COLUMBIA LIBRARIES OFFSITE HEALTH SCIENCES STANDARD FROM THE LIBRARY OF WILLIAM DUNCAN McKIM GRADUATE OF COLUMBIA UNIVERSITY A. B., 1875; A. M., 1878; M. D., 1878 '¥t%.- RD^n flnl mtfteCtlpofllrttig0rk CoUege of ^fjpsiiciang anb burgeons! Hibrarp ft Digitized by the Internet Archive in 2010 with funding from Open Knowledge Commons http://www.archive.org/details/rectalanalsurgeOOandr EECTAL ANT) Al^AL SUEGEET DESCRIPTION OF THE SECRET METHODS OF THE ITINERANT SPECIALISTS. EDMUND ANDREWS, M. D., LL.D., Professor of Clinical Surgery, Chicago Medical College, Surgeon to Mercy Hospital, Etc. EDWARD WYLLYS ANDREWS, A. M., M. D., Professor of Clinical Surgery, Chicago 3Ieclical College, Surgeon to 3Iercy Hospital, Etc. SECOND EDITION REVISED AND ENLARGED, WITH ILLUSTRA- TIONS AND FORMULARY. CHICAGO: W. T. KEENER, 96 Washington St. 1889. Copyrighted, 1889, by W. T. Keeneb. PEEFACE TO THE SECOND EDITION. The rapid sale of the First Edition of this manual has compelled the preparation of a second much sooner than was anticipated. Advantage has been taken of the opportunity thns given to re-write and enlarge almost every part of the work, and to introduce several new chapters and an appendix. A few cuts have also been added. A chapter has been introduced upon the Anatomy of the Rectum, which, it is thought, will aid the explanations found in other parts of the work. Works upon general anatomy do not usually contain all that is needful for a comprehension of the questions that have been raised in rectal pathology. A chapter on Proctitis and its treatment has also been inserted, the subject being one now clearly recognized as of clinical importance. As in the earlier edition, the chief emphasis has been put upon the practical side of the subject, and an endeavor has been made fairly to outline all the forms of treatment for all affections, including the secret methods of the local and traveling •• Rectal Specialists." Further to make this book a vade mecum, in the hands of those who must hurriedly tur]^l many books in the intervals of active practice, a compact Formulary has been prepared, which contains in classified form every prescription in the body of the work and a considerable number of others. These are all tried remedies and many of them have their authors' names affixed. With this formulary for reference, the practitioner who has once read the book, can by almost instantaneous reference secure the necessary details for the treatment of any given case which is before him. These formulas have been collected from a very large number of works in various languages. Over fifty are given, and these are nearly all that can be found in a score or iv. PREFACE TO SECOND EDITION. more of the best modern treatises, those being omitted, of course, which are practical repetitions of each other. A chapter has also been given to the sacculi Horneri and columns of Morgagni in order more clearly to expose the ridicu- lous pathology which some have sought to connect with these innocent structures. 6 East-Sixteenth Street, Chicago, Jan. 1, 1880. PEEFACE TO THE FIEST EDITION. The itinerant "Rectal Specialists" of the Western States have become so nnnierous that very general notice has been attracted to their methods, and one good result, at least, has been brought about through their influence: Their competition has compelled physicians to give more attention to the neglected sub- ject of rectal diseases. Hence has arisen an urgent call for infor- mation upon two points: 1. What are the best modern methods of diagnosis and treatment known to the regular profession? 2. What are secret methods of the " specialists,'' and what their value? To answer these questions we have written this book. We have endeavored to condense into it the results of our own special investigations and the established o})inions, unequivocally stated, of authorities both European and American. To this we have added, in each department, the secret fornuilas of the irregulars which, for several years, we have been collecting. The evolution of the itinerant pile doctor is an amusing bit of histor}^, and here may be given space more properly than in the text. About 1871, a young and ingenious physician in Central Illi- nois hit upon a means of removing piles by injecting into them, with a hypodermic syringe, a caustic mixture of carbolic acid and olive oil. Having tested the plan and found that it often effected perfect cures he abandoned an insignificant local practice for a veiy lucrative business as a traveling pile doctor. The method was kept a secret, but its fame extended and the original inventor and his partners were enabled to sell the right to use it for large sums to regular and irregular practitioners in a large number of places. Many of the itinerants who bought and used the secret were VI. PREFACE TO FIRST EDITION. not medical men at all, yet even in their hands a certain amonnt of success was obtained, and reputation of being able to cure piles "without pain or operation " was fairly well sustained. Regular physicians were for a number of years wholly at a loss to account for the sviccess which these itinerants obtained. Our own discovery of the secret resulted partly from the indiscretion of a " specialist " who exemplified the saying in vino Veritas, and partly from the information obtained by a Chicago druggist who. furnished the same man and others their solutions. We pub- lished the knowledge thus obtained simultaneously in five promi- nent medical journals, and as a result were shortly in receipt of hundreds of letters from persons of all classes, with reports of thousands of cases, and the results, both good and bad, of the method. The sale of " rights " ceased quickly. In several cases application was made for our testimony that the publication had been made at a certain date, in order to enable persons who had been victimized to recover money paid for what was no longer really a secret. The sums so paid for exclusive rights in a lim- ited district were from one thousand to fifteen hundred dollars. The modern Western " Rectal Specialist " is lineal descend- ant of the original pile doctor. He uses still, in common with many reputable physicians, the hypodermic method in treating piles, but his evolution has proceeded so far that he now under- takes to treat other common rectal diseases as well, in a fashion peculiarly his own and suited rather to his own convenience as an itinerant than to his patient's real welfare. He no longer buys his secret and local right to practice, but invests from fifty to one hundred dollars in one of the "systems." He thus obtains a complete set of instruments and small secret manual of instruc- tions which "enable persons of no particular skill to treat suc- cessfully all rectal diseases." As a matter of fact many of these persons are not medical graduates at all, but mere adventurers whose entire knowledge of their specialty consists in what their little book of instructions has furnished them. In some instances the itinerant is not allowed to know the composition of the various remedies directed by the secret pamphlet. He must buy them of the author of the " system," thus continually paying him tribute. Several of these " systems," by underselling each other have greatly reduced their prices, so that from three hundred dollars PREFACE TO FIRST EDITION. Vll. they have now fallen in price to iifty, or even less, and are much improved in quality. The itinerants themselves, moreover, have now enlarged their field of operation and their incomes by adopting an iniquitous mass of pathological rubbish concerning the sacciili Horneri and Morgagni's columns. There are few things more melancholy tha|^ the weakness of afflicted human nature for all kinds of quackeiy. If, however, there are differences in degree of charla- tanism, that form which invents imaginaiy diseases for its victims is surely more vicious than that which only offers use- less remedies. From what has been said of the general attainments of the "Rectal Specialists"' it will be seen that most of them are too ignorant to know better when told that the saccuU Horneri, the papillcB and columns of Morgagni (long ago discovered, and studied by anatomists and rectal surgeons) are signs of disease hitherto undescribed. They have a motive, too, in believing that these simple structures are lesions, which demand treatment. A new source of revenue, not taxed by the author of any system, has been offered them and they have availed themselves of it with eagerness. Thus the evolution of the pile doctor proceeds. From know- ing originally but one thing he has come to a smattering of five or six, and is called a "Rectal Specialist." Most practitioners have greatly neglected the study and treatment of common surgical affections of the rectum and anus, and left an important field vacant for the occupation of charla- tans and self-styled experts. This manual has been prepared with a view to furnishing practical rather than historical or theo- retical information, for which the reader is referred to the syste- matic treatises such as the works of Curling, Van Buren, Esmarch, Cripps and Ball, or special monographs like those of Bodenhamer, Allingham, Kelsey, Smith, Yount, and others. 6 East-Sixteenth Street, Chicago, Nov. 1, 1887. TABLE OF CONTENTS. CHAPTER I. Anatomy and Physiology of the Rectum. Page Relation of parts — The peritoneal coat — The muscular coat — The mucous coat — The external sphincter muscle — The skin — The con- nective tissue — Arteries — Veins — Lymphatics — Nerves 1 CHAPTER II. Methods of Examining the Rectum. Thoroughness — Preliminary inquiries — Scheme of questions — Light — External inspection — Digital examination — Aseptic lubricator — Rectal sounds — Internal inspection — Speculums — Sets of rectal instruments 9 CHAPTER III. ■ Ha:MOKBHOIDS. Historical account — Causation — Varieties — Palliative measures — Oper- ative treatment — Stretching sphincter — Operation of ligation — Preparation of patient— Treatment of haemorrhage after oper- ations in the rectum — Hyjiodermic injection method — Clamp and cautery — Ecraseur — Crushing operation — Various cauteries — Ex- cision of internal piles — Circular excision, or Whitehead's operation 21 CHAPTER IV. Pboctitis. Causes — Varieties — Symptoms — Treatment 45 CHAPTER V. Diseases of the Sacculi Hoknebi. Ignorance and quackery— Anatomical history — Horner and Morgagni — Henry H. Smith — Ulcerated sacculi — Excision when diseased. . . 52 X. TABLE OF CONTENTS. CHAPTER VI. Abscess and Sinus ; Fistula in Ano. Page Comparative frequency of abscesses — Causes — Treatment — Fistula in ano — Varieties — Symptoms — Treatment — Hippocratic method — Itinerant methods 57 CHAPTER VII. Fissure of the Anus; Rectal, Ulcebs. Historic note — Influence of French surgeons— Causes — Hilton's dia- grams — Symptoms — Course and prognosis — Operative treatment — Forced dilatation — Milder measures — Itinerant methods — Ulcers above the anus — Causes — Clinical history — Diagnosis — Treatment 67 CHAPTER VIII. Prolapsus. Classification — Prolapse of mucous membrane — Prolapse of all the coats — Treatment — Operations — Excision — Cauterization — Potential cautery — Itinerant methods 81 CHAPTER IX. Polypus and other Innocent Growths. Polypus — Treatment — Itinerant method — Warts and papillomata — Treatment — Condylomata — Fibrous, fatty, and cartilaginous tumors — Cystic tumors 87 CHAPTER X. Mechanical Obstruction. Stricture of rectum — Causes — Examination — Treatment — Dilatation — Divulsion — External proctotomy — Internal proctotomy — Lumbar Colotomy — Obstruction from foreign bodies — From benign tumors — From displaced organs — From inflammatory thickening — Spasm of anus — Impaction of fteces 90 CHAPTER XI. Malignant Tumors. Carcinoma of rectum — Causation — Heredity — Climate — Diagnosis — Treatment — Mortality — Sarcoma of rectum — Colotomy for com- plete obstruction — Details of operation 101 TABLE OF CONTENTS. XI. CHAPTER XII. Malfokmations; Peukitus Ani. Page Imperforate amis — Imperforate rectum — Operative relief — Pruritus ani — Causes — Treatment — Successful formulae — Nerve stretching.. 110 CHAPTER XIII. Mechanical Injuries. Incised wounds — Treatment — Punctured and lacerated wounds — Gun- shot wounds — Precepts 118 APPENDIX AND FORMULARY. Specimen of "contract" to cure piles (1) —For use on fingers and instru- ments (2-3) — For proctitis (4-9) — For haemorrhoids (10-21) — For hypodermic injection of haemorrhoids (22-29) — For fistula in ano (30-32)— For fissure of anus (33-36)— For ulcers of rectum (37-38) — For prolapsus (39-40) — For pruritus ani (41-52.) ILLUSTRATIONS. Page 1. Section of male Pelvis, - - - - - - 3 2. Nerves of Anus and Rectum, ----- 7 3. Electric Lamp, - - - - - - - 11 4. Aseptic Vaseline Holder, ----- 13 5. The Authors' Rectal Sound, - - - - - 14 6. Speculum with Slide, - - - - '. - - 15 7. Authors' Deep Tubular Speculum, - - - - - 16 8. Authors' Curved Rectal Speculum, - - - - Ifi 9. Authors' Short Tubular Speculum, - - - - - 17 10. Allingham's Short Speculum, - - - - - 17 11." Van Buren's Speculum, - - - - - - 17 12. Kelsey's Speculum, ------ 18 13. Allingham's Four-bladed Speculum, - - - - 18 14. Internal and External Piles, - - - - . - 23 15. Haemorrhoids with Polypus, - - - - - 24 16. External Pile formed by Thrombus, - - - - 24 17. Vulsellum Forceps for Piles, - - - - - 30 18. Smith's Cautery Clamp. ----- 38 19. Authors' Ecraseur Forceps. - - - - - - 39 20. Smith's Wire Cable Ecraseur, ----- 40 21. Notfs Ecraseur, - - - - - - - 41 22. Sacculi Horneri and Columns of Morgagni, - - - 54 23. Sim's Blunt Hook, - - - - - - - 56 24. Curved Scissors, ------- 56 25. Fistula Traversed by Probe, ----- (50 26. Internal Incomplete Fistula. - \ - - - - fiO 27. External Incomplete Fistula, - - - - - 60 28. "Horse-shoe " Fistula with Diverticula, - - - 61 29. "Royal" Bistoury. ------- 63 30. Diagram of Nerve Supply of Anus, - - - - 68 81. Nerve Trunks concerned in Reflex Sjiasm, - - - 70 32. Fissure of Anus Unfolded, ----- 72 33. Concave Mirror, - - - - - - - 77 34. Prolapse of Mucous Membrane, - - - - 81 35. Prolapse of all the Coats, - - - - - - 82 36. Club-Shaped Polypus, ------ 87 37. Rounded Polypus. ------- 87 xiv. ILLUSTRATIONS. Page 38. Villous Polypus, ------- 88 3!). Sargent's Rectal Dilator, - - - - - - 93 40. Cancerous Stricture of Rectum, - - . - 106 41. Imperforate Anus, ------- 110 42. Imperforate Rectum, ------ 111 43. Nerve Distribution about Anus. ----- 117 EECTAL AND AT^AL SUEGEEY CHAPTER I. ANATOMY AND PHYSIOLOGY OF THE KECTUM. The rectum is that portion of the great intestine extending from the left sacro-iliac synchonch"osis downward to the anus. Its relations to the other organs of the pelvis are shown in Fig. 1. The anus is the terminal orifice of the rectum, including the nerves, vessels, muscles and integuments which constitute the mechanism of the organ. The length of the rectum in the living state is from six to eight inches, but in post- mortem relaxation it becomes greater. In the main it follows the curve of the sacrum, being sharply concave in front, so that the name rectum (straight)., given by the ancient anatomists from its straightness in the inferior animals, which alone they dissected, is vvholly false in the human anatomy. At the lower border of the prostate gland, the anterior concavity ceases, and the gut turns abruptly downward and backward, giving at that point a concavity behind. The upper part of th6 rectum lies somewhat to the left of the median plane of the pelvis. The interior of the organ is almost smooth, showing only in two or three places any tendency to the abundant formation of large folds and pouches seen in the colon, yet the few valve-like projections which exist are sufficient very seriously to embarrass the examination of the viscus by bougies and bulb sounds. The Peritoneal Coat. — The peritoneum nearly sur- rounds the rectum at its upper extremity, but as we trace it 2 RECTAL AND ANAL SURGERY. downward it leaves, first the posterior, and then the lateral surfaces, and is absent altogether in most cases from the lower two inches. At a somewhat variable height, the peri- toneum is reflected upward in front, forming a cul-de-sac, and passing over the bladder in the male, and the uterus in the female. It would be of great importance in surgical operations if there were a fixed and invariable height, below which the peritoneal pouch never extended, but examination of cadavers has so far failed to fix this danger point, that the anatomists contradict each other surprisingly, as the following list of opinions as to its height above the anus shows : Malgaigne, 6 to 8 centimetres in males and 4 to 6 in females. Lisfranc, 4 inches " " " 6 " " Ferguson, 10| ctm. " " " 15 ctm. " " Richet, IOt^o " " " " l^T^i) " " Blondin, 8yV " " " " 4iV " " " Velpeau, 5|^ ctm. with bladder empty and 8 ctm. distended. Legendre, " " " " " " " " " Sappey, " " '^ "■ " " " " " Dupuytren, 7 centimetres. Luschka, 5*, to 8 " Hyrtl, 8 " Sanson, 11 " Quain, 4 inches. Gronj, 4 " Roberts, 2^ These wide discrepancies may be partly due to careless observation, but they arise mainly from the great variations found in the cadavers examined. In short, the danger point has no fixed level, and varies even in the same patient with the fullness or emptiness of the bladder, being higher when this viscus is full, and lower when empty. The most that can be averred is this: In no ordinary case will the peritoneal fold be found nearer to the anus than an inch and a half, but as hernial elongations of the pouch occasionally exist, the surgeon is compelled to hold himself ANATOMY AND PHYSIOLOGY OF THE RECTUM. in readiness to meet both the peritoneum and small intes- tines at any level, even below the sphincter (if he happens to be dealing with a prolapse). The Muscular Coat. — The three bands of longitudinal fibres pertaining to the colon become thickened as they descend upon the rectum and sjjread out so as to envelop the whole organ in a somewhat uniform coating. At the lower end however, certain fascicles become separate as they approach the sphincter, and constitute the longitudinal ridges which are quite visible in the living state but which are scarcely discernible in the post-mortem relaxation. The circular muscular fibres lie inside the longitudinal ones, and are rather loosely con- nected to the latter, so that they often come down in pro- lapsus, leaving the longitudi- nal ones behind. As we de- scend, the lower portion of the cii'cular fibres becomes much thicker, constituting what is called the internal sphincter. Its lower border terminates abruptly at an elastic ring of fibrous tissue which forms the verge of the anus. The fibrous ring may often be seen through the mucous mem- brane as a narrow and somewhat obscure whitish circle called "Hilton's white line." Just above the verge of the anus some fascicles con- taining both muscular and fibrous tissue project as ridges under the mucous membrane and are called the columns of Morgagni. In post-mortem relaxation they are obscure and spread out in a reticulated form, as shown in the upper Fig. 1. Section of the Male Pelvis cob- BECTED FEOM A FbOZEN CaDAVEE. R. The Rectum. B. The Bladder. K. K. Reflections of the peritoneum before and behind a distended bladder. G. The Pros- tate. U. The Urethra. A. The Bulb of the Urethra. P. The Pubis. S. The Sacrum. M. Rectus Muscle. 4 RECTAL AND ANAL SURGERY. cut of Fig. 22, but in the living state the action of the spliincter compresses the bands laterally, so as to make them assume a perpendicular position. They then appear as short longitudinal ridges closely crowded together, each about a centimetre long, and converging to an insertion into the fibrous ring of the anal verge. They are often described as mere folds or wrinkles of the mucous membrane, but this is an error. By close inspection the delicate and translucent mucous membrane can be seen to glide loosely over the more substantial framework of the columns beneath, but conform- ing to their shape. The lower ends of the ridges are connected by delicate webs covered by mucous membrane and forming little pouches at the lower ends of the grooves between the columns. The pouches are called the sacculi Horneri, after the celebrated anatomist Horner who described them. Their function is to retain a reserve of mucus which is pressed out by the passage of the fecal mass, and lubri- cates it at the moment of expulsion. The sacculi, like other organs, are sometimes diseased, and may require surgical treatment, but they are usually normal and healthy organs. Many of the itinerant "pile doctors" traversing the country claim that the sacculi are essentially and always abnormal and diseased tissues and they make an important part of their fees by slitting them down. The Mucous Coat. — The mucous membrane lining the rectum has certain microscopic peculiarities of interest to the histologist, which it is not necessary for our purpose to give in detail. Suffice it to say that its glandular struc- ture secretes freely a tenacious, transparent mucus having a double function. First, it is antiseptic, and prevents the putrid fermentation of the fecal mass during its stay in the rectum; and secondly, it lubricates the organ to facilitate the act of expulsion. The mucous membrane just above the verge of the anus is almost transparent in the healthy state, and so exceedingly extensible that it sinks into pouches before the pressure of ANATOMY AND PHYSIOLOGY OF THE RECTUM. the blunt hook like the softest and thinnest india rubber, and unskilled examiners deceive themselves with the idea that they find the sacculi Horneri wherever the blunt hook happens to take hold. The true sacculi, however, exist only at the lower ends of the grooves between the columns of Morgagni. Between the grooves there are a few small papillae, often very obscure, situated just above the verge, in a position analogous to the carunculae myrtiformes of the vagina. Under each one is situated a small bulb or enlargement of a nerve twig. The papillae are probably tactile organs, which under the friction of the faecal mass in defecation provoke reflex contractions of the expulsory muscles above. The traveling pile doctors generally claim that they are diseased projec- tions, and must always be snipped off with the scissors. The External Sphincter Muscle. — ^This organ is a thin plane of muscular fibres, surrounding the anus as the orbicularis oris does the mouth. It is funnel-shaped, the inner edge being turned upward and attached to the fibrovis verge of the anus, while the outer edge curves downward and outward. The general form is elliptical, the posterior extremity arising from the tip of the coccyx, and the anterior being inserted into the fibrous raphe of the perineum. Its superficial fibres are rather closely related to the skin, and throw the latter into radiating folds. The two sphincters acting together close the anus. \ The Skin. — As above stated, the skin of the anus is very closely connected with the surface of the external sphincter. It is studded with hairs, and lies in radiating folds. At the line of junction with the mucous membrane it is richly sup- plied with sensory nerves, so that it is subject to excessive pain in many diseased conditions. The Connective Tissue. — This is thin and dense on the external surface of the external sphincter. Deeper and sur- rounding the rectum the connective tissue is very loose, to 6 RECTAL AND ANAL SURGERY. allow of the movements of the rectum, a condition which permits an extensive burrowing of pus when abscesses form there. This accounts for the fact that anal fistulas often lead to cavities almost surrounding the rectum. Arteries. — The arteries of the rectum and anus consist of three pairs, the superior hsemorrhoidal, which arise from the superior mesenteric, the middle haemorrhoidal, which have a variable origin, and the inferior hsemorrhoidal, which spring from the internal pudic. They are all freely con- nected by anastomoses. Those ramifying above the verge of the anus form an abundant network between the mucous membrane and the muscular coat, and in cutting operations in that part are liable to bleed dangerously, unless properly secured. Veins. — The veins constitute a complete network under the skin and mucous membrane, extending the whole length of the organ. They inosculate freely with each other. Those outside of the verge join together to make the external hemorrhoidal veins, and terminate in the internal pudic trunks. Those in the anus proper combine into the middle hsemorrhoidal veins, which send their blood to the internal iliac trunks. The superior hsemorrhoidal veins arise from numerous minute blood sacs, quite variable in size, but aver- aging about three-sixteenths of an inch in diameter when injected, which lie under the mucous membrane a little above the anus. Good anatomists believe that this is the normal condition of things, and that the little blood sacs are healthy organs, and not incipient haemorrhoids. Their proper function, if they have any, is a matter of conjecture. Pro- ceeding upward from these sacs between the mucous mem- brane and the muscular coat of the rectum, the superior hsemorrhoidals at about three inches above the verge pass through certain foramina, or "button-holes," to gain the connective tissue outside the rectum, and thence proceed to join the portal circulation on its way to the liver. Verneuil, of Paris, believes that the contraction of these " muscular ANATOMY AND PHYSIOLOGY OF THE RECTUM. button-holes " often obstructs the superior haeinorrhoidal veins, causing distention of the little blood sacs near the anus, and thus originating piles. The older pathologists have generally believed that the true seat of obstruction is in the capillory circulation of the liver itself. Each of the blood sacs sends a small anastomotic twig through the sphincter to join the external hemorrhoidal plexus, thus making a regular anastomotic connection between the portal and the general systems of veins. Lymphatics. — The lymphatic trunks of the more ex- ternal parts converge to the glands in the groin, while those higher up join the glands of the pelvic and abdominal groups, hence cancers and chancres of the anus infect the inguinal glands. Nerves. — The rectum and anus are copiously supplied with nerves, both from the sym- pathetic and the spinal sys- tems. The spinal supply predominates up to a little above the verge of the anus, but as we trace the rectum up- ward we find the spinal twigs gradually giving way to those of sympathetic origin, so that at three inches above the anus the sense of touch in Fig. 2. — Nekves or Anus and Rectum. 1. Sacral Nerves: posterior root di.^tributed to coccyx and ext. sphincter. 2. Anterior Root, to ext. sphincter. 3. Pudic Nerve and its branch the inferior hfemorrhoidal. t. Tub. ischii. s. Sacrum, c. Sacrum, sp. Ext. sphincter. /. Levator ani. p. Transversus perinei. ri. Ischio-rectal space. b RECTAL AND ANAL SURGERY. the healthy organ is almost absent, while at the verge itself we have one of the most acutely sensitive surfaces of the body. The spinal trunks come mainly from the sacral plexus. Owing to the complicated supply from both sys- tems, the reflexes of the rectvim and anus are exceedingly numerous and energetic, causing frequent perplexity and some mistakes in diseased conditions as to the real seat of the patient's malady. CHAPTER II. METHODS OF EXAMINING THE KECTUM. Like all other diseases depending for their diagnosis upon skill and accuracy in physical examinations, rectal troubles are the source of endless blunders and failures on the part of those who are content with half measures, or who let mere inference take the place of that persistent study which is due each individual case. The false method is that of the bungler and amateur who is only right by hap-hazard; the true one is that of the professional expert who cannot be balked by petty obstacles, but who will reach success where others have failed, not less by his dogged persistence and thoroughness than by his superior knowledge. Preliminary Inquiries. — The patient's own account of his ailment forms the most convenient introduction to the investigation of most cases. Despite the very erroneous liotion which many patients have of the true nature of their disease, this will often throw a flood of light upon the case at once, and, to the mind of the surgeon, render farther examination almost superfluous. It is best, however, to take nothing for granted, but to proceed systematically even in the simplest cases, with a definite line of inquiries, as suggested by Allingham, so that no important symptom can escape notice. 9 10 RECTAL AND ANAL SURGERY. No better scheme of questions lias been devised than the following: 1. Is there pain? Kind of pain — sharp, lancinating, burning, pulsat- ing, gnawing, dull, paroxysmal, persistent, local, reflex. Is it connected with the act of expulsion (tenesmus) ? Is it felt ((.fter defecation ? Is it relieved by defecation? What is its duration? Is it relieved at times? 2. What of the functional activity of the bowels? Is there costiveness, or the reverse? Is there stomach, intestinal or liver complaint? Are the stools normal in color? In consistence? In shape? In odor? 3. Is there a discharge from the rectum? Is it mucous? Purulent? Bloody? Is the hemorrhage abundant? Is the blood fresh or coagulated? Does it come during or after movements? 4. Is there during defecation or at any time a protrusion of the membranes? Does this return spontaneously? Can it be made to return ? Is this painful, itching, or bleeding? 5. Is there incontinence of fseces or urine? 6. Is there a history of tuberculosis? Syphilis? 7. What has been the patient's mode of life — active — sedentary — temperate — eh'.? The answers to these questions determine to some extent the direction of the phusical examination, which is next in order, and which must modify or confirm the conclu- sions toward which the general symptoms point. Position. — For operations and examinations requiring very complete access to the interior of the rectum the METHODS OF EXAMINING THE RECTUM. 11 lithotomy position is the most satisfactory. A gynaecological chair is more convenient than a table for this purpose. The knee-chest position upon a lounge or table offers certain advantages for inspecting the deeper portions of the rectum which cannot be obtained in any other manner. The light- ing is also excellent in this posture, l)ut the use of an an8esthetic of course is not possible. For most cases the Sim's position Avill be found most suitable, both in examining and operating. This is especially true in hemor- rhoids, fissure, prolapse and such troubles as do not require deep exploration. Light. — Abundant daylight should be had from an undraped window, or a powerful arti- ficial light such as an argand burner or oil reading lamp placed on a stand in close prox- imity to the parts being examined. The tub- ular rectal specula require rather more light than those used in the vagina. About the same conditions are found here as in the use of the laryngoscope, and a similar condenser and hooded lamp are very useful. Darkening the room also assists very materially in their use. The best portable illuminator to be carried to all sorts of localities and residences is a coil of magnesian wire. This, when held in the fiame of an oil lamp or a gas jet (a spirit lamp is better), gives a magnificent white light almost equal to direct sunshine in its Ijlinding splendor. The beam may be reflected into the speculum by j-j^., 3 a plain or concave mirror, or thrown obliquely Electbic Lamp. past the surgeon's shoulder directly into the opening. A plate or basin should be under the light to prevent the red-hot particles of magnesia from injuring the carpet or the bedding as they fall. A calcium light of course would be excellent, if one should happen to be accessible at the 12 RECTAL AND ANAL SURGERY. place needed, but this could almost never be expected. In no class of work are the small incandescent electric lamps so useful as in examinations about the rectum. These can be held in the hand, find thrust into the deeper parts of the cavity, furnishing a powerful illumination which no reflector can give. Small electric lamps of about one-half or one candle power are now furnished, for the use of surgeons and dent- ists. They are from the size of a pea upward and are usually mounted upon slender handles provided with a key for closing the circuit. From six to twelve Le Clanche cells costing about a dollar apiece furnish a battery which will operate such a lamp intermittently for a year without any attention. External Inspection. — The first step in the physical examination for supposed rectal disease is a thorough inspec- tion of the external parts. The most important signs of the presence of several common diseases are here visible. Swelling, redness or tenderness should be carefully looked for in the tissues surrounding the anus, and the existence especially of any fistulous outlet determined at once. The protrusion of hemorrhoids or prolapsus will also be noted. Hemorrhoids, usually, are not externally visible until forcibly extruded by an act similar to that of defecation. Many patients can do this at will, while in others the tumors cannot be determined by external inspection. External inspection will also show the presence of any redness, excoriation or ulceration of the parts about the anus or of discharges from the rectum. Fissure of the anus will often show a distinct sign of its presence by a little " sentinel pile " immediately below tbe fissure. Other troubles such as ulceration and stricture of the rectum, or cancerous tumors above the anus require different modes of examination. In the progress of cancer of the rectum, the inguinal glands become enlarged before the tumor has attained a large growth. METHODS OF EXAMINING THE RECTUM. 13 Digital examination supplements the external inspec- tion in certain cases and is in some respects more to be depended upon than internal inspection. For the detection of enlargement of the prostate, in strictures low down, and in testing the irritability of the sphincter, the finger is superior to all other instruments. The nail being made short and smooth, the finger is well lubricated, and gently insinuated through the orifice. Most surgeons prefer the index finger on account of its superior delicacy, but others like the middle digit, because of its greater length, though the superiority in length is more than lost by the interfer- ence of the adjacent knuckles. In using the index, the deepest touch is effected by putting the radial side of the hand toward the perineum, and letting the three unused fingers extend backward behind the sacrum; but in examin- ing the prostate the middle finger is best with the palmer sui'face turned towards the pubis. It is safer for the examiner to have the finger well anointed with some unguent which is both protective and antiseptic. Too much care cannot be exercised against poisoning the finger, as chancroidal and syphilitic ulcera- tions are not uncommon in and about the rectum. An incautious exposure of an abraded finger, or a " hang-nail," may give rise to very serious infection. Vaseline con- taining ten per cent, of boric acid, or five per cent, of carbolic acid, is useful for apply- ing to the fingers and instruments. The latter causes a little temporary smarting when used freely upon the anal mucous membrane. To guard against possible infection of ^^'^^'^^ Holdeb. one patient from another it is well, in addition to the ordi- nary disinfection of hands and instruments, to keep the lubricant in collapsible tubes, which allow the escape of Fig. 4. — Aseptic 14 RECTAL AND ANAL SURGERY. sucli small (|UJiiitities as are needed from time to time without risk of infecting the remainder. When the lubricated finger-tip is pressed gently into the anus the resistance noticed will mark the amount of reflex irritability of the sphincters. In the normal anus this is slight, and will be felt only as feeble contraction, which is soon overcome. In diseased conditions the spasmodic resist- ance is sometimes very decided, and the introduction becomes painful and difficult. The state of the sphincter is an im- portant part of the examination, and should always be noted. Within the sphincter the finger finds the rectal walls in the normal state, smooth, elastic and distensible. The exist- ence of stricture low down, of cancerous induration, or of inflammatory exudates, or oedema, can thus be determined. The finger Avhich has become educated will readily detect any decided departure from the normal size in the prostate, and this should be noted carefully, as there occasionally seems to be an interdependence of bladder irritability and rectal disease. As a further extension of examination by the sense of touch, recourse must be had to rectal sounds for the purpose of detecting obstructions in the deeper parts of the rectum. The author's sound consists of a hollow steel staff of a curve taken from repeated examinations on the cadaver, and oval bulbs of graded sizes, from 1 cm. to 4 cm. in dia- meter, which can be screwed upon it. This instrument is used for diagnosis only. Its curve has prov- ed so correct that it can readily pass the sigmoid flexure, and be felt through the abdominal wall without serious inconvenience to the patient. The handle, staff and bulbs are perforated for convenience in injecting through them. 'Al Fig. 5. — The Author's Rectal Sound. METHODS OF EXAMINING THE RECTUM. 15 Sounds must be used with great gentleness, as ulcerated spots in the intestine are sometimes exceedingly thin and may be ruptured. The easy passage of a large bulb proves the absence of stricture as far as it goes, biit its arrest does not prove the existence of one. The ujiper rectum and lower colon have not only plications of membrane projecting into them, but the walls of the gut are liable to fold up over the end of an instrument, so that in deep sounding a mere arrest of progress does not prove the stricture. Tlie hand is sometimes introduced into the rectum for deep exploration. The operation, however, has sometimes caused death, and should only be resorted to when the emergency is such as justifies incurring some risk. The hand to be introduced should be small in circumference, well lubricated, and introduced very slowly and carefully, with the fingers gathered into the form of a cone. Of all explor- atory instruments, the index finger is the one most frequently called for, but probes are necessary to trace fistulfe, and a grooved needle, an aspirator or a hypodermic syringe, may be wanted to detect abscesses. Internal Inspection. — Speculums for the rectum have been multiplied until nearly every surgeon who has written upon rectal diseases, and many an ambitious " specialist" of provincial fame has invented one of his own to bear his name. The sharpers of the so-called "systems," which have had considerable patronage among the more- gullible and poorly-qualified members of the codman & shurtleff, . BOSTON. __— — -r;^^^ profession, have each some cheap ^^——:^^^^^^g^StStt% form of ironmongery which is a ^fniiiffjiiiiiri iiijpi. iiliiijjiij|M__ more or less successful imitation fig..;.-8pkcui.umc.. Kkmuvable of a standard form of speculum. Slide Type. All of these instruments are copies of a few distinct types. The simplest type is perhaps that of the straight tube. Tubular specula were very early employed for the rectum and were made both cylindrical, conical and sometimes 16 RECTAL AND ANAL SURGERY. fenestrated. For examining the deep parts of the rectum a speculum in the form of a cylindrical tube, inserted by aid of a plug, is the best. The author's tubular speculum is made in three sizes. The tube is five inches in length and made of thin polished metal, and the plug is of pol- ished hard rub- ber. The light is thrown in by a concave mirror, and the membrane easily inspected in every part as it pro- lapses over the end of the tube during its withdrawal. If it is desired to inspect still deeper, we use a tube curved at its inner part. This being inserted follows the curve of the rectum, and the membrane prolapsing over the end is viewed by an oval mirror inserted on a staff, giving an inverted view, like the laryngoscope. The mirror is concave and gives a magnified view of the parts. The plan is modified from one Fig. 7. — Authob's Deep Tubulae Speculum. Fig. 8. — Authoe's Cukved Rectal Speculum. devised many years ago by Bodenhamer. This enables one to get a very deep view of the rectal walls. Still nine-tenths of practical rectal surgery lies within two inches of the verge of the anus, and the deeper instruments do not coine to very frequent use. When a critical inspection of every point on the rectal METHODS OF EXAMINING THE RECTUM. 17 Fig. 9. Author's Shoet Tubulab Speculum. walls is desired, there is nothing equal to a full-sized tubular speculum, even for parts near the outlet. We use a short one for that location, on account of the illumination being better, and the fact that with a short tube the membrane closing over the end can be \dewed at widely varied angles. It must be borne in mind that nine-tenths of the lesions to be examined lie within an inch of the orifice, and hence the speculum oftenest used must show the latter, even if it fail on the deeper parts. Practically one needs at least two kinds, one short one to show the lower walls of the rectum either through the end or through lateral openings, and the other much longer and open only at the end, for the exploration of the remoter portions of the viscus. The long instrument is inserted deeply and then slowly withdrawn, showing successively every part of the membrane as it prolapses over the open extrem- ity. Of the short instru- ments, one of the best is that of All- ingham. It consists of a thin, metal- lic, trumpet- shaped shell, fitting closely to an ebony removable plug or core, which projects beyond the tip to facilitate insertion. A fenestrum or slot extends the whole length. The instru- DMAN & SHURTLEFF, BOSTON. Fig. 10. Allingham's Speculum. Fig. 11. — Van Buben's Speculum. 18 RECTAL AND ANAL SURGERY. Fig. 12. — Kelsey's Speculum. ment is inserted with the plug in, and the fenestrum on whatever side it is desired first to examine. The plug is then withdrawn and the membrane inspected; the plug is then re-inserted and the fenestrum turned in a new direction, when the plug is again with- drawn. The plug prevents the edges of the fenestrum from scraping the membranes pain- fully, and by several re-insertions of it the opening can be turned to every part of the rectal walls. The inner opening shows something of the membrane prolapsed over it, but the orifice of the tip is too small, and the instrument too short for efficiency in deep explorations. The present rec- tal itinerants generally use a small, tapering speculum, open at the tip, and having a plug to facilitate en- trance. Like Allingham's, it is too short and too small for deep work, but as it has a lateral fenestrum, closed by a removable slide, most of the objects sought by that ignorant class can be brought into \aew by means of it. Fig. 13. — Allingham's Foub-bladed Speculum. METHODS OF EXAJIINING THE RECTUM. 19 Tubular specula, however, are solely for examination. One cannot use them in operating. A pair of Sims' specula set in handles is very convenient in many cases both for examination and for operations. Dr. Kelsey, of New York, has devised a good bivalve speculum, which is, however, not equal for general use to the four-bladed speculum of AUingham. Sets of Instruments for Rectal Surgery. — The diminu- tive cases of instruments sold at extravagant prices to itin- erants and some unwary physicians are an illustration of the adage " knowledge is power," since the possession of so very little knowledge on the part of an ignorant vender enables him to extract one hundred dollars from the j^ocket of his still more ignorant patron for ten or fifteen dollars' worth of very simple appliances. Of late competition has brought down the prices of these sets somewhat and improved their quality. Chicago parties advertise outfits at from thirty to fifty dollars, which are not different from those which at first found a market at double those figures. Nevertheless the price charged is exorbitant, and the selection is meagre and wholly insufficient for any surgeon who wishes to treat all rectal diseases. If a physician wishes, he can provide himself with a far better outfit at a much cheaper rate by ordering from any first-class instrument store one of the following sets: SMALL RECTAL CASE. 1 Allingham's rectal speculum. ^ 1 Scalpel. 1 Curved, sharp-pointed bistoury. 1 Curved, blunt-pointed bistoury. 1 Straight scissors. 1 Grooved director. 1 Silver probe. 1 Porte- causti que. 1 Small vulsellum pile forceps. 6 Curved needles (assorted sizes). 20 RECTAL AND ANAL SURGERY. 1 Tait's lock artery forceps. 1 Spool heavy ligature silk. LARGE RECTAL CASE. 1 Allingliam's rectal speculum. 1 Andrews' tubular rectal speculum. 2 Van Buren's specula. 1 Scalpel. 1 Curved, sharp-pointed bistoury. 1 Curved, blunt-pointed bistoury. 1 Straight scissors. 1 Small vulsellum pile forceps. 4 Tait's lock artery forceps. 1 Grooved director. 1 Silver probe. 1 Porte -caustique. 1 Double tenaculum. 1 Large laryngoscopic mirror. ^ Ounce magnesian wire for illumination-. 1 Small spirit lamp. 6 Curved needles (assorted sizes). 1 Smith's clamp and cautery irons. 1 Hypodermic syringe. 1 Spool heavy white silk. 1 Hard rubber clyster syringe. 1 Curved rectal sound with six bulbs. The small case will be furnished by most Chicago instru- ment dealers for about sixteen dollars, and the large one for about fifty dollars. If fewer or more instruments are required, the price will be lower or higher, in proportion. Even the smaller case is much better than those possessed by the itinerants. CHAPTER III. HJEMOREHOIDS, OR PILES. Haemorrhoids, in the strictest sense, are varicose haemor- rhoidal veins. However, the term as used in popular language has been loosely extended to include almost every small tumor about the anus, whether of varicose origin or not. Some centuries ago they were called "Emerods," and the disease appears under that name in King James' version o£ the Old Testament, where the Philistines are said to have been smitten with emerods, and to have made golden models of them as expiatory offerings. jEtiology. — This disease has its origin in the fact that when the patient strains in defecation, the mucous membrane is more or less everted, and in that position the hsemorrhoidal veins have no support from surrounding parts, so that the straining, by forcing the blood downward, distends them into pouches, or varices. When the rectum is continually packed with retained faeces, the veins are compressed above the anus, and the return of blood being restricted, they become additionally distended by this obstacle, so that constipation is a leadinor cause of the disease. The contraction, or iuilam- matory obstruction of the "muscular button-holes" by which the superior veins emerge from the rectum is also supposed to be causes of their dilatation, and hence of piles. Any obstruction of the portal vessels acts in the same way, hence diseases of the liver, large abdominal tumors and the pressure of the gravid uterus in pregnancy are com- mon causes. When the inflammation of acute dysentery progresses downward to the vicinity of the anus, the veins are obstructed by inflammatory deposits around them, so that piles often appear in the later stages of that disease. Finally 21 22 RECTAL AND ANAL SURGERY. sundry small iijievoitl tumors of the anus, as well as liyper- tropliied folds of the skin and mucous membrane, soft polypi, and lumps formed by clots of extravasated blood under the skin, are popularly classed as piles, though not properly varices. In cases where the obstruction is temporary, recent haemorrhoids may recover spontaneously; but if subjected to the continued action of the cause, they tend to enlarge and become more and more inflamed. At first they are trouble- some only at intervals, but these "fits of piles" grow gradu- ally longer and ultimately merge into each other so that the tumors become permanent. As the distended condition continues, the parts become inflamed, and the integument and the connective tissues around the veins become first swollen and then permanently hypertrophied, and protuber- ances which originated as mere venous pouches, become solid and firm fleshy tumors. Sometimes clots of blood form in the veins, obliterating them, and leading to their cure by atrophy. At other times the veins burst, forming globular clots in the connective tissue outside the vessels, and these, like all other lumps in this region, are generally termed piles. They sometimes give origin to suppuration and are discharged, but generally the clots are absorbed in the course of a few weeks. Frequently the enlarged veins burst during defecation and copious haemorrhage occurs. Where this occurs daily, the patient may be brought to the verge of death from an?emia. Piles are usually divided into internal and external forms. The internal are those which originate just above the verge of the anus, and are therefore covered with mucous membrane. They are primarily varices of the superior hsemorrhoidal veins, and probably may originate izi disten- tion of the little globose blood sacs, described in the chapter on Anatomy of the Rectum as being the starting points of the radicles of these veins. Indeed, there are those who doubt whether these sacs are anything more than incipient HJEMORRHOIDS. OR PILES. 23 internal hpemorrhoids, though there is respectable authority for their normal existence. (Duret. ) At first internal piles only appear when thriist down in defecation, and recede out of sight when the effort is over. As they grow larger they are gripped by the sphincter when down, and prevented from returning, causing much pain, and sometimes bursting under the muscular grasp of the sphincter, and free bleeding. The patient now learns to relieve his pain by pressing them in again with his fingers. At a still later stage they often become too large to remain in at all, and though still called internal piles they are now habitually external in position. At the verge of the anus, where the skin joins the mucous membrane the subcutaneous con- nective tissue is somewhat denser than above or below, binding the integument there closer to the inner edge of the external sphinc- ter. This circle of denser tissue resists the distention of the veins at that line, so that we usually find the internal piles above separated by a narrow groove from the ex- ^ ternal piles below. However, the dense tissue does not always main- tain its grip, and we often find internal and external piles running ^^^^^^^^ a/d ExTtENAi. Piles. into each other with no groove to mark the boundary between them. In short, the same pile may be both internal and external. Physicians often speak of suspected internal piles high up in the rectum. This is an error. There are no internal piles so high up that they never show during defecation. They rarely occur more than an inch above the verge. External piles are specially liable to become obliterated by thrombus, suppuration, etc., in which case they leave 24 RECTAL AND ANAL SURGERY. sundry projecting tabs and folds of skin which are still called external piles, though no longer containing enlarged veins. Most of the ' ' temporary piles form- ed by extravasated clots are also in the external group. Owing to the translucency of the mucous membrane internal haemorrhoids ^ show the color of the distended veins be- FiG. 15. — Internal and Extebnal Piles not Cleablt Sepabable with a Small Polypus lieatll, and are OI a GBOWING ON AN InTEBNAL PilE. ^j^-^j^ ^^^^j^ ^^j^^.^ while external piles approach more to a pink tint. When internal piles are found protruding, they generally present a rip- pled, irregular surface on account of the presence of the reticulated ridges of the columns of Morgagni, and of the sacculi Horneri among them. External piles on the contrary if distended are smoother in contour. The difference is well shown in Fig. 14, page 23. The skin and mucous membrane cover- ing piles near the verge of the anus are excessively sensitive, but the mucous mem- brane covering the upper portion of in- ternal piles is nearly devoid of sensibility, a fact which should influence all our plans in operating. Hsemorrhoidal tumors have a remark- Pile fobmed by , - ,., , ,• 1 1 L Globuled Clot able erectile power, not mentioned by most undee the Skin.— authors, and resembling that of the coiyi(s (Smith.) spoiKjiosiim of the penis. This singular tendency enables Fig. 16. External HEMORRHOIDS OR PILES. 25 US to bring internal piles into A^eAv for examination or opera- tion, by simply irritating tliem by a slightly rough handling with the finger. Under the touch they, in a few moments, erect themselves to their full size and are readily brought to view. The treatment of haemorrhoids is palliative or operative. Palliative Treatment. — We have called the non-opera- tive measures palliative, for in the majority of cases they fail to make a real cure, and only mitigate the suffering, yet it is true that in recent cases, where organic changes have not yet become established many haemorrhoids return to a state of nearly perfect health under palliative treatment, so that we may say that in such cases they actually assist nature to effect a real cure. One of the most important measures, is to combat constipation, because the pressure of the fecal mass com- presses and obstructs the superior haemorrhoidal veins, and thus distends them with blood and produces internal haemorrhoids. Without occupying too much space with a topic familiar to every physician, suffice it to say that the mode of life, the diet, and the medicine are all regulated Avitli a view to producing a gentle unirritating looseness of the bowels. When full control of the patient can be had, it is well to place him for some days in a horizontal position, with a mild astringent wet compress bound against the anus. As defective action of the liver causes distention of the superior haemorrhoidal veins, that organ should be regulated. Strain- ing, or "bearing down" distends all the pelvic veins; hence the patient should be cautioned against all such efforts. Inflammation of the bladder often causes piles by inducing tenesmus and straining at the frequent micturitions ; hence haemorrhoids are common in cystitis, especially if a calculus exists in the bladder, and the cure of the urinary difficulty greatly relieves the rectal trouble. Astringent ointments and washes with anodyne supposi- 26 RECTAL AND ANAL SURGERY. tories are favorite })alliatives. Tannin, alum, zinc sulphate, plumbic acetate, and carbolic acid may be used in almost any form and combination. The opiates, cocaine, hyoscya- mus, belladonna, or atropine, iodoform and bismuth are favorites for suppositories. It should be remembered that all the astringents of the tannin group are incompatible with morphine, cocaine, and vegetable alkaloids and salts gener- ally. The aim in the use of washes and ointments should be to get an astringent effect, but never an irritation, and the strength of the preparation should be calculated accord- ingly. Alum and tannin may be used in almost any strength, but sulphate of zinc and all caustics must be better guarded. The tissues tolerate from two to four times more of an article in the form of an ointment, than in a wash. Compression bulbs have been invented to slip into the rectum, and gently compress and support internal piles, but are not very effective except in a few cases. The application of decided caustics has been resorted to, such as brushing internal piles with strong nitric acid, or nitrate of silver, or chromic acid. Good is sometime done in this way, but mischief also may follow. Operative Treatment by Stretching the Sphincter. — Perhaps the mildest operation upon internal or half internal piles is that employed by the French surgeons, Professor Verneuil and M. Fontan. It consists simply in making a rather slow and gentle, but complete and thorough, dilatation of both internal and external sphincters. This may be done by dilating instruments or by introducing gently through the sphincters two oiled fingers of each hand, and slowly pulling the sphincters in opposite directions until they are thoroughly stretched or dilated. An anaesthetic may be needed. Dilatation succeeds best in piles not already chronic. We have not fully tested the plan in our own practice, but French authorities claim that a large proportion of haemorrhoids are radically cured by this manipulation. It may, therefore, be a desirable method, especially when the HEMORRHOIDS OR PILES. 27 patient is timid and cherishes a horror of ligatures and instruments. Yet it must be remembered that severe and long continued inflammation sometimes follows these forced dila- tations, and in these cases they are by no means a mild measure. Treatment by Ligature. — Probably the English and American surgeons have favored ligation for internal piles more than any other plan, on account of its comparative safety from haemorrhage, embolism and abscesses. Dr. Allingham, of London, surgeon of St. Mark's Hospital for Rectal Diseases, has been the most conspicuous champion of the method, but Konig, of Gottingen, and many others on the continent, also favor it. The application of the ligature renders haemorrhage nearly impossible, and puts a very efficient barrier against the entrance of clots or septic material into the channels of the veins. The use of the ligature for piles is very ancient. Hip- pocrates mentions it, and Celsus describes it. The success is excellent. When properly done, the cure is as near to absolute certainty as surgical operations ever attain, and the danger is a mere trifle. The mortality thus far ascertained is nearly as follows: CASES. DEATHS. Allingham's report of cases in St. Mark's Hospital up to 1859, ------ Allingham's report of cases in St. Mark's Hospital since 1858, - - - \- Allingham's report of cases in St. Mark's Hospital since previous report, - - - - Allingham's private practice, - . - . Total, - 5,863 6 This is about one death in a thousand cases. It should be noted that five of these deaths occurred previous to 1859, when antiseptics were unknown and the hospitals of London were in a very unhealthy condition. Since that Allingham 1,763 5 2,250 1 250 1,600 28 RECTAL AND ANAL SURGERY. reports 4,100 cases with only one death. The following authors have expressed their opinion in favor of ligation: Gross, Van Buren, Bodenhamer, Gowlland, Alfred Cooper, Curling, Quain, Ashton, Syme, Bushe, Copeland, Sir Benja- min Brodie, Konig, Frank Hamilton, Ashurst, Cripps, and many others. Preparation of the Patient for Operation. — It is best to investigate the })atient's whole condition, and rectify as perfectly as possible all diseased tendencies. Bright's disease of the kidneys adds greatly to the risk of all opera- tions, and such cases are to be avoided if possible. Cripps refuses operations also in all cases of piles dependent on cystitis, but this is an error. When cystitis and piles co- exist, each one powerfully aggravates the other, and the cure of the piles greatly assists the cure of the bladder. Many times the latter can never be cured until the piles are operated on. In malarious regions a full dose of quinine four times a day for forty-eight hours is a good preparation for the operation. The hair about the anus should be shaved off, and an antiseptic wash used there three times daily for two or three days. A good solution is carbolic acid, one part to fifty, or corrosive sublimate, one part to three thousand of water. On the day of operation the bowels should be well emptied by a cathartic, and the meal next preceding the operation should be omitted, so as to avoid vomiting during the anaesthesia. When one or two small piles only are to be operated on, they can be anaesthetized sufficiently by clamping their bases and in that state injecting them with cocaine; but where the disease is extensive, ether is necessary. If the latter is used, the patient should strain down the piles, if possible, just before the operation, so as to bring them to view, and then go upon the table and be anaesthetized. After etherization, he may be placed in the position of lithotomy, or upon either side, with the knees drawn up, at the pleasure of the operator. HEMORRHOIDS OR PILES. 29 Most surgeons now forcibly dilate the sphincter, which excites the erectile action of the piles, and also opens the anus, thus bringing the tumors well into view. It is done by inserting one or two fingers of each hand into the anus, and gently but steadily drawing in opposite directions for three or foar minutes. All rapid traction is to be guarded against, because there is danger of rupturing the tissues. It is not true, however, as some writers imply, that this dilatation is necessary. We can assert from many years of experience that ligation without forced dilatation is one of the most successful operations in surgery, so much so that it rarely fails to cure; sometimes it has seemed to us that when we have employed the dilatation, the patient has suffered severe pain and inflammation without any better final result. We doubt the wisdom of inflicting this added injury indiscriminately. In many cases the piles are suffi- ciently exposed already, and in most of the remainder a slightly rough handling of them with the finger and forceps, or tenaculum, causes the erection before described, and enables one to bring them well into view. The irritation of a forced dilatation may be avoided whenever it is un- necessary, yet, the parts just above the verge must be well searched, lest hidden piles escape notice and make future trouble. We next consider the number and size of the piles, for if they occupy the whole verge of the anus, an absolutely complete removal of them down to their bases will make a circular wound completely surrounding the orifice, whose contraction in healing will cause a stricture of the anus, — a fact which many eminent authors strangely neglect to mention. It is necessary in all cases to save mucous membrane enough to constitute a soft and distensible verge to the anus. Hence, when the piles occupy the whole rim, we do not tie them close to their bases, but about half way between the base and summit, so as to leave some mucous membrane and skin between the tumors, and not included in the ligatures. 30 RECTAL AND ANAL SURGERY. There need be no fear of failure on this account. Although the ligature takes oft' only half the height of each })ile, the stumps, after swelling temporarily, always shrink down and become atrophied, leaving a perfect cure. Having con- sidered thus where to place the ligatures, the surgeon seizes a pile with small vulsellum forceps, or a tenaculum, and draws it out. At this stage Allingham takes a pair of scissors, and commencing at the white line where the lower end of the mucous membrane covering the pile joins the skin, dissects it up from the sphincter some slight distance into the bowel, keeping close to the muscular coat. The wound does not bleed much, because the arteries of the pile enter it at its superior border. This incision severs the nerves of sensation, which enter from below, and makes the presence of the ligature less painful. However, when the pil es constitute almost a continuous ridge around the anus, this plan cannot be adopt- ed, as a ring-shaped Fig. 17. woundaudsubsequent Small Vulsellum Fokceps fob Piles. j. • i -ii i. stricture will result. This deep dissection also is not free from chances of haemor- rhage. Arteries sometimes take abnormal directions, and scissors also go at times a little deeper than was intended. Hence many surgeons prefer, after seizing the pile, to cut a little groove at the proper place, around the lower half of its circumference, simply going through the integument, so as to divide the cutaneous nerves, and thus blunt the sensibility and prevent the pain which would otherwise occur after the anaesthesia passes away. The ligature, which should be very strong, is tied in the groove made by the knife, and if the pile is large it should be tied three times around, as other- wise the yielding of the tissue under the pressure of the ligature is liable to slack its tightness and prevent complete strangulation. After tying the knots very securely it is best HEMORRHOIDS OR PILES. 31 to snip off the summit of each tumor, hut not to cut so closely to the ligature as to risk the latter's slipping off. We prefer silk, hemp or linen threads. Catgut can be used. but it needs special care in tying, as under the softening effect of moisture it becomes slippery and is liable to yield, and permit haemorrhage. Chromicized catgut is partly free from this danger. Many tr}- to press the ligature stumps back into the bowel, but we are of the opinion that there is no use in that procedure. If they remain outside they can be kept w^ell disinfected, and all bad odor and danger of septic infection prevented. The operation being finished the stumps should be washed with an antiseptic solution, dressed with iodol or iodoform and covered with a handful of antiseptic gauze held in position by a T bandage. Anodynes may be given as required, and it is well to give a hypodermic injection of morphine just before the operation. By a careful application of an eight per cent, solution of cocaine externally, or of a four per cent, solution by a hypodermic syringe under the skin and mucous membrane of the anus, many mild cases can be ligated with but little pain without any ether or chloroform, but care must be taken not to exceed a safe dose. A young surgeon in New York trying to operate under cocaine, and not getting full anaesthesia, yielded to the temptation to repeat the dose until he had injected eighteen grains into the tissue of the rectum, causing the death of the patient. Overcome with horror at the result of his error he then committed suicide. Frequently the operation will be followed by a spas- modic contraction of the sphincter of the bladder, causing retention of urine, and compelling a resort to the catheter once or several times. The catheter may be tied in if necessary. Some surgeons try to prevent the spasm of the neck of the bladder by dilating it with a large urethral sound at the close of the operation. The treatment of the bowels is not agreed upon among surgeons. If they are 32 RECTAL AND ANAL SURGERY. made to operate daily they cause a repetition of the painful movement. If they are restrained by opiates several days, as advised by AlliniJ^ham, the fecal mass in the rectum becomes large, and hurts the more violently at last. The best way is to empty the bowels thoroughly before operating, and allow but little solid food for three days after. At the end of some two or three days after the operation give a mild cathartic, and at the same time soften the contents of the rectum by a warm injection. This will cause an evacu- ation with but little pain, and by similar means we can procure daily painless movements afterward, especially if the parts be well brushed with cocaine. On the whole we prefer the ligature to other operations in almost all internal haemorrhoids, on account of the superior safety. Treatment of Haemorrhage after Operations in the Rectum. — All operations for piles are liable to a possible primary or secondary hjiemorrhage, thoiigh the method by ligature is nearly safe from this accident. As the bleeding may take place inside the sphincter, a great quantity of blood may accumulate in the colon before it is observed. If haemorrhage is discovered, or suspected, the bleeding point must be sought for, even if one has to forcibly dilate the anus and pull down the mucous membrane. The spot cannot be much above the verge. If it cannot be discovered Allingham ties a double string into the center of a large bell-shaped sponge, and pushes it up five inches above the bleeding point, so as to prevent the blood escaping upward into the colon. He then firmly packs the parts below with cotton dusted with powdered alum or iron persulphate, and leaves the tampon there a week or more. If the bleeding point can be found approximately, but not exactly, the whole adjacent patch of mucous membrane can be pinched up and tied en masse, or a double ligature may be passed under the spot by a curved needle and tied each way, thus enclosing the bleeding spot. Slighter haemorrhage may often be arrested by ice in HEMORRHOIDS OR PILES. 33 the rectum, or bj astringent tampons, but severe cases require ligatures. The Hypodermic Injection of Piles, or the Method of Itinerants. — In the year isTl there lived in the villao-e of Clinton, Illinois, a young jihysician named Mitchell. His practice was small, aiid afforded him superabundant leisure, which he employed in devising a new treatment for piles. Being a good thinker he soon conceived the idea of treating haemorrhoids by the hypodermic injection of a mixture of olive oil and carbolic acid. Having tried his plan upon an old farmer of the neighborhood he accomplished a triumphant cure. The old farmer was delighted and garrulous, and the young doctor was needy but ambitious, and the two made a sort of copartnership, the old farmer attending to the adver- tising, while the young doctor received the patients and punctured their piles and their pockets with his hypodermic syringe. Knowledge of their method spread. Certain itinerants began to sell the secret to others, pledging them •to secrecy in turn, and binding each to practice only in the district for which he had " purchased the right." Two men in Chicago are said to have paid three thousand dollars for the exclusive secret " right " to a certain portion of Illinois, including their city. Flocks of itinerants bought the secret of each other, and traversed the country in every direction until their handbills fluttered on the shores of the Pacific Ocean. In the year 1876 one of the quacks revealed to us his method, and by taking measures adapted to the pur- pose we found that his information was correct. We then entered into correspondence with a cojisiderable number of the itinerants, some of whom seemed willing to make a clean breast. We also communicated with a large iiumber of regular physicians who had observed the practice of the itinerants, and in some cases had made use of the method ttiemselves. In the course of this investigation we received about 300 letters, and got rough estimates of the results of the injections in about 3,300 cases. 34 RECTAL AND ANAL SURGERY. Mitchell commenced with a mixture of one part of carbolic acid to two parts of olive oil, but he gradually varied from liis first method, and at length, as I am informed, he partly abandoned the injections and adopted the plan of tearing the interior of the piles to pieces by angular needles set in handles. He probably met some of the dangerous accidents which have occurred in the injection practice, and changed to the needles on that account. His disciples, however, persisted, and in their hands the injections were varied in numerous ways. One of the itinerants wrote us that he had tested " every caustic in the vegetable and mineral kingdoms," but that he came back to carbolic acid as the best, "and the stronger the better." The excipients generally used were oil, glycerine or alcohol, to which water was sometimes added. Carbolic acid was generally but not always the active ingredient and the strength varied from twenty to one hundred per cent. We were disappointed on the whole in the results. Although there were many beautiful cures, thirteen deaths were reported to us out of about 3,304 cases, besides a large number of dangerous abscesses, sloughings, and in some cases prolonged and terrible pain, or desperate shock, the latter being probably from embolism. In a number of cases very dangerous hsemorrhages occurred, presumed to be from the spasmodic grip of the sphincter bursting the thin walls of a pile, squeezing out the clot, and letting loose the floodgates of the hsemorrhoidal veins, which above the verge have no valves. It is an old experience over again. Twenty years ago the profession was charmed by the results of coagulating injections thrown into venous enlargements in other parts of the body, but we were soon stopped by the occurrence of deaths from embolism. The hypodermic injection of piles confronts us with similar dangers. The following accidents have been reported to us out of about 8,304 cases: Deaths, 13; embolism of liver, 8; sudden HEMORRHOIDS OR PILES. 35 and dangerous prostration, 1 ; abscess of liver. 1 ; dangerous haemorrhage, 10; permanent impotence, 1; stricture of the rectum, 2; violent pain, 83; carbolic acid poisoning, 1; failed to cure, 19; severe inflammation, 10; slouo'hingf and other accidents, 35. We are the more particular to mention these disasters, because Dr. C. B. Kelsey, of New York, has recently tried the plan and states that he has never heard of a death from it. Our expei-ience in the West is very different. Twelve years ago we published nine of these deaths in an article which was extensively republished in the medical journals of this country and of Europe, and about four more fatal cases have come to our knowledge since. Dr. Kelsey, like one of the present writers, was at first highly pleased with his results, but with his usual sound judgment and candor he observes that further experience developed so many instances of abscesses, sloughing, etc., etc., that he has modified his first conclusions, and now applies the j^lan mainly to selected cases of completely internal piles of moderate size, and having well defined pedicles. (Kelsey on the Treatment of Haemorrhoids, p. 64. ) For ourselves, we were long ago reluctantly compelled to admit that these injections are dangerous, and until some way of avoiding the perils is shown we can not recommend them except in special and selected cases. The itinerants varied greatly the strength of the fluids used. The weak solutions acted more mildly than the others, but they often failed of cure. The strong preparations almost always cured the piles, but they pro- duced a multitude of cases of abscesses and sloughings. The Michigan itinerant above mentioned states that he preferred positive results, and always sought to cause the piles to suppurate or mortify, and to that end he "preferred carbolic acid, and the stronger the better." Some of them use the acid at a strength of only three per cent, and others as high as 95 per cent. 36 RECTAL AND ANAL SURGERY. The secret pile remedy of the " Brinkerhoff System," is the following: Carbolic Acid 3 j Olive Oil :v Chloride of Zinc grs. viij Mix. The little pamphlet furnished to the itinerants pur- chasing the " System " directs that the amount of injection Inserted into the tumors shall be as follows: Largest Piles 8 minims Medium " 4 to 8 " Small " 2 to 3 " Club-shaped painless piles near orifice 2 " " Brinkerhoff's System " forbids the injection of any but internal piles. He directs hot sitz-baths for cases where violent pain follows. His prohibition against the injection of the external kind, is doubtless because of the agonizing distress apt to follow in the latter, owing to their great supply of sensory nerves. He directs to treat only one large, or two small piles at a sitting, and to allow from two to four weeks between the operations. Some add ergot, and others cocaine to their injections. The itinerants have used a great variety of coagulating substances besides carbolic acid, such as iron persulphate, iron perchloride, zinc sulphate, zinc chloride, mineral acids, tannic acid, etc., but on the whole carbolic acid mixtures have received the preference. The dangers have generally arisen from embolism, haemorrhage, abscesses and septicaemia. The lower portion of the heemorrhoidal plexus empties into the iliac veins, and the upper into portal system ; hence clots or globules of the injection may be carried either to the heart or to the liver. Dr. Whitmire, a well-known physician of high standing at Metamora, 111., tampons the rectum for twenty-four hours after the injection to prevent the clots from moving upward. In case of haemorrhage, Allingham's HEMORRHOIDS OR PILES. 37 method of tamponing, as described ou page 32, can be employed. Up to the present time science has not discovered any method o£ wholly avoiding the risks of the hypodermic injections. The method is moderately, but positively dangerous, and we cannot recommend it as proper in ordinary cases. If the injection plan is resorted to at all the following rules should guide us: 1. Unless cocaine is used, inject only internal piles, as those have much less susceptibility to pain than the external ones; however, if an external pile be injected a few minutes beforehand with cocaine, the pain can be in a great measure prevented. 2. Use diluted forms of the injection first, and stronger ones only when these fail. 3. Inject only one or two piles at a time, and alloM' from ten to thirty days between the operations. 4. Apply cosmoline to the surface to protect it from possible dripping during the operation, and keep the syringe in a few moments to prevent the mixture from flowing out. Inject slowly. 5. Confine the patient to the bed the fii-st day. Treatment of Haemorrhoids by the Clamp and Cau- tery. — Yon Langenbeck, of Berlin, and Smith, of London, are the chief advocates of this operation, but Mr. Cusacle, of Dublin, is said to be the inventor of it. The operator seizes the pile with a double tenaculum or with a small vulsellum forceps and draws it out. He then applies to its base the clamp shown in Fig. 18, so as to prevent hasmorrhage and protect the parts beneath from the cautery instruments. Smith then cuts off the piles outside the clamp with hot serrated cautery knives, while others simply use the scissors. In either case the tissue is not divided close to the clamp, but about a quarter or third of an inch external to it. The projecting stump is now thoroughly but slowly cauterized by 38 RECTAL AND ANAL SURGERY. irons at a black lieat, so applied as not merely to sear the cut surface, but to thoroughly "cook" the whole projecting stump well up to the clamp. The electro-cautery can be used instead of hot irons. The method effectually cures the piles, but it is a little more liable to haemorrhage than the ligature, and the idea of burning the parts with hot irons is horrifying to the imag- ination of the patient and his friends, hence the clamp has had less favor than the liga- ture, though many excellent surgeons employ it. The after- treatment is the same as that after ligation. Treatment of Haemor- rhoids by the Ecraseur. — Many French surgeons former- ly favored the removal of piles by the chain ecraseur. We have often used for the purpose the Ecraseur forceps here shown (Fig. 19) which are of our own devising, though by an accident they are credited in the instru- mental catalogues to Professor Byford. The error was not due to him, as he never laid any claim to the invention. The instrument is easily -Smith's Cauteey Clamp, gleaned, simple in structure, and much more easily applied than the complicated chain Ecraseur, and does not break like the wire ecraseur. The effect on the pile is exactly the same as that of the others, neither better nor worse. Smith, of London, has devised Fig. 18. HEMORRHOIDS OR PILES. 39 a small pile ecraseur (Fig. 20), using a wire cable instead of a chain. The pile being seized with vulsel- lum forceps, the instrument is applied at the same point where a ligature would be, generally half way between the base and the summit, and slowly tigfhtened until the tissues are severed. The patient must be kept some days in bed, the stumps are treated antisepti- cally, and the general management is the same as after ligature. As in all other methods of removing piles, it is necessary to be careful and leave suffi- cient mucous membrane to make a dis- tensible verge of the anus, otherwise a stricture will follow. The ecraseur cures piles effectu- ally, but it is occasionally followed by dangerous haemorrhage, so that its popularity in this country has decidedly weaned. In our own practice we have discarded its use. Crushing the Pile. — Another fill m/ method consists in crushing the pile with an instrument devised for the pur- pose, without removing it. This merely diminishes the danger of haemorrhage without attaining the safety of ligation. It, however, destroys the pile, and causes it to slough off, thus effecting a cure. It has been considerably but not gener- ally employed. It is a more severe opera- tion than ligation and has no advantage ^^^- 19- Authok's ^ . . " ECBASEUB-FOEOEPS. over other methods in its results. Various Cauteries. — Hot irons of various forms have 40 RECTAL AND ANAL SURGERY. been applied to piles with the effect of curing the tumors. Cautery by needles, either heated by a spirit lamp or by the galvanic current, has been a favorite with some. Electricity in a weaker current is also used to coagulate the blood in the piles with considerable effect. Potential cautery has been practiced on internal haemor- rhoids with fuming nitric acid, with sodium ethylate, and with potassa cum calce. Many successes and many failures have resulted from the use of these inconvenient articles. Treatment of External Piles. — External ha3morrlioids may be excised, ligated, or destroyed by cautery. When they consist, however, of globular subcutaneous blood clots, operation is unnecessary because they will be absorbed in a Fig. 20. — Smith's Wike Cable Eckaseue. few weeks or months. If painful they may be slit up and the clots turned out. Excision of Internal Piles. — A few aiithors have lately advocated a partial return to the discarded plan of cutting out internal as well as external piles, resorting to one or another method of preventing haemorrhage, according to the fancy or the judgment of the writer. We are sorry to say that none of these plans are safe. One may operate a hun- dred times and have no trouble, but sooner or later the surgeon who cuts out large numbers of internal piles will have instances of dangerous haemorrhage. If the incision were external, where unskilled attendants could apply com- pression, it would be less objectionable, but the bleeding point is above the sphincter, and the patient bleeds a colon- full before he knows the cause of his faintness. He then HEMORRHOIDS OR PILES. 41 expels a great mass of clots, and the sphincter closes, stop- ping the external How and deceiA'ing the patient with a false appearance of improvement, until an- other mass is expelled, and so on through a perilous series of refiUings and expul- sions. If the surgeon who operated happens to be inaccessible, or not to be found, the patient will be in great dan- ger, for, even if some well-educated physician not in surgical practice is called, he will often be baffled and per- plexed to control a bleeding from an internal point, whose exact location is very obscure to him. For the method of arresting rectal haemorrhage the reader is referred to page 32. The Circular Excision, or White- head's Operation, — Mr. Whitehead, of England, published in the British Medical Journal nearly five years ago a new plan of operation, which was very energetic, but involv- ed some dangers, and was not tlierefore acceptable to( most surgeons. Professor Eobt. F. Weir, of New York, tried it, however, but soon abandoned it on account of its obvious de- fects. Mr. Whitehead him- self became dissatisfied with his method and in February, 1887, published in the Brifish Medical Jourmd a modifica- tion of the plan, and claimed complete success in three Fig. 21. — Nott's Ecbaseub. 42 RECTAL AND ANAL SURGERY. hundred consecutive cases without a single death, secondaiy haemorrhage, abscess, ulceration, stricture or incontinence of the ffBces. Notwithstanding these brilliant claims the method is liable to several objections, so much so that we have declined thus far to use it, but Prof. Weir, after trying it six times, announces his approval of it. Mr. Whitehead's improved procedure is as follows: The sphincters are lirst forcibly stretched. Next the surgeon with dissecting forceps picks up the integument near the junction of the skin and mucous membrane and with scissors cuts through the mucous membrane at or pretty near the white line indicating its junction with the skin, making a rapid incision entirely around the bowel and upward until the upper edge of the external sphincter and the lower edge of the internal one are exposed to view. The dissection is then carried upward along the inner surface of the internal sphincter separating the piles and mucous membrane from the muscle, pulling the piles down- ward a little firmly and snipping any resisting bands of tissue, but using the fingers and handle of the scalpel as far as possible to peel the piles away from the muscle until the healthy membrane above the piles is reached. The mucous membrane, now hanging loose in the rectum with the piles attached, is divided transversely, cutting only a moderate portion of it at a time, and securing the bleeding vessels by torsion and not by ligatures. As soon as the vessels of a section are secured, that portion of the cut edge of the mucous membrane is dusted with iodoform and pulled down and fastened by fine silk sutures to the cut edge of integu- ment at the verge. The stitches are never removed but allowed to fall out spontaneously. Another portion of the circumference is then cut, and secured in the same manner and so on until the whole of the circumference is divided, and the circle of mucous membrane which naturally lined the lower part of the rectum is taken away, and the mem- brane higher up pulled down to take its place. Prof. Weir HEMORRHOIDS OR PILES. 43 thinks the subsequent pain is less than after Allingham's ligation, but it is difficult to see why, since the most exquisitely sensitive portion of the integument at the verge of the anus is pinched up in a circle of numerous fine stitches, while its sensory nerve supply is not cut olf as in Allingham's method. Prof. "Weir's six cases are perhaps not enough to settle this question. At this distance we are not able to ascertain whether there are any mistakes in Mr. Whitehead's enthusiastic claim to entire exemption from the accidents known to be common elsewhere after excision of internal piles, but we think caution should be for the present observed. In the United States some very disastrous results have followed the operation. Prof. AVeir facilitates the separation of the piles and mucous membrane from the internal sphincter by dissecting to the upper limit at one spot first, and then with the nail or blunt point of the scissors peeling around in a circular direction. Allingham recognizes some of the objec- tions to the method, but has tried it and even invented a complicated four-armed forceps to hold the mucous mem- brane during the dissection. He diminishes the risk of haemorrhage by passing a needle and ligature through the cut edge of the skin and through the mucous membrane from the external side above each principal pile and thence around the base of the pile and doAvn through the skin again, and tightens it, thus clamping the artery of each principal pile to the skin by the knot, and compressing its nutrient artery. The objections which will occur to every one are these: 1. There is a great difference in patients about the liability of arteries closed by torsion to untwist their fibres under the arterial blood pressure, and resume li£emorrhage. If this occurs, the row of fine stitches set in a tender mucous membrane is not adequate resistance against the force of arterial blood. Haemorrhage will not be common, but accord- ing to general experience in other operations at this part. 44 RECTAL AND ANAL SURGERY. it seems nearly incredible that it should not sometimes occur. 2. According to the experience both of Prof. Weir and of Mr. Whitehead, union by first intention will not always take place, and if it does not, a circular ulcer, and, after it, a contracting circle of cicatrix will surround the orifice. In such cases it is impossible to see why stricture may not occasionally occur, precisely as it does sometimes where a surgeon incautiously removes in other operations a complete zone of mucous membrane at the same place. All things considered, it is an operation of great severity, and some danger, and ought not to be performed except in a few peculiar cases, since safer and milder methods have almost a perfect certainty of success. CHAPTER IV. PEOCTITIS OR INFLAMMATION OF THE RECTUM. Proctitis or inflammation limited to the rectum is as distinctly a clinical entity as colitis, typhilitis, duodenitis or any localized affection of the intestinal tube. It deserves to be considered entirely apart from periproctitis or cellulitis, with which it has little in common. Causes. — Mechanical irritation is often the direct cause of an inflamed condition of the lower bowel. After wounds and contusions there is apt to be slight muco-purulent dis- charge and some degree of tenesmus lasting for a few days. This is equally true of operations, particularly the removal of haemorrhoids and forcible dilatation. When the sphincter has been forcibly dilated an increased sensitiveness of the organ almost always follows for a certain length of time, so that whatever material has descended to within a short distance of the anus is likely to be evacuated suddenly. To this is probably due the fact that forced dilatation of the sphincter is reputed to have a powerful influence in curing chronic constipation. Foreign bodies are not very rarely introduced into the rectum by accident or design. Chilcb-en and persons of perverted instincts frequently thrust objects of considerable size into the anus. When from their shape or size these cannot be expelled in the natural motions great irritation is likely to ensue, sooner or later leading to perforation of the bowel and periproctitis. Improper or too frequent use of syringes may also cause considerable proctitis. When the faeces contain angular or sharp-pointed objects the rectum is 45 46 RECTAL AND ANAL SURGERY. more likely to suffer laceration than tlie bowel higher up because of the indurated and inspissated character of the material which must cause such objects to be pressed more strongly in contact with the membranes. Such objects are fishbones, nut-shells and occasionally even coins, pins and needles which have been swalloAved. Certain kinds of food which undergo putrefactive changes frequently cause slight transient catarrh of the rectum. Among such articles are Brie and Limburger cheese and game too long kept. The influence of cold is occasionally felt in producing slight irritations here as in other mucous membranes. In parturition there is sometimes transient acute proc- titis. It may also result from the presence of oxyurides. Among prostitutes the practice of sodomy is a frequent cause of proctitis apart from the effect of contagion. The sphincter also becomes relaxed or torn. Gonorrhoeal and syphilitic proctitis are, however, not generally the effects of sodomy but of infection from other parts, or of constitutional disease. Women, as is well known, are the usual victims of gonorrhoea of the rectum. Dipliiheria of the rectum as described by Trousseau is certainly a form of proctitis rarely noticed in America. It does not occur as a primary affection but in conjunction with the same disease in the throat and only in cases of severe general poisoning. Tuberculosis of the rectum has not so much to do with proctitis as with periproctitis and fistula in ano. Another condition favorable to the production of proctitis is a hsemor- rhoidal condition of the rectal wall. Verneuil has called attention to the fact that the veins of the rectum in their upward course penetrate the muscular layer in such a way that they are constricted with each contraction of the bowel. Stasis of blood and engorgement of the vessels are thus broug^ht about with each act of defecation. A condition is set up not unlike that seen in varicosities of the lower limbs, predisposing to oedema and indolent ulceration of the mem- PROCTITIS OR INFLAMMATION OF RECTUM. 47 brane. This has been termed by Eokitansky " hsBmorrhoidal ulceration." Dyseniery is commonly associated with some proctitis. Many cases of chronic inflammation and ulceration of the lower bowel are due to this cause, especially in hot climates. Amyloid disease of the kidneys is sometimes responsible for inflammation and deofenerative changes in the mucous membrane. Bartels assigns as the cause of this the degener- ation of the blood vessels in tlie lining membrane. Follicular disease of the mucous membrane is another cause of proctitis. The scattered glands of the large intestine become inflamed, enlarged and finally suppurate, discharging each a sphacelus and leaving small rounded ulcers upon the membrane. It is uncertain whether these should be considered as a cause or as an effect of catarrhal inflammation. Symptoms. — Acute proctitis gives rise to symptoms not wholly unlike those of dysentery. It is now held that the rectum, even in health, does not act as a receptacle for any length of time, but tends normally to expel its contents very shortly after they are received. In proctitis this tendency is very markedly increased and exaggerated. While there may be no true diarrhoea, the faeces and gases are expelled spasmodically almost as soon as they reach the rectal pouch. This may occur without the patient's con- sciousness, but more often it is accompanied by slight tenes- mus like that of dysentery. An increased secretion of mucous is another symptom of acute proctitis. This may be clear or streaked with blood, sometimes it is expelled in small gelatinous masses apart from defecation. More or less irritation of the skin about the anus often exists as a result of the irritatinor discharges. This is much more likely to occur in the gonorrhoeal form. Swelling of the mucous and submucous tissue is usually present, but there is not much local pain except the tenesmus during defecation. The oedema often causes some 48 RECTAL AND ANAL SURGERY. protrusion of the swollen membranes, a condition described by Roser as " ectropion recti." Accompanying all forms of proctitis there may be more or less irritability of the prostate or bladder and an increased frequency of urination. Gonorrhoeal proctitis differs little in its general features from gonorrhoea elsewhere. Large quantities of muco-pus are discharged during the height of the inflammation, which usually lasts from two to four weeks. Microscopic examin- ation will show the presence of the characteristic microbe or gonococcus (Klein). Bumstead and Taylor and Neumann have proved that chancroids within the rectum are not by any means unusual. This must nearly always be the result of sodomy rather than of auto-infection, although the latter is possible, as by the insertion of an infected finger or syringe within the rectum. In Neumann's clinic a very clearly marked case of chan- croidal ulcer well above the sphincter was observed and described in 1881. The patient admitted the practice of sodomy. True chancres of the rectum and anus would hardly be noticed by the patient. Fournier has proved their frequent occurrence both within and outside of the rectum. Condylomata are the most familiar of all sy2:)hilitic manifestations about the rectum. They are essentially like mucous patches or papules occurring elsewhere in secondary syphilis but owe their peculiar form to the irritation to which they are constantly subjected. At times they take on almost the appearance of warts or vegetations. In the folds of the mucous membrane of the anus where there are mucous patches, there is often a tendency to the formation of small rounded ulcers with sharply elevated edges [rhagades). The subsequent healing and contraction of these ulcers produce a curious folding and wrinkling of the skin, described by Sir James Paget as a true characteristic of syphilis of the rectum. PROCTITIS OR INFLAMMATION OF RECTUM. 49 Another form of syphilitic proctitis is often met in ■which there is a diffused thickening of the whole rectal wall, causing it to become harder than natural and some- what oedematous. Fournier describes this condition — under the name ano rectal sijpliiloma — as a hyperplasia followed by sclerosis of the membranes so that they ultimately become contracted and fibrous. Tertiary syphilis of the rectum begins by the deposit of gummata upon the membrane in the form of smooth, globular, painless tumors. These run the usual course of such deposits, breaking down and producing rounded ulcers which coalesce and destroy the mucous and submucous tissue. The healing of these ulcers if extensive inevitably brings on stricture of the rectum. There is little doubt that tertiary syphilis of the rectum is very common. That it is not oftener seen in its earlier stages is due to the painless character of the affection and its remote location. Accompanying iilcerative proctitis, of a syphilitic or any form, there is of course some mucous and purulent dis- charge, which, however, may not attract much attention. There is not infrequently amyloid degeneration of the rectal wall in advanced syphilis. This results from a similar condition of the intestine above. Alliugham applies the term "lupoid" or "rodent" ulceration to what is probably identical Avith lupus in other parts of the body, though occurring often in persons not in advanced years. Some cases of extreme destruction have been observed from this disease in which the rectum was extensively undermined and the bowel left "hanging loose and ragged" "like the torn sleeve of a coat." Treatment of Proctitis. — Acute proctitis is commonly a transient affection when due to extension from the same condition higher up and calls for no separate treatment. When due to mechanical irritation, local interference except to remove foreign substances is often unnecessary, the inflammation subsiding quite rapidly when rest in bed 50 RECTAL AND ANAL SURGERY. is maintained. The local use of anodynes and antiseptics in the form of suppositories is often to be recommended, however. To ensure rest the bowel should be kept evacuated. A recent British writer advises against enemata for this purpose on account of the danger of spreading infection upward. This danger can only exist in special cases. Small injections of hot water are decidedly soothing and help to control the inflammation, at the same time cleansing the rectum. For tenesmus it is well to use Mucilage of starch ^ij Tr. opii x-xxx Inject slowly. An anodyne antiseptic of great value is Iodoform 3i Ext. belladon gr. v Pulv. opii gr. X 01. theobrom q.s. M. Ft. Suppositories No. xii Boric and carbolic acid are slightly irritating and cause some smarting of the anus. Corrosive sublimate is not a suitable antiseptic for use within the rectum on account of its irritating properties not less than its poisonous properties when absorbed. Chronic proctitis is best treated by the free use of hot water to cleanse and soothe the congested membrane. The hot douche is also advised after certain injections to remove them and prevent their absorption. Thus, for chronic proctitis Argent, nit g^- v. Aq. dest 3ij may be injected and removed by a subsequent enema. While the local effect of this solution ought to be favor- able, its immediate removal probably prevents any decided action. Neither are we inclined to recommend for general PROCTITIS OR INFLAMMATION OF RECTUM. 51 use within the rectum any solution which safety requires shoukl be washed out again. It is not always possible to know how far injections are carried and whether they are subsequently removed or not by washing with additional water. The following by Ball is of use where the discharges are fetid: Liq. carbonis detergent 3ii Tr. kramerise 3iv Mucil. amyli q. s. ad ^iv M. Liq. Inject 3! morning and night. A solution of bismuth with mucilage of starch is recommended as a safe local application, viz: Liq. bismuth 3i Mucil. amyli ^vi It is well to remember that glycerine if used freely in the rectum will of itself be decidedly irritating. Mucilage of starch is therefore better than any preparation such as "glycerite of starch." CHAPTER V. DISEASES OF THE SACCULI HOENERI. Fortunately the sacculi are not very prone to disease, except as they participate in inflammations of adjacent parts. Still they occasionally give lodgment to small foreign bodies, which may cause ulcers of a septic character, and which by their location close to the zone of greatest nervous supply of the rectum may give origin to extensive and distressing reflex symptoms, even in distant parts of the body. At the present time special attention has been directed to the sacculi by the traveling "pile doctors" who have gotten the idea that the sacculi, or "pockets" as they com- monly call them, are never healthy, but are themselves a disease in their very nature, and that they must always be destroyed. As the patient cannot see the sacculi and is unable to deny their diseased nature, he is at the mercy of the traveling man and gladly pays a high fee to have such dangerous organs split open and destroyed. The sacculi are described in Chapter I., but we may be allowed to refer again briefly to them, since noisy itinerants are making use of them so extensively in their trade and doing injury to thousands of deluded patients. The anatomy of the organs referred to is given by various authors, both old and new, and we have been at the trouble to verify their descriptions and drawings, by new dissections of our own, assisted by Prof. Billings, of the Chicago Medical College. In a healthy rectum the mucous membrane just above the verge of the anus is traversed by minute branching ridges, enclosing slight concavities of varied shapes and sizes. If a healthy rectum from a cadaver 52 DISEASES OF THE SACCULI HORNERI. 53 be laid open and spread out after the rigor mortis is past, the ridgfes will be found to curve and interlace in all direc- tions and to be only faintly visible, but if examined during life it will be seen that the action of the sphincter ani presses them together laterally, so that the ridges run in a more perpendicular direction, and receive the name of colummv recti. The framework of these little ridges does not consist of mere folds of mucous membrane, as some authors state. They are reticulate bands of muscular and connective tissue, and the delicate mucous membrane, when healthy, can be made to glide freely over them. These little columns are inserted at their lower extrem- ities into the verge of the anus, and at that point one is often connected to its nearest fellows by webs of mucous membrane, making the "pockets" above mentioned, which wefe long ago named the scicculi Horneri, by anatomists, after the distinguished Dr. Horner. They are figured by various authors, and good illustrations may be seen in Smith's Anatom. Atlas, fig. 331, page 112; Esmarch's recent w^ork on the Rectum, and in Allen's Anatomy, plate 101. They are much less distinct in some persons than in others, but in all perfectly healthy rectums, where the mucous membrane is normally thin and elastic, the lower ends of the grooves between the columns will show hollows, which sometimes are of considerable depth, but, even if shallow, a little traction with a blunt hook readily makes them assume the form of sacculi or " pockets," well adapted to deceive an examiner who is not aware of the elasticity of the membrane. In perfectly sound rectums the membrane covering the reticulated ridges and lining the hollows is exceedingly elastic and distensible, to allow of the requisite dilatation during the expulsion of the fsecal mass. The sacculi and other hollows of the reticulated zone contain a reserve of tenaceous mucus, which is pressed out as the faeces descend, and lubricates the descending mass. When carefully examined in healthy organs, the sacculi show no 54 RECTAL AND ANAL SURGERY. trace of disease, but are lined with a perfectly normal and beautifully delicate mucous membrane, which moves freely on the parts beneath, and stretches readily in any direction. The claim that they are "diseases" is simply absurd. However, these reservoirs of mucus, like the analagous pockets in the tonsils, occasionally become inflamed and even ulcerated, and then may require clipping out, as was long ago stated by Henry H. Smith, of Philadelphia, as well as by the elder Gross, and by Ashhurst and others. Berry seeds and other minute objects occasion- ally, but not often, lodge in them. Between the lower ends of the grooves are frequently found a few papillae, reminding one of the anal- ogous carunculcB myrtiformes of the vagina, though they are usually se^ro^n^'S'the^JrhorrxSJi" Smaller. They show a healthy struc- cut shows the reticulated arrange- , • . ^ j ment under post-mortem relaxa- turC lU mOSt CaseS, and are SUppOSBQ tion. The lower cut shows the same parts compressedlaterally by to be tactile OrgaUS, WhOSC UerveS the contraction of the sphincter. _ i • i c. c. c. coiumnie recti, s. Dotted commuuicate rcflex impulscs to the curves, showing the position of J- sfwcuu Horneri between the bases exDulsorv muscles engaged iu defe- of the columns. P. P. Papulae. r J O o cation. These little papillae with the adjacent " pockets " constitute an important part of the harvest field of the itinerants. The following letter, from the distinguished Prof. Henry H. Smith, of Philadelphia, shows the error of the claim that the so-called "pockets" are a new thing in science : PmLADELPHiA, May 4, 1887. Prof. E. Andrews: Dear Sir: " The rectal pouches " ( "Sacculi Horneri " ) are a normal structure, intended to hold mucus, which is forced out in defecation, to lubricate the margin of the anus, and protect it from hardened faeces. In 1792 Physick called attention to them DISEASES OF THE SACCULI HORNERI. 55 (see American Encyclop. of Med. and Snrg'y. article '• Anns," by Coates; see also Smith's Operat'e Surg., Yol. II., p. 590, 1863), for the operation sometimes required. For their structure, see Horner's Special Anatomy, Vol. II., p. 46, 1851; see, also, Ameri- can Jour. Med. Science, Vol. XVII., N. S., p. 410, 1849; Winslow (Vol. II., p. 149) described these pouches in 1749. In " Smith's Anatomical Atlas," published in 1844, by Lea, you will find in figure 331, page 112, an accurate drawing of the " Sacculi Horneri," which I guarantee to be correct. '• Truly yours, "HENRY H. SMITH." The rise and progress of the itinerant is usually this: He buys for fifty or a hundred dollars from the owner of one of the "Systems of Kectal Surgery" a little poverty- stricken box of instruments, containing a speculum, a blunt hook, a hypodermic syringe, and a few^ other things. The box also contains a little pamphlet telling him how to use the instruments on piles, '' pockets," fistulse, and ulcers. AVith the box he receives a mixture of carbolic acid, some salves, washes, etc., wdth the gracious privilege of buying more of them at a tremendous price of the owner of the " System " when the stock is exhausted. He is not always allowed to know their composition. Inserting his speculum into a patient the fully developed traveling quack ahvays finds "pockets." If they are not there he makes them by pressing his blunt hook into the delicate membrane. A fold being thus caught he splits it down with a Sims' knife, and then finishes the operation by a forced dilatation of the sphincter, and by collecting his fee. The cutting is trivial, and including only a few of the sacculi, it does not seriously injure the patient, but the indis- criminate forced dilatations, though useful in some cases, leave prolonged bad results in others. However, as before stated, the sacculi may be really diseased. Hence it is often necessary carefully to examine the entire circle of them, when obscure reflex distresses are 56 RECTAL AND ANAL SURGERY. found harrassing the })ntient. For this purpose place the patient in Sims' position in a good light and insert any good speculum. Carefully try the lower ends of all the grooves between the columns of Morgagni with the point of a Sims' r- Ferri. sulph. exsiccat. Quinine sulph ail 3 ij Ext. nuc. vomicae. Ext. aloes fia gr. xij M. Ft. pil. No. XL. S. One three times a day. 13. For haemorrhoids (laxative, "Pv7 salidis^'' ). P^ Ext. aloes. Ext. hyoscyami aa 3j Ext. nuc. vomicae gr. iv 01. anisi gtt. iv M. Ft. pil. No. LX. 14. For haemorrhoids, with ulceration (Allingham). 1^ Bismuth, sub-nit 3ij Hydrarg. chlor. mit 3 ij Morph. sulph I^^^- iij Glycerinse 3ij Ung. petrol 3 j M. S. Use in pile syringe. APPENDIX AND FORMULARY. 125 15. For li?emorrlioids, l)t Acid, tannic 3ij Ext. belladon. Pulv. opii ajl 3ss Ung. petrol, (or lanolin) 3J M. S. Apply inside and outside. 16. For haemorrhoids. 1^ Cocaine hydrochlor gi'- ^ 01. Theobrom q. s. M. Ft. suppositories No. XV. 17. For haemorrlioids (Ball). 3 Morph. hydrochlor gi'- ^ Ext. belladon. Acid, tannic aa 3j. Vaselin. Lanolin 3,a 3 j M. 18. For eczematous external haemorrhoids (Ball). 1^ Liq. carbonis detergentis . . . . : j Liniment, calcis 3V 19. For inflamed external haemorrhoids (Yount). IJ Cocaine hydrochlor g^"- ^ Ext. belladon. Ext. opii. Ext. aconite. Ext. stramonii aa 3ii Glycerinse 3ss M. S. Apply on cotton or lint continuously. 20. For haemorrhoids. I^ Plmnbi subacet. Bals. Peru. Ext. belladon. Zinci. benzoat aa 3j Adipis 3J M. 126 RECTAL AND ANAL SURGERY. 21. For htemoiTlioids (with tenesmus). 1:J Pulv. opii. Ext. belladon a<1 gr. x 01. Theol)rom q. s. M. Ft. suppositories No. XV. 22. For hypodermic treatment of haemorrhoids. I^ Acid, carbol. (crystals) gr. xx — 3ij Glycerinse q. s. Aq. dest ({. s. ad 5j M. 23. For hypodermic treatment of haemorrhoids. 1$ Acid, carbol. (crystals) . . 3ij — 3iv Glycerinse q. s. ad 3 j M. 24. For hypodermic injection of hsemorrhoids (not much used). 5 Acid carbol. (crystals) ... 95 per cent. Aq 5 per cent. M. S. 95 per cent. sol. carbolic acid. 25. For hypodermic treatment of haemorrhoids (early formula ) . I^ Acid carbol. (crystals melted) . Zj — 3v 01. olivse . . . . q. s. ad 3 j M. 26. For hypodermic treatment of haemorrhoids ("Brinker- hofP System"). I^ Carbolic acid 3J Olive oil 3V Chloride of zinc grs. viij Mix. The little pamphlet furnished to the itinerants purchasing APPENDIX AND FORMULARY. 127 the " System " directs that the amount of injection inserted into the tumors shall be as follows: Largest Piles 8 minims Mediiim •' 4 to 8 " Small " 2 to 3 " Club-shaped painless piles near orifice 2 " " Brinkerhoff's System " forbids the injection of any but internal piles. 27. For hypodermic treatment of hsemorrhoids ("Rorick System"). I^ Carbolic acid. Glycerinse ^^ ~U Fi. ext. ergot 3j Water 3iss Mix. 28. For hypodermic treatment of haemorrhoids ("Painless injection" of Dr. Green, a traveling pile doctor). I^ Carbolic acid 3J Creosote gtt. x Acid, hydrocyanic gtt. j Olive oil fi Mix and unite under water. Sig. Inject enough to turn the tumor an ashen grey color. 29. For hypodermic treatment of haemorrhoids. (Dr. Silas T. Yount of Lafayette, Ind., advocates very weak injections, viz). * 5 (5 per cent. sol). Acid, carbol gr. xxiv Aq. dest 5 j M. IJ (3 per cent. sol). Acid carbol gr. xviss Aq. dest 3J M. 128 RECTAL AND ANAL SURGERY. SO. For fistula (Itinerant method), 1^ (First ste])) Hydrogen pex'oxide 3j — "iv Aq q. s. ad 5j M. S. iQJect the listula deeply. 81. Ijt (Second step) Acid carbol gr. xl — 3j Glycerine or alcohol q. s. Aq (J. s. ad 3 j M. S. Inject 15 drops after the hydrogen bubbles have ceased. Or (BrinkerhofP) 32. Ij. Dist. ext. hamamelis fl. 3v Liq. fer. subsulph fl. 3j Acid, carbol. cryst gr. ij Glycerinse fl. 3ij M. S. Inject ten or fifteen drops deeply into the fistula, and press the track of the fistula with the finger, to force the fluid more deeply in. Many itinerants finish the operation two hours later by injecting the fistula with equal parts of oil of eucalyptus and glycerine. 33. For fissure of the anus. I^ Corrosive sublimate gr. j Cryst. carbolic acid 3 ij Hydrochlorate of morphia . gr. v Water fl. z^'v M. S. Apply with a camel's hair pencil. 34. For fissure (Allingham). I^ Hyd. sub. chlor g^"- iv Pulv. opii g^- ij Ext. belladon gr- ij Ung. sambuci 3 j M. Sig. Apply several times a day. APPENDIX AND FORMULARY, 129 35. For fissure. ^, Hydrarg. oxid. flav gr. xxx Ung. petrol 3! 36. For fissure. 5 Iodoform 3j Belladonna ointment ^^s. Carbolic acid gi*- ^ Simple cosmoline ^ss M. Apply this ointment thoroughly every day, after having each time cleansed the sore vs^ith antiseptics, and touch with nitrate of silver very gently every third day. 37. For rectal ulcers (see also Nos. 4, 5, 6, 7, 8, 9). 5 Argent, nit gr- ij Aq. dest ; j M. S. Inject and wash out with warm water. 38. For rectal ulcers. 5 Iodoform 3ss Bismuth, subnit 3 j Morph. sulph gr. j 01. theobrom q. s. M. Ft. Suppositories No. X. S. Insert one, morning and night. 39. For prolapsus (Itinerant method). IJ Cocaine hydrochlor. Phenol sodique aa gr. viij Aq 3J M. S. Inject in spots one inch apart over the tumor. (" Brinkerhoff's system " advises its followers to avoid treating prolapsus). 40. For prolapsus (Vidal de Cassis). I)!, Ext. ergot, fl nqx — lx S. Inject with hypodermic syringe. 130 RECTAL AND ANAL SURGERY. 41. For pruritus ani (parasitic form). I^ Camphor. Spts. rectif iia, 3j Adipis 3 j M. S. Inside and outside the rectum. 42. For pruritus ani (Kelsey). I^ Saponis viridis. 01. cadini. Alcohol '''^''^5.] M. 43. For pruritus ani. I^ Chlorof ormi fl. 3 j Ung. oxid. zinc 3 j M. 44. For pruritus ani. IJ Mur. cocaine gr. xv Mur. morph gr. x Acid carbol. cryst 3 j Tinct. aconiti rad A- "iij ^ Unguent petrolii 3] M. > This must not be inserted inside the verge in large doses. 45. For pruritus ani (AUingham). I^ Liq. carbon, deter. (Wright's), .fl. 3J Glycerinse A- ^ j Zinci oxid. pulvi, „ T . , aa 3SS Calamin. prep., Sulphuris precip. pulv 3SS Aqu?e pur 3VJ M. APPENDIX AND FORMULARY. 131 46. For pruritus ani (Allingliam). I^ Sodae biborat 3ij Morph. hydrochlor gr. xvi Acid, hydrocyan. dilut . . . . fl. 3SS Glycerinse 11. ^ij Aquse il. 3viij M. 47. For pruritus ani (Kelsey). I^ Acid carbol 3ss Glycerinse A- j j Aquae H. 3iij M. It is pretty strong, and often requires to be diluted. 48. For pruritus ani (Kelsey), ^ Chloral 3j Camphorse 3j Ung. petrol f j M. 49. For pruritus ani. 5 Menthol 3 j 01. aniygd. dulc fl. 3 j Acid, carbol 3j Zinc, oxid 3ij Cerat. simp . . . j 3ij M. 50. For pruritus ani. 5 Ung- picis 3iij Ung. belladon 3ij Tr. aconiti rad fl. 3ss Zinci oxid 3j Ung. rosarum 3iij M. 132 RECTAL AND ANAL SURGERY. 51. For pruritus ani. ]^ Ext. conii (freshly made) . . . . 3j Lanolin 3ij M. 52. For pruritus ani (with external eruptions). IjL Acid, salicy] gr- x Spts. rectif 3J M. INDEX A PAGE BSCESS near rectum ---... 57 Aetius, --------- 67 Allingham, - - 9, 17, 27, 30, 32, 36, 49, 57, 59, 86, 105, 115, 124, 131 Amyloid disease in rectum, ------ 47 Antiseptic tubes for vaseline, - - . - - - 18 Anus, fissure of, ------- 67 fistula of - - - - - - - - 59 imperforate, ------- no pruritus of, .---.-. 112 Arteries of rectum, ------- g Ascarides, ----_... 113 Ashton, -.---... 28 Ashurst, - - - - - - - 28, 54 B. )ALL, ------- 50, 69, 125 Bible, the, on haemorrhoids, - - - - - - 21 Billings, -----.-. 52 Billroth, --------- 105 Bistoury, " royal," ------- 63 Blondin, --------- 2 Bodenhamer, - - - - - - 16, 28, 67 Boyer, - - - - - - - - 78, 71, 73 Bright's disease, ------- 28 BrinkerhofiE, - - - - - - 36, 65, 125, 131 Brodie, -------- 28 Bumstead, ----.,.. 43 Bushe, - - - - \ - - - - 28, 120 Cancer of rectum, --.--_ loi colotomy for, . - . . - 107 diagnosis of, - - - - - - 102 palliative measures for, . - - . - 106 treatment of, ------ - 107 c ARTILAGINOUS tumors of rectum, - - - 89, 98 Celsus, --------- 27 Census, U. S., on distribution of cancer, . - - - 101 Circular excision (Whitehead's operation), - - - - 41 Clamp and cautery, ------- 37 133 134 INDEX. PAGE Collapsible tube for vaseline, - - - - - - 13 Cocaine, use of, - - - - - 28, 66, 93 Colotomy, lumbar, ------ 96, 101 Columns of Morgagni, --..-. 3 Condylomata, - - - • - - - 48, 89 Connective tissue of rectum, - - - - - 5 Contraction, spasmodic, of anus, - - - - 67, 70, 99 Cooper, ..--.--- 28 Copeland, - - -- - - - -28 Cripps, ------- 28, 101, 105 Crushing piles, -------- 39 Curling, ..-.--.- 68 Curshmann, -.----.. 72 Cusach, .--.-.-- 37 Cystic tumors of rectum, - - - - - - 89 D. 'AVISON, -------- 93 Digital examination, - - - - - - - 13 Dilator, rectal, Davison's, ------ 93 Sargent's, - - - - - - 93 Wales', ------ 93 Diphtheria of rectum, - - - - - - - 47 Displaced organs, obstruction from, - - - - 98 Dupuytren, - - - - - - - 2, 68, 121 Duret, - - - ----- 23 Dysentery, - - - - - - - - 47 IjCRASEUR, Andrews', - - - - - - 39 in cancer, ------ 105 for piles, - - - - - - - 39 in proctotomy, ----- 66 Nott's, - - - - - - - 41 Smith's wire, ------ 40 Elliot, --------- 124 Erectile property of haemorrhoids, ----- 24 Esmarch, - - - - - - 53, 60, 63, 81, 106, 110 Examination of rectum, ------ 9 digital, - - - - - - 13 electric lamp for, ----- 12 by external inspection, - - - - 12 light for, ------ 11 positions for, - - - - - - 10 questions for, ----- 10 whole hand in, - - - - - - 15 sounds in, - - - - - - 14 INDEX. 135 FFAOE ^CES. impaction of, ------ 99 Fatty tumors of rectum, - - - - - - - 89 Ferguson, -------- 2 Fibrous tumors of rectum, - - - - - - 89 Fistula in ano, ------ 59 " horseshoe," - - - - - - - 61 treatment of, - - ^ - - 62 itinerant treatment of, - - - - - - 64 urinary, . - - . - . - 62 UTLANDS, inguinal, enlargement of, - - - - 12 Gonococcus, diagnosis by, - - - - - - 48 Gonorrhceal proctitis, -...-- 46 Gosselin, . . - - .... - 68 Gowlland, -------- 28 Gronj, --------- 2 Gross, - - - - - - - - 28, 54 rl ^MORRHAGE, means of controlling, - - - 32 Haemorrhoids, - - ----- 21 Bible allusions to, - - - - - - 21 causes of, - - - - - -21 classification of, - - - - - - 23 clamp and cautery in, - - - - 37 circular excision of, - - - - 41 ^craseur in, - - - - - - 38 erectile property of, - - - - - 24 excision of, - - - - - 40 forced dilatation for, - - - - 26 itinerant treatment of, - - - - 30 hypodermic injection of, - - - 33 ligature in, - - \ - - - - 27 palliative measures for, - - - - - 25 Hamilton, -------- 28 Hand in rectum, - - - - - - 15, 92 Hilton, - - - - - ■ -68,117 " white line" of, - - - - - 67, 69 Hippocrates, -------- 27 treatment of fistula by, - - - - 64 Horner, sacculi of, - - - - - - - 4, 52 Hypodermic injection of piles, - - - ■ - - 33 accidents from, ----- 34 deaths from, - - - - - - 34 136 INDEX. PAGE Hypodermic injection of piles, Kelsey on, - - - - 35 rules for, formulas for injections. - 36, 126, 127 Hyrtl, --------- 2 Imperforate anus, . . - . - - no Incised wounds, - - - - - - 118 Infection, avoidance of, ------ 13 Inflammation, see " Proctitis," . - - - - Inguinal glands, enlargements of, - - - - - 12 Inspection, external, ------ 12 Itinerant " rectal specialists," methods of, - - - - 33 contracts guaranteeing cure, - 122 fissure, - - -. - 75 fistula, - - - - 64 haemorrhoids, - - - 33 "pockets," - - - 55 polypi, - - - - 88 prolapse, - - . 86 K. .ELSEY, - - - 18, 19, 35, 78, 82, 101, 105, 115, 130 Klein, ....---- 48 Konig, ■ -.----- 27, 28 L. jANGENBECK, ------- 37 Leclanche battery for electric lamp, - - - - - 12 Legendre, -------- 2 Lemonnier, -------- 68 Ligation of haemorrhoids, ----- 27 Ligature for fistula, ------- 64 Light for examination, ------ 11 Lisfranc, -------- 2 Luschka, -------- 2 Lymphatics of rectum, --_--. 7 Magnesium light, - - - - - - ii Maisonneuve, -------- 68 Malignant tumors of rectum, ----- 101 Malformations of rectum, - - - - - - 110 Malgaigne, ------- 2 Matthews, - - - - - - - 65, 66, 123 Mechanical injuries of rectum, ----- 118 Mechanical obstruction of rectum, ----- 90 INDEX. 13 PAGE Mikulicz, -------- 82 Mitchell, ----...- 33 MoUiere, -------- 68 Morgagni, columns of, - - - - - - - 3 Muscles of anus, ------- 5 Muscular coat of rectum, ------ 3 N: ERVE stretching for pruritus, - -• . . \\^ Nerves of rectum, ------- 7 Neumann, -------- 43 Nott, - - - - - - - - - 41' BSTRUCTION of rectum, ----- 90 from benign tumors, - - - - 97 from displaced organs, - - - - 98 from foreign bodies, - - - - 96 from impacted faeces, - - - - 99 from spasmodic contraction, - - - 99 from inflammatory swelling, - - - 98 P. AGET, .--.-.-- 48 Papillomata of anus, ------- 88 Papillae of rectum, ------- 5 Pare, Ambrose, - - . - - - - 67 Paulus ^gineta, . - - - - - - - 67 Pediculi, ------- 113, 114 Peritoneum, danger line of, - - - - - - 2 Piles, see " haemorrhoids," ------ Pile, " sentinel," - - - - - - - - 12 Polypi, -------- 87 rounded, - - - - - - - - 87 villous, .-,--.- 88 treatment of, - - - - - - - 87 itinerant treatment of, V - - - - 88 Proctitis, - - - - - - - - 45 causes of, - - ----- 45 diphtheritic, - - - - - - - 46 dysenteric, - - - . - - - - 47 follicular, ------- 47 gonorrhoeal, ------- 46 syphilitic, - - - - - - - 49 tubercular, ------- 46 hsemorrhoidal, - - - - - - - 48 symptoms of, ------ 47 treatment of, - - - - - - - 50 138 INDEX. ** PAGE Prolapsus of rectum, ------- gi of all the coats, ------ 82 of mucous membrane. - - - - - 81 cautery in, ------ 85 cautery, potential, in, ----- 86 excision of, ------ 84 itinerant treatment of, • - - - - - 86 Pruritus ani, - ------ - 112 causes of, ------- 113 treatment of, --.--. 113 Q, LUAIN, -------- 2, 28 Questions, list of, for examinations, - - * - " - 1*' R. .ECAMIER, -------- 68 Rectum, anatomy of, - ----- - 1 • arteries of, - - - - - - - 6 lymphatics of, ----- - 7 mucous membrane of, - - - - - - 5 muscular layer of, - - - - - - . 3 nerves of, ------- 7 papillcB of, ------ - 6 peritoneal coat of, - - - - - - 2 skin about, ------- 5 veins of, - - ----- 6 Retention of urine. ------- 31 Richet, -------- 2 Roberts, -------- 2 Rokitansky, ----.-.. 47 Roser, -------- 47 " Rorick System," - - - - - - - 127 s ABATIER, --.-.-. 68 Sacculi Horneri, - - - - - - - 4, 52 Sappey, -------- 2 Sanson, --------- 2 Sarcoma, -------- 105 Sentinel pile, -------- 12 Sets of rectal instruments, ------ 19 Simon, --------- 121 Skin about anus, ------- 5 Smith, London, - - - - - - - 37, 39, 40 Smith, Henry H., - - ' - - - - - 53, 54 INDEX. 139 PAGE Sodomy, infection of rectum from, - - - - 46, 48, 76 Sounds, rectal, - - - - - - - 14, 92 Speculum, rectal, - - - - - - - 15 Andrews' deep, ------ 16 curved, - - - - - - 16 short, ------ 17 Allingham's, - - - - - - 17 four-bladed, - - - - 18 Van Buren's, - . - - - - 17 Kelsey's, ------- 18 Sphincter, dilatation of, - - - - - - 26, 29 St. Bartholomew's Hospital, . . _ - - loi St. Lazarre, " ------ 76 St. Mark's, " - - - - - - 27, 57 Syme, --------- 68 1 AYLOR, -------_ 48 Trousseau, -------- 47 Tuberculosis of rectum, - - - - - - - 47 Tumors of rectum, benign, ------ 97 colotomy for, _ - - - . i07 ^ malignant, - - - . . \q\ sarcoma, ------ 105 treatment of, - - - - 104, 106, 107 u> LCERS of rectum, - - - - - - - 76 causes of, - - - - - - - 76 clinical history of, - - - - - - 76 diagnosis of, ------ 77 chancroidal, - - - - - - - 78 syphilitic, ------ 77 tubercular, - - - - - - - 80 treatment of, - - \ . . . . jg Urine, retention of, ------- 31 V. AN BUREN, - - - - - - 17, 28, 68, 124 Vaseline, aseptic holder for, - - - - - - 13 Vegetations on anus, ------- 88 Veins of rectum. - - ------ 6 Velpeau, -------- 2 Vernenil, - - - - - - - 6, 26, 46, 105 Vidal de Cassis, - - - - - - - 86, 129 Vulsellum forceps for piles, - - - - - - 30 140 INDEX. W- PAGE ALES, - - ------ 93 Warts on anus, - - - - - - - - 88 Weir, --------- 41 Whitehead's excision of piles, - - - - - - 41 Whitmire, ....---- 36 Wounds of rectum, - - - - - .. - 118 incised, .-.-.-- 118 after lithotomy, ------- 118 gunshot, - - - - - - - 120 lacerated, ------- 120 punctured, ------- 120 I OUNT, - - - - - - - - - 127 COLUMBIA UNIVERSITY This book is due on the date indicated below, or at the expiration of a definite period after the date of borrowing, as provided by the rules of the Library or liy special ar- rangement with the Librarian in charge. ^^^ DATE BORROWED DATE DUE DATE BORROWED DATE DUE ^ m \ 1 ^Pl 1 ^^ 1 /yi/"/ i 1 1 1 1 i^ 5 ^^ 1 0^^ 1 4»- 1 ^ 'A 1 9 C28(638)M50 .— W(^^Af& ^simss&mm ^^B^mmm mmi^m^ wsi^mi^ COLUMBIA UNIVERSITY LIBRARIES (hsl.stx) RD 544 An2 1889 C.1 Rectal and anal surnery 200224861 1 RD544 Andrews An2 1889 vrrw .^ ^^ML