inferior hemorrhoidal arteries. The inferior hemorrhoidal arteries, two or three in number on each side, are given off by the internal pu- dics after they have re-entered the pelvis. They pass transversely, giving branches to the levatores ANATOMY OF THE RECTUM. 17 ani, and both sphincters, as well as to the cellular, fatty and tegumentary tissues in the anal region; and anastomose with the other hemorrhoidal arte- ries at the extremity of the rectum. The veins, which are very tortuous, correspond with the arteries, and terminate in the meseraics and hypogastrics. The former have no valves; col- lectively, their branches constitute a plexus, termed hemorrhoidal, which is situated at the extremity of the rectum, between the mucous and muscular tunics. Some of the branches of the above plexus pass through the internal sphincter, supplying the cellular and adipose tissues by the side of the rectum, and anastomose with the body of the plexus below the edge of this muscle. The nerves are derived from two sources, viz. the sciatic and hypogastric plexuses. Those from the sciatic, pass to the lower and posterior part of the rectum, in which course they give off twigs to the hypogastric plexus, and then divide into two sets of branches, viz. the ascending, which proceed towards the sigmoid flexure of the colon, and the descending, which extend to the sphincter ani : the ramifications of both terminate, partly in the mu- cous, and partly in the muscular tunics. The branches derived from the hypogastric plexus pass forward and downward to be distributed to the rectum and anus. The absorbents are much more numerous than 3 18 ANATOMY OF THE RECTUM. is generally supposed; and terminate laterally in the hypogastric, posteriorly in the sacral, and supe- riorly in the meso-colic and lumbar ganglia. Relations. 1. That portion of the rectum covered by peritoneum, lies in the hollow of the sacrum, and corresponds, in the male, with the posterior surface of the bladder; in the female, with that of the uterus, as well as a small piece of the vagina, and in both sexes with a fold of the ilium, which is lodged in the intervening cul de sac. 2. That part of the intestine destitute of peritoneum, is attached, anteriorly, for about three inches, by cellular tissue, to a small portion of the lowej fundus of the bladder, to the vesiculee seminales, vasa efferentia and prostate gland in the male, and, by a vascular network, to the vagina in the female, thus constituting the recto-vaginal septum.* Laterally it is covered by cellular tissue, tortuous veins, and the levatores ani. Posteriorly, beneath the attachment of the meso-rectum, it corres- ponds with the lower bone of the sacrum, os coc- cygis and levatores ani. The account which we have given of the rectum would be incomplete, were we to omit a description of the anus, and the muscles connected with it. The anus is a small oval orifice, directed down- * Some authors have spoken of an interlacing of muscular fibres in this septum ; an arrangement which, in the many dissections I have made of these parts, I have never been able to observe. ANATOMY OF THE RECTUM. 19 ward and backward, situated about an inch in front of the extremity of the coccyx, behind the pe- rineum, between the tuberosities of the ischia, and in the median hne, at the bottom of the cleft between the buttocks.* It is covered by fine, soft, pHant skin, of a dingy colour, especially in adults, furnished with sebaceous follicles, which secrete an unctuous matter endowed with a peculiar odour, and from whose centre, in the male adult, hairs spring. This integument is plicated by the action of the sphincter ani; ascending a short distance above the verge of the orifice, it gradually assimilates in structure with the mucous membrane, and disappears opposite the inferior border of the internal sphincter.f " L'an- atomie de texture demontre, dans le lieu de cette reflexion, un grand developpment dans la trame erectile, que je regarde comme le charactere anato- mique essentiel de toute muqueuse."t ^^ this opinion I entirely coincide with Cruveilhier ; and several years ago made many preparations to illus- trate it. * In the male it is situated considerably above the tuberosities of the ischia; but in the female it is much lower down. t M. Cruveilhier says, " L'epiderme cutan^ s'y prolonge pour se terminer un peu au-dessus i la manifere d'un feston irreguliferement decoup6 et pour etre remplace par l'epiderme muqueux, que j'admets sur I'universalitfi des mem- branes muqueuses." This arrangement I could never observe ; and, with all due deference to his opinion, I tliink M. C. has been led astray by the conti- nuation of the cutaneous epidermis as far as the transverse folds spoken of in p. 15. t Dictionnaire de Med. et de Chinirgie Pratique. Paris, 18-39. Art. Anus, 20 ANATOMY OF THE RECTUM. The muscles proper to the anus, are the sphinc- ter and levatores ani. The sphincter ani, to which the term externus is added to distinguish it from o the inferior circular fibres of the gut, is a thin, oval, pale muscle, which arises from the tendinous raphe, extending between the os coccygis and rec- tum. From thence passing downward and forward, it di\-ides into two semi-elhptical bundles of concen- tric fibres, which are directed outward at an acute an- gle, expanding, on each side, nearly to the tuberosity of the ischium ; then, cur\dng forward and inward, they form the arch of a circle, and unite in front at an angle similar to that at which they parted behind. Thus, they encircle the margin of the anus, and form two commissures, one behind, and the other an- terior to this opening, which are rendered firm by the interlacing of the fibres of each side. E xtending for- ward in a pointed manner, the sphincter ani is insert- ed, in the male, inferiorly, into the tegumentary raphe and superficial fascia ; while superiorly, a fasciculus perforates this fascia to be inserted with the trans- verse and accelleratores urinae muscles, midway between the anus and bulb of the urethra, into the common central tendinous point of the perineum.* Inferiorly, it is connected with the skin by cellular and adipose tissue ; the latter of which, in robust persons, except near the verge of the anus, extends •Sometimes a small slip passes fonvard. to be attached to the ejaculator ^nuscle, and is called musculus lateralis urethrtr. ANATOMY OF THE RECTUM. 21 between its fibres. Superiorly, it corresponds with the internal sphincter and levatores ani, with which it is intimately confounded in the neigh- bourhood of the rectum, as will be presently de- scribed. Its edges are directed downward and outward, and are imbedded in cellular tissue. In women, the anterior extremity of this muscle is shorter and less acute than in the male subject, and is confounded with the sphincter vaginge. The levator ani is a thin, flat, and irregularly quadri- lateral muscle, broader above than below, and with its fellow of the opposite side forms a concave wall ; which, with the ischio-coccygei muscles, closes the inferior outlet of the pelvis, and sustains the posterior portion of the urethra, prostate, vesiculse seminales, and inferior part of the bladder and rectum.* It arises from the posterior and inferior part of the pubes near the symphysis,! from the aponeurotic arch resulting from the separation of the two layers of the pelvic fascia, and from the spinous process of the ischium.t The fibres which come from the * It has been said to resemble a funnel, the concavity being directed towards the pelvis, and the convexity towards the perineum, with two openings in it inferiorly for the transmission of the rectum and urethra. 1 1 do not include in this description the muscles of Wilson ; the origin of which is separated from that of the levator ani by a few veins, that communi- cate between the dorsal veins of the penis and those on the side of the neck of the bladder. t Most anatomists have described the levator ani as arising from the ilium over the obturator foramen. This is a great mistake ; because the layers of the pelvic fascia separate above the margin of this muscle; one being applied 22 ANATOMY OF THE RECTUM. pubes are fleshy ; those from the more anterior part of the arch are thin and tendinous * while the pos- terior are thick, tendinous and fleshy. The ante- rior fibres, passing obhquely downwards, backwards and inwards, course along the side of the prostate, to be inserted into the central point of the peri- neum, and into the fore part of the rectum, mixing with the fibres of the sphincters, as well as with those from the opposite side. The middle fibres are inserted into the side of the rectum above the sphincters, and are confounded with the longitudinal fibres of this intestine. Finally, the posterior fibres, which are more transverse than the rest, are inserted into the side of two or three of the last coccygeal bones, still more forward, into the back part of the rectum, and, with those of the opposite side, into the tendinous raphe, which extends from the extremity of the coccyx to the rectum. This muscle lies between two layers of the pelvic fascia. Its anterior border is directed downward and inward, embracing the prostate, as before de- scribed ; while its posterior is a little inclined upward, and is parallel to the inferior border of the ischio-coccygeus. In. the female it is incorporated with the vagina, is more weak than in the male, and its posterior fibres are less curved. to its internal, and the other to its external surface. The error must have arisen from cutting away the internal layer of the fascia, and then examining the muscle superficially from its inner surface. CHAPTER II. FUNCTIONS OF THE RECTUM. The feces accumulate slowly in the rectum, and gradually lose their thinner parts by absorption. They do not give rise to any uneasiness until a considerable quantity is amassed, when a sensation is created,* which demands their expulsion.f * This sensation is supposed by some to result from the contact of the fecal matter with the rectum, but such is not the case ; for the feces generally accu- mulate in large quantities before the sensation alluded to is felt. Some of the advocates of the above opinion assert, that this peculiar feeling is to be referred to the acrimony which the feces obtain by their stay in the rectum. This ex- planation, however, is not less specious than the former, for the following rea- sons : 1st. When the feces are fluid, this sensation is produced very soon after their arrival in the gut. 2nd. If the sensation be not complied with, it ceases, and generally does not return until the next accustomed period. And, 3rd. The longer (after the sensation has been once disobeyed) the feces remain in the rectmn, the less likely is it to return. In truth, we are ignorant of the cause of this feeling, and must, in the present state of our knowledge, admit that it is organic, and, consequently, depending upon some spontaneous change in the intestine, about which we know nothing. tDr. O'Bieme, of Dublin, published, in 1833, a work on defecation, in which he promulgated opinions on the functions of the rectum altogether at variance with those of other physiologists. His object is to prove that the feces do not pass freely from the sigmoid flexure of the colon into the rectum, gradually distending it, as has been generally supposed ; but that they accumulate in the sigmoid flexure, and are forced into the rectum immediately before their evacu- ation. Consequently, that the power of retaining and controlling their dis- charge does not depend upon the sphincter muscle. 24 FUNCTIONS OF THE RECTUM. ' Until this period they are supported by the rec- tum, which seems curved for this purpose, and He says, " In the first place, it is universally admitted, and it has been shown, that a design to retard the progress of fecal matter, and to convert the large intestines into a depot for its reception, is obvious throughout the intes- tinal canal, particularly in the caecum and colon ; and it must be manifest, that if a free communication existed between the sigmoid flexure and the rec- tum, that design would fail to be accomplished at the point, of all others, at which it was most necessary to have secured its object ; for such an arrange- ment would necessarily expose the rectum to frequent accumulations, and such as, besides interfering with the ordinary fimctions of the bladder, would sub- ject the sphincter ani to continued irritation, and thus deprive man of the im- portant advantage he enjoys of retaining the alvine contents not only for hours, but for days, without suffering any inconvenience whatever. " Secondly. The circimtistance of nature forming one of her chief depots for excremental matter in a part of the intestinal canal, so close to, and con- tinuous with, the rectum, as the sigmoid flexure is, appears altogether incon- sistent with the idea of a free passage between these portions of the caned. " Thirdly. In the act of receiving an enema, every person is sensible of a considerable degree of opposition to the ascent of the fluid in the rectum. It is well known, also, to those in the habit of administering injections per anum, that, although the syringe may be in the best order, properly filled, and its pipe fairly inserted up the rectum, considerable force is generally required to discharge the fluid, from the resistance given to its passage upwards. These facts would lead us to infer that the rectum, so far from its being open, is firmly contracted and closed. " Fourthly. Surgeons find it necessary to pass a finger up the rectum, either to direct the course of a catheter, sound, or staff, to discover whether a fistula communicates or not with the bowel ; to detect the presence of a calcu- lus in the bladder, or a stricture in the intestine itself; to ascertain the state of the prostate gland ; and for various other purposes. And yet it is a fact, that it has exceedingly rarely happened, that, on any of these occasions, the finger has encountered either solid or fluid feces in the rectmn, or presented a soiled ap- pearance when withdrawn. Indeed, as far as my experience and inquiries enable me to speak on the point, in the few instances in which such examinations have detected the presence of excrement in the healthy rectum, it has been invariably found in a very small quantity, and never in any but the lowest part, or pouch, of this intestine. It is, also, a fact, familiar to apothecaries and nurses, that the pipe of the injecting syringe, however long it may be, is rarely. FUNCTIONS OF THE RECTUM. 25 more especially by the permanent contraction of the sphincters, which is perfectly independent of the if ever, found soiled with fecal matter when withdrawn after administering an enema. These circumstances show that the rectum is contracted and closed so as to prevent free communication between it and the sigmoid flexure. " Fifthly. Membranous filaments have seldom, if ever, been found tra- versing in various directions the cavity of either the small intestines, the caecum, or the colon, while they have often been met with in tjie rectum. This fact proves that the parietes of the rectum must have been contracted, and its lining membrane in close contact at all points, for a time sufficient to effect the firm organization of these filaments, and consequently that there could have been no communication between this intestine and the sigmoid flexure for, at least, several hours. " Sixthly. The two sphincter muscles of the anus are considerably weak- ened in the disease called prolapsus ani. In the operation for fistula in ano, these muscles are completely divided, and thereby wholly incapacitated, for a certain time, from acting as sphinctus. Not only these muscles, but also a part of the rectum above them, arc occasionally destroyed by venereal, can- cerous, and other ulcerative processes ; yet it rarely happens that the power of retaining the alvine contents is found to be at all impaired in any one of these cases. It is therefore manifest that this could not possibly occur if the passage into the rectum were as free as it is supposed to be, or if the power of retaining the feces, and regulating their discharge, depended solely on the sphincter muscles of the anus. " Seventhly. Seeing the forcible nature of the foregoing facts, and anxious to test the truth of the inferences drawn from them, 1 have been led to examine the rectum of a number of healthy persons, — healthy at least as far as the bowels were concerned, — at different tunes in the same day, in order to ascer- tain its actual state, and as nearly as possible the time and manner in which it is filled. I proceeded in the following manner, and ahnost invariably obtained the following results. On passing a stomach tube to the height of half an inch up the rectum, neither flatus nor feces escaped through it. Passing it up about an inch and a half higher, it was still found that nothing escaped, but that it could be moved about freely in a space, which, on intro- ducing the finger, was ascertained to be what anatomists call the pouch of the rectum, in a perfectly open and empty state. From the highest part of the pouch to the upper extremity of the bowel, generally a distance of from six or seven to eight inches, it was found that the tube could not be passed upward.'? without meeting with considerable resistance, and using a degree of force 4 26 FUNCTIONS OF THE RECTUM. will. Now, however, by an instinctive effort, the sphincters, particularly the external, contract still sufficient to mechanically dilate the intestine, which was plainly felt to he con- tracted so as to leave no cavity for this extent. When the instrument reached' in this way, the uppermost point of the rectum, the resistance to its passage upwards was felt to be sensibly increased, until at length, by using a propor- tionate degree of pressure, it passed forwaixl rapidly, and as if through a ring, more or less tight, into a space in which its extremity could be moved with great freedom ; and as instantly a rush of flatus, of fluid feces, or of both, took place through the tube. In some instances, indeed, it happened that neither gaseous nor liquid matter escaped at this moment ; but in all these, the distinct feel of the extremity of the tube having entered a solid mass in the flexure, was communicated to the hand. The instrument, on being withdrawn, exhibited a few inches of its upper extremity covered, and its eyes plugged up, with solid excrement. The person generally went to stool soon after, and passed a large quantity of solid feces. In every instance where the tube presented the least appearance of feces after being removed, this appearance was confined to that poition of its upper extremity which had entered the sigmoid flexure. " In this way I have also examined the rectum of healthy persons in a few minutes after they had passed a stool, and of others at the moment when they felt a moderate inclination to go to stool ; and have ascertained that the rectmn is in a perfectly empty and contracted state at both these periods. " The results of these exeuninations establish the correctness of the inferences drawn from a number of facts, but in a much more positive and pi-ecise man- ner, for they distinctly prove, first, that in the healthy and natural state, all that part of the rectum above its pouch is, at all times, with the single excep- tion of a few minutes previous to evacuation of the bowels, fim^ly contracted and perfectly empty, at the same time that the pouch itself, and also the sig- moid flexure of the colon, are always more or less open and pervious. Lastly, that the sphincter ani muscles are merely subsidiary agents in retaining the feces." We shall now examine the correctness of this evidence, so ingeniously brought forward by Dr. O'B. to support his peculiar views ; in doing which, we shall reply to his assertions in the order he has made them. Firstly. It cannot be denied that when the rectum is much distended, parti- cularly in paralytic subjects, it will press more or less on the bladder. But does even this tend to prove that the rectum is not a receptacle for the feces 1 Dr. O'B. might with as much propriety assert that the uterus is not the organ in which the foetus is developed, because, when distended, it presses on the bladder. FUNCTIONS OF THE RECTUM. 27 more, and until voluntarily relaxed, they continue to antagonize the expulsatory effort. The rectum and bladder, as every one knows, are commonly more or less distended at the same time ; and, in such cases, if the feces be fluid, both organs discharge their contents simultaneously; but if solid, and the sensa- tion soliciting their evacuation be urgent, they precede the discharge of the urine; — however, if the sensation be torpid, the urine will be excreted first. These are facts which any one may verify in his own person. As the urine may be evacuated independently of the feces, no mechanical obstacle can pre- vent its passage ; but, as the feces are sometimes discharged before the urine, it becomes necessary to explain the reason. The reader will therefore bear in mind, that no matter how abundant fluid feces may be, they are discharged simultaneously with the urine; consequently the inference is irresistible, that the retention of the urine depends upon the solidity and altered position of the fecal mass. The explanation then is, that when the anus is dilated by the passage of the feces, the prostatic and membranous portions of the urethra are mechanically compressed ; first, by feces, and, secondly, by the anterior fibres of the levatores ani, which are thrown into action during tlie ex- pulsatory nisus. From what has now been said, it appears that as the fecal accumulation must take place above the internal sphincter, and though indeed it may diminish the capacity of the bladder, yet it cannot interfere in any marked degree with the discharge of the urine. This pressure, then, which the bladder suffers from the distension of the rectum, is similar to that which all the hollow viscera experience from the plenitude of adjacent organs. It appears very odd why Dr. O'B. should suppose that irritation of the sphincter is the cause of the sensation which solicits evacua- tion of the rectum, and we much regret that he did not give us his reasons for this opinion. But, even admitting the position to be correct, his inference is not tenable ; because, no matter how great the accumulation may be, the mass never comes in contact with the coverings of the external sphincter, except during evacuation. However, the fact is, that the irritation of the sphincter can have nothing to do in determining the evacuation of the feces, as I have mentioned in the preceding note. If the sensatien demanding their expulsion be not complied with, the desire or indeed capability to evacuate them, will not return, perhaps, until the following day, or even a more distant period ; though, according to Dr. O'B.'s theory, the sphincter all this time must be in a state of irritation. Secondly. The assertion that the sigmoid flexure is the chief depot for the feces, is peculiar to Dr. O'B.; and it becomes his duty to establi.sh the fact 28 FUNCTIONS OF THE RECTUM. The contraction of the muscular fibres of the intestine would be insufficient to effect defecation before drawing conclusions from it. If his assertion were correct, we would be ready to join him in his conclusion ; but the truth is, that there exists a free passage between the sigmoid flexure and the rectimi ; of which any one can be satisfied by the most superficial observation. Consequently, his inference, though plausibly drawn, is from false premises. Thirdly. When difficulty occurs in administering enemata in subjects whose large intestines are healthy, it results from improper manipulation or bad instruments. Impressed with the knowledge of the clumsy manner in which both nurses and apothecaries exhibit lavements, I have never neglected in important cases to operate myself; and I now declare, that I never encountered the difficulties set forth by Dr. O'B. Those who are in the habit of injecting their own bowels would be far from testifying in favour of his opinion. * Fourthly. It has constantly and repeatedly occurred to me to find the rectum filled with feces, when making examinations for ascertaining the nature of disease. Dr. O'B. admits that a small quantity may in a few instances may be discovered in the pouch of the rectum. Even admitting that only a small quantity be found in the pouch of the rectum, I should be glad to learn how he has ascertained in these cases that a coliunn of feces does not occupy that portion of the rectmn above its pouch. Fifthly. Can Dr. O'B. point out any case in which the sides of the rectum adhered above the internal sphincter, or that part of the gut admitted by all to be in a state of contraction, in which this intestine did not sustain any unna- tural pressured (1) My reading has not furnished me with such a case. Sixthly. When the sphincters are divided, paralyzed, or destroyed, the individual is unable to retain his feces, provided they be fluid. This is not a vague assertion ; for every surgeon who has followed his calling upon an enlarged scale, has had opportunities of observing its truth ; but, when the feces are solid, the patient is much less troubled, being generally able to anti- cipate the period when they must be expelled, very little passing at each time. This is my own, as well as the experience of those who have removed the extremity of the rectum. The same observation applies to paralysis ; but here it may be argued, that the muscular fibres of the rectum are, in conse- quence of the nature of the disease, in a state of inaction. This I am ready to admit : still such patients retain solid feces until the rectum becomes enor- mou.sly distended ; and even afler we scoop and Avash tlicm out, we experience (1.) ppp ;Iir> C'hiipfor on Piriftiire of tlip ■Rpctnm. FUNCTIONS OF THE RECTUM. 29 without the aid, firstly, of the diaphragm, the con- traction of which is followed by the inflation of the quite as much difficulty in passing tubes into the sigmoid flexure of the colon as in the natural state, and I may, I think, say more, arising from the pouchy and folded condition of the mucous membrane. Seventhly and lastly. How does Dr. O'B. know that from six to eight inches of the rectum above its pouch was contracted, and that a certain amount of force was necessary to dilate it ? Is it not quite as likely that the difficulty he experienced arose from the obstruction offered to the instrument by the collapsed state of the intestine ? Whenever I have experienced any difficulty in introducing a tube, I have injected a little of the prepared fluid, and then proceeded with the operation. The resistance which Dr. O'B. speaks of as occurring at the upper extremity of tlie rectum, is very easily accounted for by the fact, that this intestine, with the sigmoid flexure of the colon, fonns a curve, against which the extremity of the instrument strikes. By continued pressure, however, it bends in the direction of the canal. To obviate this, which is not edways devoid of danger, I have been in the habit of using very flexible tubes, which certainly would be insufficient to dilate the rectum were it contracted. Here I may remark, that in a case which lately occurred to me, I experienced more difficulty in passing the tube through the sigmoid flexure of the colon than the rectum ; both being empty, as was proved by dissection. Dr. O'B. next endeavours to show, " that the structure and disposition of the parts in question, the sources from which they are supplied with nervous influence, and the nature of the functions they have to perform, are such, that these parts cannot be in any other than the conditions just mentioned. " WhUe the small intestines can be said to have little more than one mus- cular coat, and the caecimi and colon but a similar, with the addition of three narrow longitudinal bands, the rectum possesses an internal coat, composed of strong fleshy fibres set closely together, and arranged circularly, and an external, composed of still stronger and more fleshy fibres, arranged longi- tudinally; also set closely together, and so as to completely surround and cover the internal coat. In addition to these, each of these longitudinal bands of the sigmoid flexure sends down strong fleshy fibres to be expanded upon and intermixed with those of the proper external coat. It is, therefore, both an anatomical and a physiological fact, that this intestine exceeds every other pari of the intestinal canul in the number and strength of its muscular coats,andconsequently in muscular power. Again, this intestine is the only portion of the intestinal canal into which we can trace branches from the regu- 30 FUNCTIONS OF THE RECTUM. lungs ; secondly, of the aretenoid muscles, which close the glottis, and prevent expiration ; and, lar spinal nerves going directly, and witlimu previously interlacing with fila- ments of the sympathetic, into its substance ; for we can not only trace, but plainly see, that the right and left sacral plexus, which consist of nerves of this description, send the hemorhoidal branches in this manner to supply the rectum. It is also, therefore, both an anatomical and a physiological fact, that this is the only part of the intestinal cana.l which receives nerves directly from the motif c and sensific columns of the spinal marrow; and, consequently, that a much higher order of irritahility and sensibility is bestowed upon it, than upon either the small intestines, the ccccum, or the colon, and that it is thus directly subjected to the influence, bothhealthy and morbid, of that all important organ. "Now, when an intestine so supplied with nervous influence, and endowed with such muscular power, is called into strong action, as in the act of expel- ling its contents, it is quite manifest that the effect will be pi-ecisely similar to that which we know to be produced on the oesophagus after an act of deglu- tition — namely, to contract its parietes so powerfully as to obliterate its cavity; for, whether we regard the number and arrangement of their coats, the sources from which they derive their nervous influence, or, as will soon be apparent, the nature of the respective functions they are destined to perform, perhaps no two parts will be found to resemble each other more than these, the upper and lower extremities of the digestive tube. But anatomy points out, that the extent to which the contraction of the rectum takes place, must be limited to that portion of the intestine above the pouch, in consequence of the middle and posterior divisions of the levator ani muscles being inserted into the lower portion, and continually acting as antagonists to keep the pouch open. It is equally manifest that immediately after the bowels have been sufiiciently freed, the rectum, being empty, is in a state of rest, and placed in a situation the least capable of counteracting that contraction of its parietes, which accom- panies and follows the last expulsive effort ; but I shall now show that a change which the flexure undergoes at the same moment, maintains the rectum in this favourable situation until such time as another evacuation of the bowels is about to take place. This change consists in the inferior and greater portion of the empty flexure falling into the pelvis, hanging doubled over and rather to the left of the rectum, remaining in this situation until it is raised by distension into the place it had previously occupied in the left iliac fossa ; and it is scarcely necessary to obser^^e, that the first of these changes of posi- tion is one which would effectually prevent the descent of fluid or solid feces, FUNCTIONS OF THE RECTUM. 31 thirdly, of the abdominal muscles, which act against the diaphragm, so as to compress the viscera if not flatus, anrl thus secure the undisturbed condition of the rectum. But as this change in the situation of the sigmoid flexure has not been noticed, it will be necessary to mention the grounds upon which I infer its occcurrence. Here, however, I shall merely mention that whenever the flexure is found empty in the dead body, the above is the situation in which its inferior half is invariably observed ; and take leave to refer to the general account, which I shall presently give, of the process of defecation, for reasons in favour of be- lieving that such also must be its situation in the living body, after the bowels have been freed." We entirely agree with Dr. O'B. that the rectum possesses greater strength, sensibility and irritability than the other intestines ; for these are necessary to enable it to perform its functions. Thus, in some instances, when the rectum is impacted with feces, if the muscular coat were not thrown into action, the most powerful eflforts of the diajihragm and abdominal muscles would be insufficient to dislodge the fecal mass ; while in others, when the intestinal fibres contract en- ergetically and co-operate with thedaiphragm and abdominal muscles, large in- durated fecal masses, whichmay have been accumulating for days in the rectum, are forced out with such violence as to lacerate tlie mucous membrane, and in some rare instances, even the fibres of the sphincter; therefore, we easily seethe utility of the greater strength, irritability, and sensibility of the rectum, without having recourse to the reasons assigned for them by Dr. O'B. Dr. O'B. anxiously draws a comparison between the rectum and oesophagus, and infers that, like the oesophagus, the rectum contracts so as to obliterate its cavity. It would be protracting this note, already too long, to show the dis- similarity of these two organs ; however, as pertains to the oesophagus, I should like to learn what evidence Dr. O'B. can adduce to prove that it is contracted in the intervals of deglutition. (l.J Unfortunately for his theory, we have sometunes an opportunity of testing the truth of this assertion in opera- tions on the neck. I have had three such myself, but did not observe that this tube was more contracted than in the dead body. The small intestines have strong muscular fibres, but are these intestines always contracted when empty 1 It may be asserted thatwe experience difficulty in passing instruments into the stomach ; but, do we not also experience difficulty in passing catheters into the (1.) Majendie says, "In the upper two thirds of tin- oesophagus, the rela.\aiion of tlie circu- lar fibres follows immediately the contraction by which they displaced tlie alimentary bolus. It is not the same with the inferior third ; this Auaius some moments contracted, after the in- troduction of the food into the storaacli. 32 FUNCTIONS OF THE RECTUM. and force them backward and downward towards the cavity of the pelvis, causing the perineum to descend.* healtliy methra. Are we not to take into account the spasm excited in the muscular fibres by the presence of the foreign body 1 The action which Dr. O'B. ascribes to the levatores ani, with the view of ac- counting for the pouch of the rectum, is not tenable"; for this pouch does not descend as far, and ascends higher than the attachment of the levatores ani to this intestine. What he says of the position of the sigmoid flexure of the colon is not pecu- liar to hbn, as every anatomist knows ; still, I may remark, that the amount of flexure which dips into the pelvis is different in different subjects, and it re- mains for him to prove, that it is raised into the iliac fossa by distension. (1.) Finally. Dr. O'B. says, " When tliis occurs," (the distension of the sigmoid flexure, and its ascent from the cavity of the pelvis into the left iliac fossa,) " the flexure, according to the rapidity and degree of jits distension, begins to turn upon the contracted rectum as upon a fixed point, imtil, at length, like the stomach, it directs its greater arch forwards and upwards, and its lesser back- wards and downwards. By this movement the contents are brought some- what perjoendicular to, and so as to bear directly upon the upper extremity or annulus of the contracted rectimi, but as their weight is insufficient to force a passage downwards, and as this end cannot be accomplished either by such gentle pressure as that exerted by the alternate contraction of the diaphragm and abdominal muscles in ordinary respiration, or by the efforts of the flexure itself, in consequence of its muscular power being so very inferior to that of the rectum, they are compelled to remain stationary, until such time as the in- creasing accmnulation and distension produce a sense of uneasiness sufficient to call into action those great expulsive agents, the diaphragm and abdominal muscles. These muscles, instead of acting alternately, now act simultaneous- ly, compress the abdomen and its contents on all sides, urge the free and float- ing mass of small intestines downwards, and even into the cavity of the pelvis, so as to press forcibly not only upon the distended sigmoid flexure, but also * Some are of opinion that the levatores ani, by pressing the rectum for- wards and upwards, and thus oblitei-ating its curve, assist in tliis act. (1.) A few months since, in examining the body of a lady who died of ilius, in conse- quence of stricture in the rectum, I found the sigmoid flexure of the colon, which was very much distended with feces, resting in a great measure on the bladder, which contained from half to three quarters of a pint of urine. FUNCTIONS OF THE RECTUM. 33 The force thus produced being greater than the upon the caecum and the urinary bladder. By tliese means the contents of the distended flexure are acted upon in every direction, and so as to be impelled against the upper extremity or annulus of the contracted rectum, with a force sufficient to compel the parietes of this intestine to separate and afford a free passage. The nisus now ceases, but as soon as the rectum becomes filled, it is roused to make an expulsive effort, by which the whole of its contents are driven and impacted into the pouch. Here their accumulation produces a great sense of weight and uneasiness in the perineum, and urgent desire to go to stool, and a still stronger nisus, by which the sphincters are forced open and dilated, and the final expulsion of the egcsta is effected. But the urinary bladder, although it is subjected to considerable pressure during this process, is not evacuated at the same moment, but immediately after, because, during this the last stage of the process of defecation, the accumulation within the pouch and dilated sphincters presses upon the gland, against the arch of the os pubis, and thus effectually prevents the flow of urine, until the accumulation is removed. The evacuation of the rectum and bladder being completed, im- mediately the nisus ceases, the rectiun and the sphincters return to their former state of contraction, the diaphragm re-ascends, carrying with it and restoring to their proper situations, the liver, the stomach, the spleen, the small intestines, the caecum, and the ascending, transverse and descending portions of the colon. But the inferior portion of the sigmoid flexure is differently situated. Having a remarkably long and free process of peritoneum, and being empty, it is com- pelled, during the last expulsive nisus, to occupy part of the space which the evacuation of the bladder and rectum leaves in the cavity of the pelvis, and must of necessity remain in this situation, until it becomes again distended ; because, as a mere glance will show, the manner in which the peritoneum connects the small and large intestines with the diaphragm is such, that from the descending portion of the colon being bound down to the abdominal parie- tes, this is the only portion of the intestinal canal which does not follow, and is not in the least influenced by the action of the diaphragm. This is the fact which induced me to assume that the situation of the empty flexure in the living body, is the same as that in which it is uniformly found afl,er death." All this is very reasonable, admitting the validity of those points which we have endeavoured to controvert. To conclule, I have extracted every thing from Dr. O'B.'s ingenious and very valuable practical book, that had a bearing on the physiology of the rectum, and offered those objections whieh occurred to me to be just. But it remains with the reader to judg: for himself. 5 34 FUNCTIONS OF THE RECTUM. resistance of" the sphincters,* the anus is dilated and the contents of the rectum expelled; an act which is facilitated by the secretion of the follicles. The contraction of the diaphragm and abdomi- nal parieties is so powerful, that it would exercise a baneful influence on the rectum, by causing it to protrude, were it not for the resistance of the leva- tores ani muscles, which, though small, yet, from their favourable situation, sufficiently antagonize this force. The anus being narrower than the rectum, the expulsion of the feces is accompanied with more or less difficulty in proportion to their solidity ; for, when liquid, the contraction of the gut alone seems to be nearly or altogether sufficient for their evacuation. After the discharge of the feces, a considerable amount of mucous membrane is displaced by the contraction of the circular fibres of the intestine ; but, in proportion as the action of the diaphragm and abdominal muscles ceases, the sphincters be- gin, and the levatores ani continue to contract, until by their pressure, as well as by the diminution of the mass, in consequence of the return of respira- tion, the protruded membrane is gradually returned to its ordinary situation.f * The sphincters, particularly the external, are relaxed to a certain extent by the will, (see page 27;) a cnxumstauce whicii renders their resistance more easily overcome. + A fanciful and ingenious Italian physiologist, Beliengcri, entered upon FUCNTIONS OF THE RECTUM- 35 The frequency of fecal evacuations is uncertain, and depends, in a great measure, upon the quantity and the nature of the food. They occur at shorter intervals in children than in adults, because in the former digestion is more rapid, the secretions more profuse, the contents of the bowels not only more abundant but fluid, and the intestinal sensibility greater than in the latter. They are more rare in females than in males, in so much as the absor- bents extract a larger proportion of nutritious matter from the aliment, and the menstrual dis- charge supplies, in a great degree, the 2^^^ce of intestinal secretions. These evacuations, how- ever, may be said to take place once or twice in twenty-four hours, following some one or two of the meals ; instances, nevertheless, are not wanting in which they only occur after days and weeks — indeed, in none of the numerous functions of the body do we find habit more influential than in defecation. The gases are more easily expelled than fecal matter. Like liquid feces, they can be dislodged by the action of the intestine alone, though the diaphragm and abdominal muscles most commonly an experimental inquiry into the functions of the spinal marrow ; in the course of which he thought he proved that the posterior columns of the spinal marrow gave nerves to the sphincter ani, which endowed it with the power of contraction, while branches from the anterior columns bestowed on it the fa- culty of relaxation. This is not the place to offer objections to his experiments, or to demonstrate the invalidity of his deductions. 36 FUNCTIONS OF THE RECTUM, co-operate with the intestinal fibres. Their passage is neither regular nor constant: certain kinds of food are more likely than others to give rise to their formation ; and, while there are some persons who seldom or never pass any, there are others, particularly those labouring under bad digestion, who are in the habit of doing so unceasingly. CHAPTER III. MALFORMATIONS OF THE RECTUM AND ANUS. These malformations are far from being uncom- mon, and as some of them can be remedied, they re- quire to be well understood by the surgeon."^ For practical purposes, they may be arranged as follows : Imperforation f Incomplete, of the anus. t Complete. ' By one partition. By two j)artitions. By puckering and induration of its walls. * It would be foreign to the object of this work, to enter into an investigation of the causes wliich determine these malformations ; therefore, those who would be informed on this subject must consult Meckel, Serres and GeofFroy Saint-BQlaire. Here, however, I may observe, firstly, that the colon and rectum are gradually elongated by successive accretions, until they gain their proper length, secondly, that the amis is closed for a long tune by a dense thick membrane, and, thirdly, that the vagina, urethra, bladder and rectum are confounded in the earlier periods of feotal life ; consequently, that a cessation of growth would cause the rectmn to be more or less imperfect, the anus im- perforate, or an occasional opening to exist between the rectum and genito- urinary organs. I may add that, according to Serres, these malformations depend upon the imperfection or absence of the hemorrhoidal arteries. Imperforation of the Rectum. 3S MALFORMATIONS OF THE Unnatural ter mination of the < Rectum. In the bladder or urethra. In the vaccina. In the sacral region. In two extremities. In a cloaca with the vagina and urethra. Termination of other organs < in the rectum. Absence of the rectum. r Of the ureters. Of the vagina. Imperforation of the anus. Incomplete. This species of malformation con- sists either in an extension of skin over the border of the sphincter ani, or in a contraction of the extremity of the rectum.* Complete. This is a much more common form of anomaly than that which has just been described, and is produced by a lamina of fibro-cellular tissue, surrounded by more or less puckering of the adjoin- ing skin.f In most cases this membrane is so thin * Scultetus relates a case in which the opening was so small, that a probe about the size of the head of an ordinary pin could not be introduced. (Ar- mamentarium Chirurgicum, obs. 77. XJlmse. 1653. fol.) Roonhuysen men- tions a similar case, in which the mother was compelled to extract the sterco- raceous matter daily ; a task which she accomplished with great difficulty, in consequence of the exti-eme smallness of the orifice. t Some authors have described the membrane shutting up the anus as " fine skin," but in the cases I have examined in several cabinets, it did not resem- ble skin in any one instance. RECTUM AND ANUS. 39 and transparent, that when the infant strains, the meconium forces it downward, thus constituting a dusky, jfluctuating tumor. However, in some rare instances, it is thick, hard and unyielding, particu- larly at the circumference ; for, in the centre, it is almost invariably so thin, that the meconium can be seen through it.* hnperforation of the Kectwn. By one partition. The situation of this partition varies from two lines, to an inch or more above the anus. In the majority of cases, it is thin, and trans- parent, though occasionally thick and hard. The anus is always well formed, but we are soon appri- zed of the nature of the case, by the retention of the meconium, by the inability of the nurse to throw *Many authors have described cases of this kind, among whom we may mention; Fabricius ab Aquapendentc, (Opera chirvn'gica, parti, cap. 88. Pa- tav. 1617. fol. He says, '^Etsi aid locus jjclliada obdiidus est tamcn orificii vestigium, et iangentihis perscntitur vacmim intus") Fabricius Hildanus, ^Observationum et curationum chiurgicarum centur. I. obs. 73. p. 54. Basil, 1606. fol.) Van Meeckern, (Observationes medico-chiurgicse cap. 24. p. 114. Amstelod. 1682, 8vo.) Saviard, (Nouveau r'ecueil d' observations chiurgicales, obs. 3. p. 8. Paris, 1702, 8vo.) Littre, (Hist, de 1' Acad, des Sciences, p. 47. an. 1710.) Wagner, (Commer. litterar. Norimberg. p. 364. an. 1735.) Mo- tais, (Memoir dc 1' Acad, des Sciences, p. 579. an. 1771.) Simmons, (Medi- cal Facts and Observations, vol. i., p. 102. London, 1810.) Dr. George To- bie Durr, a physician of Augsbourg, related a case in which the membrane that closed the anus was prolonged forwards to the anterior part of the perineum, where was a small hole, through which the meconium draiijcd off. (Miscella- nea curiosa sive cphem. acad. natur. curiosor. dcr.ur. If. ap. VI. obs. 62. p. 3. 166S.) 40 MALFORMATIONS OF THE up injections, and by examination with the extre- mity of the httle finger.* By two partitions. The situation as well as the structure of these partitions may vary. I once saw a case of this kind in a new born child brought into the dissecting room. The upper part of the rectum was loaded with meconium, the partitions were thin and friable, being about three quarters of an inch apart, while the lowermost was nearly half an inch from the anus.f By puckering and induration of its walls. This species of anomaly must be very rare, as I have ne- ver seen a specimen illustrating it, and the only case I have met with in the course of my reading, is that which occurred to Engerran. In this instance, so great was the induration and puckering, that it presented the appearance of a knob, or knot in the intestine. t * Instances of this aberration have occurred to Bonn, (Papendorp, Disscrta- tio sistens observationes de ano infantum imperferato, p. 253. Lugd. Batav. 1781, 4to.) Petit, (Mem.de 1' Acad, de Chirui-gie, tome ii., p. 250. Paris, 1781.) Saviard, (Op. cit. obs., 3.) Grimaud, (Journal Generale de Med., tome xxiv. p. 238.) Wayte, (Edinburgh Med. and Surg. Journal, vol. xvii., p. 232. 1821.) Troussel Delvincourt, (Journal de Med. par Beclard, tome xiii., p. 3.) Dupuytren, (Journal Hebdom. de Med., tome ii., p. 421. 1829.) Colson, (ibid, tome ii., p. 150. 1829.) Fourcade, (Revue Medicale, tome iv., p. 52. 1830.) CruTeilhier, (ibid, tome ii., p. 422. 1833.) t Jessen witnessed the case of a female infant whose anus was well formed, but when the finger was introduced into this opening, which was narrow, ob- literation of the rectum was discovei-ed. On examination after death, he found that, ^^ Rectum intcstimcvi bis latcribus concreverat, bis orbiculari intersepieba- tur Ttietiihrana." Scheuckius, (Observat. medicinal, de int. recto, obs. vi. lib. iii, p. 384.) t Mem. de 1' Acad, de Chirurg , tome ii., p. 253, 4, 5. Ed. cit RECTUM AND ANUS. 4] UNNATURAL TERMINATIONS OF THE RECTUM. In the bladder or urethra. When the rectum ter- minates in the urinary organs, it opens either ob- liquely between the ureters into the neck of the bladder, or into the posterior part of the urethra. It generally tapers down very considerably before it arrives at its destination ; though, in some few in- stances, (one of which I have seen,) it terminates ccecojine, about half an inch above which, a narrow tube passes off anteriorly to communicate with the bladder or urethra. In either case the recto- vesical orifice is so small, that only the thinner part of the meconium can be evacuated ; and thus it is, that the unfortunate infant generally dies within a week from its birth.* * Berlin asserted that this malformation was constantly a cause of death. (Mem. de 1' Acad, des Scienc. p. 496. 1771.) In this, however, he was mista- ken ; for many cases are recorded of children so mis-shapen, who lived for months and years. Fortunatus Licetus mentions a woman who voided her feces through the urethra. (De monstorum causis, natura et differentiis lib. 11. cap. liil. Patav. 1616. 4to.) Flajani relates the case of an infant in whom about three inches of the rectum was wanting, the intestine terminating in a canal four inches in length, which passed under the prostate gland, and opened into the membranous portion of the urethra. The stercoraceous mat- ter of course was voided with great difficulty by the urethra, nevertheless the miserable babe lived eight months, and then only died in consequence of having swallowed a cherry-stone, which lodged in the recto-urethral canal. (Osservazioni di Chirurgia, tome iv. obs. 39.) Bravais records the case of a boy, four and a half years old, in whom the rectum, after becoming veiy narrow, opened into and appeared continuous with the urethra. (Actes de Lyon, tome ii. p. 97.) Finally, PouUetier observed a similar case in a boy three years old. (Dictionnaire de Scienc. Med. tome iv. p. 157.) 6 42 MALFORMATIONS OF THE When the opening is vesical, the meconium and the urine are mixed ; but, when urethral, a small jet of meconium generally precedes the passage of the urine. This malformation is much more common in males, and from the length, narrowness, and cur- vature of the urethra, is much more dangerous than in females. It is often accompanied with im- perfect developement of the genito-urinary organs, especially, with imperforation of prepuce and urethra.'* Though rarely, the anus sometimes exists in these cases, and permits the entrance of a probe for a few lines.f * Desgenettes relates a case combined with occlusion of the mouth. (Ga- zette Salutaire.) + Besides the authors just cited, many others have noticed such cases, among whom may be mentioned: Fabricius Hildanus, (Op. cit. centur. I. obs. 75.) Sanden, (Miscellanea curiosa sive ephemer. acad. natur. curiosor. decur. II. an. IX. X. obs. 194. p. 364. 1706.) Wrisberg, (De Proeternaturali et rara intestini recti emu lotii vesica coalitu et independente ani defectu, — Com- ment, Societal, Reg. Scientiar. Gottingens. tome i. p. 1.) Morand, (Memoir del' Acad, des Scienc. p. 50. 1755.) Pierre Borel, (Historiarum et Observa- tionum Medico Physicarum. centur. I. obs. 77. Paris, 1657.) Kaltschmeid, (Dissertatio de rare casu ubi intestin. rectum in vesca urin. insertum fuit. Jena, 1756.) Boirie, (Hist, de 1' Acad, des Scienc. p. 50.) Monclat and Cle- ment, (Nouv. Biblioth. Med. tome ii. p. 99.) Dumas, (Journal Generate de Med. tome iii. p. 46.) Hasselmann, (De ani intestinorumque atresia. Utricht, 1819.) Vrolik, (Mem. sur quclques sujets d' Anat. et de Phys. p. 22. Am- sterdam, 1822.) In this case there was extraversion of the bladder, Dele- salle, (Bullet, de la Soc. Med. d'Emul. Juin, 1824.) Cavennc" (Archives Generalcs de Med. tome v. p. 63. 1824.) Willaume, (Ibid, tome ix.p. 507. 1826.) Bonnet, (Ibid. torn. xx. p. 576. 1829.) Miller, (Edinburgh Med. and Surg. Journal, Jan. 1829.) Roux Brignole.ject to frequent attacks of colic, and her stomach was so weak that it scarcely retained any nourishment. Her efforts to defecate were sometimes so considerable that they were followed by con^■uisions, and cold perspiration. So much did she dread these efforts, that she resisted the calls of nature, and consequently seldom had a motion oftener than once in fifteen days or three weeks, when she moderated the violence of the bearing down pains, and facilitated the issue of the feces, by resting the fun- dament on a round stick. On examining the reclimi, he perceived a solid body, apparently of large volume. He injected almond oil into the intestine, and then introduced a lithotomy forceps, with which he seized the concretion, but in the extraction it broke ; however, the fragments were easily removed. This concretion was of the size of a large pippin. (Mem. de TAcatl. de Chi- rur. toine vii. pp. 317 — "30. Paris, 1700.) 66 FOREIGN BODIES IN THE RECTUM. succeeded in softening down, and consequently in causing complete evacuation of the indurated mass. During each of the operations now described, the patient should be placed in the same position as for lithotomy. It will not be necessary to say more on this subject, than that with the instru- ments above mentioned, and moderate ingenuity on the part of the surgeon, he will be able, under almost any circumstances, to clear the rectum of foreign bodies. I may mention that leeches, in attempts to apply them to the anus, may make their way into the rectum. They will, however, be readily expelled by injecting an infusion of tobacco, or a solution of salt.* Finally, ascarides are occasionally lodged in great numbers between the folds and in the lacu- nce of the mucous membrane of the rectum. They give rise to aching, and even lancinating pains in the anus, setting in generally towards the latter end of the day, or beginning of the night. In some instances these attacks are periodical. This is not the place to enter upon the general treatment of ascarides. The only part which concerns us now, is their mechanical removal. Brera * Zacutus Lusitanus records a case in which a leech, about to be applied to a hemorrhoid, made its way into the recttmi. He injected onion juice into this intestine, and the leech was soon discharged, almost dead. He recommends injections of ox gall, or castor, in similar cases. (De Med. princip. Histor. lib. i. obs. 7.) FOREIGN BODIES IN THE RECTUM. ' 67 has recommended this to be accomphshed by the introduction of a piece of lard ar tallow candle, which, he says, when withdrawn, will, bring along with it the greater part of those impacted in the lower part of the bowel. Insertion of the finger, as recommended by Howship, is, however, much more effectual, as we are able to withdraw it in such manner as to extract worms that would elude the lard or candle. The better plan is to use a small lithotomy scoop for the intestine, and that of a director for the lacunse. This latter instrument I found particularly useful in the case of a boy nine years old, who from his weaning had been torment- ed with ascarides, and for some weeks had suffered from excruciating pain in the anus, which was greatly aggravated for a few hours after going to bed, attended with fever and slight delirium. CHArTER V. LACERATION OF THE KECTUM. This species of injury may be either incomiDlete or complete. When incomplete, the laceration sel- dom extends beyond the mucous tunic, and, in the majority of cases, is produced by the expulsion of in- durated feces ; it may, however, result from the intro- duction* or extraction of foreign bodies. If the con- sequence of defecation, the rent is either transverse or vertical. When transverse, it is situated above the internal sphincter, and is the effect of the for- cible extrusion of a fold of the mucous membrane, which lapping under the mass of indurated feces, becomes forcibly everted by their expulsion, and in undergoing this change of position, is torn from side to side. When vertical, it generally termi- nates where the skin and mucous membrane unite, and is the result of forcible and violent distension of the anus.f • Tliepipc ol'a syriii2;c when awkwardly introduced, may lacerate the lau- cous membrane. tin some easels of ronstipation, while the expulsive muscles act with great energy, the sphincter remains contracted, and yields hut slowly; 10 that the 70 I.ACEHATION OF THE RECTUM. The production of this accident is attended with a painful sensation of tearing and a discharge of blood. The pain, however, gradually, but never entirely subsides, and is always renewed, with more or less severity, by each successive evacuation. Soon after the accident occurs, inflammation com- mences, effusion of lymph takes place, the edges and base of the rent become swollen, granulations sprout up, followed by suppuration, and now either cicatrization ensues, or the wound is converted into an ulcer. The great object in the treatment of this injury is to keep the bowels easy by the use of emollient lavements and after each evacuation to cleanse the wound ; for I have seen some cases in which the lodgement, even of a small quantity, of feculent matter between the lips of the wound, created the most agonizing pain and spasm of the sphincter ani. If the patient be very irritable, and the wound ten- der to the touch, the better plan will be, to pass a pencil of caustic over it twice or thrice, and then apply a cataplasm made of bread, and a solution of the superacetate of lead with laudanum. Should ulceration be established, the treatment recom- mended for fissure (see chapter ix.) will become necessary. With respect to the constitutional treat- ment, nothing more in the common run of cases will indurated feces contuse and abraid tlic suilacc of one or more points of tlic mucous membrane, which, if they do not heal, become converted into fissures. LACERATION OF THE RECTUM. 71 be advisable, than to restrict the patient to a low vegetable regimen, and enjoin the horizontal posi- tion, so as to prevent, as much as possible, the ac- cumulation of blood in the hemorrljoidal veins, which, in consequence of the absence of valves in the portal system, is invariably increased by the erect position. Blood-letting can seldom be neces- sary ; if, however, the patient be of a full habit and labours under general excitement from pain in the anus, it may become so. Purgation is never advi- sable, from the tendency which the most active ca- thartics have to produce vascular repletion of the rectum, and also from the stimulating character which they one and all impart to the fecal matter. This I would desire to impress on the mind of the student, for he will find the efficacy of purgatives advanced by some of the best authors, and, as the advantage which they attach to them consists solely in their power, of evacuating the large intestines, I would suggest the propriety of substituting emollient enemata. I shall now subjoin three cases, with the view to illustrate and give a more practical bearing to this subject. Mr. D., from whom I removed some piles a few months previously, called on me about six weeks ago, in consequence of a laceration about three quarters of an inch long, situated on the pos- terior part of the anus, and extending vertically into the bowel. He stated that it had been produced 72 LACERATION OF THE RECTUM. by the passage of indurated feces three daj'^s pre- viously, and was then attended with a sensation of tearing and a sanguineous discharge. By keeping the horizoi:\J;al position, using lavements, ablution and saturnine poultices with laudanum, the rent soon healed. Mrs. C, from whom I removed piles last summer, sustained a laceration of the mucous membrane, and fine skin of the verge of the anus, in the act of expelling indurated feces. After suffering great annoyance for five days, she sent for me and com- plained of pain in the anus, with spasm of the sphinc- ter ani, great nervous excitement and constipation. On examining the parts, I discovered a crevice on the left side of the anus, with an extensive base and tumid edges, between which were two small pieces of indurated fecal matter. I ordered an emollient lavement, tepid ablution, and a saturnine j)t)ultice with laudanum, by which her symptoms were miti- gated for some hours, but the spasm of the sj^hinc- ter returning with violence during the night, her sleep was broken ; therefore on the following morn- ing when 1 visited her, 1 passed a cane of caustic thrice over the lacerated surface, having previously exhibited an enema and cleansed the parts tho- roughly. I then applied a fresh saturnine poultice with laudanum, and enjoined a continuance of the horizontal position. The burning pain soon abated, the spasm did not return, and with the aid of ene- LACERATION OF THE RECTUM. 73 mata, ablution saturnine poultices, impregnated laudanum, and the horizontal position, she rapidly recovered. In the winter of 1829, Dr. Mason called me to visit Mr. H., who, in consequence of the sudden evacuation of indurated feces, had been labouring under pain and weight in the fundament for a few weeks, attended with purulent discharge. On in- troducing my finger, which was not easily effected, I discovered an indurated and swollen flap of the mucous membrane standing across the right half of the bowel, corresponding to the upper edcre of the internal sphincter, and above a chasm, from which it had been detached* containing small par- ticles of indurated feces. I now carried the knife, which I commonly employ for fissure, (see plate viii. fig. iii.) flatwise along my finger, and divided the flap of mucous membrane, the sphincter ani and all the intermediate parts. The wound was then dressed from the bottom, and the care of Mr. H. intrusted to Dr. M., who informed me that a ra- pid cure ensued. As complete laceration of the rectum varies in situation and extent, according to the causes which give rise to it, we shall describe each sjDecies under a distinct head, and thus endeavour to remove the obscurity which at present prevails on this subject. First species. The accident, most commonly de- signated rupture of the rectum, is in reality nothing 10 74 LACERATION OF THE RECTUM. more than rupture of the sphincter ani, and is pro- duced by parturition. The circumstances on which it depends, belong either to the mother or the child. Those which appertain to the mother, are, firstly, her position ; secondly, the form of her pelvis, and thirdly, the figure of her perineum. We shall now succinctly explain how these tend to the production of this form of laceration. He?' position. When she is allowed to remain in the sitting posture, or to lie on her side, with the lumbar vertibrEe curved forward, as in the case when iDressure is made against the loins, the head of the child is directed downward and backward, pressing on the rectum "and perineum. Forin of her pelvis. When the lower extremity of the sacrum is but little curved forward, as is sometimes the case, the pubeo-cocygean diameter of the pelvis is increased, and in this case, as well as when the sacro-vertebral articulation is prominent anteriorly, the axis of the pelvis passes more backward, con- sequently, the inclination of the plane which ought to direct the head of the child forward, is diminish- ed, and the arch of the j^ubis presses it, or, to speak more correctly, gives it a direction doAvnward and backward. Figure of her perineum. The peri- neum is occasionally prolonged considerably for- wards, so that the vulvular orifice is exceedingly small, and situated close under the arch of thepubes. The majority of cases of this kind are of original LACERATION OF THE RECTUM. i -i conformation ; but there are a few purely acciden- tal. About a month ago, in examining an un- married lady, who was the subject of an immense uterine tumour, I could scarcely insert my finger in- to the vagina, and this did not depend upon an ob- struction caused by the hymen, but was produced by the prolongation of the perineum. When this state of parts is accidental, it is the result of cica- trization consequent upon laceration or ulceration of the inferior portion of the vulva and perineum. M. M. Buet* and Dupuytrenf each relate a case of this kind resulting from laceration. In Buet's case, sutures were not used, but were in that of Du- puytren. Should a female so formed become im- pregnated, it will, in all probability, be impossible to prevent laceration of the perineum, which will take place in the median line if this be the weaker part, but if the barrier be equally sjrong, there may be perforation. In 1833, 1 attended a lady, about thirty years of age, in her first accouchement, in whom the perineum was prolonged much forward. Her labour went on kindly until the head of the child came in contact with the external parts, then, the most violent pains, frequently repeated, were scarce- ly sufficient to propel the child. It was with great difficulty that I was able to prevent the perineum frombeing extensively lacerated; it howeversuffered * Journal compl^mentaire des Sciences Medicales, tome xxxix. + Lecons oralcs, tome iii. p. 198. 76 LACERATION OF THE RECTUM. much. Being called to this case in the night, and not expecting any necessity for my pocket case, I did not bring it, else I should have had recourse to a pro- cedure in this instance which, afterwards, I advan- tageously pursued, under the following circumstan- ces : In May, 1834, a gentleman with whom I was partially acquainted, but whose family I did not attend, called on me to see his wife. In conse- quence of my not being yet up, he left his message, but did not specify her case, consequently I was not aware that there was an immediate necessity for my visit. I therefore merely added her name to my list, with the intention of seeing her in the course of my morning round. Two hours after- wards a messenger met me, and urged my imme- diate attendance. I therefore repaired to her dwelling with all possible speed, and found a healthy young lady, (about twenty,) in labour with her first child, and from the piercing character of her cries, I lost no time in making an examination ; when, to my great surprise, I found the perineum much elongated, the orifice of the vagina extremely nar- row and close to the pubes, and the head of the child pressing forcibly downward. When the pain, which was violent, subsided, and the head re- treated, I introduced my finger, and to my discom- fiture, found a rent at least four inches in length, extending transversely through the posterior part of the vagina,, about an inch and a half from the LACERATION OF THE RECTUM. 77 vulva. I now inserted my finger into this laceration, and distinctly felt the lower extremity of the rectum firmly contracted. Another pain soon came on, which fortunately was not very strong, so that I was able to support the child's head, while I had a probe pointed bistoury taken from my pocket case, and when the pain ceased, I divided the perineum ob- liquely downward and outward on both sides, to an extent sufficient to allow of delivery without further laceration. In this case, I have no doubt had I been a little later, there would have been perforation of the perineum.* The circumstances relative to the child, which give rise to the accident, are numerous^; but I shall restrict myself to the most common. The large size and solidity of the head ; the rapidity with which it is propelled ; neglect in supporting the perineum ; omitting to see that the child pursues properly the axis of the pelvis, in proportion as it passes through the external parts ; disengagiiig the child clumsily and violently with the arm turned towards the rectum, when either the head or feet present ; attempting forcibly to pull the arm corres- ponding to the rectum, directly downward and backward, instead of bringing it laterally across the concavity of the sacrum, before withdrawing it; neglecting to loop the forceps when placed on ♦ See Dupuyireii fif ia d^cliinire centrale du pferin^e pendant rncroucliement. Op. cit. p. 175. 78 LACERATION OF THE RECTUM. the child's head ; leaving them locked and continu- ing their use after the head has been brought to the external orifice ; making the traction too rapid- ly and carrying the instruments too far backward, when they are used to bring the head through the external parts ; forgetting when the occiput corres- ponds to the symphisis pubis to commence eleva- ting the forceps as soon as the head presses on the perineum, so that when this part has passed through the vulva, the forceps will describe a right angle with the abdomen of the mother. These lacerations, as I have said, commence in the perineum, and never occupy more than the sphincter ani and mucous membrane. Of this last fact, I have satisfied myself by the exami- nation of several cases ; nor is the opposite opinion in accordance with the anatomj^ of the parts. We can easily conceive how the posterior and inferior portion of the vagina, together with the sphincter of the vagina and anus, may be torn through ; and that such laceration may implicate not only the integuments, but also the mucous membrane of the rectum; but that the muscular tunic should be lacerated, is beyond all credence ; for the pressure of the child can surely have no other effect than that of approximating the sides of this intestine. In fact, to tear through the rectum, a distending force would be necessary, as will hereafter be de- scribed. Now in the case before us, there is no 4-. LACERATION OF THE RECTUM. 79 distending force, no matter whether the rupture be , produced by the pressure of the child or the use of instruments, the rectum merely suffers a pressure, by which its sides are more closely approximated. In such cases, therefore, I fear there has been an error, as to the extent of the laceration, and this I am disposed to think, has arisen from the depth of the cleft, which depends upon the facility with which these over distended and naturally lax parts admit of swelling. In consequence of the depth of this cleft, it entangles the feces, which in such cases are rendered fluid by either medicine or enemata: so that, on a superficial examination, a surgeon may be easily deceived as to the real nature of the acci- dent. Second species. In this, the rupture is above the sphincter, and is sometimes produced by the elbow, or lower extremity of the child, by the crotchet, by forcible straining to evacuate the rectum, when im- pacted with indurated feces,* but more commonly by the introduction of foreign bodies, particularly of bougies and injecting pipes, these instruments being forced in some instances into the vagina, and * The following interesting case is related by Mr. Mayo.*** "^Et. 40, natu- rally of a ver)' constipated habit of body, and at the time being on a journey, on striving to relieve her bowels, which had not acted for many hours, felt something give way, to use her own expression, and on the following morning some feces passed ^er vaginam. On exemiination of the vagina an \ rectum, a transverse rent was found two inches within the parts, sufficiently large to admit the end of the finger." (Observations on Injuries and Diseases of the Rectum, by Herbert Mayo, London, 1833. p. 13.) 80 LACERATION OF THE RECTUM. in others into the peritonial cavity. I once wit- nessed a case in which the end of an umbrella was projected, in the act of sitting on it, into the rectum, and, passing on obliquely, perforated the recto-vaginal partition. Third sjyecies. The vagino-rectal partition, sphincter and perineum, are sometimes, though rarely, lacerated. This is most commonly pro- duced by the head or buttocks of the child being directed so far backward, that when the uterus contracts, the recto-vaginal partition is forced down- ward before the head of the child, and protruded through the dilated anus, and then ruptured from ■v^thin outward. In 1833, I accouched Mrs, W., the mother of several children, who was in an ad- vanced stage of consumption. Her pains advanced so rapidly, that on my arrival I made an examina- tion, when I found that the head of the child was forcing down the vagino-rectal partition, and had dilated the anus to a great extent. With as little delay as possible, I turned her on her back and gave the head of the child an inclination forward, so that the delivery was safe and rapid. In the treatment of the different lacerations of the rectum, the patient should be confined to the hori- zontal position, and put upon a meagre diet; the lacerated parts should be kept clean, cloths satura- ted with lead water and laudanum ought to be ap- plied, and the bowels kept easy with emollient LACERATION OF THE RECTUM. 81 enemata, until suppuration is established. If there be much fever, blood should be taken from the arm ; and, provided the surrounding parts be unduly in- flamed, leeches may be applied. When granulations sprout up, we should cease administering enemata, and, on the contrary, give small doses of laudanum to suspend the alvine evac- uations during the healing process. It is only at this period, that sutures should be inserted; for in the many cases I have witnessed, I have never seen one in which union by the first intention took place. This I think may be accounted for by the profuse- ness and irritating character of the vagrinal dis- charge. When the sutures are inserted in the first instance, they are put upon the stretch by the sub- sequent tumefaction, and having partly cut their way out, they become quite loose, and consequently are useless during the process of granulation. When the rupture only extends through the sphincter and mucous membrane, I do not think that the sutures commonly used are always suffi- cient to accomplish the desired end ; because they do not extend to the bottom of the cleft, consequent- ly, while they retain the superficial parts in contact, the internal or deeper portion of the wound receives the vaginal discharge, which by distending it, keeps the sutures on the stretch, and finally works out be- neath them. That this is not always the case, espe- cially when the laceration is moderate, I am well 11 82 LACERATION OF THE RECTUM. aware ; but that it frequently is, particularly when they are inserted immediately after the accident occurs, I have had many opportunities of satisfy- ing myself . To obviate the inconvenience which I have ascri- bed to the interrupted suture, I have devised a pin which is represented in plate viii. fig. iv. This instrument is as thick as that used for hare-lip, and consists of three parts. The first, which is made of silver, is from one and a half to two inches long, curved as represented in the plate, termina- ting at one end in a female screw, and at the other in atransverse shoulder about a quarterof an inch long. The second is a triangular steel pin, exactly resem- bling that used for hare lip, and screws into the extremity of the first portion. The third is made of silver, and resembles the transverse shoul- der of the first portion, with this exception, that a small male screw passes vertically from its centre, so that it may be fixed into the first portion, when the second is removed. This instrument is to be used in the following manner : the first and second portions being united, provided the tumefaction has nearly subsided, and granulations are formed, the patient should be brought to the edge of the bed, her hips elevated, and her knees approximated and carried towards the chin. The parts being now cleansed, the needle ought to be dipped in oil and in- serted into the left side of the perineum, aline more LACERATION OF THE RECTUM. 83 than half the breadth of its curve from the edge of the wound, and immediately above the verge of the anus. AVhen it has passed vertically for a distance equal to two thirds of the depth of its curve, its point should be projected transversely, so as to cross the bottom of the wound, and then carried outward through the other side of the perineum. This stage of the operation will be greatly facilitated : firstly, by pressing out the left labium during the transmission of the needle through the left portion of the perineum and the base of the wound ; and secondly, by steadying the right side of the perineum, with the extremity of the thumb placed immediately without the point through which we desire the needle may pass. When the puncture has been completed, the steel pin should be unscrewed and the third portion fixed in its stead. If it be thought advisable to insert a smaller pin higher up, it may be done, and then a thread should be twisted over their extremities, as in hair-lip. It may be prudent to place a light bolster of lint beneath the twisted ligature. This method , of operating was first carried into effect, in the alms-house of this city, by my friend Dr. Steven- son, who, not only in this, but on other occasions, afforded me opportunities of testing chirurgical innovations. About eighteen months ago, a lady came from the country, to consult me concerning a rent of this de- scription, of five months standing. On examination. 84 LACERATION OF THE RECTUM. I found that the surface of each hp of the wound had cicatrized separately, but from the entangle- ment of feculent matter and leucorrheal discharge of an acrid character, she was continually torment- ed with excoriation and tumefaction of the parts, which rendered her situation most miserable. I recommended the use of zinc lotions, frequent ablu- tion, enemata, low diet, and the horizontal position. In a few days all irritation having ceased, I then excised the new skin from the surfaces originally wounded, and inserted two pins as described above. The horizontal position was maintained, her bow- els were quieted with small but frequent doses of opium, and she was allowed nothing but broths for eight days. At this period the rectum was washed out with warm flaxseed tea, and on the ninth day the pins were removed. A complete cure followed. When the rectum is ruptured above the sphinc- ter, provided the rent be not large, it will generally heal : firstly, by keeping the patient on a meagre diet, enforcing the horizontal position, and relieving the bowels with enamata, provided the peritoneum be not lacerated, and with castor oil if it is ; and se- condly, when suppuration is established, by exhibit- ing opium to quiet the bowels for a few days. If, however, the wound does not heal, its edges should be pencilled with lunar caustic In the case above alluded to, in which the rectum was torn bv the LACERATION OF THE RECTUM. 85 extremity of" an umbrella, the edges of the wound required three applications of caustic before they adhered. Though I have not seen or read of such a case, it is only in accordance with our knowledge of therapeutics to say, that some few of this kind may require the application of the actual cautery. When the recto-vaginal partition, sphincter and perineum are torn through, the case assumes a very serious aspect. I have never seen but one of this character, and that was in the person of Mrs. D., who, in 1828, had a dreadful accouchment. Thir- teen months after this, when the surfaces of the wound had healed separateh', and all the parts were puckered, tumid and partly excoriated, after having removed as far as possible the existing irritation, I performed the following operation. Having placed her as in the operation for stone, I excised the edges of.the wound on a wooden gorge- ret, and passed two sutures, each half an inch apart, through either lip of the recto-vaginal septum, and then tied them in the vagina. F inally, I inserted one of the perineal pins as described in pages 82-3. The sutures and pin were removed on the eighth day, when all the parts appeared firmly united. I may say that I experienced no difficulty in passing the sutures, which I attribute to the employment of small curved needles, (see plate viii. fig. vii.) and the pince porte aiguille, of Dieffenbach. The treat- 86 L4CERATI0x\ OF THE RECTUM. ment subsequent to the operation, was similar to that of the last case. Before I quit this subject, I ought to mention that some surgeons have divided the sphincter in order to remedy rupture of the rectum. I have already demonstrated that the majority of cases styled rupture of the rectum, are in reality cases of lacera- tion of the anus, the rectum being intact. It is only in such cases, therefore, that the division of the sphincter, if an appropriate remedy, can be ap- plicable. I think I have clearly shown, that other means, of a less severe character, suffice for the re- paration of this injury. CHAPTER VI. INFLAMMATION OF THE RECTUM. Inflammation of the rectum arises from a variety of causes — as, the introduction and extraction of foreign bodies — the lodgment of indurated feces, biHary or alvine concretions — ascarides — hemor- rhoids — repelled dartrous and other cutaneous erup- tions — gout* — rheumatism — the application of cold and wetf — surgical operations — and acrid secretions, produced by a vitiated state of the system, disease of some other viscus, or the action of drastic purga- tives. ' * This disease is manifested by a sense of fulness, weight, burning and throbbing in the fundattient, which is increased by sitting erect. The act of de- fecation is accompanied with and followed by severe ♦ In two cases, I could not trace inflammation of the rectum to any of the causes mentioned in the text; both patients, however, were subject to gout. One of them had repeatedly suffered from inflammation and excoriation of his throat, which was invariably a precursor of a gouty attack. In both cases the inflammation of the rectum was reUeved by the appearance of gout in the foot + Coach driver.s, from silting on cold and wet seats in winter, are very subject to inflammation of the rectum. 88 INFLAMMATION OF THE RECTUM. pain, which, from the contraction of the sphincter ani, assumes a spasmodic character. The heat of the intestine is much increased, as may be ascer- tained by the introduction of the finger, which, how- ever, is attended with horrible suffering. There is considerable fever. The urinary organs sym- pathize — there may be disury, strangury, or even retention of urine ; the first and second of these arising from actual inflammation of the trigone vesi- cate, and the third from spasm of the perineal mus- cles. After the disease has continued for some time, the cellular tissue external to the rectum be- comes engorged, and if the primary affection be not removed, suppurates. Occasionally, the peritone- um becomes inflamed, and the patient's suffering and danger are thereby much increased ; but, fortunate- ly, this is a rare occurrence. In some cases, par- ticularly in robust persons beyond the meridian of life, hemorrhage occurs from time to time, especial- ly after stool, and invariably brings relief. The in- flammation sometimes extends to the colon, and then %, new series of sj^mptoms set in, viz : tormina, tenesmus, muco-sanguinolent evacuations, andacon- siderable increase of fever. Females are sometimes tormented with bearing-down pains, and profuse mucous discharge from the vagina. It not un- frequently happens that after the disease has con- tinued a {q,w days, an abundant purulent secre- tion takes place, with which the pain, burning and INFLAMMATION OF THE RECTUM. 89 throbbing subside, the febrile symptoms disappear, and complete restoration rapidly ensues. Some practitioners are alarmed at the appearance of this discharge, supposing that it indicates an extension of the inflammation to the colon ; therefore, it is well to know that the feces are of their natural aspect in inflammation of the rectum, while in dysentery they are mixed up with blood and mucus. In the treatment of this affection, the first object should be to ascertain the cause which has produ- ced it. If it has arisen from the lodgment of fo- reign bodies, alvine concretions, or indurated feces, they ought to be extracted ; if from ascarides, ver- mifuge medicine should be exhibited, and in some rare cases, in which they are very abundant, it may be desirable to extract them.* These objects being attained, the bowels ought to be washed out with flaxseed tea, great care being taken in the intro- duction of the pipe of the syringe. If the fever be violent, blood should be taken from the arm ; but under ordinary circumstances, the application of ]eeches around the anus will serve the purpose of general blood-letting.f Ten or twenty ought to be applied, according to the urgency of the symptoms, and repeated daily until the inflammation is evident- ly on the decline. When the leeches drop off', the • See Chapter iv. and xir. + When leeches are applied immediaiely to the verge of the anus, they in- '.reasethe irritation. 12 90 INFLAMMATION OF THE RECTUM. patient should, if possible, sit over the vapour of warm water, so as to encourage the bleeding, and when it ceases, cataplasms of flax-seed meal, satura- ted with laudanum, ought to be applied and chang- ed every three hours. Diluent beverages may be taken freely, but every other species of injesta should be strictly prohibited. If there be symptoms of peritonitis, blood ought to be taken freely from the arm, and a large num- ber of leeches, followed by anodyne fomentations, applied to the abdomen ; calomel and opium should be administered according to the urgency of the symptoms, and counter irritation established on the lower extremities. Should there be dysenteric symptoms, general blood-letting may be necessary, especially in robust individuals ; but leeches applied to the anus will answer in the majority of cases.* Small starch ene- mata containing laudanum, anodyne fomentations to the abdomen, stimulating pediluvia and small doses of blue pill, ipecacuanha and opium, will gene- rally be sufficient for the removal of these symptons. When women suffer from bearing down pains, anodyne enemata and warm hip baths afford them most relief ♦ The advantage of applying leeches to the interior of the anus in dysen- tery, arises from the free bleeding which ensues in consequence of the great vascularity of the part, and the free connexion between its -vessels and those of thepart intlanied. INFLAMMATION OF THE RECTUM. 91 Strangury and dysury require no other treatment than the warm hip bathing ; but should there be retention of urine, we ought, in addition to the reme- dies already mentioned, exhibit a full dose of mor- phine. In case this fails, a solution of tartar emetic should be given every ten minutes until it produces vomiting ; when, if it does not produce the desired effect, as a last resort, a gum elastic catheter ouoht to be cautiously introduced. CHAPTER VII. INFLAMMATION AND EXCORIATION OF THE ANUS. These affections are generally combined and may be produced by long continued walking or ri- ding on horseback, the passage of irritating secre- tions, or want of cleanliness. Obesity and warm weather strongly predispose to them. When they arise from excessive walking or riding on horseback, nothing more will be necessary than to keep the bowels easy with enemata, to wash the parts three times a day, to dust them with hair pow- der or lapis calaminaris, to place a fold of old linen between the buttocks, and to enjoin the horizontal position. Should they depend upon irritating secretions produced by cathartic medicine, they will subside when the purgation ceases. If they co-exist with diarrhoea or dysentery, they will disappear with the cure of these diseases. When the secretions, how- ever, become vitiated from luxurious living, it will be necessary to enforce a vegetable diet, to exhibit 94 INFLAMMATION AND EXCORIATION. blue pill and cathartic extract at night, and Rochelle or Epsom salt in an infusion of senna, quassia, or some such preparation, on the following morning. This course should be continued until the alvine discharges become healthy. The local treatment necessary in each of these cases, is similar to that specified above. When they arise from want of cleanliness, the hair and discharge become matted together, and thus form a crust, which covers the excoriated sur- face. Under such circumstances, the parts ought to be poulticed until the crust becomes so soft that it can be removed without cutting the hair, for should this be done, as I have once seen, the irrita- tion created by the stumps will increase the inflam- mation, protract the healing of the suppurating sur- face, and render the patient exceedingly uncomfor- table, until the hair has again acquired sufficient leno^th to diminish the friction of the buttocks on each other.* After the parts are sufficiently cleansed, a saturnine cataplasm impregnated with laudanum should be applied, and changed every six hours, at which time the diseased surface ought to be washed with cold water and the common yellow soap. An emollient lavement may be taken daily, the hori- zontal position maintained, and a low diet strictly * Excision of the hair surrounding the anus, without the co-operation of any other cause, may give rise to more or less inflammation of the integument* fn this region. OF THE ANUS. 95 observed. In some cases, particularly those of long standing, it is sometimes necessary, to use lotions of the sulphate of zinc or nitrate of silver. The ointments of the oxide of zinc, superacetate of lead, white precipitate, or nitrate of mercury, are also very useful remedies. CHAPTER VIII. INFLAMMATION OF THE RECTUM AND ANUS, ARISING FROM THE APPLICATION OF GONORRHCEAL MATTER. In c»ses of this kind, in addition to the symptoms of inflammation mentioned in the two last chapters, there is profuse purulent discharge from the com- mencement, which produces excoriation of the anus, and in some instances, a considerable portion of the adjacent parts. In the treatment of this disease, besides the means recommended in the chapters alluded to, in- jections ought to be employed. Those of the su- peracetate of lead, sulphate of copper, and more especially of the nitrate of silver, in the proportion of five or ten grains to an ounce of distilled water, are the most appropriate.* * Valpeau recommends Howard's calomel in a decoction of marsh-mallows, in the proportion of a drachm to an ounce. He also entertains a good opin- ion of a white precipitate ointment. (Diet, de M^d.) 13 CHAPTER IX. FISSURE OF THE ANUS. The disease so named is an ulcer, about the eighth of an inch in breadth, and from a quarter to an inch in length, situated immediately within the anus, generally on one or both sides, occasionally on the posterior, and still less frequently on the anterior part of the aperture. In the majority of cases it is confined to the mucous membrane, though occasionally it extends to tlfe muscular tissue.* Its inferior extremity generally corresponds to the edge of the external sphincter, though sometimes * Merat says, " Le tissu affect^ est la membrane muqueuse, mais il n'est pas rare que I'ulceration depasse son niveau, et gagne la portion musculaire de Fin- testin." (Dictionaire des Sciences Medicales, tome xv. p. 544.) Dupuytren and Blandin assert that the ulceration rarely extends through the mucous membrane. " Cette ulceration n'attientque trfes rarement toute I'epais- ,seur de la membrane muqueuse." (Lemons Orales par Baron Dupuytren, tome iii. p. 284, Paris, 1833.) " Cette ulceration n'attient que rarement toute I'epais- seur de la membrane muqueuse," (Blandin, Dictionaire de Medicine et de Chirurgie Pratique, tome viii. p. 156.) From the above statements we may fairly infer that these authors differ with Merat, as to the possible extent of the ulceration, especially as they make no mention of its attacking the muscular tissue; however, they all admit the occasional destnirtion of the entire thick- ness of the mucous membrane. 100 FISSURE OF THE ANUS. it is placed a little higher up or lower down.* The base of this oblong ulcer is generally red, but sometimes gray, in consequence of the deposition of lymph. When recent, its edges are soft, pliant, and but little elevated ; in proportion, however, as it becomes chronic, so are they more hard and pro- minent, changes which depend upon the interstitial deposition of adventitious matter from the irritated capillaries. The surrounding mucous membrane is in its na- tural state in some cases, particularly when recent, but not unfrequently it wears an erysipelatous hue, and again assumes a livid aspect, and becomes soft. Women are more subject to this affection than men, which arises from their leading more seden- tary lives, and, consequently, being more subject to constipation of the bowels. It generally occurs in the meridian of life ; nevertheless, I have treated a case in a girl of eighteen, and another in a woman of sixty-nine years of age.f ♦ Bland in has described both rhagades and ulcers above the sphincter under appellation of fissure, (Op. cit. p. 158.) As far as the orthography of the term goes, no objection can be offered to his arrangement, viz: — Les fissures infirieures an sphincter. Les fissures superieuers au sphiricter de Vanus, and Us fissures a Vanus qui sont placees au nii'eau du sphincter. Yet, I think that for pathological purposes, fissure a Vanus, may be judiciously limited to the affection described by Boyer. + Boyer says, " les adultes paraissent 6tre exclusivement sujets ft. cette mala- die; je ne I'ai jamais vue chez des enfans ou des adolescens. La plupart des personnes qui en ont 6i6 atteintes etaient ft.g^es de vingt cinq a. quarante ans ; quelques une* <5taient au dessus de cet ft,ge, une seule avoit plus de soixante ans. Aiicune classe de la sncicte n'cn parait etre k I'abri : les deux sexes y sent FISSURE OB' THE ANUS. 101 In the majority of cases it is preceded by vascu- lar tumours of the rectum ; then it is situated between two of them, and is produced by the for- cible passage of indurated feces. In this act the vascular tumours are first prolapsed, and then sepa- rated, during vv^hich process the mucous membrane, rendered friable by inflammation, is ruptured. The contraction resulting from operations performed in this region, and the spasm of the sphincter, by opposing the free egress of the feces, become a frequent source of fissure in the former, by disposing to rupture, and in the latter by contusion and abra- sion of the mucous membrane. In the three different instances I have mentioned* the larceration of the mucous membrane does not heal, because the primary affection still continues, and even in some instances, as heretofore explained, (see chapter v.) the rupture is converted into an ulcer, though no primary affection existed. Besides the causes now specified, inflammation, and consequent abrasion, may, from the columnar arrangement of the mucous membrane of the lower extremity of the bowel, give rise to one or more fissures.* egalement exposes ; mais les femmes en sont peut 6tre attaqu^es plus souvent que les hommes." (Traitd des Maladies Chirurgicales, tome v. p. 63, Bruxelles, 1828.) ♦ Dupuytren says, " le virus vdn^rien ou d<^pose imm^diatement sur la marge de I'anus comme dans un coit contre nature, on ayant reflu^ des organes g^ni- taux vers cettc overture, comme cela arrive chez beaucoupde femmes, est une cause tres commune de ccs nfiections." (Op. cit., p. 28.5.) 102 FISSURE OF THE ANUS. In the commencement of this disease the symp- toms are not severe, being merely, at one time, a pricking or stinging sensation, at another, a sHght smarting in a certain point of the anus, which, under the use of lavements and low diet, subsides either altogether, or, after a few days, returns with some severity. The pain, gradually increasing, becomes burning, sometimes lancinating, and when severe, throbbing. It is increased by forced expirations, as coughing, sneezing, and urinating. Every effort to discharge gas and feces, is attended with excru- ciating torment, which continues for one or more hours, attended with violent spasmodic action of the sphincter ani. So violent is the agony, that most persons thus afflicted put off" the calls of nature, maintain the recumbent position, and some even avoid taking a proper quantity of nourishment, for fear of increasing the fecal mass. The pain is always increased by stimulating food, and in females during menstruation. Occasionally I have seen it assume a periodical character, which depended Blandin agrees with Dupnytren in this opinion ; he says, " Au primier rang nons placerons le vice venerien, soil que la sanie impregn6e de ce principe mor- bide ait cte deposee directement sur la marge de I'anus, comme, dans le coit contre nature ; soit que eette matiere impure ait flu<3 des organes genitaux vera I'anus, et ait irrite cette partie par son contact, comme nous Tavons observd chez plusieurs femmes; soit enfin que les fissures puissent etre considcr^es comme le produit local d'une syphilis devenne constitutionnelle." (Op. clt. p. 156-157.) That venereal matter, when deposited on the verge of the anus, will produce ulceration, no one can doubt; but such cases do not deserve the appel- lation of fissure. See note, p. 100. FISSURE OF THE ANUS. 103 upon some peculiar state of the constitution * When the feces are solid, they are slightly streaked with blood and matter, and when more soft, are figured, and of small size. To examine the fissure, the buttocks should be forcibly divaricated, when its inferior extremity will be brought into view ; but in some rare instances we cannot accomplish this object, in consequence of its elevated site, and we are compelled to trust either to the introduction of the finger, or to the dilatation of the anus with the speculum for its de- tection. In a few cases, though it is immediately discovered upon separating the buttocks, we can only ascertain its length by the means just men- tioned. The introduction of the finger is attended with great difficulty and torture, particularly when pres- sure is made on the fissure, which seems, in some instances, to be a mere depression, in others, to be surmounted by pretty high edges, while in a few rare instances, we only become cognizant of its situation by the increase of suffering in a certain point, under the same amount of pressure. * Merat says, " II font ajouter que la douleur a des especes d'acc6s, et que parfois elle cessc d'une maniere inattendue, de m6me qu'elle vient aussi sans cause appreciable, et sans qu'il soil rien arriv6 qui ait pu la provoquer. Cette douleur parait due li la retention des matiferes sur I'extremite du rec- tum, dont la constriction du sphincter nc permet pas I'expulsion." (Op. cit.) That the presence of fecal matter in the lower extremity of the rectum may cause pain, will he readily admitted; but how are wc to account for its sudden cessation. To be sliort, I have tested Merat's explanation, by thS introduction of the finger, without verifying it. 104 FISSURE OF THE ANUS. When the pain is violent during and after stool, it is accompanied with fever ; and when it con- tinues for any length of time, emaciation, hypo- chrondriasis, and an irritable state, with a severe train of nervous symptoms, ensue. During the treatment of this disease, the patient should be kept on a low diet, and confined to the recumbent position. The common practice of administering cathartics, so as to produce fluid evacuations, cannot be too highly censured, — for such discharges stimulate the ulcerated surface, and thus induce dreadful irritation and spasmodic contraction of the sphincter ani; therefore, the better plan is to administer daily an enema of flax- seed tea, and after its operation to cleanse the parts well. If the disease be mild, the application of the unguentum acetatis plumbi will be sufficient for its healing, and if there be much spasm of the sphinc- ter, the extract of belladonna will prove a power- ful auxiliary. Dupuytren recommended an oint- ment of this kind, the proportions being a drachm of the lead, and the same quantity of the bella- donna, to six drachms of lard. Before I became acquainted with his practice, I was in the habit of applying the nitrate of silver to superficial fissures attended with spasm, and then introducing meshes of lint, besmeared with a mass consisting of one part of the extract of belladonna, and seven of spermaceti ointment, a course of practice which FISSURE OF THE ANUS. 106 has succeeded when Dupuytren's ointment has failed.* When a fissure will not heal under this treatment, and the patient continues to suftbr, we should no longer delay the division of the sphincter, which never fails to give immediate relief, and to effect a rapid cure.f To perform this operation, the patient should be placed opposite a window, couched on his side ; an assistant ought to separate the buttocks, and retain them so during the operation. The surgeon having oiled the fore-finger of his left hand, inserts it into the anus as far as the second joint, and uses it as a conductor for the knife, delineated in plate viii., fig. iii., whose blade is two inches long, and one eighth broad, with a blunt extremity. Having passed the blade flatwise as high as the superior border of the internal sphincter, he then turns its edge towards the fissure, provided it be on the side of the bowel, and divides both sphincters, by cutting from within * I have lately had a case under my care, (since the text was written,) in whiih I adopted this practice with the following results: — one hour after the application of the caustic, dreadful pain ensued, which continued for eight hours, though he took morphine freely, and sat in a warm hip bath. Ice was then applied, and he obtained immediate relief. On the following evening theljelladonna ointment was employed, and the pain immediately returned, but was soon allayed by ablution and the application of ice. The bowels were relieved on the morning of the third day with an injection of flax-seed tea and sweet oil, and as he continued free from pain, I applied the ung. acet. plumb., under the use of which, emollient enemata, low living, and the horizontal po- sition, he soon recovered. •^ This operation was first devised and performed by Boyer. (Op. cit.) 14 106 FISSURE OF THE ANUS. outwards, gradually increasing the pressure so as to ensure the complete section of the external muscle. Provided a fissure exists on the opposite side, it ought to be treated in the same manner. When the posterior or anterior portions of the intestine are the seat of disease, as the division of the sphincter and not the fissure, is the desirable object, the incision ought to be made on the side ; because in this way, the external sphincter can be safely, yet perfectly, cut across, and the inconve- nience arising from the shortness of the space be- tween the coccyx and verge of the anus, the prox- imity of the bulb of the urethra in the male, and the shortness of the perineum in the female, is avoided. But there is also another objection to the performance of this operation in the median line, viz. : the difficulty in healing wounds in this situa- tion, in consequence of the friction created by the motion of the inferior extremities. After the he- morrhage ceases, dossils of lint should be placed in each wound, and secured by a compress and T bandage. A full dose of morphine ought to be ex- hibited, and nothing but toast water, broths, gruel, and the like, allowed for two or three days. The dossils of lint, compress and bandage, should then be removed with great care, the bowels washed out with an emollient lavement, and fresh dressings applied. This course ought to be pursued daily, gradually diminishing the size of the dossils of lint, FISSURE OF THE ANUS. 107 until the wounds heal, which will be in about three weeks. I shall now detail a few cases of this painful disease. Mr. D., mentioned in the fifth chapter as ha\'ing a rupture of the mucous membrane, two years pre- viously had a fissure of five weeks standing, with but little induration of its base, elevation of its edges, or spasm of the sphincter. I recommended him low diet, daily lavements, ablution, and the application of the ung. acet. plumbi; under which plan of treatment the ulcer soon healed. Mrs. C. had, for two months, burning pain in the anus, which was particularly distressing after stool,, and was much increased by the erect position. She had become exceedingly nervous, lay upon a sofa during the day, and took scarcely any nutri- ment, fearing the pain which attended defecation. I mentioned to her husband the probability of her complaint being fissure, which on examination proved to be correct. The cre\'ice, however, was not deep, neither was its base hard, yet the sur- rounding membrane was tumid, and the sphincter was in a state of violent contraction. Having ad- ministered an emollient injection, I cauterized the fissure with nitrate of silver, and then applied meshes of lint besmeared with one part of extract of bella- donna, and seven of spermaceti ointment. This treatment, together with low li\ing and the hori- 108 FISSURE OF THE ANUS. zontal position, was continued for about a fortnight ; when the wound had healed and she was restored to her usual state of health. IMrs. B. had for years been troubled with hem- orrhoidal tumours, and for seven months was confi- ned to her room in consequence of dreadful pain in the anus, particularly during and after stool : she was emaciating rapidly, and, being advanced in life, had become very helpless. I was called to see her ; and on examination discovered a large fissure between two piles. (See plate i., fig. i.) I divided the sphincter on the side affected, carrying the knife through the fissure, and conducted the rest of the treatment as above described. In a short time the wounds healed and she was restored to health. Dr. Sickels, of the U. S. Navy, called me to see Mr. P., who for some years had been in delicate health, and at the suggestion of a friend took large quantities of Morrison's pills, which purged him vio- lently, and gave rise to violent burning pain in the anus, aggravated by the erect position, coughing, sneezing, urinating, and thepassage of gas. Defeca- tion produced the most horrid pain, which increased for three or four hours, attended with fever, and then subsided, leaving him weak and exhausted. By this continued suffering for six months, he had become emaciated, melancholv, and so irritable that- he could not bear to be touched. On examination, I found a fissure, with an indurated FISSURE OF THE ANUS. 109 base and elevated edges, on each side of the anus, surrounded by an erysipelatous state of the adja- cent mucous membrane, and attended with most violent spasm of the sphincter ani. Having open- ed his bowels with an injection, I introduced my finger, and on it conducted the knife and divided the sphincters on both sides. The dressings were then applied, and a dose of morphine exhibited. Dr. S. took charge of the case, and when I again visited Mr. P., in about twenty days, the wounds had just healed, he was free from suffering, was gaining flesh, and had returned to his mercantile pursuits. CHAPTER X. NEURALGIA OF THE EXTREMITY OF THE RECTUM.* Though in the fourteenth chapter, I have given three cases of neuralgia of the extremity of the rectum and genito-urinary organs, arising from hemorrhoidal tumours, I have a strong suspicion that the majority of cases described by authors, in which both the anus and genito-urinary organs were said to be the seat of neuralgia, no such dis- ease affected the anus, but that in consequence of irritation in the genito-urinary apparatus, the sphincter ani was thrown into a state of painful contrgLCtion.f Here, however, I ought to mention the only genuine case of neuralgia commencing in the genito-urinary organs, and from thence extend- * Many species of organic disease of the anus, were grouped together by Sauvage, under the genus proctalgia. Montegre, however, was the author who first treated of douleurs tw.rveuses, (Conseils aux personnes affect^es d'ht'morroides, Gazette de sante de 1812-13,) which though frequently coupled with fissure and constriction, he many times observed to be independent of them. tSee Chapter xi. 112 NEURALGIA OF THE EXTREMITY ing to the extremity of the rectum, which has come under my observation. A physician of middle age, active habits, and tolerably good health, but of a nervous temperament, was subject to occasional attacks of neuralgia of the face, stomach, and testi- cles. Twice or thrice in the year, he would be seized with pain over the pubes and a desire to micturate, which generally subsided in twelve or twenty-four hours. More rarely, he suffered ex- cruciating pain in the end of the penis, or in the posterior part of the urethra, attended with a simi- lar state of the extremity of the rectum, but with- out contraction of the sphincter. These attacks were generally either preceded or followed by neuralofia elsewhere. He tried various remedies o without advantage, and at last contented himself with pressure during the paroxysm, which he thought was always considerably moderated by this expedient.^ I shall now give the outline of three cases, in which the disease seemed to be confined to the ex- tremity of the rectum. In 1829, I was called to see Mrs. H., a nervous lady, about thirty years of age, who, for several months, had suffered from lancinating pain in the extremity of the^ rectum. For weeks this pain would be very severe, and then nearly, but not ♦Campaignac has described a case of " Nevralgia ano-genito-urinaire." This appellation houses after his master, Mr. Roux. (Journal Hebdomodaire de Medicine, tome ii. p. 405. Paris, 1829) OF THE RECTUM. .1 ] 3 altogether subside. Her distress was greatest to- wards the close of the day, and then she was com- pelled to go to bed and take hlack drop. Changes of temperature had a baneful influence on her, not only increasing the pain in the anus, but rendering her restless and melancholy. Her bowels were generally constipated, to remedy which she generally took three doses of magnesia every week. During defecation her distress was very much in- creased, especially when the excrement was hard. I examined the parts with great care, but could not detect any organic lesion. There was no spasm of the sphincter, and she bore pressure on every part of the rectum that the finger could reach without pain, save on a spot about the size of a shilling on the left side of the intestine, rather less than half an inch above the verge of this orifice, which was so exquisitely tender that she screamed out when the finger was pressed against it. I recommended her to try anodyne suppositories, blue pill, and the car- bonate of iron ; but never heard whether she deri- ved any advantage from this course of treatment. In 1831, I witnessed another case of this kind, in the person of Mrs. E., a delicate lady, of nervous temperament, aged twenty-five. She informed me that for three years she had laboured under some disease of the anus, which commenced insidiously, and without any known cause.* She had become * Tlie followinfi; opinion of Montogre as totlie muse of tlirsp pains may not 15 114 NEURALGIA OF THE EXTREMITY irritable, desponding and emaciated. Her bowels were never moved without medicine, which she had recourse to every alternate day. During the fecal discharges, and for some time afterwards, she invariably suffered the most excruciating pain, which was attended with involuntary contractions of the sphincter. For some months past, she was never entirely free from pain, and for weeks togeth- er it assumed a periodical character, gradually in- creasing every afternoon, and then mitigating in about three or four hours. Atmospheric changes never failed to affect her, — the pain, when stormy weather was about to take place, being most ago- nizing. Wliile suffering severely, I made an exami- nation of the parts, but could not discover any struc- tural derangement; howevei', the sphincter was so forcibly contracted, as to render the introduction of my finger, not only exceedingly difficult, but pain- ful ; and one point of the gut, a few lines above the anus, on the right side, was so tender that, when I touched it, she was thrown into the greatest agony. I therefore carefully examined the parts, thinking that I might detect a fissure, but my conjecture was not realized, for the painful point in every respect be uninteresting to the reader. " Je les regarde comme.une complication quipeut survenir dans toutes les maladies longnes et graves de I'anus, mais sp^ciale- mcnt h, roccnsion des r^cidives frcqnentes d'acccs hemorrhoidaux." Again, he says, "elles succfedent souvent aux doulcurs inflammatoires, et persistent encore apr^3 la destruction dc la cause sous I'influence de la laquelle elles se sont manifestoes." OF THE RECTUM. 115 appeared perfectly healthy. I endeavoured to re- lieve her by purgatives, iron, quinine, arsenic, lave- ments, opiate suppositories, and the introduction of meshes of lint besmeared with seven parts of sperma- ceti ointment, and one of the extract of belladonna; but v\^ithout effect. It then occurred to me that an incision carried through the painful part and the sphincter, was a feasible means of relief I com- municated my views of the case to Mr. E., who consented to the proposed operation, which I per- formed with perfect success. In 1833, I was consulted on the case of Mrs. W., which is the last that I have seen. She was about nineteen years of age, of a fragile constitution, ex- ceedingly nervous, and for seven years had occa- sionally been the subject of neuralgic pains in the face. She had been married between five and six months, and pregnant for three ; during the last six weeks, she was seized every two or three days with violent lancinating pains in the anus, attended, when severe, with alternate contraction and expan- sion of the sphincters of the most forcible and sud- den character ; the latter being productive of a discharge of mucus mixed with a small quantity of blood, and sometimes with feces. During these attacks she was in the habit of folding a napkin into as small a compass as possible, placing it between her buttocks and sitting on a wooden chair.* By *Montegre, when treating of the character of these pains, says, "et alors 116 NEURALGIA OF THE EXTREMITY this expedient she found that her suffering was greatly mitigated, though she was constantly com- pelled to have recourse to morphine. I tried vari- ous remedies, as iron, quinine, arsenic, anodyne enemata, &c., without eff^ect ; however, upon quick- ening, the pain ceased, and did not return until last spring, when she was again pregnant ; but upon her miscarriage, which occurred on the third month, it again vanished. I may mention, that after this lady weaned her child, I have seen her nearly deranged with neural- gia of the face. This case is not exactly like either of the pre- ceding, as there was no part of the extremity of the / bowel more affected than another, and the pain, which was not constant, instead of being increa- sed, was relieved by pressure ; yet that they were all cases of neuralgia, there can be no doubt.* chose remarquable, la compression les soulage." Valpeau has expressed the Tery opposite opinion, (Diet, de Med. ed. 2d. tome iii, p. 282.) As these cases demonstrate, both authors are in error, and the cause has been the same in both instances, viz: an avidity to draw general conclusions from isolated facts. * Mr. Mayo relates the following curious case of this disease; " I attended a patient with Mr. Stephenson of the Edgewaro Road, who suffered from pain in the rectum. Something less than two years before this, he had a syphi- litic ulcer on the penis, for which he had taken an unusual large quantity of mercury, owing to the difficulty of producing sensible mercurial action on his system. The ulcer, however, healed; but while he was i-ecovering, and his system was yet charged with mercury, he began to experience aching pains in the incisor teeth and in the rectum. The sense of aching in the teeth and in the rectum was not constant, but would come on frequently during the day, without any assignable cause. It had lasted a year and a half, during which he remained perfectly free from symptoms of Icues. This patient, wlio was OF THE RECTUM. 117 otherwise in good health, suffered his mind to be greatly distressed by the continuance of the neuralgia. He was anxious to try every plan which held out the least promise of benefiting him. But of all the remedies which he tried, he appeared to experience relief from one only, which was a course of sarsaparilla," (Observations on Injuries and Diseases of the Rectum. Lon- don, 1833, p, 5G-7.) CHAPTER XL SPASMODIC CONTRACTION OF THE SPHINCTER ANI, In the ninth chapter it has been demonstrated, that spasmodic contraction of the sphincter ani may be produced by fissure ;* while in the tenth and *Boyer says: " EnefFet, la gercurede I'anus est constamment accompag^ n6e de la constriction spasmodique des sphincters ; mais cette constriction existe quelquefois sans gerciire, peut-etre meme celle-ci n'est-elle qu'un effet ou une complication de la premiere. Nous avons observ6 bien plus souvent la fissure, ou, si Ton veut, la constriction avec fissure, que la constriction sans fissure. Nous avons trouve entre le nombre relatifde ces deux mala- dies, ou de ces deux (;tats de la meme maladie, la rapport de neuf h. un ; viola. notre excuse. II est probable cependant que lorsque la constriction et la ger- cure existent, ces deux aflTections n'ont pas commence simultandment ; ou lagercurea amen^ la constriction, ou la constriction a precede la gercure; de sorte que I'une de ces affections seriat primative, et I'autre accessoire ou con- secutive; maisjen'ai jamais vude gercjre sans constriction, etj'ai plusieursfois recontr6 celle-ci sans fissure. L'incision des sphincters fait disparaitre la fissure, sans qu'il soit necessaire de porter sur elle I'instrument tranchant, on pouvrait presumer d'aprfcs cela, ce me semble, que I'affcction principale est le resserre- ment spasmodique." (Op. cit. p. 64-5,) Dupuytren entertained the same opinion. " La fissure n'cst meme qu'un accident; ce qui le ddmontrcrait c'est I'existcnce de la constriction douloureusc sans gercure, qui d'apres des chirur- giens celfebres, serait &, I'autre cas comme 1 est d 4." (Op. cit. p. 284.) On the other hand, Blandin, after explaining the views of Boycr, remarks : "La 120 SPASMODIC CONTRACTION fourteenth, it is proved to be occasionally the conse- quence of neuralgia. But besides these there are two other species of spasmodic contraction of the sphinc- ter, viz : that which depends upon functional or structural disease of the glenito- urinary organs, and that in which we cannot trace any other pri- mary affection, either in the rectum or elsewhere. The following outline of cases will illustrate the species of disease in which the genito-urinary or- gans are primarily affected. Mr. O., a grocer, twenty-eight yeai's of age, robust and of good habits, in 1830, being about to enter into the matrimonial state, consulted me for an affection of the urinary organs, which, from his account, I took to be stone in the bladder, I there- fore sounded him very cautiously, but without being able to find a calculus. As he complained of spas- modic pain in the lower extremity of the rectum, constriction spasmodique du sphincter arrive, parce que I'anus est irrit^ par rinflammation de la fissure; elle est tr^s forte quand la fissure est tres-enflammee, surtout elle s'accroit par le passage des matieres fecales pendant les excretions, pour la memo cause. Le sphincter anal se contracte sous I'influence de I'irritation dc la fissure, comme I'estomae, comme I'intestine se contractent lors de I'irritation ou de I'ulceration de la tu- nique muqueuse qui les tapisse. (Op. cit. p. 157.) Sanson also, is an advo^ cateofthis opinion, " Nous croyons au contraire que la fissure, ou aumoins I'irritation de la partie, procede et provoque la constriction spasmodique." (Nouveaux E16mens de Pathologic, &c.,'ed. iii.tome iv. p. 227.) I shall only observe that to me it appears illogical, to assert that fissure is the consequence or a complication of spasm, because the fissure is always accompanied with spasm, and .spasm sometimes exists without fissure. Now, tliat spasm may cause fissure, T have before explainal : but, that fissure may arise from odiPr causes, is, 1 think, beyond disimte. OF THE SPHINCTER ANI. 121 especially when the urinary symptoms were severe and for some time after stool, I proceeded to ex- amine this intestine, when I found the sphincter firmly contracted ; however, all the parts in this region were perfectly healthy. The pain resulting from the examination of both these organs was very distressing, though the greatest possible gentleness was observed. He took pills of henbane, valerian and white oxide of zinc, according to the formula of Meglin, and inserted suppositories of opium and bel- ladonna at bed time, while his bowels were kept easy with lenitive electuary or oil, and I injected his bladder daily with a thin solution of gum arabic and opium. His improvement was very slow, and as I found his urine to be surcharged with lithic acid, I put him upon vegetable food, ordered soda in sufficient quantity to correct the acidity of his urine, and a warm bath daily. By pursuing this course steadily for a few months, wearing flannel next his skin, and sedulously avoiding cold, he entirely recovered, then married, and since has had no return of the disease. In 1831, I was called to Mr. M., who for five years had been afflicted with symptoms of stone, and was repeatedly sounded, both in this country and in Europe, by distinguished surgeons. When I saw him, in addition to the ordinary symptoms of stone, he had close and painful contraction of the sphincter ani; which he informed me had only set 16 122 SPASMODIC CONTRACTION in within six months, and occasionally was almost insupportable. His urine was loaded with acid, and deposited much mucus. Being a man of fashion, he was frequently exposed at night to cold air, from "v^hich he suffered dreadfully ; indeed, if from missing his carriage, he was compelled to walk home at night, he never failed to have a marked change for the worse in all his symptoms. For some time he took the pills of Meglin without any advantage. Then I injected a solution of opium and gum water into the bladder, and ordered a lini- ment containing the extract of belladonna to be rubbed over the pubes and perineum. This plan of treatment being no more efficacious than the first, he consented to try the course which I first recommended, viz: Confinement to the house except when the thermometer was above 60°, vege- table diet, flannel next the skin, warm baths, leni- tive electuary or oil when the bowels were out of order, soda to neutralize the acid state of the urine, and an infusion of buchu as long as a mucous sediment was deposited by the urine. By follow- ing up this course for about nine months, he entire- ly recovered. Mr. A. applied to me last November on account of a hydro-sarcocele. The water was frequently let off by puncturing the tunica vaginalis with a lancet. He was put on a low diet, had leeches applied twice a week, and after the bleeding ceased, linen cloths wet with a lotion composed of sal am- OF THE SPHINCTER ANI. 123 moniac vinegar and water, were kept on the scro- tum. He maintained the horizontal position for five weeks, took calomel and opium in small doses, and underwent two or three courses of purging. Camphorated mercurial ointment was rubbed on the scrotum, and afterwards the gum ammoniac plaster with mercury was applied with- out any advantage. In consequence of the failure of the remedies now mentioned, I proposed exam- ining the urethra, to which he acceded. While passing a steel sound in the most gentle manner, though a very reasonable person, he screamed violently, and the spasm of the canal was so great, that I could not pass the instrument into the bladder. I ordered him a waiTn hip bath, and an ounce of castor oil, with twenty-five drops of laudanum. As no bad symptoms followed this attempt to introduce the sound, I made three more essays, on alternate days, with no better result, the same irritation being manifested on each occasion. In the evening of o the last day on which I endeavoured to pass the instrument, he sent forme, complaining of excessive irritation of the bladder. I ordered warm bathinof, marsh mallows syrup with water, and a dose of morphine. He soon obtained relief; however, on the following day, he had a similar attack, which yielded to the same means, but returned at midnight. In his distress, he had a carriage called, and drove to my house, complaining dreadfully. I recom- 124 SPASMODIC CONTRACTION mended him to repeat the bathing, to continue the marsh mallows syrup with water, and to take, according to circumstances, one or two enemata, composed of four ounces of the mucilage of starch and forty drops of laudanum. At nine o'clock in the morning he wrote me a note, beseeching my attend- ance, as his suffering was dreadful. When I arri- ved, I found him moaning, and the tears flowing down his cheeks. He said that a short time after taking the injection, he was seized with violent pain and contraction of the anus, which subsided ; but returned every ten or twenty mi- nutes. The vesical pain had continued, but was mild, when compared with the other. I now order- ed him a liniment containing the extract of belladon- na, warm hip bathing, mustard cataplasms to the inside of the thighs, and a full dose of morphine. He experienced no relief; therefore, it occurred to me that the better plan would be to revulse on his bowels, with which view, I prescribed for him pills of calomel and cathartic extract, and afterwards a solution of Epsom salt in an infusion of senna. Suffice it to say, that his symptoms soon yielded to this plan of treatment. Mr. H. was seized two years ago, after exposure to wet, with symptoms of vesical inflammation, which continuing in spite of remedies, and being also affected with what he was informed was stric- ture of the rectum, he came to New- York, and OF THE SPHINCTER ANI. _ 125 placed himself under my care. He was emacia- ted and depressed. On examination, I found both the anus and rectum in a state of spasmodic contraction, (more of this case, when treating of stricture of the rectum,) the bladder and urethra in a highly irritable condition, and the urine loaded with lithic acid. I ordered him a vegetable diet, warm hip baths, soda to correct the acid state of his urine, and pills composed of the blue mass and cathartic extract, so as to produce two or three motions daily. It is now three weeks since he came to town, and he is about to return to his home in perfect health. Wm. Birmingham, on whom I operated for stone in 1826, laboured under most painful spasm of the sphincter ani, so that he dreaded an examination by the anus, more than by the urethra. Mr. S., whose bladder I tapped through the rec- tum in 1829, for retention of three days duration, caused by stricture, had so contracted a state of the sphincter ani, that I had to divide it, before I could puncture the bladder. Mr. C, aged 81, who labours under enlargement of the prostate gland, is occasionally seized in the night with spasmodic contraction of the sphincter ani, which causes so much pain, that he becomes alarmingly weak. He is now generally aware of the approach of an attack, which he can always prevent by taking first an emollient injection, then a warm hip bath, and lastly, an enema composed of 126 , SPASMODIC CONTRACTION four ounces of. the mucilage of starch and thirty drops of laudanum. The cases now about to be related are intended to illustrate the species of disease in which w^e. cannot discover any primary affection.* Mr. N., a robust young man and a high liver, con- sulted me last fall, with a view of obtaining relief from a forcible, painful and sudden contraction of the sphincter ani, which occasionally aroused him from his sleep at night, and generally lasted two or three hours. He had been subject to these attacks for eight or ten weeks, and altogether may have had a dozen seizures, for which he could assign no cause. I prescribed a vegetable diet, exercise, a warm hip bath every other night, three grains of blue pill with one of ipecacuanha at bed time, and a teaspoonful of Epsom salts in two ounces of quassia tea on the following morning. Under this treatment he soon recovered, and has not had a return of the disease. Dr. , an eminent physician in this city, ex- ♦ Boyer, after discussing the connexion between fissure and spasmodic con- striction of the sphincter, says of the latter ; " Je crois qu'elle peut etre, comma je I'ai dit ailleurs, congenitale. J'ai vu deux personnes chez lesquelles elle a commenc€ pour ainsi dire avec la vie. La liquidite, la moUesse des matiferes f^cales, dans les primiferes annees de la vie, rendent plus supportable leur ex- cretion; mais i mesure qu'on avance en age, les dejections stercorales devien- nent plus ^paisses plus abondantes, les douleurs del'anusplus aigu^s pendant ct aprea la sortie de mati^res que chaque jour rend plus difficile. L'introduc- tion du doigt cause une douleur tr^s-vive; il est foncment serr«5 ; mais, sur quel- que point de I'anus qu'il appuie, la douleur n'augmente pas. (Op. cit. vol. v. p. 65.) OF THE SPHINCTER ANI. 127 ceedingly muscular, of a nervous temperament, and very subject to mental depression, informed me a short time since that, for seven years past he has been seized, while in his cabriolet, about every three months, with violent contraction of the anus, at- tended with almost insupportable suffering, which, however, soon subsided ; that he was occasionally attacked during the night with paroxysms of much longer duration, but of a less distressing character; and that his feces, when solid, were of smaller di- mensions than natural. In November, 1829, I was called to see Mrs. Q,., who was labouring under what she had been inform- ed was stricture of the rectum. She informed me that in April she had a diarrhea, after which her bowels became constipated, and a train of symptoms exactly similar to that mentioned in the chapter on fissure set in, save that the feces were neither streak- ed with blood nor matter. She had become emacia- ted, restless, feverish and depressed in mind, with a firm conviction that her end was drawing near. On examination, I could not discover a fissure, nor that any one point was more tender than another ; but the anus was closed so firmly, that I could only enter my finger with difficulty. I prescribed a light nutritious diet, hip baths daily, a tablespoon- ful of castor oil every morning, and the introduc- tion of meshes of lint, besmeared with one part of the extract of belladonna, and seven of lard. As she did not improve under this course, I substituted 128 SPASMODIC CONTRACTION the bougie for the Hnt; but so painful did this remedy prove, that I had to abandon it. Then, I divided the sphincter as in fissure, the result of which was a rapid cure. The only other case which I have seen was that of Miss D. When I was called to her last spring, the symptoms which had existed for a number of months, and had come on gradually, were precisely similar to those of the preceding case. This lady was about twenty years old, and very delicate. She had been treated very judiciously for some months, with bougies and internal remedies suited to her symptoms, without any advantage. I ex- amined the parts carefully, but could not discover any structural disease, nor did the introduction of the finger through the contracted sphincter pro- duce any more pain in one part, than in another. I divided the sphincter, and in less than a month she was up and well. As the four cases now related are the only sub- stantive forms of spasmodic contraction of the sphincter ani that I have observed, I am disposed to consider it as a rare disease,* though I have wit- nessed many cases in which the sphincter was some- what contracted, particularly in costive habits ; but from the absence of pain, even when the finger was cautiously introduced, I should think it improper * Doctor BaiUie saw but one case. (Transactions of the College of Physi- cians of London, vol. v.) In like manner, Mr. Colics witnessed but one case. (Dublin Hospital Reports, vol. v. p. 1 IP. Dublin, 1830.) OF THE SPHINCTER ANI. 129 to class them with the affection now under con- sideration.* * Some may object to the arrangement of the two last chapters ; but in ex- tenuation of my plan, I would say, that though future experience may lead to a different classification, I am almost certain that the cases are so grouped, as to render them most useful, and, therefore, most likely to serve the purposes of some future writer on this subject. The import of the word neuralgia, is too well understood to need any ex- planation from me. That the cases I have described under this head, merited such a place, will scarcely be doubted ; but whether those described under the title of spasmodic contraction of the sphincter ani, should not be placed under the same head, is the question. I would just remark, thru I think they ought not to be so arranged ; because neuralgia of the anus can not only exist with- out contraction, but with relaxation of the sphincter ; and it is no reason be- cause contraction of this muscle is sometimes combined, and in such cases, is in all probability the consequence of neuralgia, that spasm of the sphincter, because painful, merits the appellation of neuralgia. I am disposed to think, that it would be as reasonable to style fissure, neuralgia of the anus, or cramp of the gastrocnemius muscle neuralgia of the leg, as to class all the cases I have narrated under the head of neuralgia. Though this is my present opinion, when I see a better version given of the subject, I shall be the first to adopt it. 17 CHAPTER XII. ULCERATION OF THE RECTUM. In the chapters on laceration and fissure, ulcera- tion of the rectum has been treated to a certain ex- tent ; a course which, from the nature of the subject, could not be well avoided. It, therefore, only re- mains to consider the ulceration which may arise from inflammation, the eiitanglement of feces in the lacunae, the venereal poison, and malignant deposits. I now merely purpose to treat of the disease, as pro- duced by the two former, and shall reserve a de- scription of it, when resulting from the two latter, for subsequent chapters.* In this, as in similar affections of other organs, there are three circumstances to be considered : firstly, the influence of the cause which produces it ; secondly, the state of the constitution ; and, thirdly, the situation it occupies. Thus, when it arises * In chronic dysentery, the follicles and mucous membrane of the rectum are generally ulcerated; but as this disease belongs to the province of the physi- cian, it would be foreign to a work of this description. 132 ULCERATION OF THE RECTUM. from the entanglement of feces in the lacunae, it is of moderate size, somewhat circular, deep, and sur- mounted by an ind^urated brim. In a sound consti- tution, though sometimes pretty extensive, it is generally superficial and without induration. In unhealthy persons it becomes inactive, and some- times phagadenic. Finally, when within the limits of the sphincters, it is exquisitely painful, and the system^ympathises as in fissure. The symptoms of this disease, are pain, a sense of weio^ht in the sacral reodon extending to the loins, vesical irritation, tenesmus, the discharge of a thin bloody fetid pus from the anus, besmearing of the feces with the same,* smarting, and even acute pain in the rectum, invariably increased by defeca- tion ; and, when the ulceration extends low down, spasm of the sphincters with the other concomitants mentioned under the head of fissure. If the finger be introduced, the ulcerated, surface may be detected by its roughness; but the better plan is to dilate the anus with the speculum,! when the situation, extent, form and character of the dis- » Mr. Colles says : "At times, the quantity of the discharge is much lessen- ed, and then the sufferings of the patient ai-e aggravated; but on the flowing ofTof a larger quantity, he experienced great relief." (Op. oil. p. 156.) This I have not observed ; indeed, in the last case specified in this chapter, the pain has always been most severe, when the discharge was most abundant. + Mr. Colles recommends a blunt polished gorget, with its concavity looking towards the seat of the disease, to be passed upon the finger into the rectum; then by everting the anus as much as we can, we shall obtain a full view of the ulcer by the light reflected from the gorget. (Op. cit. p. 1.5G.) ULCERATION OF THE RECTUM. 133 ease can be easily determined. In many cases, however, nothing more will be necessary than to separate the buttocks, and press apart the edges of the anus with the fingers. Ulceration of the rectum is difficult to heal : firstly, because, from the absence of valves in the portal system, and the depending situation of the hemor- rhoidal veins, they are loaded with blood, a condi- tion which is still further increased by the accumu- lation of feces in the lower bowels and the action of the sphincters; secondly, because the passage of the feces contuses, and stretches the ulcerated sur- face; thirdly, because, if the ulceration be within the limits of the sphincter, it is not only unduly compressed, but puckered ; fourthly, because the plicated condition of the mucous membrane, and the action of the sphincters, prevent the proper adjust- ment of suitable applications; and fifthly, because we are unable to make pressure, a most efficient remedy in similar diseases of other parts. All ulcerations in this region require the recum- bent posture, a diet affording the least excrementi- tious matter, and emollient enemata. If there be fullness and throbbing in the anal region, leeches should be applied ; and, if there be much general excitement, phlebotomy may prove serviceable; but the cases in which one or the other may be requi- red, are very few indeed. When the general health is impaired by other diseases, or improper habits, it should be improved by appropriate means ; and 134 ULCERATION OF THE RECTUM. when there is great irritabihty, anodyne combined with sudorific remedies may become necessary. When the ulceration is not extensive, and unat- tended with urgent symptoms, it will generally heal under the treatment just mentioned, and the appli- cation of the nitrate of silver, or of stimulating oint- ments, to which, if there be spasm of the sphincter, belladonna may be added, and, if there be much pain, opium. If, however, it be more extensive, painful, and attended with severe spasmodic contraction of the sphincter, no application will jDrove of any avail without the division of the sphincters, and of the ulcer, when practicable ; a remedy which, when followed by proper dressings, insures a rapid cure. By this operation, the sphincters cease to exert any influence on the circulation of the rectum, the great pain arising from their contraction abates, the ulce- rated surface no longer suffers from the pressure which they were wont to exercise on it, the con- gestion is removed by the hemorrhage which ensues, the ulcer is converted into a wound, and we are enabled to make applications to the diseased parts. Finally, when it attacks many points of the rectum, and extends high up, it will generally terminate fatally, especially in bad constitutions, in spite of the most judicious measures. The following cases are examples of this disease. Mr. S., a high liver, asked my advice, in Novem- ber, 1832, on account of a smarting sensation in the rectum, attended with purulent discharge and pain ULCERATION OF THE RECTUM. 135 in defecating, which he had laboured under for nearly two months. I examined him, and detected an ulcer, about the size of a sixpence, situated about an inch above the verge of the anus. This ulcer was superficial, covered with a whitish, tena- oeous matter, and surrounded by a fiery red edge. I cauterized it, enjoined a light diet, the recumbent position, and an enema daily. A rapid recovery ensued. Mrs. — , a lady of middle age, delicate frame, and subject to attacks of mucous diarrhea, became affect- ed, in July, 1S29, after one of these visitations, with superficial and extensive ulceration of the rec- tum, m two patches, one on either side, situated immediately within the anus, and attended with profuse purulent discharge, sense of weight in the sacrum and loins, tenesmes, irritation of the bladder, painful defecation, and slight spasm of the sphincter. After suffering for three weeks, and using empirical remedies recommended for piles, she consulted me, when I. examined the rectum, and discovered the nature of her disease. I directed her to lie on a couch, live on arrow root and animal broths with rice. I injected her bowels with flaxseed tea, and then passed a cane of the nitrate of silver slightly over the ulcerated patches ; after which, I injected four ounces of the mucilage of gum arable rubbed up with two grains of the extract of belladonna, and ordered it to be repeated every six hours. Finally, I directed her to take one grain of calomel, two of 136 ULCERATION OF THE RECTUM. rhubarb and a quarter of ipecacuanha, every six hours. On the fourth day her mouth became ten- der ; after which a pill was taken but once in twelve hours. This course was pursued for eleven days, at the expiration of which period, the ulcerated parts had healed. In July, 1826, Capt. H. consulted me for what he called the piles. He said that during ten weeks previously he had a discharge of bloody matter from the anus, pain in the rectum, greatly increased at and after stool, vesical irritation, and weight in the sacrum and loins. I examined him, expecting to find a fissure, but discovered an ulcer, of a circular form, as large as a shilling, situated above the sphinc- ter, on the right side of the intestine, with indura- ted edges and a foul surface. The recumbent posi- tion and a light diet were adhered to, the bowels were kept open with emollient injections, and a variety of stimulating and anodyne applications were made in vain. It then occurred to me, that the division of the sjDhincters, as practised by Boyer in cases of fissure, would be a justifiable operation. I therefore performed it, including the ulcer in the section, and then dressed the wound from the bot- tom. The pain immediately subsided, the wound healed kindly, and in one month he had perfectly recovered. In the fall of 1831, I was called to visit Mr. M. He informed me that for seven months previously he had suffered from pain, at and after stool, which ULCERATION OF THf: RECTUM. 137 being accompanied with purulent discharge from the anus, led his physician to make an examination, which resulted in the discovery of an ulcer, about the size of a shilling, on the right side of the gut, above the margin of the anus. Various applica- tions were now tried, but without any advantage, for the disease steadily increased; therefore, Mr. M. visited New-York, with the view of obtaining pro- fessional aid. For three months before I saw him, he had been treated here, still the ulceration increas- ed. He informed me that during stool, he suffered the most excruciating torture, and for a £ew hours af- terwards the grasping and burning pain, as he descri- bed it, was so acute, as on many occasions to elicit the strongest expressions of suffering. He said that two hemorrhoids had existed, and were removed by his previous medical attendant; that he had been leeched very extensively, and had counter-irritation established on his abdomen and lower extremities by tartar-emetic ointment and issues ; that he had been kept on a low regimen, and had taken medicine to act on the bowels, alkalies, &c. ; and, finally, that he had many applications made to the diseased part without any advantage, — on the contrary, his legs had become cedematous, he had emaciated, the ulce- ration had extended, and his sufferings were inva- riably aggravated by the applications made. He was a man over the ordinary size, had been fleshy, ap- parently about 50 years of age, and subject to gout. 18 138 ULCERATION OF THE RECTUM. By interrogation, I ascertained that his stools occa- sioned most pain when firm or liquid, and least, when in an intermediate state ; being then small and flattened. On examination, I found that the sphincter ani was so firmly closed as to offer considerable resist- ance to the introduction of the finger ; and when, after much difficulty, I succeeded in this effort, the muscular contraction was more violent than I have ever known it to be in any other case. He suffered dreadfully, but I persevered, and found that a con- siderable portion of the right side of the gut was rough, from the verge of the anus, for an inch or more in a vertical direction. I was not, however, satisfied with this examination ; therefore, on the fol- lowing day, I dilated the anus with a speculum, and found that the extent of surface w hich felt rough, was ulcerated, inflamed, and partially covered with flakes of lymph. I now proposed to remedy the dis- ease by operation, to which he consented ; therefore, on the following dayl divided the sphincter, and ap- plied the usual dressings. It is sufficient to state that within the month he was quite well. Mrs. was placed under my care in August, 1834 : for a long time she had suffered from piles, her health was impaired, and she was in the habit of taking cathartic medicine. Ten days before I was called in attendance, she complained so much of pain in the rectum and anus, that, at her request, her husband examined the parts, and discovered an ULCERATION OF THE RECTUM. 139 ulcerated point on the right side of the bowel, im- mediately within the skin, and between two hemor- rhoidal tumours. The ulcer must have spread very rapidly, for when I first saw her, it had extend- ed vertically for half an inch, and encircled nearly two thirds of the extremity of the intestine ; being excavated, with jagged and livid edges, devoid of granulations, covered with an ash coloured, tena- ceous matter, and surrounded by a deep inflamma- tory blush. She was weak, her bowels were confi- ned, her face was flushed, skin hot, and tongue parched, being brown in the centre, with a fiery red state of the margin and point. The pain in the dis- eased part was severe, and became excruciating du- ring and for several hours after defecation. Having freely evacuated the bowels by means of enemata, I touched the surface with a swab soaked in nitric acid, the action of which I limited by the application of a solution of alkali. I then introdu- ced my finger into the rectum, and on it passed the knife in the usual way, and divided the sphincter, after which, I dressed the wound from the bottom. This being accomplished, I placed an emollient poultice over the parts affected, and administered ten drops of the solution of morphine. The pain soon subsided, and sound sleep ensued. In the evening, the poultice was changed, and ten more drops of the solution of morphine were taken. On the following day the poultices were renewed t^\ ice, and I ordered her to take five grains of 140 ULCERATION OF THE RECTUM. Dover's powder every six hours, and to live on ar- row root and animal broths. While removing the poultice on the morning of the fourth day from the operation, the lint came away from the wound, which looked perfectly healthy ; and the thin slough created by the nitric acid had begun to separate. Having washed the lower bowels out with flaxseed tea, I dressed the wound afresh with dry lint, and the sloughy surface with dossils of lint saturated with equal parts of balsam copaiva and castor oil. As the Dover's powder had greatly composed her, and she had derived strength from the arrow root and beef tea, I ordered her to continue them, and to take calf's foot jelly, as she desired it. This plan of treatment was continued, with the exception that when the slough was detached, the ulcerated sur- face was dressed with a solution of nitrate of silver, until the parts had healed. I have at this moment, a gentleman from Mexico under my care, who, eighteen months ago, after exposure to wet and cold, was attacked with pain in the rectum, attended with tenesmus and mucous discharge. To be short, after trying various remedies, he came to New- York a few weeks since, and put himself under my care. He was emaciated, sallow and dejected. He had con- stant purulent discharge from the rectum, pain, te- nesmus, and obstinate constipation of the bowels. The rectum was studded with many small deep ul- cers, and strictured about three and a half inches ULCERATION OF THE RECTUM. 141 from the anus, so as barely to admit the passage of the finger. His diet has been hght and nourishing. He has taken small doses of rhubarb, blue pill and ipecacuanha, and large quantities of the syrup of sarsaparilla. The stricture has been considerably dilated, and a weak solution of the sulphate of zinc injected into the intestine. Under this treatment he has rather improved, though, from the abundance of the purulent discharge, I fear the rectum is ulcera- ted above the stricture, and consequently that the result will be fatal. I have seen a case, where death resulted from many small and deep ulcers in the rectum. The patient had been treated for dysentery in India, but on examination after death, the colon appeared healthy. CHAPTER XIII. VENEREAL ULCERATIOxN OF THE RECTUM. This species of ulceration may arise from the direct application of venereal poison, or it may be consecutive to disease in the genital organs, and then co-exist with other secondary symptoms. The character of the ulceration, w^hether primary or secondary, varies as in other mucous or dermoid tissues, with this exception, however, that the pli- cated arrangement of the latter in the anal region, renders the ulcers situated between its folds, of an oblong form ; a circumstance which has obtained for them the appellation of rhagades. Should these ulcers be superficial, their edges regular and soft, and their secretion healthy, they will heal rapidly ; but on the other hand, should they be deep and painful, surmounted by hard irregular edges, and secrete a thin foetid matter, they will not heal easily, and may become phagedenic. When extensive, this species of ulceration may 144 VENEREAL ULCERATION OF THE RECTUM. destroy life. In many cases, the recto-vaginal partition in the female, and the recto-vesical in the male, is perforated. Provided the opening be small, a spontaneous closure may ensue; but, this is a very rare occurrence.* What has been said with regard to the symptoms and treatment of pure ulceration of the rectum, is applicable to the imjiure form now described ; but, in addition, antisyphilitic remedies will become necessary. ♦ Cullerier has seen two cases, in which the fistulse closed spontaneously. (Boyer, Op. cit, p. 78.) CHAPTER XIV. AFFECTIONS CALLED HEMORRHOIDAL. In consequence of causes hereafter to be mention- ed, the vessels of the rectum become preternatural- ly distended with blood, which state either subsides after a few da^'s, gives rise to hemorrhage, the for- mation of tumours at the anus, inflammation, or mu- cous discharge.* This conjestion is generally manifested by a sense of weight and fullness in the rectum and pe- rineum. Generally, however, some of the follow- ing symptoms are present : rigors, — rigidity and occasional spasm of the extremities, — pallor, — din- giness of the skin beneath the eyes, — cold, strictured and dry skin, — weight and pain in the forehead, — vertigo, — dryness of the fauces, — white tongue, — * Several years ago, the talented and lamented Montegre demonstrated that, a determination of blood to the rectum was the substantive disease, and that hemorrhage, tumors, &c., were the consequence of it. (Des Hemorroides, ou Traill Analitique de Toutes les Affections Hemorroldales. Deuxieme edition. Paris, 1830.) 19 146 AFFECTIONS CALLED HEMORRHOIDAL. vomiting, — temporary augmentation of the liver, — flatulence, — pain in the abdomen, — constipation, — scanty and colourless urine, — increased velocity, hardness and contraction of the pulse, — precordial anxiety, — palpitation, — stricture of the epigastrium, — syncope, — hurried respiration, — a feeling of weight in the loins, hips and groins, — dull throbbing pain in the rectum, attended w^ith a sense of increas- ed heat, tenesmus, mucous discharge, and occasional darting sensations resembling those of electricity, — itching of the anus, — and finally, painful, difficult and frequent micturition. It generally happens that a similar condition of the hemorrhoidal vessels occurs from time to time, and scarcely ever fails to give rise to one or other of the accessary phenomena before mentioned, and which we shall now consider. Hemorrliage. The bleeding usually occurs du- ring defecation, sometimes preceding, but general- ly following the passage of the feces. Frequently, the loss of even a small quantity of blood relieves the feeling of weight and tension in the perineum, rectum and lower part of the back, as well as any other disagreeable symptoms which may have ex- isted. The amount of hemorrhage, however, is not always in proportion to the severity of the symp- toms denoting the loaded state of the hemorrhoidal vessels, — the quantity being sometimes very great, though not preceded by well marked premonitory signs ; while, in other cases, the discharge of blood AFFECTIONS CALLED HEMORRHOIDAL. 147 is trifling, notwithstanding the fluxionary movement may have been well marked. Generally it ceases after a £e\v days, yet not unfrequently, it continues for months. In some instances, it occurs but once in life ; again, it may return in the course of a few weeks, months or even years. Occasionally, it as- sumes a periodical character, returning with the season or the month. The amount of blood lost varies ; a drachm, an ounce, or even a pint may be discharged at a time, though it must be confessed that, the admixture of other fluids is apt to impose, upon the inexperien- ced, the belief that the loss of blood is much greater than it really is.* * Montanus, according to the report of Schwevcher, saw a patient who had passed two pounds of blood for forty-five successive days, and finally recover- ed. {Append, consilior. MoiUani, p. 50. Basil, 1588.) Cornarius mentions the case of a gentleman who, after drinking freely of Hungarian wine, lost two pounds of blood from the nose, and six pounds on each of the four follow- ing days from the anus. Nevertheless, he got well without any remedy. {Ob- serv. mcd., 20.) Pomme gives the case of a man thirty-six years of age, of an atribilious temperament, who for a long time had been subject to an exces- sive hemorrhoidal flux, for which he had tried many remedies, without obtain- ing relief. At length, having adopted the idea that it had a venereal origin, he underwent an antisyphilitic course of treatment, in consequence of which the flux disappeared. However, he was soon attacked with distressing symp- toms of cholera, when the hemorrhage reappeared. During a month, he lost nearly a pound of blood daily, which was followed by colic pains and swell- ing of the face and extremities. By a generous diet, nutrient injections, and cold baths, the hemorrhage was arrested, and exercise on horseback rendered him convalescent. ( Trait s des maladies Vaporeuses.) Lanzoni cites the case of a priest, who daily passed a pint of blood per anum. (Consult, med. 97. Oper. I. 2. p. 203.) Ferdinand says that a girl twenty years of age, of a sanguineous temperament, sedentary habits, and endowed whh much vivacity, in consequence of violent chagrin, arising from jealousy, became affected with 148 AFFECTIONS CALLED HEMORRHOIDAL. The blood evacuated, is of a bright vermiHon colour, and is exhaled by the extremities of the ca- hemorrhoids, and for many months daily evacuated about half a pint of blood while at stool. The menstrual discharge ceased, her face became pallid and oedematous, and she was rendered so weak, as to be unable to walk; never- theless, under proper treatment she perfectly recovered. {Hist, med., 16. p. 40.) Panarola knew a Spanish nobleman who, for forty years, rendered each day a pint of blood per anum, and at the same time enjoyed perfect health. ( Ob- serv. med. peniec. 2. obs. 46.) Harris says that a widow of meagre ^ame and bilious temperament, lost upwards of four pounds of blood from hemor- rhoids, in a few hours ; during the night, she had nearly died from exhaustion ; however, the bleeding was arrested by the application of cloths soaked in spirits of wine. {De Morbis Aliq. Gravior. Obs. x.) Bozelli mentions llie case of a tailor, who lost as much as ten pounds of blood at a time. This man was nevertheless vigorous and of a jovial character. Bozelli diminished this flux by means of the syrup of roses. Spidler saw a potter, who after ha- ving suffered for a week with pain in the loins, was seized with violent colic, and severe vomiting. A cathartic was administered, which relieved him ; but he passed from twelve to fourteen pounds of vermilion coloured blood from the anus, in twenty-four hours, each dejection being accompanied with a slight colic pain. After many remedies were tried in vain, the hemorrhage was arrested by a stimulating injection. (Observ. med. Ai.) HofTmau says he saw a widow, fifty years old, of a very full habit, who in consequence of an indo- lent course of life and full living, was for eight years subject to hemorrhoids, at the same time she continued to menstruate. The uterine discharge having ceased, and being blooded but once, she was seized, towards the autumnal equinox, first with lassitude, and then with coma, for which she was bled in the foot, and took cold water in large quantities without any benefit. At the end of two days, however, a stimulating lavement was administered, when an excessive flux of blood occurred, amounting in twenty-four hours to more than twenty pounds; the consequenceof which was, a cessation of thecoma. Her strength gradually returned by the employment of invigorating and gently astringent remedies, together with eneraata of cold water. Smetius relates the case of a man forty years of age, who passed per anum at least thirty pounds of blood in two or three days. He was cured by a tonic plaster. {Miscell. med. I. 4. epistol. 9. p. 222.) Finally, Pezold speaks of a Saxon chevalier, who in one attack lost sixty-four pounds of blood. (Obs. med. chir. 51.) Montegre, Op. cit. p. 27. There can be no doubt in the mind of any rational man, but that these statements abound with exaggeration. AFFECTIONS CALLED HEMORRHOIDAL. 149 pillary vessels, as may be demonstrated by an ex- amination of the mucous membrane when protru- ded, an occurrence which very often takes place in these cases. In some instances, fine streams of blood are seen to issue from dilated pores, which we are afterwards unable to detect. Besides this evidence of the source of the discharge, the symptoms which precede the flow of blood, their subsidence on the occurrence of hemorrhage, together with the colour of the blood, plainly demonstrate the nature of the attack. However, when the bleeding has been profuse, the vessels may become so debilitated, as to allow the blood to escape from their extremities, constituting passive hemorrhage. This flux, by presenting a determination of blood to the organs essential to life, wards off fatal disease, and, therefore, its suppression is attended with imminent risk. The nervous temperament, predisposition to disease in some other organ, par- ticularly if the morbid action has already commen- ced, or if the organ is in sympathy with the rectum, the application of heat or cold, depressing passions, wet feet, fatigue, profuse perspiration, vomiting, hemorrhage from some other part, phlebotomy and the application of astringents, are the causes which suppress this discharge, and consequently give rise to colic, fever, inflammation, hemorrhage, organic lesions, and nervous complaints. Both ancient and modern authors abound with such cases, and from my own observation, I shall furnish a few, in a sub- ]50 AFFECTIONS CALLED HEMORRHOIDAL. sequent part of this chapter. There are two, how- ever, which proved fatal, and accordingly are well suited to this place. A gentleman between fifty and sixty, of short statue and full habit, who for many years had been subject to a profuse discharge of blood from hemorrhoidal tumours, underwent an effectual operation for their removal, and died in seven months afterwards of apoplexy. Another gentleman, under thirty, for a few years laboured under a free hemorrhoidal discharge, which, as it debilitated him, was checked by astrin- gents. In a short time, however, he was attacked with pulmonary hemorrhage, and at the end of a year and a half, he sunk, after a profuse discharge of blood. The diseases with which the hemorrhoidal flux may be confounded, are disentery, scurvy, and he- morrhage, either from the small intestines or sto- mach. In dysentery there is high fever, abdominal pain, and the blood is blended with muco-feculent mat- ter, while in the hemorrhoidal affection there is no fever, the abdominal pain, if present, is much less severe, and the blood is not mixed with the feces. When blood is evacuated per anum in a person labouring under scurvy, other symptoms of this disease are present, for it only occurs during the termination of severe cases, and it is necessarily of a passive character. In the flux, which has its source in the small in- AFFECTIONS CALLED HEMORRHOIDAL. 151 testines, the blood is generally mixed with the fecu- lent matter ; but when in large quantities, it is more or less pure. Such cases, however, are not prece- ded by weight in the loins and perineum, nor by fullness, pain and throbbing in the rectum. Finally, in gastric hemorrhage, the blood dis- charged per anum, is decomposed, grumous, fetid, black and mixed with other matter. Tumours. Generally, after the blood has accumu- lated immoderately in the rectum several times, but occasionally as the result of the first conjestion, especially, when there has been no hemorrhao-e tumours form, in consequence of the opposition offered by the structure of the rectum, to the es- cape of the blood. These tumours may be divided into two classes, the first is situated within, and the second, imme- diately without the anus. Those situated immediately within the anus, vary in number, in many instances being so numerous, as to prevent the free discharge of feces, while in other cases, they are few, even solitary. Their size is as variable as their number, differino- from that of a small pea to a pullet's egg. (See plate ii. fig. li.) They are generally globular, and in many instances pedunculated, particularly when large, and subject to prolapse during defecation; for un- der such circumstances, they swell and suffer a constriction at their bases, from the contraction of the sphincter. Generally, they are of a dark red 152 AFFECTIONS CALLED HEMORRHOIDAL. colour, and when prolapsed, they become perfectly livid, in consequence of the obstruction created to the return of the venous blood; firstly, by the forced expirations necessary for the act of defecation, and secondly, by the constriction of the sphincter. (See plate ii. fig. i.) I have repeatedly injected these tumours with coloured water, both from the arteties and veins, and when cut into while the fluid was projected, small jets were observed to issue from many points. I have frequently dissected them with the greatest care, and found that they were spongy, reddish, and contained both arteries and veins, the latter being most capacious, but always perfectly healthy. (See plate ii. figs, iii., iv, and v.) Their surface is villous, and generally bleeds when touched roughly, or scratched with the nail, the blood which issues being of a florid red colour. In many instances, I have been able to rub off exceedingly vascular and fragile adventitious membranes from their surface. Thus, it would seem, that they may acquire an in- crease of magnitude in this way.* * The writers on hemorrhoidal tumours, may be divided into two classes. The first consider them as varices, while the other ascribe to them a different origin. One might suppose that the question could be easily solved ; but, to accomplish such a task is no easy matter, as may be deduced from the fact, that both classes can number some of the ablest men in the profession. Hippocrates, who considered them as dilatations of the extremities of the veins, did not derive his opinion from dissection ; but from the absurd notion that they served to evacuate the black bile or melancholic humour. (HEPI AIMPPOlAnN — De.Alimento liber — De morbo vulg.) Galen, (Ascriptee finit. Medio, in fine isagog, lib.) and Celsus (lib vi. 9. p. 323, also AFFECTIONS CALLED HEMORRHOIDAL. 153 When these tumours are small, they are generally attended with slight heat and itching, but as they enlarge they produce a disagreeable sense of full- lib vii. 3. p. 39G. Edin. MDCCcxxxi.) merely reechoed the opinion of Hippo- crates respecting their structure. In fact, the different authors who succeeded Hippocrates maintained his opinions, not only as to the structure, but also as to the office which he ascribed to these tumours. (Forestus, 1. 23. Obs. 345 — Ludovicus Mercatus, tomei. 1. 3. cap. 17. p.m. 320. and tomeiii. 1. Leap. 15, p, m- 177.— Vidus Vidius, tome iii. lib. 2. cap. vi. p. m. 117.— Victor Trincavel- lius, opp. tomei. lib. 9. cap. 14. p. 266.) Nor was it until the memorable Har- vey discovered the circulation of the blood, that the absurd notions respecting the functions they performed was dispelled. A more correct system of physio- logy being now introduced, pathologists began to render their science more perfect, by calling anatomy to their aid; and among other investigations of vast importance, they took up the subject of hemorrhoids, and established a doctrine pertaining to their formation, still adopted in its principal features by some of the ablest men. Wiseman, surgeon to Charles the Second, was the author w ho fully described this doctrine. (Chirurgical Treatises, third edition, London, MDcxcvii. p. 208.) De Hcan, who advocated the new doctrine, asserted that the bleeding from the external veins, depleted the system generally, while that from internal, only acted on the portal system. (Thes. pathol. de hemorrhoi- dibus, c. i.) However ingenious these axioms may appear, the anatomist who is acquainted with the anastomosis of the veins in this region, will reject them as fanciful, and originating with a studious man, regardless of the limits which dissection imposes on the theorist. Alberti, though not much of an anatomist still turned to account the discoveries of Vesalius, "Veslingius, Verheyn and Bartholinus, in proving that the internal hemorrhoidal veins were derived from the inferior mesenteric, while the external were branches of the hypogas- tric, and thus the opinions of De Haen, for a time, seemed so rational, that it met with but little opposition. (Tractatus de hemorrhoidibus, Halae, mdccxxii. cap. V. p. 74.) Stahl, Hoffman, Booerhave, Lieutaud, Morgagni and Petit, with other celebrated men, believed that they were varices, and the weight of their names, added to those already quoted, has created such an impression in favour of this opinion, that it will not be readily removed. Those, however, who have studied pathological anatomy, will be but little disposed to submit to my authority, which is not derived from it; therefore, the testimony of Jobert (Traits des maladies chirurgicales du canal intestinal, tome i. p. 138. Paris, 1829.) and Dupuytren (Lecons orales, tome i. p. 341. Paris, 1832.) is alone worthy of the attention of the modern pathologist, since these gentlemen deri- ved their opinions from dissection. However much respect we may enter- 20 J51 AFFECTIONS CALLED HEMORRHOIDAL. ness in the lower extremity of the rectum, and are prolapsed during defecation, after which they gradually shrink up, and by the action of the mus- cular apparatus of the anus are returned to their original situation. In some cases, however, the sphincter becomes more or less relaxed, and these tumours in descending drag along with them a por- tion of the adjacent mucous membrane. Indeed, so large is the protrusion, that persons thus afflicted are compelled to return it with their fingers, and many of them postpone the calls of nature, until tain for the assiduity of Jobert, and the great surgical acumen of Dupuytren, we hold at least an equal admiration for those who have denied the varicose character of hemorrhoidal tumours, and whose names, with a reference to their writings, we shall now subjoin. Le Dran, (Trait^s des operations de Chi- rurgie, p. 228. Paris, mdccxlii.) Cullen, (Practice of Physic, vol. 1. p. 435 — 932. Edin. 1812,) Recamier, (Essai sur les henwrrhoides. Paris, 1800, in 8vo.) Abernethy, (Surgical Works, vol. ii. p. 240, new edition. Lon- don, 1830.) DeLarroque, (Traite des hemorrhoides. Paris, 1812, in 8vo. p. 61.) Chaussier, (Dissertation sur les hemorrhoides, par Lavedan. Paris, 1814. p. 12.) Cruveilhier, (Essai sur I'Anatomie pathalogique, tome ii. p. 146. Paris, 1816.) Delpech, (Precis Elementaire des maladies reputes- chirurgicales, tome iii. p. 262. Paris, 1816.) Boyer, (Traite des maladies chirurgicales, tome v. p. 28. Bruxelles, 1828.) Kirby, (Observations on the treatment of certain severe forms of hemorrhoidal excrescence, London, 1317. p. 39.) To which list we may add the immortal Laennec and Beclard. Perhaps here, also, we might insert the names of Richter, (Anfangsgr der Wandarzn. t. vi. p. 395.) and Ribes, (Memoirs de la Soci€t^ Medicales d' Emulation, tome ix. p. 109. Paris, 1826.) who though they admitted the vari- cose state of the veins, yet considered the extravasation of blood as properly constituting hemorrhoids. Those who desire to become acquainted with the peculiar opinions of each of these authors, had better refer to their works, for to state them here would be out of place, to abreviate them would be unjust, and to analyse them a use- less undertaking. In the text, I have briefly described the result of my own researches, without bias for any peculiar theory. AFFECTIONS CALLED HEMORRHOIDAL. 155 they are about to retire for the nio^ht, in consequence of the difficulty they experience, and the time they require, to reduce it, and above all, as they can only effect this in the horizontal position. In many cases, the protrusion occurs, when the patient walks, or even attempts to ride in a carriage, and thus given rise to great uneasiness and mucous discharge. Besides the protrusion of the mucous membrane now described, that of the pouch frequently takes place from the constant nisus these tumours are apt to create. In a few cases, when there is but one tumour, it is situated low down, and though not large, partial- ly projects through the sphincter and gives rise to very great annoyance. In a case of this kind on which I operated a {ew days since, the mucous discharge was very .considerable, the surrounding parts were much engorged, and the patient not only suffered from the friction which his clothes exer- cised on the tumour, but also from a constant teas- ing nisus, with, occasionally, irregular and painful contraction of the sphincter. However, the relief which he obtained from the removal of the tumour, was immediate and permament. In consequence of the irritation and pressure of the feculent matter, as well as the effort necessary to dislodge it, blood accumulates in the rectum during defecation, so that though there has been no previous hemorrhage, these tumours may exhale blood, and in such cases, it very often happens that 156 AFFECTIONS CALLED HEMORRHOIDAL. it is squirted out from one or more dilated pores.* Sometimes, though rarely, these tumours do not bleed for weeks or months ; but I never yet have seen a case in which they did not bleed at some time. Generally, indeed, when they exist, they are the source of the sanguineous discharge which, oc- curs, though previous to their appearance the mu- cous membrane, as before pointed out, gave rise to it, and a most extraordinary fact, which I have veri- fied repeatedly, is, that, when they have been removed, the mucous membrane has again become the organ for throwing off the super-abundant blood. When we consider the stricture and situation of these tumours, we ought not to be surprised, that they very often become inflamed, increase much in size, are attended with great .pain, muco-purulent discharge, and disorder of the urinary organs. (See chapter vi.) In this state, provided the tumefac- tion be great, the patient feels as if there were for- eign matter in the rectum, straining ensues and they are prolapsed, now, the sphincter becomes affected spasmodically and presses on their radices, giving rise to great suffering. The inflammation may sub- side in one, two, or three days, and then these tu- mours will either recede of themselves, or the patient be able to return them in the usual manner ; but it * Some aiuliors seem to think that varicose veins entwine themselves around these tumours, and give rise to hemorrhage by rupture of their tunics. This I will not deny, but I must say that I have not witnessed such au occcurrence. AFFECTIONS CALLED HEMORRHOIDAL. 157 sometimes happens that the sphincter contracts with so much force, as to strangulate them, and cause mortification ; an event which generally effects a radical cure, though a few cases are recorded in which the issue therefrom was mortal. Of four cases of this kind which I have seen, three ter- minated favourably, and one fatally. It not unfrequently happens, that in consequence of inflammation in these tumours, small abscesses form in them, attended with a discharge of puru- lent matter from the anus, and more pain and irritation of this part than usual. Such ca ses are far from being uncommon, and are too often over- looked. To detect these small fistulae, the finger ought to be cautiously introduced, and after a little exploration, a small depression, marking the fistu- lous orifice, may be discovered'on each tumour thus affected. But should this attempt fail, the buttocks ought to be forcibly separated by an assistant, while the patient bears down ; then, with a strong light and a probe of small size, the sinus will be easily found. In the majority of cases, but one tumour is fistulous, though, I have occasionally seen two or more so. Occasionally, these tumours are attacked with ulceration, and in such cases, it generally seizes on many points at the same time, but seldom advances to any great extent. I have, however, seen a case in which three very large hemorrhoidal tumours were one half consumed ; and in the twelfth 158 AFFECTIONS CALLED HEBIORRIIOIDAL. chapter, page 138, I have related another, which is interesting on account of the phagedenic character of the disease. Hemorrhage is sometimes the re- sult of the ulcerative process, as I had an opportu- nity of observing in the two following cases : Mr. C, a gentleman advancing in life, of full habit, and subject to hemorrhoids for many years, during a salivation, which resulted from the mercureal treat- ment of a severe fever in the West, was attacked with more than usual uneasiness and purulent discharge from the rectum while at stool. In a few days he began to bleed, and so much did this in- crease, that he repaired to New- York, and became my patient. He was very low from loss of blood, and distressed in mind. I made a careful examina- tion, and found four hemorrhoidal tumours, one of which was as large as a peach stone, and ulcerated deeply. When he strained, all the tumours were prolapsed, and florid blood issued freely from the ulcerated surface. I removed the tumours, and he soon regained his health. The other case was that of a planter from Louisiana, who arrived here this summer, on his way to Paris, to be operated on ; but so low was he when he reached this city, that he felt unable to proceed, and, therefore, sent for me, and had the operation performed. In this case there were several ulcerated points on each tumour, :and though they were superficial, the hemorrhage from them was very brisk. Notwithstanding I have seen several cases of ulcerated hemorrhoidal AFFECTIONS CALLED HEMORRHOIDAL. 159 tumours, those are the only ones that were hemor- rhagic, and this I am incKned to attribute to the condensation which they generally undergo from repeated attacks of inflammation, previous to the commencement of the ulcerative process. Though these tumours maintain their spongy structure for years, yet it occasionally hap- pens that, from constant irritation they become transformed into a semi- cartilaginous mass, being firm, yellow, and nearly bloodless. I saw a case of this kind some weeks ago in a lady, who visited New- York for the purpose of having them remov- ed. I performed the operation, and two of the tumours are represented in plate ii. fig. vi. and vii. In some cases when we cannot detect any other lesion, and these tumours appear perfectly free from engorgement, the patient, who is generally of a nervous constitution, is affected with contraction of the sphincter ani and exquisite pain, which, when violent, extends to the uterus, vagina and external organs of generation in the female, to the perineum and testicles in the male, and to the bladder and urethra in both sexes. The constant tenesmus^ strangury and dysury which it produces, wears the patient down, giving rise to sleeplessness, anxiety and fever, and in some rare cases, so excruciating is the pain, that the patient must remain perfectly tranquil, as the least motion exasperates his suffer^ ing to an intolerable degree. As these cases are not of common occurrence, the three following may prove interesting. 160 AFFECTIONS CALLED HEMORRHOIDAL. In September, 1832, Mrs. , aged twenty- nine, of spare habit and light complexion, called me to see her, when she gave the following history of her case: In 1829, she began to menstruate irregularly and scantily, but lost blood occasionally from hemorrhoidal tumonrs, which Were very painful. In 1820, she first experienced some difficulty in micturition, attended with shooting sensations in the vulva, which towards the end of the year became very distressing ; notwitstanding, she married, but so great was her suffering that she was seldom able to cohabit, and only with ex- quisite pain. In 1825, her husband died, and then she menstruated more profusely, yet irregularly, while the hemorrhoidal discharge diminished, the pain became far less, sometimes disappeared alto- gether, but occasionally returned with severity, at- tended with frequent and distressing calls to void urine, tenesmus, small mucous discharge, and firm contraction of the sphincter. During these attacks, the hemorrhoidal tumours were swollen, but when they began to bleed freely, the symptoms moderated. It frequently happened, however, that this did not oc- cur, but that the uterine f!ux set in, which also mode- rated the symptoms, but not at all to the same extent. Beino- about to make an advantao^eous match, she was desirous to obtain relief if possible ; therefore, she willingly submitted to an examination, which led to the detection of five or six large hemorrhoi- dal tumours, attended with sreat tenderness, not only AFFECTIONS CALLED HEMORRHOIDAL. 161 of the anus, but also of the external organs of gene- ration, and spasm of the sphincter ani. To be short, I removed the tumonrs, and with such success, that she shortly after entered into matrimony, and did not experience any return of her disease. Mrs. , from childhood had been subject to constipation of the bowels. She menstruated at fourteen, and experienced no derangement of the uterine system until between fifteen and sixteen ; then, the discharge ceased for four months, durino- which time she lost a considerable quantity of blood from hemorrhoidal tumours. With the return of the uterine, the hemorrhoidal flux disappeared in great measure ; but the tumours continued and be- came exquisitely painful, as well as the surrounding parts, attended with frequent painful calls to mic- turate. At the age of seventeen she married, but so painful was the vulva in May, 1833, four months after her marriage, that her husband had not been able to cohabit with her. I was then consulted, and on examination found that the lower extremity of the gut was filled with pretty consistent tumours* which, when prolapsed, proved to be hemorrhoidal. The examination gave rise to exquisite pain, extend- ing to the organs of generation, and I do not recollect having seen, but in one instance, a more perfect state of spasm of the sphincter. I removed the tumours, regulated her bowels, ordered a warm hip bath daily, and supposatories of belladonna and opium every twelve or twenty-four hours. SufHce it to 21 ]62 AFrECTIONS CALLED HEMORRHOIDAL. say, that in three weeks she had perfectly re- covered. Mr. , a fine young man, consulted me last summer for neuralgia of the testicles, as he called it. He had piles, from which the pain extended to the perineum, testicles, bladder and urethra. He was emaciated and worn down by continual suffering and nervous excitement. For fourteen months, he had tried all the most powerful narcotic remedies, as well as iron, bark and arsenic, both warm and cold bathing, exercise, a sea voyage, and so on ; but with- out advantage. When he came under my care, I first regulated his diet and bowels, and then remo- ved the hemorrhoidal tumours, with such advantage, that in a month he had not a remnant of his very painful disease. These tumours may be confounded with pro- lapsus of the mucous membrane of the rectum, and polypi of this intestine. The form of prolapsus with which they are likely to be confounded, is that chronic affection in which •a flap of the mucous membrane, on either side, is forced down and becomes thick and rugous. How- ever, the semilunar form of these flaps, the extent of their base, our ability to glide the folded mem- brane between the finger and thumb, as well as their freedom from erection and hemorrhage, are characters so opposite to those which we have described as pertaining to hemorrhoidal tumours, that a very cursory examination enables us to dis- tinauish between them. AFFECTIONS CALLED HEMORRHOIDAL. 1G3 The slow, progressive and indeterminate increase of every species of polypi ; their incapability of erec- tion or collapse ; their large size ; their pale red co- lour ; their very soft spongy feel, when of the mu- cous species ; their solidity, when they possess a fi- brous structure, together with their freedom from inflammation and ulceration, unless when of a ma- lignant character, or when under the influence of an irritating cause, enable us to avoid confounding hemorrhoidal tumours with them. The second class of tumours are those situated on the verffe of the anus, thouo^n I have seen a few cases in which they extended a short way within this orifice, being in part covered with the mucous mem- brane. They are more or less livid, generally elas- tic, have an extensive base, and are formed of ex- travisated blood, which is encysted by condensed cellular tissue, and covered by a few fibres of the sphincter and fine skin of the verge of the anus. I have satisfied myself of these facts, by cutting off the prominent portion of the tumour and then turn- ing out the extravisated blood, in the living body, and by cautious dissection in the dead. (See plate iii. fig. i.) Sometimes the blood is absorbed, leav- ing no trace behind ; occasionally, however, in con- sequence of the first, but more especially of repeat- ed attacks, the superincumbent integuments and surrounding cellular tissue, become hypertrophied, and pendulous flaps or tumours, which in some in- stances, from the friction they are exposed to, obtain 1G4 AFFECTIONS CALLED HEMORRHOIDAL. a rough or warty aspect, and become a source of great irritation. It not unfrequently happens, that when there is but one large tumour, it suppurates and then gradually shrinks up.* When small, these tumours are attended with itching, a sense of fullness, and pain upon pressure ; but when large, the pain is constant, and is accom- panied with more or less throbbing, and sometimes contraction of the sphincter. Indeed, so severe is the anguish, that the patient is feverish, and unable to walk, or take any other species of exercise, espe- cially if suppuration be about to occur. These tumours, when recent, are apt to be con- founded with internal tumours, and partial prolap- sus of the rectum. They may be distinguished from the internal tumours by being covered prin- cipally by the skin ; by smoothness of surface ; by our ability to glide the superincumbent parts over them ; by their greater lividity ; and finally, by their excessive hardness and freedom from hemorrhage. They differ from partial prolapsus of the rectum, not only by their density and lividity, but, by their great tenderness and tubercular form. However, there is occasionally but one tumour, which is very large and flat, with the mucous membrane stretched over its internal and infe- rior aspect, so as to simulate very much a descent * I had an oppnrhinity of rlissp'^ting a case of this kind, in a soldier, wliodied of fever, and I ascertained tlint tl^e abscess was in the ceHular tissue, vol in o. vein. AFFECTIONS CALLED HEaiORRHOTDAL. 105 of a portion of the mucous membrano. The diag- nosis, however, is by no means difficult ; for, inde- pendent of its deeper colour, firmer consistence, partial cutaneous covering, and limited extent, if the finger be introduced, the tumour will be found to extend a considerable way within the sphincter. When these tumours undergo the changes I have before mentioned, they are liable to be confounded with excrescences which form about the anus, and are sometimes of a venereal character. They may, however, be easily distinguished from them by the history of the case ; by the absence of other venereal symptoms ; by the pliability of the skin ; by the healthy condition of the surrounding parts ; by the absence of a purulent secretion ; by their lighter colour ; generally, by their greater density and roughness ; and finally, by being confined to the verge of the anus. Injlammation is produced by the difficulty which the blood experiences in circulating through the rectum. It always, in a greater or less degree, ac- companies the formation of tumours, and frequently acquires great severity when there is no hemor- rhage. Provided it has not proceeded too far, the hemorrhoidal flux arrests it. (See chapter vi.) Mucous discharge. This may arise from the same cause as inflammation, and in this way supply the place of the sanguineous evacuation. Sometimes it precedes, but more commonly follows the hemor- rhoidal flux. When the capillary irritation is con 166 AFFECTIONS CALLED HEMORRHOIDAL. siderable, it is aqueous, and so acrid, as frequently to excoriate the surrounding parts; when chronic, however, it is Hke the white of an unboiled egg, or frog's spawn. If moderate, it is only thrown off during defecation ; but when more profuse, the ex- ertion of coughing, sneezing or laughing, will cause its excretion. This discharge can be distinguished from vene- real blenorrhagia, by the history of the case, by the absence of venereal symptoms, and generally, by its tenaceous and transparent character. In consequence of the affections which we have now treated of, the following consecutive accidents in addition to those we have already specified, may occur : fissure, stricture, and abscess by the side of the rectum. — See the chapters which treat of these diseases. The causes of hemorrhoidal affections, are, the "structure of the part, — age, — sex, — climate, — period of the year, — hereditary pi-edisposition, — the sup- pression of other hemorrhages, — habit, — plethora, — other diseases, — passions, — constipation, — pregnan- cy, — the developement of tumours in the pelvis and abdomen, — disease of the liver, pancreas, spleen, lungs, heart or aorta, — obliteration of the inferior mesenteric vein, — tight lacing, — concussion of the abdomen, — the application of bandages to the infe- rior extremities, — pierced seats, — certain alimenta- ry substances, — stimulating purgatives, — irritating enemata, — diarrhea, — dysentery, — prolapsus of the AFFECTIONS CALLED HEMORRHOIDAL. 167 rectum, — ascarides, — external irritation, — stone in the bladder, — stricture of the urethra, — disease of the prostate, — and excessive venery. It will not be unprofitable to offer a few remarks on these causes. Structure of the part. The absence of valves in the veins, together with the contraction of themus- culur coat of the rectum, prevents the free ascent of the blood, and thus gives rise to sanguineous con- jestion of this intestine. Age. Adults are more Hable to hemorrhoidal affections than youths. I have, however, observed a well marked case, attended with hemorrhao-e, in a boy five years old, who laboured under stone ; and another in a girl, between six and seven. Such cases, however, are very rare, first, because in early life, the head and chest are more subject to vascular repletion, than the abdomen; whereas, in mature life, this region is peculiarly susceptible of sanguineous engorgement; secondly, because the venous system is more fully developed in the adult, and the circulation less rapid"; and, thirdly, because the biHous temperament and depressing passions pertain, for the most part, to those who have passed the period of puberty. Besides these differences, which are applicable to both sexes, there is another peculiar to females. This is the cessation" of the natural menstrual discharge, in consequence of which, especially in plethoric women, the system becomes surcharged with blood. If, under such 168 AFFECTIONS CALLED HEMORRHOIDAL. circumstances, the vessels of the rectum exhale the superfluous blood, we look upon the hemorrhage as a fortunate occurrence, for in this way fatal attacks of apoplexy and other diseases are warded off. Sex. There has been great diversity of opinion as to the comparative frequency of hemorrhoidal affections in both sexes. My own experience leads me to believe that males are more subject to theni than females, and this is in accordance with what, physiologically speaking, we ought to expect ; for the functions of the uterus should, so long as they last, be sufficient to rid the system of superfluous blood. Indeed until the menstrual flux ceases with the turn of life, it is not common to see women suffer from more than occasional attacks of hemorrhoids, and then the uterine function is more or less de- ranged. In a case which came under my care, for seven successive months the hemorrhoidal and ute- rine flux appeared simultaneously, and also subsi- ded together on the third day. In another case, on which I am now in attendance, the menstrual dis- charges ceased five months ago, since which the young lady, (twenty-three years old,) has had a daily discharge of blood from the rectum while at stool. Finally, I have seen two cases, in which the hemorrhoidal and uterine flux alternated with each other. s Climate. It is generally believed that warm cli- mates dispose to hemorrhoidal affections. Mon- tegre thought that they operated by inducing the AFFECTIONS CALLED HEMORRHOIDAL. 169 bilious constitution. However this may be, I am inclined to think that changeable weather, such as we suffer from in this region of the world, is a fre- quent source of these diseases. The number of persons in America thus afflicted is immense, which I am disposed to attribute to the accumulation of blood in the internal organs, when the surface of the body, which has been hot, becomes rapidly chilled down by the sudden reduction of tempera- ture. Period of the year. The spring is the period most favourable to the developement of hemor- rhoids; firstly, because the mass of the blood is increased, in consequence of the secretions having been diminished during the winter; secondly, be- cause the absorption of caloric expands the blood ; and thirdly, because the phenomena of life are more active at this season. Some authors have asserted, that the hemorrhoidal flux is most likely to occur, when the winds are northerly, and others again say, that it is apt to take place during the solstices and equinoxes ; assertions which, though I do not deny, I have been unable to verify. Hereditary predisposition. Children of hemor- rhoidal parents, possess a similar organization, and are, in consequence of it, predisposed to these affections. Many authors have related cases, with a view of illustrating this tendency. M. de Larroque mentions an entire family, amounting to eight or 22 170 AFFECTIOMS CALLED HEMORRHOIDAL. nine in number, who were thus afflicted, and I have ■witnessed several cases mvself, in which the heredi- tary predisposition could not be doubted. Thus, I have seen hemorrhoidal tumours in the father and son, in two brothers, and in four brothers whose father was operated on for the same disease. That persons thus predisposed are generally of a bilious constitution, with a greater developement, than usual, of the venous system, subject to depressing passions, and exalted sensibility, I am ready to admit; but this is far from being invariably the case, as I have had repeated opportunities of proving. Sedentary habits. Those who lead sedentary lives, especially, when they eat largely, becorfie plethoric, weak, and enervated. Thus, they are predisposed to sanguineous fluxions, so that, even without the conspiration of other causes, the redun- dant blood may be discharged by the hemorrhoidal vessels. The sitting position, however, as well as constipation, are generally connected with this method of life, and favour the accumulation of the blood in the hemorrhoidal vessels. It is very com- mon for the hemorrhoidal flux, in such persons, to be not only moderate, but regular, so as to enable them to pass through life, free from other more se- rious diseases. The suppression of other he^norrhages. We men- tioned before, the influence which the menstrual and hemorrhoidal flux exercise on each othei*. AFFECTIONS CALLED HEMORRHOIDAL. 171 Now it only remains to state, that those persons who are predisposed to fluxionary movements, and who have laboured under epistaxis, hemoptysis, hematemesis, &c., have them occasionally arrested by the appearance of the hemorrhoidal flux, a trans- lation of disease, to them, of great importance. Se- veral cases of this kind have come under my obser- vation, and as the subject is highly interesting, I shall give a brief outline of two of them. A gentleman, now upwards of fifty, left Ireland several years ago, in consequence of a dangerous spitting of blood, and settled in the south, where he transacted a large commercial business. The ex- pectoration of blood soon subsided ; but he was at- tacked with hemorrhoids, and though the discharge of blood was considerable, he continued to enjoy excellent health. Having made his fortune, and being excessively annoyed with the constant protru- sion of the tubercles, when he attempted to walk, he went to Paris, and had them removed by the late M. Dupuytren. He soon recovered from the ope- ration, and returned to the United States, labouring under a determination of blood to the head, for which he consulted me. I recommended low living, leeching the anus, and pills consisting of the extract of aloes and blue mass. Under this treatment, he experienced great relief; but though a period of three years has since elapsed, he has been com- pelled repeatedly to have recourse to the same means. 172 AFFECTIONS CALLED HEMORRHOIDAL. A gentleman, between forty and fifty years of age, from boyhood had been subject to epistaxis, yet enjoyed perfect health. In 1832, he laboured se- verely for some weeks from headache, vertigo and syncope, in consequence of the suppression of the nasal hemorrhage. He consulted me, and I recom- mended leeches to the schneiderian membrane, and a cathartic, from which he derived no advantage, for the symptoms above mentioned continued, and he became chilly, suffered from abdominal pain, and a sense of weioht in the rectum. I now order- ed a stimulating pediluvium, and a brisk purgative. He soon felt a desire to defecate, and while on the chair, evacuated quite a pint of blood. Immediate relief followed this discharge, and in the course of the night he lost about as much more blood, during the operation of his medicine. When I visited him on the following morning, he felt perfectly restored, and wished to go to his counting house, a request which I, of course, did not comply with. He was rapidly restored to his wonted condition, in which he still continues, through the medium of a regular hemorrhoidal flux, which seems to have supplied the place of the epistaxis. Habit. When the hemorrhoidal flux has once taken place, it is reproduced with great readiness, even though the causes do not act energetically. Plethora, Those whose systems are surcharged with blood, either from the suppression of artificial or natural discharges, or from too abundant ali- AFFECTIONS CALLED HEMORRHOIDAL. 173 mentation, are more liable than they otherwise would be, from the co-operation of other causes, to be affected with hemorrhoids. Other diseases. The hemorrhoidal flux not un- frequently serves as the crisis of other diseases, as inflammation of the different organs contained in the head, chest and abdomen, and some nervous diseases, as melancholia, hypocondriasis, and so on. Passions. Rage, fear, sorrow, ennui, restlessness, &-C., produce a strong impression on the coeliac plexus, as manifested by a sense of pain, weight, and sometimes constriction of the epigastrium. The consequence of this impression, is a repulsion of the blood from the surface, and an accumulation of it in the internal organs, especially in the abdo- men, which may be followed by indigestion, vomit- ing, diarrhoea, jaundice, or the hemorrhoidal flux. Constipation. Indurated and impacted feces produce hemorrhoidal affections; firstly, by irrita- ting the mucous membrane of the rectum, and thus causing an afflux of blood towards it; secondly, by compressing the hemorrhoidal veins, and thus impeding more or less, the ascent of the blood ; and thirdly, by the engorgement which the hemorrhoidal vessels suffer during violent efforts at expulsion. Pregnancy . This state of the system tends to the production of these affections; firstly, by the state of plethora which it creates; and secondly, by the pressure which the enlarged womb exercises on the mesenteric veins. 174 AFFECTIONS CALLED HEMORRHOIDAL. The developement of tumours, as well as the indu- ration and other diseases of the organs specified above, together with tight lacing, cause hemor- rhoids by the impediment they create to the ascent of the blood. Concussion of the abdomen determines an increa- sed quantity of blood towards it ; the application of bandages to the inferior extremities obstructs the cir- culation, and consequently causes a fluxionary move- ment in the direction of the inferior portion of the body ; and, pierced seats leave the anus unsupport- ed, so that not only is the blood allowed to gravi- tate without resistance, but, in consequence of the pressure on the surrounding parts, the circulation is obstructed, hence they are occasional causes of hemorrhoidal attacks. Certain alimentary substances. Onions, shallots, radishes, spices, salt, and aromatics, as well as cla- ret, cider, beer, honey, &c., in certain people, also very warm or cold drinks, by creating abdominal plethora, and exalting the sympathy between the stomach and the rectum, favour hemorrhoidal dis- eases, Stimulating purgatives, as aloes, rhubarb, sul- phate of soda, &c., stimulating enmata, diarrhoea, dy- sentery, prolapsus of the rectum, and ascarides, all act, by directly irritating the mucous membrane, and thus creating an increased flow of blood to the rectum. External ii-ritation. Riding on rough horses, AFFECTIONS CALLED HEMORRHOIDAL. 175 blows, inflammation, the application of heat or cold, leeches to the anus or lower extremities, and stimu- lating pediluvia, operate on the vessels of the rec- tum, by attracting the blood downwards. Stone in the bladder, stricture of the urethra, dis- ease of the j^rostate, and excessive venery, create en- gorgement not only of the genito-urinary organs, but also of the rectum, in consequence of its situa- tion, structure, and office.* From the causes now mentioned, it is evident that hemorrhoidal affections are either consti- tutional or accidental, and as this distinction is im- portant, we shall point out in a general way how it may be made When they are constitutional, there is an heredi- tary predisposition, they are generally of long stand- ing, and the attacks, which are frequently periodi- cal, occur independently of local and accidental causes. The relief resulting from the attack, the quantity of blood effused, the existence of tumours, the intensity and duration of the pain, the ao-e, season, climate and habits, should be taken into ac- count, when determining the nature of the affection. In the accidental affections, the hereditary pre- disposition does not exist, and neither age, season, chmate, nor habit are concerned in their produc- tion. The paroxysms are not periodical, and they afford but little relief, unless the evacuation has * Monlegre has, in liis excellent treatise, accumulated nearly all the facts re- lating Jo the production of these affections. (Op. cit. from p. 72 to ill.) 176 AFFECTIONS CALLED HEMORRHOIDAL. been preceded by violent congestion of the vessels of the rectum. A local cause easily determined, produces and prolongs the attack ; but the best proof of the accidental nature of the disease, is the ab- sence of the symptoms denoting a fluxionary movement, and finally, the presence of but a few- local symptoms. I shall follow the same order in describing the treatment of these affections, which I adopted, after Montegre, in investigating their pathology. Congestion. When symptoms denoting repletion of the vessels of the rectum exist, we ought to direct the bowels to be evacuated with castor oil, or some other mild cathartic, then, a dozen of leeches to be applied to the anus, and after they have been re- moved, a warm hip bath. In some individuals, particularly in those who have heretofore suffered from the hemorrhoidal flux, this plan of treatment will reproduce it, and thus free the patient from his uncomfortable condition. In others, it will afford relief without the appearance of this flux ,- though in such cases it will generally be necessary to repeat some or all of the remedies mentioned, once or oftener. Hemorrliage. As long as the hemorrhoidal dis- charge is moderate, we ought not to interfere with it, but when a considerable portion of blood drains off daily, so as to render the patient rather weak and ner- vous, we ought to order a drachm of the confectio pipe- ris nigri, to be taken three times a day, and should AFFECTIONS CALLED HEMORRHOIDAL. 177 the bowels be torpid, a portion of the lenitive or sulphur electuary at bedtime. Many patients cannot take the confection of black pepper. In such cases, four ounces of lime water ought to be injected into the rectum every morning and eve- ning, and retained as long as possible. When the patient leads a sedentary life, he should take exer- cise, by which the secretions will be increased, and the circulation equalized. I know a studious gen- tlemen, who suffers much from the hemorrhoidal flux in the winter, but in the summer, when he travels, the bleeding ceases. The diet ought to be plain and moderate. The stimulating nature of the food used by the better description of people, together with their sedentary habits, renders them more subject to hemorrhage from the rectum than the more humble classes. Should the hemorrhage become suddenly so jDro- fuse as to exhaust the patient, it becomes our duty to use active measures to check it. He should be placed in the horizontal position, and the following means employed, according to the urgency of the case: ice to the perineum and sacral region; sina- pisms and ligatures to the upper extremities ; cup- ping glasses, with or without scarifications, over the scapulse ; dilated sulphuric acid, or acetate of lead with opium internally; and, injections of ice water, — spirits of wine, — port wine, — a solution of alum, of sulphate of iron or copper in a decoction of oak 23 178 AFFECTIONS CALLED HEMORRHOIDAL. bark, — tincture of the muriate of iron and water, — or, the decoction of bistort, tormentil, pomegranate, nut galls, &c. Some authors have recommended bleeding in the arm ; but I cannot add my assent to this practice, for though I am ready to admit that it diminishes the nervous agitations, renders the disposition to me- tastasis less easy by emptying the vessels, and tends to draw the blood to the superior part of the body, I am disposed to think that a patient reduced by the hemorrhoidal flux, has got no blood to spare. In the early stages of the flux, when the vital for- ces are exalted, this objection will not hold good, but at such time phlebotomy would be a highly improper remedy, for, as I have said before, it is only when the hemorrhage is profuse that we are justified in meddling with it. When the hemorrhage has continued so as to exhaust the patient by slow degrees, and has assu- med more or less of a passive character, we ought to administer the sulphate of quinine and sulphuric acid, or some chalybeate preparation, with great caution ; but most advantage will be derived from sea bathing. I have seen a few cases, in which much improvement took place during a course of ferru- ginous waters. If the bleeding proceeds from tumours, they ought to be removed. Tumours. When the tumours are exceedingly AFFECTIONS CALLED HEMORRHOfDAL. 179 painful, they should to be anointed with the follow- ing salve, three or four times a dav. ]^ Extracti opii grana duodecim, Unguenti Cetacei unciam, • M— Sometimes the patient derives great relief from the apjolication of cold water in a continued stream. Thus, in England, many of those afflicted with hemorrhoids are in the habit of allowinor the stream which issues from the water closet, to strike against the parts prolapsed, while defecating. When the sphincter is affected spasmodically, I have found the following ointment very useful. . I^ Extracti Belladonnge drachinam Unguenti Cetacei unciam, M— Should the tumours be inflamed, leeches ought to be applied to the surrounding parts, and followed by tepid cataplasms. Some authors have recom- mended scarifications, but, I cannot approve of this practice; firstl}', because I have seen much annoy- ance, and never any good, arise from them ; and se- condly, because the principle upon which they have been recommended is erroneous, viz. : that as piles are dilated veins, their puncture ought to afford much blood, and thus disgorge the vessels of the rectum. When they descend, and the sur- rounding parts are relaxed, we may advantageously use the ointment of galls. In consequence of pain, it may be advisable to add opium, or of spasm of 180 AFFECTIONS CALLED HEMORRHOIDAL. the sphincter, belladonna to this ointment; and should there be ulceration and fungous asperities on their surface, the super-acetate of lead will prove a useful addition, in the proportion of half a drachm, or even a drachm, to an ounce. Where the spasm of the sphincter and pain did not forbid it, I have ordered half a drachm of the sulphate of zinc, in half a pint of water, to be inject- ed every morning after defecation, and in the eve- ning a steel bougie to be passed a few inches into the bowel, and kept so for half an hour. This plan has in some instances answered very well, and on the whole, appears to me much more useful than it was esteemed by those who first tried it. The means now stated are sufficient, in the ma- jority of cases, to enable the individual to pass his life comfortably ; but when, in spite of their judi- cious employment, the tumours continue to be neu- ralgic, attended with spasm of the sphincter, sub- ject to protrusion, or bleed profusely, they ought to be removed. I must here, however, caution the inexperienced against precipitate determination, and this I cannot more effectually do, than by re- peating that heraorrhoidal affections are generally constitutional, and serve to ward off fatal disease of other organs ; therefore, it is absolutely necessary to interrogate the patient as to his hereditary predispo- sition to other disease, to the present state of the or- gans most essential to life, to his health previous to the formation of these tumours, and the influence AFFECTIONS CALLED HEMORRHOIDAL. 181 they have since exerted on it. Having, after a ma- ture consideration of his case, determined upon the propriety of removing them, the patient ought to be informed of the course of treatment, which w^e shall specify in another place, as necessary after the operation, and without he consents to pursue it, the surgeon ought not to proceed to operation. Indeed, when we meet with a rational patient, we ought to explain to him all the circumstances rela- tive to his case, or, if he be not a sound thinking person, it will be prudent to confer with some of his friends; a course not only proper in this, but in all other cases, which may present themselves for ope- ration. The operation being determined on, the next subject is the best method of performing it. Some surgeons prefer excision, and others the ligature. Those who advocate the former, say that there is no danger of hemorrhage, that it is more readily executed, attended with less pain, and followed by a more rapid recovery, than when ligatures are applied ; but above all, that it is entirely free from- phlebitis, tetanus, and peritonitis. That it is more easily and quickly executed, I am ready to admit, though it cannot be denied that the operation by ligature is simple enough, and far from being tedious. Perhaps, also, it may be some- what less painful, but in this respect there cannot be much difference, when the ligatures are properly applied. That it is followed by a more rapid re- 182 AFFECTIONS CALLED HEMORRHOIDAL. covery, I den3%. As to the occurrence of phle- bitis, I have never seen a case, nor am I acquainted with one on record. The dread of this conse- quence has arisen in the minds of some French authors, because they set out with the preconceived idea that these tumours were varices, and then, rea- soning from analogy, they arrived at a conclusion which is not tenable. An author, therefore, instead of quoting cases of inflammation of the veins of the leg, from ligature of the sephena, to illus- trate the consequences arising from tying hemor- rhoidal tumours, ought to have read some of our English authors, who, though they agree with Briquet, Danse, and others, as to the occurrence of inflammation in some cases of ligature of the sephena, have, at the same time, demonstrated that the extremities of this vein are much less lia- ble to become inflamed than its trunk, in conse- quence of external violence. Mr. Kirby has given a case in which tetanus followed the operation, and in the same manner, I could cite two fatal cases of this dreadful disease, one of which suc- ceeded to a thorn in the heel, and the other followed a very slight ^brasion of the skin. It is very much to be regretted that the opponents of the me- thod by ligature have not, like Mr. Kirby, quoted cases, instead of making assertions : such a paucity of facts, therefore, is not likely to have much weight with an impartial surgeon. As to peritonitis, IJvnow of no case on record in which it ivas proved by dis- AFFECTIONS CALLED HEMORRHOIDAL. 183 section. Indeed, the occurrence of this disease, as a consequence of the tying piles, was started by Petit, who related two cases, in which, after the operation, the patients were seized with symptoms resembling those of strangulated intestine, to wit, nausea, vomiting, hiccough and abdominal pains. One of these patients recovered, and the other died on the second day, but as no examination of thebody was made after death, Wb are not justified in draw- ing any conclusion from it. That it was a case at all fitted for operation, we do not know, and, however probable, it may be questioned, whether the fatal attack, whatever it may have been, was the result of the operation.* That excision is not likely to be attended with hemorrhage I deny, for I have performed the opera- tion several times, and after it, have had to tie up arteries, plug the rectum, and in one instance to ap- ply the actual cautery. Indeed, I so nearly lost two patients, that when left to my own choice, I no longer have recourse to this operation. In the cases I have operated on, the hemorrhage has never been alarming during the operation, but in one in- stance, and in it, I was compelled to make firm pressure with the two first fingers of my left hand, for a considerable length of time, a procedure which appeared necessary to prevent a most fright- ful hemorrhage. Generally, however, after these * Traite des maladies chirurgicales, &c.. ouvrage posthume de J. L. Petit, Paris, AiDccxc. tome ii. p. 123 — 4 — 5. 184 AFFECTIONS CALLED HEMORRHOIDAL. Operations, the hemorrhage does not occur for a few hours, then, the patient who may have been perfectly comfortable, becomes anxious, restless, and is seized with rigours, spasms of the extremities, cold perspiration, sickness of the stomach, swelling and tension of the abdomen, particularly in the left iliac fossa, and colic pains. His pulse becomes small, frequent, and irregular ; his respiration anxious ; his countenance pale ; he is vertiginous, and faints. All this time, the blood is accumulating in the colon, and he may die without discharging it; but frequent- ly the tenesmus is so great, that he goes to stool, evacuates large clots of blood, faints, and sometimes dies. More commonly, however, the discharge, if it takes place in the recumbent position, brings relief; but, after some time, the hemorrhage returns, and in this way some patients have died. From what I have now said, it will appear that excision of hemorrhoidal tumours, is far from being a safe operation. Indeed, we cannot free it from the danger of hemorrhage, unless we touch the cut surfaces with the actual cautery, as recommended by Dupuytren, and I have no hesitation in saying that this is a barbarous proceeding, and one that ought not to be adopted, since we possess a certain and comparatively safe remedy in the ligature. However, if the patient will not submit to this reme- dy from prejudices he may have formed, we ought excise the tumours in the following manner. The bowels having been gently moved with oil AFFECTIONS CALLED HEMORRHOIDAL. 185 or an enema, the patient should sit over warm water, and strain until the tumours are prolapsed ; then, placing himself sidewise on a couch opposite the window, with his knees drawn towards the chin, an assistant separates the buttocks, while the sur- geon with a polypus forceps in the left hand, and a long curved scissors in the right, seizes and exci- ses the tumours one by one, taking care not to in- clude any of the surrounding mucous membrane. If the bleeding be profuse, the operator should in- troduce his finger, and desire the patient to con- tract the sphincters as closely as possible, so as to compress the bleeding vessels. In a short time, the finger may be withdrawn; but, it will be prudent to elevate the hips, and apply small bags of ice to the anus. If the hemorrhage recurs after a £ew hours, the anus ought to be dilated with a specu- lum, and if possible, the bleeding vessel or vessels secured with ligature ; but, if we cannot accomplish this, the cut surfaces should be touched with the actual cauter3^ Some patients, however, wil] not hear of this means of security, and under such cir- cumstances we are compelled to resort to com- pression. With a view to accomplish this in the most unexceptionable manner, I would recommend the use of the following instrument, which I had constructed for suppressing hemorrhage after li- thotomy. This instrument is seven inches long, tubular, about as thick as a swan's quill, terminated 186 AFFECTIONS CALLED HEMORRHOIDAL. with a button at one end, to facilitate its introduc- tion, and with a stop cock at the other. One inch from the stop cock, and half an inch from the button, there are two projecting rings, and on the proximal side of the distal ring, the tube is perfora- ted by a number of holes. Finally, a portion of in- testine is bound by means of waxed silk, on the tube, behind the rings. See plate ix. figs. xi. xii. This in- strument should be introduced and then inflated. In some little time we can let off the air, and with- draw the instrument, provided the hemorrhage has ceased ; but, if we find that it returns on the removal of the pressure, we must again inflate the intestine.* ♦ Several methods of plugging the rectum have been employed, of which the following are the most remarkable. " Je forme avec de la charpie un tampon de figure oblongue, ni trop dur ni trop mou; sur I'un des bouts de ce tampon, je passe en croix deux gros fils, je les reunis h. I'autre bout ; et pour les assu- jettir dans cette situation, je passe circulairemer^ quelques brins de charpie fort longs, depuis unbout jusqu'A I'autre : les quatre fils reunis, fomlentun cordon, que doit avoir au moins huit k dix pouces de longueur. Je mouille rint6rieur de I'anus, et I'exterieur du tampon, avec du blanc d'oeuf, ce qui me donne la fa- cility de I'introduire dans I'anus, au-dessus du sphincter, ou du moins au-deli du vaisseau ouvert. Ce tampon est assez gros pour remplir I'intestin, mais non pas assez pour arrfiter I'liemorrhage ; pour lui donner cette faculte, je prends un autre tampon de charpie, i travers lequel je passe le cordon du premier tampon, que je tiens ferme avec I'une de mes mains, et je le tire k moi, pendant qu'avec I'autre main je pousse le tampon ext^rieur, comme sije vou- lois le faire entrer dans le fondement : il arrive alors que le tampon ext^rieur se raccourclt, qu'il s'elargit par consequent, et vient presser les parois du vais- seau ouvert. La pression est d'autant plus grande, que le tampon ext^rieur, pouss6 i contre-sens, lui resiste, etde cette maniere le vaisseau setrouve press6 par trois forces, savoir, par la dilatation du tampon int^rieur, par sa determi- nation de haut en bas, et par la pression du tampon ext^rieur, de bas en haut. II sort au-dehors un grand bout de ce cordon, que j'envelloppe dans un linge, et AFFECTIONS CALLED HEMORRHOIDAL. 187 After the operation, the patient ought to be con- fined to arrow root, barley water, and such nourish- ment. If he suffers pain, or is restless, it will be necessary to administer morphine, and mental ex- citement should, if possible, be prevented. On the third day an enema, consisting of gruel and oil, should be given, and repeated every second day until the parts heal. The operation by ligature, is that which I prefer when the option is left with me. I have now per- formed it, I am sure, upwards of a hundred times, and I have never seen a bad symptom follow it. Having experienced some annoyance in perform- ing the operation with precision, neatness, and ex- pedition, in the ordinary manner, I invented some instruments, which, I have used with much satis- faction. This apparatus consists of a forceps for seizing que je replie sur la charpie, qui fait le tampon exterieur. Je le couvrede plu- sieurs compresses, puis d'un bandage en T. Par ce moyen, ce cordon est ar- rfete de maniere que les deux tampons ne pouvent s'^carter I'un de I'autre." (Traiie des Maladies Chirurgicales, &c., ouvrage posthume de J. L. Petit, Paris M.DCCjXC. tome li. p. 128.) Dassault succeeded in a case, by the following method: " Unmorceaude lignecarre, portanta sesquatre angles des rubans de fiU, ful iiUroduitdansi'anus. Ou entassa, dans lacavit^qui en resulta, des boulettes de charpie saupoudrees de colophane : sur elles furent appliques de gft-teau X de charpie qu'on retint en nouant les fils. Cet appariel, laisse pendant quatre jours en place, fut bt6 a. cette^poque, sans qu'il survint la moindre h6- morrhagie." (CEuvres Chirurgicales, tome ii.p. 417. Paris, 1830.) Finally, the late Baron Dupuytren, when recommending the cautery, says, " Unproc^d^ moins sdr, pour arr6terrh6morrhagie,est rintroduction dans I'anus d'une ves- sie de pore, que Ton bourre ensuite de charpie." This method, however, is not peculiar to Dupuytren, as it has been adopted by several other surgeons. 188 AFFECTIONS CALLED HEMORRHOIDAL. and bringing forward the tumours, needles of differ- ent sizes, needle carrier, and forceps for removing the needles. The forceps is six inches in length, shaped like that used for dissection, except that its blades, which are gently curved, terminate in two prongs,- one sixteenth of an inch apart, and bent inward for one quarter of an inch, so as to overlap each other. The blades are furnished with a graduated clasp, about two inches from their extremities, so that when pressed together, they remain shut, and con- sequently keep their hold. See plate ix. fig. i. The needles vary in length, from half an inch, to an inch, but are of the same breadth and curve. In each the hole for receiving the ligature is about a quarter of an inch from the point, and the other extremity, for nearly the same extent, is reduced one half; so that it may fit into a socket intended for it, in the needle carrier. See plate ix. fig, iv. The needle carrier is eight inches in length, and formed like a dissecting hook, save at its distal ex- tremity, which is considerably thicker, less curved laterally, with a socket in its extremity for receiv- ing the needle, and a bracket on its most convex part for supporting the ligature. Besides these differences, it is also gently bent forwards. See plate ix. fig. iii. The forceps for withdrawing the needle is like he common dressing forceps, except that the blades AFFECTIONS CALLED HEMORRHOIDAL. 189 are curved, so as only to touch at their extremities, which are so scooped out as to accommodate the needle. See plate ix. fig. ii. Having now described the instruments, we shall proceed to the manner of using them. The patient being placed in the same position, with the tumours prolapsed, and the buttock eleva- ted by an assistant, as in the operation for excision, the operator seizes the largest tumour with the forceps, and bears it downwards ; then, with a needle, long or short, according to the size of the tumour, armed with a strong double ligature of three twist silk, and secured in the needle carrier, he transfixes the centre of the tumour. All this can be expeditiously accomplished, without entang- ling the needle in the surrounding parts ; because, the convex portion of the needle carrier, being alone opposed to the prolapsed parts, it pushes them out of the way without injury, and thus makes room for the ascent of the needle, so that we can see pre- cisely where to enter its point. The needle should now be seized with the second forceps, withdrawn, and cut off. Each half of the tumour being tied as firmly as possible, all of it, save a small por- tion in front of the ligatures, ought to be cut off with a curved scissors. The other tumours should be treated the same way in succession, and finally, the ligatures being cut off, half an inch from the knots, they ought to be returned, together with the 190 AFFECTIONS CALLED HEMORRHOIDAL protruded membrane, and remnants of the tumours, within the sphincter. Some surgeons do not tie the ligatures tight, as they conceive that it is unnecessary to do more than in- terrupt the circulation ; and moreover, they assert, that binding the tumours firmly, gives rise to great pain. In reply to these assertions, coming from great authority too, I would beg to observe, that liga- tures require to be tied pretty tight, to interrupt the circulation in these very vascular tumours ; more- over, that there is not much pain in tying internal piles. In fact, in the many operations of this kind which I have performed, I have always tied the ligatures as tight as possible, without causing much pain, or any bad consequences. Some surgeons again, are in the habit of removing but one or two tumours, fearing, that a bad result would arise from tying many at the same time. Of this, I have no dread, because my experience teaches me, that such fear is puerile. However, when I wish to moderate, not to check, the hemorrhage, I only remove one or two tumours. After the operation, the patient should be put to bed, a large dose of morphine exhibited, and nothing but light fluid nourishment allowed. If the pain does not subside, a warm bath* will sooth the irritation of the rectum, and also, of the urinary organs. By this course, the pain generally abates AFFECTIONS CALLED HEMORRHOIDAL. 191 in a few hours, and it will scarcely ever be found necessary to repeat the remedies now mentioned. On the third day an emollient lavement ought to be administered, and after its operation, a small opiate enema. The patient may now be permitted to lie on a couch, to take rather more substantial nourish- ment, and to walk about his chamber. On the fifth day the enemata should be repeated, and if the weather be fine, he may be permitted to walk out. Provided the lis^atures do not come awav in a week, they should be pulled gently daily, until they sepa- rate ; but on no account, ought they to be pulled off, a practice which, I regret to say, I have seen more than once followed ; not only by those who had fairly obtained a good surgical reputation, but also, a character for humanity. After their remo- val, the anus may be besmeared with diluted ace- tate of lead ointment, or four ounces of a weak so- lution of the sulphate of zinc may be injected three times a day, and retained as long as possible. When the patient has regained his usual health and strength, he should take a great deal of exer- cise, so as to throw off by perspiration and other excretions, the superabundant blood. He ought also, to live very sparingly, and be careful to keep his bowels easy with oil, lenative, electuary, or enemata. If in spite of these means, he be threatened with congestion of any other organ, he ought to im- merse his feet in warm mustard water every night, 392 AFFECTIONS CALLED HEMORRHOIDAL. or else, sit in a hip bath, as hot as he can bear it, — to have six leeches applied to the anus every second day, — and, to take a pill consisting of one grain of calomel, half a grain of ipecacuanha, and three grains of the extract of aloes, every eight hours, until his symptoms are moderated. In this way, great danger may frequently be averted, as I have had much proof; but, to illustrate the point better, I shall give the outline of three cases. Mr. S., on whom I operated for bleeding hemor- rhoidal tumours, lived sparingly, and took exercise for some months, by, which he was restored to excel- lent health. Hethengave up his exercise, and lived well, taking a moderate quantity of wine daily. In nine months after the operation, and two after his change of regimen, he had an apoplectic seizure, from which he recovered under antiplogistic treat- ment. He then enjoyed good health, by taking five grains of the extract of aloes, two of blue mass, one of ipecacuanha, and two of ginger, in two pills' every night, and applying four leeches to the anus every morning, at the same time exercising much, and living very sparingly. After a few months, he gradually sunk into his usual way of life, and had another slight apoplectic attack, which, however, soon subsided, under bleeding, purging, and revul- sion on his extremities. Sines his recovery, which is now more than eighteen months, he has lived altogether on vegetable food, has drunk nothing but AFFECTIONS CALLED HEMORRHOIDAL. 193 water, and has ridden on horseback from ten to twenty miles a day, when the weather permitted. His healthhas been good ; but, occasionally he has suffered from vertigo, which has yielded to stimula- ting pediluvia, and the pills above mentioned. I removed five large hemorrhoidal tumours from Mr. L., and gave him directions, as to the course of life he ought to pursue. He did not attend to these, and consequently was attacked with spitting of blood, for which I was consulted, and recommended leeching the anus twice a week ; two pills containing five grains of the extract of aloes, and five of blue mass, at bed time ; a solution of the sulphate of soda, in the morning ; low diet ; and, after the spitting of blood ceased, regular exercise. He took alto- gether, twenty-four pills, three ounces of the neutral salt, and applied two dozen and a half of leeches, when he felt himself perfectly recovered, but weak. It is now fourteen months since the spitting of blood ceased, and by exercise and low living, he enjoys uninterrupted good health. Mr. E., from whom I removed four bleeding hemorrhoidal tumours, was attacked, two months after the operation, with spasmodic cough, and ir- ritation of the membrane of the larynx, in conse- quence of which, he exjDectorated an immense quantity of a frothy tenaceous matter. He was an immense eater, and a man of sedentary habits. I had great difficulty in conquering these failings, but, when I did so effectually, with the aid of warm 25 194 AFFECTIONS CALLED HEMORRHOIDAL. hip bathing, leeches to the anus, and pills, consisting of the extract of aloes, calomel, ipecacuanha, and extract of belladona, he gradually recovered. See also, the case, p. 171.* The treatment of external tumours is very simple. When they are not attended with much pain, the horizontal position, low living, gentle cathartics, emollient fomentations and poultices, will be suffi- cient for their removal. If, however, the pain be considerable, in addition to the means now recom- mended, we ought to apply a few leeches ; but, should there be but one large and elastic tumour, the better practice will be to lay it freely open, and then, with the scooped extremity of a director, turn out the clotted blood. This operation never fails to give relief, and prevents the formation of matter. Some years ago, I attended a Scotch gen- tleman, who had just arrived from the West Indies, and had one of these tumours, as large as a hickory nut, on the verge of the anus, extending for half an inch within the sphincter. I ordered him castor oil, forbid all nourishment except gruel, and en- joined the horizontal position. In the evening, he had not im.proved, and therefore, I recom- * Since the text was written, I operated on Major S., a delicate person, but apparently, free from organic disease. On the morning after the opera- tion, he was seized with a little cough, and expectorated an ounce of blood. On inquiry, I found that he had, during the night, slight symptoms of a flux- ionary movement, with pectoral oppression. I ordered him a stimulating pediUu'ium, and a diaphoretic draught, which had the effect of rendering him very comfortable. He soon recovered without a bad symptom. AFFECTIONS CALLED HEMORRHOIDAL. 193 mended leeches, fomentations and poultices. On the next day the leeches were repeated, but, notwithstanding, the tumour suppurated. About three months since, a full habited merchant, just arrived from Rio, went to shoot on Long Island; but was compelled to return to town, in conse- quence of considerable swelling of the side of the anus. He sent for me, and on examination, I dis- covered just such a tumour, as that under which the Glasgow gentleman laboured, save that it was rather larger. I immediately laid it open, and turn- ed out the coagulated blood. So sudden and per- fect was his relief, that on the same day, without my knowledge, he dined out, and took his wine as usual. The relation of these two cases, will show I hope in a pretty clear light, the advantage of in- cision, when these tumours are large, tense, and painful. When pendulous flaps of integument remain after the absorption of the blood, they ought to be seized with a polypus forceps, and removed with a curved scissors ; otherwise, they will entangle the secretions, and in this way give rise to irritation, and finally degenerate, as I have mentioned at pages 163 — 4. Injiamination. See chapter vi. Mucous discharge. If this discharge be the result of acute capillary irritation, we ought to treat it as mentioned in the chapter on inflammation. When it assumes a chronic character, and is coupled with tumours, they should be removed. As the con- 196 AFFECTIONS CALLED HEMORRHOIDAL. stitution is generally weak and nervous, we ought to regulate the bowels with calcined magnesia, and then exhibit quinine or ferruginous medicines, at the same time that we recommend exercise, and a resi- dence in a dry pure atmosphere. Cold bathing, as well as ferruginous or sulphureous waters, are also very desirable adjuvants, when accessible. Authors have recommended balsam of copiavi, oil of cajeput, and turpentine, in combination with aro- matics, such as canella and mace, or with astrin- gents, as alum, blood dragon, the bark of the pomegranate, &c., all of which, I have never tried. The local application of astringents is how- ever sometimes attended with good effects. I have used solutions of alum, sulphate of zinc, sulphate of copper, acetate of lead, and nitrate of silver, with advantas^e. The insertion of issues in the thighs, as recom- mended by some French authors, is a useless and wanton practice. When the discharge has been profuse, and has continued for a long time, we ought to guard against disease in other organs, by such remedies as we have specitied, when treating of the consequences which may follow the removal of hemorrhoidal tumours. J CHAPTER XV. ENLARGEMENT OF THE HEMORRHOIDAL VEINS. In the chapter on hemorrhoidal affections, I gave such a description of the tumours which resuh from a determination of blood to the rectum, as I M'as w^arranted, from the examinations I had made of them. Whether they had their origin in diseased veins, I did not, nor do I now, pretend to determine. Some one possessing more leisure than falls to my lot, would do well to renew the investigation, free- ing his mind, in the first instance, from the plausible theory of their venous origin, and recollecting also, that a morbid structure may not have the same identical arrangement, from the commencement. Slight dilitation of the hemorrhoidal veins is very common, especially, in persons subject to enlarge- ment of the veins of the inferior extremities, and in such persons, the portal veins are generally more am- ple, and have thinner tunics, than in those who are free of this infirmity. These facts I long ago satis- 198 ENLARGEMENT OF THE fied myself of.* I must say, however, that the di- lutation of the hemorrhoidal veins, which I have seen, bore no resemblance, whatever, to the hemor- rhoidal tumours ; nor did it appear to me, that the dilated veins were undergoing any structural altera- tion, which would lead to the supposition that they were about to be converted into hemorrhoidal tu- mours. In plate iii. fig. ii, is represented the anus of a gentleman, who laboured under excessive dili- tation of those veins. The appearance of the dis- ease is certainly very different from that delineated in plate iii. fig. i. and in plate ii. fig. i ; the first rep- resenting a case of internal, and the second, a case of external hemorrhoidal tumours. The gentle- man from whom the drawing alluded to was taken, never lost any blood from the anus, and only expe- rienced inconvenience from the impediment crea- ted by the venous mass, to the evacuation of the feces. The dilated veins could be easily felt, not only through the skin, but also through the mucous membrane, even above the edge of the internal sphincter.f * See an Essay on Phlebectosls, by George Bushe, M. D., Medico Chirur- gical Bulletin, vol. i. p. 230. New-York, 1831. + M. Petit relates a case, in which the patient sunk under hemorrhage from the rectum. On dissection, he says, " je trouvai le foie peu goufl^, mais dur; les veines mesenterique, spl<;niques et autres, qui forment la veine — porte, etioent considerablement dilat^es, parce que le troue etoit comprimd, non par le volume, mais par la durete du foie; Ics veines hemorrhoidales, depuis 1' S du colon jusqu' au sphincter dcl'anus, dtoient variqueuses, crevees et nlcerues dans rintericur du boyau ; les bords de plus d'une trentaine de ces ulceres, le HEMORRHOIDAL VEINS. 199 boyau meme, danspresque toule son dtendue, 6toientdurs et calleux." (Trait6 des Maladies Chirurgicales, tome ii. p. 74—5 — 6. Paris, m.dcc.xc.) Petit, who considered hemorrhoidal tumours as varices, employed this remarkable case in illustration of his views, and none of his followers have failed to bring it into their service; but with what justice, I leave the reader to decide. # I % CHAPTER XVI. PROLAPSUS OF THE RECTUM. There are two forms of this disease. In one the mucous membrane is alone prolapsed ; whereas, in the other, all the coats of the rectum come down. The first is by far the most common, in conse- quence of the great extent and loose connection of the mucous tunic, while, the firm union of the in- testine itself, with the surrounding parts, the longi- tudinal direction of its strono;est and most numerous fibres, together with the action of the levatores ani muscles, offer much resistance to the descent of the entire gut. Childhood, constitutional relaxation,want of tone in the muscular apparatus of the anus, and debility of the intestine itself, predispose to prolapsus of the rectum. — Childhood. Children are more subject to this disease than adults, because the intestine is less curved ; the sacrum is more pendicular ; the coccyx is not yet ossified, and is moveable on the sacrum ; the connections of the rectum are less e, tensive, in consequence of the imperfect develo 26 #« 202 PROLAPSUS OF THE RECTUM. ment of the prostate, urethra, and vesiculoB semina- les ; the abdominal viscera are more voluminous ; and finally, the mobility of the intestines is greater. — Constitutional relaxation occurs most commonly in scrofulous children, especially females, who grovi^ up rapidly, — in infants poorly nourished, particular- ly in those who have been nursed too long, — in per- sons who have suffered from protracted disease, or from a residence in hot climates, — and, in aged per- sons. — Want of tone in the muscular aji^aratus of . tlie anus, exists in those who labour under compres- sion or disorganization of the spinal chord, — who have undergone operations for fistul a or fissure, — who have had large foreign bodies extracted, — or, who have been in the habit of expelling bulky masses of indurated feces. — Finally, dehility of the intestine itself is found in those who have constantly re- course to large enemata, or who are subject to excessive fecal accumulations. Constipation, hemorrhoidal tumours, colitis, paint- er's colic, ascaricles, severe cathartics, prolap- sus uteri, parturition, stricture of the urethra, en- largement of the prostate gland, stone in the blad- der, violent coughing, sneezing, &c., may be con- sidered as so many occasional causes of this affec- tion. — Constipation. The accumulation of feces, and the distension of the anus during their expul- H » ^^ sion, as explained above, predispose to this disease ; ■^^1 ^ijhile the straining to force them down, together ^ith the pressure which they exercise on the bowel PROLAPSUS OF THE RECTUM. 203 in descending, may not only protrude the mucous membrane, but the rectum itself, by elongating the cellular tissue, which connects it with the surround- ing parts, and b}^ overcoming the resistance of its longitudinal fibres. — Hemorrhoidal tumours. There are two species of prolapsus which depend upon these tumours. In the first, the tumours in descend- ing drag along with them a portion of the mucous membrane, while, in the second, the protrusion re- sults from the straining which they provoke. This has already been explained, when treating of he- morrhoidal affections. (See page 154 — 5.) In such cases, the displaced portion of the mucous membrane is situated within and below the piles, which maintain their usual position. — Colitis. The violent straining which occurs in this disease, causes more or less of the rectum to descend, while the expansion of the anus during such effort, facilitates the displacement. This is more especially the case, in the chronic form of the disease to which teethinor children are so subject, and in whom on dissection, the mucous membrane is found studded with numerous small ulcers. The other causes, with the exception of coughing and sneezing, operate in the same man- ner. These two can only effect those who are much predisposed to the disease, as during such efforts the glottis is not closed, and the sphincters are not relaxed. The amount of intestine displaced, varies fro fold of the mucous membrane, to several inches ^ 204 PROLAPSUS OF THE RECTUM. the bowel itself. (See plate iv. fig. i.) In a boy with stone lately under my care, at least six inches of the intestine was prolapsed. In some instances, the protrusion forms very rapidly, as in weakly children, in consequence of the great mobility of their intes- tines, and the severity of the nisus which deter- mines it. In other cases again, it takes place very slowly, especially in adults who are not advanced in* life, and who do not labour under constitutional debility, or atony of the muscular apparatus of the anus. When the mucous membrane is alone prolapsed in the child, it assumes the appearance of a small py- ramidal, red, and coiled tumour; while in the adult it is less red, and generally takes the form, either of two lateral flaps, (see plate iv. fig. ii.) or of a circular fold. In some of these cases, the portion of mem- brane thus protruded comes from the pouch of the rectum, while that within the sphincters remains in situ. When this is the case, we can pass the ex- * tremity of the little finger between that portion of the membrane which adheres to the internal sphinc- ter, and that which is protruded. This form of dis- ease may be accounted for, by the comparatively greater extent of the mucous membrane of the pouch, and its looser adhesion to the muscular coat, than that which lies within the internal sphincter. When the protrusion is allowed to remain down, ecomes engorged with blood from the pressure which the sphincter exercises on the veins, as mani- PROLAPSUS OF THE RECTUM. 205 fested by its increase in size and livid colour. If it be not soon reduced, inflammation sets in, and is attended not only with great local pain, but fever, and in some rare instances, death ensues, in conse- quence of extensive peritoneal inflammation. In some other, and yet more rare cases, the protru- ding portion sloughs off", and a cure follow^s. When the descent of the bowel is often repeated, the mucous membrane becomes indurated, looses its villous surface, and in some instances even ulcer- ates. This is more likely to be the case, when the sphincter has become relaxed from the repeated dilitation it has suffered, and there is a constant nisus causing the bowel to contract, and force out the mucous membrane. Such cases are generally hemorrhoidal, and the persons so afflicted are mise- rable, as by no artificial means are they able to keep the membrane reduced for any length of time. Indeed, they can scarcely assume the erect posi- tion, cough, sneeze, or laugh, without suffering from its descent. The only diseases with which prolapsus of the rectum can be confounded, are hemorrhoidal, tu- mours, and intussusception. At page 162, we have shown how it may be distinguished from the former ; therefore, it now only remains to explain how it differs from the latter, and this, though very im- portant, is easily done. In protrusion of the rec- tum, we are not able to insert a probe or finger higher than the border of the internal sphincter, in 206 PROLAPSUS OF THE RECTUM. consequence of the doubling down of the mucous membrane, while in intussusception no resistance is offered to the ascent of either one or the other. In the treatment of prolapsus of the rectum, our first great object is to replace the protruded portion of the bowel. If recent, we may proceed to its re- duction at once ; but if it be engorged with blood or inflamed, leeches should first be applied to the surrounding parts, and the tumour itself fomented with a warm decoction of poppy heads. The pa- tient being placed on his side in a recumbent posi- tion, and the buttocks separated by an assistant, the surgeon having oiled his fingers, endeavours by a slow and steady compression, to diminish the size of the tumour, and then to push it within the inter- nal sphincter. He should be careful not to intro- duce his finger within the anus, unless it be abso- lutely necessary ; else in withdrawing it, especially in children, a portion of the bowel will be again pro- lapsed. Some authors, fearing this difliculty, have with more ingenuity than practical skill, recom- mended the reduction to be accomplished with a distended gut, from which the air should be let out when the protrusion is replaced, and then withdrawn. Sir C. Bell recommends the point of the finger to be armed with a cone of paper, wetted at the point, and oiled on the outside ; this, he says, will easily slip out, without bringing down the bowel. I can scarcely think that this will ever be necessary ; but at all events, it is a very superior PROLAPSUS OF THE RECTUM. 207 expedient to the distended gut.* Should the sphincter be so contracted, as to prevent the return of the prolapsed portion of the intestine, the fissure knife ouoht to be cautiously introduced, and this muscle completely divided. If it occurs in infants who have been too long nursed, they must be weaned, — if in children badly nourished, they ought to be well fed, — if in delicate and relaxed persons, bark, iron, cold bathing, a substantial diet, a bracing atmosphere, and regular exercise will be necessary, — if from injury or disease of the spinal marrow, this organ should be treated according to the character of the affection, — if from division of the sphincter, the introduction or extraction of foreign bodies, the repeated expulsion of indurated feces, or the distention of the bowel, advantage may be derived from the injection of the infusion of galls or catechu, of a solution of alum or acetate of zinc, &c. Costiveness should be prevent- ed, but every thing like brisk purging ought to be avoided ; therefore, emollient enemata, and mild cathartics, such as castor oil, calcined magnesia, an infusion of senna, manna and tamarinds, cream of tarter, lenitive electuary &c., are desirable remedies. Should there be irritation of the colon, orivino- rise to frequent discharges of an unhealthy character, and attended with tenesmes, castor oil, chalk, julap, ipecacuanha, rhubarb, calomel, and opium, combi- * A treatise on the diseases of the Urethra, Vesica Urinaria, Prostate, and Rectum. London, 1822. p. 345 — 6. 208 PROLAPSUS OF THE RECTUM. ned according to circumstances, together with ene- mata of starch and opium, will be necessary. If ascarides nestle in the rectum, and by the irri- tation they create, give rise to prolapsus of the mu- cous membrane, or a portion of the intestine itself, we ought to inject some of the following prepara- tions, viz : a decoction of worm wood and rue, — a decoction of chamomile flowers with castor oil and salt, — aloes suspended in milk, or rubbed up wdth oil, — lime water and oil, — camphor, turpen- tine, or the essential oils, suspended in water with the white of egg, — sulphuret of potass in water, — tincture of the muriate of iron in water, — or, tobacco smoke. Calomel and jalap, or aloetic purges, should be administered at the same time.* In some few cases, they may be so numerous as ta require extraction. (See chapter iv.) Finally, the removal of the other causes, above specified, will be necessary for- the cure of the pro- lapsus. * Bresmer's electuary has been much praised as a remedy for ascarides ; but I am unable to offer any opinion on it, as I have never seen it administered. As its composition is not very generally known, I shall cojTy it here, ^ Semen. Santonici et s. tanaceti rude coutus, a. semunciuam ; pulv. valerian, s. drach- mas duas ; jalapae, drachmas duas; sulphat. potassae, dracmasduas; oxymel. scillitici, q. s. ut fiat electuarium. A teaspoon full to be taken in the morn- ing and evening. Besides the use of this electuary, Bresmer advises an enema, consisting of an infusion of worm-wood, tansy, orange peel, and Talerian, with a spoonfull of the empyreumatic oil of hartshorn, twice a day. He recommends these injections immediately after defecation, as then the worms are not protected by fecal matter. When the patient is not of an irri- table habit, he orders a spoonfull of fresh o,x-gall to be added to each lavement. This plan of treatment, he says, must be continued for many weeks. PROLAPSUS OF THE RECTU5f. 209 Should the means recommended, fail, we must proceed to a surgical operation, the nature of which will depend upon the character of the disease. Thus, when there is a considerable prolapsus, and the sphincterdoes not appear much relaxed, one, two, hree, or four portions of the mucous membrane, according to the extent of the disease, each about the size of a shilling, ought to be pinched up with a for- ceps, on opposite sides of the bowel, at different alti- tudes from the sphincter, then tied after the manner of hemorrhoidal tumours, and finally snipped off" out- side the ligatures, with a curved scissors. The pro- lapsus should then be reduced, the patient put to bed, and a dose of morphine exhibited. On the second day, the bowels must be opened with an enema consisting of oil and gruel, and this should be afterwards repeated, as often as may be ne- cessary. The ligatures are generally cast off' with- in ten days, after which, the heahng process goes on rapidly, and so firm does the adhesion become, that the prolapsus gradually disappears.* If the sphincter be relaxed, and the folds of fine skin at the anus elongated, an operation nearly similar to that first performed by the late Mr. Hey, * Tliis operation has been recommended by many surgeons, among whom we may mention: Copeland, (Observations on the principal diseases of the Rectun and Anus. London, 1&J4. p. 81.) Howship, (Practical Observations on the diseases of the Lower Intestines and Anus, p. 140.) Calvert, (A Prac- tical Treatise on diseases of the Rectum and Anus, London, 1824. p. 202.) Mayo, (Observations on injuries and diseases of the Rectum. London, 1833. p. 40.) &c. 27 210 PROLAPSUS OF THE RECTUM. of Leeds in England, ought to be preferred.* It consists in excising some of the mucous membrane and fine skin of the verge of the anus, so as to give rise to more firm adhesion of the remaining mu- cous membrane and skin, to the subjacent parts. To perform this operation, the patient should lean over the back of a chair, or else be placed in the same position as for lithotomy ; then, the operator removes as many folds of the fine skin and mucous membrane, as he may think neces- sary, by means of a slender dressing forceps, and curved scissors. The subsequent treatment, should be similar to that recommended after the operation by liofature. In a fortnight or three weeks, the wounds will have healed, and the adhesion become so firm, as to enable the anus to support the bowel.f ♦Practical Observations in Surgery, London, 1814. chap. xiii. p. 438. At page 413, when relating his first case, that of Mr. W., he says, " The relaxed state of the parts which come down at every evacuation, and the want of suffi- cient stricture in the sphincter ani, satisfied me, that it was impossible to afford any effectual relief to my patient, unless I could bring about a more firm adhe- sion to the surrounding cellular membrane, and mcrease the proper action of the sphincter. Nothing seemed to me so likel)' to effect these puqioses, as the removal of the pendulous flap, and the other protuberances which surrounded the anus. I hoped that the inflammation caused by this operation, would produce a more firm adhesion of the rectum to the surrounding cellular sub- stance; and I could not doubt that the circular wound would bring on a greater stricture in the sphincter ani." tDupuytren is entitled to the merit of having projected, and performed the operation, we have described ; but the sagacious Hey established the principle. " L'operateur, la main gauche armee d'une pince Si dissection, d, morslarges, aftn de causer moiiis de douleur saisit successivement, d. droite et ti gauche, et mfeme en avant et en arrifere, deux, trois, quatre, cinq ou sex de ces plis rayon- nans, quelquefois effaces ou plus ou moins saillans; de la main droite, et avec des ciseaux courbes sur la plat, il enlfeve chaque pli d, mesure qu'il est soulevfe ; PROLAPSUS OF THE RECTUM. 211 I have I'epeatedly performed both of these opera- tions; but the latter, with the most success. Should lateral flaps of the mucous membrane hang down, in the adult, as described at page 204, they ought to be seized with a forceps, and cut off with a knife or curved scissors ; or, they may be re- moved with ligatures, after the manner of hemor- rhoidal tumours. These cases are exceedingly com- mon, in proof of which, I have operated on four in eleven weeks. When a portion of the mucous membrane be- comes indurated, and partially ulcerated, as men- tioned at page 205, it should be excised. I have seen a few such cases, the most remarkable of which, was that of Mrs. A. She had been affected with protrusion of the mucous membrane for seventeen years. When she consulted me, she was v.orn down by pain, purulent discharge, and confinement, for the moment she stood erect, the protrusion oc- curred. She had tried all possible local remedies, as leeches, fomentations, anodyne and astringent lotions and ointments, at the same time that she took internally an endless catalogue of drugs, and gave sea bathing and sulphureous waters a full trial. On examination, I found that the protruded mem- I'excision doit6tre prolongee jusqu' A, I'anus, et meme au-dedans, pour que Taction s'etenJe jusqu' au deld, de I'ouverture : ou pouvrait porter I'excision juqsu'i la hauteur d'un de unpouce, si le relachement 6tait tres considerable mais il suffit ordinairement de ne le porter qu' a quelques lignes. Si le re- lachement est mediocre, ou eiilfeve un,deux ou trois plis de chaque c6i6 ; S'll est trfes grand, ou fait I'excision d'un plus grand nombrede plis." (Lemons orales parM. le Baron Dupuytren, Paris 1832, tome 1. p. 162.) 212 PROLAPSUS OF THE RECTUM. brane consisted of a circular fold, which was very hard, and ulcerated in many points. (See plate v. fig. i.) When reduced, it felt like a thick welt, or cartilaginous ring, and was immediately prolapsed by the erect position, coughing or sneezing. To be short, I removed the diseased membrane, and a perfect cure ensued. When the patient will not submit to the opera- tion suited to his case, his condition may be pallia- ted, by wearing the truss recommended by the late Mr. Gooch.* * The Chirurgical Works of Benjamin Gooch. London, mdccxcii. vol. ii. p. 150. CHAPTER XVIT. RELAXATION OF THE ANUS. This condition of the anus depends upon a want of contraction in the sphincters, the causes of which are, — disease or injury of the brain or spinal chord, — exhaustion attending weak health, sedentary ha- bits, protracted diseases, or old age, — excessive or repeated dilatation of the anus, produced by strain- ing in chronic dysentery, the introduction or ex- traction of foreign bodies, and the growth of tu- mours from within the intestine, — and, finally, ope- rations performed for fistula, fissure, &c. The consequences of this affection, are propor- tionate to the want of power in the sphincters; thus, when they are completely paralyzed from disease or injury of the brain or spinal cord, the feces are discharged involuntarily ; whereas, in that diminu- tion of tonicity in their fibres, which depends upon constitutional exhaustion, the discharge of mucus, attended perhaps with slight excoriation of the 214 RELAXATION OF THE ANUS. verge of the anus, is the most troublesome symptom. It not unfrequently happens that the mucous mem- brane is protruded; and should .the dilitation be considerable and 23rolonged, especially in elderly persons, the surrounding skin will lose its elasticity, which it is not very apt to recover, even though the sphincters be restored to their primitive condition. In the treatment of this disease, we must take into consideration the cause which produces it; thus, if it depends upon disease or injury of the brain or spinal chord, our remedies ought to be directed, so as to operate on these organs. When it arises from the growth of hemorrhoidal or other tumours, they must be removed, and should the general health be impaired, it ought to be improved by air, exer- cise, diet, and internal remedies suited to the nature of the case. The best local remedy, is the injec- tion of half a pint of cold water, three times a day. Some authors recommend the application of stimu- latino- vapours and compresses wet with astrin- gent fluids, as the solution of alum, sulphate of zinc, superacetate of lead, or sulphate of copper, the decoction of the bark of the pomegranate, galls or rose petals, port wine and tannin. When the mucous membrane and skin are much relaxed, the removal of a few vertical folds will become necessa- ry. (See chapter xvi.) CHAPTER XVIII. RELAXATION OF THE RECTUM, WITH lNVAGlNATIO> OF THE MUCOUS MEMBRANE. Tins disease is disposed to, 1)}' repeateci disten- sion of the bowel w^ith feces or injections. A^ hen the rectum is empty and relaxed, and the individual strains violentl}', to eflfect a motion, the mucous membrane may be forced into the inferior part of this intestine, and thus partially obstruct it, so that the fecal matter lodged above, can be but imper- fectly discharged. If the finger be introduced, the nature of the case will be easily discovered. The bowels are confined ; the calls to defecate are fre- qujent, urgent, and generally ineffectual ; nothing being voided, but mucus or puriform matter, often streaked with blood ; finally, the pain is always con- siderable, but occasionally violent. A well regula- ted diet, gentle* aperients, emollient followed by astringent injections, and the use of the inflated 216 RELAXATION OF THE RECTUM, WITH gut, or bougie, will generally suffice for its removal. If, however, the nature of the case be not detected, one of two things must follow ; either a complete prolapsus will ensue, or what is worse, the displaced membrane will, from irritation and inflammation, become thickened and indurated, and the opening through it contracted.* A few months ago, I attended a lady who la- boured under this disease for six weeks before I was consulted. Durinor this time she had colic pains, vomiting, constipation, and hysterical symp- toms. She had repeated calls to stool, but very seldom discharged more than a sanguineous or puriform mucus, which, however, was rather abundant. She asserted that there was something within the gut, and attributed all her suffering to it. This led me to make an examination, when I found that the lower part of the pouch of the rectum w^as large and empty ; but by making her bear down, I perceived at once, an invagination of the miucous membrane, which was rather firmer and harder than natural, with an opening in its centre, not much ex- ceedino- an inch in diameter. I ordered her a light diet, the horizontal position, a blue pill at night, and a tea spoonful of Epsom salt on the followrng morning. Provided her medicine did not operate by noon, an injection consisting of gruel and oil was administered. After her bowels were evacua- ♦ See a paper by Mr. Earl in the Medical Gazette. INVAGINATION OF THE MUCOUS MEMBRANE. 217 ted, I daily introduced into the rectum, a gut nine inches long, and then inflated it; this she retained for an hour, when the air being allowed to escape, it was withdrawn. Finally, alum dissolved in a decoction of galls was injected into the bowel, every afternoon, and retained as long as possible. Urider this treatment, she recovered in a little more than a month. 28 CHAPTER XIX. ITCHING OF THE ANUS. This affection generally occurs in weak consti- tutions, in old people, and in women who have late- ly ceased to menstruate. Ascarides in the rectum, and old hemorrhoidal tumours, not unfrequently give rise to it. At other times, it depends upon a mor- bid state of the alvine secretions, which is often con- nected with general debility, especially in those who follow sedentary occupations. Sometimes an erup- tion of papulae, or even of tubercles, form on the fine skin of the anus ; the first species very often vesi- cate, and discharge a watery humour. Patches of a similar eruption occur on other parts of the sur- face at the same time. Thus, Mr. F. had a patch on his neck, and another on the side ; Mr. C. one on his back, and another on the left groin ; Mr. J. one on the sacral region ; and finally, Mr. H. had the back of his scrotum and inside of both thighs, cover- ed with an eruption, which was continuous with that around the anus. 220 ITCHING OF THE ANUS. The itching is often very distressing on going to bed, and not unfrequently prevents sleep for several hours. After a few months, it generally subsides, but is sure to return in consequence of irregularities in diet, fatigue, watching, or hot weather. From con- stant rubbing, the skin about the anus becomes thick, dense, and furrowed, even when there are no he- morrhoidal tumours. The furrows assume a radia- ted direction, and converge in the anus ; they vary in number, from six to ten, and are from one quar- ter to an inch in length. Though pretty deep, they are generally free from ulceration in those who are cleanly in their persons ; but when ablution is not daily resorted to, they become impacted with irrita- ting secretions, which create inflammation, excoria- tion, and even ulceration of the lining integument. I have seen many cases of this affection, and from a gentleman on whom I lately attended, I had the accompanying drawing taken. (See plate v. fig- ure ii.) The late Dr. Lettsom thought that the pruri- ginous state of the anus, prevented the occurrence of more serious diseases. He formed this opinion from having seen many persons, after various long indispositions, relieved by it. A gentleman, sixty years of age, who had been subject to pectoral dis- ease, i-vas perfectly cured by the appearance of this pruriginous affection. A favourable termination of the same kind, occurred in a case threatening apo- ITCHING OF THE ANUS. 221 plexy. Another patient was relieved from gout, in a similar manner ; he, however, imprudently en- deavoured to allay the itching by the application of a strong saturnine lotion, which produced the desi- red effect, but after a few days he suddenly expired. In the treatment of this obstinate and very troublesome disease, we should first endeavour to detect the cause which produces it. If it arises from ascarides, the means recommended in the sixteenth chapter, p. 208, should be employed according to circumstances. When there are old hemor- rhoidal tumours, they ought to be removed. Pro- vided the habits are sedentary, and the health delicate, exercise in the open air, alterative and cha- lybeate medicines, with a well regulated nutritious diet, will be necessary. Bark has been recommend- ed by some ; but I have found it less efficacious than the preparations of iron. Should the patient have been in the habit of partaking of highly seasoned food, and drinking liquors freely, he must be put upon a vegetable diet, and restricted to water. Oc- casional purgatives will be found useful in leuco- phlegmatic habits. Finally, if the skin be covered with an eruption, Plummer's pill and the com- pound decoction of sarsaparilla, will be indispensa- ble. Five or ten grains of the former, and a pint of the latter, may be taken daily. The pills ought to be continued until the mouth is touched, and renewed when it gets well, provided the erup- tion has not disappeared. The sarsaparilla may 222 ITCHING OF THE ANUS. be advantageously taken for some weeks after this event. During the course of treatment now recom- mended, much comfort and advantage, will be de- rived from two or three warm baths each week. The local applications, which I have found the most useful, are the vellow wash, lead w^ater and laudanum, tobacco water, vinegar, tar, and citrine ointment. I have, however, observed far more bene- fit to arise from rubbing the surface lightly over with the nitrate of silver, so as to produce a slight exfolia- tion of the skin, and then washing the parts frequent- ]y,°with water and the common turpentine soap. CHAPTER XX. EXCRESCENCES ABOUT THE ANUS. These sprout out from the fine skin and mu- cous membrane in the neighbourhood of the anus, and assume a variety of forms, in consequence of which, the Greek, Latin and Arabic authors have designated them by the fanciful appellations of sy- coma, thymion, ficus, marisca, porrus, myrmecion, condyloma, crista, verruca, &c. They are, general- ly, soft and fragile, though sometimes hard; very com- monly fissured on the surface, but, occasionally, per- fectly smooth, and usually of a dark red, though, in some instances, of a pale red colour. In general, they possess but imperfect vitality, and, consequent- ly are endowed with but little feeling.* * I have seen a few cases where these excrescences grew from the mucous membrane, opposite the superior part of the internal sphmcter, and were soft, •mooth, and elongated. At one period, I thought smoothness of surface, and softness of texture, belonged to all such excrescences, when situated within the anus; but two cases I have since seen, removed this opinion, which, however, _ is generally applicable. May not the elongated form of these growt^js, when they are attached high up, depend upon the action of the inter- nal sphincter 1 224 EXCRESCENCES ABOUT THE ANUS. The cause of these productions is inflammation of the fine skin and mucous membrane ; and this is, generally, the result of friction, compression, con- tusion, erosion arising from filth and acrid secre- tions, or the syphilitic poison.* When at, but more particularly when within the anus, they may so close the extremity of the gut, as to interfere with the fecal evacuations. I once saw an old woman who suffered much during stool, and whose feces were small, irregular in form, and streaked with both blood and matter. On exami- nation, I found the integuments around the anus covered with pus, and extensively excoriated, while the membrane, immediately within this ori- fice, was studded with warty excrescences, which very considerably diminished the outlet of the rec- tum. They may be confounded with carcinomatous tubercles, polypi, and hemorrhoidal tumours. The absence of hardness and ulceration of the bed from which they spring, as well as their softness, and fragile structure, in the majority of cases, distin- guish them from carcinoma ; their roughness in most * Some autliors look upon these excrescenses as arising, in every instance, from the syphilitic poison. This opinion, h owever, isnot tenable, for the fact is, that they existed, as we have undoubted testimony, when syphilis was unknown. In the authors now alluded to, we discover the sameperverseness, which led them to assert that almost all diseases of the genitals, were syphilitic. I have frequently seen them in persons, who never had the syphilis, and one of these was a fine child, two years old, who was placed under my care by Dr. Fanning, of Brooklyn. EXCRESCENCES OF THE ANUS. 225 instances, vascularity, varied form, small size, fre- quently, great number, and constant purulent secre- tion from polypi ; and their colour, structure, form, incapability of erection, and, in some instances, their situation from hemorrhoidal tumours. In the greater number of cases they exist alone, though they are, sometimes, combined with hem- orrhoidal tumours. When they are situated within the anus, they ought to be excised with a curved scissors, and the cut surface then touched with lunar caustic. When they are without the anus, if the patient objects to their excision, we may destroy them with any of the following applications, viz. : lunar caustic; savin powder, either alone or mixed with burned alum or the red oxide of iron ; sulphate of copper ; verdi- gris ; muriated tincture of iron ; oxymuriate of an- timony ; red oxide of mercury ; the liquid nitrate of mercury ; Plenck's lotion, (yellow wash,) or, what I have found the most safe and effectual, the strong acetic acid. Of course, when a syphilitic taint exists, anti- syphilitic treatment will become necessary. 29 CHAPTER XXI. POLYPI OF THE RECTUM. Polypi occasionally form in the rectum, and are generally of the mucous, though sometimes of the sarcomatous species.* They may be multi{)lie(l or solitary. In the majority of cases, they are situ- ated near the anus, though they are not unfrequent- ly beyond the reach of the finger. They are gene- rally globular, being pedunculated or sessile. Of- tentimes, they seem to be made up of the reunion of many lobes.f Mucous polypi are developed very slowly, and never grow to any great size, va- rying from that of a pea, to that of a pullet's egg. ♦ Sanson says that the fibrous polypi are more commonly found in the intes- tines, than the mucous species. (Nouveaux Elemens de Pathologie, tome iii. p. 52. Paris, 1833.) My own observation would lead me to the belief, that the mucous were the most common. I may mention, here, that Sanson con- siders the fungous and fibrous, to be of the same species. t Sir A. Cooper describes a polypus of the rectum, in form, like on earth •worm, very vascular, and occurring, generally, in children. (Lectures by Tyrrell.) I am not acquainted with any other author, who has observed a similar polypous growth. 228 POLYPI OF THE RECTUM. (See plate vi. fig. i.) Sarcomatous polypi, on the contrary, grow rapidly, and attain a very considera- ble magnitude.** (See plate vi. fig. ii.) If we may form any opinion from the cases of polypi of the rectum that have been recorded, they appear to have generally occurred in adults, and for the most part in females. The probability is, that they arise in consequence of long continued irritation ; though, we ought to admit that we are in total darkness on this subject. Those afflicted with this malady, complain of weight and fullness in the rectum, tenesmus, and difficulty in defecation. The evacuations, when soft, are contracted, flattened, and generally besmeared with blood, mucus, or pus, so as to lead to the belief, that there is stricture of the rectum, but the touch at once determines the point. If the polypus be situa- ted near the anus, it will descend during stool, and when large, can only be returned with difficulty. In some rare instances, the bowel contracts with so much force, as to detach the tumour. The late Mr. , on whom I attended in consultation with Dr. Stevenson, discharged a large mucous polypus in this way.f Mucous polypi are not very sensible, nor are they dangerous, if within reach and attended to in ♦ Boyer mentions a case, in which the tumour was as large as the two fists. (Traite de Maladies Cliirurgicales, tome v. p. 76. Bruxelles, 1828.) Troien relates a case, in which he unsuccessfully removed, a very large, ulcerated, and scirrhous polypus from the rectum. (Observat. Med. chirur. fasicul. p 55.) t Journal de Medicine, tome xv. p. 57. Contains a case of this kind. POLYPI OF THE RECTUM. 229 time ; but should they be neglected, they may de- generate, and prove fatal. The fungous polypi are, however, much more sensible, and as they are prone to ulceration, the result will generally be fatal, be- cause of the almost impossibility of removing every part of them, and the certain return of the disease, if this be not effected. When the polypi increase in size and malignancy, the patient becomes sallow, and loses his appetite ; his tongue is coated, and his thirst intense. He is troubled with flatulence, and colic pains. Ema- ciation, oedema, and hectic fever now set in. The fecal discharges can only be effected with diffi- culty, and in small quantity, and even this cannot be accomplished without the aid of enemata or medicine. The tenesmus and weight in the rec- tum increases ; there is much muco-purulent dis- charge, lancinating pains, and, frequently, considera- ble hemorrhage. These polypi, when free from induration and ul- ceration, provided the surrounding parts be sound, ought, by all means, to be removed. To sCC- complish this operation, tepid water should be in- jected into the rectum, and when, by its evacuation, the tumour is prolapsed, the patient ought to lie on his side, and while an assistant separates the but- tocks, the surgeon should seize the polypus with Mu- seux's forceps, and cut it away with a curved scis- sors. If there be a plurality of these growths, they ought to be treated in the same manner. In some in- '230 POLYPI OF THE RECTUM. Stances, the polypi do not descend with the evacu- ation of the water, and then we will be compelled to dilate the anus with the speculum, and having care- fully secured the tumour, and nothing else, in the for- ceps, to drag it down. I have twice performed this operation, and in neither case was there more than an ounce of blood lost. Should hemorrhage, however, occur, it may be arrested by injection of cold water, or by some of the other means before mentioned. (See page 185.) Some surgeons, ' through fear of hemorrhage, prefer the ligature, removing, of course, the tumour, after they have made the knots fast. That this method answers very well, I have no doubt, yet it is more tedious and painful than excision, and indeed, some sur- geons have been compelled to remove the ligatures in consequence of the bad symptoms which have ensued ; but such cases must be very i-are. When the polypus is very high up, it will be im- possible to prolapse it. Under such circumstances, the operator may be able to conduct a probe point- ed curved scissors along the finger, and cut through * its peduncle, or it may be possible to tie it after the manner of a uterine polpyus, as did Desault, even though it was six inches from the anus.* I must, confess, however, that at such a heighth, there is considerable danger of including other parts than the neck of the polypus. •Journal de Chirurgie. tome iv. p. 281. CHAPTER XXII. ABSCESS NEAR THE RECTUM. The cellular tissue, as is well known to patholo- gists, is very liable to suppuration, and this is more especially the case in those situations where it is de- pending, and unsupported by muscles, as under such circumstances, blood easily accumulates in the capillaries. Considering, then, the abundance of cellular tissue which invests the lower extremity of the rectum ; the great number of veins which it contains; its depending situation ; the accumulation of blood produced by the distension of the gut, with feces ; its exposure to compression and contusion ; omitting the causes hereafter to be mentioned, we ought not to be surprised at the frequency of puru- lent collections in this situation. These abscesses may be independent of disease of the rectum, or they may arise from a morbid con- dition of this intestine. 232 ABSCESS NEAR THE RECTUM. Abscesses independent of disease of the rectum, m^y be divided into the idiopathic, traamatic, critical, and symptomatic. The idiopathic abscesses are either phlegmo- nous or oranorrenous. The phlegmonous may be acute or subacute. The acute are ushered in with fever, pain, throb- bing, swelling, and induration of the parts in the neighbourhood of the anus, with frequent and diffi- cult micturition. In a few days matter forms, and is discharged either into the intestine or exter- nally, by one or more openings, after which, the pain and fever subside. The subacute are attended with irritative fever. Generally, they are large, deep seated, and accom- panied with a sense of weight, occasional throbbing, and spasm of the sphincter. The tumefaction, though not very great externally, is, however, very- perceptible to the finger in ana. The urinary or- gans sympathize, but not to the same extent as in the acute form of disease just described. These abscesses are slow to burst, and if artificial means be not used, the patient will become exceedingly low, and the rectum will be stripped of its cellular tissue. Sometimes, they open into the rectum, but more commonly, the superincumbent integuments give way in one or more points, and the matter is thus discharged. Fatigue, deterioration of health, and insufficient nourishment, dispose to this form of disease, and in ABSCESS NEAR THE RECTUM. 233 some instances, seem sufficient for its production ; while contusions, sitting on wet seats, and riding on horseback, excite ahke the formation both of this and the acute form of abscess. The gangrenous, also, vary in their character, being sometimes acute, while at others, they are chronic. The acute generally occur in bad constitutions, especially in those who have lived luxuriously, and are advanced in life. They are preceded by rigours, and attended with fever. In the com- mencement, the pulse are full and hard ; the tongue is white and furred; the thirst urgent; the skin hot ; and there is much restlessness. In a short time, however, the pulse become small, weak, and even irregular; the face flushed ; the eyes suffused ; the teeth and lips covered with sordes ; and the tongue dry, brown, acuminated, and red along the edwe. In addition to these symptoms, there is more or less stupor, extreme debility, extension of the extremities, and fetid pitchy evacua- tions. The patient first complains of deep seated pain by the side of the anus, where we may easily detect a hard point, which soon spreads ; then, the pain assumes a burning character, there is consider- able tenesmus, and the dysuria is more severe, than in any of the other forms of abscess. The swelling becomes diffused, the tension increases, though not to a very considerable extent, and the skin turns livid. If the diseased parts be laid open, the cellu- 30 234 ABSCESS NEAR THE RECTUM. lar tissue will be found extensively gangrenous, and infiltrated with very bad pus. Partial openings arise from the mortification of the integuments, and the pus with portions of cellular tissue are discharged, very slowly. Sometimes, however, the skin and cel- lular membrane are much more extensively diseas- ed. I have seen a few cases, in which nearly all of both these tissues, on each side, between the anus and tuberosities of the ischia, were so completely destroyed, as to leave the rectum perfectly bare for a considerable extent. (See plate vi. fig. iii.) The chronic are rare : they come on almost im- perceptibly, the cellular tissue and skin are less ex- tensively diseased, and they are not attended with much fever, or local suffering, as the following case w411 demonstrate. In October, 1827, Richard Jones, aged 59, of a weakly habit, began to feel some unea- siness in the anal region near the right ischium, at- tended with slight swelling, which increased gra- dually, and assumed a livid aspect. On the following July, when T first saw him, the tumefaction was moderate, and without much tension, the integu- ments were of a dark colour, and there existed two openings, which discharged a small quantity of ill conditioned pus. His pulse were slow and unequal, his spirits depressed, and his health very indifferent, as it has been for some years. I laid the diseased parts freely oj^en, and found that the cellular tissue was partly condensed, partly gangrenous, and the seat of two cavities, each about the size of a ABSCESS NEAR THE RECTUM. 235 filbert, with which the openings above mentioned communicated. The traumatic abscesses are very uncommon, and for the most part, fall to the care of the army surgeon. M. Ribes, in his inimitable essay on fistu- la in ano, relates the case of a lieutenant, who re- ceived a musket ball in the centre of the right but- tock, Avhich fractured the tuber ischii, and passed into the rectum, as proved by the immediate flow of blood from the anus, and the exit of the ball on ] 6th day, by the same outlet. , The external wound suppurated freely, and in six weeks had healed; but then, the right side of the perineum inflamed, and seemed, from its bluish appearance, about to become gangrenous, so as to lead Ribes to suspect asterco- raceous abscess ; however, he punctured it, but could not detect any opening in the rectum, on the con- trary, he found that the walls of this bowel were much thickened. In a few days, he extracted a frag- ment of bone, and some pieces of cloth, after which, the abscess healed, and the patient was restored to health.* I once saw a case, not unlike this, in a sol- dier who was wounded in India ; the bone, however, was not injured, but the ball passed into the rectum, and was ejected from the anus. The wound in the intestine healed, while the cutaneous one re- mained fistulous, until I extracted two pieces of * Memolres de la Society Mddicale d'Emulation, tome ix. p. 112, 113. Paris, 1826. 236 ABSCESS NEAR THE RECTUM. cloth from it, several months afterwards. Punctur- ed wounds, may produce abscesses in this situation. I have seen but one such case, and it was in a porter, who had sustained the injury in climbing a spiked railing. In this instance, the cellular tissue of the scrotum, as well as of the lower part of the abdomen, was attacked with diffusive inflammation. The critical abscesses occur after fevers and re- pelled eruptions. In those much emaciated, they resemble the subacute phlegmonoid abscess ; in bad habits, the acute gangrenous abscess; while in others, as in children after eruptive diseases, they are small and healthy. The symptomatic abscesses may be divided into two classes, viz : those which form in other organs, and extend downwards by the side of the rectum, and those which arise from sympathy with the res- piratory organs. The first class, includes spinal, urinary, and uterine abscesses The purulent col- lections, depending upon disease of the spine, or the soft parts in its neighbourhood, arc pre- ceded by symptoms of disease of this column, or these parts ; and the matter, after working its w^ay downv/ards, between the folds of the meso- rectum, appears at the verge of the anus, with out discolouration, pain, or induration of the surrounding tissues. The urinary abscesses are either gangrenous, arising from the extravisa- tion of urine, or phlegmonous, the urine being pre- vented from escaping by an organized lymjohatic ABSCESS NEAR THi: RECTUM. 237 barrier, and are preceded either by disease or injury of the urethra, which easily points out their true character. The abscesses, which arise from disease of the uterus, take place, most commonly, in the advanced stages of cancer of this oruan, and discharge a sanions fluid, well mark- ino- the maliornant character of this fatal disease. The second class occurs in those who labour under chronic laryngeal, tracheal, but more especially, pul- monary disease, and may be accounted for ; firstly, by the constant impulse communicated to the anal region by coughing ; secondly, by the unsupported condition of the veins in this situation, in the latter stages of consumption, in consequence of the absorp- tion of fat; and thirdly, by the retardation of the por- tal circulation, which depends upon the pulmonary obstruction ; for as explained in page 17, a free com- munication exists between the veins of the cellular tissue, without the lower extremity of the rectum, and the hemorrhoidal plexus. Abscesses icliicJi arise from, a rnorhid condition of this intestine, may be divided into the idiopathic, traumatic, and symptomatic. The idiopathic abscesses may arise from three causes ; iirstly, the accumulaton of feces, by which the circulation is retarded, and the rectum engor- ged with blood ; secondly, the entanglement of small particles of indurated feces in the lacunas ; and thirdly, from the slow inflammation which takes place, either in the vicinity or substance of tumified hemorrhoidal tumours. From these differ- 238 ABSCESS NEAR THE RECTUM. eiit causes, ulceration ensues, fecal matter is extra- visated, and an abscess is the result. The traumatic abscesses proceed from the pas- sage of balls, punctures, badly directed incisions in lithotomy, and foreign bodies which have been en- tangled by the internal sphincter.* The symptomatic abscesses depend upon disease of the liver, spleen, heart, and lungs, and may in all probability be the result of retarded venous circu- * I have seen but one case, in which a stercoraceous abscess resuhed from the presence of a foreign bod)', and this was in the person of a boy, eleven years old, who swallovv^ed, between three and four months previously, a por- tion of the thigh bone of a chicken, about half an inch long. He had suffered severely, for some weeks before I was called ; but the nature of his complaint was not suspected. I laid the parts freely open, and extracted the bone. There are several interesting cases of this kind on record, of which, the following are the most remarkable: Le Dran relates a case, which occurred to M. Destendau, of a man who for nine months laboured under a fistula caused by the lodgment of apiece of bone. (Observations de Chirurgie, tome second. Observation Ixxxvi. p. 2"22. Paris, m,dcc,xxxi.) Petit mentions some cases of this kind. In one, he extracted a needle, which, for six months, had given rise to excruciating pain during defecation. In a second, he remo- ved a small triangular bone, which for four or five months, had created great suffering. In a third, there was extensive mortification of the parts sur- rounding the anus, in consequence of the lodgment of a chicken bone, of ten years duration. Finally, in a fourth he opened an abscess, w^hich contained fecal matter and shot. The disease was of ten years standing, (Trait^ des Maladies Chirurgicales. Ouvrage posthume de J. L. Petit, tome ii. p. 186, 199,201,205.) Stalpart Vander-Viel relates a case of a man, who swallow- ed the jaw of a fish, and, seven months afterwards, had it extracted from an abscess near the anus, (Cent. ii. Part. i. Obs. 21.) Shennan mentions a case, in which a fish bone was swallowed, and discharged twelve months after- wards, from an abscess by the side of the anus, (Philos. Trans. 1723.) Harrison describes a case of abscess, which resulted from the retentionof an apple core, eight months after it was taken into the stomach. (Memoirs of the Medical Society of London, vol. v. p. 154. 1796.) M. de la Peyronie extracted a beef bone, M. Febvrier removed a pullet bone, and M. Dubois a piece of an earth- en ware pot, from stercoraceous abscesses. (M^moires de I'Acad^mie Royale de Chirurgie, tome iii. Paris, m,dcc,lxxxi. p. 124, 126, 128, 129.) ABSCESS NEAR THE RECTUM. 239 lation. Disease of the lungs, and, especially, tu- bercular degeneration, is, however, that which most commonly gives vise to them ; and this may be ac- counted for, by the tendency which exists to ulcer- ation of the intestines, in this disease. For the sake of arrangement, the different spe- cies of abscess which we have now described as arising from a morbid condition of the rectum, may be divided into the phlegmonous, and gangre- nous. The phlegmonous are of two kinds; the most common are circumscribed, red, painful, hot, swollen, accompanied with fever, and ir- ritation of the urinary organs. Suppuration is esta- blished, they point, and open externally ; then, a probe can be easily passed through the fistulous opening into the bowel. In some rare cases, these abscesses do not follow this course, being small, in- dolent, and attended with but little inconvenience.* The gangrenous are generally acute, though sometimes chronic, and pursue a similar course to those already described, (See pages 233, 234.) When an acute phlegmonous abscess is about to form near the anus, no matter whether it be inde- pendent of disease of the rectum, or arises from a morbid condition of this intestine, the patient should be kept in the horizontal position, and on * Ribes relates a case, in which a tumour about the size of a large nut, situated near the verge of the anus, continually varied in size and d'^nsity, yet never became discoloured. After many years, it discharged pus, and then collapsed. A probe passed through the external opening, entered the gut; therefore, the operation for fistula was performed. He styles it abces tuber- culeux, (Op. cit. p. 125, 126.) 240 ABSCESS iNKAU THE RECTUM. the most meagre diet, leeches ought to be apphed to the part affected, and followed by emollient fo- mentations and cataplasms. I'he bowels should be opened w^ith some mild purgative, and if the patient be phlethoric, and feverish, it may be prudent to take blood from the arm. Diluent drinks ought to be taken freely, as they not only re- duce the fever, but facilitate micturition, and with the same view, a tepid hip bath will prove very useful. The repetition of these means, must de- pend upon the skill of the practitioner. As soon as there is any thing like fluctuation, a bistoury should be 2^1unged into the most prominent part of the tu- mour, and the matter evacuated, after which the cataplasms ought to be continued.* In milder cases * We are neitlier justified, in this, nor in any other form of abscess, in search- ing after foramina in the walls of the intestine, and, above all, we are not warranted, either by experience, or reason, in dividing the sphincter and walls of the gut, to Llie bottom of the abscsss, as recommended by Paget, and his numerous followers. Perhaps, a stronger proof of the impropriety of draw- ing gensral conclusions from isolated facts, cannot be brought forward, than the essay of Paget. In fact, on the 9th June, 1739, he was consulted by M. Gel6, who, on the Gth of January, preceding, was attacked, at Nantes, with pain in the fundament, which he attributed to internal piles. On the 15th of the month, a suppurating tumour occupied the right side of the buttock, extending from the coccyx to the middle of the perineum. On the 17th, a surgeon opened this tumour extensively, but left the rectum untouched. Pifteen days after, another abscess appeared, which occupied all the left side of the perineum. This ab- scess was laid open in the same manner as the first, when the rectum was found denuded laterally and posteriorly for two inches. Various dressings were applied, but with so litle effect, that the disease was considered incurable ; and hence it was that M. G. proceeded to Paris, to obtain surgical uid. Paget, with the assistance of his brother, and M. Boudou, divided the rectum, and, to be short, the patient got well, (M^moires de FAcad^mie Royale de Chirurgie, tome deuxieme, Paris, m,dcc,lxxxi. p. 257.) Poubert, a much more experienced practitioner, proved what has since been verified, by the best surgeons, that, the intestine can unite with the surrounding parts, without liavinf recourse to the procedure recommended by Paget, and which is not ne- ABSCESS NEAR THE RECTUM. 241 of this kind, nothing more will be necessary, than to open the bowels, apply emollient cataplasms, and puncture the abscess. When the abscess is of a subacute character, rather a different course of treatment will be- come necessary. The diet should be nutritious, consisting of meals, poultry, beer, and wine. The bowels ought to be regularly moved, but no more, and this may be effected by the lenitive electuary, or some other mild cathartic, given at bed time. Small doses of the sulphate of quinine, with diluted sulphuric acid, gradually increased, will j^rove highly useful. The early evacuation of the matter is all-important, and this should not be accomplished by one free incision, as in the former case, but by two or three small ones ;* for in this way, the matter can be freely evacu- ated, at the same time that the danger arising from the introduction of air, and erysipelatous inflamma- tion, is avoided, as well as, inversion of the lips of the wound, and consequent dilBBculty in healing it. Of course, both before and after the evacua- cessar^-, either to the prevention of new aijscesses or fistulcc. He says, '" Le succfes que j'ai obtenu en ne me conformant pas &. cette maxima g^nerale dans quelques cas particuliers, oil il auroit ^te fort dangereux de la suivre; et I'eia- men des motifs surlesquels ou a fond6 ce principe, me I'ont fait abandonner ; je me propose de le detruire par un nombre de fails et de raisons, qui, 1 ce que j'espere, ne laisseront aucun doute sur cet objet." He then goes on to relate eight cases, six of which occurred in his own practice, one in Rufiel's, and the other in Loui's, all confirming the propriety of his views. (M^moires de I'Acad^mie Royale de Chirurgie, tome ix. Paris, M,Dec,LXXi. p. 111.) * Petit recommended the opening to be made thvo\:gh the bowel. 31 242 ABSCESS NEAR THE RECTUM. tion of the matter, emollient cataplasms are neces- sary. In the treatment of the acute gangrenous abscess the greatestcare is required. Should the practition- er be induced, by the jarring condition of the pulse, and the feverish state of the patient, to bleed, he will have to regret it. Should he, on the contrary, administer tonics, and stimulants, he will also find his practice hurtful. While the feverish state con- tinues, the patient must be allowed nothing more than barley water, arrow root, gruel, and w^eak broths; the parts ought to be covered with an emol- lient poultice, and he should have a little jalap, crys- tals of tartar, and molasses, or some other mild ca- thartic, to keep his bowels eas^-. If there be delirium, a blister must be applied between his shoulders, and mustard cataplasms to the legs. I have seen, under such circumstances, a dose of opium produce the most beneficial effects. We should not wait, in this case, for the appearance of suppuration, the livid colour of the skin is a suffi- cient index for the performance of a free and deep incision, extending through the discoloured parts from before backwards. If this be not early prac- tised, the deadening process will continue, until a greater loss of skin and cellular tissue is effected, than can, afterwards, be easily repaired. After this operation, a fermenting poultice should be apphed, and renewed every eight hours. When the fever has subsided, we ought to increase the diet, allow- ing animal food, and beer or wine, at the same time ABSCESS NEAR THE RECTUM. 243 that we administer a few grains of blue pill with a similar quantity of antimonial powder, at bedtime, and a bitter infusion with some soda and a carmina- tive tincture, in the course of the day, or, perhaps, a solution of the sulphate of quinine, with a little dilu- ted sulphuric acid. Should the skin and cellular tissue be destroyed, as described at page 234, the tonic course, which we have now mentioned, ought to be continued, until the health improves, when it will be necessary to perform an operation to remedy this state of dis- ease ; for the contraction of the sphincter, by sepa- rating the intestine from the walls of the pelvis, will render reparation impossible. The operation, which I have performed in these cases, consists in passing Desault's wooden gorget into the anus, and then carrying the bistoury into the chasm, I divide the sphincters on it, to the verge of the anus.* *I^o matter how far the rectum may be denuded, we are not justified ni ex- tending the incision beyond the upper edge of the internal sphincter. Those who think it necessary to divide the rectum, when an abscess fonms by its side, take especial care to extend the incision to the bottom of the chasm. The im- propriety of touching the rectum, under such circumstances, I have before explained, in note to page 240. Therefore, it now only remains for me to show the absurdity of dividing so much of the gut. My own opinion is, that how- ever ingenious M. Faget may have been in surgical expedients, he was not much of an anatomist, as may be deduced from his statement, that the bowel at the bottom of the abscess is surrounded by bunches of circular fibres, (On. cit. p. 261.) Now, if this were the case, his practice would be more excusable ; but, the fact is that, above the internal sphincter, the cir- cular fibr:>s of the rectum are neither particularly strong, nor numerous, (see gage 12.) and no anatomist ever cnteitained the most remote idea, that the pouch of the rectum was in a state of contraction, except during defeca- tion. Kven Dr. O'Bierne, . who contends so strongly for the contracted state of the rectum, admits, that the pouch does not partake of this condition. 244 ABSCESS NEAR THE RECTUM. Should both sides be similarly affected, I treat them in the same mamier. I then pass a ligature through the angle of each flap, and plug the intestine with lint. Finally, I fasten the threads, by means of ad- hesive plaster, to the buttocks. In this way, the gut is prevented from retracting, while it is well pres- sed out towards the hips. In a few cases, I have omitted the lioatures, but not without havinor had to regret it. For some time after this operation, the patient should live upon the most meagre diet, so as to render the feces as scanty as possible, and the bowels ought to be quieted by small doses of lauda- num. Every three days, however, we must re- move the dressings, and wash out the rectum with an enema of gruel and oil. In the chronic gangrenous abscess, stimulating dressings, consisting of elemi ointment and warm turpentine, or of castor oil and balsam of co- paiva, will be necessary, until the sloughs are detach- ed, after which, stimulant and astringent lotions, or ointments, ought to be employed. The m.edical treatment recommended in the acute form of gan- grenous abscess after the subsidence of fever, will be requisite in this also. Should any of the forms of disease, now mention- ed, depend upon ulceration or laceration of the To be short, as tbe object in dividing the rectum, is to prevent its contraction, and consequent separation from the walls of the pelvis, it is unnecessary to divide more than the portion, which, under ordinary circumstances, is in a state of contraction ; hence, the incision ought not to extend higher than the upper €>dgeof the internal sphincter. ABSCESS NEAR THE RECTUM. 245 bowel, giving rise to extravisation of fecal matter, the treatment of them will not differ from that which we have described, but, should it arise from the lodgment of a foreign body, it ought, of course, to be extracted ; and, indeed, it will be prudent, in every case, to make a very cautious examination of the lower extremity of the rectum, with a view of ascertaining whether the cause of the 'abscess may not be a foreign body, which has been entangled by the internal sphincter. It is not to be expected, that in a work of this kind, I should enter into any detail of the treat- ment of -the abscesses, which depend upon dis- ease of the spine and adjacent parts, of the uterus* or urinary organs ; therefore, we shall pass these subjects by, with the following observations. First- ly, unless the spinal abscess be very large, it ought not to be touched, fearing inflammation of the sac, and rapid hectic, which are apt to ensue when it is punctured ; but if it obstructs the rectum, a small valvular opening may be made in its most promi- nent part, and the matter partially evacuated; after which, the wound ought to be closed with adhesive straps, and gentle pressure made with a broad flannel roller. Secondly, when the abscess proceeds from disease of the womb, it should be punctured, poulticed until the irritation subsides, and then dressed lightly. Thirdly, if ulcera- tion, or rupture of the urethra, gives rise to the ab- scess, the parts should be laid freely open, so as to 246 ABSCESS NEAR THE RECTUM. allow the urine to drain oft'. The principal open- ing ought to correspond to the aperture in the ure- thra, and a flexible catheter should, if possible, be lodffed in the bladder. CHAPTER XXIII. FISTULA IN AXO. FisTULiE follow the abscesses, of which we have just treated, and have with propriety been divided into three classes, viz. those which communicate with the gut, and open on the cutaneous surface ; those which, though they communicate with the gut, do not open externally ; and those which do not com- municate with the gut, but open externally. The number of external openings vary ; generally, there is but one ; but sometimes, two, three, or even more. There is seldom more than one internal opening ; in some, particularly in phthisical sub- jects, there are two ; and M. Ribes, who investi- gated this subject with the greatest care, savs that he once observed three. Until the researches of this accurate investigator were published, surgeons were of opinion that the fistula frequently opened into the intestine, at a great heighth, a mis- take which led to a severe and hazardous opera- tion. He, however, demonstrated that the internal 248 FISTULA IN ANO. orilice was generally situated immediately above the spot where the internal membrane of the rectum unites with the skin, sometimes a little higher up, but neve] more than five or six lines. In eighty subjects, the internal orifice did not exceed this heighth, and in a certain number, its elevation was not more than three or four lines.* I can bear testimony to the truth of M. Ribes' conclusions, for in none of nineteen subjects, was the internal orifice of the fistula situated higher than in those examined by this surgeon, and in the many cases I have operated on, I never found the internal orifice higher up, than the region of the internal sphincter, and hemorrhoidal plexus. The internal orifice is sometimes round and cal- lous, especially in phthisical patients. In other cases, and these by far the most numerous, it is irregular and soft. The external orifice in like manner ma}"" be round, and studded with exuberant granulations, which readily bleed, particularly when old: or it mav be irreo^ular and without Granulations, especially when recent, and the result of gangre- nous inflammation; for the skin, in such cases, is generally undermined, partially livid, and deprived of its vessels by the sloughing of the subjacent cellular tissue, so that it does not really possess the power of creating granulations. The parts sur- rounding these fistulas are general^ very hard, and •M^moires de la Soci^i^ M^dicale d'Emulalion, toAie ix. Paris, 18-6, p. 135, 136. FISTULA IN ANO. 249 some time they are so disorganized; that we trace with difficulty the course of the sinuses. If we examine a recent fistula, we shall find that there is a consi- derable cavity between its orifices, because the sac of the abscess, which gave rise to it, has not yet con- tracted. This cavity, however, gradually diminishes in size, until it becomes a simple tube, lined by a fine smooth tissue, resembling a mucous mem- brane, save that it is destitute of villosities. The direction and situation of these fistulse vary. We mentioned, when treatinor of hemorrhoidal tu- mours, how likely they were to suppurate, and in describing stercoraceous abscesses, how the entan- glement of particles of fecal matter in the lacunse of the mucous membrane gave rise to purulent col- lections. Both these forms of disease generate small fistulse, situated either entirely within the sphincter, or in its substance. The other fistulas open at a greater distance from the verge of the anus, and extend obliquely upwards and inwards, through the external sphincter, and cellular and adi- pose tissue, until they open into the gut. In this course they, sometimes, run between the sphincters, and then ascend a little, before perforating the mucous membrane ; while at other times they pass through the fibres of the internal sphincter. From what we have said, when treating of ster- coraceous abscesses, it is very apparent, that a great many of them depend upon disease of the lungs ; therefore, when they degenerate into fistulae, we 32 250 FISTULA IN A\0. should not ojierate on them, else their healing will give rise to an increase of the pulmonary disorder, and curtail life. There are also other sympathetic fistuloe, which it would be improper to meddle with, as those depending upon disease of the uterus, and spine, as well as those which occur in the last stages of other organic diseases. When, however, these complications do not exist, an operation becomes necessary, and this will vary according to the cha- racter of the case, which can only be determined by examination. To examine a patient, he should be placed lean- ing over the back of a chair, or in the position for lithotomy; the buttocks being separated by an as- sistant, the suro^eon ouoht to search for the external opening. If the fistula be large, and complete, he will find it at some distance from the anus ; but, when small, it may be concealed in the folds of the fine skin close to, or at this orifice. Then, having oiled, and gently introduced his fore-finger, he should take a probe of large size, if the external orifice be far from the anus, and small, if in the folds of fine skin, and introduce it gently, rather in a transverse direction, varying its point accord- ing to the resistance it receives. In this way, if there be an internal orifice, he will soon discover it. Should the surgeon direct the probe more upwards, he will elevate it above the internal orifice of the fistula, and as the least force will be sufficient, espe- cially in recent cases, to carry the probe onwards, FISTULA IN ANO. 251 throiicrh the walls of the sinus into the cellular tissue, by the side of the gut, he will be impressed with the idea, that he is only pursuing the trajet of the fistu- la; and when he cannot find the internal orifice, he attributes his failure to the great heighth of the opening. I have committed this mistake myself, and how often have I not seen others do the same 1 How many persons are there not, even since the publication of M. Ribes' essay, who have had the rectum split open, — have been confined to their backs for weeks, — have been subjected to repeat- ed operations, — and have been rendered misera- ble for life, who might have been rapidly cured, by a trifling operation ? Should we be unable to discover an external open- ing, we may suspect that there is an internal fistula, if there be difficult defecation, and the feces are streaked with matter. These symptoms, how- ever, may depend upon other diseases of the rec- tum and anus ; but they are sufficient to warrant a very careful investigation. The parts adjacent to the anus ought to be cautiously examined, and should this disease exist, we will generally be able to discover some induration, perhaps fullness, and, by pressure, matter will issue from the anus. When the finger is introduced, a depression mark- ing the site of the orifice, can in most cases be dis- covered. If the fistula be small, concealed be- tween the folds of the mucous membrane, and com_ municates with a small purulent sack, situated 252 FISTULA IN ANO. within the sphincter, it may escape observation, and the patient be tormented with the most agonizing suffering. I once saw a case of this kind in a man, who had consulted various surgeons, and whose sufferings were as great, as those of any patient I have seen tormented with fissure. When he strained forcibly, and I made pressure on the verge of the anus, I perceived that matter issued from a point a little above ; therefore, I passed a curved lachry- mal probe into the sinus, which I laid open, and thus afforded him relief I have seen some cases, in which there were several of these small fistulsB. Having now ascertained the nature of the case, we ought to exhibit mild cathartics, poultice the diseas- ed parts, and enjoin quietude, so that all irritation, both local and constitutional, may be allayed as far as possible. Then we should proceed to the operation. M. Ribes has asserted, that it is never necessary to divide the gut, unless there is an opening in it.* Mv own experience has proved to me that this opin- ion is not correct; though, I admit, that such a step is seldom necessary, and I am perfectly satisfied that many of those who are constantly subjected to the division of the sphincters, would get well without it. Compression made with a piece of cork supported by an elastic T bandage, — the injection of a solution, the sulphate of zinc or copper, or nitrate of silver, of yellow wash, or port wine, — the horizontal position, — and, an easy state of the bowels, are gene- • Op. cit., p. 13«, 139. FISTULA IS ANO. 253 rally sufficient for the cure. When, however, the cellular tissue has been extensively destroyed, we will sometimes be compelled, after the failure of the means mentioned, to divide the external, and, perhaps, a portion of the internal sphincter. This may be accomphshed v/ith a sharp pointed straight bistoury, armed with a small ball of wax, on Desault's gorget, or, we may introduce the finger into the gut, and a probe pointed bistoury with a projecting cutting edge, into the purulent chasm, and when the extremity of the instrument has arrived at the upper edge of the internal sphincter, provided the chasm be so deep, we should steadily cut on the nail of the finder which has been introduced into the rec- turn. Then, turning the finger round, and pressing it on the end of the bistoury, we ought to depress both hands, and thus divide the intervening parts. Some surgeons prefer performhig this operation with Savigni's double bladed bistoury. When this instrument is used, it should be introduced with the sharp pointed blade concealed, until it arrives at the spot about to be transfixed ; then, while the instrument is held steadily, the sharp pointed blade ought to be projected through the gut, and immediately withdrawn, so as to enable the surgeon to pass the united blades through the orifice thus made, and to complete the operation, as when he employs the single probe pointed instrument. In some of these cases the integuments are livid and cribriform. They are badly supplied with 254 FISTULA IN ANO. blood, in consequence of the sloughing of the cellu- lar tissue, and no eSTort that we can use, will cause the chasm to fill up. The proper course under such circumstances, is to remove the diseased integument, and if then, after we have dressed the parts proper- ly, the chasms do not fill up, \ve will be compelled to divide the sphincter. I have seen a great many cases of this kind, and have verified, repeatedly, the justness of what I have asserted. In some instances, I have merely divided the diseased integument, throwing the different openings into one, and ex- tending the incision forwards, backwards, outwards, and inwards, to the union of the integument with the surrounding parts, but in all these cases I have afterwards been compelled to remove the angles of the flaps, as they curled up, became indurated, overlapped the wound, and in some instances cica- trized internally. When the fistula is complete, the surgeon should introduce his right or left fore-finger into the anus, according to the side affected ; then, with a probe pointed bistoury, he ought to traverse the sinus, and having placed the finger in ano on the extremity of the bistoury, he should cut his way out, either by steadily depressing both hands, as before described, or else by projecting the knife through the anus, and pushing it downwards, and to the opposite side. If the operator be inexperienced, he may first pass a director, and on it the bistoury. If the fistula be either in the substance, or within FISTULA IN ANO. 255 the sphincter, we will experience great trouble in using the common probe pointed bistoury ; there- fore, I would recommend the small knife, plate viii. fig. viii, I have employed it for a long time and I think with great advantage. When the fistula does not open externally, he may follow one of two methods, in the perform- ance of the operation. In the first, the orifice being discovered by the finger in ano, the operator should carry the knife used for fissure along his finger, and fixing its extremity in the orifice of the fistula, he ought to cut outwards, dividing the sphincter, &c. In the second, having hooked a strong probe, and passed it into the fistula, he should press it down until it appears by the side of the anus, and then cut on its extremity, so as to convert the incomplete into a complete fistula ; after which he ought to fin- ish the operation with a probe pointed bistoury, as above described. If this species of fistula be small, and situated between the sphincter and mucous membrane, or in the sphincter itself, we should use the small sharp pointed bistoury, plate viii. fig. ix. After these different operations for fistula, so much lint as will prevent the adhesion of the lips of the wound, should be introduced, and ought not to be removed by the surgeon, but allowed to come away with the feces. The patient ought to be confined to his bed, and his diet should be as meagre as possible. On the third day, a dose of oil should be exhibited, and after its operation, the wound ought to be cleansed, and a saturnine poul- 256 FISTULA L\ ANO. tice applied. On each succeeding day, until the wound is nearly healed, the surgeon should inject a little gruel and oil into the rectum, so as to pro- cure an easy evacuation. On the fifth day, sup- puration will be fully established, and generally the inflammation sufficiently subdued, to permit the in- troduction of a very small dossil of lint into the bot- tom of the wound; a practice which, when repeated a few times, insures the healing from the bottom. At one period, surgeons followed the hurtful prac- tice of cramming the wound with lint, but for some years past, they have stepped into the opposite ex- treme, introducing but a very small quantity of lint, applying but one or two dressings, and insinuating a probe occasionally, between the lips of the wound, so as to prevent adhesion. Should bleeding follow the operation, gentle pressure will generally be suffi- cient to check it. If this fails, we may try the appli- cation of ice ; bat if necessary, we may remove the dressings, and introduce a blunt gorget or specu- lum, and thus expose the bleeding vessel, which ought to be seized with a forceps, and tied.* Should the wound be slow to heal, we may ex- hibit Ward's paste or cubebs, and apply a lotion of the sulphate of zinc, sulphate of copper, or nitrate of silver, or we may prefer of the ointments of the oxide of zinc, superacetate of lead, white precipi- tate or nitrate of mercury. * It must be confessed, however, that bleeding is a rare occurrence, when the operation is properly performed, though it is by no means uncommon, when the incision i& carried high up. CHAPTER XXIV. COiNTRACTION OF THE ANUS. This condition of the anus may be produced; firstly, by the approximation of portions of skin naturally at a distance ; secondly, by the depo- sition of lymph in the submucous cellular tissue, constituting a species of ring around the anus ; thirdly, by the effusion of lymph on the surface of the mucous membrane, which frequently assumes the form of filamentous bands; and fourthly, b}^ a process of disorganization, manifested by irregu- lar thickening, cartilaginous induration, and partial ulceration of the line skin and mucous membrane, extending upwards, sometimes, for more than an inch. The first species results from excision of hemor- rhoidal or other tumours, the second and third 33 258 CO.NTilACTION OF THE A.NUS. from inflammation,* while the fourth arises from the syphiUtic poison. f The symptoms of this aflection, are similar to those of stricture of the rectum ;| the pain in the last mentioned sjDecies is, however, more severe, and attended with constant purulent discharge. Sometimes, in consequence of the contracted state of the anus, defecation oives rise to longitudinal la- ceration of the mucous membrane, which is soon followed by spasmodic contraction of the sphincter ani, constituting the disease called fissure. The introduction of the finoer, which is attended with great pain, determines the nature of the disease, and enables us to assure the patient that, though it is attended with more suffering, provided it be not of the syphilitic species, it is much less danserous, and not only more speedily, but more effectually cured, than stricture of the rectum. * Sir C. Bell says, that the cause of the inflammation " for the most pan is costiveuess, atid straining, by which the fibres are strained, and burst, and be- come inflamed. Sometimes, I believe, it may come from tenesmus, and fre- quent excitement of the orifice, by painful and ineffectual calls to evacuations." A treatise on the Diseases of the Urethra, Vesica Urinaria, Prostate, and Rec- tum, London, 1832, p. 321 — 2.) This explanation is very ingenious ; but I am inclined to think that it is not applicable even to the majority of cases of this kind. t As mentioned in the ensuing chapter, many authors have attributed stric- ture of the rectum to the action of the syphilitic poison ; but Mr. White was the first [Q describe the peculiar contraction of the anus, now mentioned. (Ob- servations on Strictures of the Rectimi, &c., by W. "White, Bath, 1S20, p. 18.) Calvert has also very well described it. (A Practical Treatise on Hemor- rhoids or Piles, Strictures, and other important Diseases of the Rectum and Anus, by George Calvert, London, 1821, p. 196.) T See chapter xxv. CONTRACTION OF THE ANUS. 259 111 the treatment oi'this disease the bowels should be kept soluble with castor oil, lenitive electuary, or emollient enemata, and the diet ought to be the same as in stricture of the rectum ; should there be inflammation, leeches and fomentations will be ne- cessary ; when there is a fissure, the sphincter must be divided ; if there be hemorrlioidal tumours, they ought to be removed; and il" there be much' pain, and nervous irritation, anodynes will become neces- sary. In all cases, the anus ought to be dilated with bougies,* and here I would observe, that great cau- tion is even more necessary than in stricture of the rectum, especially when the disease is cutaneous, else, much pain, w^eight in the loins, abdominal dis- tress, and disturbance of the generalhealth will ensue. When the contraction is the result of disorganiza- tion, produced by the syphiliticpoison, antisyphilitic remedies should be employed, though they are, for the most part, inefficacious, as such affections are generally fatal. The following cases will serve to illustrate what I have said on the subject. In November, 1831, I removed several large, ul- cerated, old, external hemorrhoidal tumours, from Mrs. R. When the parts had nearly healed, she returned to the country, but did not use the bougie as I had recommended ; the consequence of which * Sir C. Bell says, that stricture produced by the marginal integument, ad- mits of extirpation by the knife. (Op. cit. p. 3-2-2.) This is not the species of advice one would expect frorti so reasonable a surgeon as Sir C. Bell. 260 CONTRACTION OF THE ANUS. neglect was, contraction of the anus, and a small fis- sure. She, therefore, came to New- York, and con- sulted me. To be short, I cauterized the fissure, and so completely dilated the anus with the bougie, that in less than a month, she returned to her home in good health. Mr. D. complained to me in the latter end of 1829, 'of difficulty in defecating. He said, that he had been subject to piles