Columbia ^nitJer^itp CoUege of ^f)^&imn& anb burgeons! Hibrarp FISTULA, HAEMORRHOIDS, PAINFUL ULCER, STRICTURE, PROLAPSUS, AND OTHER Diseases of the Rectum: THEIR DIAGNOSIS AND TREATMENT. BY WILLIAM ALLINGHAM, M.D., Fellow of the Royal College of Surgeons of England ; Surgeon to St. Mark's Hospital for Fistula and other Diseases of the Rectum, etc. FOURTH REVISED AND ENLARGED EDITION. WITH ILLUSTRATIONS NEW YORK : BERMINGHAM & CO., UNION SQUARE. i882c W. L. Mershon & Co., Printers^ Electrotypers and Binders^ Rahway, N. J. o oo C3 2s: PREFACE TO THE FOURTH EDITION. That this book has not been written in vain, appears to be evidenced by the facts, that three large editions have been sold in this country and in England, that it has been trans- lated into the French, Italian, Spanish and Russian languages, and that a fourth edition is now demanded, the third having long been exhausted. An endeavor has been made to remove obscurities, correct errors, and revise generally, without much enlarging the work. An Index is added, which it is hoped will facilitate reference. CONTENTS. PACE Chapter I. — Introductory. — Statistics 9 Chapter II. — Examination of the Patient — Exploration of the Rectum ; Use of the Speculum ; Introduction of the Hand ; Dilatation of the Sphincters ii Chapter III. — Fistula in Ano — Causes; Abscesses and Treat- ment ; Use of Drainage Tubes ; Various Forms of Fistula ; Examination of a Patient with Fistula or Sinus ; Dangerous kinds of Fistulse ; Treatment of Blind External Fistula ; Spon- taneous cure of Fistula ; Cases ; Cure by Treatment without Cutting l6 Chapter IV. — Fistula and its Treatment by Elastic Liga- ture 28 Chapter V. — Operations on Fistula in Ano — Directions for the Operation ; Internal Fistula ; Causes of Incontinence of Faeces, how to avoid ; Dressing and Healing Wounds after Operating ; Treatment of difficult Cases 34 Chapter VI. — Fistula in Conjunction with Phthisis — Opin- ions of Authors ; Discussion of this Subject ; Cases ; Question of Cough ; Treatment of Fistulous Sinuses in Consumptive Patients 47 Chapter VII. — Hemorrhoids — Classification — External Piles, Diagnosis, Varieties and Treatment 60 Chapter VIII. — Internal Hemorrhoids — Causes, and Opinions of French Authors ; Verneuil's Theory of Predisposing Causes ; Discussion ; Varieties of Internal Piles ; Structure, etc. ; Ques- tion of Operating ; Cases ; Dangers resulting from Losses of Blood ; Protrusion of Haemorrhoids ; Cases best suited to Con- stitutional Treatment ; Connection of Diseases of the Uterus • and Haemorrhoids, with cases 66 VI CONTENTS. PAGR Chapter IX. — Operations on Internal Haemorrhoids — Eleven Methods Described — Excision of Hsemorrhoids ; Treatment by the Ecraseur ; Application of Caustics ; Injection of Carbolic Acid, etc. ; Cauterization " ponctuee ;" Cauterization " linear ; " Operations by Galvanic Cautery ; Removal of Hsemorrhoids by Clamp, Scissors, and Heated Iron ; Dilatation of Sphincter Muscles ; Treatment of Internal Hsemorrhoids by Crushing ; Treatment of Internal Piles by Ligature ; Author's Mode of Operating ; After Treat ment ; Question of Pain ; Retention of Urine ; Success and Statistics of the Operation ; Exceedingly small Mortality 85 Chapter X. — Complications of H/emorrhoids — Impaction of Faeces iio Chapter XI. — HyEMORRHAGES after Operations— Varieties ; Treatment and Cases 1 14 Chapter XII, — Procidentia Recti — Definition, Diagnosis, etc. ; in Children ; in Adults ; Permanent Cure ; Cases 122 Chapter XIII. — Polypus Recti — ^Varieties ; Diagnosis ; Cases ; Treatment „ 130 Chapter XIV. — Pruritus Ani — Causes; Varieties; Treatment.. 136 Chapter XV. — Fissure and Painful Irritable Ulcer of the Rectum — Diagnosis ; Connection with Uterine Disease ; Com- bined with Polypus ; Cure by Simple Treatment ; With Cases ; Treatment by Division of Sphincter Muscles ; Method of Operat- ing ; Nervous Symptoms associated with Fissure ; Why are these Ulcers so Painful ? Treatment by complete Dilatation of the Anus ; Results 143 Chapter XVI. — Impaction of Faeces — Diagnosis, Causes, and Cases ; Treatment ; Concretions in the Rectum 159 Chapter XVII. — Ulceration and Stricture of the Rectum — Symptoms, Diagnosis ; Statistics of Seventy Cases in Hospital ; Observations ; Linear Rectotomy ; Twenty-nine Cases in Private Practice, with Observation ; Causes of Ulceration and Stricture with reference to Syphilis and Venereal Sores ; Opinions of French, American, and English Authorities ; Treatment ; Stricture of the Rectum without Ulceration ; Treatment, etc. . . 166 CONTENTS. Vli PAGE Chapter XVIII. — Cancer of the Rectum — Observations and Varieties ; Treatment ; Chian Turpentine ; Operations for Relief or Possible Cure ; Extirpation ; Cases — Thirteen Partial Exci- sions, Sixteen Complete, by the Author ; Criticism on the Operation ; Colotomy in Cancer ; Thirty-nine Cases by the Author ; Mode of Performing Colotomy 202 Chapter XIX. — Rodent or Lupoid Ulcer — Diagnosis; Treat ment ; Cases 232 Chapteb XX. — Villous Tumor of the Rectum. — Descriptions ; Cases , .... 239 Chapter XXL — Miscellaneous — Neuralgia of the Rectum ; Removal of Coccyx ; Inflammation of the Rectum 245 DISEASES OF THE RECTUM. CHAPTER I. INTRODUCTORY. Rectal diseases are among the most common that affect civilized humanity. They are of rare occurrence in barbar- ous countries. From information obtained when traveling in South Africa, I have reason to believe that the natives of that part of the world very seldom suffer from these affec- tions, but some of my medical friends practicing in India, and also in China, have informed me that the natives of those countries are not exempt, and that severe cases of various kinds of rectal disease are not uncommon. The native doctors, treat bleeding piles by thrusting red-hot skew- ers into the centpe of each tumor. It is curious that a some- what similar plan has been recently advocated by a London surgeon. Food and alcohol, sedentary indoor occupations, and defects in clothing, have much influence in the causa- tion of these maladies, which though not actually dangerous to life, certainly give rise to a vast amount of suffering, by which I mean not only pain, but also the distress arising from inability to work for daily bread. Both laborious and and sedentary occupations are often rendered almost unendurable. It is true that the majority ot these affections are very amenable to proper treatment ; the amount of benefit that can be conferred by a well skilled surgeon is really remarkable ; but there is the opposite proposition to be considered. When diseases of the rectum are neglected, or when the surgeon prescribes confection of senna and gall-ointment in every case cures do not frequently result. An accurate diagnosis in rectal diseases is all important, and to prescribe for patients suffering from these maladies without examining them, both ocularly and digitally, is not D lO INTRODUCTORY. only false delicacy, but radically wrong, and likely to bring the treatment of these diseases into contempt. It still constantly occurs to me to see patients who have been for a long time under treatment by qualified practition- ers, and to whom medicine and ointment have been plenti- fully prescribed, yet no digital examination has been made; perhaps, only a look has been vouchsafed, and the disease diagnosed and treated as piles, whereas fistula, or ulceration or even malignant disease has been present. Some forms of rectal disease are much more common than others, notably fistula and piles. The popular mind seems, indeed, to recognize the existence of only these two diseases of the rectum, for all affections of this part are gen- erally classed by the public under one or other of these heads. The following is a table showing the relative oropor- tions found in 4000 cases taken from my own practice at St. Mark's Hospital: — Analysis of 4000 consecutive cases observed by Mr. Allingham in the Out-patie?its' Departinent of St. Mark's Hospital. Fistula* , 1208 Abscess, 196 (of these 151 became fistulse, the rest prob- ably were cured) 45 Haemorrhoids, internal 863 Haemorrhoids external 102 Fissure or painful ulcer 446 Syphilitic diseases of the anus and rectum 348 Ulceration (neither malignant nor syphilitic) 190 Constipation 185 Pruritus ani 180 Stricture of the rectum (with or without ulceration) 178 Cancer of the rectum 105 Procidentia 53 Polypus without fissure 16 Hsemorrhage (cause not ascertained) 15 Impaction of fasces 14 Neuralgia '. 12 Dysentery 12 Spasmodic contraction of the sphincter (no fissure) 8 Proctitis 7 Foreign bodies in the rectum - 5 I^ecrosis of bone (sacrum and tuberosity of the ischium). . 4 Rodent ulcer 2 Vicarious menstruation from the rectum 2 4000 *0f these cases of fistula there were 172 that presented more or less marked symptoms of affection of the lungs, viz: haemoptysis, frequent cough, or want of reasonance in some part of the chest. EXAMINATION OF PATIENTS. II Some of my critics have thought the above table mislead- ing, and that haemorrhoids are more common than fistulse. I do not say that this may not be the case, if we take into con- sideration the middle and upper classes as well as the labor- ing population, whose cases alone are included in my table. Slight cases of piles did not often present themselves at the hospital, for the laboring man or woman struggles on under an attack which would certainly bring the well-to-do to the surgeon. In my private practice I find during the last seven years I have treated a few more cases of haemorrhoids than of fistula, but it must be observed that a large number of the former were of a very slight nature, or suffering only from external piles, and not requiring any, or more than triv- ial, operative interference for their cure. CHAPTER II. EXAMINATION OF PATIENTS. There are certain questions which it is desirable to ask the patient when inves1,igating a case of rectal disease, in order that nothing may be forgotten or overlooked. It should be remembered that we have not done enough when we have discovered that a patient has a certain mal- ady; it is our duty then to find out if any other disease coexists. Thus, I often see a correct diagnosis made, as far as regards piles, but at the same time, a fissure, or fistula, or ulceration, or even malignant disease of the bowel, has escaped observation. The following are the principal queries I generally put : Is there any pain ? If so, of what character ? Let the patient describe it — leading questions should be avoided. Does the pain exist always, or is it intermittent or par- oxysm.al ? Is the pain set up or increased by defecation ? Does it come on as the bowels are acting, or does it follow immediately, or some time after the action ? How long does the pain last ? Does it pass away entirely, only to recur again on going to stool ? Does anything protrude on the bowels acting, or on making exertion ? If so, does it bleed ? Does it go back spontaneously, or has the patient to return it.^ 12 EXAMINATION OF PATIENTS. Is there any discharge ? if so, what is its nature ? is it of offensive odor ? Is the patient constipated, or does he suffer from diarrhoea ? What is the character of the fecal evacu- ation, as to size, form, etc. ? Has the patient incontinence of wind or faeces ? Is there any hereditary tendency to rectal disease ? Does the patient cough, or is there any proclivity to chest affections ? Ascer- tain the state of the liver; and should an operation be in view, never fail to examine the urine; any advanced dis- ease of the kidneys will, in all probability, render an opera- tion inadmissible. In the present day much is ascribed to gout, and it is well to bear in mind that a gouty person sud- denly confined to bed is liable to get an attack which may, at all events, unpleasantly complicate the case; lastly, inquire into habits, especially with reference.to the consump- tion of alcoholic drinks. I am by no means one of those who think that a moderate indulgence in beer or light wine damaging to the hard-worked man, but a patient saturated with alcohol is the worst subject a surgeon can have to deal with. In such a case I always insist on four weeks total abstinence, and at the same time that the patient should be subjected to preparatory treatment before anything in the way of operation is attempted. In women, inquire into the condition of the uterus, and if any suspicion is aroused, make such investigation as will satisfy yourself as to its state. When your verbal interrogations are concluded, make your examination. There are various postures and methods in which this examination can be conducted. Some sur- geons prefer the patient to kneel on a chair and lean over the back; others to kneel on a sofa, the head being lower than the buttocks; others the lithotomy position; but on the whole, I think the most comfortable and delicate position for the patient, and that most generally convenient for the surgeon, is to lie on the right side, on a couch, with the knees drawn up to the abdomen. In special examinations to discover growths and strictures, I often direct the patient to stand up and bear down; in this manner the diseased parts will be brought nearer to the anus, and so enable you to reach nearly a couple of inches higher than you can when the patient is lying down in the usual position, even if he strain down. To commence. Externally, what is to be seen ? Note any discoloration, the condition of the anus, patulous, con- EXAMINATION OF PATIENTS. 13 tracted or nipple-shaped. Look for tumors, ulceration, or fistulous orifices; feel around outside the anus with the fore- finger, for induration in any part; by this means the situa- tion of an abscess or sinus may be discovered, and the con- dition of the sphincter as to spasm observed. Then, if pos- sible, administer an injection of warm water. I hold that no examination of the bowel can be considered complete if this be dispensed with. After the contents of the bowel are voided, you see what protrusion has taken place, if any; remark its character in every way, particularly as to struc- ture, vascularity, mode of origin from the bowel, by pedun- cle or otherwise; finally, examine the interior of the bowel with the finger. Never neglect this. Much information — to the initiated all that is needed — is to be obtained by pass- FlG. X. Fig. a. Mr. AUingham's Four-bladed Speculum. Speculum Anl« ing the instructed and practiced finger into the rectum; internal fistulous orifices, polypi, minute ulcerations, fissures, etc., can all be easily detected. Although personally I do not use a speculum very frequently, in some cases it is a valuable aid to diagnosis. I have had many varieties of that instrument constructed, to be used with or without artificial light; but for ordinary use the plated metal specu- lum employed at St. Mark's Hospital is, in my opinion, the best. It is open up one side and at both ends, and has a well-fitting plug; the whole is so shaped as to resemble as much as possible a forefinger. It is made by most instru- ment makers — Ferguson, Weiss, Krohne, and others. Some surgeons prefer the bi-valve speculum, and I like it also; its 14 EXAMINATION OF PATIENTS. only drawbacks are some difficulty of introduction, and the risk of injuring the mucous membrane during withdrawal. When you desire to explore the rectum high up, you may, with advantage, use a long metal tube with the interior " nickeled," one end being trumpet-shaped and large. The smaller end may be about three-quarters of an inch in diameter, and it is very easily introduced into the bowel, by using as the plug a small india-rubber bag, which you can inflate with air by means of a syringe. Useful as the above is, to make thorough examination of the rectum for the pur- pose of diagnosing the existence of ulcerations, malignant or other growths, too high up the bowel to reach with the finger, it is best to place the patient under the influence of an anaesthetic, and in the prone position, with the hips well elevated upon hard pillows, so that the intestines will gravi- tate toward the diaphragm, and then gradually and gently, by palpation, to dilate the sphincters, taking four or five minutes in accomplishing this operation. When thoroughly done the whole rectum is opened to view, and if one or two retractors are also used, nothing can escape careful obser- vation. I need scarcely say before any thorough examina- tion is made the bowel must be well cleared out by aperients and injections, and also you must- be provided with sponges mounted on holders, to wipe away all discharge that would impede your view. Even when this has been done something more may be desirable, and that is the introduction of the hand and arm into the intestine. In the year 1867 I first introduced my hand and arm into the bowels of a woman at St. Mark's Hospital, and found a malignant stricture in the sigmoid flexure. From that time I have on many occasions repeated this manoeuvre, and have saved several lives. In one case, which I saw with Dr. Wilson Fox and Mr. Towne, of Kings- land, I found and completely stretched a band of false mem- brane or peritoneum, which was binding down the bowel as it crossed the brim of the pelvis; the obstruction was relieved and the patient recovered. Up to the year 1873, I had never introduced my hand into the male rectum, believing that it was impossible that a man's hand could be passed through the comparatively unyielding, narrow inlet to the male pelvis; but. learning that the late Professor Simon, of Heidelberg, had accomplished this I have on many occasions (my hand being small) followed his example, without inflicting any injury. I do not, however. EXAMINATION OF PATIENTS. I5 think that, at all events in a man, much aid to diagnosis is gained, the hand being so firmly compressed in the sigmoid flexure as to prevent extensive manipulation. I need scarcely say in this proceeding the utmost gentle- ness should be used, and that a small hand is absolutely necessary. Dr. Heslop, of Birmingham, relates in the Lancet, May nth, 1872, two cases of death in women after passing the hand into the rectum, and I think, justly infers that the operation was the cause of rupture of the bowels close to or above the stricture. I have myself seen death result from this procedure in a case "where I believe no undue violence was employed. My opinion is that in this operation, where a stricture exists, it should not be forcibly or widely dilated, and that the dilatation should not befollowed by copious enemata, which will unduly distend the weak part of the intestine, and cause much straining; it is better not even to give any purgative for at least forty- eight hours, and I think it wise to administer repeatedly small doses of opium. Referring again to the condition of the rectum after well dilating the sphincters, I wish to point out how easily opera- tions may be performed — a large bi-valve vaginal speculum may be introduced, or Bozeman's duck-bill, and recto-vesical openings may be readily closed. I have now on three occasions successfully sewed up large vesico-rectal fistulae made by experienced surgeons in performing lithotomy. I have removed a piece of stick three and and a half inches in length, which a man had introduced into his rectum, and allowed to escape into the bowel, where it got fixed cross- wise in the rectum, so high up as not to be felt by the finger, and also an impaction of faeces measuring three inches in diameter, the nucleus of which was a large biliary calculus. As regards impactions generally^ after dilatation of the sphincters, the whole mass can be removed at one sitting, and this is a great adventage. I shall have occasion, further on, to again consider this question of so-called " forcible dilatation." In examining the rectum in women. Dr. Horatio Storer, of Boston, U. S., has recommended eversion by the fingers passed into the vagina. This method is use- ful in women who have borne children, but not in the young and unmarried. Moreover, it is only the anterior wall of the rectum, and that not high up, that this method enables you to examine; by putting your fingers into the vagina you can- not bring down the posterior wall of the rectum, as I have assured myself on many occasions. 1 6 FISTULA IN ANO. CHAPTER III. FISTULA IN ANO. Fistula is, at all events in hospital practice, the most com- mon rectal disease affecting the adult. Out of 4000 cases, taken consecutively and without selection, at St. Mark's Hospital, from the out-patient department, there were 1075 persons suffering from fistula, and 196 from abscess, of which 151 subsequently became fistulae, so that more than one- fourth of the whole cases treated were fistula. I have recently examined the records of the in-patients at St. Mark's Hospital during several years, and these show that two-thirds of those operated upon were cases of fistula. There is one great difficulty in making deductions from statistics, which deserves mention; it is due to the fact that many patients suffer from more than one malady. It constantly happens that a fistula is found in connection with haemorrhoids, either as the substantive disease, or as a complication. Again, a fissure or circular ulcer often has a sinus running from it, so that it may fairly be considered as the opening of an internal fistula, and the case called a fistula, or the sinus is not detected, and the case is called ulcer or fissure, and so error creeps in. Men are more subject to fistula than women. This disease is most frequently met with during middle age, but it is by no means restricted to that period of life. I have operated upon an infant in arms, and upon a man seventy-eight years of age. * The causes of fistula, or abscess ending in fistula, are many and various, and several causes may combine to produce the result. These may be generally specified : Injury to the anus, injury to the mucous membrane of the bowel by very costive motions, by straining at stool, by foreign bodies swallowed (fish bones, and the bones of rabbits are occ'asionally found in rectal abscesses), exposure to wet and cold, and particu- larly sitting upon damp seats after exercise, when the parts are hot and perspiring — I have traced many cases of rectal abscess to sitting on the outside of an omnibus shortly after active exertion; the scrofulous diathesis; and certain depraved conditions of the blood, such as frequently give rise to boils or carbuncles. Here I would observe that sudden and deep- FISTULA IN ANO. 17 seated suppuration is often found to occur after severe itch- ing in the part with only erythematous redness on the surface. Fistula in children almost always results from worms or injury to the anal region. Fistula, in the majority of cases, commences by the for- mation of an abscess immediately beneath the skin just out- side the anus; it is generally said to commence in the ischio- rectal fossa, but I am certain this is the rarer situation; it may also begin by ulceration of the mucous membrane of the rectum, as seen in phthisical patients; when it arises in this manner fecal matter collects in the connective tissue, and then an abscess will form and open outside; and, lastly, and abscess may form in the sub-mucous connective tissue of the rectum, and then burst into the bowel. This is its ordinary termination, but it may insidiously undermine the rectum in any direction, and I am convinced that the most serious forms of fistula not uncommonly originate in this manner. Rectal abscess may arise rapidly, when there will be red- ness, tenderness and often very acute pain with constitu- tional disturbance; or it may be months in formation, and be perfectly painless even on manipulation; the only evidence of the abscess being a flat, boggy, crepitating enlargement, which can be felt at the side of the anus. This form of abscess in the most dangerous, as it is apt to be neglected; it has little tendency to open spontaneously, and it results in a burrowing up by the side of the rectum to some distance, as well as under the skin toward the perineum or buttock, or both. I think, on the whole, by far the most usual course is for the abscess to form rapidly, with great pain, and if not inter- fered with to burst externally ; the patient then becomes suddenly easy, and fancies that his trouble is over. The cavity of the abscess seldom entirely closes, but sooner or later it contracts, leaving a weeping sinus with a pouting, papillary aperture, which may be situated near or far from the anus. It is not often that one sees a rectal abscess very early ; either the patient is not aware of the importance of attend- ing to the early symptoms, or he temporizes, using fomenta- tions or poultices ; or even when seen by a surgeon, the proper treatment is not always promptly adopted. I have seen large abscesses painted with iodine, under the idea of 2 l8 FISTULA IN ANO. obtaining absorption. It is well to remember that as soon as pus is formed, there is only one method of treatment to be for a moment entertained, and that is incision. It is cer- tainly less damaging to cut into an inflamed swelling near the anus without finding pus than to let a day pass over after suppuration has commenced ; the longer the abscess is left unopened the greater the danger of the formation of lateral sinuses. Before any pus exists, rest, warm fomentations and leeches may cut short the attack, but such a result is very rare. Very small abscesses can be well and easily opened in the following way : Place the patient on the side on which the swelling exists ; pass the forefinger of the left hand, well anointed, into the bowel ; then place the thumb of the same hand below the swelling on the skin. Now make out- ward pressure with your finger in the bowel, and you render the swelling quite tense and defined, it being, in fact, taken between your finger and thumb. A curved bistoury is then to be thrust well into the abscess, in a direction parallel to the long axis of the bowel, and made to cut its way out toward the anus ; it is well to make a thoroughly free incis- ion, commencing at the outermost part of the swelling. If the part be thoroughly frozen by the ether spray, this opera- tion, otherwise exquisitely painful, may be rendered almost, if not quite, painless. The method of operating above described is by no means suitable to a severe and deep-seated abscess ; I can, however, safely say that if a patient suffering from this latter form will allow me to act in my own way, I can almost guarantee that no fistula shall result. The following is the method to be adopted. The patient must take an anaesthetic, as the opera- tion is very painful. I first lay the abscess, outside the anus, open from end to end, and from behind forward /. e., in the direction from the coccyx to the perineum. I then introduce my forefinger into the abscess and break down any second- ary cavities or loculi, carrying my finger up the side of the rectum as far as the abscess goes, probably under the sphincter muscles, so that only one large sac remains; should there be burrowing outward, I make an incision into the buttock deeply, at right angles to the first. I then syringe out the cavity and carefully fill it with wool soaked in car- bolized oil, one part to ten or twelve ; this I leave in for a day or two, then take it out and examine the cavity, and dress again in the same manner, l3ut in addition I now use, if I think it necessary, one or more drainage tubes. In a FISTULA IN ANO. I9 remarkably short time these patients recover ; the sphincters have not been divided, and the patient therefore escapes the risk of incontinence of faeces or flatus which sometimes occurs when both the sphincters are deeply incised. I could cite numbers of cases of very unfavorable aspect, and in old persons, that have done quite well, treated as I have described. To give your patient the best possible chance of recovery, you must keep him on the sofa, if not in bed. I always think it advisable to clear out the bowels once, and then confine them by an astringent dose of opium for three days ; you thus secure entire rest to the parts, and give every opportu- nity for the cavity of the abscess to fill up. After a time the carbolized oil should be discarded and lotions used contain- ing nitrate of silver, copper, zinc, or friar's balsam, which last does great good. I find boracic acid ointment, not strong, or a solution of thymol, advantageous ; you must be pre- pared to ring the changes ; but one thing always remember, never stuff an abscess, but put wool in very lightly and use drainage tubes ; on the whole, I prefer the India rubber tube to any other contrivance, and have had the best results from it, as it gives rise to no pain, an advantage which cannot be claimed for either the wire tube or the horsehair. The questions naturally arise. Why do these abscesses usually fail to close up ? Why do they form sinuses ? There are doubtless several reasons, but the following may be suffi- cient. The mobility of the parts, caused by action of the bowels and movemant of the sphincter muscles, almost at every breath, and the presence of much loose areolar tissue and fat. The vessels also near the rectum are not well supported, and the viens have no valves ; there is therefore tendency to stasis, and this is inimical to rapid granulation. We know that abscesses are always apt to degenerate into sinuses when situated in any lax areolar tissue, as in the axilla, neck, or groin. After an abscess has long existed the discharge loses its purulent character ; it becomes watery ; the abscess has gradually contracted, and now only a sinus, very often formed of dense tissue, remains. If the sinus be laid open, you may observe that its interior resembles in appearance the inner coat of an artery, so glistening and smooth has it become. This was formerly called a pyogenic membrane ; it certainly secrets pus, but it is not a membrane. If now a probe be passed very tenderly into this sinus. 20 FISTULA IN ANO. allowing it to follow its own course, and after this is done, the finger be placed in the rectum, you will probably find that the probe has traversed the sinus, passed through an internal opening, and can be felt in the bowel. In this case you would have a typical, simple complete fistula ; and this is by far the most common variety, very few fistulae that have existed for more than three months being without an internal opening. Besides this common form there are two other descriptions of fistula, viz., the blind external fistula, and the blind inter- nal fistula. In the blind external fistula there is an external opening, and it is therefore called an external fistula, but no internal opening, hence "a blind external." In the other variety there is and internal opening, consequently it is an internal fistula, and there is no external opening, therefore it must be called a blind internal fistula. I have so often seen confusion in the use of these terms that I have been particular in describing them ; and consid- ered in the way I have put it, I think there can be no mis- conception. The blind internal form of fistula results usually from some injury to, or ulceration of, the lining membrane of the rectum, or abscess in the connective tissue beneath the mucous membrane, and is most commonly found in subjects who have consumption or who are predisposed to it. Now, these terms, " complete," " blind external," and ** blind internal," are useful, but suigically they are of little moment ; there is a very much more inportant divis- ion which affects the character of the fistula as regards its seriousness to the patient and also to the surgeon, I mean the division into anal fistula and pelvic or rectal fistula. An anal fistula is one which, commencing on the skin a few lines from the margin of the anus, opens just inside the orifice, passes at most under a few fibres of the external sphincter, and is trivial and can be rapidly and safely cured. By pelvic or rectal fistula I mean a fistula which, commenc- ing probably by an abscess in the ischio-rectal fossa, passes underneath both the spliincter muscles and opens possibly high up in the bowel, indeed, in the pelvis. This is the fistula which is dangerous lo the patient, and will call forth all the knowledge and experience of the surgeon to bring to a successful issue. My friend, Dr. David Molliere, of Lyons, in his exceedingly exhaustive and able work on " Diseases of the Rectum," makes practically the same division, calling FISTULA IN ANO. 21 the first " Fistules sous-tegumentaires," and the second *' Fistules sous-musculaires." We will now imagine that you have a fistulous patient before you. Proceed to examine him thus: Place him upon a hard couch, on the side upon which the disease is supposed to be situated, the buttocks being brought close to the edge of the couch, and the knees drawn up. Look at the anus and the surrounding parts carefully, to detect any visible malady. You may see the orifice of a sinus, or some dis- coloration of the skin may show you the site of the disease. Then feel gently all around the anus with the forefinger, and you will often, by the induration, detect the course and position of the sinus, which feels like a pipe beneath the skin. Having satisfied yourself in these respects, pass the probe into the external aperture; hold the probe with a very light hand, and let it almost find its own way. In many cases, as I have before said, it will pass right into the bowel; when the probe has been passed as far as it will go without using any force, introduce the forefinger of the left or right hand, whichever, according to the position of the patient, is most convenient, into the rectum; do not, as is often done, introduce your finger before the probe; if you do, you will excite contraction of the sphincter, and the sinus will be drawn up or contorted, and consequently the passage of the probe is obstructed. When the finger is in the bowel, if the probe has not come through the internal orifice, feel for the opening — an educated digit will nearly always detect it; and, having found the opening, you can with the other hand guide the probe toward it. The internal aperture is usually situated just within the anus, in the depression which exists between the external and internal sphincters. I do not say that it is by any means invariably so placed, but I am sure that this is its common situation; and one reason why the opening is not felt when the finger is inserted is because the search for it is made too high up the bowel. I think the reason the internal opening is situated so often in the position I have named, is this: The abscess forming, in most cases, just outside the anus, does not burrow deeply, but passes close under the external sphincter; it then is prevented from ascending higher up the bowel by the thick band of the internal sphincter, and consequently is turned inward, and makes its way through the lax areolar tissue, in the space between the two muscles. When the abscess 22 FISTULA IN ANO. really commences in the ischio-rectal fossa, it burrows deeply, and then most usually passes beneath the internal sphincter, and opens, if at all, high up in the rectum. Occasionally more than one internal opening exists, and I have now many times seen what the late Mr. Syme declared could not occur, viz., two internal openings in the same patient at the same time; at St. Mark's I recently treated a case in which there was an internal aperture at each side of the bowel. It is all-important that this internal aperture be felt with the finger (so that in operating it may be included in your incision), for not unfrequently, from the tortuous nature of the fistula, the probe cannot readily be got through it; this is markedly the case in the horse-shoe form of fistula, which is not uncommon. The sinus here runs round, generally dorsally, from one side of the anus to the other, so that the external and internal openings are placed on opposite sides of the bowel. This variety, if not properly diagnosed, is rarely cured by operation, the sinus being laid open on one side of the bowel, and left untouched on the other; this mistake may generally be avoided by a careful examination with the finger externally, as you can feel a hardness on both sider of the anus; the patient will also sometimes assist you by telling you that he has felt something like a " piece of wire " on both sides of the bowel. When you pass your finger into the bowel to search for the internal opening, never forget to carry it higher up, to see if the rectum be otherwise healthy; you may find stric- ture, ulceration, or malignant disease co-existent; without this precaution these conditions may be overlooked. A fistula may be a very trivial matter indeed, which you can operate upon in the out-patients' room, and send your patient home afterwards, or it may be a really serious affair, demanding extensive surgical interference. I have often seen a buttock so riddled with sinuses as to resemble a miniature rabbit-warren more than anything else. Fistula may exist for years without causing much pain or inconvenience to the patient. I have met with many persons who have had rectal sinuses for ten years and upward, and never had anything more done than the occasional passing of the probe when the external aperture got blocked up, and pain was caused by the formation and retention of matter. When the tissues c.round the sinus become very dense there may- be, for a long period, an arrest of burrowing, but FISTULA IN ANO. 2$ an attack of inflammation set up at any time will cause a fresh abscess. When seeking to determine whether you can safely leave a fistula for a time, the nature of the case is an import- ant element for consideration. The blind external hstula is the safest to leave. An internal fistula with a large internal opening, and the sinus running from it toward the anus, is sure to burrow, because, being funnel-shaped, with the larger end of the funnel upward, faeces readily pass into it and inflammation, much pain, and extension of the disease will certainly ensue. Usually it may be said the longer a fistula is left the more does it burrow, and the more difficult it is of cure; therefore I think it unwise to tell a person to have nothing done as long as he is not suffering — advice which I frequently hear is given to patients. I am often anxiously asked by sufferers if a fistula can be cured without an operation, or, as they say, " the use of the knife." To this I reply that I have seen all kinds of fistula get well, with and even without treatment, but these occur- rences are quite exceptions to the rule, and should not be depended upon; still, if the fistula be simple, and the patient be unwilling to submit to any operation, certain methods may fairly be tried. For the last few years, I have been successful, on many occasions, in curing blind external, and even complete fistulse, by means of carbolic acid and drainage tubes. This mode of treatment, if carried out with great care, and some perseverance, offers, in my opinion, the best chance for the patient. I find it is essential that the outer opening of the fistula should be much dilated before applying the acid or using tubes. The dilatation can be accomplished by keeping in a small portion of sea-tangle for a few days, or by a small sponge tent. When the opening is large enough, I clean out the sinus well, and then rapidly run down to the end of it a small piece of wool saturated in strong carbolic acid with ten per cent, of water. I mount the wool upon a stiff piece of wire set in a handle and just roughened at the free end. The wool can, with a little practice, be wound tightly on the end of the wire so as to be small enough to go right to the bottom of the sinus. I then withdraw the wire and put in a drainage tube just large enough to fill the sinus and keep it in; the interior of the sinus is, by the acid, induced to granulate, and if you are successful, you will find almost day by day, that a shorter drainage tube will be 24 FISTULA IN ANO. required until the whole sinus is filled up. It may be necessary to apply the acid more than once, and to use other stimulants, as Friar's balsam, solutions of sulphate of copper, or nitrate of silver, etc., but never strong injections; care should always be taken to keep the external opening well dilated. I had thought the heated galvanic wire passed to the bottom of a sinus would be very effectual, but many trials have convinced me that it cannot be relied on, and that it causes much pain. I have now seen many spontaneous cures of simple fis- tula, and have also seen an ordinary examination with a probe set up exactly the quantity of inflammation required to obliterate the sinus, and a good many of such results I have had opportunities of watching, and no return has taken place ; but, on the other hand, the bulk of the so-called spontaneous cures are illusory, and the disease returns in time, and even the same may be said of those in which treat- ment, short of division, has seemed effectual. In my opin- ion, there is nothing equal to the division of the fistula and getting it to fill up soundly from the bottom. I will relate a few cases of spontaneous cure, and also an example or so of cure by treatment, which have recently occurred in my practice. Spontaneous Cure of a Bli7id External Fistula. — ^Wm. B — , 3et. 49, a draper's assistant, admitted into St. Mark's August 30th, 1864. Had an abscess five months ago, by the side of the anus, which was opened, and ever since there has been a discharge from it; at times it is very sore and swells, then it breaks and discharges again, and he is quite comforta- ble. On examination a blind external fistula was found, the ori- fice being close to the external edge of the sphincter; the sinus ran up quite an inch, and did not approach near to the mucous membrane. I was quite sure, from a most careful examination, that no internal aperture existed. No treatment was adopted, as I intended to take him in when there was a vacant bed. He only had a little calomel ointment ordered, and a pill, to keep the bowels acting. In three weeks he told me the sinus had healed, and on exami- nation I found it to be so. Of course, I expected it to break out again October nth. It remains soundly healed, and the hard- ness is fast disappearing. December 20th. The fistula remains quite well; there is no evidence now of where it was, no mark of the original FISTULA IN ANO. 25 aperture, and no induration. My opinion is that the prob- ing in this case was just sufficient to set up granulation and rapid closure of the sinus. It did not return, I am sure, as the man would certainly have come to me, being so delighted with the result of what he considered my skillful treatment. Blind External Fistula j Spontaneous Cure. — J. C. — , aet. 46, a porter at the Tilbury Station; admitted into St. Mark's, May, 1867. Steady man; suffers from ague. Six months ago had a rectal abscess, which burst, and has con- tinued to discharge more or less up to the present time. A sinus was found running some distance up by the bowel, rather deeply situated, and not communicating, I wished to take him in, but he said he could not lay up yet. Ordered a mild aperient, and some zinc ointment. In a fortnight he came again, and said the fistula had healed. I examined him, and found it closed; moreover, it was not tender. June 7th. Again examined; found it still well; no pain; very little hardness; no discharge from the bowel; and I explored the rectum to see if it could have opened inter- nally, but this was not the case. July. Saw him again, and he was quite well, and has con- tinued so. I believe he has never had any return of this malady. Bli?zd External Fistula; Spontaneous Cure. — Jas. L. — , aet. 65, came to St. Mark's, July 5th, 1864. The external aperture was some distance from the anus; the sinus passed up beyond the external sphincter, and the probe could be felt rather nearer the mucous membrane. No particular treatment. The probe was passed again in about a fort- night after he was first seen. The sinus healed up while he was waiting his turn to come in. I kept him under observa- tion until the end of December, when, finding no return of the fistula, no pain, no discharge, no internal opening, no hardness in the old track of the sinus, I discharged him as cured. Complete Fistula in Ano ; Spontaneous Cure. — W. H. K. — set. 30, clerk, admitted into St. Mark's, April 2d, 1867. Not yery strong; habits regular. On examination a small but complete fistula was found on the right side of the anus, the external opening being quite an inch from it, the inter- nal aperture being in the usual place between the two sphinc- ters. In the middle of May I took him in as an in-door patient, and on going to operate I found the external orifice so firmly closed that I cauld not without unwarrantable 26 FISTULA IN ANO. force get a probe into it; I could feel the internal aperture very small. There was no pain, so I left him. Next week I asrain examined him, and found the internal orifice also closed. I kept him in the hospital another week, and still the fistula remained healed, so I put him upon the out- patient list, and he attended up to the end of August, when, finding the fistula still closed, and there being no pain and no induration, I discharged him as cured, requesting him to come again immediately on any return of pain or swelling. I have not seen him since. Most of the cases of fistula which I have tried to cure without an operation have occurred in private practice; the reason is, that time is generally a great consideration to the poor man; he does not mind a little pain; he wants to be cured as quickly as possible, and therefore prefers to be operated upon at once; in order to get well certainly and speedily. It is only the rich who can afford the luxury of three or four months' treatment, finding themselves perhaps, at the end of that time, in much the same condition as they were at its commencement. Altogether I find that I have had twenty- one successful cases, and a considerable number in which I have failed to effect a cure after a prolonged attempt, there- fore I cannot say the prospect is very encouraging, but patients who will not submit to the knife will often allow me to use the elastic ligature, and of that I shall have more to say presently. CASES CURED BY TREATMENT. A gentleman, set. 50, a free liver and very nervous, came to me with a blind external fistula on the right side, January 9th, 1875. I could hardly examine him, in consequence of his terror, so I ordered him some sedative ointment, and requested him to come again m three days. He was on his second vi&'t less timorous, and I made out that he had an anal fistula of the blind external kind. I advised division, first by knife, then by the elastic ligature, but he turned a deaf ear to all I could say. Cut or tied he would not be. The experience of Louis XIV was nothing to him, and he thought very disparagingly of an art which could do no bet- ter than cut people. He readily assented to my making trial of any treatment not very painful, so I dilated the opening with sponge tent, and then wiped the sinus thor- oughly with the carbolic acid. The pain was trivial, only slight'burning for a few minutes. After twenty-four hours FISTULA IN ANO. 2J I put in a small india-rubber drainage tube. He went about as usual, but the bowels I kept confined for six days. At the end of that time a copious enema of oil and gruel thor- oughly relieved him. The discharge from the fistula had been gradually diminishing, and the sinus was much less deep. All I now did was to keep the external opening wide by a piece of sponge, and in three months the sinus was quite healed. I have good reason to know that this case was a genuine success, A gentleman set. 40, robust, but wonderfully cowardly, came to see me on the 26th of June, 1875. ^^ examina- tion showed a small, blind external fistula. He had suffered from abscess near the rectum, which a gentleman opened for him nine months ago, and the pain he had gone through from that was such as to make him determine that nothing should persuade him to be cut again. I immediately pro- posed the elastic ligature, in which I assured him I had great confidence; but unfortunately he had, before seeing me, consulted a surgeon, who related to him an awful case he had experienced with the ligature, which did not come away for nine days, during which time the patient was in incessant pain. So he would have none of it. I dilated the external opening with the tangle, and then put in a drainage tube, but did not use carbolic acid or any strong applica- tion, as the patient feared pain. For some time this case did not do well, and I was on the point of giving it up, when I persuaded him to take an anaesthetic and allow me to dilate his sphincter muscles (which were very spasmodi- cally contracted), and apply the carbolic acid. He con- sented; and the result of this combined attack, and keeping him in bed a week, conquered the sinus, and it healed rapidly. I fancy this patient has remained well. A difficulty in these cases is to keep the external orifice very large without irritating too much ; and my friend Mr. Clover, with his usual ingenuity, effected that object wonder- fully well in a case I saw with him, by inserting a bone col- lar stud into the opening. When this was slipped in, it remained fixed, and the patient wore it and went about without complaining even of discomfort; since seeing this case I have tried the collar stud on many occasions, but have had a small hold drilled through from end to end, in order that no pus might be retained in the sinus, and it has ans- wered the purpose I desired, viz., to keep the external ori- fice large. 28 FISTULA AND THE TREATMENT BY ELASTIC LIGATURE. A lady came to me from the country, in the beginning of 1879, with a small abscess, which had been opened, and a sinus running up the bowel for quite an inch. She was most desirous to be cured, but would not have the knife, and feared the elastic ligature. I was able, after a little dilatation of the orifice, to get the bone stud in, and in ten days the sinus had healed. To give her every chance she kept her soia, and I confined the bowels for seven days. I saw this patient recently, and she kept quite well. Since the publication of my last edition I have cured many patients by dilatation of the sphincters and the use of the bone stud and carbolic acid. I do not think anything would be gained by relating more cases. One practical point I would mention. The further the external aperture is from the sphincter the more likelihood is that the sinus may heal. This is shown as well in the cases of spontane- ous cure as in my own successes. It. is very important, in these attempts, not to do any harm. You must always enjoin rest after a strong application, and watch that not too much inflammation be set up. CHAPTER IV. FISTULA AND THE TREATMENT BY ELASTIC LIGATURE. As I have been considering the treatment of fistula with- out cutting, I think before describing the usual methods of operating, I had better relate my experience of the use of the elastic ligature, describe its mode of application, and endea- vor to point out what really it can do and what it cannot be expected to do. And at once I will fully confess that when I read a paper before the Medical Society of London, in February, 1875, on the treatment of fistula and other sinuses by the elastic ligature, I anticipated a wider use for it than I have found. Still, I must assert that the ligature is most valuable in many cases, and frequently invaluable as an auxiliary to the knife. Professor ] >ittel, of Vienna, may certainly be called the apostle of the elastic ligature, but he was not the discoverer, as Mr Henry Lee and also Mr, Holthouse had previously FISTULA AND THE TREATMENT BY ELASTIC LIGATURE. 29 used it for the removal of naevi and in anal fistulas. When I read Professor Dittel's paper I came to the conclusion that the indian-rubber ligature might be found very useful in the brance of surgery to which I had paid special attention. I therefore determined to make a fair trial of it, and have now employed it in more than 150 varied cases. I can truly say I have over and over again been very glad that the utility of the elastic ligature had been brought forward by Profes- sor Dittel after it had quite fallen into oblivion. Ligatures of thread have been employed for a great many years, even, we may say, from the time of Ambrose Pare, for cutting through certain structures, mainly arteries ; but haemorrhoids, naevi, warty and pedunculated growths have constantly been removed by the application of a ligature, and the reason it has not been removed by the application of a ligature, and the reason it has not been more extensively available has arisen from the fact that only a comparatively limited thickness of tissue can be cut through by one appli- cation of the ligature, which, as suppuration takes place, becomes loose, and then does not penetrate further unless it be re-tightened; it is therefore only small and soft growths that can be safely and advantageously treated by the inelastic thread ligature. Various means have been devised to overcome this inherent defect, and make the thread ligature cut, by con- stantly Oi frequently tightening the thread; such means are shown in Ricord's instrument for the treatment of varicocele; Mr. Luke's double screw, which he invented for cutting through rectal fistulse which ran so high up the bowel as to be considered dangerous of division with the knife. A variety of methods, of which a spiral spring is the essential have also been employed, from a wooden spiral-spring letter- clip up to the very ingenious sarcotome of Dr. Ainslie Hollis. To all these methods, comparatively good as they may be, some very strong objections may be raised. From consider- able experience, I know that Mr. Luke's double screw, advantageous as it has proved, causea very intense pain; the daily or frequent necessity for tightening the ligature inflicts upon the patient a torture often unendurable, and on many occasions the knife has had to complete what the ligature began, the patient being unable to endure the long-continued suffering. Another very grave objection to the intermitting application of pressure is the frequency with which secondary 30 FISTULA AND THE TREATMENT BY ELASTIC LIGATURE. abscesses result. I have noticed this result in my own practice, and seen it also in that of other surgeons. Dr. Hollis's sarcotome is very superior to the others in action, but even this requires tightening or re-setting from time to time ; it acts likewise only in one direction, and therefore lacks the even, circular pressure exerted by the india-rubber. Another important objection is its size and weight, which render it under many conditions inapplicable. It must be evident, on reflection, that the pressure of the india-rubber band or loop is not always the same during all the progress of the cutting, in fact, it diminishes gradually as the loop of the ligature becomes less in circumference ; but practically the pressure up the moment of separation, if the loop be properly adjusted at first, is sufficient for its work. The greatest pressure exerted by a solid india-rubber liga- ture of the thickness of yV^b of an inch, stretched to the utmost, only equals 2^ lbs. weight; for example, 6 inches of india-rubber, when stretched to its utmost, /. e. 3 feet, exer- cises a power of 2^ lbs.; when stretched to 2 feet only a little more than i;^ lbs.; and when stretched only i foot, or double its length, -|- lb.; and even this power is quite suffi- cient, as shown by experiment, to pass through any ordinary tissue, in consequence of its unremitting and even pressure in every direction. I have for a long time now used only solid india-rubber, so strong that I cannot break it ; and I put it on as tightly as I can and fasten it by means of a small pewter clip pressed together by strong forceps. The ligature cuts through in about six days, z. e. that was the average time in ninety cases of fistula. The shortest time has been three days, and the longest fourteen days, and in the latter case a solid portion of flesh, three inches in length and two inches in thickness, was cut through without any tightening of the ligature. You may be assured that those who find a difficulty in getting the ligature to cut quickly and painlessly are ignorant of the proper method of applying it. What are the advantages of the ligature ? Briefly these, that in simple cases there is little or no pain inflicted by the operation ; the patient can walk about without danger. I have had many cases proving that nervous persons will often submit to the ligature when they will not to the knife. There is no bleeding — a manifest advantage in dealing with patients whose tissues bleed copiously on incision. I have found it FISTULA AND THE TREATMENT BY ELASTIC LIGATURE. 3I useful in several such cases. In phthisical cases it is, in my opinion^ the best means of dividing a sinus. In very deep bad fistulae the elastic ligature is most valuable as an auxil- iary to the knife. I now most frequently use it in this way, avoiding haemorrhage, in sinuses running high up the bowel, where large vessels are inevitably met with. I have recently had many examples of this, and have readily and painlessly divided vascular structures without any danger of bleeding. In an unusually bad case sent me by Dr. Wm. Price, of Mar- gate, a timid lady did not know the ligature had been used until it came away, on the seventh day, as she had absolutely suffered no pain worth complaining about, and certainly not more than when the knife is used alone. I have now oper- ated on eight medical men, and they all have told me that there had been no pain, and even very little discomfort, from the ligature, and it had been a great advantage to them, as they were able to get about in a moderate way and see their patients. One mistake committed by those who oppose the use of the ligature is this : they think the wound does not commence healing unt 1 the ligature has come away; nothing is further from the truth. When the ligature, if it has been well applied, has cut its way out, the wound is often very nearly healed. I beg to refer my readers to a monograph by Professor Courty, of Montpellier, in corroboration of my statement. This gentleman has used the elastic ligature fre- quently, and has been most successful. Now, what is the great objection to the general use of the ligature in fistula ? It is this. It is very difficult, or even impossible in many instances, to be absolutely sure that only one sinus exists. If there are lateral sinuses, or a sinus burrovv'ing beneath or higher up the rectum than the main trunk through which you pass your ligature, the patient will not get well at one operation. In these complicated cases the knife alone, or conjoined with the ligature, is the only trustworthy remedy. So it comes about that surgeons not very au fait in the diag- nosis of fistula soon get into trouble, and at once condemn and throw aside the ligature. I had employed the india-rubber ligature in only a very few cases before I came to the conclusion that if I intended operating frequently, or if ever the method were to become popular, other and better means than those recommended and used by Professor Dittel must be devised for the intro- duction of the ligature through the fistula. Professor Dittel has described several ways of accomplishing the end in view; 32 FISTULA AND THE TREATMENT BY ELASTIC LIGATURE. all of them appeared to be theoretically imperfect, and I found them in practice difficult of performance, tedious, and exceedingly painful to the patient. For complete fistula he Fig 3. used a probe with an eye near its point, which was to be passed from without to within, carrying the india-rubber and a strong thread, so that if the india-rubber •5 broke in tying, another ligature could be •| drawn by the thread through the sinus. rt Another method was to pass a tubular ■|j probe ; through the tube a fine wire was J to be introduced, and the end hooked ^ down by the finger passed into the bowel; J the probe was then to be withdrawn so 2 that the wire traversed the fistula, one ■-3 end hanging from the outer opening, the ^ other emerging from the anus ; the India- 's -rubber was then to be fastened to the ,s'i wire and drawn through the fistula. This ^ I was really a very difficult task to accom- •70 plish; sometimes the wire broke and the •£J probe had to be reintroduced, it was o-;^ therefore found better to attach to the = c wire a piece of strong, thin cord, and |J draw that through the probe, and then y> attach to it the india-rubber, which, in i its turn, was at last got into the desired ^ position. I need scarcely say that this ^ is a very lengthy, as well as painful, c mode of procedure, as the thin wire or ^ cord cuts the inner opening of the fistula. •| For cases of incomplete fistula Professor i Dittel recommends a director to be - passed as far as possible up the sinus, •0 and along the groove a sharp needle ^ armed with the india-rubber is to be carried and the bowel perforated, the ligature drawn from the eye of the needle by the finger, and the needle removed. This, I may remark, if the sinus runs far up the bowel, is by no means so simple of accomplishment as it may appear. Being, then, very dissatisfied with these methods of operating, I set myself to find some better and simpler plan, and on reflection I came to the conclusion FISTULA AND THE TREATMENT BY ELASTIC LIGATURE. 33 that the india-rubber could be drawn much more readily from within the rectum, through the internal opening (or through an anificial i^erforation in the bowel), than by com- mencing to pass it from the external opening. This con- viction led me to devise this simple instrument (which is shown in the wood-cut) for drawing a ligature through a fistulous sinus or beneath a tumor, and Messrs. Krohne and Sesemann have with much care and pains rendered it, in my opinion, practically, quite perfect. It consists, as will be seen, in the combination of a con- cealed hook or notch, with a blunt or sharp-pointed probe, as the case may require. A shows the curved probe with the hook concealed by the sliding canula, ready to be passed through a fistula, or, if a sharp point be substituted for a blunt one, under a tumor. B exhibits the instrument with the canula drawn back, and the previously concealed notch exposed ready to receive the loop of India-rubber; when this is placed in the notch, the canula is pushed home, and the ligature is held so firmly that it cannot escape. Thus a double ligature can be readily drawn through a fistula or beneath a tumor. It is not necessary, in fistula, to see the hook, for if the finger, with a loop of India-rubber around it, be passed up the rectum, the loop can, with perfect facility, and without the aid of vision, be directed over the end of the probe and caught in the notch. C shows the sharp-pointed instrument adapted to the same canula, so that only one handle and one canula are required to com- plete the double instrument. It is obvious that with my instrument a double ligature is carried through the sinus; this is an advantage, for if the india-rubber breaks as it is being tied, there is a second ligature to fall back upon. I ceased, however, to use the knot very soon after making trial of the ligature, and I now use only a small oval ring of soft metal; the two ends of the ligature are threaded through this, the india-rubber is pulled as tight as is required, and the metal ring is then closed by a strong pair of forceps. The ring holds perfectly tight, it never breaks the ligature, never gives way> and the closure is effected in a moment. 34 OPERATIONS ON FISTULA IN ANO. CHAPTER V. OPERATIONS ON FISTULA IN ANO. Before proceeding to operate upon a case of fistula, it is highly important that the bowels should be well cleared out, and I preter, whenever possible, to administer a purge three days prior to operating, and again the night before; an injection may also be given in the morning. The patient should be placed on a hard mattress, on the side on which the fistula exists, the buttocks being brought quite to the edge, or rather overhanging the edge of the couch, and the knees well drawn up to the abdomen. I have no hesitation in saying that, for the majority of rectal oper- ations, this position is by far the most convenient, both for the surgeon and the patient, but occasionally the litho- tomy posture is preferable, as, for example, in performing excision of the rectum. Now, take a Brodie's probe direc- tor, made of steel, with a small probe point; oil it and pass it into the external opening, through the sinus and the internal opening, if possible; then insert your finger into the rectum, and on feeling the point of the director in the bowel, if the patient be not anaesthetized, tell him to strain down; yon will then be able, without any difficulty, to turn the point out of the anus. Tins done, the tissues forming a bridge over the director are to be divided with a curved bistoury. If the fistula be deep, running beneath the sphincters, you will not be able to get the point of the probe out at the anus, even if the patient be anaesthetized; in such a case you must pass the director well through the sinus, then insert your left forefinger into the rectum, steady the director, and run a straight knife along the groove, catting carefully toward the bowel until the parts are severed. This is by no means an easy operation, and requires much prac- tice and experience to accomplish quickly and without bungling. To the inexpert surgeon, in such a case, I recom- mend my deeply grooved director and scissors, which I shall describe furthtr on ; I may add that gentle dilatation of the sphincters, under these difficulties, gives the surgeon an immense advantage, of which I now constantly avail myself. If there be no interrial opening, you will almost alw^ays OPERATIONS ON FISTULA IN ANO. 35 find some part where only mucous membrane intervenes between the point of the probe and your finger. At this spot work the director through, and bring down the point as before. You must not rashly thrust the point of the probe through the mucous membrane, or you will wound your own finger; this accident may always be avoided by a little gentle and patient manipulation, even when the tissues are indur- ated. When you have divided the fistula from the external to the internal opening, search higher with the probe for any sinus running up beyond the internal opening; if this exists you should lay it open. I know many authorities have stated that it is only neces- sary to incise the fistula between its external and internal openings, and that the sinus above the internal opening will spontaneously close; my experience is most decidedly opposed to this statement. In the great majority of cases you will not cure your patient unless you lay the whole sinus open, from end to end. Over and over again I have left the sinus above the internal opening uninterfered with, and almost invariably have had to regret having done so, and to perform a second operation. It constantly occurs to me, at St. Mark's, to treat cases which have been operated on at other hospitals, the upper part of the sinus having been left and the patient not being cured. In such cases fresh or continued burrowing takes place from the upper track, and a second operation, often more severe than the first, is rendered necessary. It needs scarcely be said that in private practice this is very damagmg to the surgeon's reputation. Having, then, opened the fistula in its whole length upward, search for lateral sinuses extending from the outer opening; also see if there be any burrowing outward beyond the outer opening. A fistulous orifice is only not at either end of the sinus, but somewhere in its course. Examine carefully to see if there be a secondary sinus running from and beneath the track of the main sinus. Frequently, in fact nearly always, in old standing cases, the deeper sinus does exist, and unless it is incised with the rest the patient will not get well. Here, again, some surgeons have asserted that it is unnec- essary to divide any but the principal sinus, for that if this is done the rest will heal. On this point I cannot speak too strongly. I am certain you can never guarantee the healing of a fistula so long as any lateral or deep sinuses 36 OPERATIONS ON FISTULA IN ANO. remain; and so long as they do remain fresh sinuses are apt to form. As a rule, the best plan is to lay open the original sinus first and the tributary ones afterwards. It is impossible, in any work, to do more than lay down general rules; every case will call more or less upon the surgeon's knowledge, dexterity, and prudence; but in thus strongly expressing my opinion, contrary to the dicta of many eminent men, I can only say that I am stating what I see almost every day to be the truth. When all the sinuses are slit up, with a pair of scissors take off a portion of the overlapping edges of skin; they are often thin and livid, having very little vitality. If not removed, they will fall down into the wound and materially retard the healing process. I have frequently induced healing in a fistulous track which had been only laid open, by paring off the edges of the skin which were undermined. It must be observed that I am not advocating ''the cutting out of a fistula," as it used to be called; I am only recom- mending the removal of any overhanging, undermined, degenerate skin. When several sinuses have to be laid open, I am in the habit of carefully preserving islets of skin from the edges of which granulations will take place, and by which cicatrization is materially hastened. Indeed, I have in many cases practiced skin-grafting with good results, though fail- ures have not been infrequent. In old-standing cases, where there is much induration, it is very good practice to draw a straight knife through the dense track of the fistula, and out- ward beyond the external opening; it is wonderful how rap- idly quite cartilaginous hardness passes away after this has been done. This incision was commonly practiced by the late Mr. Salmon. He called it his "back cut," and although if carried to excess incontinence of faeces may result, I have no hesitation in saying that Mr. Salmon cured many cases by this means where other surgeons had failed. Having completed your operation, take some finely carded cotton wool, and with a probe pack it well into the bottom of the wound, packing it into every part, and being the more particular about this if your incisions have been extensive, or pass high up the bowel, or if the parts are very dense and gristly, as they are in old fistulae, and especially in cases operated upon for the second time. A good, firm pad of wool should then be placed between the buttocks, over the wounds, and a T-bandage firmly applied. With these pre- cautions you need never fear haemorrhage, for if the bleed- OPERATIONS ON FISTULA IN ANO. 37 Fig. 4. ing be thus arrested by pressure at first all will be well; if, however, the wool be carelessly stuffed into the bowel without method, it will not be placed evenly at the bottom of the wound, and then, as soon as the patient rallies from the shock of the operation bleeding will recommence, and both patient and surgeon will be put to much annoyance, and probably some anxiety. Of course, if you see a large vessel spurting at the bot- tom of a wound it is best to close it by torsion ; when, however, the track of the fistula is very callous you cannot twist the vessel, and a ligature may then be ap- plied. By careful atten- tion to the details above given, a sinus may be open- ed to any possible distance up the bowel, or in any direction or depth, without positive danger, but on the whole, for very deep, bad fistulae, the elastic ligature is, as I have before said, generally to be preferred. If the rectal sinus runs up so high and the parts are so dense that you can- not get the point of your probe-director out of the anus, and you prefer to cut, the safest and easiest way It should be observed that the scissors can ^f operating is with the only be removed from the groove by drawing 10 ^ '-'^^^ them out towards the handle of the director. At the side is shown the strong spring scissors sed. at St. Mark's Hospital in the operation upon internal hemorrhoids. and first made by Ferguson, of Giltspur street, London; with this instrument you can divide fistulae high up the bowel, however dense they may be, with great facility and quickness. The director is made with a deep groove, the section of which is more than three-quarters of a circle; in this the globe-shaped probe- point of one blade of the scissors runs. Once placed in the groove it cannot slip out; so, having passed your director Spring Scissors, with Probe Point in the Grooved Director. spring-scissors and special spring scissors j* _4. j • 11 used at St. Mark's Hospital in" the operation QireCtOr, designed by me 38" OPERATIONS ON FISTULA IN ANO. through the sinus, you introduce the fore-finger of your left hand into the bowel, then insert the probe-pointed blade of the scissors into the groove in the director, and run it along, cutting as you go, the finger in the bowel preventing the healthy structures from being wounded. By this instrument operations usually very difficult, and in which, without great caution, you are apt to break your knife, are rendered quite simple. A country hospital surgeon told me that after see- ing my description of this instrument he procured one, and uses it in all his cases of fistula; he says it is " operating made easy." I have not said a word about the old method of operating, usually described in works on surgery, because I consider the mode I have detailed so much more satisfac- tory and practicable. It was in cases of sinuses running high up in the rectum, or where stricture existed in conjunction with fistula (the internal aperture being above the stricture) that Mr. Luke, in the year 1845, recommended cutting through the diseased structures by means of a fine piece of strong twine and a screw-tourniquet. It is an operation by no means easy of performance, but this is the way in which it is done, and it was, no doubt, very useful in some cases. Introduce a hollow probe through the sinus and into the bowel, then pass a piece of thin wire through it, hook the end down, and bring it out at the anus; then withdraw your probe, fasten the twine to one end of the wire, and draw on the other end By this means you get the twine to traverse the smus, one end coming out at the anus and the other at the external opening of the fistula. Attach the twine now to your tourniquet, and screw up a little every day or two. In this way you may cut through very dense structures without any great danger; but the method is often painful, and is apt to cause inflammation, suppuration, and fresh abscesses. I have noticed these results in my own practice, and also in that of my colleagues. But in all these cases the elastic ligature is so very superior, being more easily applied, quicker in action, and absolutely painless, that I cannot conceive of anyone using Mr. Luke's tourniquet now. When the fistula is complete, wind may pass through it, and also faeces, if the bowels are relaxed; as a rule, however, this symptom does not occur, in consequence of the small- ness of the internal aperture, its situation, or its valvular form. It follows ihat, though the passage of wind is a cer- tain indication of a complete fistula, the absence of this OPERATIONS ON FISTULA IN ANO. 39 symptom should not induce the belief that there is no inter- nal opening. The most painful form of fistula, at the same time, for- tunately, the most uncommon, is the blind internal fistula. I have seen many cases where the aperture was as large in circumference as a threepenny-piece; the faeces, when liquid, pass into the sinus and create great suffering — a burning pain often lasting all day after the bowels have acted. Moreover, these fistulse are frequently severe, m consequence of the burrowing caused by the irritating matters which get into them. In operating upon a blind internal fistula, if you can feel, by the hardness externally, the site of the abscess, you may plunge your knife into it, and thus make a complete fistula, through which, of course, you pass your director. If you cannot feel any hardness or see any discoloration to guide you to the situation of the sac of the abscess, the best w^ay of proceeding is to bend a silver probe-director into the form of a hook, and then hook this into the internal aperture, and bring the |)oint down close under the skin; you then cut upon it, thrust it through, and complete the operation. This re(|uires a little dexterity and some practice to man- age well, but it is by far the surest way of hitting off the sinus. These cases of blind internal fistula are very often not understood, and consequently are mistaken for other diseases. Not infrequently an internal fi.->tiila is connected with haemorrhoids. I have seen many such cases. I think when strong applications are made to haemorrhoids, suppura- tion may be set up, and then an internal fistula may form. Here is a case, probably, of that kind : — A gentleman came to me this year having great pain in the rectum on and after defecation, generally worse after; sometimes coming on half an hour after leaving the closet. His history was that he had suffered from haemorrhoids, which came down and bled, and that about seven weeks before seeing me he had undergone an operation for the cure of the piles. The operation consisted in thrusting a cautery iron into all the piles; great pain followed, and he kept his couch for fourteen days, when he began to feel better, and his piles did not come down, but there was discharge of matter. He was told that now all was right, and in a few days he might go about as usual, but after another week he still had pain on and after stool, and lost blood. He went into the coun- try, but, not getting well, at last sought my advice. On 40 OPERATIONS ON FISTULA IN ANO. passing my finger into the rectum, T found a large, deep ulcer, and a sinus running from it upward and downward; the piles which still existed were angry and tender, and very ready to bleed. As nothing but an operation could cure him, I slit up the sinuses, drew a straight knife through the bottom of the ulcer, bringing it right out so as to divide the sphincter freely. I also placed two fine ligatures around the haemorrhoids. He had no bad symptom, remarkably little pain, and was quite well in five weeks. In this case, the thrusting of a fine cautery set up suppuration, and caused an abscess, which, bursting, made a great ulcer, and which ulcer formed the internal opening to the sinuses. These cases of blind mternal fistula are instructive; I will therefore relate another: — I saw, with my late friend, Mr. T. Carr Jackson, a profes- sional brother who had been suffering for some time from pain on defecation, and burning afterwards, with discharge of matter always upon the motions; he was also much trou- bled with his water, having considerable irritation of the bladder. He had been operated upon, but without getting any better; there was no ulceration, nor was there any fissure. On examining this gentleman I at once found what I expected, a small internal aperture about two inches from the anus; from this a sinus ran upward and downward. The anus (with its outside surroundings) was perfectly healthy. Mr. Jackson, assisted by me, at once slit up the sinuses, and the patient was rapidly and permanently cured; all his blad- der symptoms likewise vanished. These cases of internal fistula require very careful exam- ination to make a correct diagnosis. Often the surgeon finds an ulcer, but does not attempt to pass a probe into it. Truly it is an ulcer, but in addition it is the opening of an internal fistula, which may burrow in more than one direc- tion. Operations upon internal fistula also require more than ordinary care. If you find an internal opening in the bowel, and a sinus running up higher from it, never lay the sinus open simply; in the first place, if you do, you are very likely, after you leave yoar patient, as you think, quite safe, to have some haemorrhage take place, and the blood will be retained in the rectum until so much has accumulated that the patient must pass it. In such a case always bring your incision out through the anus, that no blood may be retained. Blood retained iii the hot rectum foments the part, and pre- vents coagulation and closing of the vessels, which are fre- OPERATIONS ON FISTULA IN ANO. 4I quently large and increased in calibre by the long-continued inflammation of the part. Again, if you divide an internal sinus, you make a deep cavity whence pus or discharge can- not thoroughly escape, and in consequence the wound will not heal. Whenever you have to make an incision through the mucous membrane and into the submucous tissue in the rectum, without continuing your cut to the outer parts, beware of haemorrhage. Plug the rectum well and use a styptic, either the subsulphate of iron or a saturated solution of tannin. I have seen one death from this form of haemorrhage occur in the hands of a very good surgeon, and another case recently, during very hot weather, in which a patient most narrowly escaped with his life, from a like want of care. Internal fistula, as I have already said, may commence by an ulceration of the mucous membrane; or perhaps more rarely, by a small abscess forming in the submucous areolar tissue; this may be the result of wounding or bruising by hardened faeces or foreign bodies swallowed. Of this I will mention two excellent examples I have seen, one in the practice of Dr. Cottew, of Hornsey, and the other in that of Mr. Kelson Wright, Of Brixton. Here two ladies com- plained of considerable pain in the rectum. On examina- tion in each case a rounded, hard swelling was felt, about an inch from the verge of the anus. On more carefully invest- igating, a very small orifice was found running into this swelling. In both instances foreign bodies, i. e., fish bones, had been felt by the medical attendants before I saw the patients. I am decidedly of opinion that when internal fistula com- mences by ulceration it is most frequently found associated with phthisis. I shall not go into this important question here, intending to devote the next chapter to the special consideration of this subject. In operating upon women suffering from fistulae (espe- cially when the sinus is near the perineum), cut as little as possible, for anything like too free incisions are apt to end in incontinence of faeces, or, at all events, in such partial loss of power in the sphincter, as to prevent the patient retaining flatus, a result which, I need scarcely say, is a most disagree- able one. I have been several times consulted by ladies on account of this condition, and in some cases 1 have been suc- cessful in restoring the lost power, much to my patient's sat- 42 OPERATIONS ON FISTULA IN ANO. isfaction. Of very great importance is the question of incontinence of faeces, w.liich may result from extensive ope- rations on the rectum, where the sphincter muscles are freely divided. A patient who suffers from inability to retain flatus or faeces is in a most unpleasant condition; in fact, some sensitive persons would not undergo any operation which was at all likely to induce such a state, and would prefer any physical suffering rather than the perpetual fear of being in any way offensive to others. It behooves us, then, to con- sider how much we dare do without danger of damaging or destroying the power of the muscles at the outer end of the rectum. Should you feel doubtful about the preservation of this power, you are bound to tell your patient what may hap- pen, and then place the good and evil before him; if you fail to do this, and the patient recovers, with much loss of the power of retention, he is justified in complaining of your treatment. Incontinence of wind or liquid faeces results almost always from cutting the muscles, and principally the internal sphincter in more than one place. If you have a double fistula, /. ' dilate the sphinctei muscles, and employ a retractor to keep the anus well oper I then seize the pile deeply by its base, cut it off above the level of the volsel- lum, and do not let it go until all bleeding is arrested by torsion of the arteries; rarely more than two vessels spout and require twisting. I wiait for a little while to see that all bleeding has ceased, and then I treat the other piles in a similar manner. After all the arteries have ceased to bleed, I place a piece of cotton wadding, previously saturated in a solution of tannin and water (strength, one ounce of tannin to one ounce of water), within the anus, as higH as my scis- sors have cut. In no case did any recurrent haemorrhage take place. This operation must be done slowly and care- fully, and therefore occupies more than the usual time, which, however, is of no moment, as the patient is insensi- ble. As far as my present experience can lead me to judge, I am of opinion that numerous cases are amenable to this treatment. The single perineal hasmorrhoid, so frequently found in women, is peculiarly well suited to this operation. I have used several times the ingenious toothed scissors of Dr. Ric^iardson, but I do not like them. The theory upon which they have been constructed is excellent, but the prac- tice is bad, the haemorrhage is not always controlled, and often very nasty, irritable wounds result. II. THE CHAIN OR WIRE ECRASEUR. I really do not know any sufficient reason for the contin- ued, practice of this mode of operating on piles. I have called it " barbarous and unsurgical," and I cannot see why r should modify that expression. The chain is undoubtedly Of>ERATlONS UPON INTERaAL HAEMORRHOIDS. 87 worse than the wire, but neither is definite in its action; they remove either too much or too Uttle. Thus I . have seen several cases of most intractable stricture follow, and, on the other hand, cases in which nothing curative had resulted, a timid operator taking away only two or three portions of mucous membrane, and really leaving the haemorrhoids almost untouched. A Brazilian gentlemen was sent to me eight weeks after he had been operated on by a distinguished French surgeon with the ecraseur; the hemorrhoids still existed in abundance, and he was losing much blood. I have seen at least half a dozen such failures. A metropolitan surgeon of eminence told me he had obtained success with ecraseur, but upon interrogation his idea of success did not come up to my notion of the word. Another objection to ecraseur in haemorrhoids is the intense and prolonged pain which follows, especially when skin is removed. An Italian surgeon related to me a case where death ensued in a woman from shock and pain in less than twenty-four hours, and I can quite credit his statement. I once saw a woman die in St. Thomas' Hospital, from the same cause, after an opera- tion by ligature applied in the old way, I mean by trans- fixion and ligature or skin as well as haemorrhoids. The patient was operated upon by Mr. Simon on the 19th of November, 1859. She was a pale, feeble woman^ aet. 53; she died on the morning of tne next day; she had suffered intensely. I have no note of what was d.one to relieve the pain. The post-mortem examination, made by Dr. Sydney Jones on the 21st, was as follows: — " Some piles had been the subject of operation by liga- ture; the ligatures were present. Nothing abnormal was detected in the veins leading from the ligatured piles. The thoracic viscera were healthy. There was some congestion of the posterior part of the lungs. The liver was rather large and pale. The kidneys were healthy. The perito- neum and intestines were quite healthy." I do not think the death in this case could be attributed to anything but shock and exhaustion from excessive pain. III. THE APPLICATION OF VARIOUS ACIDS AND CAUSTIC PASTES. The treatment of haemorrhoids by acids or caustics may scarcely seem to justify the use of the term " operation," but as some manual dexterity is necessary in order to apply them properly, I must beg permission of my readers to allude to 88 OPERATIONS UPON INTERNAL HEMORRHOIDS. them here. For many years acids have been used in attempts either to destroy or cause such consolidation in piles as should lead to their cure. The acids chiefly used have been the fuming nitric acid, the acid nitrite of mur- cury, chromic; and more recently carbolic acid. It was thought at one time that even large piles could be destroyed by acids, and many cures were published, but I very much doubt if any lasting cures of developed haemorrhoids were affected by such means. I have seen numbers of cases in which the attempt was made, but the patients were either not relieved at all, or only very temporarily benefited. Haemorrhage was often arrested, but it generally recurred, and on many occasions, after the free use of acid, violent bleeding took place on the separation of the sloughs, and patients were brought nearly to death's door. If the appli- cation of acids were restricted to cases of small granular piles, or patches .of villous, bleeding, mucous membrane, I should not object to their use, as often patients will submit to such treatment when they will not to anything more for- midable, and relief and even cure in this stage of disease may be obtained; but no satisfaction can result from touching large haemorrhoids with any acid known to me. A few years ago I had an opportunity of testing all the acids I have men- tioned, in the case of an old Indian general, who had three prolapsed arterial haemorrhoids of vascular surface and con- siderable size. His shattered health, with partial paralysis, forbade any serious operation, and he was unwilling that more than external applications should be made. For three months I persevered; I managed not to cause him much pain, though the diseased mucous surfaces were painted freely and frequently. The method in which I applied the acids I will mention, as I think it a good way to avoid pain. The piles being fully prolapsed (he could strain them down easily), I surrounded one with a piece of wool soaked in a saturated solution of bicarbonate of soda; the surface of the pile was then dried, and the acid applied with a small wooden brush several times, waiting between the applications for the part to dry. Each pile being thus treated the parts were washed, well oiled, and returned within the sphincters. On one or two occasions troublesome bleeding followed the separation of a slough, but usually it came away in small portions; by this mode of using the acids I never caused any burning of skin or healthy structure. At times the patient thought himself better, but the final result was a failure. OPERATIONS UPON INTERNAL HEMORRHOIDS. , 89 I came to the conclusion that the chromic and carboHc acids were better agents than nitric acid and acid nitrate of mercury. Still more recently I had a good trial with acids on a gentleman who one haemorrhoid placed anteriorly, which was always prolapsed, and consequently bled, and gave him much annoyance, but no great pain. I really expected to obtain a fair result here but all failed. My friend, Dr. B. W. Richardson, had recommended me to try the application of his " Iodized Colloid" as a remedy in internal haemor- rhoids; he told me the resulting pain would be considerable, but that a dozen touches would generally suffice for the cure. I made trial of this in the above case, but the pain experi- enced was so great that my patient became restive and refused to persevere; while in that humor I suddenly pro- posed to excise the offending pile; he consented; I at once removed it, twisted the vessels, and he was quite well in a few days. Caustic Pastes. — Personally I have had no experience in this practice as applied to haemorrhoids, but in France and Germany it has been freely recommended; to my mind the uncertainty of the result, added to the great pain inflicted by caustics, is sufficient to deter me from using them. Caustic pastes are mostly formed by adding an inert material to some chlorides, zinc, calcium, etc. Ricord's paste (sulphuric acid and carbon) is a favorite with some surgeons. Dr. Laroyenne of Paris, in the Gazette Hebdojnadaire de Me'decine, No. 34, 1872, passes in review the usual methods of treating bleeding internal piles, and considers them all to have many objectionable features and dangers, and recom- mends, as Bonnet and Valette have done, the use of Vienna paste and chloride of zinc; but instead of applying the caus- tic all over the pile, he uses it in the following manner: When the partis prolapsed several lines are drawn along the surface of each haemorrhoid with Vienna paste, the lines con- verging towards the orifice of the anus. After two or three minutes the application is followed by placing small frag- ments of chloride of zinc paste where the Vienna paste has been. Eight or ten caustic lines are sufficient to cure the largest prolapse. In this manner deep radiating cauteriz-a- tions are produced without destroying much of the surface of the piles. The application remains for seven or eight hours. The only painful period, -says Dr. Laroyenne, is dur- ing the application of the Vienna paste. He has employed 90 OPERATIONS UPON INTERNAL HAEMORRHOIDS. this method fourteen times without the sHghtest ill effects resulting, all the patients being cured, and he believes the treatment to be less often followed by haemorrhage, pyaemia, and other accidents, than any other. I am sorry I cannot concur with Dr. Laroyenne, and submit that his experience is far too small to justify his belief. IV. THE INJECTION OF CARBOLIC ACID OR OTHER FLUIDS INTO THE SUBSTANCE OF THE PILE. I have read in American pamphlets, that the injection of carbolic acid into internal piles, for the purpose of effecting radical cures is very commonly practiced in America and that "shoals of quacks" perambulate the country, armed with a hyperdermic syringe, and a bottle containing a so-called secret remedy, this remedy being carbolic acid diluted in dif- ferent ways and of different strength; the favorite formula is equal parts of strong carbolic acid, glycerine and water. This treatment is strongly advocated by Dr. Cook, of the Ken- tucky School of Medicine, who obligingly sent me his essay upon the subject. I most sincerely hope he is in error as to the " shoals of quack" who employ this remedy ; but if radi- cal cures are affected, and no evil results, the only objec- tion I can see is that the legitimate practitioner loses his fees. After carefully reading Dr. Cook's pamphlet I did not feel quite satisfied that he had made out a good case for the car- bolic acid treatment ; in fact he only relates the histories of two persons on whom he had performed injection ; he gen- erally uses the formula I have mentioned, and squirts through a large needle ten to twenty drops of the solution into the substance of the pile; he does not inject all the haemorrhoids at once, but one or two at a time every other day until all are done. Many American surgeons who came to see the practice at St. Mark's have repudiated the treatment in round terms, and call it uncertain and dangerous. Dr. Matthews, of Louisville, has kindly sent me his pamphlet, read before the Kentucky State Medical Society in 1878, and in that paper he endeavors to show that the injection of the acid into a pile is painful and inefficient and that death is to be feared {a) from peritonitis, (3) from embolism, {c) from pyaemia. In support of his assertion he relates a case under the care of another i:)ractitioner, where in twelve hours vio- lent inflammation followed, b'lt the piles were not cured, for in twenty days after the injection one tumor had to be OPERATIONS UPON INTERNAL HAEMORRHOIDS. 9I removed by ligature. He also cites another case of periton- eal inflammation, and says embolism and pyaemia have been known to result from injecting nsevi with solution of iron, and death have occurred from injecting inter- nal haemorrhoids with carbolic acid. For my own part I am much inclined to agree with the opinion of Dr. Matthews. I tried the injecting plan on some few cases, but the 'result was much pain, more inflam- mation than was desirable, a lengthy treatment, and the result doubtful ; certainly not a radical cure. It appears to me that all attempts to destroy vascular growths by causing coagulation of blood or inflammation in them, while they are not shut off from the general circula- tion, must be fraught with danger. You can have no guaran- tee that the coagulum may not break down, and minute par- ticles of dead tissue find their way into the vascular or lym- phatic system and result in embolism or pyaemia, or both. Perchloride and persulphate of iron in solution have been used in the same manner as carbolic acid, but a similar risk is connected with them, and this, I submit, far outweighs the advantages they are said to offer. V. CAUTERIZATION " PONCTUEE." As far as I can ascertain, M. Demarquay, in the year 1868, practiced and strongly advocated the use of a red-hot cautery as a cure for internal haemorrhoids; the iron was to be thrust deeply into the pile twice or thrice; he had not much success. I have been informed by several friends in military and civil practice that the native doctors in China and some parts of India treat haemorrhoids according to the plan of M. Demarquay, and possibly have done so for hun- dreds of years. My informants have not been able to satisfy me as to the results of the treatment, only my friend. Dr. Beaumont, said " he thought that many died." In 1873 Enoch Bottini, of Novare, published a thesis entitled "La galvanico caustico nella practica Chirurgica." I make the following extract on haemorrhoids: "The opera- tor provided himself with a galvanic cautery heated to a fine red, applies the point of it to the haemorrhoidal tumor, and introduces it slowly and progressively to a depth varying from ten to fifteen millimetres. When the point of fire has arrived in the interior of the tumor he moves it around allows it to remain for a few seconds, and then rotates as it is withdrawn ; he repeats the treatment in the 92 OPERATIONS UPON INTERNAL HEMORRHOIDS. same manner and with equal precautions to all the piles. If the tumors are extensive he again introduces the cautery parallel to the rectum." A case of pyaemia following this operation is related in full detail by Verneuil. A similar operation was performed in 1873 by E. Lartisen, a pupil of Verneuil. Mr. Reeves of the Hospital for Diseases of Women has brought this method forward in an article in the La7icet of Feb., 1877. He calls it " imme- diate" and " new ;" the one is just as correct a definition as the other. Wishing to see whether the conical cautery attached to the '' Paquelin" instrument was better than the hot iron of Demarquay or the Chinese, within a fortnight of the appearance of Mr. Reeves' paper I used it in three cases. One was a patient of Dr. Hills, of Abbey Road, St. John's Wood, another was a case which I left to the late Mr. Ernest Carr Jackson, seeing him only twice or so myself, and the third was a hospital patient. I am bound to say that although Meyer & !Meltzer made my cautery, and I rigidly followed Mr. Reeves' directions, these cases were all failures great pain, retarded recovery, and abscesses occur- red in two; in one a cure did not result. I was only pleased nothing worse happened as the same objection applies to this mode of treatment as I brought against the use of injections of acids into piles, viz., you produce a slough or inflammation, the extent of which you cannot measure or control in the interior of a vascular tumor not cut off from the general circulation. VI. CAUTERIZATION, " LINEAR," OF WOILLEMIER. The operation of Woillemier, I think, is "unique," and I feel I cannot do better than translate from V U?iion Medicate (1874) such portions of his lecture as shall make his method quite clear to my reader. I must express my pleasure at the straightforward manner in which M. Woillemier describes the advantages and disad- vantages of his operation. He does not hesitate to say that the patient may be one month in getting w^ell, he states that in very bad cases two operations may be necessary, and fur- ther considers the dangers which may arise. '' The patient, whose rectum has been emptied in the morning, by means of an injection, ought to be chloroformed; but if he prefer to remain awake, it is of little importance, as the operation lasts only some seconds. He is laid on an edge of the bed, with one leg extended, and the other bent OPERATIONS UPON INTERNAL HAEMORRHOIDS. 93 as if he were going to be operated on for a fistula. The assistant raises the disengaged buttock, the surgeon paints the anus and the surrounding parts freely with collodion, while another assistant, by means of bellows, drives off the fumes of the ether, which are sure to catch fire when a highly heated cauterizer is brought near them. During these pre- parations, two knife-shaped cauterizers have been placed in a small furnace, full of charcoal or burning wood. The blades of these cauterizers should be two centimetres long and one wide; the tip and edge should be blunt, as in ordinary cauterizers, but the back should be four or five millimetres thick, so as to hold enough heat. The surgeon takes one of these cauterizers, when it is white hot, and introduces it about one centimetre into the anus, bearing with the shoulder of the instrument rather more on the cutaneous than on the mucous orifice, and makes four cauterization lines, before, behind, on the right, and on the left. The operation is terminated when it has lasted five or six seconds. The patient is brought back to consciousness, and simple water dressings only are applied to the anus. We must premise that, under the influence of the congestion produced by cauterization, the hsemorrhoidal' tumor will reappear the first day or so, and may sometimes be larger than usual, but no notice need be taken of it. We can relieve the pain of the patient, pain which has no relation to the cauterization, only by coating over the hsemorrhoids with a narcotic ointment, and covering them up with a poultice. The tumor soon ceases to be painful, aud is at last com- pletely and spontaneously retracted. The time necessary for cure varies only according to the size of the haemorrhoids, the relaxation of the anus, and the age of the patient. It has never exceeded one month, and has sometimes been much less. In some subjects, even when circumstances have made success doubtful, cure has taken place as in simple cases. The patient ought to be chloroformed, par- ticularly in private practice, where the assistance is less efficient than in a hospital, for though the operation is rapid it is also very painful. The patient may struggle after one or two applications' of the cautery, and even refuse to allow others to be made, so that the operation would remain incomplete. The orifice of the anus and the surrounding parts must be painted with collodion. This is a very impor- tant precaution. All surgeons have affirmed the difficulty of preventing the effects of radiated heat. To preserve the 94 OPERATIONS UPON INTERNAL HAEMORRHOIDS. parts from these effects, cloths steeped in cold water, and thin plates of wood, have been used; but not only are these in the operator's way, but they are, as a rule, inefficacious. Collodion, on the contrary, even when applied in a thin layer only, forms an artificial epidermis scarcely permeable to heat and sufficiently protecting the skin. " It is necessary to dissipate the ether vapor, or it would take fire as soon as the heated cauterizer is brought near the anus. The accident would not be of much importance, for fhe burning vapor is easily extinguished by blowing it out; but it is better to avoid it altogether. It is easy to under- stand the importance of the use of collodion in relation to the pain which succeeds the operation. The patient cannot feel pain in the parts to which the iron has been applied, for the tissues are dead, but he suffers in the surrounding parts which have been attacked by the radiated heat, and the painful nature of superficial burns is well known. The burns, however, are not very serious, and the pain lasts only about four days, being principally felt at the time when the inflammation necessary for the falling off of the sloughs develops itself, or during defecation after the sloughs have fallen off. T'he cauterizers ought to be knife-shaped, or even with round points. To ensure the rapidity of the operation they should be heated to white heat. One opera- tion is frequently enough, but more than two are never necessary, how large soever the hsemorrhoidal tumor may be, for we do not act directly on the latter, but on the anus. " In some cases the tumor cannot be reduced before oper- ation, or can be only partially replaced, the involuntary con- tractions of the muscles causing it again to protrude. No notice need be taken of this accident. The cauterizer is slipped between the tumor and the walls of the anus, for it is of little consequence if the haemorrhoids should be lightly cauterized by the back of the instrument. " Sometimes the shoulder of the cauterizer implicates the cutaneous circumference of the anus; but that is of no importance; it is even sometimes useful, when the anus is considerably relaxed. There is no need to dread haemor- rhage, for the cauterizer interferes only with the mucous membrane, the submucous cellular tissue at the entrance of the anus, and the skin at the edge of the orifice. At all these points the vessels are small, and when the haemor- rhoidal tumor is touched by the back of the cauterizer, it is OPERATIONS UPON INTERNAL HEMORRHOIDS. 95 in SO light a manner that no vessel of any magnitude can be opened. " If any accident is to be feared it would be stricture of the rectum; but the four cicatrices which have been formed at the entrance of the anus, although possessed of great retractile power, are, made linear and in the direction of the intestine. Between them are intervals occupied by highly elastic tissue, and the presence of these renders stricture impossible. It may be objected that, if the anus remains sufficiently dilatable, the patient may have a relapse. This accident is certainly not impossible, but it is the business of the surgeon to estimate the state in which he finds his patient. If he is going to operate upon an old person having a large and old-standing tumor, and whose anus has little resilient power, he should lean a little more heavily on the cauterizer, so as to implicate a greater thickness of tissue than in ordinary cases; by this procedure he will be sure to avoid a relapse." I will only remark that I have no doubt the operation is efficient. The recovery is rather long, and the pain is con- siderable, but by experiment I find that the application of collodion does away, in great degree, with the pain usually inflicted by radiation of heat. VII. OPERATION BY THE GALVANIC CAUTERY. The galvanic cautery may be employed for the removal of haemorrhoids, the division of fistula, and other surgical operations about the rectum. I have, myself, some personal experience in its use. I fail, however, to see any good reason for the adoption of this method of operating in ordinary cases. If a cautery be required, I cannot tell why the galvanically heated wire should be preferable to an iron heated in the fire, or to any form of platinum cautery ren- dered hot by the rapid combustion of benzoline, as in the " Paquelin " instrument. In my humble opinion, in almost all cases, the " Paquelin cautery " is superior to any other. As a matter of course, the person working the cautery must thoroughly understand the mechanism of the instrument, and have had some practice in its use. All the failures I have seen with it have been consequent upon the small knowledge of those who were working it. An expert can at an instant give any heat you may require, from white to black. The galvanic cautery requires a cumbersome battery ; it 96 OPERATIONS UPON INTERNAL HiEMORRHOIDS. Fig. 5. is exceedingly apt to fail ; you may at the supreme moment get either too much or too little heat, and this difficulty will occur even in the hands of a specially trained assistant. There is still another objection, which applies chiefly to simple cases, as, for example, the removal of piles ; there seems an amount of fuss and pseudo-scientific show about it, which to my mind is exceedingly repugnant. The only battery at all reliable is DanieJl's. VIII. THE REMOVAL OF HAEMORRHOIDS BY THE CLAMP AND SCISSORS, THE BLEEDING BEING ARRESTED BY APPLICATION OF THE HEATED IRON. This operation is generally known as the " clamp and cautery " operation, and is now most frequently associated with the name of Mr. Henry Smith, although, in truth, it was devised in its entirety by Mr. Cusack, of Dublin, and was first introduced into London by Mr. Henry Lee, of St. George's Hospital. In its performance, each pile is seized by a volsellum and drawn well down ; the clamp is then applied so as to embrace its base, the portion above the clamp is cut off with a pair of scissors curved on the flat, and a cautery iron heated to a dull red heat is feely applied to the stump until all the vessels are well seared. In my opinion, this operation has little to recommend it. As regards danger to life — after all, the issue of the greatest moment — as far as my most careful researches have led me to a conclusion, it is quite six^ times as fatal as the ligature properly and dexterously applied. Mr. Henry Smith, in the La^icet of April 20th, 1878, has published his last series of cases, numbering 530 in all ; he acknowledges 4 deaths. In 195 cases operated upon by me by means of clamp or cautery, I have had 2 deaths. This result is the more to be regretted, seeing that in 1600 cases of ligature combined with incision, I have not had a single death from any cause whatever. Mr. Allingham's Clamp for Haemorrhoids. OPERATIONS UPON INTERNAL HAEMORRHOIDS. 97 X. DILATATION OF THE SPHINCTHl MUSCLES. The treatment of hasmorrhoids by the complete dilatation of the external and internal sphincter muscles has been strongly advocated in France by many eminent surgeons, and notably by Verneuil, Fontan, Panas, Gosselin, Monod, and others. The benefits resulting from dilatation seem to have been accidentally discovered, and I cannot admit that the rectal physiology of Verneuil gave, by any means, the clue to this treatment. For my justification for this statement I must refer my readers to previous pages of this work. I have now no doubt that in certain cases of haemorrhoids dilatation, fall but gentle, of both sphincter muscles will give wonderful relief, and I have myself in many cases seen great good accrue ; but, on the other hand, there are cases in which no good has resulted, and reflection would lead one to conceive that such would almost certainly be the case. When, for example, in old-standing disease, the haemor- rhoids easily prolapse at stool, and on walking, stooping, coughing, and other common physical acts, the sphincter muscles become so dilated that more dilatation could not possibly mend matters. For here no strangulation or pressure takes place ; the piles themselves are large, but they do not swell and become livid when outside the body, and the dis- comfort and suffering result not from any "pinching," but from the exposure of mucous membrane to accidental friction or injury, and from the mucous and muco-sanguineous dis- charge, and I have often seen such cases where no remnant, even, of the sphincter muscles could be detected ; and when the haemorrhoids were returned a large patulous opening could be seen, into which the hand might easily be passed. To cure these patients it is necessary not only to remove the growths, but often, also, to obtain contraction of the anal orifice by applying freely the hot iron, so as to produce several 'linear cauterizations, after Woillemier's plan. The cases best suited to dilatation are the very opposite to those just described. When the piles protrude they are tightly embraced by the sphincter muscles, and immediately become swollen and livid, and perhaps bleed freely, the patient being able only with much trouble and considerable pain to return them. Here it is manifest that dilatation of the sphincters may afford speedy relief, and even result in a cure. In such a case the muscles around the lower inch or 98 OPERATIONS UPON INTERNAL HAEMORRHOIDS. SO of the rectum are, from irritation, in a state of almost constant spasmodic contraction, consequently all the vessels are engorged, and the return of blood from the rectum is greatly impeded, and the haemorrhoids grow with great rapid- ity. Complete dilatation is to be effected in the following way : The patient being fully under the influence of ether, you insert both thumbs into the rectum and dilate gradually, first in the antero-posterior, and afterwards in the opposite direction, using an amount of force sufficient thoroughly to overcome the spasm. You continue to manipulate the sphincters until the muscles feel as if reduced to a thoroughly pulpy condition ; care must be taken to act high enough up in the rectum to include the whole of the sphincter. The result is that the state of contraction is abolished and no spasm can occur ; in fact, for the time, as in any over- stretched muscle, paralysis has been induced. With practice and great gentleness the desired result may be accomplished without tearing the mucous membrane, or even drawing blood, but a little extravasation is usually noticed around the anus for a few days. After this, place an opium suppository in the rectum, and keep your patient recumbent in bed. What takes place ? First, all the blood returns freely to the liver, no stasis remains, the piles diminish in size, the pain passes away, and in four or five days your patient may rise and go about his business wonderfully relieved. If at the end of two or three days you examine the sphincters, you will find them both capable of acting, though gently ; there is no spasm. When you insert your finger the muscle closes upon it, but does not grasp it ; the spasm, indeed, which before the. operation rendered it difficult for you to get your finger into the bowel, has gone, and with care and judicious treatment may never return, in which case the patient would, at all events, for a considerable time, be cured of his haemorrhoids. When in addition to piles, a fissure or ulcer exists, more immediate benefit is obtained, as great pain on going to stool will no longer be felt, and in the majority of cases the sore place will heal. In the early conditions of haemorrhoids, when there is little or no protrusion, and, as often happens, only occasional loss of blood and spasm of the sphincter, the dilatation will, as I have personally found, really cure the patient, or at all events postpone for an indefinite time the growth of the haemorrhoids. In the case of a gentleman recently under my care, painful internal hemorrhoids existed as complication of cancer of the rectum. Careful dilatation OPERATIONS UPON INTERNAL HAEMORRHOIDS. 99 cured the hsemorrhoids and made him comparatively com- fortable. In properly selected cases I am of opinion that dilatation is really an admirable method of treatment, devoid, as it is, of danger, causing only trifling pain, and not keeping the patient in bed more than a very few days. THE TREATMENT OF INTERNAL HEMORRHOIDS BY CRUSHING. In the Lancet of July 3d, 1880, Mr. George Pollock, of St. George's Hospital, advocates treatment by crushing. He says: " It is now some two or three years since I commenced to put into practice my views as to crushing. The earlier attempts to crush the base of the pile were partial failures as regarded the perfect freedom from haemorrhage. From want of proper construction the clamp did not effectually Fig. 6. K8D11U£2< SE5EMANN LONDON j Screw-Crushing Instrument. spoil the tissues at the base of the piles, seldom, however, were more than two or three ligatures necessary, and there never was troublesome or recurring haemorrhage encoun- tered." Mr. Pollock proceeds to state that the subsequent pain is much less than ^hat which usually follows the use either of the ligature or of the clamp and cautery, and he recommends the crushing pincers designed by Mr. Benham. A plan of treatment recommended by such a sound surgeon as Mr. Pollock I could not but consider worthy of a fair and extended trial, and I at once procured Mr. Benham's crusher and immediately commenced to operate, following strictly Mr. Pollock's directions. After operating on about ten cases at St. Mark's Hospital, I came to the conclusion that even Mr. Benham's instrument did not sufficiently crush the base of the pile, and that more or less haemorrhage nearly always lOO OPERATIONS UPON INTERNAL HEMORRHOIDS. resulted. In one bad case concealed bleeding took place (/. e. haemorrhage into the bowels without any escape from the anus). Some hours after the operation, the patient said he must go to stool, and he evacuated a large quantity of arterial blood, and this haemorrhage continued until the clots were got rid of by injection of cold water, and plugging the rectum with wool and perchloride of iron was resorted to by the house surgeon. I had the pleasure of consulting Mr. Benham with regard to his invention, and he suggested a modified form with which he saw me operate on several cases ; still, however, the crusher did not on all occasions perfectly arrest hemorrhage, although I kept it applied in bad cases for two minutes. My son, Mr. Herbert W. Ailing- ham, then devised a new form of crusher, in which a screw movement was substituted for the lever action in Mr. Ben- ham's instrument. We then had an instrument capable of exercising an almost unlimited amount of crushing power (see the woodcut). A good many were made before any- thing like perfection was attained, but now I believe that the screw-crusher is a very safe instrument, provided that due care be taken in operating. The crusher is made of solid steel, forming an open square at one end, between the sides of which a second piece of steel slides up and down. This bar is connected with the screw, which brings it firmly home against the distal end of the square, first by sliding and then by screw-action, and exerts great crushing power upon any tissues which are brought between the two opposing sur- faces. To enable the instrument to be cleaned, the handle can be opened by pressing the ends of the levers aa. After use, the instrument should be cleaned, dried and oiled, to ensure its easy working. A few words about the method of using the crusher. As above stated, in my first dozen or more cases, I followed rigidly Mr. Pollock's directions, but afterward I thought it better to avoid crushing skin, and therefore made an incision where the mucous membrane joins the skin. I also com- menced the opperation by gently but fully dilating the sphincters — a plan I always adopt when applying a ligature to internal piles. The haemorrhoid is drawn into the screw crusher by means of a volsellum or hook, and this being entrusted to an assistant, the screw is pushed up and screwed home as tightly as thought desirable, the projecting portion of the pile is cut off with the knife or scissors, and the pres- sure may be kept up as long as the operator thinks fit ; I OPERATIONS UPON INTERNAL HEMORRHOIDS. lOI Fig. 7. now keep the instrument applied for about twenty-five seconds only. In this operation, care must be taken not to remove too much tissue. If this precaution be not attended to, some amount of uncomfortable contraction is sure to take place. This, in my experience, is one drawback to Mr. Benham's clamp ; the instrument is large and difficult of adjustment, consequently more tissue may be taken away than the operator is aware of. Fig. 7 represents the spring- forceps used in bringing into the clamp the portion of pile to be removed. I have now (1881) operated upon 72 patients, 37 at St. Mark's Hospital, and the remainder in private practice. I shall continue to employ the crushing method in selected cases, as I am by no means convinced of its universal applicability or advantage. As regards freedom from pain, I have been on the whole disappointed ; in some cases there was but little suffering directly after the operation, but great pain followed every action of the bowels for some time. In others the immediate pain was quite as severe and pro- longed as that caused by the ligature. QEdema of the external parts, when many or large piles were removed, was very marked in nearly all my cases ; often the external swelling did not show itself until after the first action of the bowels. I cannot say that the patients recover very rapidly ; my average at St. Mark's in thirty- seven cases was twenty-three days, and in thirty- five private patients the average was twenty days. Contraction, so as to require the use of bougies or dilatation by the finger, occurred, on an average, once in every 9 cases. As to haemorrhage, when Mr. Benham's clamp was used, ligatures were necessary in nearly all severe cases, and in two the bleeding was so free a few hours after the operation as to necessitate plugging the rectum with a tube. I cannot say that with the screw-crusher bleeding has never occurred, but it has not done so to any extent, and ligature of a vessel has rarely been required, torsion usually sufficing. On the whole, in my opinion, crushing is a satisfactory method of removing internal piles, and is in every respect superior to the clamp and cautery. I am inclined to consider it a safe operation, but on that point no definite conclusion can yet be formed. That the operation I02 OPERATIONS UPON INTERNAL HiEMORRHOIDS. as regards snfety to life, freedom from haemorrhage, pain, and troublesome complications, is vastly superior to the ligature skillfully applied has yet to be proved, and cannot be admit- ted until many hundreds of operations have been recorded. THE TREATMENT OF INTERNAL HEMORRHOIDS BY LIGATURE. In expressing, as I most unreservedly do, the opinion that the ligature is the safest, easiest, and best operation for the great majority of cases of haemorrhoids, I must be under- stood to mean the operation usually performed at St. Mark's Hospital, viz., ligature combined with incision. The oper- ation was devised by the late Mr. Salmon, and has been practiced at that institution for more than forty years. I must premise that in all operations about the rectum, but more particularly in cases of piles, it is essential that the ali- mentary canal should be thoroughly cleared of its contents. For two or three' days prior to the operation some mild but efficient purgative should be taken, and it is well, if possible, to have an enema of warm water administered a few hours before operating. In cases of piles I prefer the patient to lie on the right side, on a hard couch, with the back towards the light, and the knees drawn well up to the abdomen. The assistant should stand with his back towards the patient's head and raise the upper buttock with the right hand, the right elbow being at the same time hooked over the pelvis so that he can control movement on the part of the patient and keep him in good position. The patient being thus prepared and fully under the influence of the anaesthetic, I now always gently, but completely, dilate the sphincter muscles; this completed, the rectum for three inches is within your easy reach, and no contraction of the splincters takes place, so that all is clear like a map before you. The haemorrhoids, one by one, are to be taken by the surgeon with a volsellum or pronged hook-fork snd drawn down; he then with a pair of sharp, strong, spring scissors, separates the pile from its connection with the muscular and submucous tissues upon which it rests; the cut is to be made in the sulcus or white mark which is seen where the skin meets the mucous membrane, and this incision is to be carried up the bowel, and parallel to it, to such a distance that the pile is left, connected by an isthmus of vessels and mucous membrane only. There is no danger in making this incision, because all the OPERATIONS UPON INTERNAL HAEMORRHOIDS. I03 larger vessels come from above, running parallel with the bowel, just beneath the mucous membrane, and thus enter the upper part of the pile. A well-waxed, strong, thin, plaited silk ligature is now to be placed at the bottom of the deep groove you have made, and the assistant then drawing out the pile with some decision, the ligature is tied high up at the neck of the tumor as tightly as possible. Be very careful to tie the ligature, and equally careful to tie the second knot, so that no slipping or giving away can take place. I myself always tie a third knot; the secret of the well-being of your patient depends greatly upon this tying — a part of the operation by no means easy, as all practical men know, to effect. If this be done, all the vessels must be included. The silk should be so strong that you cannot break it by fair pulling. If the pile be very large a small portion may now be cut off, taking care to leave sufficient stump beyond the ligature to guard against its slipping. When all the haemorrhoids are thus tied, they should be returned within the sphincter; after this is done, any super- abundant skin which remains apparent may be cut off; but this should not be too. freely excised, for fear of contraction when the wounds heal. An injection of Liq. Opii Sedativus may be administered, or a suppository of half a grain of morphia made with gelatine and glycerine. I always place a pad of wool over the anus, and a tight T-bandage, as it relieves pain most materially and prevents any tendeney to straining. It is advisable to commence operating upon these piles that are situated inferiorily, as the patient lies, in order that the others may not be obscured by blood, but when the hasm-- orrhoids are numerous, and there is a small pile, either anterior or dorsal, as is frequently the case, it is better to tie the small one first, as there is danger of their being overlooked, and if they are left they are likely to grow, and a return of the piles may be confidently anticipated in a few months. I have seen many cases in which this occurred. When the patient takes an anaesthetic it sometimes happens that the protruded piles slip up into the bowel again. I have seen inexperienced operators much worried by this, but you need give yourself no anxiety about it; when the patient is fully narcotized carefully dilate the sphincters as I have before recommended. The advantages are that the whole rectum is fully exposed and even every abrasion can be seen. I04 OPERATIONS UPON INTERNAL HEMORRHOIDS. and, secondly, the spasmodic pain after the operation, by this dilatation, is almost entirely done away with. Spasm of the sphincter muscle is in a great degree the cause of pain and its long continuance; my patients now never have pain after about three, or at most, four hours. The only suffering that may remain is caused by spasm of the levator-ani, which will act from time to time, and a retraction of the anus into the rectum takes place, attended with momentary darting pain. I was never certain why it was that patients who had suffered long from large protrud- ing piles, which they could not keep up, scarcely experienced any pain after ligature; now I know that the sphincter muscle caused most of the pain, and those who had practi- cally no sphincters did not have a tithe of the pain the per- son with a strong sphincter had. After the operation the bowels should be confined for three or even four days. I find a solid one-grain opium pill given half an hour after the operation, and repeated every two hours twice, the best to begin with; the pill arrests or prevents vomiting; later on, if required, a draught may be administered. The formula I often use is the following : 5 . Pulvis Cretse Aromat 3 j ' Tinct. Opii or Liq. Opii Sedativus mxv Spt. ^ther. Nit 3 j Mist. Camphorae ad | iss To be taken night and morning, or three times in the day, for two days. In very bad cases and in delicate persons, I occasionally keep the bowels quiet for a much longer period than four days. I have done so for a week or ten days, and I think, in some instances, with very manifest advantage. The diet at first should be light: soup, beef tea, a little boiled fish, milk gruel, tea and toast, will be quite sufficient; no alcohol at all should be taken; perfect rest in the recumbent position enjoined. On the third or fourth night, according to the state of the patient, a mild aperient may be administered, and followed by a draught or a carefully administered enema of warm gruel in the morning, and after it has acted, a more liberal diet may be allowed, but I always advise abstinence from wine, beer or spirits, unless there be some special con- dition indicating the necessity for their use. It is well to tell your patient that some temporary^ and possibly rather acute, pain may be experienced on the first OPERATIONS UPON INTERNAL HAEMORRHOIDS. IO5 action of the bowels, and also that a slight discharge of bl(j»od may take place (it by no means always occurs) ; if you neglect this, needless alarm is often created, the patient imagining, if he sees any blood, or has much pain, that all his old trouble has returned. I think it advisable, though not absolutely necessary, that the patient should keep lying down until the ligatures sepa- rate, which process almost invariably takes place about the sixth or seventh day, occasionally a day sooner, very rarely a day later. If the ligatures are tied tightly and the incision has been free, this course of events is but very seldom departed from. I have been in the habit for a long time of giving daily a gentle pull at the ligatures, commencing the day after the bowels are first relieved; by this plan the liga- tures always separate on the fifth or sixth day. Active exertion, even after the separation of the ligatures, is to be deprecated until the sores left in the rectum are healed; a fortnight or a little longer is generally about the time required to accomplish this. It is quite unnecessary that the patient should be kept in bed all this time, or even to his chamber — he may move about m moderation ; but I am certain that a too speedy resumption of the erect position is likely to retard the cicatrization of the wounds. The patient is con- valescent, but not quite well. I have had patients who have gone about their business with ligatures on their haemorrhoids, and have sustained no injury; here is a case of that kind: A gentleman on the Stock Exchange was operated on by me some years ago; it was rather more than an average case; five ligatures were applied. On the day following the operation some sudden turn of the markets rendered it absolutely necessary for him to go to town. When I called upon him, to my surprise I found that he had left home; and for three days consecu- tively he went to his office and remained there for five hours transacting his business, as he afterwards assured me, with very much less inconvenience than he had frequently experi- enced before the operation, when the piles came down. He was, in the end, none the worse for his temerity, but it is an example by no means to be commended or followed. On another occasion a naval officer found himself compelled to go on board his ship on the third day after operation, jour- neying to Portsmouth for the purpose. This gentleman did not suffer any serious inconvenience. Mr. Quain, in his work, relates a parallel case. It is no uncommon thing for I06 OPERATIONS UPON INTERNAL HEMORRHOIDS. me to have patients who are able to resume their ordinary occupation on the eighth or ninth day. In a case sent me by my friend Mr. WiUiams, of Brentford, who also assisted me at the operation, the haemorrhoids were very large, and four ligatures were applied, but there was no superabundant skin requiring removal. On the eighth day this gentleman was really quite capable of walking a distance, and was rather surprised that I requested him to abstain from much exercise; he had no pain or any symptom to indicate that he had not perfectly recovered, but I am sure it would have been very unwise for me to allow him to do as he wished. The wounds inside the rectum, I knew, could not be soundly healed, and the delay likely to be occasioned by too much exertion or standing about might be serious. Under these circumstances the sores possibly would not heal, and painful and troublesome ulceration, very difficult of cure, might be the result. For years I have digitally examined all my patients upon the thirteenth or fourteenth day after the operation, and in the great majority I have not found the rectum perfectly sound; constantly some unhealed sore remains, and in my opinion such a patient cannot be said to be well and allowed to go about his ordinary avocations, without incurring considerable danger. The veins of the rectum are destitute of valves, and only badly supported by areolar tissue; these sores, therefore, much resemble in their conditions varicose ulcers of the legs; and we well know in such cases rest in the horizontal position is absolutely necessary to ensure a speedy and certain cicatrization. AVhen, from alow condition of health, wounds in the rectum are long in healing, ulceration will in all probability take place, with contraction as an almost certain result. Pain after the operation varies according to the constitu- tion and nervous sensitiveness of the patient, and also as to the condition of the parts before the operation; but, as I have said, by performing gentle and full-dilatation, pain is almost done away with. Lately I had three cases of haemor- rhoids consecutively with my friend Mr. Aiken, and really these patients scarcely complained, though they were sensi- tive persons who, I am sure, would have had great suffering under any other method of operating. The rapidity of the cure in these three cases was very remarkable; one gentle- man, more than sixty years of age, and whose skin, from great losses of blood, had become quite the color of old wax, was well in a fortnight, the wounds being perfectly healed. OPERATIONS UPON INTERNAL HAEMORRHOIDS. I07 Still more recently a gentleman, aged sixty-four, who was seen by me with Mr. Leggatt, positively never lost an hour's sleep, and averred he had no pain, and in twelve days was fit for anything; was not merely convalescent, but all the wounds had healed. If pain should be acute at first, push your opium or hypodermic injection (Morph. gr. }(, Atro- pine gr. -gVj is my favorite formula). A sponge wrung out of very^hot water and applied to the sacrum nearly always affords relief, and however sharp the pain may be at first (it is always exaggerated by the want of moral control brought about by the inhalation of ether), in two or three hours it will have subsided, and you may comfort your patient by the assurance that the worst of his troubles will soon be over, and the pain will most surely, if gradually, become less. After the ligatures come away, I always direct my patients to douche the anus well, night and morning, with cold water; this is very comforting, and materially hastens the convalescence. Every now and then you may have retention of urine fol- low the operation; in most cases a warm hip-bath will enable the patient to pass water in the morning; if not, of course a catheter must be introduced. Straining to mictur- ate should be avoided under any circumstances. This retention is by no means very uncommon in women, but I have found it occur much oftener in men. It may be accounted for by the fact that the male urethra is so much more liable to stricture than the female, and very slight irritation will set up spasm of the strictured part sufficient to induce retention. After a few days the power to pass water will return ; but I have seen retention for ten days or a fortnight. It sometimes happens that after a severe operation upon internal haemorrhoids, contraction takes place in the bowel on the healing of the wounds. This contraction is not usually at the anus, nor does it affect the skin, but mucous membrane only; time alone will generally remove it, but as it may occasion straining and distress to the patient, I advise the passing of a bougie for a few nights, or what answers as well, and is less alarming, I direct the introduction of the fore-finger, well anointed, into the bowel, night and morning. In rare cases, when the wounds have been long in healing, and also if a great deal of the bowel has been removed longitudinally, a tight hour-glass contraction takes place — usually the contracted part is ulcerated — the patient suffers Io8 OPERATIONS UPON INTERNAL HEMORRHOIDS. much pain, has obstinate constipation, atid cannot sit up without a sensation of bearing down and great discomfort. This is the form of stricture and ulceration which I have so frequently found following operations "when heated irons are applied. I very often see this result in the practice of others, and have had it occur in my own cases. To get them well requires great attention, gentleness and persever- ance; usually constitutional treatment is required as well as mechanical; the patients are nearly always weak and unhealthy, often strumous, and the malady is more common in women than in men, and the uterus therefore usually requires attention. Subinvolution, retroversion, and ante- version, with flexion and chronic endometritis, are the dis- eases, frequently complicating the rectal mischief, and no surgeon can hope to cure those patients who does not take into consideration the state of the uterus. I do not think in the whole range of surgery there is any procedure worthy of the name "operation." which can show a greater amount of success or smaller death-rate than the ligature of internal haemorrhoids. In the year 1865 I published, in the Medical Times and Gazette, some statistics of the practice at St. Mark's Hospi- tal, which showed that in 1763 operations upon haemorrhoids there had been 5 cases of tetanus, 4 occurring in the spring of 1858, 2 in March, and 2 in April. Since the year 1858 about 2250 operations have been performed, and there has not been any case of tetanus ; -ana in the 4013 cases there has been but one case of doubtful pyaemia. This death occurred in Mr. Gowlland's practice. An old Hebrew was operated on for bad piles, with the Hgature. A few days after diarrhoea set in and he died exhausted. Pyaemia was suspected, but no necropsy was made, as the Jews object, so there is still an element of uncertainty in the case. Since the publication of the last edition of this work about 250 cases, have been operated upon without a single fatal case or any symptoms of pyaemia or tetanus. The in-patient books at St. Mark's have been excellently kept, and any one interested in the matter could easily satisfy himself that the statistics of operations and deaths resulting are worthy of entire confi- dence. Let us see how the matter stands. In St. Mark's Hospi- tal the death-rate from all causes in operations on external haemorrhoids by ligature during a space of more than forty years is just i in 670. Now, hospital practice is notoriously OPERATIONS UPON INTERNAL HEMORRHOIDS. I09 more fatal than private practice, yet what a brilliant result has been obtained ! Referring to the four cases of tetanus occurring in St. Mark's in the months of March and April, 1858, they must be considered quite exceptional, as since that year no case of the disorder has appeared. Mr. Curling, in his work on " Diseases of the Rectum," says, " In the year 1858 tetanus was very rife in London." I have the good fortune not to have had one single fatal result from the liga- ture, either in my public or private practice, which now extends to more than 1600. operations. Copeland, in his work, mentions that he had only seen one death. Bushe that he never had a fatal case with the ligature. Sir Benjamin Brodie, whose experience was unusually large, states he never lost a case. Mr. Smye says, " In the whole of my practice I never met with a case which either terminated fatally, or even threat- ened to do so. Mr. Curling, in the last edition of his work, affirms *'that, with one exception, no fatal case of operation by the ligature has occurred, either in my public or private practice." Mr, Quain had only one patient succumb in his practice with the ligature. Mr. Ashton has not recorded a single death from his method of operating by ligature. My colleague, Mr. Gowlland, who, in all probability, has had a larger experience in rectal surgery than any other sur- geon in London, has had a most remarkable success with the ligature in haemorrhoids ; and after a prolonged trial with the clamp and cautery, he finally abandoned it. My friend, Mr. Alfred Cooper, with large opportunities for arriving at a correct judgment, informs me that he has never had a fatal case with the ligature, and now does not employ the cautery. My remaining colleague, Mr. Goodsall, is also at one with me in preferring the ligature. Let us for a moment see what our American confreres think : — Gross, in his great work on surgery, says : " The operation (ligature) is as simple of execution as it is free from danger and certain in its results." Dr. Van Buren, so well known here, and whose experience in the treatment of rectal disease is very extensive, says : " I have never had and unpleasant symptom." no COMPLICATIONS OF HAEMORRHOIDS. Bodenhamer states ; " I have yet to encounter my first serious accident." I could go on citing the favorable opinions of my American friends with regard to the safety of ligation, but I feel I need not add anything to what I have written to prove the great success in every way of the operation when properly performed, and when the patient is well treated and placed in good hygienic conditions. It must be clear that if the death-rate at St. Mark's Hospital, in so many years, has been I in adout 670 cases, equally good results ought to be obtained in private practice. If patients are placed in hos- pital wards teeming with septic poisons, the deaths which take place cannot be justly ascribed to the operation. Mr. Annan dale, of Endinburgh, in the Edinburgh Monthly Journal^ for June, 1877, pubHshes an article " On the Operative Treatment of Internal Piles," and comes to the conclusion that the clamp and cautery is the safest and best operation. That Mr. Annandale cannot base his con- clusions on his own experience is quite evident ; for he says (p. 1080) : " In about two hundred cases of this operation (the ligature) I have met with at least four instances of fatal pyaemia," a fearful mortality in such an operation. And he goes on to say that, " since 1872, I have operated with the clamp and cautery on twenty-four patients, with one death " — a still higher rate of mortality. Mr. Annandale, however, still advocates the use of the clamp and cautery, while by his own showing he has had a greater fatality with these than with the ligature CHAPTER X. COMPLICATIONS OF HEMORRHOIDS. Haemorrhoids are not infrequently complicated by the coexistence of other affections of the rectum. I have often seen piles, polypus, and fissure in the same patient. I will mention the more trequent complications, so that the reader may be warned against the error of being satisfied with merely finding his patient has piles, without searching to see if any other malady be present. Fissure or small painful ulcer is very often associated with COMPLICATIONS OF HAEMORRHOIDS. Ill haemorrhoids, and a careful examination is needed to detect it, as one of the tumors may overlap the fissure so as entirely to conceal it. Always suspect fissure or ulceration when your patient tells you he suffers pain on defecation, or pain con- tinuing long after the bowel is relieved. In operating on haemorrhoids, when fissure or ulcer was found to exist, I always used to divide the superficial fibres of the sphincter muscles, so as to set them at rest. I now find this unnecessary, as the dilatation I make of those mus- cles allows the fissure or ulcer to heal. It is well, in these cases, not to omit examining the upper part of the, fissure, to see if any sinus runs up from it ; if so, it must be laid open. Fistula is not so common a complication, but I have often seen it. If the fistula be well marked there is no difficulty in the diagnosis, but if it be of the blind internal variety, or if the external orifice be very small and concealed, as it may be, by an external flap of skin, it is quite possible to overlook it. I have frequently met with examples of this. I will relate a case in point : — A gentleman consulted me, on the recommendation of Sir Risdon Bennett. His statement was, that three months ago he was operated upon for piles, and was pronounced by his surgeon to be cured, but he still had occasional pain and throbbing in the anus ; there was also a constantly recurring discharge which soiled his linen ; it ceased for a day or two and then returned. He had mentioned this to the gentleman who operated upon him, and had been told he was only suf- fering from a little weakness of the bowel, which would soon right itself ; of this, however, the patient could not feel con- vinced, and he was alarmed, thinking that he would have a return of his haemorrhoids. The frequent discharge and staining of his linen gave him great concern, and worried him to a degree which seemed almost absurd, and quite dis- proportioned to the gravity of his case. This I have often observed in persons of refined feelings. In hospital practice patients do not often complain of a discharge unless it be very copious or accompanied by pain. On a careful exami- nation of this gentleuian I detected, just at the verge of the anus, and hidden by a small tab of skin, a minute orifice; a fine probe passed into this and through a short sinus, not quite three- quarters of an inch in length, into the bowel. From the history of the case (there having been always the same purulent discharge), I had no doubt that this slight fis- 112 COMPLICATIONS OF HAEMORRHOIDS. tula had existed in conjunction with the haemorrhoids, but the major malady had masked the minor one. I laid open this sinus, and in a week the patient was quite well and relieved from his annoying discharge. When examining a case of haemorrhoids, never omit to pass the finger well into the bowel, to ascertain that no stricture, ulceration,, or malignant disease is present. I have made the same remark before, but I do not mind repeating it; as I have so often seen this grave error committed. It has many times occurred to me to find that patients have been operated upon in metropolitan hospitals, by eminent surgeons, for piles, when they were suffering at the same time from can- cer or ulceration of the bowel. I need scarcely say that an operation under such conditions cannot be of any benefit to the patient. A healthy-looking young man, set, 28, came into my con- sulting room quite recently, sent to me as a case of piles for operation ; a few questions, however, satisfied me that there was something besides the piles. An examination revealed carcinoma high up the rectum, the lower margin not being nearer than three inches from the anus. The termination upward could not be reached, but by using my ball-staff I found indications of contraction and great hardness at the upper part of the rectum or commencement of the sigmoid flexure. Impaction or accumulation of faeces in the rectum or colon is another complication worthy of mention. I have said that, prior to operating upon piles, the bowels ought to be thor- oughly cleared ; this precaution is too often neglected. It is remarkable how much better patients do when the portal system has been unloaded by free purgation ; and unless there be some care exercised in this matter you may occasion yourself a good deal of trouble, to say nothing of the suffer- ing of your patient. For my own part, I am tolerably cer- tain that, in the majority of those cases where the healing process does not go on kindly, a loaded colon and congested liver are the chief cause. I saw with a professional friend a lady upon whom he had operated for slight internal haemor- rhoids, and in whom unhealthy ulceration had followed. Prior to the operation the patient was not in bad health, and might reasonably have been expected to do well. Before examining the rectum I inquired as to the state of the bowels for some time past, and from the account given I was quite satisfied that there had not been a good clearance COMPLICATIONS OF HAEMORRHOIDS. II3 effected. Moreover, although action had taken place since the operation, there had been only scanty relief, and when the patient got out of bed and stood up, she experienced inclination to go to stool, and abortive straining on doing so. On introducing my finger into the bowel I found it quite blocked up by hardened faeces. This impaction was got rid of by manipulation and enemata; then aperients were given by the mouth, and a large quantity of lumpy faeces was evacuated. When I saw this patient again, in about ten days, the ulceration was nearly healed. I operated for haemorrhoids upon a young gentleman whose bowels, he said, generally acted fairly, and had done so freely before the operation; but at the end of a week he complained of abdominal pains and desire to go to stool, without having a satisfactory evacuation; this led me to examine his abdo- men, and I found his colon quite dull on percussion, nearly throughout its course. A brisk purge administered daily, for three days, and followed by enemata, produced most copious action, and soon improved his general condition, and hastened the healing of the wounds. Another marked instance of this complication occurred in a lady recommended to me by my late friend Dr. Daldy. She was a delicate person, who had long suffered from the frequent combination of uterine and rectal disorder. She had a considerable and painful prolapsus of the bowel when she came under my care, her uterine malady having been previously greatly ameliorated, if not cured. The bowels acted daily and, according to her statement, sufficiently. She had the usual aperient administered, and also an enema prior to the operation, with good effect; but about the time of the separation of the ligatures she was seized with severe abdominal pains and straining, and on examination I found the rectum blocked up by hard, dry, friable lumps of faeces, which were with very great difficulty got rid of ; after this aloetic aperients procured the evacuation of a really enor- mous collection of faeces; it seemed as if the whole colon had been fully charged. All this delayed her recovery, and caused a great deal of pain, but eventually she got well. Polypus is sometimes found in conjunction with haemor- rhoids. I operated some time back on the wife of a well- known physician, who, in addition to haemorrhoids, had a large-sized, hard, pedunculated polypus. My colleague, Mr. Goodsall, assisted me once in operat- ing upon a lady who had a fissure, polypus, and hsemor- 114 HiEMORRHAGE AFTER OPERATIONS UPON PILES. rhoids; her sufferings had really been very great, and she had lost much blood. In these cases a ligature must be placed upon the polypus as well as the piles. A gentleman with fissure, haemorrhoids, and a very large fibrous polypus, with a hard peduncle, was recently introduced to me by my friend, Dr. Wm. Henry Stone, of St. Thomas's Hospital. This condition, by the patient's history, had clearly exis- ted for years, and caused him great pain when the growth came outside the anus, as it frequently did at stool. This gentleman had been operated on twelve years before my see- ing him, a small polypus being then removed. CHAPTER XI. HAEMORRHAGE AFTER OPERATIONS UPON PILES. This will occasionally take place, and it may be either accidental, recurrent, or secondary. Just as in midwifery you may go on for years without the occurrence of an untoward event, and then get a batch of troublesome cases, so it is in this operation; you may per- form it a large number of times without the slightest unpleasant symptom resulting, and then have a run of cases which cause you more or less anxiety. If the operation be carefully done, primary haemorrhage is very rare; occasionally, when large and very vascular haemorrhoids are ligatured, and there is also much super- abundant skin cut away, a small vessel will bleed when the patient recovers from the shock; this is a trivial matter, and a ligature is easily applied. I think it will scarcely ever occur if the precaution of putting on a good pad of wool and a T-bandage is adopted. Now and then, particularly if the patient has been unruly under the operation, the ligature may not have been placed quite at the bottom of the incis- ion, and some bleeding may then result. The ready way to arrest this is to draw down the bowel by the ligatures, the patient assisting you by straining; you will then, in all proba- bility, be able to see the bleeding vessel and tie it. If you do not see it, or if a general oozing is apparent, pass all the ligatures through a hole made in the middle of a small, t HAEMORRHAGE AFTER OPERATIONS UPON PILES. II5 round sponge, then tie them across a piece of stick, and twist this round. In this way you construct a sort of tour- niquet, and can make firm and strong pressure with the sponge, so that no bleeding can take place. In a few hours after it is all arrested the stick may be removed. In the old plan of operating with a double ligature and transfixion of the base of the haemorrhoid, bleeding used from time to time to occur from perforation of a vessel — usually a vein — by the needle. When this takes place, on the ligatures being tied, the vessel would be more or less torn open, and bleeding would ensue at the time, or shortly afterwards. I have more than once been called to see a patient to whom this accident had occurred. It is easily remedied by drawing down the piles by the ligatures, and placing one ligature above the spot where the bleeding haemorrhoid was transfixed. In cases of sloughing haemorrhoids the parts are some- times so much disintegrated that very free haemorrhage takes place ; at the same time a ligature is not easily applied, in consequence of the tissues readily breaking down. I once had a rather startling accident occur after operat- ing. A gentleman came up from the country, and was operated upon by me for piles; it was a bad case, and five ligatures were applied. The night fol- lowing the operation he was attacked quite sud- denly with delirium tremens, and in a paroxysm of mania tore off three of the ligatures. The loss of blood was very considerable. When I arrived at the house I found the patient, the bed, and the floor of the room covered with blood. I had much difficulty in placing ligatures on the bleeding vessels, as the patient, although very collapsed, was capable of offering resistance. Curiously enough, he did exceedingly well afterwards; I do not think that the acci- dent delayed his recovery a single day. He had not been an habitual drunkard, but the fear of the operation induced him, for about a week before he came up to undergo it, to drink quantities of champagne and brandy; this, with the chloroform and the shock of the operation, brought on acute delirium. Another case of accidental haemorrhage occurred to a patient of my friend Mr. Blackman, of Highbury. I operated for him upon an elderly gentleman who had a Il6 HAEMORRHAGE AFTER OPERATIONS UPON PILES. very large hsemorrhoid, which had undergone fibroid degeneration; it was situated dorsally, was as large as a hen's egg, and always came down at stool, giving a great deal of trouble. Ulceration had taken place at the upper part of the pile. I placed a ligature upon it, and then cut the tumor off. At the time of tightening the ligature I felt that the tissues were very friable, and I examined the site of the ligature to see if it had cut through much, but could not discover that it had done so, and there was no bleeding. When I saw the patient in the morning, with Mr. Blackman, we found that considerable haemorrhage had taken place since 4 a m., the cause being probably as follows: He had not passed any water, and feeling a very urgent desire, he jumped quickly out of bed, and strained violently to empty his bladder; at the time he was doing this he felt something give way in the rectum, and on getting back into bed his wife observed that he was bleeding. I forcibly dilated his sphincter, and then with a volsellum drew down the bowel, and placed another ligature above the first one. This at once arrested the bleeding, but the next day but one it recurred to an alarming extent, and I found the parts so soft and sloughy that no ligature would hold; under these circumstances I plugged the rectum (in the manner I will presently describe). This plug was retained for about ten days, and he had no more haemorrhage, and eventually did well, although for some time he gave Mr. Blackman and myself no little anxiety. I will relate one more case. In the year 1866 I operated at St. Mark's with the clamp and cautery, upon a really severe case of internal haemorrhoids. The parts were very vascular, and I had considerable difficulty in controlling the haemorrhage, having to apply the cautery a good many times. When the patient left the operating table there was no bleeding at all; but in the evening I was sent for by the house-surgeon, as very free arterial haemorrhage had come on. The patient was very timid and the parts very tender, so that I had much trouble to introduce a speculum; and when I did I could not find the spot whence the blood came. I ordered the injection of ice water and perchloride of iron; this had the effect of arresting the flow, but only tempor- arily. When I saw the patient, early in the morning, I was told that he had lost a good deal of blood during the night, and the flux was still going on, so I determined to find the ves- HEMORRHAGE AFTER OPERATIONS UPON PILES. II7 sel, if it were possible. Accordingly I passed my finger into the bowel, and on that I guided a volsellum, and catching a good hold of the rectum, I pulled that part down; while that was held I used another volsellum on the other side of the bowel, and thus succeeded in bringing the inside of the rec- tum well into view. This done, I found two points from which the blood escaped in jets, so I placed ligatures upon these vessels, and the haemorrhage was arrested. I leave the reader to imagine how much pain the patient must have suffered from this proceeding. He had such a tendency to faint that I was afraid to give him chloroform. Ether was not then in vogue. These cases may, I think, be correctly styled accidental or recurrent haemorrhage. Of late years I have had this form of hemorrhage occur much less frequently. As a rule, I should say what we have most to fear is secondary haemor- rhage, which usually comes on at or about the time of the separation of the ligatures. This form of bleeding occurs generally in elderly people of broken-down constitutions, or in those who have been very free livers. I may say, as far as my experience goes, that this haemorrhage is usually more venous than arterial. Of course there are exceptions to the rule of its occurrence in elderly people. Here is one: — A gentleman, aet. 23, had all his life suffered from rectal disease; when a child from procidentia, and by the time he was eighteen from bleeding haemorrhoids. When I saw him he had a prolapse of the lower part of one side of the rec- tum, which came down on very slight exertion; he was very thin and weak, and subject to fainting. I put two ligatures upon his prolapsus, assisted by my colleague Mr. Goodsall. Mr. Buxton Shillitoe administered the chloroform, with his usual care and discrimination, and although very little was given, and the operation did not take one minute to per- form, the patient fainted, and we had considerable trouble in recovering him. I was quite convinced that had the chloroform been given recklessly or unskillfully death would have ensued. This gentleman went on very well indeed until the sixth day, when the ligatures came away on the bowels acting. Soon after this — he had returned to his bed — he said he felt faint, then that he wanted to go to stool; and on being assisted up to do so, he nearly filled the pan with dark blood, and fainted away. I was sent for in great haste, and directly saw that he had lost and was still losing a large Il8 Hi¥:MORRHAGE AFTER OPERATIONS UPON PILES. quantity of blood. This was not a case in which one could afford to temporize, so I at once plugged his bowel with cot- ton wool and subsulphate of iron, which I had with me. I was quite sure that it was no use to search for the bleeding vessel or vessels. The plugging immediately arrested the haemorrhage, and I kept the wool in for ten days; I then carefully removed it, and no further bleeding took place. The patient soon got quite well. This is the only case of severe secondary haemorrhage I ever had in a young person. An elderly gentleman came from the country to be under my care. He had been much in hot climates, had led rather a dissipated life, and worked very hard. He was only fifty- four, but he looked sixty-five at least. He suffered from a constantly prolapsed hsemorrhoid. I saw no reason why it should not be removed; accordingly I applied a ligature in my usual way. The patient did capitally until the fifth day, when the ligature came away on his going to stool. I saw him in the afternoon and he was very comfortable, and said he should get up and lie on the sofa. I made no objection, and he did so. At night, I was summoned hastily, as he was bleeding; when I arrived I found him quite collapsed, and the blood was literally pouring out from his rectum. The haemorrhage had come on suddenly when he was moving from his sofa in the sitting-room to the bedroom on the same floor, I plugged instantly and arrested the bleeding; he suffered a good deal of distress from flatulence, and I was compelled to remove the sponge on the sixth day. To my intense annoyance, after twenty-four hours, the haemorrhage recur- red quite as badly as at first. I was thus obliged to re-plug the rectum, but this time, not wishing to remove the plug early, I adopted the precaution of introducing a full-sized elastic catherer at the side of the wool, so that he was able to get rid of flatus through it. This was all retained for nineteen days, when I gradually and carefully drew the plugging out; there was no turther bleeding. I am free to confess that this case caused me much anxiety. A man, aet, 62, was operated upon by me at St. Mark's Hospital, in July, 1868. He was a feeble man, and had no power in his sphincter muscles. He suffered from prolapsed haemorrhoids, which were always down. I used the clamp and cautery. On the fourth day hemorrhage commenced after action of the bowels; at first the blood was small in quantity, and HEMORRHAGE AFTER OPERATIONS UPON PILES. II9 passed only when he moved or coughed; it came away fluid, and also in small clots; it was venous in character. Ice water with perchloride of iron was injected, but failed to arrest it. When I saw him he was very pale and faint, and the haemorrhage was nearly constant, the blood slowly trick- ling out of the anus. On examination I found the bowel full of blood. I plugged the rectum fully, with cotton wool, into which was dusted the sub-sulphate of iron; this at once stopped the bleeding. The plug was retained for six days, and when it was removed there was no return of haemor- rhage. This patient was very weak and ill for some time, and he suffered from an attack of purpura. He rallied, however, under good diet and stimulants, and left the hospi- tal quite recovered. When bleeding is taking place internally and in conse- quence of tightness of the sphincter the blood does not escape; the patient will always tell you " that he feels some- thing running inside the bowel," and this may continue until the rectum (and even the sigmoid flexure) is full of clots and fluid blood. If you suspect this, and pass your finger into the anus, you will excite contraction of the gut, and the contents will then be expelled with more or less force. The trickling sensation I always take as a pretty cer- tain indication of internal bleeding, and I act accordingly. If you dilate the sphincters prior to operating, this retention of blood in the bowel is not likely to take place, as there can be no contraction of the orifice of the anus. This is another advantage resulting from dilatation. These cases do very well if prompt and judicious treatment be adopted. I have never lost a patient, although I have seen persons in considerable danger. If the bleeding were allowed to con- tinue long, I have not the slightest doubt that a fatal issue would be the result; so I will in some detail describe the method of treatment I consider most advisable. I have found it utterly futile, in cases of secondary haem- orrhage, to try and place a ligature round the vessels; it is usually the large veins or venous sinuses which are opened by sloughing or ulceration, and when you introduce a specu- lum and try to find the source of bleeding, you can only see that the whole rectum is filled with blood, and on passing your finger you will feel a quantity of clots. When called to cases of severe haemorrhage, always arm yourself with a full-sized, bell-shaped sponge and plenty of cotton wadding; take also some subsulphate of iron, or if I20 HAEMORRHAGE AFTER OPERATIONS UPON PILES.. you have not that, powdered alum or tannin. Pass a strong silk ligature through, near the apex of your cone-shaped sponge, and bring it back again, so that the apex of the sponge is held in a loop of the thread. Then wet the sponge, squeeze it dry, and powder it well, filling up the lacunae with the iron or other astringent. Pass the fore-finger of your left hand into the bowel, and upon that as a guide push up the sponge — apex first — by means of a metal rod, bougie, pen-holder, or a rounded piece of wood, if you can get nothing better. Now, this sponge should be carried up the bowel at least five inches, the double thread hanging outside the anus. AVhen this is so placed fill up the whole of the rectum below the sponge thoroughly and carefully with cotton wool well powdered with the alum or iron. When you have completely stuffed the bowel, take hold of the silk ligature attached to the sponge, and while with one hand you pull down the sponge, with the other hand push up the wool. This joint action will spread out the bell shaped sponge, like opening an umbrella, and bring the wool compactly together; if this be carefully done no bleeding can possibly take place, either internally or externally. Half measures in these cases are worse than useless, as valuable time is thereby lost. This plug should remain in at least a week, and it may be retained a fortnight or more. It may be thought that much straining and pain would be caused by it. I assure you this is not the case; if you keep your patients fairly under the influence of opium they very rarely complain. The only trouble may be wind, and this often will find its own way out. If you fear this, and have a male catheter or flexible tube handy, you may introduce it through the centre or by the side of the sponge, packing the wool around it. I have done this several times, and found the patients passed not only wind through it, but also broken-down blood and liquid faeces. I am sure you need never fear a case of haemorrhage if you only plug methodically and thoroughly. I think very highly of the subsulphate of iron; no styptic, in my opinion, answers as well. It is far superior to the perchloride, as it does not cause burning or pain. In slight cases of bleeding the injec- tion of a strong solution of tannin, or even ice water, keeping a lump of ice on the sacrum, and the patient cool and quiet, may be suflicient, but I say never leave a patient who has at all continuous or free haemorrhage without the plug. Practitioners who are not frequently operating on haemor- rhoids cannot be expected to possess all the most modern ttiSMORRHAGEl AFTER OPERATIONS UPON PILES. l2l appliances, but I can recommend my friend Mr. Gowlland*3 tubes, which are made of vulcanite, shaped like a bougie, seven inches in length and about one inch in diameter; the base terminates in a rim, which is perforated, 'so that it can be sewn to a bandage, I have had tubes made with holes two inches from the apex, so that sponge can be sewn on around them. When this is passed up the rectum you pack wool all around it. The advantages are obvious; flatus, liquid faeces, and broken-down blood can pass; you can also inject frequently a weak solution of Condy's fluid, which will keep the part clean and sweet; do not use carbolic acid as it frequently gives rise to much irritation. The after-treatment of these cases requires considerable care and attention to details; generally the patient is very greatly alarmed at the bleeding, but his fears wnll be soon allayed if he finds you are prompt and confident of your own powers to succor him. After the haemorrhage is arrested by the plugging, the recumbent position must be maintained, and on no account whatever should an upright posture be assumed. If the packing be tight, frequently retention of urine will occur, and you must pass a catheter; but you should, if possible, at once teach the patient to introduce the instrument for himself, A Mercier's flexible coudee catheter goes so readily into the bladder that any but the most timid person may in one lesson acquire the art. The buttocks and lower part of the back should be kept cool, I employ dry cold, by means of ice in an india- rubber bag, applied to the sacrum. If the patient is exceed- ingly collapsed do not apply cold. I have found hot sponges to the sacrum advantageous. Stimulants may be given, but it is better, if possible, to wait for some hours and observe what amount of reaction takes place; this is sometimes con- siderable, and will make you wish that you had withheld alcohol or used it very sparingly. As soon as it can be taken, nourishment is to be given, and Liebig's cold soup, which can be quickly prepared, I have found a wonderful restorative.* Hot liquids, I need scarcely say, are to be avoided. I do not think it necssary to keep these patients entirely on fluid diet; directly they can take solid food let them have it, but it should be nourishing and easy of diges- * Liebig's cold soup is prepared thus: Take 8 oz. of raw, lean beef, finely minced, put it into 20 oz. of cold water, add 10 drops of strong hydrochloric acid and a little salt ; let it stand half an hour and then strain. One or two ounces may be given every half hour. 122 iPROCIDENTIA RECTI. tion. As secondary hgemorrhage generally occurs in persons whose blood and tissues are deficient in plastic material, the aim of treatment must be to remedy that defect, and thoroughly nutritious food judiciously administered is, I imagine, the most valuable means to that end. I do not place much trust in the internal use of astringent remedies. The hypodermic injection of ergotine I shall use when I have a case that I consider not very urgent, but I always prescribe iron, not only as a haemostatic, but also for its blood-repairing' property. I prefer either the Tinct. Ferri Perchloridi, or the Liq. Ferri Peracetatis. If the stomach bears this well, full doses may be given twice or thrice in the day; in addition, a pill containing one grain of solid opium, night and morning, or at night only, if the bowels do not exhibit any tendency to act and there is no straining, will generally meet the requirements of the case. CHAPTER XII. PROCIDENTIA RECTI. There is sometimes a confusion of ideas occasioned by the use of the words procidentia and prolapsus. Internal hsemorrhoids,when they have come down outside the anus, are said to be prolapsed, and the case if frequently called prolapsus ani ; but there is a very marked pathologi- cal distinction to be observed between prolapsed haemorrhoids and prolapsus of the rectum. Prolapsus is a descent of the lowest part of the rectum, the mucus membrane and sub-mucous tissue, both occasion- ally thickened, being turned out of the anus. Now, this condition differs from prolapsed haemorrhoids thus: The haemorrhoids exist as separate and distinct rounded tumors, while the prolapsus may be seen to surround the anus with- out any division into definite tumors, only the natural folds of the bowels being observed; generally there is one distinct fold towards the perineum,and the remainder forms a horse- shoe-shaped projection around the sides and back part of the anus. The appearance and touch also of prolapsus PROCIDENTIA RECTI. 1 23 differ from piles in its not being smooth, hard, and shiny, but soft and velvety. If you thought fit, you would operate upon such a case in the same manner as you would upon internal haemorrhoids, with this exception, that the larger segment of the rectum will require to be divided vertically into two or three por- tions,in order that several ligatures may be applied, to ensure a complete strangulation of the part. True procidentia is the decent of the upper part of the rectum, in its whole thickness, or all its coats, through the anus. There is a variety of procidentia which one may call intus- susception, the upper part of the rectum descending through tha lower part; this is diagnosed from ordinary procidentia by there being a more or less deep sulcus around the inner column of the intestine, so that there are, as it were, two cylinders of rectum, one inside the other. This condition is often associated with, and caused by, the growth of a poly- pus; it givet rise to a train of very distressing symptoms, which may continue long after the removal of the growth which has been the starting point of the malady. I had a a lady under my care, sent to me by Dr. Gervis, who some time before had a rectal polypus removed, but she still had great suffering; a sensation of burning and fullness in the bowel attended with tenesmus and difficulty in defecation. She has an intussusception of the upper part of the rectum into the middle and lower part; the bowel does not gener- ally come outside the anus, but approaches, when she strains, near to it. I have seen many cases of this kind. One very troublesome case, a middle-aged single lady, sent me by Dr. J. Grey Glover, had an intussusception and constipation, with constant straining; she suffered greatly, and took all kinds of aperients and other medicines. At last she regained much comfort by following out my suggestion — of always having action of the bowels lying down, and keeping recum- bent for an hour or so afterward. The worse thing that cah be done for these patients, is to give way to their craving for purgatives. Sometimes a procidentia occurs conjointly with internal haemorrhoids; in this case, when the procidented gut is gently returned, there still remains outside of the anus a ring of haemorrhoids, or loose and thickened mucous membrane; and I may mention that these cases are the most satisfactory to treat, as ligature of the haemorrhoids, will almost certainly 124 PROCIDENTIA RECTI. cure the procidentia. This was clearly shown by the late Mr. Hey, of Leeds. Procidentia of the rectum is more often seen in children than adults, although it is by no means a rare affection in women — particularly those who have borne many children — and in men in advanced years. Procidentia in children is much favored by the formation of the pelvis, the sacrum being nearly straight. Moreover, all infants strain violently when their bowels act, even when their motions are quite soft. There appears to be some physiological necessity for this, which I do not pretend to explain or understand; but these facts are not quite sufficient to account for the prone- ness of children to this malady; there is always, in addition, some inherent weakness or extraneous source of irritation present, by which excessive straining is caused. We may mention diarrhoea — often the result of strumous inflammation of the intestines, worms, stone in the bladder, phimosis, polypus recti, etc. There are many cases, however, in which we can assign no special cause, where the child is not mani- festly unhealthy, and no source of irritation can be detected. I am sure that the very bad custom of placing a child upon the chamber utensil, and leaving it there for an indefi- nite period, as practised by many mothers and nurses, is a fertile cause of procidentia. In children the treatment is generally successful; it should first be addressed to the removal of any source of irritation; this accomplished, a cure is speedily affected. When no source of itritation can be discoved, the general health must be attended to. The child should never be allowed to sit and strain at stool; the motion should be passed lying upon the side, at the edge of the bed, or in a standing position, and one buttock should be drawn to one side, so as to tighten the anal orifice which the faeces are passing; this device I have found to be very useful; it is recommended in " Druitt's Surgery," but upon whose authority I do not know. When the bowels have acted, the protruded part ought to be well-sluiced with cold water, and afterward a solution of alum and oak bark, infusion of matico, krameria, or weak carbolic acid, should be thoroughly applied with a sponge; the bowel must then be returned by gentle pressure, and the child should remain recumbent for some little while, lying upon its face on a couch, before running about. If there be any intestinal irritation, I generally order small doses of Hydrarg. cum Creta, with rhubarb, at bedtime, and PROCIDENTIA RECTI. 1 25 steel wine two or three times in the day. When the child is very ill-nourished, cod-liver oil does much good; the diet should be nourishing and digestible. If these mild measures do not succeed, I find the appli- cation of strong nitric acid the best remedy. Chloroform should be given, and the protruded gut well dried. The acid must be applied all over it, care being taken not to touch the verge of the anus or the skin. The part is then to be oiled and returned, and the rectum stuffed thoroughly with wool ; a pad must after this be applied outside the anus, and kept firmly in position by strapping plaster, the buttocks being by the same means brought closely together; if this precaution be not adopted, when the child recovers from the chloroform, the straining being urgent, the whole plus; will be f'orced out, and the bowel will again protrude. When the pad is properly applied, the straining soon ceases, and the child suffers little or no pain. I always order a mixture of aromatic confection, with a drop or so of tincture of opium, so as to confine the bowels for four days. I then remove the strapping and give a teaspoonful of castor oil. When the bowels act, the plug comes away, and there is no descent of the rectum. I have had experience of this treatment in a great many cases; I never knew it to fail if properly carried out, and only on two occasions have I had to apply the acid more than once. The result, also, is not a temporary, but a per- manent benefit. Procidentia in the adult is a very much more unmanagea- ble affection, and is supposed in many instances to be quite incurable. Numerous operative procedures have been recommended for the cure of this malady, in its advanced stages, but I cannot say I am satisfied with any of them, save one to be presently described; all the others I have seen fail. The application of fuming nitric acid, or, what I think prefera- ble, the acid nitrate of mercury, often does much good, although, unfortunately, the relief is usually only tempo- rary; I have had patients to whom the acid has been fre- quently and very thoroughly applied, but without effecting a cure. The use of the acid in such cases is not at all pain- ful if the skin be not touched; it causes only a burning sen- sation, which soon passes off. As in children, the gut should be oiled before returning it, and the bowels should be confined for a few days. 126 PROCIDENTIA RECTI. In old persons, or in those with a broken down constitu- tion, a very free application of the acid is to be deprecated, as a deep slough may form, some vessel be opened on its separation, and severe haemorrhage take place; this compli- cation occurred to me at St. Mark's, in the person of an elderly woman of feeble powers; she lost very much blood, and the flux was arrested only by plugging the rectum. The same observation applies to the use of acid to venous haem- orrhoids in old people. I saw a very profuse haemorrhage take place in an old man who had been a free drinker, and had great dilatation of the veins at the lower part of the rectum, probably depending upon a diseased condition of liver. It was not thought desirable to use the ligature, and nitric acid was applied; it caused a considerable slough, and bleeding commeneed in four days; before, in fact, the slough had separated. This patient nearly lost his life. A stricture of the rectum may result from the use of the fuming nitric acid; I have seen this occur on several occa- sions, and very notably in a girl at St. Mark's Hospital, to whom acid had to be applied three times, and in whom a stricture formed about three and a half inches from the anus; this gave us much trouble, as, although the bowel did not come down, the symptoms were quite as distressing as those of that affection. I have used strong carbolic acid in these cases; it is not likely to produce a slough, and you may apply it frequently — in fact, every day, if you desire to do so; benefit results, but the effect is not, in my opinion, so permanent as that derived from the acid nitrate of mercury. In very bad procidentia good may be effected, but unfor- tunately very temporary, by dissecting off triangular or ellip- tical portions of the mucous membrane, and bringing the edges together with sutures of horsehair or carbolized cat- gut. Care must be taken, in performing this operation, not to remove more than mucous membrane, for if you carry your knife into the sub-mucous tissue, you will get very pro- fuse haemorrhage. If you like you can clamp portions of the gut, cut them away and use the actual cautery, or you may apply a ligature; I have tried all these methods, but I can only say that I have achieved very partial success; the patient may leave the hospital very well, and you may con- gratulate yourself upon having effected a cure, but in a few months the bowel will again protrude, in all probability, as badly as ever. PROCIDENTIA RECTI. 12 J In the second edition of this work I said, " Dr. Van Buren, of New York, has recommended in these intracta- ble cases the application of the actual cautery to the gut, in spots or lines, and also to the verge of the anns over ihe external sphincter muscle, so as to get contraction and thus support the bowel. This strikes me as a very good sugges- tion, and I shall certainly try it on a case where other means have failed." I have now used this method on many hos- pital and private patients and effected permanent cures. The procidentia in the adult is sometimes very large; I have seen it in a woman, larger in circumference than the foetal head, and seven or eight inches in length. I have had, in my own practice, many cases of prociden- tia, in which there was a hernial sac in the protrusion, and in all it was situated anteriorly, as from the anatomy of the part, of course, it must be; you could return the intestine out of the sac, and it went back with a gurgling noise. Directly the bowel is protruded you can tell that there is a hernia also present by the fact that the opening of the gut is turned toward the sacrum; when the hernia is reduced the orifice is immediately restored to its normal position in the axis of the bowel. I have seen several similar cases in the practice of my colleagues at St. Mark's; the condition is therefore not very uncommon, but I have never found it in children. In very old and bad cases of procidentia more or less incontinence of faeces always exists. There may be two reasons for this symptom. First, loss of tone in the sphinc- ters; the frequent protrusion stretching these muscles so that they lose a great deal of their contractile power; and sec- ondly, the mucous membrane gets so altered in structure as to lose, in a great degree, its natural sensitiveness; thus when fecal matter comes into the ' lower part of the rectum, the sphincters are not stimulated to action, nor is the patient aware of its presence. The operation by the hot iron or Paquelin cautery, sug- gested by Dr. Van Buren, is thus performed by me: The patient is put under the influence of ether, and if the part be not down it can be readily drawn fully out of the anus by the volsellum. I then, having the intestine held firmly out, with the iron cautery at a dull red heat, make four or more longitudinal stripes from the base to the apex of the pro- truded intestine. I take care not to make cauterization so deep toward the apex as at the base, because near the apex 128 PROCIDENTIA RECTI. the peritoneum may be close beneath the intestine, while a deep burn near the base is not dangerous. I take care to avoid the large veins which can be seen on the surface of the bowel. If the procidentia be very large I make even six stripes. I then oil and return the intestine within the anus; having done this I partially divide the sphincters on both sides of the anus with a sawing motion of the hot iron, and then insert a small portion of oiled wool. From the day of operation I never let the patient get out of bed for anything; the motions are all passed lying down, consequently the part never comes outside. If the wounds have not all thor- oughly healed in a month, I continue the recumbent posi- tion for two weeks more, by which time it very rarely hap- pens that all is not healed. The patient can then arise and get about, but still for some time I enjoin that evacuation of the motions should be accomplished lying down. The reason for the success of the treatment is simple enough. When the burns are all healed, the bowel, by contraction of the longitudinal stripes, is drawn upward, and circumferen- tial diminution also takes place. In these cases, before ope- ration, the sphincter muscles have quite lost power, the anus is large and patulous; by sawing through the anus with the iron the muscles contract and regain their power, the patient having strength to cause the anus to close at will, and even, to some extent, to squeeze the finger when introduced. With this method of treatment I have had great success, many persons being quite cured, while others have been greatly benefited, so as to be able to work, by only wearing a pad of cotton wadding. In a case I had with Dr. Way, of Eaton Square, a lady who had for years suffered from a procidentia recti five inches long and nearly three in diameter, a perfect cure was effected. She wrote me on the anniversary of the operation, to say the bowel had never come down, though she walked very much and had to go up and down flights of stairs con- stantly. I need not say how grateful she was. In another case in the practice of Dr. Woodhouse, of FuUham, in which several operations had been performed unsuccessfully before I saw him, and the procidented intestine was very large, a permanent cure was effected. In a very bad case attended by the late Mr. E. Carr Jackson and myself, the vessels on the bowel were so large that great bleeding took place when the cautery was applied^^ and ligatures had to be used. Secondary haemorrhage, to an extent requiring very careful plugging, PROCIDENTIA RECTI. I29 also occurred when the sloughs separated. This patient was very anaemic, through large losses of blood prior to the operations, and he was blanched to a dirty white, yet he thoroughly recovered, and the bowel has never again pro- truded. This patient was seen quite recently and remains perfectly well. Several hospital cases which I have had during the last few years have done admirably, though some have required care and watching for months after the operation. Sometimes, when a large portion of the bowel comes down, there is much difficulty experienced in returning it. I have found, on several occasions, that the passing up the bowel of a large flexible bougie, so as to carry before it the upper part of the descended gut, is of great service; gentle taxis should at the same time be used, and in this manner the mass can generally be returned. When the gut comes down, and the patient cannot get it back and does not seek assist- ance, it gets tightly girt about by the sphincter, great swell- ing takes place, and sloughing may ensue. I have seen many cases of this kind, but, as far as my experience goes, the sloughing is partial, and only the mucous membrane separates. After a few days' rest, with the buttocks well raised, to favor the return of blood, the part can be replaced and considerable benefit may result. The only case I ever saw where anything like dangerous or deep sloughing took place was in consultation with a medical man who had most assiduously and constantly applied a bladder of ice to the protruded part, and this had so much favored sphacelus that nearly the whole mass came away, and there was free secondary haemorrhage. In this case the sloughing was so considerable that a very intractable stricture resulted. This shows the necessity of care in the application of ice; if it be too long continued, or if the patient be old or of feeble con- stitution, dangerous results may ensue. I am not aware of any internal remedy which is of much use in cases of procidentia, but small and frequent doses of opium, with confection of black pepper, benefited some of my patients. A nasty, teasing diarrhoea is very commonly present, and there is often a discharge of mucus, which keeps the linen always damp, and adds not a little to the general discomfort. Powdered acorns I have used frequently with advantage, for the diarrhoea. The acorns should be baked and grated to powder, and the dose is one teaspoonful in half a tumbler of 130 POLYPUS RECTI. milk every morning. I have found this answer better than either gallic or tannic acid. The frequent and bountiful application of cold water in these cases is to be strongly recommended. It is as useful as ordinary astringent lotions. CHAPTER XIII. POLYPUS RECTL This disease was formerly looked upon as a very rare one; recently, however, it has been considered rather more common, and it is supposed that in times gone by, rectal maladies not being so well understood, many cases of poly- pus escaped diagnosis. At a meeting of the Pathological Society, in February, 1873, a gentleman stated that he had seen fifteen cases in twelve months. His, I think, must be a somewhat singular experience. I find that I have noted altogether 6;^ cases without complication, as having occurred in my own practice. My statistics at St. Mark's Hospital shows that in 4000 cases of rectal disease there were only sixteen of polypus without fissure. It has generally been believed that polypi are much more frequently found in children than in adults; this has not been the case in my experience, as ;^6 existed in children under fourteen years of age, and 27 in older persons. By the word " polypus " I must be understood to mean a pedunculated growth attached to the mucous membrane of the rectum, and generally situated not less than an inch from the anus. I have seen them quite two inches up the bowel, but only occasionally more than that distance. In the majority of cases the polypus grows from the dorsal portion of the rectum, but I have found it on the perineal and lateral segments. I think some surgeons apply the term " polypus " to those small muco-cutaneous polypoid growths which are so often found at the upper end of a fissure, and' thus swell their statistics. My friend Dr. Daniel Molliere, of Lyons (whose work on rectal surgery surpasses all others in its pathology), says, *' There is no word in surgery that has been more abused in POLYPUS RECTI. I3I its use than the word polypus, especially when applied to tumors of the rectum. As a matter of fact, the term ' poly- pus of the rectum ' is used to describe any neoplasm, no matter whether benign or malignant, hard or soft, provided only that it adheres to the rectum by a stalk or relatively limited base." Polypi have been usually described as of two kinds; the soft or follicular, and the hard or fibrous — the former being found in children, and the latter in grown-up persons. I do not concur in the statement that the soft polypus is always the one found in young children, and I am of opinion that the true fibrous variety is rare even in the adult. In fact, this rough division is very far from the pathological truth, for the true fibrous polypus, in its anatomy, is an almost perfect counterpart of the fibroid tumor of the uterus. In the Hunterian Museum is one specimen of rectal polypus arising from the muscular fibres of the rectum, and it is in reality a fibro-muscular tumor, or, in the nomenclature of Virchow, a myoma. The few I have s^n myself have been nearly as large as an English walnut; they creak when cut, and the incised surface is of a pale color. The peduncle is about an inch and a half long, and is always attached above the sphincters; the tumors do not usually appear outside the anus, they do not bleed, but when they do protrude they cause pain, irritation, and spasm, and often set up an ulcer in the bowel. The discharge from them is of a very icho- rious and ill-smelling character. These polypi have been observed and minutely described by both French and Ger- man pathologists, and. are considered quite exceptional' specimens of this form of tumor. The polypi usually found in the adult are smaller than the mucous polypi of children; they are multiple. I have often found two growing from opposite sides of the rectum; there may also be two stems with one head only. The pedicle may be an inch or a little more in length, and is not uncom- monly hollow; the polypi are neither very hard nor soft, and are easily compressible; they are sometimes cystic; a large vessel runs up the stem; in some cases you can feel it pul- sate. The soft follicular polypus of children is no doubt rarely met with in adults, but even in these it is not so rare as my colleague, Mr. Gowlland, believes, who once stated at the Medical Society that there were only two kinds of polypi, "the soft and the hard." He had evidently not consulted 132 POLYPUS RECTI. the writings of foreign pathologists, or he would have found that there are numbers of different forms. The soft polypus is almost always found in women, and thus Dr. Routh is likely, as he says, to have seen a considerable number. The stem is remarkably long and rather slender. The polypi of children are small, vascular tumors, with a peduncle often two inches long. They are about the size of a raspberry, and resemble a small, half-ripe mulberry more than anything else; they bleed very freely at times, and occasion in the young great debility. They are said to be either hypertrophies of the glands of Lieberkiihn, or of the mucous follicles of the rectum. They may be dangerous when high up, by occasioning intussusception of the bowel, with total obstruction and death. When the peduncle is more than an inch in length they usually protrude at stool, and require to be returned after the bowels are relieved. They are sure to be described by the child's mother as piles, or as " the body coming down." The peduncle is ^something so slender that it breaks on very slight traction, and I dare say many polypi become detached when the child is straining or passing a hard motion, and are thus spontaneously cured. A most valuable and original account of polypi in children, by the late Dr. Bathurst Woodman, and founded on his experience at the Northeastern Hospital for Children, may be found in the Medical Press and Circular^ May 5th, 1875. He names five kinds of polypi — i, the soft and gelatinous; 2, the cystic; 3, the papillomatous; 4, the dermoid; 5, the sarcomatous. Dr. Woodman states, that the most common variety in children is the hard polypus (I must say that such has not been my experience), and that " the children of arthritic parents, and those suffering from the syphilitic, tuberculous, and cancerous cachexiae are most liable to these affections." From the polypus of the adult I have often seen abscess, ulcer or fissure, and fistula arise. A short time since a patient was sent to me with a fistula, complete and dorsal; the probe passed readily through it into the bowel. On introducing my finger I found the internal opening very large, a hard polypus as big as a marble projected into it; the stem was quite half an inch long, and was attached near the promontory of the sacrum. I have seen, on post-mortem examination in both adults and children, full-sized polypi attached as high as the sigmoid flexure of the colon, and POLYPUS RECTI. I33 also in the colon itself ; they cause diarrhoea and may bring on obstruction of the bowel by setting up inflammation, which occasions paralysis of the muscular coat of the intes- tine. When fissure exists with polypus, the removal of the polypus and gentle dilatation will cure both maladies. The diagnosis of polypus has been stated to be difficult. I cannot myself see why any difficulty should arise. The his- tory of the case and symptoms will usually lead you to sus- pect what the disease is, and if you are careful to administer an injection and thoroughly search the bowel you must feel or see it. When a polypus has a long pedicle it is apt to slip away from the finger, but even then the peduncle can be readily felt at its point of attachment to the rectum. The general symptoms in children are — frequent desire to go to stool, accompanied by tenesmus, occasional bleeding, with discharge of mucus, and a fleshy mass protruding from or appearing at the anus when the bowels are acting. It is possible to mistake this disease for internal piles, pro- cidentia recti, or dysentery. An examination after an injec- tion will clear up the doubt in the first two cases; in the last, the presence of fever, the abdominal pain, and the appear- ance of the motions are sufficiently distinctive indications. In the adult the history, carefully inquired into, may be found peculiar. The patient will tell you that without any previous marked discomfort in the rectum, he all at once discovered that a substance protruded on going to the closet. 1 his is characteristic of the malady; until the peduncle becomes long enough to allow of the polypus being extruded or grasped by the external sphincter, but little or no incon- venience is felt, therefore the onset of the disease is consid- ered by the patient as sudden; this is quite different from the history of haemorrhoids. I cannot at all say why these growths should arise; they are not often connected with haemorrhoids or any other dis- eases of the rectum save fissure and intussception. I have not even observed that constipation, that potent factor of bowel affections, obtains in these cases. I will relate a few cases of polypus, and then say a word or two about treat- ment. Thos. B. — , set. 4, seen at the Farringdon Dispensary, October 27th, 1862. For more than twelve months has had what was supposed to be prolapsus of the bowel; he lost a good deal of blood at times, and was very feeble and anaemic. After an injection there came down to the anus 134 POLYPUS RECTI. a spongy, irregular-shaped, bleeding mass, fully as large as a medium-sized walnut ; it felt soft, but not gelatinous. A tolerably long pedicle connected it with the anterior wall of the rectum. I applied a ligature and cut the polypus off. He was ordered an astringent draught to confine the bowels for a few days. November ist. He took a dose of castor oil and the ligature came away on the bowels acting. There was no bleeding. Discharged cured. Jane H — , aet. 7, brought to St. Mark's Hospital, October, 1864. Her mother said that something came down when the bowels acted, and she lost much blood; she was obliged to put the substance back again. After an injection two tumors made their appearance, and I at first thought it was a case of haemorrhoids; but on closer examination, passing my finger into the rectum, I found that they were polypi, arising by two peduncles from quite an inch and a half up the bowel. One appeared to be attached dorsally, and the other laterally. I applied two ligatures and snipped off the growths. In three days the ligatures came away, and she was soon quite well. Henry de C — , admitted into St. Mark's, March, 1866. He was six years old, and looked a very feeble, delicate boy. For two or three years he had lost blood at stool, and latterly something had protruded after an evacuation; it had to be returned by pressure. He had taken a quantity of medicine, and been treated at several public institutions. After an injection a dark-colored, very vascular polypus came into view; it had a well-defined, rather thick neck. I applied a ligature and cut through the pedicle; the tumor was about the size of a raspberry. The thread separated in five days, and there was no haemorrhage. I kept him under observation some time, giving him tonics; he was ultimately discharged, perfectly recovered. Hugh L — , aet. 9, a weak and irritable boy, emaciated and bloodless, suffers from cough. His mother says he has been troubled for five years, at least, with his bowel coming down whenever he went to the closet. He returned it himself by pressure. He had been taken to medical men, and also to hospitals, and she had been told that it was a weakness of the bowel, and had used ointments and lotions for it. The loss of blood he had sustained lately had been very severe. He did not suffer any pain. When I first saw him his mother said '' his body " would come down if he stooped and strained a little, and on his doing so a round, vascular, bright- red, villous body, bleeding freely, was seen outside the anus. POLYPUS RECTI. I35 It was not at all painful to the touch. I found that it was connected with the bowel just above the internal sphincter, by a pedicle of pale color, at least two inches long. I applied a silk ligature and ordered him a little aromatic confection, to confine the bowels. In three days the ligature separated on action taking place. I then prescribed for him some iron and cod-liver oil. In a fortnight they brought him again, saying that another substance had made its appearance, and sure enough, on his straining, a tumor, almost precisely sim- ilar to the former one, protruded from the anus. To this also I applied a ligature. When I saw him at the end of the week I administered an injection to see if there were any more polypi, but I found none, so I discharged him as cured. Duncan J — , set. i8, came to St. Mark's in 1867. His health was generally good. For twelve months he had some- thing protrude from the anus on visiting the water closet, and he had lost a quantity of blood. It retracted spontane- ously on his rising up after the action. He has been under the care of many physcians and surgeons, and has always been treated for bleeding piles. He has a pain of a dragging, burning character in the rectum, but it is not severe. After an injection a large (the size of a walnut), vascular, velvety- looking polypus appeared at the verge of the anus. The pedicle was rather thin, and not so long as usual. I held it with a volsellum while the house-surgeon applied a ligature; this was pulled so tight that it cut the peduncle at once. I was apprehensive of bleeding, and so kept him lying down in the out-patients' room for a couple of hours, when, finding there was no haemorrhage, I sent him home. In a week he came and said he was quite well. Martha H — , aet. 25; married; no children; several mis- carriages; admitted into St. Mark's, 1865. She had one perineal hsemorrhoid and a dorsal fibrous polypus, the size of hazel-nut. The polypus had a shortish broad pedicle; it was situated above the internal sphincter, and I found some difficulty in applying the ligature. She left the hospital well. Mr. James B — , set. 37, was sent to me by a medical man who thought he was suffering from piles After an injection a polypus came down, resembling much that found in children, but it was firm and not so vascular; it was about the size of a raspberry. I placed a ligature on the stem and cut it off. This gentleman did not rest, as I advised him to do, for a few days, and he had an abscess form a week after the separation of the ligature. 136 PRURITUS ANl. A lady, set. 46, who had been supposed to be suffering from some uterine affection, was sent to me by Dr. Priestley. He had found on examination that the patient's symptoms were due to a polypus of the rectum; this was easily felt from the vaginia. I removed the polypus, and the patient soon recovered. • These cases of polypus forcibly illustrate the desirability of always giving an enema before making an examination, as it is only by seeing the patient just after the bowels have acted that you can make certain of your diagnosis. The only treatment to be recommended is the removal of the growth. I do not think it safe either to cut or tear polypi off, as troublesome arterial haemorrhage may ensue. I have seen them bleed very freely indeed, and, as they are attached at some distance from the anus, it would be by no means easy to place a ligature upon the bleeding vessel. I have used the clamp and actual cautery twice, and it answered very well, but it is rather a formidable proceeding, the idea of hot irons frightening the patient, although really the operation is painless, as also is the ligature; the latter has the advantage of being always at hand. The simplest method, however, is to seize the peduncle close to its base, with the German catch torsion forceps, and gently twist the polypus around until it comes away. There is no danger of haemorrhage, no pain, and scarcely any necessity for resting more than one day. If a ligature be used, I think it is very desirable that the patient should rest until it separates, and I usually order a mild astringent draught, to keep the bowels confined, for three days, then I administer^an aperient, and on relief tak- ing place the ligature comes away. In two cases I have seen abscesses follow where much exercise had been taken. CHAPTER XIV. PRURITUS ANI. Pruritus ani, or, as it may well be called, painful itching of the anus, is a most distressing malady. I have often heard a patient say that his or her life was rendered almost PRURITUS ANI. 137 unendurable by it. In fact, one very nervous invalid told me that unless he had obtained relief, he believed that he should have gone out of his mind. It is very intractable, but I am confident that it is always curable if the patient will strictly, patiently, and persistently follow the advice of his medical attendant. The disorder is frequently induced, or at all events kept up, by habits of too free eating and drinking, and its success- ful treatment, therefore, calls for a considerable amount of self-denial on the part of the patient ; and thus it often hap- pens that as soon as the sufferer gets relieved he forgets all his prudent resolutions and relapses into his old way of life — a step which is pretty certain to result in the return of his enemy in full force. He then usually blames his doctor, very rarely himself, and either gives up in despair all hope of cure, or seeks new advice, so that the affection comes to be considered as not only an exceedingly troublesome one, but almost incurable. I can truly state that I have rarely, if ever, failed to cure a patient who adhered rigidly to my directions ; and when a person, the subject of bad pruritus, comes to me, I always say, " Unless you intend to conform most religiously to my directions, as long as I think necess- ary, I cannot cure you, and I had much rather that you con- sulted some other surgeon." Although, as I have said, free living often induces pruritus, I have met with many cases in very abstemious persons ; I have seen a most ascetic clergy- man suffer dreadfully, and I have had under my care a lady who nearly all her life has been a total abstainer from alco- hol, and is a remarkably small eater, yet she has been quite a martyr to this complaint. The irritation, in the majority of cases, is worse at night, especially when the patient gets warm in bed, so that often the greater part of the night is rendered sleepless and inex- pressibly wretched; towards the morning, irritable and worn out, he falls off into a fitful slumber, from which he often awakens himself by scratching ; this, of course, makes the part more or less raw, and materially adds to his discomfort in the daytime. I need scarcely say that the more the suf- ferer scratches the worse he makes himself, although it is very difficult indeed to avoid seeking the temporary relief it affords. Many persons have told me they would infinitely prefer decided pain to the dreadful and constant itching they have to endure, which really, after a time, becomes pain of a most sickening character. Excitable people are often 138 PRURITUS ANT. greatly troubled in the day as well as at night, the itching setting in badly after exercise or on leaving the cold air and coming into a warm room. Doubtless there are many cases of pruritus for which we are unable to assign any cause, and it may then be consid- ered as a pure neurosis ; but usually it is possible to dis- cover some reason for the irritation in derangement of other organs. The secauses may be mentioned — liver affections, internal haemorrhoids, constipation, anything causing press- ure upon the hsemorrhoidal veins so as to retard the return of blood from the rectum, disorders of the stomach induced by errors in diet, latent gout, uterine diseases, and we must not forget parasites, as vegetable growths, pediculi similar to those found on the pubes, and ascarides. It is generally stated that there is a very little alteration in the aspect of the part affected, and that nothing is to be observed beyond a roughened, thickened and more rugose state of the skin just around the anus. This I think is by no means usually the case; sometimes there is a distinctly eczematous rash, the part being always moist from exuda- tion; at others there is a dry, rugose condition, with bright redness consequent upon scratching; occasionally there are a quantity of minute scales to be seen, forming irregular rings; often cracks are seen radiating from the anus, and even extending up to the sacrum; but what I consider the characteristic condition — which may ahyays be noticed when the disease is severe, and has lasted for any length of time — is the loss of the natural pigment of the part. To such an extent does this often obtain, that patches around the anus, extending backward as far as the sacrum and for- ward to the scrotum, are of a dull, dead white, the skin looking more like very white parchment than natural integu- ment, and if you pinch it up you will feel that it has lost its normal elasticity. I have seen a similar condition induced by genital pruritus in women. When considering a case as to the question of treatment, it is always important to discover the cause of the irritation; particular articles of diet or drink affect some persons in a remarkable manner. I once, had a patient who invariably got an attack of pruritus from eating lobster or crab, and of these shellfish he was inordinately fond, but rarely dared to indulge his taste. I have seen a similar result from eating salmon. Another of my patients was sure to suffer if he drank any quantity of champagne or ale, and the irritation. PRURITUS ANI. 139 once started was very difficult to arrest. There is but little doubt that excess at table, combined with a want of active exercise,are not only a predisposing but also an exciting cause. Excessive smoking is another excitant of the disorder; I have seen several instances (where patients had a tendency to the malady) of over-indulgence in smoking being fol- lowed immediately by an attack of pruritus. Spare no pains to investigate closely the habits of your patient. Stout, plethoric people should be put on a rather low diet; they should avoid all rich and highly seasoned dishes, eat but little meat, and take fish, poultry, vegetables, and ripe fruits. Interdict both beer and spirits, and restrict the drinking to a little light sherry or claret and Vichy or Seltzer water. Coffee should be given up, weak tea or cocoa being taken at breakfast. Enjoin a walk of three or four miles daily, and, if possible, at such a speed as to induce slight perspiration; let the patient take a sponge bath every morning, a warm or Turkish bath once in the week, and every night when retiring to bed wash the anus and parts around with warm water and tar or Castile soap. If the bowels are at all confined the following prescription will be found beneficial: ^. Magnes Sulph 3j Magnes. Carb. pond gr. v Vini Colchici mv Syrupi Sennae 3 j Tinct. Cardam. comp 3 ss Ex. Inf. Chiratae § j M. Twice or thrice in the day. And I also often order — ]^ . Pil. Plummer gr. ij Til. Rhei. comp gr. iij M. To be taken every other night for a week. The mineral waters of Carlsbad, Friedrichshall, Vichy, Hunyadi Janos, Pullna, etc., are good remedies, and I fre- quently employ them. After the washing at night let the patient apply this oint- ment freely: 3 . Hydrarg. Subchlor gr. x Ung. Sambuci 3 j M. I40 PRURITUS ANI. Or this lotion, which, is very efficacious in allaying irrita- tion : — ^ . Sodse Biboratis 3 ij Morphias Hydrochlor gr. xvj Acidi Hydrocyanic, dil | ss Glycerinse | ij Aquae ad § viij. M. Dab the part frequently. A chloroform pomade made thus is often useful: — ^ . Chloroform 3 ij Glycerinae | ss Ung. Sambuci | iss. M. A lotion of borax with colchicum, a saturated solution of borax, the Ung. Boracis c. Vaseline (gr. x, ad 3 j), the sul- phide of calcium internally and externally, as recommended by Hebra, a pap of Tenax, are other remedies that may be tried. Sir Benjamin Brodie had much success from the white precipitate ointment. The following prescription of the late Mr. Startin has been of great service to many patients suffering from eczema. I have seen a bad case cured in forty-eight hours by its application alone: — 5" Liquoris Carbonis Detergent. (Wright's) Glycerinae aa. . . . | j Zinci Oxidi, Pulv. Calamin. prep aa . . . . | ss Pulv. Sulph. precip 3 ss Aquae purae ad | vj. M. The part affected to be painted thickly over once or twice daily and allowed to dry. Lastly, I must not omit to men- tion carbolic acid, with glycerine or water, as being very useful, and also prophylactic, after other treatment has suc- ceeded. All remedies may for a time be disappointing, and in long-standing cases you must be prepared to alter your pre- scriptions until you find what best suits your patient. In old and feeble persons the combination of the sulphates of iron and magnesia with dilute sulphuric acid and infusion of quassia often does good; with it I have cured a number of elderly people whose lives were embittered by long con- tinued itching. Often in them the parts are quite raw, and PRURITUS ANI. 141 discharge an ichorous irritating fluid, The tonic and laxa- tive mixture above mentioned, and the borax lotion, with great attention to washing the part with warm water and Castile soap, have usually been followed with great benefit and ultimate cure. When you have made up your mlhd that the essence of the disease is in the nervous system, as I think it often is, particularly in spare and delicate, excitable people, you should give arsenic and quinine freely, and be prepared to push them to their physiological effect. They may be taken separately or combined. I have rarely failed to cure this class of cases by pereverence in these remedies; at the same time, of course, using local means to allay irritation. In obstinate, old-standing cases I usually commence the treat- ment by rubbing the parts thoroughly with a solution of nitrate of silver, 3ij to the ounce; this softens the skin and induces a more healthy action and secretion. At times I have found Condy's fluid, undiluted, useful for the same purpose; it should be applied twice or oftener in the week. The disorder is not, by any means, so common in women as in men, nor is it frequently met with in young persons ; but one of the most obstinate cases I ever had occurred in a delicate lad of seventeen. There did not appear to be any ascertainable cause for the irritation, and he was eventually cured by Liquor Potassae Arsenitis in full doses and cod- liver oil. I had once a very intractable case in a man nearly eighty years of age, who was an inmate of the Bookbinders' Almshouses at Kingsland; it resisted all remedies for some time, but eventually yielded to arsenic internally and the strong caustic solution frequently applied. In women the uterine functions should be attended to; and I have fre- quently found the citrate of iron, quinine, and strychnine very advantageous. I have met with a good many examples of latent gout as a cause of pruritus ani. A gentleman was under my care some time ago who had often suffered from pruritus, and always got rid of it when gout attacked him, and he was free for some time afterwards. Here diet is a most important element in the treatment. I think the irritation is best allayed by a strong solution of bicarbonate or bisulphate of soda frequently applied in a poultice. I have formed a good opinion of the usefulness of lithia water and the effervescing citrate of lithia. In some cases, where the irritation is very severe, colchicum with 142 PRURITUS ANI. alkalies answers best, but if it can be managed, a course of waters at Baden-Baden, Ems, or Carlsbad, will be found most beneficial. I have a very excitable, nervous patient who frequently gets an attack of pruritus when he is mentally overworked or irritated, and in this and similar cases I have found the bromide of potassium very advantageous, and I have com- bined with this ten or fifteen grains of the hydrate of chloral, This mixture taken at bedtime generally ensures a fair night. An extended experience in this class of cases has induced me to think most highly of the bromide of potassium and chloral in combination. In alternation with the chloral I have seen great advantage result from the Succus Conii in full doses (one to two drachms given three times in the day); to this may be added cod-liver oil after meals, by which means I think you may repair nerve-tissue and induce a more regular distribution of nerve-force. I am fully con- vinced that the more you treat pruritus ani as a general dis- ease the more successful you will be; the difficulty in curing it has arisen in great measure from its having been consid- ered as merely a local affection, and only local means having been applied for its relief. In the treatment of pruritus ani it is well to avoid the internal administration of opium in any form; you may pro- cure a night's rest by its use, but you pay dearly for it after- wards, in an increase of the disorder. When the irritation is so great that the patient is quite worn out for w^ant of rest, I have for years past recommended the introduction into the anus at bedtime of a bone plug, shaped like the nipple of an infant's feeding-bottle, with a circular shield to prevent it from slipping into the bowel; the nipple should be about an inch and a half in length and as thick as the end of the forefinger. This is most efficient in preventing the nocturnal itching; a good night's rest is almost sure to result from its use, but I advise it to be worn only every other night. I presume that it benefits by exercising pressure upon the venous plexus and filaments of nerves close to the anus. The idea of this plug occurred to me from several of my patients telling me that the only way they could obtain relief and sleep, when the itching was very bad, was by introducing the end of the forefinger into the anus, and making pressure; this instantly arrested the irritation. When pruritus is accompanied by internal haemorrhoids, their removal almost always cures the itching; this result PRURITUS ANI. 143 was well shown ii> a very bad case operated upon by me in the practice of Mr. Gervis, of Haverstock Hill. The irrita- tion had been present for a long while, and it had resisted all kinds of treatment, but yielded when the piles were got rid of. Pruritus caused by a parasitic vegetable growth is readily cured by the application of sulphur ointment; or, what is much cleaner, and equally efficacious, a lotion of sulphurous acid of the strength of one part to six of water. I had soma time ago, in an adult, a very obstinate case of anal irritation, caused by ascarides. I really did not expect these to be the origin of the malady, but I happened to see one of the worms just at the orifice; a brisk purge, and a few injections of solution of iron freed the patient of the parasites and the pruritus also. It always well to bear in mind the possibility of these causes of the disorder. CHAPTER XV. FISSURE AND PAINFUL IRRITABLE ULCER OF THE RECTUM. This is an excessively painful and by no means uncommon affection; it is more frequently found in women than in men, although not rare in the latter. I have seen fissure in a baby in arms, and in a old woman of eighty, in whom it was associated with ^n impaction. By far the most usual position of fissure is dorsal or nearly dorsal, although it may be anterior or lateral. It may be brought about by an injury or tearing of the mucous membrane at the verge of the anus; it may therefore be caused by straining, or by the passage of very dry, hard motions; sometimes it follows severe diarrhoea; it is frequently the sequel of a confinement, and the accompaniment, and occasional result, of polypus. The origin of many fissures is syphilis. As a rule patients suffering from fissure of the rectum imagine that their symptoms are due to haemorrhoids; they tell you that they have a discharge of blood and matter, a swelling outside the bowel, and pain at stool, and they believe they have piles. Unfortunately, not infrequently the medical attendant is satisfied with the patient's diagnosis, and treats the case as one of external haemorrhoids* 144 FISSURE AND PAINFUL I should say generally that when a patient complains of great pain on defecation, it is not piles that he is suffering from, and certainly not uncomplicated piles. In fissure the pain on the bowels acting is more or less acute; some describe it as like tearing open a wound, and doubtless it is of very excruciating character. I have known patients who for hours could not bear to stir from one posi- tion, the least movement causing an exacerbation of the pain. This agony induces the sufferer to postpone reUeving the bowels as long as possible, the result being that the motion becomes desiccated and hardened, and inflicts more grievous pain when at last it has to be discharged. After action of the bowels, the pain may in a short time entirely cease, and not return at all until another evacuation takes place, but often it continues very severe and of a burning character, or it is of a dull, heavy character, and accom- panied by throbbing, which lasts for hours, sometimes even all day, so that the patient is obliged to lie down, and is utterly incapable of attending to any business. In some instances the pain does not set in until a quarter or half an hour after the bowels have acted. In children and young persons, unless a polypus com- plicates the fissure, I think it is almost always curable without operation. I have had many cases resembling the following. A child, aet. 4^, admitted into St. Mark's, September, 1867. For twelve months or more he has been subject to procidentia every time his bowels acted; he is usually rather constipated. About five or six months ago he began to suffer pain, which lasted for hours after the bowels had been relieved; this was so severe that he screamed and rolled about in his bed; he often passed a little blood; the pain was much aggravated when he was costive. On an injection being given, the rectum came down, and a very distinct fissure with a papillary growth at its commencement was seen. There was no polypus in the bowel; Ung. Zinci with extract of belladonna and opium was ordered to be used night and morning, and confection of senna with sulphur to be taken to keep the bowels gently acting. This prescription afforded immediate relief; in three weeks the ulcer was healed and the child perfectly cured. In children suffering from hereditary syphilis, numerous small cracks round the anus are common, and they cause much pain. Mercurial applications and extreme cleanli- ness soon cure them, but they will return from time to time IRRITABLE ULCER OF THE RECTUM. 145 unless anti-syphilitic medicines be taken for a lengthened period. Fissure, although really so simple a matter, and its cure generally so easy, wears out the patient's health and strength in a remarkable manner; the constant pain and irritation to the nervous system are more than most persons can bear; I have frequently seen women suffering from small anal ulcer, who thought they must have cancer, in consequence of their extreme illness and pain. What under these circum- stances is very extraordinary is the length of time people go on enduring the malady without having anything done for it. It is not an uncommon thing for one to see fissures of many years' duration, especially in young women, who, through delicacy of feeling, often conceal rectal affections. It is common for fissures to heal for a time and then break out again, so patients are apt to think a perfect cure will result, and defer proper treatment. The usual position on the side is the best for making an examination. Let the patient raise the upper buttock with the hand, then with your fore-finger and thumb gently open the anus, at the same moment telling the patient to strain down; you will then be able to see, just within the orifice, an elongated, club-shaped ulcer; the floor of it may be very red and inflamed, or, if the ulcer is of long standing, of a grey- ish color with the edges well defined and hard. Frequently the sight of the fissure is marked externally by a small clavate papilla or minute muco-cutaneous poly- poid growth; this must not be confounded with ordinary polypus, and it is not the cause of the fissure, but the result of the local irritation and inflammation which have been going on. Sometimes the situation of the fissure is indica- ted by an inflamed and swollen piece of skin, and in this case ulceration through the portion of the integurr^ent not infrequently occurs, and a small but extremely painful fistula results. In such a case very probably a small abscess had formed just above the external sphincter, and had burrowed under it, making in time a complete fistula. These small abscesses are very painful. It occurred to me to observe this in the wife of a medical man. When I first examined her I found she had well-marked fissure and an inflamed piece of skin close to the anus. I predicted that the ulcer- ation would perforate this, and so it did, for in- about ten days, when I went to operate upon her, I found a small fistula had formed. 146 FISSURE AND PAINFUL Occasionally, on proceeding to examine a patient, the first thing you see is the small club-shaped papilla I have already mentioned protruding from the anus; you may then be certain that an ulcer exists. I may here mention that when operat- ing, this growth ought to be snipped off, or the case may not do well, as it falls down into the wound and retards or quite prevents healing. Fissure is very commonly associated with uterine displace- ment. I have stated that of)erations upon haemorrhoids under similar conditions are not satisfactory; the same observation applies with quite as much truth to fissure and uterine disease. I have many times had reasons to repent interfering with these cases. The successful treatment of the uterine disorder may be sufficient to cure the fissure (if no polypus exists), or at all events the ulcer will afterwards yield to local applications and general treatment. If the fissure should be benefited by operation, as long as the uterine malady exists there will be a constant danger of a relapse taking place. The most common forms of uterine displacement in connection with fissure are, according to my experience, anteversion and retroversion, and associated with these I have frequently observed affections of the blad- der, chronic cystitis, and spasmodic pains in micturition. When you find these three disorders united, depend upon it you will have a case that will call for all your skill and patience to bring to a successful issue. Gelatinous and fibrous polypi are not at all uncommon complications of fissure. The polypus is usually situated at the upper or internal end of the fissure, but it may be on the opposite side of the rectum. Here is a case: Mary G ; aet. 47,. was admitted into St. Mark's, April, 187 1. She had a well-marked and very painful fissure near the anus. There was no polypus to be seen, but on passing my finger into the rectum I found a pedunculated fleshy polypus on the opposite side of the bowel to that on which the fissure was situated. I am quite confident that had I incised the fissure and left the polypus this patient would not have recovered. If you do not remove a polypus at the time you divide the ulcer, failure is certain to result, as I have myself seen many times. If the fissure is of recent origin it may often be cured without operation, especially if it be situated anteriorly. In women this can almost certainly be accomplished. Of all IRRITABLE ULCER OF THE RECTUM. 147 the varieties of fissure the syphilitic is most amenable to. general treatment; when of syphilitic origin they are often multiple. I have noticed three distinct, mell-marked fissures in one patient. I have seen, in the practice of my colleagues at St. Mark's, many instances of multiple fissure. I may here mention that if you are obliged to operate upon a multiple fissure one incision through the sphincter will be sufficient. Now as to the treatment. In all cases, rest in the recum- bent position should, as much as possible, be adopted. Mild laxatives should be given, not to purge, but to keep the bowels acting once daily; this may sometimes be effected by diet alone. The domestic remedy of figs soaked in sweet oil, or onions and milk at bedtime, may be sufficient. I often order a combination of equal parts of the confection of sulphur and confection of senna; small doses of sulphate of magnesia or sulphate of potash, half a tumbler of Pullna or Friedrichshall water taken in the morning fasting, the com- pound liquorice powder of the German pharmacopoeia, and the liquid extract of the Rhamnus frangula, are great favorites of mine. You must be prepared to alternate the medicines as one or other seems to lose its effect. All drastic purges should be avoided, but I do not object to small doses of the aqueous extract of aloes, especially when combined with nux vomica and iron. It will be an advantage if the patient can manage to get the bowels to act the last thing at night instead of in the morning, as the rest is very beneficial and the pain does not continue so long when lying down. After the action 3 ss of Liq. Opii sedativus may be injected with 3 ij of cold starch; this is especially valuable if the patient has the bowels relieved at bedtime. As an application, I know nothing better than the following ointment : — ]^ . Hydrarg. Sub-chloridi gr. iv Pulv. Opii gr. ij Ext. Belladonnae gr. ij Unguent. Sambuci 3 j. M. To be applied frequently. I have effected many cures with this ointment alone. An occasional very light touch with the nitrate of silver (not to cauterise but to sheathe the part with an albuminate of sil- ver) is useful, and it relieves pain for some time. If there be very great spasm of the sphincter, extract of belladonna 148 FISSURE AND PAINFUL may be thickly smeared around the anus over the muscle, and this I have at times found effective. If ointments do not agree with the sore, lotions maybe preferable; Goulard water with opiates and sedatives may afford some temporary relief, but one must acknowledge that the best devised and most carefully carried out general treatment frequently fails, save in favorable cases. In my opinion, if the base of the ulcer be gray and hard, and if on passing the finger into the bowel you find the sphincter hypertrophic and spasmodically contracted, feel- ing, as it often does, Hke a strong india-rubber band, with its upper edge sharply and hardly defined, nothing but the adoption of such means as will utterly and entirely prevent all action of the muscle for a greater or less length of time, is likely to effect a cure of the fissure. Some authors specify the time at which this disease may be curable without operation, and say, " If it has existed more than three months the attempt is hopeless;" but really the time is not of importance; the question is, what patho- logical changes have been brought about ? I have cured fissure of months' standing when there was no great hyper- trophy of the muscles. Here are some cases: Mrs. E , aet. 24, was sent to me by Dr. Simpson, of the Old Kent Road. Five months ago she was confined with her first child after a somewhat lingering labor. . The first time the bowels acted she had pain; and ever since then she has never had an action without suffering. This has been gradually increasing, and now her life is almost unendura- ble; the pain lasting for hours, and compelling her to lie down, so that she is quite unable to attend to her household duties. On examination a very characteristic dorsal fissure was seen; there was no polypus or piles. The rectum was generally healthy, and there was not very marked spasm or thickening of the sphincter. The bowels were confined. Ordered: — 5- . Magnes, Sulph 3 j Ferri Sulph gr. j . Acid Sulph. dilut Mv Inf. Quassise | j M. Ter die. And to use the following ointment: — IRRITABLE ULCER OF THE RECTUM. I49 1^ . Ung. Hydrarg. subchlor 3 j ^ Ext. Opii Ext. Belladonnas aa gr. iij M. To be applied after action of the bowels and also at night. I touched the ulcer every other day with a solution of perchloride of mercury. In a fortnight the fissure was nearly healed, and she had scarcely any pain after defeca- tion. Soon after this I heard she had got quite well. A city dignitary consulted me some time back, on the recommendation of Dr. Sedgwick Saunders. His history was that for eighteen months or more he had suffered pain on defecation; at times he was much better and only experi- enced uneasiness, and then again the pain returned as bad as ever. Homoeopathy had been tried for some six or seven months, and he had derived benefit as far as his constipation was concerned, but the pain was no better. He had culti- vated the habit of getting his bowels to act about six o'clock in the morning, so that afterwards he could return to bed and lie quiet for a couple of hours; he was then able to get up and come to town by train without suffering much; but if he had to travel soon after visiting the water-closet he was in pain all day. He was very careful in his diet, drank very little wine and was accustomed to take oatmeal porridge, brown bread, fruits, and vegetables, which I dare say had more effect on his bowels than the globules of nux vomica to which he attributed his regularity. As he laid very much stress upon the use of these globules, and was strongly of opinion that he would have no action without them, I did not oppose their continuance, knowing, as I well do, how much the belief that a certain drug is beneficial tends to make it so. On examining this patient I found a small, cir- cular, perineal ulcer situated at the upper edge of the exter- nal sphincter; it was clean cut and inflamed. The rectum was otherwise healthy, and the sphincter was not much hypertrophied. Taking into consideration the length of time the ulcer had existed, I advised incision, but that he would not listen to, so I prescribed my usual ointment, but was speedily obliged to leave out the extract of belladonna, as he was so sensitive to the action of this drug as to get dry mouth and dilated pupils with affected vision, in twenty-four hours after applying it. After three weeks I found the ulcer was not any better, although I had varied my treatment, 150 FISSURE AND PAINFUL touched it with nitrate of silver, perchloride of mercury, etc.; he had also used lotions of the tartrate and persulphate of iron. I had observed that there was one minute spot most excessively tender, much more so than the rest of the sore. There, no doubt, was an exposed nerve; so I took a hint from the late Mr. Hilton's work on " Rest and Pain," and applied, once, some acid nitrate of mercury. From that day the ulcer rapidly healed, and soon this gentleman got perfectly well; I know that he continues so to this day. I may here remark that I have several times had a similar success from the fuming nitric acid, but I prefer the acid nitrate of mercury. I have had very good results from a suppository of oxide of mercury. A lad. aet. 19, came to me at St, Mark's with double fissure; both the ulcers were very well marked, and there was one on either side of the anus. He suffered the greatest pain for hours after defecation. On examining him I found that he had a syphilitic rash, squamous and coppery; his tonsils were ulcerated, and he had also enlarged and hardened glands in his groin. He admitted that he had suffered from a sore on his penis, and had been treated for it at St. Bar- tholomew's Hospital ; he did not know whether he had taken mercury or not. The sore on the penis had been well about five months and the pain on going to stool had existed for four months. The rectum was healthy, and there were no mucous tubercles. I put him on a course of bichloride of mercury and tonics, as he was much out of health ; he took the hospital confection to keep his bowels gently act- ing, and used strong calomel ointment with powdered opium; after three weeks' treatment the fissures had quite healed, so then he ceased to attend, although his syphilitic symptoms had not disappeared. I have headed this chapter " Fissure and painful irritable ulcer" because the symptoms and treatment do not differ, whatever form the ulcer assumes, whether it be elongated and club-shaped, oval, or circular but as a rule the small circu- lar ulcer is situated higher up the bowel than fissures, are which generally extend to the junction of the mucous mem- brane with the skin ; the ulcer being more commonly found above or about the lower edge of the internal sphincter ani. I think also that in the circular ulcer there is less severe pain at the moment of defecation but it comes on from five min- utes to a quarter or half an hour after that act, and then is quite as intolerable as that resulting from the fissure. These IRRITABLE ULCER OF THE RECTUM. 15 X minute ulcers are more difficult to find than the fissures, as thfey often cannot be seen without the use of a speculum, or getting the patients to strain violently; which they will not do for fear of exciting pain ; in fact they generally draw up the anus as much as they can when you are examining them. An educated finger detects these ulcers directly; they feel much like the internal aperture of a fistula, but the edges are harder' and therefore more defined ; and there is no elevation above the surface of the surrounding mucous membrane as if frequently the cas.e in fistula. These ulcers often borrow and then they become the internal openings of blind internal fistulae. There has often been a controversy at times as to the depth of incision necessary to cure a fissure, some advocating a slight cut and others a free one. There is no doubt that in some cases a very superficial incision through the base of the fissure, so as to divide the fibres of the muscles immedi- ately beneath the ulcer or even to cut through an inflamed filament of nerve, may be enough ; but on the other hand, I have frequently seen slight incisions fail, and I am confi- dent that a tolerably free one, sufficient to secure the relaxa- tion of the sphincter, and put the parts entirely at rest, is by far the safer plan ; and this indeed, is the physiological reason of the success attending the operation. I do not mean by this that you need cut right through both sphincters into the cellular space beneath, as the older sur- geons used to do, but I am sure that a fairly free incision heals quite as quickly as a small one, and that it is much better to cut rather too deeply than too superficially. Those who are in favor of a slight cut say that inconti- nence of faeces may be brought about by too free an incision through the muscles. That may be the case when the cut is not properly made, /. e., when the mescles are not cut at right angles to the direction of the fibres. An incision at right angles will join so as to leave a perfect narrow scar, but an oblique incision leaves a very weak wide scar. I am quite certain that both the internal and external sphinc- ter muscles (on one side only) may be divided entirely in a healthy person, without any danger of a weak bowel following. You maybe confident that your patient will not readily par- don your not curing him at the first operation, and will be very disinclined to submit to a second incision should the first have failed. Most likely he will take himself out of your 152 FISSURE AND PAINFUL hands, and seek other advice ; it has occurred to me to have to operate upon patients both hospital and private, where eminent surgeons had failed to effect a' cure, and I have found that failure had resulted from one of two causes either the too sparing use of the knife, or the overlooking of a polypus. When operating, if not very au fait at rectal surgery, I should advise you to introduce a speculum ; you then see exactly where your knife should go, and the parts are also rendered tense, so that their division is facilitated ; the incis- ion should commence a little above the upper end of the fissure, and terminate a little beyond the outer end, so that the whole sore is cut through ; as a general rule the depth of incision should not be less than a quarter of an inch. If the outer end of the fissure be marked by a swollen, inflamed piece of skin, it is better to remove that with a pair of scissors for by so doing the healing process is greatly expedited; the small polypoid growth also, so frequently found in fissure, should at the same time be snipped off. Please to note that I am not recommending the cutting off of true rectal polypi. It has been suggested that a curved bistoury may be passed beneath the ulcer, and the ciit made from beneath toward the bowel. I do not see any advantage in this mode of operating for my own part, I always insert my forefinger into the bowel, feel the situation of the fissure, pass upon my finger a straight knife with a rounded point, then turn the edge to the base of the ulcer and make the incision ; or, the knife- blade can be laid flat upon the forefinger and both intro- duced together into the bowel, and the cut then made ; this is a good plan where there is much spasm of the sphincter. When the fissure is quite dorsal, the cut should be made not directly through it but somewhat laterally, by which means you are certain of completely dividing the fibres of the mus- cle and the wound will heal more readily. A small piece of cotton wool may be placed in the wound and allowed to remain for twenty-four or forty- eight hours. It is well to keep the bowel confined for two or three days. Usually there is no occasion for the patient to beep in bed but it is advisable that much exercise or standing about should be interdicted ; a few days' rest on the sofa is in sim- ple cases, all that is required. The reverse of all this is absolutely necessary when there is any uterine complication ; the patient here must be kept entirely at rest and lying down IRRITABLE ULCER OF THE RECTUM. 1 53 until the wound has soundly healed, for most, assuredly, if she gets about too soon, either the wound will not close, or a worse result, viz., unhealthy ulceration will ensue. I have seen many cases showing the good policy of long-continued rest, and numbers more where bad result have followed a speedy resumption of ordinary duties ; on this point I could relate numerous illustrative cases, but one shall suffice. Ada T was admitted into St. Mark's Hospital August, 1866; she was twenty-four years of age, was married, and had five children; she was in the hospital three months ago, and was operated upon by Mr. Lane, for fissure; she left not quite well. It was noted on her card that she suffered from retroversion, and had an enlarged uterus. On examining her, on her re-admission, rather extensive but superficial ulceration was found to have taken place since her going out. The ulceration extended above the upper edge of the internal sphincter. She had a good deal of pain and fre- quent harassing diarrhoea. There was no history or sign of syphilis. After three months' treatment by injections, seda- tive and astringent, and the internal administration of iodide of potassium and tonics, she was discharged cured. The uterus was kept in its place by means of a Hodge's pessary. These fissures, or irritable ulcers, not very uncommonly give rise to a train of nervous aid hypochondriacal sensa- tions, which continue even after the ulcer itself has healed. I have seen examples of this in both hospital and private practice, and both in men and women. An elderly maiden lady has been seen by me at various times for the last four or five years, her history being that, fully five years back, she had a small painful ulcer situated over the upper part of the internal sphincter muscle, which was much hypertrophied and spasmodically contracted. A limited division of the muscle failed to effect a cure, and after six months' trial to get the ulcer to heal I again ope- rated, this time assisted by my friend Dr. Crosby; I made a very free incision through both muscles, and after that there was no difficulty, the wound healed thoroughly and soundly; but ever since then, although there is not the slightest lesion of the bowel — I have often examined her with both specu- lum and endoscope in the most thorough manner, to be sure of the fact; she frequently, indeed almost constantly, com- plains of her old pain. There is a burning uneasy sensation in the bowel, but no local tenderness to touch. She cannot walk about much, nor sit long in one position, nor ride far 154 FISSURE AND PAINFUL in any vehicle without suffering. She is stout, looks well, and her general health has not suffered. There is no dis- charge of any kind, mucous, purulent or bloody; and, as a rule, she does not have pain on defecation. There is no abnormal redness or heat of the bowel, although she always has the sensation of great heat in the part. She has no uter- ine affection (two eminent obstetric physicians have exam- ined her, and say so), and she has ceased menstruating some years. Now, what is the matter with this patient ? Some may call it neuralgia or hysteria; but it has resisted all the usual remedies prescribed for these complaints, including hypo- dermic injections of morphia and quinine; in fact, she has taken all kind of remedies prescribed by other medical men as well as myself. I have two ideas as to the cause of suf- fering in this case: The first is, that it is possible that some filament of nerve is included in the cicatrix of the wound, and thus irritation or inflammation is kept up, as one sees occasionally after amputations of the extremities; the second idea is, that her mind has been dwelling for so long a time on the state of her bowel that, although now there is nothing organically the matter with her, she retains the power, by mental concentration, of reproducing the sensation of pain in the old spot. This may not be the correct explanation, but there is some evidence, I think, tending to show that it possibly is so; for instance, the pain is not always consist- ent in its behavior; the bowels act generally without pain; the pain does not come on directly after defecation, but some hours after; sometimes the pain sets in before the action, and is removed or relieved by the bowel being emp- tied (a condition of things quite inconsistent with the pres- ence of true ulcer or fissure). Then, again, when the patient is occupied pleasantly or intently she has no pain, but it can be produced immediately by excitement of a disagreeable kind; it is also uncertain in its coming and going, as well as in its character; som.etimes it is smarting, then burning, as if the rectum were- very hot; at another time pulsation is the chief annoyance, or the bowel may feel quite plugged up, as if the anus were swollen; and then suddenly the pain is lan- cinating, causing her to call out; all this leads me to think that the pain is mental. Whatever may be the* explanation, the fact is clear that here is a person who has no discoverable lesion of structure in a part, constantly suffering almost all the pain and misery IRRITABLE ULCER OF THE RECTUM. 155 which was formerly induced by a marked organic disease. This patient has written to me stating that she is now quite well, although nothing special has been done for her. I have not related this case because it is unique; I have seen others precisely similar, both in men and women. I know for years I was tormented at the hospital by a man, per- fectly healthy and strong looking, who used constantly to attend the out-patient room complaining of a dreadful burn- ing and painful sensation in the rectum a little way from the anus; ,he said it kept him awake at night, haunted him all day, was never out of his thoughts, and made his life utterly miserable. I examined him many times and could never detect anything abnormal (he had been operated upon for fissure years before I saw him, by the late Mr. Salmon); there was no redness, no discharge, and the thermometer showed no excessive heat; in fact, there was nothing to see or feel. No remedy did him any permanent good, but he was always a little benefited by a fresh one. He used to leave me every now and again and go to one of my col- leagues, and glad I was to be quit of him, but in a few months he was sure to come back, and not a whit better for what had been done for him. I called the malady hypo- chondriasis, but I suppose that was only expressing by a long word that I did not understand what was the matter with him. I can emphatically say that such patients are about the most unsatisfactory you can have. Why are ulcers near the anus so very painful, while those situated higher up the bowel are not generally so ? There are two reasons which suggest themselves at once: ist, the great mobility of the external sphincter; 2d, the supply of nerves. The lower part of the rectum and the anus are very fully supplied by branches from the posterior and anterior sacral plexus, and more especially from the pudic. These nerves send numerous branches between the fibres of the sphincters and immediately beneath the mucous membrane; thus very superficial ulceration exposes the nerve, and the slightest touch, contraction, or stretching of the sphincter, causes intense pain. If you carefully examine one of these ulcers you will usually find one or more spots that are most exquisitely ten- der; this is where the nerve is exposed. The lightest draw- ing of the knife across the ulcer, if done at the right point, will be sufficient to divide this nerve, and to induce cessation of the pain for some little time; but the muscle beneath 156 FISSURE AND PAINFUL being irritated and hypertrophied, prevents, by its move- ments, the ulcer from healing, and very soon the pain will be reestablished; hence the necessity, in all but the slightest cases, for the division of the sphincter. When the muscle is cut the divided fibres retract, and they do not unite so quickly as the ulcer heals; the result is that the muscle, being set quite at rest, soon loses its hypertophy and irritability. I have often noticed, after a fissure has been cured, how much reduced in size and thickness both sphincters have become. The cause of failure after imper- fect division of the muscle is, that entire quiet is not obtained; the undivided fibres, though paralyzed for a time, soon recover themselves, and the old contraction is resumed before the ulcer has had time to heal, so that very speedily it reassumes its former character. A great many apparently anomalous symptoms are pro- duced by small, painful ulcers of the rectum; retention of urine, pain in the back, pain and numbness down the back of the legs, leading to unfounded fears of paralysis, may be mentioned as not uncommon. When in a fissure the nerves are exposed the pain is most acute at the time of an evacua- tion; when they are not so exposed the pain generally sets in shortly after the action, in consequence of the irritation to the sphincter. In many of these ulcers an examination with a magnifying glass has shown me the fibres of the external sphincter laid quite bare. Patients sometimes tell you that the first time they suffered pain was after a very hard motion, when they felt something give way with a crack. Dr. Dolbeau, of Paris, considers the essence of this disor- der to be neuralgic, and defines " fissure of the anus as being a spasmodic neuralgia of the anus, with or without fissure." He states that he has seen cases where all the intense pain and agony of fissure were present, but no structural lesion whatever could be detected. For my own part I cannot wholly subscribe to this view ; out of the thousands of patients who have been under my care suffering from rectal diseases, I have never yet met with a case in which the persistent, regularly repeated, intense pain, commencing on passing or immediately after the passing a motion, which distinguishes fissure, was not associated with an anatomical lesion, though that lesion might be very slight and difficult to discover. I have seen a good many nervous patients who complained IRRITABLE ULCER OF THE RECTUM. 157 of rectal or anal pains, severe in character, but still wanting the essential characteristics of the pain of fissure. I have also observed cases of spasmodic contraction of the sphincter inducing obstinate constipation and attended with pain, but not at all strongly resembling the paroxysm due to fissure ; often a sudden spasmodic acute stab seems to run up the bowel just before action, but when the fecal mass is passed a feeling of relief and comfort is experienced. I do not say that neuralgia may not coexist with fissure, and modify or aggravate the suffering, but I think if it were the essential cause of the pain I should be justified in expecting that this would occasionally yield to the internal exhibition of anti- neuralgic remedies, a result which certainly is not within the range of my knowledge. I am inclined, but doubtingly, to express the opinion that the one essential of the malady in its severest form is an exposed nerve, and that the spasmodic contraction of the sphincter, excited by reflex irritation, occasions the peculiar character of the pain. Dr. Dolbeau is strongly in favor of forced dilatation of the sphincter, originated by Recamier, in the treatment of anal fissure ; in fact, he scarcely admits of any other method. He says : — *' The cure is thus complete after the operation, but it is not a lasting one, relapses often occurring ; this is another argument in favor of the neuralgic nature of the complaint." A post-mortem examination was made in Paris, on a girl who died of cholera within a few hours of having forcible dilatation made for the cure of fissure. The surgeon whose name I have forgotten, states that none of the fibres of the sphincter muscles were in the least degree torn, though the mucous membrane was slightly lacerated. Although I had in several cases employed Dr. Dolbeau's method, I found, as he had done, relapses were not uncom- mon, and I further looked upon " forcible " dilatation as a cruel operation. My first experience of this treatment was gained in Paris, and I will describe literally what I saw, and it was so repugnant to my feelings that I was greatly disin- clined to it. A male patient was brought into the theatre suffering from fissure of the anus. The surgeon introduced one finger into the anus, and then another, until he gradually but with much pressure, got the whole hand into the rectum; he then made a fist of his hand and forcibly drew it out. The cries of the patient were really heart-rending, and six or seven assistants were employed in holding him down. 158 FISSURE AND PAINFUL Now, during the past four years I have repeatedly dilated the sphincter for the cure of fissure, and as I do it, the opera- tion is not violent, and the result is, on the whole, very satis- factory. The patient being thoroughly placed under the influence of an anaesthetic, I introduce my two thumbs, one after the other, taking care to press the ball of one thumb over the fissure, and the other directly opposite to it ; this prevents the fissure from being torn through and the mucous membrane stripped off. I now gradually separate my thumbs ; then I repeat the stretching in the opposite direc- tion, /. ^., at right angles to my first ; then in other direc- tions, until I have gone round the anus. I then apply con- siderable pressure to the sphincter muscles all round, pulling apart the anus with four fingers, two on each side, and kneading the muscles thoroughly ; by thus gently pressing and pulling, the sphincters completely give way, and the muscle, previously hard, feels. like a well-beaten beef-steak, or even putty. This will occupy at least five or six minutes, to do thoroughly ; there is scarcely more than a drop or two of blood seen, but you can see that the anus is bruised, and for a few days extravasation is noticed, the part gradually undergoing the changes of color usually observed in any bruise. This operation is perfectly safe and almost painless. I place in the rectum a suppository of half a grain of mor- phia and apply cold. I am bound to say that since I have dilated as above described, I have never failed to cure a patient. I saw, with Dr. Robert Mitchell, of Lewisham, a gentle- man of more than eighty, who suffered greatly from a fissure of long standing, in conjunction with some haemorrhoids. He was too old to allow me to press a cutting operation, but dilatation perfectly cured him in eight days, and he has con- tinued in comfort until now. I could relate a number of cases in which dilatation has cured fissure and painful ulcer, as well as obstinate constipa- tion from contraction of the sphincter muscles, and in such cases I often employ it. I can remember that the late Mr. Salmon was in the habit of treating constipation by passing bougies, gradually increasing the size, until a very large one could be introduced ; I have reason to know he was success- ful. He used the same treatment as a preliminary step to the operation on piles, and there, again, I am sure he gained much advantage in lessening the pain after the operation — a result which, as noticed in a previous page, can be accom- IRRITABLE ULCER OF THE RECTUM. I59 plished by dilatation. There are still cases of fissure and ulcer in which I prefer the knife, and shall continue to use it ; but I am bound fo say my confidence in proper dilatation is greatly increased, and I am, sure, when properly done, it is very successful, though occasional relapses may occur- Som.e years ago I frequently divided the sphincter subcuta- neously for the cure of fissure, but I have ceased to practice this operation, as possessing no advantage and not being cer- tain in its results. CHAPTER XVI. IMPACTION OF F^CES. The result of prolonged constipation may be a collection of clayey faeces formed in the caecum or in any part of the colon, but the term " impaction " is generally used when the accumulation takes in the pouch of the rectum immediately above the internal sphincter muscle. This is its most fre- quent situation, and here a very large deposit, more or less globular in shape, is often found. It occurs in females more commonly than in males ; old women, and women shortly after their confinements, being especially liable to it. In aged people very often one of the first indications of failing nerve power is loss or diminution of the contractile force of the colon and consequent inaction of the bowels, leading to impaction. I have seen some cases of impaction in hysterical young girls and in middle-aged females, I have also met with it in elderly men, but until recently I never had a well-marked example of this disorder in a young man, but I have found it occur more than once in children ; I saw a little boy, only three years of age, who had a veritable impaction which gave a dood deal of trouble, but when it was removed the bowel soon regained it tone, and regular action was afterwards easily kept up. The cause of the accumulation I believe nearly always to be, primarily, a loss of power of the muscular coat of the rectum. This loss of power may have been produced by the pressure of the child's head, during a long protracted labor, or by over-distention of the bowel through habitual l6o IMPACTION OF F7ECES. neglect of the calls of nature, in which case the collection may be the result of months' costiveness, and the condition of the rectum much resembles that of a bladder paralyzed from retention of urine. Spasm of the sphincter has been said to be a cause of impaction, but I have more often thought the reverse was the case, and the impaction the cause of the spasm. I must, however, acknowledge that spasm is often the cause of the constipation which is the forerunner of impaction. In impac- tion spasm of the sphincter always exists, in some instances to such a degree that when the patient strained I have observed the anus protrude like a nipple, and an injection return in a fine stream, as if coming out of a squirt. I have certainly met with cases of idiopathic spasm of the sphincter, occurring for the most part in elderly, nervous, single women, and though no impaction was present, there was always more or less constipation. The symptoms of impaction are not uncommonly very obscure, and the malady may be mistaken for something else. I was once call to see a lady laboring under impac- tion, and found that an eminent physician had recently declared her to be suffering from neuralgia of the bowel, and had ordered her quinine and steel, and I have heard of another case which was treated as gout in the rectum. I have met with several patients who were supposed to be the subjects of malignant disease of the caecum or sigmoid flexure from the fact of there being a tumor present, and from the patient's aspect, which is frequently very suggestive of cancer. I had a very marked case of impaction in a girl, thirteen years of age, which was supposed to be enlarged mesenteric glands, and was being treated with steal and cod- liver oil. I attended a gentleman who was believed by his physician to have incipient disease of the brain, so much nervousness and hypochondriasis resulted from a very loaded colon and impacted rectum. I had a case in a young lady which was said, by more than one medical man, to be phthisis, constant cough being present, with hectic at night, and much emaciation. And lastly, a very common but sad error is often committed ; these patients are treated for diarrhoea, with tenesmus, as a considerable fluid discharge from the bowel is not at all incompatible with great retention of solid faeces. A very interesting case was sent me by Dr. Frodsham. The patient was an elderlyperson from thc'country, who was IMPACTION OF F^CES. l6l placed under Dr. Frodsham's care. She had been for a long time ill with severe pains in the bowels, of a colicky charac- ter, not especially restricted to one part of the abdomen, which was much swollen. No tumor could be detected. She was subject to hiccough and flatulence. This was attended with dyspnoea and palpitation of the heart. She had on several occasions fainted away, and fears were enter- tained that the heart was not sound. Always, or nearly so, in conjunction with the abdominal pain she had diarrhoea, copious colored watery stools ; for the correction of this she had been prescribed opium with carminatives ; a few doses generally gave her much relief. Her appetite was bad, and she had frequent retching and sometimes vomiting. Dr. Frodsham not being satisfied with the case sent her to me. She was fifty years of age, not ill-nourished, her face wore an anxious expression, and the complexion was muddy. Her general symptoms had existed over two years. The tongue was quite clean and too red. On examination, the heart and lungs were found sound. The abdomen was much distended and the diaphragm forced upward, causing dyspnoea when she lay down. The abdomen was globular, and there was no particular prominence in any one part. The skin was not shiny; on manipulation the abdomen felt doughy; it was also tender, so that she could not bear much kneading, but after a little pressure the transverse colon started into action, and it was felt to be very large. A flex- ible tube was easily passed eighteen inches, and on with- drawal it was, in parts, smeared with faeces; on introducing the finger into the rectum the latter was found filled with clayey faeces. The diagnosis was great fecal accumulation and slight impaction. I ordered her a pill of podophyllin, calomel, belladonna, and pil. colocynth co. three times in the day, and every morning an injection of a pint and a half of thin gruel, with two ounces of fresh ox gall in it. On the third morning of this treatment she passed an enormous motion, more than enough to fill an ordinary chamber uten- sil. The same pills and enema were continued now every day, and were followed by several enormous evacuations. I really may say that the quantity of fecal matter she parted with would, to most persons, appear incredible. After ten days the medicine was changed to a combination of laxa- tives and tonics, which she continued for some time, but at the termination of three weeks all her discomforts were gone, and she was quite slender, as regards the abdomen. l62 IMPACTION OF F^CES. In the history of these cases it is not rare to find that severe pains have been experienced in the right lumbar and left inguinal regions; this sympton points to the fact that the caecum had been the seat of obstruction and distention, and that when this was removed the faeces again lodged in the rectal pouch. The symptoms of impaction might be expected to be generally those of obstruction, and resemble in many respects those of stricture of the rectum, and sometimes this is so, but the absence of any jelly-like or coffee-ground dis- charge is an important point to be noticed in the diagnosis. The patient often really complains of a tendency to diar- rhoea, liquid motions beingfrequently passed, especially after an aperient, but without any sense of relief, and on assuming the erect position, straining, severe, continuous and irresisti- ble, takes place. On lying down this generally gradually passes off. Dyspepsia, irritability of temper, nervousness and dis- pondency, the patient supposing herself to be suffering from an incurable malady, a very muddy-yellow skin, suggestive of malignant disease, morning vomiting, and a loathing of all food as soon as a few mouthfuls have been taken, exces- sive and very painful thirst, are among the common symp- toms of this disorder. A peculiar ringing, barking cough, particularly in women, and also night sweats, are not uncom- mon. In both men and women I have seen very obstinate retention of urine, caused by impaction. All these symptoms may continue more or less urgent for months, and aperients and injections may be given, without affording more than temporary relief. When examining a patient, if you make careful palpation over the abdomen, tumors may be felt in the caecum, the transverse colon, or the sigmoid flexure; under any circum- stances, in the majority of cases, if you look at the anus, youVill see that it is nipple-shaped, and if you feel around the anus you will find the sphincter muscle tightly contracted and almost as hard as a piece of wood. It is only with dif- ficulty that you can introduce your finger into the bowel, and having done so, you will find a ball of hardened, clayey faeces filling up the rectal pouch. This ball I have seen almost as large as a foetal head, and quite movable, so as to admit of liquid or thin motion passing round by the sides of it, thus giving rise to the impression that diarrhoea rather than constipation existed. So deceptive is the feeling this mass gives to the finger, that I have more than once thought IMPACTIOiSr OF F^CES. 1 63 I must be touching a tumor; and I have been called in con- sultation several times, by medical men, who had discovered the impaction, but could not believe that what they felt was only a collection of faeces. In bad cases you must commence the treatment of this malady by thoroughly breaking up the ball of faeces. The best mode of accomplishing this is first to put the patient under an anaesthethic, and then forcibly but slowly dilate the sphincters by introducing both your forefingers, well oiled, and separating them in the antero-posterior direction, then again toward the tuberosities of the ischiia. You need not tear the mucous membrane, but you so stretch the muscles as to paralyze them for a time; this done, you can get at the interior of the rectum without any difficulty, and break up the mass with your finger or a lithotomy scoop, or the handle of an old-fashioned silver spoon. The spasm of the sphincters being thus overcome, you can do a great deal at one sitting, in fact, quite empty the rectum. After you have thoroughly broken up the impacted mass you may administer injections of soap and water and oil, and in this way you will often get rid of enormous quanti- ties of faeces. When the ball occupying the rectal pouch is cleared away, other masses generally come down, and I have seen as much as would fill two or three chamber utensils passed at one operation. I have found, in several instances, the rectum so much dilated that the upper part of the bowel opened into the pouch like a pipe into a bladder. It is often a considerable time before the rectum recovers its power after its great distention, and, therefore, you must take care that no reaccumulation takes place. Injections of cold water, kneading the abdomen, and the exhibition of the compound decoction of aloes with nux vomica, will be found useful. As soon as the bowel is thoroughly cleared out I am in the habit of prescribing the following pill, which is very effective in restoring power to the colon and rectum, thus inducing a regular action of the bowels : ]^ . Ferri Sulph. Exsice gr. J- Quiniae Sulph gr. j Extracti Nucis Vomicae gr. i Ext. Aloes aq gr. j Extr. Taraxaci q. s. ut fiat pil. M. Take one three times in the day, after meals. 164 IMPACTION OF FiECES. Faradization is most advantageous in these cases. Persons of sedentary habits are especially liable to these attacks, exercise in the open air must, therefore be taken daily. ' The diet should not be too liberal. An elderly lady was a patient of mine on three occasions, with impaction and loaded caecum, and I am sure it was because she was a very hearty eater and never took any exercise. I could neither persuade her to walk more or to eat less. Inpactions have, as I have mentioned, been often mistaken for malignant abdominal tumors, but the diagnosis is usually not difficult if observations be carefully made. There are two points of distinction which may always be noticed: ist. An examination from time to time will show that the tumor differs in size and shape; this the patient will often be the first to remark. 2d. A very careful manipulation will detect that the tumor is irregularly soft and has a decidedly doughy feeling. When the tumor is in the sigmoid flexure or rec- tum the introduction of the finger will at once clear up the doubt, if there be any. Concretions in the bowels are rarer than impactions, and they differ from these in that they are often formed round some foreign body and are usually cylindrical in shape. Concretions consist of animal and vegetable fibres matted together round a nucleus, which may vary according to circumstances. In one case a quantity of human hair formed the core; the patient had been in a lunatic asylum, and in a fit of mania had swallowed the hair. She had suffered from attacks of intestinal obstruction for months, and she always said there was something in the bowel which would not pass through the anus. She was brought to me at St. Mark's Hospital. I forcibly dilated her sphincter and with a lithotomy scoop and my finger succeeded, after some trouble, in removing a conical-shaped mass, more than six inches in length by two and a quarter inches in diameter; it was covered with pus and extremely fetid. On cutting through it, as I have mentioned, the centre was found to consist of human hair. Another patient of mine, an elderly gentleman, had an obstruction of the rectum which I thought was an ordinary impaction, but it was not globular in form, and when I tried to break it up I could not do so, as it slipped away and was too tenacious. After dilating the sphincters I was able to get hold of it with a pair of lithotomy forceps and gradually IMPACTION OF F^CES. 165 draw it out. The nucleus was a large biliary calculus, and aVound it were vegetable and animal fibres and dried faeces; the whole was covered by a thick coating of mucus and pus. Eighteen months before he had suffered from an attack of gall stones, and no doubt this calculus had been lodged in the bowel, probably in one of the sacculi of the colon. I have already related another case of this kind. One more case I will record, as it is peculiar; here a sov- ereign formed the nucleus. The patient, a woman, came to St. Mark's Hospital suffering from stricture of the rectum; when I dilated the stricture I found a large mass above it. Purgatives and enemata not effecting its removal, I eventu- ally brought it down with a scoop and my finger; it was cylindrical in form. On tearing it up to examine its struc- ture I found in its centre the coin I have mentioned. Quite fifteen months before the woman had swallowed a sovereign, and she had sought for it in her motions, but failed to find it; she had not any idea that it had not passed. I think it very likely that at that time she had incipient stricture of the rec- tum, and consequently the piece of money did not escape from the bowel. I will not occupy more space on this subject; the cases are somewhat rare and the treatment simple enough. When the mass comes down near the anus it must be removed bodily; you will find itso tenacious that you can not break it pu like an ordinary impaction. Unless you dilate the sphincter you will have very great difficulty in extracting these con- cretions; in fact, it will be almost impossible to do so. It is very curious how, sometimes, small substances fail to traverse the alimentary canal safely, and how, at other times, very large bodies pass without producing any severe or dangerous symptoms. There are cases related by Sir James Paget, Mr. Henry Smith, and others, where a con- siderable portion of a set of false teeth, mounted in gold, was swallowed and not arrested anywhere in the intestines. There is one thing we should recollect when such a case comes before us, that is, never give a purge. You may tell your patient to eat very freely of solid material, such as suit- pudding, bread, and the like, so as to form full-sized cohesive motions. These cases must not teach us to lightly estimate the danger of swallowing foreign bodies ; many cases are on record where such a simple matter as a cherry stone has l66 ULCERATION AND STRICTURE OF THE RECTUM. caused death, by setting up ulceration and perforation of the bowel, usually the caecum or vermiform appendix. I saw, some time back, a case, with Dr. Nash and Mr. Clover, of a fine young lad who lost his life from peritonitis caused by perforation of the appendix vermiformis. The foreign body appeared to be a small portion of wood, around which fecal matter had deposited, augmenting its size to about that of a small date stone, but pointed at each end. The symptoms were at first not very pronounced, but the fever was soon great and accompanied by much delirium. No operative interference was resorted to, the diagnosis being that the obstruction to action of the bowels was caused by peritonitis, the result of probable perforation of the caecum or its appendix. The post mortem verified the diagnosis. CHAPTER XVII ULCERATION AND STRICTURE OF THE RECTUM. Ulceration extending above the internal sphincter, and frequently situated entirely above that muscle, is not a very uncommon disease ; it inflicts great misery upon the patient, and if neglected, leads to conditions quite incurable, and the patient dies of exhaustion, unless extraordinary m*eans are resorted to. In the earlier stages of the malady, careful, rational, and prolonged treatment is often successful, and the patient is restored to health ; I wish I could say the same of the severe and long-standing cases. Ulceration of the rectum can be mistaken only for maUgnant disease ; but when the symptoms are carefully considered, and the finger is well educated, there can but very occasionally be any error in diagnosis committed. As the earlier manifestations are fairly amenable to treatment, it is of the utmost importance that the diaease should be recognized early. Unfortunately, it rarely is so ; the symptoms are obscure and insidious, the suffering at first but slight, and thus the patient deceives, not only himself, but his medical attendants, by the little heed he gives to the complaint. In the majority of these cases the earliest symptom is morning diarrhoea, and that of a peculiar character ; in my ULCERATION AND STRICTURE OF THE RECTUM. 167 Opinion it is quite indicative of the disease, and can be con- founded only with similar symptoms due to cancer. The patient will tell you that the instant he gets out of bed he feels a most urgent desire to go to stool ; he does so, but the result is not satisfactory. What he passes is generally wind, a little loose motion, and some discharge resembling " coffee grounds " both in color and consistency ; occasionally the discharge is like the " white of an unboiled egg ; " or " a jelly-fish ; " more rarely there is matter. The patient in all probability has tenesmus, and does not feel relieved ; there is a somewhat burning and uncomfortable sensation, but not actual pain ; before he is dressed, very likely, he has again to seek the closet ; this time he passes more motion, often lumpy, and occasionally smeared with blood. It may also happen that after breakfast, hot tea or coffee having been taken, the bowels will again act ; after this he feels all right, and goes about his business for the rest of the day, only, perhaps, being occasionally reminded, by a disagreeable sen- sation, that he has something wrong with his bowel. Not by any means always, but at times, the morning diarrhoea is attended with griping pain across the lower part of the abdomen and great flatulent distention. When a medical man is consulted the case is, in all probability, and quite excusably, considered one of diarrhoea of a dysenteric character, and treated with some stomachic and opiate mixture, which affords temporary relief. After this condi- tion has lasted for some months, the length of this period of comparative quiescence being influenced by the seat of the ulceration and the rapidity of its extension, the patient begins to have more burning pain after an evacuation, there is also greater straining and an increase in the quantity of discharge from the bowel ; there is now not so much jelly- like matter, but more pus — more of the coffee-ground discharge, and blood. The pain suffered is not very acute, but very wearing ; described as like a dull toothache, and it is induced now by much standing about or walking. At this stage of complaint the diarrhaea comes on in the evening as well as the morning, and the patient's health begins to give way, only triflingly so, perhaps, but he is dyspeptic, loses his appetite, and has pain in the rectum during the night, which disturbs his rest ; he also has wandering and apparently anomalous pains in the back, hips, down the leg, and some- times in the penis. There is yet another symptom present in the later stages, marking the existence of some slight con- l68 ULCERATION AND STRICTURE OF THE RECTUM. traction of the bowel, viz., alternating attacks of diarrhoea and constipation, and during the attacks of diarrhoea the patient passes a very large quantity of faeces. These seizures are attended with severe colicky pains in the abdomen, faint- ness, and not unfrequently sickness. As the ulceration extends, attempts at healing take place: these result in infiltration and thickening of the submu- cuous and muscular tissues, and consequent diminution of the calibre of the bowel, so that real stricture of various forms supervenes. Coincident with all this there results a gradual loss of the contractile power of the rectum, and almost complete immobility, so that the lower part of the gut is converted into a passive tube through which the faeces, if fluid, trickle; but if solid, they stick fast until pushed through by fresh formations above them. Invariably, also, there is loss of power in the sphincters. When diarrhoea is present the patient has little or no control over his motions. Usually by this time abscesses have formed, or are in pro- cess of formation, and these breaking, soon become fistulae. I have seen persons with as many as eight external orifices, some situated three inches or more from the anus. On examining these cases of ulceration of the rectum, various conditions may be noticed, according to the stage to which the disease has advanced. In the earlier period you may often feel an ulcer situated dorsally about one and a half inches from the anus, oval in form, perhaps an inch long by half an inch wide, surrounded by a raised and sometimes hard edge; there is acute pain caused on touch- ing it, and it may be readily made to bleed. With a specu- lum you can distinctly see the ulcer, the edges well marked, the base grayish or very red and inflamed looking, the sur- rounding mucuous membrane being probably healthy; in the neighborhood of the ulcer may often be felt some lumps, which are either gummata or enlarged rectal glands. This is the stage in which the disease is often curable, as I shall show when speaking of treatment. Later in the progress of the malady, you will observe deep ulcers, with great thick- ening of the mucous membrane, often, also, roughening to a considerable extent, as though the mucous membrane had been stripped off. At this stage you generally notice, out- side the anus, swollen and tender flaps of skin, shiny, and covered with an ichorous discharge; these flaps are com- ,monly club-shaped, and are met with also in malignant dis- ease; but in the early development of the disease no ulcer- ULCERATION AND STRICTURE OF THE RECTUM. 169 ation is found near the anus nor at the aperture. It is in private practice that we have the best opportunity of seeing these cases early, and I most positively repeat that the large majority do not commence by any manifestation at the anus, such as growths or sores; occasionally a fissure may be the first lesion, and the ulceration extend from the wound made in attempting to cure it; this is, however, the exception to the rule, and I will further on relate some cases to show that what I have stated is correct. So defi- nite is this external appearance in long-standing disease, that one glance is sufficient to enable an expert to predicate the existence of either cancer or severe ulceration; these external enlargements are the result of the ulceration going on in the bowel, and the irritation caused by almost constant discharge. The ulceration may be confined to a part of the circumference of the bowel, or it may extend all round, and for some distance, but not usually for more than four inches up the rectum. It also probably will have traveled down- ward close to the anus, and then the pain is sure to be very severe, because the part is more sensitive and more exposed to external influences and practices. AVhen the disease has reached this stage, of course, stric- ture and most probably fistulse will be present, as I have already mentioned; and possibly, but not frequently, perfo- ration into the bladder, into the vagina, or the peritoneal cavity, may occur. The state of the patient is now lament- able; his or her aspect resembles that of a sufferer from malignant disease, and no remedy short of lumbar colotomy offers much chance of even prolonging life. You may relieve these patients, but can rarely do more; a cure can scarcely be expected. I have seen ulceration utterly destroy both the anal sphincters, so that the anus was but a deep, ragged hole. Here is such a case, which was under my care at St. Mark's Hospital. Matilda G , admitted under my care January, 187 1. She is a married woman, twenty-eight years of age. Five years ago she was a patient of mine with stricture and ulcer- ation. She went on tolerably well, and continued so up to about eighteen months back; since then she has suffered much; she had constant pain and discharge from the bowels; she either has constipation or diarrhoea. There is entire incontinence of faeces. The straining and bearing down are very distressing; her aspect is worn and sallow; she is not very emaciated; there is no evidence of syphilis or consump- 170 ULCERATION AND STRICTURE OF THE RECTUM. tion. On examination a large, ragged, deep hole is seen instead of an anus; it is surrounded by swollen flaps of skin, two of which are perforated by fistulae; the hole meas- ures about two inches each way, and there is not a vestige of sphincter muscle left. On introducing the finger into the bowel, it is found quite blocked up by contraction and thickening; only a very small aperture can be felt, but into this the end of the finger cannot be passed. Chloroform being given, she strained down so violently that the strictured portion of the bowel was forced outside, so that the ulcera- tion and stricture could be plainly seen. The aperture was not larger than a No. lo male catheter. I saw this patient over and over again ; she was always benefited by treat- ment, but not cured; at length she died in the workhouse. Years may have elapsed before the dreadful condition I have been describing has been brought about, but it is one we only too frequently see at St. Mark's. Patients suffering from ulceration and stricture are very liable to attacks of a low form of peritonitis, attended with considerable abdominal pain, often intense for a short period. There are generally one or more spots that are tender on pressure; there is tympanites, often vomiting, especially on first assuming the erect position in the morn- ing, and generally the pain is brought on by standing or moving about; these attacks are sure to end in diarrhoea. The treatment should be perfect rest in bed, spoon diet, and opium "may be given freely; fomentations relieve the pain, but I have not seen any benefit result from counter-irrita- tion. I have often found that calomel and opium given for some time is advantageous in these cases. When making a post-mortem examination in such cases I have observed effusion into the peritoneal cavity, and often considerable old and recent adhesions between the intes- tines; the peritoneum is also thickened. In bad ulceration you see what great destruction of tissue has taken place. I found the whole of the rectum and sigmoid flexure involved in ulceration, and great thickening and contraction of the calibre of the bowel, caused by the attempt at repair in various parts.* The connective tissue here and there is so removed as to leave large bridges of indurated muscle and roughened mucous membrane; and there is ulceration, so deep in places that perforation must have occurred but for the adhesion kindly made by nature to the adjacent parts. In other situations the muscular coat is laid quite bare, and ULCERATION AND STRICTURE OF THE RECTUM. 171 I have seen more than one case in which necrosis of the sacrum has taken place. The following table of seventy cases which have been under my care at St. Mark's Hospital exhibits, I think, many points worthy of consideration: — Seventy Cases of Ulceration and Stricture of the Rectum, taken from Mr. Allingha77i' s Practice at St. Mark's IIosj)ifal. I Constitutional syjihilis or not. Yes, tertiary Yes, nodes Severe cons. syph. No iiistory or apearance No syphilis ; struma Cons. syph. , nodes on fore- head No history of syph. Cons. syph. ; (8 years) No symptoms of syphilis nor history Syphilis well marked Ditto Probably, Sore throat now No symptoms or hist, of syph. Cons. syph. No symptoms or history No symptoms or . history Cons. syph. None Stricture a?td ulceration, luhere _found. Stricture 2 inches up ; ulceration above and be- low Ulceration from anus ; stricture 2 inches Stricture impermeable high ^ up Severe ulceration and stric- ture 2 inches from anus Small ulcer ; stricture t% inch ; ulceration above stricture Stricture 1% inch ; hyper- trophy of nymphae Stricture 2 inches ; ulcera- tion high up Stricture 3 inches long, % inch from anus Extensive ulceration ; two strictures high up Stricture 1% inch from anus ; ulceration above and below ; hardness Stricture 2 inches from anus ; severe ulceration Stricture just within reach of finger; no ulceration between anus and stric- ture Stricture two inches ; much ulceration Stricture x^/i inch from anus ; ulceration above Stricture 2% inches ; bad ulceration above and be- low stricture Stricture j% inch ; ulcera- tion near anus Stricture r% inch ulcera- tion deep above and below stricture Simple Stricture 2 inches from anus ; much indura- tion but no ulceration Complications and observations. Fistula; mucous tubercles; primary infection 5 years since. Sores on labia ; fistula ; primary symptoms 5 years ago. Recto-vaginal fistula; colo- tomy ; lived 18 months. No complication ; outside parts normal. Outward parts quite npr- mal ; hymen present ; under treatment 8 years; died, exhaustion. Ulceration very high; colo- tomy 3 years ago ; now living. Fistulae in all directions, from which great indura- tion ; colotomy ; success. No complications ; colo- tomy successful. Attempted colotomy (right side) ; death 56 hours. Large flaps of skin outside, and fistula. Recto-vaginal fistula ; sy- philis 7 years at least. Recto-vaginal fistula; anus not affected. Fistula; no disease of anus; came on as abscess. Anus normal; syphilis 12 years ; had treatment. Fistula both sides of anus; large flaps of hypertro- phic skin; discharging. Large fibroid polypus; easy cure. Dorsal fistula; anus normal; syhilis 18 mos., rash scaly, and ulceration on tongue. No internal abnormality ; division and lasting cure. 172 ULCERATION AND STRICTURE OF THE RECTUM. No. >f^^ >9 40 20 20 21 30 22 42 P3 28 S4 39 25 24 26 53 27 27 .8^ 25 29 33 30 22 31 28 32 31 33 50 34 37 35 22 S6 13 37 28 38 25 39 33 40 37 41 27 42 37 Constitutional syphilis or not . F. Cons. syph. F. Ditto ! , F. No history of I syphilis F. Syphilis well I marked F. ^None F. I Cons, syphilis None F. Cons, syphilis None Cons, syphilis None None Cons, syphilis F. None I F. ;None F. Cons, syphilis F. [None i F. jNone F. Cons, syphilis Ditto Doubtful ; no historj' or symptoms Cons, syphilis None Cons, syphilis Stricture and ulceration^ •where J'oufid. Ulceration commencing i inch above anus, stricture 2 inches Tight stricture 2 inches ; ulceration Very little stricture 2 in- ches ; superficial ulcera- tion Stricture i inch up ; ulcera- tion severe and deep Annular cord-like stricture 2 inches ; ulceration near anus Stricture 1% inch from anus ; not much ulcera- tion Stricture 2 inches, dense and long ; ulceration se- vere j Stricture tight ; no ulcera- tion above or below j Stricture just inside anus ; no ulceration ; cure b^' incision and dilation Stricture 2 inches from anus; ulceration below and above. Stricture 2 inches from anus ; ulceration severe | Stricture annular, i^^ in- ches up ; ulceration se-i vere Stricture severe and long,' commencing i inch fromj anus ; deep and extensive I ulceration I Stricture i]A, inch ; much soft ulceration I Stricture 2 inches up; ulceration above and be-j low I Stricture^ inch from anus; ulceration high up j Stricture 2% inches up ; ulceration above and! below I Stricture about 2 inches up; little ulceration Stricture 2 inches up ; ulceration above and be- low I Stricture ij4 inches up ; ulceration above and be- low Stricture just within reach; ulceration below Complications and observations. Anus naturaL Mucous tubercles ; hyper- trophied nymphse. Verrucse ; no sores ; speedy cure. Fistula ; great induration and swollen lumps around anus. No complication Large superficial sore in perineum, extending into anus ; fistula. Recto-vaginal fistula, com- menced after child-birth; colotomy, success. Fistula in ano ; syphilis 5 years. No complication. Syphilitic rash and sores ; 9 years of sj'philis. Fistula in ano ; been oper- ated upon several times. Procidentia recti ; a curious case, it comes through the contraction. Several large external growths and three fistu- lous sinuses. Outward parts normal ; died; gradual exhaustion. No complication. Rupia ; fistula in ano ; 10 years syphilis. Haemorrhoids. Fissure and polypus. No complication ; 10 years syphilis. Fistula through labia and into anus ; growths. Fistula in ano ; recto-vagi- nal fistula. I Stricture 2 inches; severe Fistula ; growths; colo- I ulceration tomy ; success. j Stricture annular, 3 inches None ; cured by incisioa up ; severe ulceration and dilatation. Stricture i}^ inch up ; veryjHuge outside growths and severe ulceration labial fistula ; colotomy ; I euccess. ULCERATION AND STRICTURE OF THE RECTUM. 173 Vo. ^^^ 43 27 44 30 45 26 46 25 47 35 48 22 49 30 50 30 51 25 52 24 53 28 54 18 55 25 56 32 57 22 58 29 59 63 60 47 6i 50 62 53 63 40 64 34 65 26 66 38 67 29 68 19 Sex F. F. F. F. M. M. M. M. M. M. M. M. Constitutional syphilis or not. None Cons, syphilis None Cons, syphilis None Cons, syphilis Very doubtful Cons, syphilis None Cons, syphilis Ditto Ditto Ditto Ditto None None None None Cons, syphilis Ditto None Cons, syphilis Ditto Ditto None Cons, syphilis Stricture and ulceration where /ound. Stricture i inch up ; super- ficial ulceration Stricture 2 inches up ulceration slight Stricture 1% inch up ; se- vere, deep ulceration Stricture 2 inches up ; ulceration above and be- low Ulceration, so that the os and cervix uteri came through into the rectum Impermeable stricture 2 inches up Stricture 2 inches up ; not much ulceration Stricture high up ; ulcera- tion severe Stricture 2 inches ; ulcera- tion slight Stricture i inch up; ulcera- tion severe Stricture 2 inches up ; ulceration only above ihe stricture Stricture \% inch ; no ulceration at all Stricture 2j^ inches up ; ulceration severe above and below Stricture very high, only just to be felt; ulceration very deep Stricture 1% inch up ; very little ulceration Stricture 3 inches up ; ulceration below slight Stricture i inch up ; ulcera- tion above Stricture only just to be felt ; ulceration below Stricture 3 inches from anus ; much ulceration Stricture 2 inches above anus ; ulceration from anus Stricture 3 inches ; ulcera tion all around rectum Stricture i inch ; ulceration above and below Stricture i^ inch ; ulcera tion severe above Stricture 2 inches ; ulcera- tion severe Stricture i inch, annular ; slight ulceration No stricture : all sloughed away Complications and observations. None ; cured by division and dilatation. Recto-vaginal fistula. Club-shaped growths out- side around anus Fistula in ano. The uterus could not be returned ; she menstruat- ed into rectum. Constipation 3 weeks ; co- lotomy ; success. None. Fistula and outside growths ; syphilis 5 or 6 years. Internal Fistula; burrowinsj up under stricture. Fistula ; growths ; rupial rash. Fistula ; very recent stric- ture, only noticed 6 months ; indurated sores on nympha. Verrucae ; labial abscess. Haemorrhoids and fistula. Fistula ; several sinuses ; colotomy ; success. Disease of uterus. Fistula in ano and fissure. Four fistulse around anus, one perforating the vagi- nal wall. Fistula in ano ; complete opening below stricture. Numerous fistulse ; great debility ; went home and died. Several hard ulcerated growths ; very badly syphilized, 5 years. Bad fistula, fecal matter passing through; colo- tomy (alive 8 years after operation) . Ulceration down to anus ; fistula in ano. Stricture almost impass- able ; colotomy (alive now, ID years). Two fistulous sinuses ; bad condition. Phthisical ; anus lost all power. Phthisis combined with syphilis h ad played havoc with him. 174 ULCERATION AND STRICTURE OF THE RECTUM. No. Age Sex 1 Constitutional \stricture and ulceration^ syphilii or not.. where found. 1 Complications and observations. 69 70 80 50 M. M. None None Stricture extending from anus 3 inches up, very hard Annular stricture 2 inches up ; not severe ulcera- tion Thought to be cancer, but dilatation and small doses of mercury cured him. Anus normal ; speedy cure by division and dilata- tion. We may briefly call attention to some important points in the above table. In 70 patients, 60 were females and 10 males, a large predominance of the former, but not so great as has been given by some authors. Now you will find on examining the table that 35 had suffered from undeniable constitutional syphilis, while 5 had some symptoms, but not decisive, of ever having had the disease, so I think this number should be deducted from the whole number 70, before we consider the statistics of the rest, viz. 65, and we find 35 were most undoubtedly syphilitic, and 30 as undoubtedly never had contracted syphilis, and many never any venereal disease. The males, though small in number, are worthy of a moment's consideration ; of the 10 males, 6 had suffered from some form of syphilis ; but 4 had not, and there was great probability that they had not been affected by any venereal disease ; they denied any venereal taint, and I think, from the way they spoke, and the desire they had not to deceive me (as I made it a matter of great importance to them, as regards treatment, that they should tell me the truth), I felt bound to believe them. Ten of my cases were subjected to colotomy in the lumbar region, and for the most part did well, and I believe several (5 or 6) are now alive. Two of the women have married since the operation. In one female I attempted to open the ascending colon, and after a most careful search I failed to find it, but in mistake opened the duodenum, as it embraces the head of the pancreas. I like to mention this case, to show how, in difficult cases, a practiced colotomist may go astray. This patient had a very enlarged liver, and was in the habit of tight lacing, so the liver, being pressed down- ward, carried the ascending and transverse colon diagonally to the left side, and Xht post-7?iortem examination showed it was next to impossible to reach the ascending colon from my ULCERATION AND STRICTURE OF THE RECTUM. 1 75 incision. I must observe that the duodenum when brought up from a depth is very like the colon. Four hours after the operation I knew what I had done, as a large and constant flow of bile took place from the wound ; she vomitted fre- quently, could take no nourishment, and died on the third day. Before and since that operation I have opened the ascend- ing colon and found no particular difficulty, but there is no doubt that the ascending colon is more liable to be dis- placed than the descending. I do not in any way wish to extenuate my error in the case ; at the time I grieved seri- ously over it, and I have never forgotten it. I always think I ought to have made a more careful examination, and to have found that the liver was enlarged, and came so low down as the crest of the ilium, and so was almost certain to push the ascending colon out of place ; further, I now think I ought by manipulation and percussion to have found that the ascending and transverse colon was out of position. However, we may learn more from our errors, if we take them to heart and study them, than from all our successful cases. In forty-seven operations the case I have related is the only one in which I made any mistake or failed to find the colon. Of the 30 patients who had never been syphilized, it was possible that many more, but highly probable that 13, had never had any venereal affection whatever. Inoculation in all these cases proved abortive, either there being no result, or only a small, evanescent pimple appearing. The cases here mentioned are No. 5, observed for 8 years, died of exhaustion ; would not submit to colotomy. No. 7. Colotomy performed with success, all ulcers heal- ing ; this patient has now been seven years in good health. No. 16. Had large fibroid polypus with stricture and ulceration ; removal of polypus and dilatation with incision effected a cure. No. 18. Division effected a permanent cure. No. 25. Colotomy effected cure, patient watched for years and found well ; eventually, all the strictures being cured, the wound in the loin was closed. No. 29. Division of fistula and dilatation of stricture effected a cure. No. $6. Fissure and polypus, with ulceration and strict- ure ; operation, subsequent dilatation ; cured ; some months after found well. 176 ULCERATION AND STRICTURE OF THE RECTUM. No. 43. Stricture and ulceration cured by incision and dilation. No. 57. Disease of uterus, enlargement of fundus, retro- version, Hodge, dilatation, cure. No. 59. Stricture and fistula, ulceration, careful division of fistula and stricture, cure permanent. No. 67. Male, annular stricture and ulceration, phthisis, relief. No. 69. Stricture very long and hard, gradual dilatation of stricture, cure, and no relapse. No. 70. Annular stricture high up, incision and dilatation of stricture, cure. With regard to inoculation, I performed it on many patients in whom severe constitutional symptoms of syphilis with outside growths existed, and never got a true chancroid as the result ; I noticed many small pimples and sores, which healed in a few days, but never a typical soft chancre) I therefore certainly did not inoculate from a soft sore. I know many of these patients died after years of treat- ment, numbers of them being admitted and readmitted into the hospital. They die either of some intervening acute disease, obstruction in the bowel, or gradually undermined and broken-down health ; the workhouse infirmary often sees their end, which may be very rapid. In sixteen cases I performed Verneuil's operation of linear rectotomy, but always with the knife, never with the ecraseur or galvanic cautery as he has recommended. One thing I have learned in m.y long practice — not to fear any haemorrhage from the rectum. This is the essence of Prof. Verneuil's operation : the whole stricture must be divided from its upper edge down to the coccyx, and through its entire depth. Thus a deep drain is made, from which all discharges freely flow, and as it heals up, the ulceration ceases, and the stricture is some- times cured. The patient being in lithotomy position, what I do is simply to pass my finger through the stricture ; I then introduce a long straight knife along my finger, and when the point is fully above the stricture I cut firmly down, right through it, in its whole depth, even to the sacrum, if necessary, and bring the knife out at the tip of the coccyx. If you keep the median line the bleeding is but trifling, and the whole of the diseased structure will have been cut through. So rapidly beneficial is this operation, that in forty-eight ULCERATION AND STRICTURE OF THE RECTUM. 1 77 hours I have often seen night sweats arrested, and a patient who seemed about to die rally and eat and drink, and get well from that moment ; morbific discharges, instead of being absorbed, run out, and the patient is not poisoned. The wound should be well syringed, and the parts kept per- fectly clean. I always use dry absorbent cotton wadding as the dressing, and I only want my patient washed, at most, twice in the day; too frequent use of any fluid, carbolized or not, soddens and weakens the granulations ; if you want these cases to do well, dry dressings are those I advise you tc employ. Many of these patients have done well, and I have had per- manent cures, but others have failed, and I have seen a return after even three or four years. In the after-treatment I often place a tube in the wound, keeping it in at night, which tends to prevent contraction, . More of the seventy cases would have been subjected to colotomy, but often it is difficult to get the patient to con- sent, as I think it proper to put fairly before the sufferer the disadvantages as well as the advantages of the operation. Many cases were treated by dilatation, assisted, in some instances, by small incisions ; great care and pains are required in the treatment by dilatation, but it may be satis- factory, and I will relate some cases in which it was emi- nently so. Stricture of the rectum, however, is a disease infinitely more uncertain, more prone to relapse, and more difficult to treat, than stricture of the urethra. In some few cases immense good resulted from the administration of iodide of potassium and mercury; but, on the other hand, often when it was expected to benefit, no curative result followed. On the whole, therefore, I place no faith in spe- cifics. I think it is very advantageous to compare the results of our hospital with our private practice, so different are the patients in many respects — their habits, the food they take, the houses they inhabit, their cleanliness, sobriety, the com- paratively early stage of the malady at which they seek good advice — that one often finds the success in private practice so much greater as to be really astonishing. I shall pro- ceed, as shortly as I can, consistent with clearness, to give the heads of cases treated in private by me during the past few years. Time prevents my pushing my researches fur- ther back than the beginning of 1876. Case i. — Female, married, 37. No children, no miscar- J78 ULCERATION AND STRICTURE OF THE RECTUM. riages ; stricture about three inches up the rectum ; ulcera- tion both below and above it ; no history of syphiUs at all ; never had any sores nor discharge, more than a little whites; has no pain except such as arises from straining and fre- quent desire to visit the closet. The husband, perfectly willing to clear up the question, examined. Never had syphilis, but had gonorrhoea, but not since his marriage, eight years ago ; never had any soft sore or enlarged glands in groin. No scars on penis or in groin. The disease his wife suffered from was complained of about five years ago ; has had advice and bougies passed. I thought it advisable to divide the stricture in several places, and keep in a tube at night. Various plans of treatment were employed, with the result of a cure in nine months ; good reason to believe she remains well. Case 2. — Female, married, 27, Had children and mis- carriages; at her last two confinements children alive and appear well. Husband contracted syphilis since his mar- riage ; secondaries followed, and his wife, then encientey became syphilitic; child died a few weeks after birth ; it seemed healthy, but feeble. She was treated then, by her medical man, for secondary syphilis. Ulceration and stric- ture two inches from anus ; no symptoms of syphilis now. She suffers much from the bowels. Careful dilatation and treatment of ulceration made her quite comfortable, but I feel sure to this day she is not quite well. Seen with Dr.. Smith, of Blackfriars. Case 3. — Female, married, 30. Constitutional syphilis, acquired from the husband. No miscarriages ; but two children had syphilis; were treated, and are now living. Examination. — Almost impassable stricture; obstruction so great that I performed colotomy, the late Mr. T. Carr Jackson assisting me ; result good, but continued discharge from the rectum and the stricture very tight. I have been seeing this patient occasionally for the last four years. The husband, a dissipated man, has had all kinds of venereal disorders. Case 4. — Female, married, 48. No constitutional syph- ilis, and has never had any symptoms. Husband healthy, and says he never had any venereal affection of any kind; married very young, his wife being not nineteen. Eldest child eighteen, and all family healthy. Examination. — Stricture and some ulceration, two and a half inches from anus; good deal of pain and straining. Slight division and ULCERATION AND STRICTURE OF THE RECTUM. 1 79 careful dilatation effected a cure in five months. I am informed that this patient has continued well since. Case 5. — Female, married, 38. No symptoms of consti- tutional syphilis; has healthy children; very painful annular stricture near anus ; some swollen flaps of skin extrude ; ulceration extending for an inch and a half upward. The husband confesses to syphilis, but considered himself as quite well years before his marriage; has no symptoms now; division of the stricture, blue ointment with opium to ulcer- ation and careful dilatation cured her in about two years. I have not heard of any relapse. Case 6, — Female, married, 37. Stricture and ulceration rather severe; stricture one and a half inches from anus; suffers much; has dimness of vision, which I found to be caused by iritis; has syphilitic rash; rupial; is very cachectic and feeble; one child, nine years old, quite healthy. Her husband was under my care about twelve years ago, for indurated sore ; moderate mercurial treatment for six months; all symptoms gone, and left off medicine. Seen again after nine months, with secondary rash, rather scaly, and sore throat; mercurial treatment again; hydr. cum. cret. at bedtime, and blue ointment between the toes; very soon well, and would not take any more medicine. Came to me four years after, to consult me about the propriety of mar- rying. On careful examination I could find no evidence of syphilis, so thought he was justified in doing what he liked. He, soon after I saw him, married, and the only child, born fifteen months after marriage, was healthy, and has continued so. To return to the wife : three years after her marriage she had a rash and sore throat. She was treated by her medical attendant with iodide of potassium, and she quickly recovered; the husband during this time had flying attacks of syphilis, for which he saw me two or three times, but took, by his own prescription, iodide of potassium and sar- saparilla, This went on until the wife, having severe bowel symptoms, was sent to me. The treatment consisted of mercury and iron; the stricture was a little dilated, and she was sent to the seaside; great improvement took place in general health; the iritis -got rapidly well, and the stricture was" much modified by gentle dilatation; the ulceration also healed in great measure, so that she suffered but little, and the bowels acted only about twice in the day. The husband denied any fresh infection since his marriage; slight crops of secondary character were frequent, and he on one occa- l8o ULCERATION AND STRICTURE OF THE RECTUM. sion had an indurated crack at the orifice of the urethra. The wife eventually was quite cured. I have related the above somewhat in detail, as one has rarely so good an opportunity of watching such a case so long. Case 7. — Female, 36, married many years. Sent me by Dr. Playfair. Husband says never had syphilis; no symp- toms in his wife. Stricture two and a half inches from anus; slight ulceration; a very feeble woman; never any children; tendency to lung affection. Phthisis in family; has, from soon after marriage, suffered from inflammation of the uterus, and has now a fibroid in its posterior wall. Has a very spasmodically contracted sphincter, and the stricture is long, so that one cannot feel the extent of it ; despite all treatment this case went on to total obstruction, and colotomy was performed. The case did well ; duration of stricture at least ten years. Case 8. — Female, married, set. 45, no children. No his- tory at any time of syphilis. Sent me by Mr. Burton, of Blackheath. Stricture and slight ulceration three inches up from anus; no symptom of present or past syphilis in patient or husband; great relief in six months; treatment by dilata- tion and mercurial ointment. Saw this patient lately, and she remains well. Case 9. — Female, set. 50 ; this lady came from Philadel- phia to be under my care, History very doubtful, but has had many and healthy children, and several difficult labors ; no deaths; no miscarriages; children nearly grown up. Very bad stricture and ulceration; linear rectotomy in the median line; tubes kept in for weeks: eventually a very perfect cure; stayed six months in England, and went away without any tendency to contraction. I heard from this patient a few years ago; after she left my care she continued perfectly well. Case 10. — Female, married, aet. 37. No family; the wife of a medical man. Stricture near anus; ulceration, swollen tabs of skin, ichorous discharge. The husband had a hard sore and secondar5'' symptoms not long before marriage, and he knew he had affected his wife, whom he treated from time to time. Now, after an interval of about seven years, the first symptom appeared in his wife, the husband at the same time showing mucous sores on the lip and anus. Treated for a long time by specifics and local treatment, including division of the stricture, but with only great relief maintained by constantly wearing a tube ; no permanent cure, I fear, will be effected. ULCERATION AND STRICTURE OF THE RECTUM. iSl Case ii. — Female, married, ast. 29. Severe ulceration; stricture two inches up the rectum ; recto-vaginal fistula. Husband, a very dissipated man, confesses to have had syphilis and gonorrhoea many times. The wife had tertiary sores on legs; mucous papules; nodes on head; very cachec- tic and feeble; small doses of mercury were given twice in the day, with iodide of potassium and arsenic, with decoc- tion of cinchona; good diet and fresh air soon restored her health, and attention was bestowed on the stricture ; it was divided in several places very lightly and a tube worn, but the tenderness defeated all the treatment; she could not retain anything. Suppositories or sedative injections were at once returned and pain was increased. Her health again broke down, and as a last resource colotomy was performed, but she lived only three months; relieved from pain, but never rallied. Case 12. — Female, married, set. 60 (widow). Stricture a little way up the bowel, one and a half inches; slight ulcer- ation. Has many children grown up, healthy; only for a few years suffered discharge; frequent going to stool and general decline of health. Sent to me by Mr. Sloman, of Farnham. Division and dilatation of stricture; mercurial and opiate treatment of the ulceration; wearing a tube at night effected a great improvement; in fact, I think there is every reason to hope for a cure. I have since heard of this lady doing well. Case 13. — Female, unmarried, set. 55. Sent to me by the late Dr. Lockhart Clarke. For many years has suffered from difficulty in the bowels. Examination. — Long and tight stricture, two inches from anus; very little ulceration, but considerable roughness near the anus, evidently the scars of old ulceration; the index finger could be passed through the stricture after some pressure. The history" of the past showed that she had suffered much in the rectum, pain, bleeding, discharge of mucus and constipation alternating with diarrhoea. Had consulted many physicians, and taken enormous quantities of medicine, laxative and tonic ; she had taken great care of herself, lying up much. Extreme caution in diet, living almost solely on fish, vegetables, and fruit. She says, on the whole, constitutionally she is better, but increasing difficulty in obtaining relief brought her to me. The case I considered one very amenable to treatment by dilatation and keeping in the tube at night. This I adopted, and in three months she was better than she had been for l82 ULCERATION AND STRICTURE OF THE RECTUM. many years. This ulceration and stricture, I have no doubt, from the history, arose from inflamed, and perhaps suppu- rating, hemorrhoids ; the submucous tissue got affected, and ulceration and stricture resulted. There was no appear- ance of any tuberculous tendency, and certainly no syphilis, acquired or hereditary. I cannot see why in many cases a similar condition may not result from constipation and inflammation. Case 14. — Female, married, set. 34, attended with Mr. Seymour Haden. Stricture for long time ; seen by Mr. Haden one month ago, when the obstruction was almost total, and she had constant vomiting. Mr. Haden got a tube through and relieved the obstruction. No history of syphilis or struma in the patient or husband; the question of syphilis in my own mind was quite settled in the negative. I attended this patient for some time and she much im- proved. Her husband was a chemist, and with a little teaching became quite skillful in passing the bougie. I lost sight of the patient, and do not know the ultimate result. My opinion was that the cause of the stricture was very severe labors, and long pressure of the child's head. It is not uncommon for women to connect their bowel trouble with a bad or instrumental labor. Although I should not consider this a common cause of ulceration and stricture, it ought not to be left out of our consideration. Case 15. — Female, unmarried, aet. 27. Seen by me in con- junction with Mr. Aikin, and afterwards with Sir James Paget. Had been operated upon for fistula, and ulceration followed, severe in character ; got better and worse. Brigh- ton air did her so much service that a happy result was anti- cipated, but, however, she fell back again. When I saw her with Mr. Aikin the sphincters were quite ulcerated away ; with great difficulty the finger could be got through a stricture two inches up the bowel. The history led me to conclude that the disease was tubercular ; I advised imme- diate colotomy. I did not see this patient until four months later, when she was much worse ; abscesses had formed in the groin, and a communication was established between the vagina and rectum ; her condition was so deplorable that an operation was undertaken, only as a means o^ relief by turn- ing aside the faeces. With the sanction of Sir James Paget and Mr. Aikin I performed colotomy. After the operation I pointed out that the ulceration ^ould be detected from the aperture in the loin by passing the finger toward the rectum. ULCERATION AND STRICTURE OF THE RECTUM. 183 Her history from this period was, some temporary arrest of the ulceraton, but this did not last long, and soon it could be seen on the bowel in the lumbar opening. Abscesses formed in all directions, and burst or were opened in several places, so that the interior of the pelvis could be seen. She died just three months after the operation. To a certain extent relief was obtained, but not so much as I think would have resulted had colotomy been earlier under- taken. The ulceration was serpiginous in character. Case i6. — Female, married, set. 34, no children, was seen by me in consultation with Dr. T. B. Crosby. She was suffering, and had been for years, from tertiary syphilis, necrosis in the tibiae having taken place ; had not undergone anti-syphilitic treatment for lengthened periods. There was ulceration and tight stricture in the bowel; the urethra was ulcerated through in nearly its whole length, so that incon- tinence of urine resulted ; some communication had taken place between the bowel and the bladder, as wind freely passed on her making water or on introducing a catheter. Treatment was undertaken by passing a bougie, keeping the bladder empty, and her constitutional powers were much improved by small doses of mercury and tonics. Result of treatment nugatory, as regards the incontinence of urine. Case 17. — Female, married, set. 47, no children. Seen with Mr. Theophilus Taylor. Syphilis undoubted, tertiary scars being present ; ulceration of rectum and stricture ; very much discharge ; great pain, straining, and constant desire to go to stool ; constitution very much undermined. The stricture was so tight that division was made in dorsal median line, and bougies soon after introduced. Tonics (iron and mercury in very small doses) were administered; aftor long treatment great improvement took place. The wound healed and the ulceration was very slight, so that the discharge became almost nil, and was mucous rather than purulent. She was instructed to pass the bougie (very short one) herself ; she could safely do this, as the stricture was not very high up. When last seen was wonderfully improved, but had incontinence of fseces if at all fluid. Still, the comfort she had derived from treatment was most marked and satisfactory to her as well as to her medical attendants. Case 18. — Female, married, aet. 42. Three children, very healthy. Sent me by Dr. Herbert Davies. Suffered for a long time with constipation and straining at stool; no evacua- tion obtained without medicine or enemata ; rather thin, but 184 ULCERATION AND STRICTURE OF THE RECTUM. not unhealthy looking ; no miscarriages ; no history or appearance of syphilis. Examination. — Found tight, annular stricture, one and a half inches from anus; ulceration below the stricture as well as slightly above ; some swollen outside skin, not discharging. The stricture proved very dilatable, so the use of the bougie enlarged it much in about three weeks, and she was then more comfortable than she had been for years. The ulceration also got better by the use of a bismuth, morphia and pitch ointment. In fact, so much better was this patient at the end of two months that she has not visited me since. Case 19. — Female, widow, set. 59. Sent me by Mr. Pinch- ing, of Gravesend. Long troubled with her bowels ; never passes formed motions, always in small, broken pieces, with blood and slime on them; has been getting thinner, but says her health is fair, and if she was comfortable in her bowels would be quite well. Examination. — Stricture tight, /. e. could only get forefinger through, and this caused much pain ; the edge of the stricture was ulcerated. Many years ago had been operated on for piles at a London hospital ; she was in poor circumstances then ; from that day never had perfect comfort in the use of her bowels. I slightly divided the stricture and introduced bougies, gradually increasing in size, and by the application of ointments the ulceration gradually got better, so that she could sleep all night with a bougie in the stricture. In three months she was quite well ; no trace of stricture could be felt, but cor- rugations and roughness, showing the healing of the ulcera- tion, remained. I saw this patient more than a year after the treatment, and she continued quite well. I have no doubt this stricture and ulceration was the result of the operation on the piles. I have seen for years past numerous cases of ulceration with stricture result from operations upon the rectum, but as this condition usually takes place shortly after the operation, and is manifestly due to it, I have not given any histories of such cases, although they frequently take a great deal of time and trouble to cure. CASES IN PRIVATE PRACTICE, OF ULCERATION AND STRICTURE IN MALES. Case i. — Male, ast. 23. In the army. Had a hard sore some three years back and was treated. After some time he suffered from pain on defecation, and he went to a surgeon, ULCERATION AND STRICTURE OF THE RECTUM. 185 who said he had syphilitic sore and must be operated upon, but after the cutting the sore became worse, and he came to me. I found the sore unhealed and inflamed, and suspect- ing more, I wnth difficulty passed my finger up the bowel, when I found that above the sore, which had been divided, there was quite an inch of healthy mucous membrane form- in a zone around the bowel, then some other ulceration in a zone an inch in width. He had no other sign of syphilis but a sore throat. Mercurial ointment, arsenic, and iron, with cod-liver oil, as he was weak and feeble, soon made an improvement. In a fortnight a bougie could be passed, and all healed in about eight weeks. Case 2. — Male, ast. 40, married ; had never had syphilis, but told a strange story, that, if he was affected, it arose from taking a Turkish bath. Very bad ulceration extended two inches up. Stricture was tight, and he had much pain, and got no relief unless he took large doses of purgatives. Linear rectotomy and twelve months' great care nearly cured him. I have not seen him during the year and a half which has elapsed since the operation, but I have heard he is not well. Case 3. — Male, aet. 29, unmarried. Had syphilis, and was treated by Ricord, of Paris, for eighteen months, and thought himself quite well ; had lost all rash and all symp- toms for months, and then discontinued all his medicines. About six months after he experienced pain and straining on defecation. As he was coming to England he was recom- mended to me. On examination I found just inside the anus ulceration, with stricture, very painful to touch ; he could not bear the bougie. The use of an ointment com- posed of bismuth, blue ointment, and opium, soon relieved the pain, and I was enabled to dilate, and he kept bougies in. This patient had never had soft sores in his life, nor even gonorrhoea. He was not a strumous, nor in any way a delicate man. The case ended favorably, showing the desirability of early treatment. Case 4. — Male, aet. 28, unmarried, a native of India study- ing medicine in this country. Had suffered from dysentery and diarrhoea frequently, but not severely, in his own country. Has been in England two years and no severe attack ; in fact, much better here than abroad. About one month ago felt pain on defecation, but took a little laxative, and found himself better, but still straining was frequent, with mucous and occasional blood. He came to me ; he was a small, thin. 1 86 ULCERATION AND STRICTURE OF THE RECTUM. agile man of more than average intelligence. Exa^nina- tion. — I found, three inches from anus, a stricture through which only a small bougie would pass. Injections of opium and starch in very small quantities relieved the pain, and allowed me to increase the size of the bougie. The stricture proved very amenable, and he was soon restored to perfect comfort, and his health improved. I advised the continuance of a short, small bougie. Case 5. — Male, unmarried, but who intended to be married, came to me about an uneasy sensation in the rectum, fre- quent diarrhoea, and straining; occasionally mucus passes in abundance; was treated for syphilis, with mercury in various forms, by one of our best surgeons ; and now he felt himself quite well. Examination. — Stricture an inch and a half from anus ; above the stricture ulceration. The stricture was hard but the ulceration very soft. Had no other venereal affection since the sore. Health fair. I found it, after a time, necessary to divide the stricture freely; then the ulcera- tion, by treatment — topical chiefly — rapidly improved, and after nine months he was fairly well. During my treatment I sent him to Aix-la-Chapelle, as he had a return of syphilitic sore throat and rash, to be under the care of Dr. Brandish and undergo baths and mercurial inunction. He came back without any rash, and with his health greatly improved. The ulceration had then not healed, but soon after he got quite well, and I think, remains sound. Case 6. — ^Male, single, aet. 47, retired captain in the army; very bad stricture and ulceration; feeble, and much worn and emaciated; says never had any venereal affection what- ever, and as he had no reason for deceiving me, and I could find no trace of syphilis anywhere, I believed him. For some years he had this affection, and when in the army in India he was treated with bougies, but with very slight advantage. No history of phthisis in his family. Suffers very much. A careful course of bougies, keeping them in when he could bear them, a little division of the strictures (for there were two) in several places, gradually got him into comfort, but cure seemed hopeless. He returned to me a few months back and finding him suffering much I proposed colo- tomy, to which he acceded. The operation has proved a signal success, and he is alive now. Case 7. — Male, single; said to have had only soft sore, but as copious, rash followed, I am fain to believe, although the diagnosis was made by one of our greatest syphilograph- ULCERATION AND STRICTURE OF THE RECTUM. 187 ers, that an error was fallen into. Two years after this sore he suffered pains on defecation and came to me. On exam- ination I found stricture and ulceration commencing one inch from the anus, which outside appeared normal. The stricture was annular, and I divided it in several places and cautiously dilated. Blackwash lotion benefited the ulcera- tion, but iodoform did most good, and he was soon well. I advised the use of the bougie once in the week for some months. Case 8. — Male, set. 26, lieutenant in the army ; no history of syphilis or any venereal disease whatever. Ill about nine months. Saw this patient with Sir James Paget, who agreed with me in the opinion that the disease was strumous. When I first saw him he had a very tight stricture close to the anus. This I divided and dilated only to find another stricture three inches higher up, and plentiful soft ulceration between the two strictures. Local and general treatment failed to do good; a voyage of some months' duration had a like result. When he returned he was seen in conjunction with me by Sir William Gull, whose opinion coincided with Sir James Paget's and my own. He is still being watched, and on the whole is better, but frequent diarrhoea, straining, dis- charges of blood and mucus still occur. He had never had dysentery nor habitual diarrhoea. Case 9. — Male, set. 37, married. History of soft sores under prepuce and buboes, and suppurating. No hardness observed, and no eruption or symptoms of constitutional syphilis known. Healthy looking, strong man. An inter- val of eight months elapsed from the cure of his soft sores until he complained of passing blood and mucus with pain, per anum. This went on for some time, and he treated it as piles, taking laxative medicines and using lead ointment. Finding no benefit he was sent from the country to me. The history was given so truthfully that I could not doubt his words. He had no symptoms of syphilis, but he showed me a wound in the groin where one bubo was opened. Qn examining the rectum I could only just pass my finger through the stricture, and I found ulceration above it, but no trace of any below; he had small external piles, but no ichorous growths. The treatment was slight division of stricture, wearing a bougie all night smeared with bismuth and morphia ointment, to keep the bowels open by the lico- rice powder (Pharm. German), to avoid all alcohol and meat, and to live on farinaceous food and plenty of milk. l8S ULCERATION AND STRICTURE OF THE RECTUM. Success soon crowned this treatment, and in three months he was quite convalescent. Case io. — Male, set. 46, first officer in American line of steamships. Has suffered for years in his bowels, terrible constipation, and passed motions with blood; much pain and /requc-nt going to stool: been treated for piles, and ahvays took sulphur, from which he derives considerable benefit. Very strong, healthy, steady man. Never had any venereal disease at all. Steadfastly held to this statement. Did not mean to say that he had run no risk, but had been fortu- nate. I could detect no sign of syphilis, no bubo, scars, or rash. Examination of rectum. — Tight stricture an inch and a half from the anus, and there was ulceration above and below the stricture. I divided the stricture and dilated, keeping in a vulcanite tube for several days. He became so much better that at the end of three w^eeks he again went to sea, using at night a small tube, which he could wear with comfort and no danger. I saw^ this patient many times, and found him always better, but a slight discharge of mucus still continued, but as his constipation was removed and he suffered no pain, he became quite satisfied wdth the result. The only thing that radically benefited his constipation after the operation and dilatation was a dinner pill, which he took every other day, composed of extract nux vomica, ipecacuanha, and compound rhubarb pill. From a study of the history of nineteen females treated, and watched afterwards for some time, it appears that seven had undoubted signs of constitutional syphilis, and twelve had neither the symptoms nor history of any form of vene- real disease; thus there w^as much less undeniable syphilis in private than in hospital practice. In the non-syphilitic patients, the ulceration was most tuberculous. Tw^o patients ascribed the disease of the bowel to many difficult labors. I cannot see why injuries during labor should not be a source of ulceration ending in a constriction; in fact, I wonder we do not oftener meet with instances in w^hich this cause alone can be assigned. One case resulted from an operation per- formed upon the rectum long since. In most cases, having the husband before us to interro- gate and examine, we are enabled to compare his condition wnth that of his w^ife. I am confident that in the majority the evidence of the husband was to be depended upon. In Case 3, which was one of the worst strictures I ever saw, and in which I w^as compelled to perform, colotomy, the'hus- ULCERATION AND STRICTURE OF THE RECTUM 189 band had suffered from all kinds of venereal infection. Case 6 had iritis and well-marked syphilitic rash. I knew her husband had suffered from constitutional syphilis, as I had treated him. The poison probably was quiescent at the time he impregnated his wife, as the child was born healthy and has continued so up to nine years of age. Twenty months after the child was born the mother suffered from syphilis for the first time. The husband about that time consulted me for slight flying attacks of secondary symp- toms, and he said there had been a crack at the entrance to the urethra, and in my opinion that crack inoculated his wife; she was not under my care, and no search was made for any sore, and it was not until seven years after she had become syphilized that she came to me. In four cases lum- bar colotomy was performed. A few words about the male patients, who were ten in number: observe in private practice how many more men in proportion to women than in hospital practice. Three-had decided constitutional syphilis. One had doubtful symp- toms. One had suffered from a soft sore under the prepuce, accompanied by a suppurating bubo; and the remainder, viz., five patients, had no syphilitic or venereal taint. Of these, repeated dysentery was probably the cause in one, if not two. Two resulted from tuberculosis (my opinion in these cases was sustained by Sir James Paget). One resulted possibly from the hard life of a sailor; bad feeding, exposure to weather, dysenteric diarrhoea at times, but usually the most intractable constipation; his rectum for years was constantly irritated by contracting upon hard and dried masses of faces. In such a case injury to the mucous membrane could not be an unexpected event. It is often difficult to trace the cause in a case of ulceration, but really such conditions as I have described must sometimes be either predisposing or exciting. In one case only was I obliged to perform lumbar colotomy. In one case, also, Verneuil's operation was done; the success, however, was more than doubtful, as I have heard this patient is still suf- fering. I have found, speaking generally, that a- fair amount of relief is more frequently attained by treatment in men than in women. Various reasons will suggest themselves to my readers, as conditions of the uterus, ovaries, vagina, coitus, etc. Lastly, I would observe that complete cures are seldom if ever obtained, but great relief is not uncora- IpO ULCERATION AND STRICTURE OF THE RECTUM. mon, and in favorable cases, by proper attention, the patient's life may scarcely be shortened by the malady. On summing up my own statistics I can, in short, state that in women forty-two out of seventy-nine had suffered or were suffering from undoubted constitutional syphilis, and in twenty males, half were in the same condition; thus out of the total number of ninety-nine patients, fifty-two (or more than half) were syphilitic. This is a greater propor- tion than I have seen mentioned before, but, as far as I can ascertain, the truth is stated. What causes brought about the ulceration, etc., in the forty-seven patients who were not syphilitic ? We have propounded some causes, viz. tuber- culosis (not so uncommon as generally supposed), dysentery and diarrhoea, usually following prolonged residence in tropical climates; obstinate, long-standing constipation; injuries to the uterus and vagina in parturition; operations on the rectum in persons of bad constitution; but will these causes account for all the cases ? I am obliged to say I do not think so, and to confess in the majority of these patients I do not know the cause, nor have I been able to trace out any definite common state preceding the malady. If we could answer the question why ulceration and stricture is so much more frequent in the female than in the male, we should possibly have a clue, but for my part, I cannot see that any satisfactory reply has been given to this question, nor has it to another question; why is epithelioma compara- tively rarely found in woman ? In connection with this part of the subject, I must say a few words about the view entertained by some French authorities, and also by eminent American surgeons, viz., that the vast majority (some say all) of cases of stricture and ulceration, not cancerous, result from contamination by the discharges from " soft sores " or " chancroids." They scarcely admit that constitutional syphilis has anything to do with the cases I have been considering in this chapter. When a former edition of this work appeared, I well knew that Dr. Gosselin, of Paris, had published these views, but I knew also that his conclusions had been arrived at from very few observations; that another explanation of his cases, which I will not mention, could be readily found, and that his theory had received but feeble support from any of his confreres, while many of the most eminent authors on syphilis, as Ricord, Fournier, Molliere, and others, had altogether repudiated his doctrines. These I deemed sufficient reasons ULCERATION AND STRICTURE OF THE RECTUM. ipr for not discussing the views in question: but since I have received a monograph from Dr. Erskine Mason, of New York, who adopts Gosselin's views in their entirety, I have without prejudice considered the subject, and observed my cases from the standpoint Dr. Mason takes, and I must state that I am not by any means convinced by Dr. Mason, though entertaining a very high sense of the ability and spirit with which his monograph is written. I think 1 have made it quite clear in the foregoing pages that in both sexes the most intractable ulceration and stric- ture of the rectum may arise without there being any venereal element whatever in its causation, and I think I am not alone in this view. It appears from Dr. Mason's statistics, as well as my own, that about half the* patients with ulcera- tion and stricture " have, or have had," constitutional syph- ilis. A fair inference is, I think, that some form of syphilis may cause the rectal lesion. Post-mortem examinations have revealed, in addition to rectal ulceration, deposits in the liver, lesions of the brain and membranes, and diseases ef bone; at least, probably all these resulted from the same cause; but I do not wish for one moment to maintain that in every case when syphilis and ulceration of the rectum coexist the latter is caused only by the former. It is no sound argument to say that if the ulcerations of the rectum were syphilitic they ought to yield to the usual anti-syphilitic remedies, because it is well know^n that the latest syphilitic manifestations, or the sequelae of syphilis, are commonly not amenable to specific treatment, whether they occur in one or other organ; and in fact, the time has passed away in which any constitutional treatment could be expected to have much effect. Dr. Mason says, " I have repeatedly noticed the anus become contracted in women after the healing of several simple chancroids involving this portion of the intestine." I must say I have never seen such a thing myself. How can the discharge from a soft sore get into the anus and thence to the rectum ? by the discharge running down to the anus; possibly, but I should say rarely. Through menstruation ? more probably. By .direct contact from the male organ? most probably. In France this cannot be uncommon. I trust it is not common in America. I cannot say that in this country it is altogether unknown, but I hope and think it is inf?requent. I will make this assertion with- out fear of contradiction j in the large majority of ulcerations ig2 ULCERATION AND STRICTURE OF THE RECTUM. of the rectum the disease does not commence at the anus, but at least an inch up the bowel, a condition I would say, quite incompatible with the theory of inoculation from external discharge, but in accordance with what one might expect when the discharge was implanted by direct contact. Dr. Mason's own statistics bear out my statement as to the usual site of the ulcerating stricture. Has any one seen soft sores on any part of the body caus- ing induration and contraction of tissues ? do we see this in soft sores under a long prepuce ? Then, once more, how does phagedaenic ulceration accord with contraction and fibroid degeneration of tissue, which is one of the essential characteristics of advanced ulceration and stricture ? Dr. Mason asserts that he has seen " constriction of the rectum follow, and that very shortly after the healing of chancroids had taken place." I would ask is this a patho- logical probability; and is the/^.f//z^(: necessarily the/r^/^/i^r ^oc in such a case ? I shall but cite some eminent authorities on this very inter- esting subject, as space is wanting for further argument and observations. Time, I am sure, will dispel all doubt, but at present, I think, we may safely say that the chancroid theory does not account for the majotity of strictures and ulcerations of the rectum. Ricord has expressed the opinion that many cases of stricture were caused by syphilitic deposits and ulceration. Fournier has most positively asserted that stricture and ulceration of the rectum were commonly caused by consti- tutional tertiary syphilis, and most rarely by local contamin- ation of any kind. Lancereaux. in his book on " Syphilis, Historical and Practical," states that gummata have been found in the large intestine, and although inclined to agree with Gosselin, and regard these " contractions of the rectum" rather as venereal than syphilitic, yet would not too exclus- ively adopt the theory; inasmuch as gummy deposits are found in other parts of the intestinal canal, there is no reason why they should not occur in the rectum. The English surgeons most experienced in syphilis, almost with one accord, adhere to the constitutional theory, and discard the idea of the local origin of ulceration and stricture of the rectum. I have spoken to scarcely one gentleman who has not given me a similar answer to my question on this point. My friend and former colleague, Mr. James R. Lane, at my request wrote me his opinioii on this subject, and I ven- ULCERATION AND STRICTURE OF 'THE RECTUM. I93 ture to submit that few men have had greater opportunities for studying the matter than he. Many years Surgeon to the Hospital for Diseases of the Rectum, the worst forms of stricture and ulceration are perfectly familiar to him; for a still longer period, as Surgeon to the Female Lock Hospital, he has had an almost unbounded field for observing every kind of sore to which the female genitals are exposed, and what does he say ? "I believe that the ulcerated strictures of the rectum to which you allude, and with which I am so familiar, are very rarely, I am almost disposed to say never, caused by primary syphilitic ulceration of the nature of soft sores. According to my Lock Hospital experience, by far the most common seat of such sores is at the inferior four- chette, and the verge of anus. They get well in due course, under simple treatment, like soft sores generally do ; some- times, when situated on the sphincter ani, they produce the pain characteristic of *' anal fissure," but they will heal all the same and the pain will disappear. When one of these sores extends into the rectum, which is very seldom the case, the result is a circumscribed rectal ulcer, which, with treat- ment, and especially judicious cauterization, will usually heal." Mr. Lane further guards himself against being sup- posed to consider all bad ulcerations and strictures as result- ing from constitutional syphilis. In Mr. Lane's observations I most heartily concur; my experience of soft sores near the anus is that they speedily heal under proper treatment, and I have seen many cases cured in a few days by cleanliness and the use of a tartrate of iron lotion, and though these patients have been seen from time to time for other ailments, no ulceration or stricture of the rectum has been found to ensue. Mr. Walter Coulson, Surgeon to the Lock Hospital, has never seen ulceration and stricture result from a soft sore, nor has my colleague, Mr. Alfred Cooper, who, like Mr. Lane, is Surgeon both to the Lock Hospital and to St. Mark's, and, therefore, has the double opportunity of noting these sores from an early period and following them, if they came, to the Hospital for Diseases of the Rectum atterwards. Mr. Christopher Heath, of University College Hospital, has, in some lectures by him on " Diseases of the Rectum," strongly expressed his conviction that the cases we have been discussing are commonly the result of tertiary syphilis. Mr. Bryant, in his " Practice of Surgery," looks upon these ulcer- ations and strictures " as mainly syphilitic," and only thus notices Goselin's views : " Foreign authors describe chan- X94 ULCERATION AND STRICTURE OF THE RECTUM. croid disease of the rectum venereal but not syphilitic ; in this country it is hardly recognized." There are no maladies more baffling to the surgeon than ulcerations and strictures of the rectum, and, as I have before said, they are often quite incurable, and nothing affords relief save colotony. This operation, however, though doubtless it may prolong life, should not be resorted to without due consideration, because one cannot fail to see that in many cases the remedy proves a most objectionable one ; an opening in the left loin through which the faeces escape is very harrassing, and nothing but a great desire to live or the fear of immediate death would lead me to submit to such a proceeding. I presume that, as time goes on, the patients get used to the discomfort and loathsomeness of their condition. My patients who have lived long seem to have had some pleasure in life ; indeed, two woman were married after the operation, but notwithstanding such facts as these, I entertain greater repugnance to the operation than I formerly felt, and latterly have mostly performed it as a last resource or for total obstruction. It is not quite impos- sible, after colotomy, that the ulceration and stricture may get well, and then the wound in the loin might be closed ; this I have once done, but although I have tried I have never succeeded again. In the earlier stages of ulceration and stricture, from whatever cause, save cancer, treatment care- fully selected, judiciously varied, and persistently carried out may do much good, and in favorable cases even effect a cure, but the patient must have faith in his surgeon, and be pre- prred to submit to long-continued watching even when much improved ; if the sufferer runs about from one doctor to another his fate is sealed, as he gives neither himself nor his surgeon a chance. In cases of circumscribed ulceration, I have great confi- dence in the efficacy of rest in the recumbent position, and in a wholly or nearly fluid diet, and I consider milk should be the essential element in such a diet. I could relate many cases where I have really cured the patients with very little medication, occasional slight applications of a caustic solu- tion, bismuth, morphia, and a gentle regulation of the bowels, having fulfilled all the indications. These patients confined to the sofa, and fed almost entirely on milk, often improve in general health, and gain weight. If cod liver oil can be taken I prescribe it as an aid to nutrition, but it must be taken only in small dosea ULCERATION AND STRICTURE OF THE RECTUM. 1 95 Fig. 8. When the ulceration is deep, and contraction has com- menced, the disease is much more serious, and a very doubt- ful prognosis should be given ; still, in all cases a good deal may be done, and hope may be instilled, if only the patient will give up to all treatment for a more or less lengthened period. If patients walk about, stand, sit, and attempt to continue their business transactions, treatment is nearly always rendered inefficacous ; one indiscretion may render nugatory a week's labor. In these cases, therefore, rest is even more important than in ulceration in the earliest stage. Often the ulceration induces such an irritable condition of the rectum, that nothing will be retained, neither any injection, suppository, nor oint- ment ; directly anything is intro duced, uncontrollable spasmodic expulsive efforts are set up, and may continue long after the offend- ing matter is rejected ; thus great pain is suffered and the part itself damaged. I have found that bis- muth and charcoal taken internally will generally soon overcome this excessive irritability. Subcarbonate of bismuth may also be tried on the mucous membrane itself, by means of an insufflator ; this continouusly used may soothe the rectum and relieve pain. As a rule I prefer ointments to suppositories or injec- tions. The little instrument of which a diagram is given obviates all difficulties of introduction, and I am sure irri- tates less than other methods of medication ; all kinds of sedative, opiates, and astringents may in turn be tried. I am very fond of thefollowing formula, and have seen it most efficacious : — ^ . Bismuth. Subnitratis 3 i j Hydrarg. Subchloridi- = 3ij_ Morphias gr. iij Glycerinae 3 i j Vaseline 1 j. M. 196 ULCERATION AND STRICTURE OF THE RECTUM. This is a ,very sedative application, and sores seem to be benefited by it speedily. Subacetate of lead, belladonna and opium will be found serviceable; all sorts of astringents may be employed ; rhatany, friar's balsam, zinc (the per- manganate), copper, iron, nitrate of silver, etc. The last, carefully used in not too strong a solution, is one of the most admirable applications, often inducing in an ulcer a healthy appearance, and causing granulation. The tartrate of iron I also employ for the same purpose. Fuming nitric acid or strong carbolic or chromic acids applied under certain con- ditions, are potent remedies ; they often allay pain and start healing processes afresh, but they arig double-edged weapons, and must be used with great discretion and with a distinct object in view. In ulceration, when the least stricture exists, bougies may be always employed, but it must be remembered that to do any good the greatest gentleness must be practiced by the surgeon ; indeed, pain ought not to be caused, although considerable discomfort cannot in most cases be avoided. A bougie of too large a size should never be employed ; no greater mistake can be made, than to suppose that the larger the bougie you can get in the better ; keep below the size that can be well borne, rather than at all above it ; in the one case good may ensue, in the other, irritation and retrogression are sure to take place ; never give a patient an ordinary bougie to use for himself, if the stricture be more than two inches from the anus. I have now seen two deaths occur from patients thrusting the instrument through the wall of the rectum ; peritonitis immediately set in, and they expired in great agony. Occa- sionally, when the constriction is only about an inch or an inch and a half from the anus, I let the patient have a short instrument to pass and wear at night, if its introduction can be accomplished without any severe pain. I employ vul- canite tubes furnished with a collar, to which tapes are fast- ened, to keep them in the bowel, and, at the same time, pre- vent them escaping into the rectum, an accident I have more than once seen occur ; in one case, indeed, a full-sized bougie entirely disappeared, and could not be reached by the finger in the rectum; its distal end could be felt in the transverse colon; fortunately, after a few trials, I was able to seize it with a pair of long bullet forceps, and withdrew it from the bowel; the patient, as may well be imagined, being not a little frightened. When strictures are slight, and not very long, but annular, a division in a few places, with the ULCERATION AND STRICTURE OF THE RECTUM. 1 97 knife, followed by judicious treatment with the tubes, may be very beneficial and even curative. The division I usually make at four points, and I take care just to cut through the induration, and reach the healthy tissues beneath, but not to go deeper; the ]?owel should be filled with well-oiled lint or wool for twenty-four hours, and then the tube introduced and worn, only taking it out for the bowels to act, and to wash out the rectum with some antiseptic solution. I prefer Condy's fluid, very dilute, or thymol. I am of opinion that carbolic acid is always too irritant if strong enough to be of any service. Some four years ago a young gentleman, set. 19, came to me with an annular stricture about an inch from the anus ; division as I have described, the use of the tube, and general treatment, cured him in six months, and he has continued well to this day. Continuing to consider the progress of these cases, we come to the more severe kind, where the ulceration is very extensive, the constriction so bad that there is great diffi- culty in obtaining any passage through the bowels; no action taking place without the use of strong purgatives or where, on the other hand, incontinence of faeces renders the patient's life a burden to him. The lower part of the rectum will be now merely a passive tube; all elasticity has gone, and liquid faeces run away, or there is a perpetual leaking of semi-fluid motion ; the condition of the sufferer is truly pitiable ; around the anus large, hard growths exist, and fistulous passages pass up the bowel, opening into the ulceration, most frequently below, but sometimes above, the seat of constriction. These fistulas may be divided, and some tem- porary relief afforded. If in such cases the fistulas run high up the bowel, and the tissues are very dense, I much prefer the elastic ligature to the knife; in fact, I now never employ the latter in such a case ; the bleeding is sure to be exceed- ingly free at the time, and great difliculty is found in arrest- ing it, as the vessels can neither retract nor contract. The only patient I ever lost from haemorrhage afrer an operation upon a fistula was a young and delicate man, sent to me from Ireland, with stricture and numerous fistulas, the whole tissues being brawny in the extreme. At the operation I had great difliculty in arresting the bleeding, but concluded that all was safe ; unfortunately, in the evening there was a recur- rence ; and my colleague, Mr. Goodsall, succeeded in stop- ping it with plugging aud styptics; however, on the third 198 ULCERATION AND STRICTURE OF THE RECTUM. morning a sudden gush took place, and the man died at once. The induration of the parts prevented the appHca- tion of any ligatures ; they cut through, or the vessel was so deeply placed as to be out of reach. In these later stages of ulceration no good, is derived from constitutional treatment. Mercury in any form does harm. Iodide of potassium is unavailing. Tonics to maintain appe- tite and give tone to the nervous system may be used, and always cod-liver oil, which may be regarded as concentrated nourishment ; one need not say that good feeding, with nutritious, but not bulky, food, is required. I shall discuss more fully lumbar colotomy in my chapter on cancer. Stricture of the rectum without ulceration is a somewhat uncommon affection. We have seen how stricture takes place after or in conjunction with ulceration. The thicken- ing of the tissues and the contractions which result from the attempts at repair must narrow the canal, but it is not so easy to see how or why a stricture should occur ter se. The rectum is a tolerably large tube (not like the urethra, where a very little deposit is sufficient to nearly block up the pass- age), and a considerable thickening might take place without causing any great obstruction. We may, perhaps, suppose that inflammation of the sub- mucous tissue produces a deposition, and, besides this, or resulting from this, there is a spasm, t am sure this is often the case ; I have seen strictures of the rectum so tight that I could not get the end of my little finger into them, but when the patients were well under the influence of chloro- form I have been able to pass one or two fingers through easily. How inflammation and thickening are set up in the con- nective tissue of the bowel it is difficult to say. It may be that straining to evacuate the contents of the bowel forces down the upper part of the rectum into the lower, thus caus- ing an intussusception, and bringing the part within the grasp of the sphincter muscles, and I have often thought that this condition may be the starting point of the irri- tation. I have in some few cases had a suspicion that the long- continued pressure of the child's head in labor has been the exciting cause, bruising of the bowel having, perhaps, taken place. Possibly, also, inflammation may be induced by the pass- age of very dry and hardened faeces, though doubtless this ULCERATION AND STRICTURE OF THE RECTUM. I99 condition may obtain for years, as it often does in old peo- ple, without producing stricture. I have seen one case in which the frequent, and perhaps rather rough, use of an enema pipe produced a stricture, This occurred in an elderly lady who had for years given herself an injection daily. She did not at first suffer from constipation, but she had been recommended an enema, and at last she could not get an action without it. I thought in this instance it was not improbable that the passage of the bone tube had been the exciting cause of inflammatory thickening of the bowel. It may perhaps be said that I have assumed inflammation to be the cause of the exudation into the wall of the bowel. I must confess that I have, for I have rarely been able to detect decided symptoms of inflammation of the rectum pre- ceding stricture. I have constantly asked patients whether they have at any time suffered from pain, sensation of burn- ing, diarrhoea, dysentery, or discharge of matter from the bowel, and the reply has most usually been in the negative. On the other hand, I have seen cases of long-continued proctitis, especially in aged people, not followed by stricture. The coarse symptoms of stricture, viz., straining and diffi- culty in discharging the motions, have been already described. It is stated in some works that the stools are thin, long, and pipe-like. According to my experience this is not usually the case in true stricture; spasm of the sphincter, enlarged prostate gland, and tumors of the pelvis, much more fre- quently give rise to flattened and thin motions. The most characteristic feature, in my opinion, is the passage of num- erous very small, broken pieces; the faeces having no actual form, and looseness often alternating with this lumpy con- dition. The discharge in simple stricture is like the white of an unboiled egg or a jelly-fish, and is passed when the bowels first act. There is no coffee-ground-looking dis- charge, so constantly seen in ulceration, nor is there the morning diarrhoea which we get in that complaint. There is very rarely any pain experienced in the bowel itself; the symptoms are generally referred more or less to distant parts, notably the penis, perineum, bottom of the back, the thighs, beneath the buttocks, and occasionally the stomach. Fortu- nately strictures of the lower bowel are generally within reach and sight, but occasionally they are found high up in the sigmoid flexure, or still more distant from the anus. In these cases it becomes a matter of great importance to ascer- 200 ULCERATION AND STRICTURE OF THE RECTUM. tain the situation of the obstruction, but this is a question I shall not enter upon here. A stricture of the rectum resulting entirely from muscular spastn is what I am very much disinclined to believe in. I do not deny that such a condition may be found, but to me it appears to be very improbable, and I feel confident that in many of the supposed spasmodic strictures there is really no constriction at all. The operator has been misled by the bougie catching in a fold of the gut or against the promon- tory of the sacrum. If you are in doubt about the existence of a stricture, you should use long and very elastic enema tube, and inject fluid as you pass it, so as to distend the gut and remove any intussusception of the upper part of the rectum. This condition, I think, has often been mistaken for stricture, as, unless the bougie goes directly into the aperture of the descended portion of the gut, it gets into the sulcus at the side, which is a cul-de-sac, and the instrument cannot be made to pass. I have satisfied myself on several occasions of the existence of this source of error. For some years past, in exploring the rectum for stricture, I have used vulcanite balls of different sizes, mounted on pewter stems with flattened handles; ,they are easily bent into any form; they will even bend in the bowel, and by their use, as in exploring the urethra, you may make certain of detecting a stricture. For when they pass, or on gently withdrawing them, the ball is felt to come suddenly, and perhaps with some difliculty, through the constriction. Its length also can be approximately measured. In cases of stricture when there is great spasm with a small amount of organic disease, much good may be done by the use of bougies. Before passing the bougie, it is well to inject into the bowel some sedative, as opium or bella- donna with oil, and to use a stiff lubricant on the bougie (such as blue ointment); if the instrument cannot be quickly passed, it is better not to persevere, as irritation will be set up and damage done; once set up the spasm and all your endeavors may be frustrated; the stricture must, as it were be surprised. I do not like any forcible dilatation in these cases; you may tear or split the stricture with Todd's dilator, but you are more likely to get ulceration than permanent benefit to the stricture. On the same principle I should not cut, even in the slightest degree, any constriction where no ulceration existed, save in cases I will describe. If the stricture is high up, the use of Todd's dilator is dangerous. Ulceration and stricture of the rectum. 201 I have seen profuse haemorrhage follow its use, and the bowel might be torn, to the injury of the peritoneum, especi- ally in women. In these cases I am also of opinion that retaining a bougie or tube is not usually advantageous; you may produce ulcer- ation, and if this should be done you will perhaps irretriev- ably damage your patient. Gentle dilatation, very gradually increasmg the size of the instrument, is the only safe treat- ment. The conical bougie is a good form, as gentle pressure induces this to enter the stricture more easily, but you should never cause pain, and you may be sure that if blood or mucus passes after your manipulation, your patient will have little to thank you for. I used to think that twice in the week, or at most three times, was as often as the instrument ought to be used, but in obstinate cases its daily use has, in my more recent exper- ience, been followed by greater permanent good. Still, in this matter every case must be judged on its own merits, bearing in mind the axiom "never irritate." A bad form of stricture, fortunately of rare occurrence, is that in which the constriction is semicircular or annular, and feels to the touch as though the bowel were encircled by a cord. These strictures are so resilient that even if dilated to their fullest extent, they very soon return to their previous state of contraction. It is in these alone that I consider division advisable, but the incisions should be only super- ficial, aijd dilatation should be commenced on the day fol- lowing the operation. When a stricture is well dilated the patient generally experiences the greatest amount of relief; there is no more straining at stool; comfortable, good-sized motions are passed, and many anomalous symptoms vanish. One draw- back is the rapidity with which all strictures are apt to return; the relief afforded is even much less durable than that obtained in stricture of the urethra; the patient should there- fore be warned never to be long without having the bougie passed, and certainly, directly any of his old symptoms recur, at once to obtain treatment; if this advice be acted upon, but little fear need be entertained of a dangerous relapse 202 CANCER OF THE RECTUM. CHAPTER XVIII. CANCER OF THE RECTUM. There are very few parts of the human body which may not be attacked by cancer, but some are more frequently affected than others, and the rectum is one of the favorite sites of this disease. Cancer is, m the vast majority of cases a fatal disease, and when the rectum is the part affected it usually runs its course in about two years. In many instances the duration of life is much less. I have watched a case of encephaloid which terminated fatally at the end of four months from the earliest symptom of its invasion. Colotomy was performed by me when I first saw the patient, two months before death; but in my opinion it did not delay the progress of the disease one day, although it afforded relief from excruciating pain. On the other hand, I have seen a case of scirrhus on the anterior wall of the rectum, in which the patient lived about four years and a half. I will briefly record the case. A man, of not at all unhealthy appearance, came under my care at St. Mark's Hospital in the year 1865. He had suffered more or less from symptoms of obstruction in the bowel for five or six months. An examination per annum detected a hard, solid mass, appearing to rise from the neighborhood of the prostate gland; it blocked up the whole rectum; the surface was irregular, but not ulcerated at all. I thought it might possibly be a hydatid, although no fluc- ti^ation could be detected; a long exploring trocar thrust into it did not reach any fluid. He had suffered entire con- stipation for twenty days, and his symptoms were so urgent that I at once performed colotomy. He returned home in six weeks feeling very well, and he lived for four years and a half, dying at last from the extension of the disease to the bladder and consequent exhaustion. Cancer is commonly a disease of middle life, but I have seen encephaloid rapidly fatal in a boy of seven- teen; and some years ago there was in St. Mark's Hospi- tal, under the care of my colleague Mr. Gowlland, a boy, not thirteen, with cancer of the rectum. Scirrhus and epi- thelioma are not very uncommon in old people, and in them usually run a very slow course, which may be CANCER OF THE RECTUM. 203 accounted for by the fact that in old persons the vital forces are sluggish. It has been said that cancer is more frequent in women than in men. As regards the rectum, this is directly the reverse of my experience. In my statistics many more men are victims than women. I am in accord with those who do not consider cancer as an hereditary malady ; it is true that there are very few families in which cancer has not appeared, more or less remotely, but that is only because cancer in some form is so common in human beings. Although I always put the ques- tion, it has comparatively rarely happened to me to find that the father or mother, or even grandfather or grandmother, has suffered from the disease. Often uncles or aunts, or brothers or sisters, and still oftener cousins and more dis- tant relations have suffered from cancer ; but the question of heredity is not thereby affected. Some varieties of cancer may, in their early stage, be only and purely local ; but I am afraid that stage is of very short duration, and that the above statement is hardly, certainly not practically, true of the more malignant forms. By this I mean that as soon as a growth exhibits itself, so as to be noticed by the patient, the disease is already constitu- tional, and the system is infected. As a rule, cancer of the rectum is most horribly painful, the function of the part enhancing the suffering; but I have seen patients in whom there has not been excessive pain, particularly in the early period. In the more advanced stages of the malady the pain often becomes unremitting, from the fact that many nerves become involved, and are pressed upon or stretched, the neighboring organs thus becoming seats of separate pain, even if they are not actually touched by the growth. I had a patient with can- cer, which, commencing in the rectum, involved the whole cavity of the pelvis, and pain down the right sciatic nerve was one of her most distressing symptoms. The forms of malignant disease described are epithe- lioma, scirrhus, encephaloid, colloid, and melanosis. I think I have placed them in their order of frequency. I have never seen a melanotic tumor of the rectum. I have seen many colloid tumors, but I am not sure that ence- phaloid may not be colloid, or pass into it. From niy own clinical observations I should be inclined to say that in can- cer of the rectum it is often very difficult, if even possible, 204 CANCER OF THE RECTUM. to make any distinction between epithelioma and broken- down scirrhus. I have seen cancers of the rectum stony- hard at one part and quite soft at another. MaHgnant growths are commonly found seated within three inches of the anus, the most rapidly dangerous being higher up, about the lower portion of the sigmoid flexure. When cancer occurs near the anus it may extend upward beyond the reach of the finger, but more frequently it does not, and the whole extent of the disease can be ascertained. It is but rare that any form of cancer commences at the anus itself — I have seen some cases of epithelomia, but com- paratively few — nor as a rule does the cancer come grad- ually down to the anus; in the very latest stages it may do so, but this is the exception. When it comes down to the anus it is generally mistaken for piles, and caustics are applied, to the aggravation of the patient's suffering. There is some- thing peculiar about the feel of cancer, which the prac- ticed finger rarely mistakes, even for simple indurated ulceration. I think it is many years now since I mistook the one for the other. There is also a peculiar odor which one cannot describe but which once recognized will rarely be forgotten. In my opinion the odor is pathognomonic. Scirrhus and encephaloid commence according to my clinical experience, in the submucous tissue, and the mucous membrane may for a time remain quite smooth and unaffected, though adherent to the growth beneath. In epithelioma the mucous membranes seems from the first to be the seat of the disorder, and even when the growth and thickening have become considerable, the whole will be found freely movable over the structures beneath. In scirrhus and encephaloid this is not the case; very early in the disease it has spread more deeply, and in many instances it seems very immobile. Scirrhus is often found as a hard tumor seated in the rectum over the prostate gland, and although it may not have arisen from the gland itself nor invaded it at all, yet it is remarkably adherent to it. In a case in which I removed a scirrhous nodule, about the size of a large cherry, from this situation I was obliged to dissect off with the growth the fibrous capsule of the prostate itself. On microscopic examination the tumor was declared to be true scirrhus, by my friend Dr. Wm. Ord. The patient recovered from the operation and I have not heard of him since, but I should expect that the growth will almost certainly recur. CANCER OF THE RECTUM. 205 The more malignant forms of cancer do not exist very long in the rectum before they poison the blood generally, and cause secondary deposits in the lumbar glands, groins, liver, etc. The aspect of countenance which so often attends the cancerous cachexia is very usual, and seen earlier in cancer of the rectum than in the same disease of other parts. In cancerous growths high up, vomiting, frequent and severe, is an early symptom, even when not much obstruction exists. The onset of cancer in the rectum is often marked by very trivial symptoms, hence the disorder comes upon you as a surprise. A patient may come into your consulting room complaining of no more than a little uneasiness in the bowel or a slight morning diarrhoea. He may look thoroughly healthy and strong, and may really think himself, save for the slight local trouble, perfectly well, yet on making an examination you find the disease advanced beyond all possibility of doing any good. An elderly Scotch gentleman was sent to me by Dr. Nisbett, of Gravesend. To all appearance he was the wiry, healthy-looking Scot. " Hard as nails," he said he was, but he was a little troubled by irregular action of the bowels; sometimes costive,sometimes loose; and he occasionally passed a little blo&d. On examination I found what I really did not expect, a hard, scirrhous mass in the rectum extending higher up the bowel than I could reach. By sheer power of constitution he lived a little more than twelve months from that interview. In October, 1878, Mr. Wilton, of Sutton, sent a gentle- man, aet. 34, to me. He was suffering from some pain in the back, with a weary sensation after exertion; had small losses of blood at stool and rather frequent motions^ always in the morning and sometimes at night. His idea was that he had piles. On examination I found an epithelioma commencing just within reach of the finger, and extending, as I found by careful sounding, at least two inches higher up. The growth was causing some contraction of the bowel. This patient was afterwards the subject of secondary deposits in the liver. He died in October, 1881. When cancer attacks the uppermost portion of the rectum or the sigmoid flexure, the disease generally runs a more rapid course, and isjnuch more dangerous; indeed, sudden death is not uncommon, as total obstruction takes place quickly^ and unless colotomy is promptly performed the intestine gives way above the obstruction, and death ensues. 206 CANCER OF THE RECTUM. I have seen a good many examples of this, and always warn the friends of what may happen. * Cancerous stricture of the upper part of the sigmoid flexure or the descending colon is not so immediately dangerous, although the obstruction may be total. I saw with Mr. Sutton Sams, of Lee, an elderly lady, who had total obstruction high up the bowel, and yet lived for more than eight weeks. Another case I saw in consultation with Mr. John M. Burton, also of an elderly lady, who had a similar obstruction and lived for many wrecks, though she had constant vomiting. Many cases of this kind have come under my notice, where patients would not submit to colotomy. I need not say that their suffering is very great, and loudly calls for surgical inter- ference. Af the same time the difficulty of ascertaining the precise seat of the obstruction, in many instances, ties the surgeon's hands. I now come to the consideration of a very important but unsatisfactory part of my subject, viz. What can one do for the relief of these terribly unfortunate persons ? 1 have never seen any benefit result from the application of caustics to growths within the bowel, but when a cancer- ous mass protrudes, which, however, is a somewhat rare occurrence, I have relieved pain and got rid of a good deal of the growth by using the arsenite of copper with mucilage, as a paste; this destroys rapidly without increasing the suf- fering at the time; it does not cause bleeding, and, as far as my experience goes, it is free from danger. The treatment in the majority of cases of cancer still resolves itself, for the most part, into an attempt to assuage the suffering of the patient. Pain is generally mitigated by the recumbent posture, and good, easily assimilated, nourish- ing diet, with alcohol in moderate quantities. All varieties of sedatives may be used with benefit, externally and inter- nally, and when one drug loses its effect another should be substituted. Opium in its several forms is the most effective agent we possess. It may be used as a suppository in which case the best formula is morphia, with glycerine and gelatine (three of glycerine to one of gelatine), as this melts very soon, and does not feel like a foreign body in the sensi- tive bowel, as suppositories made of cacao butter so fre- • * Sir James Paget related a case to me where very little was thought to be the matter with the patient until nine days before entire obstruc- tion took place and death. CANCER OF THE RECTUM. 207 quently do; injections of Battley's sedative, nepenthe, or black drop in starch, sometimes afford great relief. Solid opium by the mouth is a great favorite with me, but the objection to it is that the stomach gets irritated, the appetite fails, and the bowels are confined. Probably most patients obtain the greatest comfort from hypodermic injections of morphia; but no opiate can be used lon-g without inducing a state of mind almost as unendurable as the pain of the dis- ease and therefore great care should be taken to husband the remedy as much as possible, never using a larger dose than is absolutely necessary, bearing in mind that you may have to rely upon it more or less, even for months. I have had many patients who from small beginnings got to inject from eight to fifteen grains of morphia in the twenty-four hours, and the condition of mind of these patients was really fear- ful. Many persons who had injected such, large doses, have told me that they preferred the most excruciating pain to the mental distress the morphia produced, and have, even of their own accord, left off the drug and endured the physical suffering. It has recently been asserted by Mr. John Clay, of Birm- ingham, that Chian turpentine has a curative action in cer- tain cases of cancer. Following Mr. Clay's method, I have administered this drug in forty-nine 'cases of malignant dis- ease of the rectum, many of the patients taking it for several months, even up to a short time before death. The turpen- tine was genuine, being obtained, for the most part, from the chemists recommended by Mr. Clay; in only two cases did I see the slightest mitigation of symptoms. Both these patients took the medicine for nearly twelvemonths, but the improve- ment was quite evanescent, and the patients died.. In all the other cases, either no effect was manifested or only a bad one, viz., nausea and frequent derangement of the appetite and functions of the stomach. The drug was exhibited in the best way, both in solution and pill, and in many cases combined with sulphur. I have seen several patients who had been under Mr. Clay's treatment, but they were in no way benefited any more than those treated by myself, although one case was considered by Mr. Clay to be doing very well, and was probably reported as cured. When cancerous growths approach the anus considerable relief may be obtained by dividing the sphincter muscles; defecation is thus rendered easier, and no possible compres- sion can be exercised. Usually, as I have said when speak- 2o8 CANCER OF THE RECTUM. ing of stricture, a cancer of the upper part ot the rectum paralyzes the sphincters, doubtless from pressure on nerves, and the patient is not able to retain the motions, especially if they are at all liquid. When diminution of the calibre of the bowel is induced by cancer near the anus. Professor Verneuil has proposed free division of the gut in the dorsal median line, or even the excision of a segment of the posterior wall of the rectum. The former operation I have frequently practiced; the latter does not commend itself to my mind. In encephaloid of the rectum great temporary advantage and much relief from pain may be obtained by tearing out the growth by the fingers or a scoop (as the late Professor Simon advocated in cancer of the uterus). I prefer my fingers. You must be bold in doing this, and enucleate the whole growth quickly and resolutely. If you tear away only superficial portions, haemorrhage may occur to a considera- ble extent, which must exhaust your patient, and no real benefit will accrue. I had a case under treatment in conjunction with Mr. Pinching, of Gravesend, in the person of a member of our own profession. An immense encephaloid growth almost filled up his pelvis, and he came to London to see if I could do anything for him. He was in such a condition that I thought he could not bear colotomy, but I saw that if I could remove the growth in great part without his losing blood to any extent great relief must follow. Accordingly, assisted by Mr. Pinching^ I made a free division of the anus, the muscles and fat around which had been so thinned away by the pressure of the growth that it was only like cutting through thin, devitalized skin. Only one small vessel appeared inclined to bleed, and this I immediately twisted. I now passed my hand gently into the pelvis, got I fingers well above the growth, and tore it out. A large mass was at once removed. I then continued to remove all I could find, and it came away, exactly like brain in appearance, and in quantity sufficient to fill a good-sized pudding-basin. I had come fully prepared with subsulphate of iron, the actual cautery, sponges, and wool, in order to be able to plug at once should haemorrhage take place, but to my astonishment there was no bleeding worth mentioning, and the cavity from which the cancer had been removed was dry and gray in color, with red spots. As a precaution against secondary haemorrhage I put in sponges powdered with the subsulphate CANCER OF THE RECTUM. 209 of iron, but there was no bleeding at all. From the day after the operation the patient rallied, lost his night sweats, ate and drank all we gave him, and was able to return home in a few weeks. After this he lived in comparative comfort for two months, then, as the growth returned, he very gradually died from exhaustion, nearly five months having elapsed since he underwent my treatment. Twice since this I have carried out this plan in a similar manner, and in both cases great, though temporary, relief followed. I do not see why it should not be adopted in some cases of epithelioma. I was surprised to observe, in the three cases after the removal of the cancerous growths, that the facial appearance of the patients so immensely improved; in fact, they all lost the malignant aspect, and not until the growth gradually returned, and with it the poisoning of their blood and tissues, did the countenance reassume its worn, haggard look. So, also^ in respect to strength, freedom from pain, appetite, and capacity for sleep, the change for the better was remarkable. In this variety of cancer, though colotomy would afford in some degree relief from pain, inasmuch as the abundant cancer elements are still present, poisoning of the general system would continue in full force, and thus extension of the term of life is not to be obtained, and, indeed, can hardly be anticipated; in such cases, where I have performed colotomy, I have found the patients have rapidly succumbed. Two operations have been practiced for the relief of rec- tal cancer. The one is extirpation of all the diseased por- tions of the rectum, which, further, is stated by some surgeons to effect a positive cure of the disease in some cases. The other operation is colotomy, lumbar or inguinal, which only professes to relieve pain, and possibly extend the term of the patient's life. Extirpation of the rectum (as it is frequently termed), broadly speaking, may be undertaken in any form of cancer which does not necessitate the removal of more than four and three quarters or five inches of the rectum in the male and about one inch less in the female. Subject to the results of increased experience, I should also say that if great adhesions are formed to the sacrum or to the base of the bladder and prostate gland, or to the neck of the uterus in women, the operation is probably not admissible, and cer- tainly not desirable. Again^ if any enlarged glands exist in the inguinal or lumbar regions, the operation cannot be recommended; lastly, I should say the patient ought not to 14 2IO CANCER OF THE RECTUM. be SO exhausted as to render it doubtful whether the neces- sarily rather free loss of blood would, to a great degree, endanger life. The length of the rectum from the anus which may be removed without opening the peritoneal cavity differs in individuals, and the conclusions arrived at by measurements of the dead body, or by taking plaster casts of the reflections of the peritoneum, are fallacious^ and must be taken as an approximation to the truth only. In a female patient on whom I operated, Douglas' pouch was only two inches from the anus. In a male fully five inches of the rectum were removed, and the peritoneum never seen; and in another male, in which not more than three and a half inches were cut off, the peritoneum was opened and a coil of intestine protruded. A point of considerable importance in operating is to divide the levator ani muscle thoroughly and dissect it carefully upward, by which means you get the rectum to come readily down, and in making the necessary traction on it you do not draw the peritoneum down with it. Another point worth remembering is that the meso-rectum is more developed in some subjects than in others, and descends below the upper half of the rectum. Care must be taken in using the knife close to the sacrum, as you may easily divide the trunk of the middle hsemorrhoidal artery, when severe bleeding will take place, and difficulty may be experienced in arresting it. This accident has occurred to me, but I was able to sieze the vessel and secure it quickly. From the full and sudden rush of blood, however, I felt con- vinced that a weak patient might readily die on the table. It is not my intention to enter into the history of the opera- tion of excision of the rectum, nor shall I describe the various ways in which it may be performed; but I beg to refer the reader who wishes the fullest information on these subjects to the able and exhaustive work of Dr. Marchand, entitled " Etude sur I'extirpation de I'extremite inferieure du Rectum." I will only here mention that Paget, in the year 1739, excised the rectum for cancer; that after this the operation remained in abeyance until 1828, when it was revived by Lisfranc, who performed it in several cases with success. At a comparatively recent date it has been fre- quently undertaken by both French and German surgeons, and with such good results as to establish the operation on a reliable basis. The Americans and ourselves have brought up the rear; possibly we are more cautious and have had our doubts as to the great benefits claimed for it by our CANCER OF THE RECTUM. 211 foreign confrlres ; certainly we are justified in distrusting such statements as Dieffenbach's, who says that he had had thirty cases of successful extirpation of the rectum, the patients living many years after the operation. We have also felt incredulous as to the advantage derived from cutting out the rectum, a portion of the urethra, prostate gland, and base of the bladder, as did Nussbaum, who gravely assures us that the patient recovered all his functions and lived for three years. My own experience of removing cancerous growths from the rectum is not great. I find that I have excised segments of the bowel by knife alone, or combined with the ecraseur or ligature (elastic or inelastic), in thirteen cases, and in six- teen patients I have removed the rectum in its whole cir- cumference, the largest portions taken away being, in two cases, five inches and five inches and a half in length, respectively. I shall not enlarge on my operations on segments of the rectum, because the question to be determined is. Can one cure a patient who has cancer — say epithelioma — by excising the whole of the diseased portion of the rectum ? Speaking generally of partial removals of the circumfer- ence of the bowel, I must say I consider the operation unsat- isfactory. In all my cases which I had the opportunity of observing for about a year, either a return of the disease took place in t]je rectum, or the glands in the groin became affected, or there ensued disease, probably cancer, in some internal organ, mostly the liver. I find seven out of thirteen cases died within eleven months of the operation, and in three there was a return of the growth in the rectum. This may, of course, be attributed, and I think rightly, to my not having totally extirpated the local disease; but in four cases the disease did not return in the bowel, but in the glands. One of my patients died suddenly, two days after the operation, from syncope on getting out of bed. Another died on the fourteenth day, from erysipelas. The four remaining cases recovered from the operation, but I have no knowledge of the ultimate result. In one case, a patient of Mr, George Ord, the growth did not return until after one year and five months had elapsed. I had, therefore, arrived at the conclusion that partial removal of the rectum was an operation which could not be very strongly recommended. Another objectionable feature in my case was that, contrary to the experience of some of my professional brethren, the 212 CANCER OF THE RECTUM. patients had incontinence of faeces when a large portion of the sphincters was removed All my cases were not epith- elioma; some presented scirrhous nodules, as in the case I mentioned, where the growth was situated over the prostrate gland. Case i. — My first excision of the whole circumference of the rectum was performed at St. Mark's Hospital on the 2d of March, 1874. The patient was a woman, forty-seven years old, who was sent to me by Dr. Thomas. She was a widow, with a family; she did not look very unhealthy, and was fairly nourished, but she said she had become thinner. Six months back she had been operated on in the London Hos- pital, for fissure, but she did not get well; soon after the operation the pain was as bad as before it. There was con- stant gnawing pain in the anus, much increased on defeca- tion, and she was obliged to strain at stool. Exa77iination. — The anus was patulous, but just inside was a contraction formed by hardish, ulcerated growths, which nearly encircled the bowel. The extent upward w^as not more than an inch. There was no history of syphilis nor any symptom. I had no hesitation in pronouncing the disease to be epithelioma, and I removed it by a circular incision around the anus including the sphincter. I dissected the bowel up without difficulty, as there was no adhesions, drew the gut outside, and cut it off with scissors. I took care to have the bowel held well out with a volsellum. There was smart bleeding, but four vessels being tied, it all ceased. I then joined the stump of the rectum to the skin with six wire sutures. On the day after the operation there was much swelling, and on the day following there was lividity of the skin and great ten- sion, so I was compelled to remove all the sutures, and a quantity of pus was discharged and the parts widely gaped. I ordered charcoal poultices and injections of Condy's fluid. After a few days the wound assumed a healthy appearance, and the patient made good recovery. I was much astonished at the way in which the rectum gradually grew downward and joined the skin, forming an excellent cicatrix. Before leaving the hospital she had some power over her motions, I watched this patient for sixteen months, following her to a distance rather than lose sight of her. No disease returned in the rectum, but in eleven months she had abdominal sysptoms; emaciation was very rapid; she suffered much, and died sixteen months after the operation, having kept her bed for five months. CANCER OF THE RECTUM. 213 Case 2. — A man, aet. 36, was taken into St. Mark s Hospi- tal, and operated upon by me on the 26th of October, 1874. He had suffered from haemorrhoids, and had been under my care fifteem months before. He continued well until three months ago, when he began to suffer pain in the rectum, and passed blood and mucus; the bowels were almost always relaxed, and he had but little straining, but he had inconti- nence of faeces. The patient was unhealthy looking, and had lost flesh and strength. On examination a cancerous growth was found encircling three-fourths of the rectum on its dorsal surface; the anterior portion seemed uninvaded, nevertheless, I thought it advisable to remove the gut in its entire circumference, by an elliptical incision. A silver catheter was passed into the bladder, to steady the urethra. The part removed was about two inches in length; no diffi- culty presented itself in the operation. . I did not put in any sutures, but filled the wound with wool soaked in carbolized oil. No bad symptoms followed, and the parts were quite healed in four weeks. The patient returned to me three months after the operation, with contraction of the anal ori- fice. I made an incision to correct this, and he had no trou- ble afterwards. Seven months subsequent to the operation the cancer appeared higher up the rectum; he refused any further surgical interferance. After a little time I lost sight of him, and therefore do not know how long he survived. For four months after the operation he was quite comfortable, had no incontinence of faeces, and was able to do his work. Case 3. — A man, in rather poor circumstances, but who would not come into the hospital, was sent to me by Mr. Slater, of Canonbury. I saw him first in January of 1875. He was a spare man, about fifty. He had suffered pain for some months, in the bowel; it was pretty constant and much aggravated on action of the bowels. He felt weak and had lost much weight. On examination I found a rather large, cancerous growth, two inches from the annus; it did not involve the whole circumference of the bowel; it was mov- able in all directions. I could easily reach its upper border, and bring the growth close to the anus. I proposed remov- ing it, but the man declined. In March following he came to me again, saying he had suffered so much that I might do what I liked to afford him relief. Examination showed that the cancer had approached much nearer to the anus, but there still remained a zone of healthy mucous membrane between the growth (which I believed to be epithelial) and 214 CANCER OF THE RECTUM. the anus. There did not appear to be any important adhe- sions except dorsally; anteriorly very little amiss was detected, and the gut was quite movable. I determined on excising the growth, and to leave the external sphincter by carrying my knife around the bowel in the space between the two muscles. I discovered when I made the incision, from which blood flowed plentifully, that I could not safely remove the growth, so I made a deep dorsal cut in the median line, nearly to the coccyx. I was delighted to find the amount of room this gave me, and how it rendered the operation comparatively easy. In all my subsequent cases I have commenced my operation by cutting from the point of the coccyx well up into the bowel, a proceeding so strongly recommended by Prof- Verneuil. No serious obsta- cles were found, and I ablated about three inches of the rec- tum, cutting well free of the growth. I attempted to bring the stump of the rectum to the skin by sutures, as I hoped thus to save the external sphincter, which I had preserved, but the tension was too great, and I therefore only filled the wound with sponges soaked in a weak solution of chloride of zinc. The after progress, on the whole was satisfactory but slow, and the wound took seven weeks in healing. This patient died fourteen months after the operation. He was in comparative comfort for twelve months, and had fair command over his motions, unless they were liquid. The disease did not return in the rectum, but the glands in the groin became affected, and possibly also some internal organs. He suffered much pain toward the last. Case 4. — A gentleman, set. 60, came to me from the coun- try saying he was suffering from stricture of the rectum, which had troubled him for about eight or nine month ; he had consulted several eminent provincial surgeons, and had used bougies with temporary benefit. He was thin, but fairly strong and active; the expression of his face was healthy. On examination I found his bowel obstructed by a growth which quite surrounded the gut; it was ulcerated in parts; it commenced about an inch from the anus, and the zone meas- ured about two inches at most in length; it was freely mov- able in all directions; no glandular complications could be detected. I advised its immediate removal. He went home to consider the matter, to consult his relatives, and one of the surgeons he had seen. He returned to town in a few weeks and I operated upon him on the 26th. of January, 1876. I operated exactly as in the last case, save that I CANCER OF THE RECTUM. 215 made the dorsal incision the preliminary step. In this case the bleeding was very free, and I liberally used the actual cautery to the cut surface of the rectum as well as to other parts. The wound was filled with sponges steeped in a weak solution of carbolic acid, and I introduced a tube into the rectum in order that wind might escape, the retention of which had much troubled my last patient. The wound healed kindly. There was no fever after the first forty-eight hours, and the patient suffered remarkably little. In five weeks he went away quite satisfied and I expected a good result; but I was disappointed, as in five months he came to me with a return of the growth, quite near the anus, involving the scar and the skin; it was a hard lump, the size of half a walnut, and I advised him to let me cut it out; he acquiesced, and I removed it freely, but did not take away the w^hole circumference of the gut. This I afterwards regretted, as I saw him in about three months again with much more growth at the anterior part of the rectum. He was now now weak and greatly broken in health, and despair- ing of relief he refused any more active treatment. I heard, from his friends, that he died just eleven months and a half from the first operation. Case 5. — I saw with the late Dr. Daldy a single lady, set. 40, who was affected with what she supposed to be piles. She lost blood in small quantities, had frequent diarrhoea with incontinence of faeces, and there was a discharge of sanious, ill-smelling mucus. The pain was not great, except when the bowels acted. She was fairly nourished, and was going about her duties as usual. On examination I found a growth in the rectum, one and a half inches from the anus, and extending but Uttle upward ; it was hard and rough to the touch in some parts and pulpy in others ; it was situated principally on the anterior part of the bowel, but extended laterally nearly to the sacrum ; it was most adherent to the vaginal wall, and could be felt distinctly with the finger in the vagina, but I thought it did not involve the vaginal mucous membrane. With some misgiving I advised the removal of the growth, fearing that I should have to take out a portion of the vagina, in order to thoroughly extirpate it. When "the patient found that no other course was open to her to obtain relief, and that the danger would probably be increased by delay, she consented to have the operation done. In order to obtain plenty of room I com- menced with the dorsal median incision, and made an 2l6 CANCER OF THE RECTUM. exceedingly careful and cautious dissection, but I found the growth so intimately connected with the vaginal wall that I was compelled to remove a portion of the vagina, fully one inch in length by half an inch in breadth, the hole made being elliptical. After having removed all the diseased tissues, I brought the edges of the wound together with four iron sutures. I put no dressing in the wound, simply placing a tube in the bowel. On examining the growth there could be no doubt that it was mainly epithelial, but there was much warty structure in it, which accounted for the rough- uess I had detected. Fortunately the wound in the vagina healed at once, and the patient made an excellent recovery. This lady I have heard from recently, and she continues quite well (three years after the operation). This is the best result I have as yet obtained, but it is clear that the growth was only feebly malignant. Case 6. — A man, ^t. 6i, was admitted into St. Mark's Hospital February, 1877, suffering from epithelioma of the rectum. The disease had existed about three months. There was slight obstruction of the bowel, and he had great pain ; he had straining at stool, and there was a constant bloody mucous discharge ; he had no incontinence of faeces unless they were liquid ; he was a small, spare man, of not unhealthy appearance ; he did not think he had lost flesh, as he was always thin ; he had always enjoyed good health. On examination a hard growth was found, commencing an inch from the anus ; it encircled the bowel, save on the left side, which was soft and ulcerated ; it extended about two inches upward ; it was fairly moveable, except toward the prostate. I operated in the usual manner, save that I used the Paquelin cautery more freely than in some cases, and I severed with the Paquelin, inserting a plug into the bowel to cut upon. The gut was very adherent to the prostate gland, and took a considerable time to dissect off ; the capsule of the prostate was removed, and the vesiculae seminales plainly seen. Rather more than three and a half inches were removed. I saved the internal sphincter muscle. The peritoneum on the right side of the bowel was opened, and I saw a coil of intestine. A sponge, well carbolized, was placed against the opening, and the wound was filled withVool well soaked in carbolic oil. After the operation the patient had not a bad symptom, and he left the hospital quite well, having gained flesh and improved in appearance. This patient died thirteen months after the operation. No return of the disease took CANCER OF THE RECTUM. 217 place in the rectum, but the glands in the inguinal regions were enormously enlarged, and one gland was the seat of fungoid ulceration. Case 7. — A man, aet. 50, was taken into St. Mark's Hospital in March of 1878, and came under my care. He was a tall, thin man, with somewhat haggard countenance, but he was not weak, and had worked as a carpenter up to his admis- sion. He had suffered for some months, he could not say exactly how many, from trouble in the bowel, the common symptoms of ulceration or malignant disease being present. On examination I detected an epithelial growth in the rectum, commencing within an inch and a half of the anus, and passing up so high that I could only, by making the patient stand up and strain down, just feel the upper border of the cancer, and satisfy myself that I could remove the whole of the disease. The growth was more than commonly adherent, especially to the left side. A silver catheter was passed into the bladder when I reached the anterior part of the rectum. I made the dorsal incision, and carried my knife around in the interspace between the sphincter muscles. The dissection was very difficult anteriorly and on the left side, and I had to go very deeply to get all the growth away. I made use of my fingers and avoided the knife as much as I could. The haemorrhage was free throughout, but con- trollable by pressure. Indeed not a single vessel required ligature ; a few were twisted. In separating the diseased portion of gut anteriorly the prostate gland and the vesiculae seminales were fully exposed. The stump of the rectum could not have been brought down to join the skin if I had desired to bring these parts together. For a few days the patient was in 'a critical condition, the temperature keeping at 104° and a little above, but these symptoms passed off with the establishment of suppuration and the separation of some largish sloughs, and he made a good though rather slow recovery. He left the hospital quite well, with the gut grown down to the skin, and the whole part as smooth and soft as healthy mucous membrane could be. Eight months after the operation the man had such a contracted orifice to the bowel that I was compelled to take him into the hospital, and finding that bougies were of no avail, to divide the anus on both sides. This soon cured the contraction, but I sent him out with a tube, to prevent any recurrence of the trouble ; this, however, failed. He still lives — more than three years after the operation. 2i8 CANCER OF THE RECTUM. Case 8. — A gentleman, aet. about 60, was sent to me by Dr. Wm. Ord, in October, 1876. He had a nodule of hard cancer in the cellular tissue just inside the anus. It was so moveable and circumscribed that I could not resist the temptation to remove it by a very free incision without cutting out the whole circumference of the bowel. I was confident I had got away all the diseased tissue recognizable by the eye or touch. A microscopic examination showed the tumor to be scirrhous. From time to time I saw this gentleman, and he had no return of the disease until the middle of March, when he complained of discomfort and some pain in the bowel. He had been quite well for one year and five months. On my examining him I detected small nodules in the mucous membrane, about two inches from the anus. The site of the old excision was quite healthy. I urged him to allow me to remove the nodules at once, but he consulted some other surgeons, and as they told him nothing could be done, as the places were too high up, he declined to allow me to interfere. Some months elapsed before this patient came to me again ; finding himself getting daily worse and losing strength and flesh, he said he was prepared to submit himself to my wish, but on examining him I found the disease had grown down nearly to the anus, and was almost all round the bowel. Under these circum- stances I said that Sir James Paget should decide whether an operation should be done or not, and as Sir James decided in favor af an operation, I performed it in August, removing fully four inches of the rectum. The growth was now clearly epithelial, in fact, was an admirable specimen, as was the first tumor I removed a typical example of scirrhus. The operation, in consequence of the adhesions, was a lengthy one, and the bleedinp^ very severe, so much so that I used the Paquelin cautery than I had done before. The peritoneum was not injured. A very large chasm was left, and was filled with sponges soaked in a solution of salicylic acid. Some pressure was required to arrest a general oozing from the large surface. A tube was put into the bowel. The night following the operation the patient had a most severe rigor, and the temperature went up to 104.5°. ^ thought something serious was about to happen. I took out all the sponges and syringed the parts well with solution of salicylic acid, and administered a large dose of quinine. In the morning the patient was quite comfortable, with the tempera- ture fallen to 99.5°. After this^ although the patient was CANCER OF THE RECTUM. 219 troubled very much by two or three actions of the bowels daily, which we could not stop, he made the most remarkable recovery I ever saw. Was able to return into the country fourteen days after the operation, and in less than four weeks the whole chasm was filled, and the bowel grown quite down to the orifice. All that was done to this patient was to wash out the wound by means of a syringe, after the action of the bowels. The parts could not be kept sweet or clean, as a perpetual oozing of faeces was taking place. This is only one example out of hundreds I have had that satisfy me that as long as putrid, filthy matter are not retained, shut up, in a wound, it will heal well and rapidly, indeed, quite as well as if all the antiseptic treatment in the world had been adopted. In January, 1879, I found this patient had some contraction of the anal orifice ; as bougies did not seem to keep it well open I divided one side of the orifice with a knife, and by keeping a tube in for a few days all got well. Curious to relate, though some of the rectum was taken away, it grew down, and a portion of mucous membrane protruded from the anus ; I thought of removing it, but as it seemed to be of no consequence I did no do so. This patient died in July, 1879 — having lived nearly three years. Case 9. — In December, 1878, an unmarried lady, set, 38, came to me from the country. She looked healthy and cheerful, but when her face was in repose there was a sal- lowness not observable when she was excited,, and also an anxious, worn expression. She at once told me, in the most matter of fact way, that she had cancer of the rectum, that she had consulted an eminent physician in the country, and a still more eminent surgeon in London, and they told her there was nothing for her but to endure and, die. Her friends confirmed her statement. The patient went on to say that for six months her suffering had been very great. She had almost constant pain at the bottom of the back, of a wearing, sickening character, and the paroxysms at and after a defecation were almost more than she could bear. She had fought against this and concealed it as much as possible from her friends, but her life was really unendurable. On making an examination an epithelial growth in the rectum was patent enough. It commenced about an inch and a half from the anus, the mucous membrane nearer the anus being quite healthy. There was no affection whatever of the external parts. The zone of epithelial growth was about an inch in width, and it involved nearly the whole 220 CANCER OF THE RECtUM. circumference of the bowel. My finger easily reached healthy bowel above the growth. There were no enlarged glands. The growth was readily movable in all directions except on the right side of the vagina, but I did not think this would.render an operation more than ordinarily difficult; indeed, taking the whole case into consideration, I felt that it was favorable for surgical interference. I expressed this opinion to the patient, at the same time guarding 'against a too sanguine view of the case. I recommended that the opinion of some eminent authority should be taken wi-thout the patient saying whom she had previously seen. The gentleman she consulted endorsed my opinion. When, therefore, proper arrangements had been made, special care being taken that my excitable patient should have nothing to worry her I performed the operation. The adhesions were more than I expected, and in dissecting away the growth from the right side of the vagina the peritoneum in Douglas' space was opened, and a coil of intestine was seen. A carbolized sponge was immediately placed against the opening. There was very moderate bleeding. I used Paquelin's cautery to separate the diseased portion of the rectum, where I found some large vessels existed, the rest I cut with scissors. The operation took just forty-five minutes in its performance. The ether had been stopped, and the patient gave evidence of recovery from the anaesthe- tic by moving, but when placed in bed she was found to be still insensible. After a very few minutes the nurse, who was sitting by her, called my attention to her appearance, and I saw that she was very pale and slightly blue in the face. The breathing had ceased, and her pulse could not be felt. Her head was lowered and artificial respiration was com- menced by my friend, the late Mr. Carr Jackson, and was continued by this gentleman and myself for two hours and a half. During this period we several times thought she was dead, as immediately the artificial respiration was remitted no natural breathing took place, and the heart ceased to beat. On resuming the artificial respiration the heart feebly responded, and the face became less deadly pale. The head was all the time kept low, and my battery being obtained, we were ready to use it if required. Very gradually to our great relief, natural breathing commenced (though at first it was exceeding shallow), and the pulse could at times be felt at the wrist. At the end of the anxious two and a half*hours the breathing was fairly restored, and the heart CANCER OF THE RECTUM. 221 beat regularly, though slowly and very feebly. At 10.30 the the operation was concluded; at 4.45 she suddenly awoke to consciousness, and was able to take some milk with egg and brandy. After this she rallied, but at 1 1 p. m. she expressed herself as feeling very exhausted, and was restless and thirsty. Her temperature was 100.5^, and the pulse 104. She was quite warm all over, her mind was perfectly clear, and she was not in pain. She took fluid nourishment freely. On the following morning I found she had slept but little during the night, was restless, and felt general malaise with great thirst. She had passed a quantity of black urine, like a strong effusion of black tea ; the pulse was 99, and the temperature barely 100^. She had taken through the night plenty of fluid nourishment, Liebig's cold soup, milk, with egg and brandy. There was no sickness, no abdominal tenderness, and she experienced but little pain in the wound. She was troubled with flatulence, but passed wind freely "from the bowel. I removed all the sponges from the wound; it looked healthy and quite sweet. I replaced a sponge which had been steeped in a solution of salicylic acid against the spot where the peritoneum had been wounded. She was not exhausted after the dressing. During the day she improved, but at night she was very low, more restless, but not in pain. She complained of a tightness in the chest and occasional spasmodic pains in the left side. Auscultation did not detect any thing wrong with the lung. She was still flatulent, but wind passed in both directions, and there was no distention of the abdomen nor tenderness on pressure. She had taken nourishment fairly. There had been no vomiting. The temperature w^as 100*^, and the pulse 94. I was summoned hastily at 5 a.m., and found she was dead. She had taken some nourishment a few minutes before her death; she told the nurse she felt very ill, became suddenly pale, and died, forty-three hours after the operation. An examination was made eleven hours after death, by Mr. Jackson and myself. All the organs where quite sound. There was no pneumonia nor pleurisy. The heart was small, healthy, and contracted. There was not a trace of lymph or peritoni- tis, and no fluid in the abdomen. The wound in Douglas's space was firmly united, and the intestine lying against it was not even congested. There was one small patch of conges- tion at the pyloric end of the stomach. I was very anxious about this patient from the first; the syncope and coma were grave matters, and she never thoroughly rallied after the 222 CANCER OF THE RECTUM. operation, Syncope, I presume, was the immediate cause of death. Case io. — A patient, aet. 52, was sent to me at St. Mark's Hospital, by Dr. Evan Evans; he had been more or less ill for fifteen months, and believed he had piles. He was a tall, thin man, with an unhealthy looking face; he had lost much flesh, and was not very strong. I saw outside the anus a ring of tabs of skin discharging ichorous matter, and inside the anus several large internal haemorrhoids, which were very vascular and came readily outside when he strained. From the piles an epithelial growth extended up the rectum for at least three and a half inches. It was adherent to the prostate gland and urethra in front, and on the right side the growth extended higher up than on the left, but I could ascertain the whole extent of the disease, and saw no insup- erable difficulties to its removal. Accordingly, on the 13th of January I operated, cutting very wide of the anus in order to get rid of the external flaps of skin, and also to avoid' wounding the haemorrhoidal vessels which I knew were large. The dorsal incision, owing to the piles, bled unusually, indeed, throughout the operation the bleeding was severe. A silver catheter passed into the bladder and steadied by Mr. Goodsall, aided me much in the delicate dissection of the growth from the base of the bladder and the urethra. The parts were so adherent on the right side that I made a wound in the peritoneum, but no coil of intestine came through. In dissecting the growth from the sacrum, where also it was more firmly adherent than I anticipated, I came on the meso- rectum and wounded the middle haemorrhoidal artery, from which the rush of blood was so great that had I not very rapidly seized it the patient would have died on the table. The house surgeon administering the ether was immediately aware of the loss of blood, as the pulse failed. Rather over than under five inches of bowel were removed. A carbolized sponge was placed against the spot where the peritoneum was wounded, and the cavity, which was very large (looking as if the whole interior of the pelvis bad been scooped out), was also filled with carbolized sponges. On the day after the operation the patient was doing well, had passed a fair night, taking his nourishment, not vomited, had a tranquil countenance, and was cheerful. The abdomen was soft and undistended; there was no pain on pressure save near the right iliac region, which was rather tender. The next day the sponges were removed, and the wound carefully syringed CANCER OF THE RECTUM. 223 out with diluted Condy's fluid. There was no sloughing, and the wound looked satisfactory. On the fourth day after the operation he was attacked with a severe rigor fol- lowed by very high temperature and sweathing; symptoms of acute peritonitis set in, and he died on the fifth day. A post-7no7'tem showed acute peritonitis all over the abdomen. Lymph was found between all the coils of the intestine, and a purulent fluid existed in the pelvis. The kidneys were not quite healthy. The patient had no serious symptom until the rigor; indeed, a few hours before he felt particularly comfortable, and I thought, on the whole, well of him. A trace of albumen had been found in this man's urine. Since the last edition of this work was published, I have excised the rectum in its entire circumference in six patients only. Four operations were performed in the years 1879-80 and two during the present year. The paucity of recent operations is due to a feeling of dissatisfaction, on my part, with the results of those performed by myself and of those I have seen done by others. Only one, I believe, of my sixteen cases is now living; he is No. 7 of the series related in full. This patient has had no return of cancer, but he is in the most wretched condition. He has perpetual incontinence of faeces, and the rectum, for three inches upward from the anus, is so much contracted that unless he constantly wore a tube, absolute closure would rapidly take place. In fact, if the tube be left out all night, great difficulty is experienced in re-introducing it. He is, as a matter of course, incapable of earning his livelihood. The method of operating employed by me is that which has found most favor with the French authorities. The deep dorsal incision I really consider the " key " to the operation. It gives you plenty of room, which is essential if you have to remove any considerable length of the rectum, and so get fully above the growth. Further, it saves much loss of blood, as it enables you to secure the vessels_ with rapidity and certainty. Lastly, it forms a deep drain or channel, through which all abnoxious matters can freely escape. It is the retention of morbific particles which is dangerous; let them all run away as they are generated, and you may defy pyaemia without any antiseptics. In saying this I am not insensible to the advantages of these chemicals when you cannot get deep drainage. In operating on the male I always have a silver catheter passed into the bladder; the assistant hooks it well up under 224 CANCER OF THE RECTUM. the pubic arch; the urethra and adjoining parts are thus steadied, and you are enabled to carry on deHcate dissections without danger, in the neighborhood of the trigone of the bladder, the prostate, and the urethra. After the operation I think it very advisable to place a tube in the rectum, to favor the escape of wind, which, if retained, will cause much discomfort to your patient. In women the assistant's finger ought to be introduced into the vagina, to give you timely warning when you approach too near the vaginal mucous membrane. In most of my cases it was absolutely impossible to bring down the stump of the rectum to the skin ; if, indeed, these parts could be brought together the tension would be so great that the sutures would be torn out in a few hours. I cannot understand how Volkmann brings the rectum to the skin, puts in sutures, and gets primary union. I can only say that the operation I do must differ much from Volkmann's. I have never used carbolic dressings with the view of following Mr. Lester in his antiseptic treatment ; in fact, these opera- tions appear to me to be about the very last to which the process, valuable as it undoubtedly is in some cases, is appli- cable. Looking at the chasm I make, and the part in which it is made, I should say that, shutting up the cavity by sutures, and then endeavoring to keep that cavity sweet and healthy by drainage tubes and deeper tubes put through holes made by the surgeon, would be making a plaything of antiseptic surgery. How can you prevent fecal matter from getting into the wound, so incompletely closed as it must be by sutures ? Perhaps it may be said that the bowels must be kept confined for days after the operation. To this I would answer, it is often impossible to do so. The intestines of these patients are always in an irritable condition, and neither opium nor any other drug will delay action for long. Then, again, I would say, it is not good to confine the bowels, for should a large mass form in the upper part of the rectum, such pressure on the vessels is exercised that congestion and stasis are induced, and these conditions are quite inimical to the healing process. I am fully convinced that the best after treatment of these cases is to establish a good drainage from the wound, to keep the parts clean by syringing with some innocent disinfectant, and if you accomplish this you need not fear ; the wound will rapidly fill up, and the return will grow downward, and unite with the skin. My cases are only sixteen in number. I will not, there- CANCER OF THE RECTUM. 22^ fore, draw definite conclusions from them, save that the operation may be accomplished even when the growths are very considerable and the adhesions even abundant ; at the same time, I would point out that there are dangers con- nected with the operation not to be despised, but which increased knowledge may enable us more surely to overcome. I would also observe there is a tendency to look too lightly on the danger of opening the peritoneum. ' In three of my cases that cavity was opened, and in two no evil resulted, but in the third I have no doubt it was the cause of death. An important question is. Do we really obtain a cure in cases of epithelioma? My modest experience would lead me to think that such a result is very uncommon, and must not usually be expected. A second question. Do we obtain much pro- longation of life by the operation ? I am inclined to the opinion that this question cannot be positively answered in the affimative. Epithelioma in many cases advances very slowly. I have had a considerable number of patients who have lived four years and upward from the first appearance of the symptoms, no operation having been undertaken. ,If the disease be near the anus, not extending, say more than two inches up the bowel, I should not hesitate to excise it. In the large majority of cases, however, the disease -com- mences at more than two inches from the anus, and extends for two or three inches higher up. These cases almost always do badly,, and it therefore follows that the number of patients who can be benefited by incision as the disease is compartively small. Mr. Rouse, of St. George's Hospital, has related a casein the Lancet, October 2d, 1880, of removal of a small cancerous growth of the rectum, about an inch from the anus, by making a curved incision just outside the external sphincter, and pushing the growth from the rectum through this opening ; it was then cut off, and the patient did well. Mr, John Gay has related an almost exactly simi- lar case, but it is obvious that the feasibility of the operation depends upon the extremely rare circumstance of the growth being so low down. Mr. Gay's patient, I know, did not long survive the operation, but I do not know how Mr. Rouse's case has terminated. Mr. James Adams, of the London Hospital, has suggested that, prior to excising cancer of the rectum, colotomy should be performed. His arguments in favor of such a step are briefly as follows : " That in cases of any but of the slightest degree, the operation might prove incomplete and the disease speedily return ; that after com- 15 226 CANCER OF THE RECTUM. plete removal of the lower part of the rectum, the subsequent contraction is often very great, and sometimes quite intract- able ; and that in any case the healing of the wound would be expedited and the tendency to local recurrence dimin- ished, by diverting the course of the faeces." The author had recently operated in a case in which this line of action had been adopted with the most satisfactory result. I am inclined to think that some, at all events, of the published cures were not really cases of cancer, but lupoid or other ulcerations. Probably a careful microscopic examination of the removed growth would be the only means of deciding the question. The - excision of epithelioma usually at once relieves the patient of great pain, and much comfort is obtained. As to there being a new sphincter muscle formed around the cut end of the rectum, I do not believe this ever occurs ; there may be some power of retaining fecal matter when not liquid, but that only arises from there always being a certain amount of contraction, and from the fact that the anal opening usually leads into a large cavity, where faeces can rest for a time, until expulsive exertions are made. This contraction is often so considerable as to become an obstacle to the passage of excretions, and then, as in three of my cases, divisions may be called for, together with the more^or less continuous use of tubes. Finally, is the operation one to be undertaken in ail cases, headless of the extent of the disease, the parts involved, or the age and condition of the patient, as some German surgeons practically assert ? I say by no means. The cases must be carefully selected if any lasting success is to be obtained. The operation of excision of the rectum and its results have been compared by some surgeons with colotomy, when really there is no ground for comparison ; both operations may be equally advantageous in fit cases, but they cannot be substituted the one for the other ; the most enthusiastic advocate of colotomy would scarcely think of operating on the cases best fitted for excision, and the converse also obtains. I shall now proceed briefly to consider the subject of colotomy. This operation may be done in the inguinal or lumbar regions, either right or left. Inguinal colotomy I have never performed, except in infants, and I have experi- ence of two such cases only, neither of which was very suc- cessful. The left lumbar region, for anatomical reasons, is the best suited to colotomy, but should the obstruction be CANCER OF THE RECTUM. 227 high Up the bowel the right side may be resorted to. I have now thirty-nine times performed colotomy for the relief of patients suffering from cancer, and twenty-five times in cases of non-malignant disease, sixty-four cases in all. I do not see the necessity (the advantages of this operation being quite established) of relating my cases in detail. Most of them have, at various times, been published in hospital reports or the medical journals. Generally, I will say that -colotomy is justifiable when an obstruction existing in the lower bowel threatens the patient's life ; also, when an opening has taken place between the rec- tum and bladder, or urethra, or even vaginia high up, the distress in these cases being exceedingly great. (I have recently had the care of a woman, into whose bladder, by some devious route, a cancer of the rectum ulcerated, and she passed faeces and wind per urethram.) When a cancer of the rectum is rapidly advancing, and great pain exists which ordinary means cannot alleviate, then colotomy may be done ; but I do not think colotomy advis- able or justifiable simply because cancer of the rectum exists ; and my large experience teaches me that the idea of prolonging life by a very early opperation is erroneous and not borne out by facts. When I say my large experience, I do not speak of my own operations alone, but of all I have seen others perform, and of which I know the ultimate result. I admit that when obstruction exists a patient may be snatched from immediate death by the operation, but that is not the question, I mean can we say to every patient seen in the early stage of cancer, " If you will submit to colotomy you will live much longer than if you do not ? " I aver that we cannot truthfully say this, and I believe my position proven by the natural history of the disease, to which I directly refer. Of my thirty-nine cases of colotomy in cancer the best result was obtained in a man with a scirrhous growth filling up the pelvis, who lived four and a half years after the oper- ation. My second in a woman, who lived nineteen months, and was or twelve months in wonderful comfort. Only five of my patients have died within fourteen days of the opera- tion. Two patients succumbed from phlegmonous erysipelas. In another case the operation was done when the patient was almost "in articulo mortis," and death took place in ten days, from exhaustion, but the relief to pain was so great that no regrets were felt by the surgeon, the patient, or the 228 CANCER OF THE RECTUM. friends. In the fourth the patient, a lady, died within nine days of the operation ; there was entire obstruction of the bowel and anasarca; surgical aid was delayed to long ; immediately after the colotomy paracentesis abdominis was performed. Acute pleurisy was the immediate cause of death. In a man, set. 39, with cancer of the rectum, of epthelial character, I operated comparatively early. There was no obstruction, no emaciation, no detectable glandular affection, but he suffered great pain. The disease, or rather the symp- toms, I will say, had existed only for four months. The patient recovered from the operation exceedingly well, and lived fifteen months after it, dying from extension of the dis- ease, general blood poisoning, and enlarged lumbar glands. This patient may fairly be said to have died about twenty months from the commencement of the disease. My observations on the natural history of cancer in all forms lead me to conclude that the large majority of victims will die, /. e. the disease will run its course in about two years. In the case I last mentioned, pain was mitigated and acci- dents avoided, but I could not say that life was prolonged. I do not consider averages in surgical statistics of any great utility, but I may mention that the average length of life after opertion in my thirty-nine cases of cancer was six months and two weeks. However interesting this part of my subject may be, I have neither time nor space to pursue it further, but shall turn to the operation itself. The method of opening the colon now generally adopted is known as Amussat's, and was advocated by that surgeon in his treatise published in 1839, "On the Possibility of Establishing an Artificial Anus in the Lumbar Region." In the adult I think there can be no doubt that Amussat's is the best procedure. By attention to certain rules, lumbar colotomy will not be found very difficult, but the not infrequent occurrence of misadventures induces in my mind the belief that many sur- geons are not yet sufficiently alive. to the necessity for con- siderable precision in the performance of this operation, more especially when the bowel is undistended. The directions usually afforded in works on surgery lack the element of precision, which I think indispensable. The error usually made in operating is to search for the colon too far from the spine ; the result of this is, that the peritoneum is inadvertently opened, a coil of small intestine at once CANCER OF THE RECTUM. 229 shoots up into the wound ; this misleads the surgeons and renders the discovery of the colon more difficult as well as the operation more likely to prove fatal. The anatomical guide to the position of the ascending or descending colon is the free edge of the quadratus lumborum muscle, but this is by no means always easily found, and con- sequently it is better to substitute a more certain and unmis- takeable guide, and this, as I have stated in my article on colotomy in the "St. Thomas's Hospital Reports" for 1870, may be obtained by marking a spot on the crest of the ilium, fully half an inch posterior to a point midway between the two superior spinous processes. From more than fifty dissections and the experience of over eighty operations of my own and others, I can confi- dently assert that the colon is always normally situated oppo- site this point. Before operating I mark this spot on the crest of the ilium with ink or iodine paint, and I have always found it, when the superficial tissues are divided, a most useful landmark and guide to the exact position of the intestine. This is especially valuable if you fail to recognize the deeper struc- tures as they are incised, which you may easily do if the patient be muscular or fat. On the whole I prefer the oblique incision, as recommended by Mr. Bryant, downward from the last rib toward the anterior superior spinous process of the ilium, and the centre of this cut, which should be made from three to four inches in length, must be opposite your mark upon the crest. When the intestine is at all dis- tended I make my incision not more than two inches in length, and I find this quite sufficient. When about to operate the patient should be placed upon a hard couch, in the prone position, with a slight inclination toward the right side, and a hard pillow is to be adjusted under the left side, so as to render the loin tense and prominent. I have frequently seen the operator stand behind the patient. I prefer standing in front, in which position I think you are less likely to make your deeper incisions too far forward, and so inadvertently open the peritoneum. The structures should be very carefully divided on a director, and this should be done slowly and deliberately, waiting until bleeding be arrested, so that the anatomical relation of the parts be duly recognized as the operation proceeds. I think it very desirable, though not absolutely 230 CANCER OF THE RECTUM. necessary, that the fascia lumborum should be thoroughly made out, and if possible the edge of the quadratus lum- borum muscle clearly exposed. If this is seen a blunt- pointed bistoury should be passed beneath it and the muscle freely divided; when this is done the colon will be found; it is generally covered by fat, which may be mistaken for the gut, but this error will be soon discovered and is very easily rectified. It is of the utmost importance that the deeper incisions be kept the same length as the cut through the skin. If you do not attend to this rule, by the time you reach the lumbar fascia you will be working in a deep trian- gular hole, the apex of which is furthest from you; and it will be almost impossible to find the gut, even if you have come down upon the right spot. From personal experience, and the many operations I have seen performed by other surgeons, I am quite convinced that this is the secret of overcoming the difficulties of the operation. If the colon be fairly exposed as I have directed, there is usually but little difficulty in recognizing it, even when it is quite undistended, and picking it up from the bottom of the wound. In most of my cases one of the longitudinal bands was clearly observed, and in others hard portions of faeces could be felt before the gut was opened. The intestine having been found, it should be drawn well out of the wound, and opened longitudinally for about an inch, the edges of the incision being stitched to the edges of the skin. The sutures should be passed through the colon before opening it, to avoid any chance of the contents run- ning into the wound. I have found thick silk sutures answer better than wire, as they do not so easily cut their way out, and I retain them until I observe that they have begun to ulcerate through the skin; but it is better not to keep them in too long; forty-eight hours is usually sufficient. The immediate fatality of the operation depends almost wholly upon whether any fecal matter or morbific fluid runs into the peritoneal cavity; therefore it should be remem- bered that it is desirable to approach the colon on its dorsal or even spinous aspect, rather than upon its outer side, and to avoid, by all means in your power, opening the perito- neum. When the intestine is collapsed I have recommended a quantity of fluid to be injected, but I must now qualify that advice, and say it is better to endeavor to distend the gut with air if you cannot find it without CANCER OF THE RECTUM. 23! If the case goes on fairly well the after-treatment is gener- ally very simple. I usually apply a weak solution of car- bolic acid or Condy's fluid to keep the part from getting dry and stiff and to deodorize, as the smell is sometimes very unpleasant. A charcoal poultice is often very advantageous. When the bowels have been long confined before the operation, they are occasionally very difficult to get to act, and you may have to employ a scoop to remove the indur- ated fecal lumps; this being accomplished, enemata may be used to stimulate the colon to action, and relief will be obtained. The patient is, as a rule, able to get about in four weeks from the time of the operation. When up they may wear a well-fitting india-rubber pad, to prevent the escape of wind and motion. I now have the pad made a little hollow and fill the concavity with cotton wool, which will absorb any slight moisture and keep the part dry. Some of my patients preferred merely a pad of wool and a napkin over it, to any mechanical appliance. It is a great thing to cultivate the habit of getting the bowels to act the first thing in the morning; by this, incontinence and trouble during the day are best avoided. I always recommend the use of plenty of cold water, night and morning, to the lumbar aperture; by which means the mucous membrane may be .kept healthy and the probability of protrusion of the gut be lessened. This, however, if the patient should survive the operation for many months, is certain to occur to a greater or less extent; generally it can be returned by gentle pressure, but sometimes it can be replaced only by passing a softened bougie or thick tallow candle and carrying the bowel upward. Since I have made a much smaller external incision I have not found the protrusion, as a rule, so troublesome, but still it will occur. Among the most distressing symptoms attending cancer of the rectum must be numbered violent straining. I had anticipated that colotomy would entirely remove this cause of suffering, but that is by no means the case. The cancer- ous growth, especially when it approaches the anus, pro- vokes reflex action, and irresistible bearing-down results; this also is the case when fecal matter passes the opening in the loin and accumulate in the bowel below. This was supposed to be almost an impossibility, but in my experi- ence it is of frequent occurrence, and causes severe pain as 232 RODENT OR LUPOID ULCER. well as straining. In a case I had with Mr. Aikin it was one of the evils we had always to combat, and it rendered syringing out the rectum from the anus a matter of daily necessity, and added much to the patient's suffering. In such conditions the treatment must consist in keeping the rectum as clear of motion as possible, by frequent washing out with warm water and some disinfectant, the particular one used being changed from time to time. I think, on the whole, carbolic acid is the worst you can employ, as, even when extremely weak, it is liable to set up irritation in the cancerous growth in the bowel and a consequent increase of local pain. Salicylic acid and thymol I find good, but on the whole I prefer a solution of permanganate of potash, which is soothing to the part and readily destroys odor, and has no unpleasant attributes in itself. Surgeons are too apt to forget that when colotomy is performed the cancer is still left in the bowel, and attention must be directed to this. The discharge must be removed by careful syringing, and great relief may be given to the patient by injections of watery solutions of opium and other sedatives, per a?ium. The patients should live well, and I always order as much cod-liver oil as they can take without disturbing the stomach. CHAPTER XIX. RODENT OR LUPOID ULCER. Although some of my critics have taken exception to the word "rodent," I cannot, on reconsideration, find a more appropriate appellation, unless it be " lupoid," but I think the term is not so very important. What I wish to do is to describe and define a species of ulcer of the rectum not often met with, which is totally distinct from simple ulcer, and, in my opinion, is very nearly allied to epithelial cancer, although it differs from that malady in several essential par- ticulars which I will presently detail. In its early stage the ulcer is very difftcult to distinguish from a syphilitic sore, and when it is situated just within the sphincter it may also readily be mistaken for the ordinary painful rectal ulcer. Rodent ulcer in the rectum differs from RODENT OR LUPOID ULCER. 233 the malady of the same name found on the face, in being, as a rule, most terribly painful, and in having no indurated margin; it also differs in another essential and important point — it is very much less curable; as far as I know, it is nearly as deadly as cancer, though not so rapid in its pro- gress. I cannot say that I ever saw a case of undoubted rodent ulcer of the rectum cured, but I have now a ease which has remained well, after excision, for more than four years. It is a happy thing that the disease is an uncommon one ; in my own practice I have had only nine decided cases, and I do not remember to have seen more than fourteen in all. Rodent or lupoid ulcer may be distinguished from epithe- lioma by the following peculiarities : It does not invade neighboring organs by infiltration, nor does it contaminate through the lymphatics ; as far as I know, it never forms secondary deposits, and it produces no hardness. It is not, I am informed by microscopists, a disease of the follicles of the rectum. It differs from secondary or tertiary syphilitic ulceration in not^ inducing stricture of. the rectum or any submucous thickening; and this difference arises from its being essen- tially a destructive ulceration, no long-continued effort at repair which would cause permanent deposits taking place. The appearance of the ulcer is peculiar, and there need be but little hesitation in deciding what it is when once it is fairly established, but as I have said, in the earliest stage, the most experienced pathologist may be at fault. The following, from my observations, I should say are the characteristics of the sore: the shape is usually irregular; I have only once seen it quite circular and symmetrical; this occurred in a case which I shall presently relate. Its edges are sharp and cleanly cut; it does not undermine the mucous membrane; it destroys completely, as far as it extends; neither its edge nor its base is at all hard, and the mucous membrane around it is perfectly, and I may say abruptly, healthy. Its surface is very red and mostly dry; there is scarcely ever any amount of discharge from it. It sometimes destroys deeply, but its tendency is to spread superficially and to attack mucous membrane rather than skin, though in some of the cases I have observed it invaded the border-land mucous membrane and skin, and it may spread even to a considerable distance on the latter. It often, for a time, remains stationary, and I have noticed repair taking place 234 RODENT OR LUPOID ULCER. very rapidly, but just as you think cicatrization will be com- pleted, all the granulations will melt away, like snow before the sun, and the ulcer will appear in its former shape and character in the course of a few hours. The patients attacked by this disease I think I may say are nearly always of a markedly scrofulous diathesis. 'Rodent ulcer is generally most horribly painful (I have seen only one exception to this); the sufferer describes it as a constant, burning, gnawing sensation, as if a red-hot iron were applied to the part. Of course, the pain is aggravated when the bowels act. Death takes place from exhaustion; the patient really appears to die from the never-ceasing suf- fering. Two of my cases had diarrhoea toward the termi- nation of their lives, and this rapidly carried them off. Phthisis was the cause of death in three others. The treat- ment generally adopted for this disease has been the appli- cation of escharotics, such as nitric acid, chloride of zinc, arsenite of copper, the actual cautery, etc. And if you burn the sore well out the patient usually has for a time much freedom from pain. One of my patients was comparatively comfortable for three months after the use of fuming nitric acid, but of all escharotics I think the best are the chloride of zinc (used after Fell's plan) and the arsenite of copper ; but even these, in my experience, will only delay the malady, but do not cure it. Internal remedies are advantageous, such as tonics, cod-liver oil, sedatives, etc., but they only lend a feeble help. Specifics are, in my Oj,- inion, worse than useless; I believe the only plan worth trying now is exceed- ingly free incision. Should a case come to me, I should, with my present knowledge, perform extirpation of the lower part of the rectum. The only patient I have had do well was a Greek gentleman, who came to me in February, 1875, and from him I removed two-thirds of the circumference of the rectum dorsally, where a well-marked rodent ulcer ' existed. He had consulted many eminent men, and all kinds of treatment had been tried internally and externally without benefit. The sore had existed twelve months at least when I first saw him. I have excised rodent ulcers before, but never so freely, and I now think my operations had not been radical enough. In the above instance I removed all the coats of the rectum, and even fat, and cut at least an inch all round away from the sore. When I last heard of the patient, four years after the operation, there had been no return of the sore, and the patient's general health RODENT OR LUPOID ULCER. 235 was very good. In another case where I performed free excision a year ago there has been no return of the growth. In my opinion some cases that occurred to me years ago are so typical, and illustrate so well the disease, that I shall not relate in detail any of later date. Mrs. H , set. 30, a delicate-looking, nervous, excitable woman, of strumous diathesis. She has three children, the youngest being two years of age. She has never had any miscarriages or any serious illness prior to her present one; but considers herself as delicate, and suffers much from sore throat. Six months ago she was supposed to have fissure of the rectum, and an operation was performed upon her by a very skillful surgeon, but she did not get well. She was bet- ter for a time, but the pain has returned, and she feels much as she did before being operated upon. On examining her I found an inflamed-looking ulcer at the entrance of the anus; it was partially external, about one- third being outside and the rest inside. It was three-quarters of an inch long by about half an inch wide; it was quite superficial, and was not at all hard. The sphincter ani was spasmodically contracted; she suffered a good deal of aching pain, worse after action, and the bowels were very confined. There was no polypus. I decided to divide the sphincter freely. My friends, Dr. Crosby and Mr. Shillitoe, who assisted me at the operation, were strongly of opinion that the sore was syphilitic. I have mentioned that she had sore throat, but she had no rash, and there was no history of syphilis. The uterus was found to be quite healthy. This lady's husband had not been a steady man, and therefore it was by no means certain that she had not been infected ; so it was agreed that she should take the bichloride of mercury with tonics and cod-liver oil. The operation at once relieved the pain, and she went on very satisfactorily. The wound looked healthy, granulated freely, and I saw no reason why she should not do well; but after about five weeks the sore became stationary, and refused to answer to stimulating lotions; moreover she began to suffer from her old pain, which she always described as being like " a red-hot iron applied to the part." I may say that the wound had healed up to nearly the dimensions it was when I operated. I had now pretty well made up my mind as to the character of the ulcer, so, when at the end of three months I found it still no better, but rather increasing in size, I determined to cleanly excise the whole 236 RODENT OR LUPOID ULCER. sore. Again, assisted by the same gentlemen, I freely removed the ulcer, cutting wide of it, and removing the base fully down to the cellular tissue, taking, of course, nearly all of one-half of the external sphincter muscle away. After this I well swabbed the wound with a strong solution of chloride of zinc. Both Dr. Crosby and Mr. Shillitoe agreed that it was impossible, by the incision I had made, not to have removed all the diseased parts. After this operation, for three months, the patient went on well, and the sore healed up to nearly its original size, when it again halted, and the pain returned as badly as ever. My colleague, Mr. GowUand, now saw her in consultation with me, and was much inclined to give a favorable prognosis, but, on taking the case in hand himself, he soon found that no remedy he had knowledge of was of any avail. This lady afterwards consulted many eminent surgeons, but without deriving any benefit, and she died in about three years from the com- mencement of her illness, under the care of the late Mr. De Morgan, in the Harley Street Surgical Home for Ladies. A girl, set. 17, who came from the country, was taken into St. Mark's Hospital, under my care, in the summer of 1867. She was a ruddy-complexioned, heavy, rather stupid, strumous looking person, and we had a good deal of diffi- culty in extracting any information from her. She had a sore just at the verge of the anus, toward the perineum, and it had burrowed through into the vagina, close to the four- chette. She did not know how long it had existed. She professed to be very innocent, and strongly denied any pos- sibility of syphilis, but she had no appearance of a hymen, and her vagina was capacious. She had a superficially ulcerated throat, and some spots of a suspicious character on her head and on her body. She had no enlarged glands in her groins; she complained of a great deal of pain in the sore. . I made but little doubt of its being syphilitic, and prescribed an antisyphiltic treatment; finding no improve- ment take place, I passed a director through the sinus and laid it open — still it did not heal. Mr. James Lane, who was then one of my colleagues, saw it, and agreed with me as to its being a syphilitic sore, so I persevered with the rem- edies for some time longer, but it did not heal, and I began to have my suspicions that I had made an incorrect diagno- sis. I then treated the ulcer freely with strong nitric acid, and for a time it greatly improved, and she suffered scarcely any pain; and then all of a sudden, without any apparent RODENT OR LUPOID ULCER. 237 cause, the sore spread and extended up the bowel, as well as the vaghia, removing the tissues rather deeply. She rapidly lost flesh, became very weak, and had almost constant pain, which was only slightly mitigated by hypodermic injections of morphia. I kept her in the hospital for a long while, but finally, at her own resquest, I sent her home, and I was informed that she did not live very long. A man, aet. 42, of delicate and feeble appearance, was an out-patient of mine at St. Mark's. He had been ill for about twelve months, and had been in several hospitals. He had ulceration of the rectum, superficial but extensive; dorsally it extended up the bowel for quite two inches, and laterally, on both sides for about an inch; the skin exter- nally was slightly involved; there was no constriction of the bowel, and no, and no deposits; the sore had a very dry and red appearance; it discharged a sanious fluid, but no pus. He suffered most horribly, scarcely ever had a moment's ease, and he took all the morphia he could get. He would not come into the hospital to have anything done; all he prayed for was something to relieve his pain. I taught him to use the hypodermic syringe upon himself, and he obtained some ease from that. When he became too weak to come to the hospital I visited him at home, wishing much to be allowed to examine the body after death, but when that event occurred, his friends would not accede to my request. He died of diarrhoea; there was no evidence of any secondary deposits having taken place. John S , a gunner in the Royal Artillery, set. 31, was sent to me at St. Mark's, January, 1872, from the hospital at Shoeburyness. The history is that he has been in India for six years, and returned to England twelve months back. While in India he had diarrhoea, fever, and smallpox, but never dysentery, always enjoyed good health; he is a steady man, single, and of very good character in the army. He cannot quite assign any date to his rectal affection, but had piles in India, and some operation was performed for their cure; after this he was but little troubled until a few months before he returned to this country. He has been six months in the military hospital without any improvement in his condition. He has never had syphilis, but has had gon- orrhoea. He is a middle-sized, slight, spare man, much marked by smallpox, aspect not very unhealthy. An examination of the chest detected dullness at the upper part of the right 238 RODENT OR LUPOID ULCER. lung; he is rather subject to cough and there is phthisis in his family, but he has never suffered from haemoptysis or inflammation of the lungs. On separating the buttocks a perfectly symmetrical, nearly circular sore is seen extending all round Ae anus; it is as large as a five-shilling piece, very superficial, with a well-defined edge; the sore discharges but little pus, is remarkably clean and red, and is covered by rather largish granulations. The anus is more patulous than natural, and the ulceration is found to extend up the bowel for nearly an inch; above this the mucous membrane is quite healthy. There is not the slightest induration about tiie sore. The sphincter is very relaxed and powerless, and the patient states that when the motions are loose he has but little control over them. There is no evidence of sj^ph- ilis; he has no rs?n sore throat, or enlarged glands. He does not surer se 7 r in. but there is a constant burning in the part : _ _:: zted by any movement and by the action ;: : t t f H:? appetite is fair; he sleeps, but his nig:. ^ t i f : ::: e i r. : : actually by acute pain, but bynneaanesf i z f e sore. He has been grad- ually losing r 1 5 ; :..z i::- - _ . Many en rt": urrt: - : . I showed this patient directly t r : :. : - t i :':.- 5 : : t : t syphilitic, but a further inve?^r :. :. :-i::ri : e .. -; ::. iraw that opinion, and the:::::"; r:r :": :::i :: : ::::i: :::: it was rodent ulcer. Iir::_-i:Ti '.':.- ::::t": ::: ::t i _'::-rT :^rom the sore, but :::f rr::z :: : ' ; ft:-::"t : ;Tri:::i.£ ":"::-£ negative. Tt :t : t ^ i:de of potassium with bark ;r : : :- : :: :r :' stimulant and sedative : 5 :: '':.- :::e : i ;. -O benefit r^mlting, the It : : : i Z : :. an's solution was adminis- t:: : ::: tt t :: '1- : ": avaiL I It : :: i i ;::::: :: '.:.z .tt with the fuming nitric 1: i : : r: r: :: ement took place; therefore I did not 1: ' 'le whole sore. 7 T T :. : :: the hospital for about four months, ;i.i lespite all that was done for him he got gradually : T The pain was mitigated by sedatives, but it became : . :t —Tie smd almost constant; he lost flesh and strength, and the ulcer increased in size until, when he left, it was ' ree inches in diameter; and deeper than at first; it ad much extended up the rectum. He went to the Herbert Hospital at Woolwich, and 1 heard, some rj. ::.:'? afterwards, from the gentleman under whose VILLOUS TUMOR OF THE RECTUM. 239 care he was, that he died; no post-mortem examination was made. I am strongly of opinion that I can do much more for the cure of the disease now than I could when the above- mentioned patients came under my care; my treatment would be, if possible, very free excision of the whole of the diseased portion of the bowel. CHAPTER XX. VILLOUS TUMOR OF THE RECTUM. This is a rare but interesting disease. Mr. Quain, in his work, gives the details of the only case that had fallen under his observation. I have now seen fourteen examples of this growth — eight in my own practice, three* in St. Mark's Hos- pital, under the care of my colleague, Mr. Gowlland, one in my colleague, Mr. Alfred Cooper's practice, and two under Mr. Goodsall's care. The leading symptoms may be stated to be the descent of a tumor, usually on the bowels acting, or even when the patient walks, and the very abundant discharge of a glairy mucous resembling the white of an unboiled egg. This latter, in all my cases, and in Mr. Gowlland's also, was the most prominent symptom ; even when the tumor was not protruded from the anus, this discharge frequently ran away from the patient without his having control over the escape ; it is evidently a very great exaggeration of the normal secre- tion of the mucous membrane of the rectum by the villi which grow from it and from the tumor. Blood, in some of my cases, was lost in quantity, two of my patients being quite blanched from that cause, but I would observe that even the loss of the mucus is a severe drain upon the constitution, and shows itself in the aspect of the patient. Exceedingly large arteries may usually be felt entering the broad peduncle of the growth. It does not appear that pain usually attends this disease, only discom- fort arising from the protrusion and constant discharge. The tumor consists of alobulated, spongy mass, with long villous- like groups studding its surface ; it resembles exactly — 240 VILLOUS TUMOR OF THE RECTUM. though the villi are much larger — the growth of the same name found in the bladder. Usually it is attached to the bowel by a stem, broad rather than round, and this appears to me to be more like an elongation or dragging down of the mucous membrane and sub-mucous tissue than a develop- ment. The flattened peduncle may be two or three inches in length, or it may be short ; in two of my patients it was quite short, indeed ; the tumor itself came outside, but grew directly from the surface of the bowel. In cases where the growth arises from the perineal sur- face, as a practical point worth remembering, I should say it is by no means impossible that a pouch of peritoneum may be dragged down into the pedicle, and in such a case, if the ligatures were applied close to the bowel, peritoneum might be tied up with it. When the second edition of this work was published, from what I had seen and heard, I was of opinion that these tumors, when removed, did not return. I am obliged now to modify that opinion, as I am also to the large losses of blood occasionally attending them. I am also compelled to express the opinion that they may become malignant, having now seen two cases in which epithelioma replaced the villous growth. From a case I have had I think it very probable that these growths sometimes shed themselves, and the patient may remain well after this for a considerable time. Supposing that, as Mr. Cripps thinks, epithelioma is a dis- ease of the follicles of the rectum, may not villous tumors be epithelioma of the villi ? not so malignant from the fact that it grows outward from the mucous membrane instead of sinking into it, and thus preventing the ready escape of the cells. Three of my cases I will relate in some detail, as they are my most recent ones : — Dr. D — , a physician, came to me in September of 1875. He is sixty years of age, a small and spare man, with an aspect of countenance suggesting malignant disease. He is married and has a family. He says that for quite two years and a half he has suffered from piles, something occasionally protruding from the anus on going to stool. About two years since he began to loose blood, and a considerable quantity of glairy mucous was discharged from the bowel. The tumor, for it was single, grew rapidly, and always came down at the closet, and occasionally on exertion. It bled profusely, often half a pint at one action of the bowel, and he had fainted in the closet from loss of blood. On being VILLOUS TUMOR OF THE RECTUM. 24I returned inside the sphincters the bleeding ceased. Latterly /. e.y within the last few months, he had much difficulty in returning it, owing to its large size, as it gradually became as large as a man's fist. It had, he said, a soft, spongy feel, and the blood could be squeezed out of it by the hand. Three weeks back he found the tumor began to disintegrate on his handling it, and now it had so decreased that he could readily return it into the bowel. His health had been very materially failing; he was weak, often giddy, with noises in his head and dimness of vision. I gave him an enema, and on going to the closet he brought outside the anus a very vascular tumor, looking like a sponge, about the size of a large hen's egg, and bleeding profusely, as it was tightly girt about by the sphincter. On examining the bowel I found the tumor was connected with the mucous membrane by a short, thick, tough peduncle, which was quite smooth. When the growth was with some difficulty returned into the bowel, you could scarcely realize the fact that so large a tumor existed; only the pedicle could be felt, as something hard; it was attached about an inch and a half up the rectum, on the left side and rather toward the dorsum. The peduncle was about the size of the forefinger in thickness. On September 226., assisted by Mr. Baly, then the resident surgeon at St. Mark's hospital, the tumor being got well down, I passed a thick, double ligature, by means of a rectangular needle, through the pedicle, close to its attachment to the rectum, and tied it tightly, in halves. I felt a large vessel pulsating forcibly in the pedicle, and, of course, avoided wounding this with the needle. The peduncle was so short that I did not dare to cut off the tumor, fearing if it did so the ligatures might slip. The growth was lobulated and distinctly villous. The patient made an excellent recovery, and speedily gained health and strength. In about twelve months after this operation Dr. D — again came to me and said the growth had returned. On examination I found he was right, but the tumor was small. This time there was absolutely no peduncle, and it was broad at the base and felt hard at its attachment to the rectum. This case led me to doubt the innocent character of villous tumor. I agreed to remove the growth again, and the patient being placed under ether, I was able to dilate the sphincters, and partly by knife and partly by ligature, to extirpate the whole very thoroughly. After this the patient recovered, and there had been no 16 242 VILLOUS TUMOR OF THE RECTUM. return up to a very recent date, when I saw this gentleman. Seen again in November, 1881. Epithelioma has developed around the rectum, extending from the site of the old growth. A young man, pale and thin, was sent to me at St Mark's Hospital in April of 1877, by Dr. Way, of Southsea. He said he had piles, that they came down at the closet and on walking about; they did not bleed much, but he lost quan- tities of watery discharge, which frequently ran away and saturated his trousers. On administering an enema he strained down a large tumor, the size of a hen's egg, with a peduncle broad and thin; it was ligatured in four portions and cut off. He made a good recovery, and left the hospital in three weeks, quite well. On examining the bowel after the liga- tures came away no trace of hardness or peduncle could be felt; the tumor was situated at the dorsal surface of the bowel and to the right side. J. B — , set, 52, was admitted into St. Mark's Hospital, under my care, on the 2 2d of April, 1878. He was in appearance, the color of old wax, was very feeble, and looked prematurely aged. His heart's action was intermittent, and a soft blowing sound could be heard. He said he had suffered from what he considered to be the piles for some years, but lately he had a very large mass come outside. He lost quantities of blood, and there was also a discharge from the bowel "like gum water." He had a tendency to diarrhoea; great difficulty was experienced in returning the growth, which bled all the while it was protruded. On examining the tumor, when down, it was found to be quite as large as a man's fist, spongy, lobulated, with the villi greatly hypertrophied; the growth was so vascular that you could scarcely touch it without arterial blood spurting out. On passing the finger into the rectum the tumor was found to grow all round the bowel and there was absolutely no stem; all attempts, therefore, to deal with it by ligature, in the ordinary way, could not be successful. As an operation was necessary, to save the man's life, I -determined to remove the tumor, and I thought I could succeed by ligature and strong harelip pins. With much trouble and great loss of blood I managed to strangulate the whole mass. When I perforated the stump of the growth with a needle threaded with a double ligature and tied each way, the bleeding was tremendous at the point where the segments were drawn apart, therefore I could find no way to strangulate and VILLOUS TUMOR OF THE RECTUM. 243 arrest haemorrhage save by the harelip needles and the figure-of-eight ligature. The actual cautery and perchloride of iron had no power over the bleeding of this huge cauli- flower-looking growth. Of course it had to be left protrud- ing from the anus. No return until December, 1880, when the rectum was attacked by epithelioma, and the growth extended high up. He died. May, 1881. The patient was exceedingly exhausted, not being in a condition to support such a sudden loss of a quantity of blood. For a few days I was in some anxiety about the ter- mination of the case, but he rallied wonderfully, and at the end of a few days I thought him safe if no secondary haemorrhage took place; this fortunately did not occur. The decomposing mass was kept quite sweet by charcoal powder, and he got on well; the part separated without any bleeding whatever and left a large granulating sore; just as we thought all was right he was attacked with diarrhoea, very difficult to control, in fact, nothing was of service but a powder consisting of bismuth, soda, charcoal, and opium, which eventually cured him. He was not sufficiently recov- ered to leave the hospital until two months after the opera- tion. I have seen this patient frequently since he was dis- charged, and no return of the tumor had taken place, but high up in the rectum I find some small nodules;* whether they would develop into anything serious I could not for some time judge, but I watched him with interest and some anxiety. After the operation his general health became quite restored and his appearance wonderfully improved. I have mentioned my belief that villous tumors at times shed themselves, and I will relate the case which supports my view: Miss H , a maiden lady, of fifty or more years of age, was kindly sent to me by Dr. Morten, of Kilburn. She was a tall, spare woman, with a rather worn expression of face. Her history was that about twenty years ago she had suffered from losses of blood from the rectum, and also from a dis- charge which she described as like thin starch. This fluid flowed away at times in abundance. At this time her health was much broken, she had pains in her back and inability to take exercise; nothing came down on the bowels acting. Her bowels were very constipated and she took some strong * Since this was written epithelioma developed, and the patient died in May, 1881. 244 VILLOUS TUMOR OF THE RECTUM. aperient pills, the result being that when the bowels acted " a large mass of flesh came away, and the bleeding was so severe that she fainted." After this she had no more bleed- ing or watery discharge, and quickly recovered her health. After being well until about twelve or fifteen months ago, to her horror, the bleeding and discharge recommenced. She consulted medical men, who said her case was one of piles, and various treatment was adopted without any effect. She told me that portions of a fleshy, soft character came away sometimes at stool. She had straining, pains, and general debility. She was ordered to take charcoal, bismuth, and soda powders three times in the day, and use an injection of rhatany. I requested her to send me a specimen of what she passed when straining. My examination detected noth- ing but a relaxed, voluminous mucous membrane, which came down into the rectum, but neither by finger nor specu- lum could I detect any disease. In a few days after the consultation the patient sent me some of the discharge, and I found remarkably good specimens of villous growth, some pieces being as large as a hazel nut. I saw this lady once more, and used all means to see or feel the growth, but could not get at it. I was quite sure of my diagnosis, and could only tell her I hoped in time the stem of the growth would increase in length and come down within reach, so that one could remove the disease. A few months after this I had a letter informing me that the charcoal had caused a stoppage in the bowels, for which large doses of aperients, castor oil among them, had been used, to obtain relief, and that when action was at length obtained, a mass came away, not so large as, but much resembling, the one she had passed years years ago, and that she felt much relieved. She sent me a portion of the specimen, and that, sure enough, was a villous growth. Whether there will be any further return remains to be seen. The case is a very interesting one, and leads me to think that villous growths may break away from the bowel more often than is supposed, and I remember some very puzzling cases I have seen which were possibly similar to the one I have related. MISCELLANEOUS. 245 CHAPTER XXI. MISCELLANEOUS. In this, my concluding chapter, I intend to treat briefly of several forms of disease of the rectum, which are of some- what rare occurrence. NEURALGIA OF THE RECTUM. I can see no reason why neuralgia should not sometimes attack the rectum as well as any other part of the body ; no doubt many other affections have been erroneously called neuralgic, and I am ready to confess that I have more than once considered pains as neuralgic which I later on dis- covered to originate from a lesion of structure. Very slight erosions or even inflammation of a spot in the rectum may set up much pain ; and at the same time be so difficult to discover as to baffle the closest and most search- ing investigation. I have been in the habit of calling pain in the rectum or sphincter muscles neuralgic, when I have not been able to find out the slightest lesion, sign of inflammation, or dis- charge of any kind, and where the pain was not aggravated by action of the bowels ; this I always consider an import- ant point in diagnosis. In my cases the pain has been at times severe, at others absent, and only in two instances was it constant. The patients have been mostly delicate, irritable, or nervous peo- ple, who have been subject to neuralgic pains in other parts. I have noticed the attack follow direct exposure to wet and cold by sitting upon damp grass. One attack predisposes to another ; several times in private practice I have been con- sulted by the same patient. Usually you will find in these cases general debility, but in addition disorders of the digestive organs ; very often the liver is much affected ; it will therefore not do to commence your treatment with tonics and anti-neuralgic remedies ; first of all unload and put the abdominal viscera into condi- tion, and then quinine, iron, strychnia, and hypodermic injections of morphia may at once cure your patient. Attention to this point is all important ; in some instances, however, one has to confess to an inability to do more than temporary good ; nothing appears to cure the malady. 246 MISCELLANEOUS. When the pain seems quite confined to the sphincter mus- cle there was always spasmodic contraction, and I believe forcible dilatation of the anus, performed as I have before described, to be the best treatment ; after this is done a hypodermic injection of morphia will often cure this affec- tion, which I used to consider a very intractable form of myalgia. There are other nervous diseases of the rectum described by authors, but they are very rare indeed ; one of them, which is called " irritable rectum," I think is really the result of a chronic inflammation of the mucous membrane, as in such cases I have observed much heat in the bowel and tenesmus, as well as a discharge of mucus. These cases are best treated by very gentle laxatives, to keep the bowels acting, by alkalies with bitter infusions, and by insufflation of bismuth and charcoal into the rectum. This treatment will soon allay the irritability, and after this is accomplished the cure will be rendered permanent by injections of rha- tany and starch, with small doses of the liquid extract of opium. REMOVAL OF COCCYX. I have seen many female patients suffering from what has been considered neuralgic pain in the rectum, but really the pain was most distinctly referable to the sacro-coccygeal joint. These are most intractable cases, and on four occa- sions I have removed the coccyx, in the hope of curing the disease which was wearing out the mind and body of the patients. ]My first case was a married woman, aet. 54, with seven children. She had for years been complaining of pain in the rectum and at the end of the spine, which rendered her quite incapable of performing her household duties. She could not sit down except on a ring-shaped air-cussion, and when from home she always wore under her dress a couple of pads to catch the buttocks, so that the end of the spine should not touch anything. If the bowels were confined she had great pain before and at the time of their acting rather than afterwards. If she stooped, and suddenly raised herself, the pain " was like a knife going through the very bottom of the back." She could walk but a short distance, and going up stairs, was a very painful exertion to her. On examining the rectum no fissure or ulcer was discover- MISCELLANEOUS. 247 able, but when the finger was pressed on the coccyx, so as to move it — and it moved exceedingly freely and easily — she complained most bitterly. As nothing I could do seemed to benefit her. and she had been under many eminent physicians and surgeons without getting better, I determined to remove the coccygeal bone at the joint ; and this I did. Making a vertical incision along the bone, and taking care not to wound the rectum, I dissected it out and disarticulated it without any difficulty. There did not appear to be any appreciable pathological change in the bone. The wound healed rapidly, and I was much pleased to find that the patient was cured. She was able, nine months after the operation, to sit down in com- fort, and to walk about without any pain. Encouraged by this success I operated, some years back, in a very similar case, at St. Mark's Hospital. The patient was an unmarried woman, 32 years of age, who had been for years suffering from pains in the rectum and end of the spine. Her symptoms were almost precisely like those I have described, and there was no lesion in the bowel, but she had an intussusception, not to any great extent, of the rectum. This made me less sanguine of success, but as the pain was undoubtedly sacro-coccygeal I removed the bone and the wound healed well. Although she is not perfectly free from pain she can sit down in comfort, which she could not do at all before, and in many other respects she is improved. Two years ago I removed the coccygeal bone from a gen- tleman who had sustained a most painful injury by falling on the side of a rowing boat from which he was getting out. He had suffered much afterwards, and a fistula formed in the bowel. This had been opened, but he was no better, when he began to get about the pain returning in all its pre- vious acuteness. On carefully examining him I found that a sinus ran close to the coccyx, and bare bone could be detected with the probe, so no doubt a periosteal abscess had formed. Believing the bone to be diseased, I requested him to allow me to remove it, and he consented. When the bone was excised there was not any necrosis evident, but it was unusually dense, so I concluded inflammation had been present. I was rather in doubt about the case doing well, but a perfect recovery was the result, all pain being gone before the wound had healed. I by no means intend to advocate the frequent removal 248 MISCELLANEOUS. of the coccyx for pains in the neighborhood of that bone, yet I think in some cases, where all other means have been exhausted, and there is good evidence that the pain is induced by every movement of the bone, its excision is called for, and may be the means of curing an otherwise incurable disease. I do not see any particular danger in the operation, and that the coccyx may be dispensed with with- out any evil resulting is, I think, certain. INFLAMMATION. Inflammation of the rectum may occur in both a chronic and acute form. The chronic variety obtains in old people. The symptoms are a sensation of heat and fullness in the rectum, frequent desire to go to stool, and great tenesmus ; there may be a discharge of blood and mucus. With these symptoms you would suspect impaction, but a digital exam- ination will settle that point. Injections of starch and opium are very beneficial, but I think in the aged the most efficient medicines are turpentine, aloes, confection of black pepper and copaiba. I usually order frequent and small doses of Barbadoes aloes ; it acts as a stimulant to the rec- tum, induces a healthy action, and very soon the disorder subsides. Hamamelis is another useful remedy ; it' is, in fact, rapidly curative in some cases. It may be used as an injection and also administered by the mouth. Acute inflammation of the rectum resembles dysentery in its symptoms, but it is distinguished from it by the absence of abdominal pain or tenderness and severe constitutional disturbance ; the pain is generally confined to the sacrum and perineum ; the bladder is often sympathetically affected, and there is not infrequently difficulty in passing water. The most effective treatment would be leeches around the anus, hot baths, injections of water in small quantities, as hot as can be borne ; to this may be added a drachm of Battley's sedative. A hot bath followed by a hypodermic injection of morphia is likely to benefit. The patient should keep the recumbent position, take very light, unstimulating nourishment, and no irritating purges should be given. If it be necessary to relieve the bowel of its contents a flask of warm olive oil as an enema is the best that can be employed. I have seen very few such cases in this country, but they are not so uncommon in hot climates IN DEX. ABSCESS, a cause of fistula, i6. formation of, after oper- tion on fistula, 44. Acid, nitric, applied to internal haemorrhoids, 89. applied to procidentia recti, 124. Acorns, powdered, for diarrhoea of procidentia, 130. Actual cautery, used by nati\e doc- tors for cure of piles, 9, Anal fistula, 21. Anus, eczema of, 138. itching of, 137. Arterial haemorrhoids, 72. Artificial anus (see colotomy). Ascarides, a new cause of prurituc ani, 143. BLADDER, diseases of, compli- cating haemorrhoids, 84. Bleeding from rectum after opera- tions on fistula, 40. on piles, 114. Blind external fistula, 20. internal fisuula, 20. Bone stud for cure of fistula, 27. CANCER of rectum, 202. colotomy in, 227. complicating haemorrhoids, 112. duration of life in, 202. ordinary site of, 204. question of heredity in, 203. treatment of, 206. varieties of, 203. Capillary haemorrhoids, 71. treatment of, 76. Carbolic acid, injection of, into haemorrhoids, 89. Caustic paste applied to internal haemorrhoids, 87. Cauterization, linear, for internal haemorrhoids, 92. ponctuee, for internal haemor- rhoids, 91 • Cautery, galvanic, for internal haemorrhoids, 95. Paquelin, for internal haemor- cause of rectal rhoids, 95. Chancroid as a ulceration, 191. Chian turpentine, useless in cancer of the rectum, 207. Children, polypus recti in, 131. prolapsus recti in, 124. Clamp and scissors for removal of haemorrhoids, 96. Coccyx, removal of, 246. Coexistence of fistula with phthisis, 47. Colloid cancer of the rectum, 202. Colotomy in cancer of the rectum, 226. Complete fistula, 20. Concretions in the rectum, 164. Contraction of bowel after opera- tions for haemorrhoids, 107. Cough, as influencing success of operation for fistula in ano in phthisical patients, 56. Crushing instruments, author's, for treating internal haemorrhoids, 99. DIAGNOSIS of rectal diseases, 9, II. Digital exploration of rectum, 14. Dilatation of sphincters, 14. for cure for fissure, 163. for cure of haemorrhoids, 97. Drainage tubes, use of, after oper- ation for fistula, 19. Drinkers, preparatory treatment for operating on, 12. 249 250 INDEX. Dysenter}' a cause of stricture of the rectum, 190. ECRASEUR, the, for removal of hsemorrhoids, S6. Eczema, a cause of pruritus ani, 138. Elastic ligature for cure of fistula, 2S. Encephaloid cancer of rectum, 202, case of, 208. Epithelioma of rectum,, 202. Eversion of rectum, how to effect, 15. . . Examination of patients, how to conduct, II. suffering from fistula or sinus, 21. Excision of internal haemorrhoids, 85. Exploration of rectum, 12. Exploration of haemorrhoids, 60. External fistula, forms of, 20. Extirpation of portions of rectum, for cancer, 209. cases of, 212. FECAL impaction, 159. Fissure of the rectum, 143. cause of pain in, 154. diagnosis, 145. method of operating for, 152. nervous symptoms connected with, 153. symptoms of, 143. treatment of, 147. by dilating the 158. 148. by dividing the uterine disease sphincters, sphincters, coexisting with, 146. Fistula in ano, blind, external, 20. blind, internal. 20. cases of cure without cuttings 34- of spontaneous cure of, 24. causes of, 16. complete, 20. complicating haemorrhoids, no. dangerous kinds of, 22. difficult cases of, 44. Fistula, haemorrhage after opera- tions on, 41. horse-shoe form of, 22. in conjunction with phthisis, 47- internal aperture of, how to find, 25. operations on, 34. prevalence of, statistics of. 10, 16. — treatment of, by cutting, 34. — by the elastic ligature, 28. treatment of, subsequent to operation, 43. Fistulse and sinuses in phthiscal patients, peculiarities of 58. Forcible dilatation of sphincters for cure of fissure, 158. for cure of haemorrhoids, 97. dilatation of stricture of the rectum, cautions regarding, 14. GALVANIC cautery for internal haemorrhoids, 95. Glycerine in the treatment of haemorrhoids, 84. Gouty patients, precautions in operating on, 12. pruritus and occurring in, 141. HEMORRHAGE after applica- tion of nitric acid, 126. in operations on fistula, 41. in operations on hemorrhoids, 114. in operations on hemorrhoids, treatment, 119. Haemorrhoids, classification of, 60. complications of, 39, IIO. external, causes of, 61. diagnosis and symptoms of, 62. treatment of. 63 . internal, cases of, 66. causes of, 76. views of French authors con- cerning, 66. constitutional treatment for, 80. — cure of, without operation, 80, — dangers from losses of blood from, 76. — in pregnant women, 73. INDEX. 251 Haemorrhoids, operations on, 85 structure of, 71. symptoms of, 70. varieties of, 70. prolapsed, 122, protruded, how to replace, 77. Hernia of bowel complicating pro- cidenta recti. 127. Horse-shoe fistula, 22. Hospital, St. Mark's, analysis of 4,000 cases at, 10. IMPACTION of f£eces, 159. 1 cases of, 160. causes of, 159. Impaction complicating haemor- rhoids, 109, treatment of, 163. Incontinence of faeces after opera- tion for fistula, 42. occurring in procidentia, 127. India rubber ligature, author's probe and canula for passing, 31. for fistula in ano, 28. Professor Dittel's method of introducing, 32. Inflammation of rectum, 248. a cause of stricture, 198. Injection, use of, when examining patients, 13. Instrument for applying ointments to the rectum, 195. Introduction of hand and arm into intestine, 14. Intussusception of the rectum, 123. Irritable ulcer of the rectum, 143- Itching of the anus, 136. LIGATURE, elastic, treatment of fistula by the, 28. treatment of internal haemor- rhoids by the, 102. statistics of, 108. Liver, examination of, in cases of rectal disease, 12, Luke, Mr., tourniquet for fistula in ano, 38. Lupoid ulcer of the rectum. 232. M ORTALITY, smallness of, after ligature of haemorrhoids, 108. NEURALGIA of the rectum, 245. Nitric acid applied to internal haemorrhoids, 76, 87. applied to procidentia recti in children, 124. OBSTRUCTION of rectum from cancer, 205. from impacted faeces, 189. Ointments, instrument for apply- ing to rectum, 195. Operations on cancer of the rectum, 207. on fistula in ano, 34. after treatment of, 43. on internal hemorrhoids, 85. on phthisical patients, for fistula, 48. Opium for relief of cancer of rec- tum, 2q6. PAIN, question of, after ligature of haemorrhoids, 106. Painful ulcer of rectum (see Fis- sure). Paquelin cautery for cure of proci- dentia, 127, Parturition, injuries during, a cause of ulceration of the rec- tum, 188. Pathology of internal haemorrhoids, Verneuil's views regarding, 66, 67. Pelvic fistula, 15. Phthisis as a complication of fistula, 47. Piles (see Hsemorrhoids). Pollock, Mr. George, on treatment of haemorrhoids by crushing, 99. Polypus recti, 130. cases of, 133. complicating fissure, 146. complicating haemorrhoids, 113- treatment, 136. varieties, 131. Procidentia recti, 122. causes of, 124. in children, 124. treatment, 125. by actual cautery, 127. by removing portions of mucous membrane, 126. 252 INDEX. Prolapsus ani (see Procidentia). Pruritus ani, 136. accompanied by haemorrhoids, 143. causes, 137. due to ascarides, 143. treatment, 138. varieties, 138. RECTAL abscess, leading to fis- tula, 17. treatment of, 17. diseases, causes of, g. prevalence in foreign coun- tries, 9. statistics of, St. Mark's Hos- pital, 10. Rectum, cancer of, 202. concretions in, 164. examination of, 11. extirpation of, 209, 210 fissure of, 143. inflammation of, 248 neuralgia of, 245. polypus of, 130, prolapsus of, 122. rodent ulcer of, 232. ulceration and stricture of, 166 • villous tumor of, 239. Recumbent position after opera- tions on haemorrhoids, 105. Removal of coccyx, 246. Retention of urine after operation on internal haemorrhoids, 107. ' - " due to impaction of faeces, 162. SALMON, MR., method of oper- ating for fistula, 36. Sarcotome, Dr. Hollis's, 30. Scirrhus of rectum, 202. Scissors and director, author's, for operating on fistula in ano, 37, 34- Scrofula, a cause of ulceration of rectum, 128. Sinuses, necessity for dividing all, in operating for fistula, 188. Soft polypus of the rectum, 131. Spasm of sphincters after opera- tions, how to prevent, 104. Speculum ani, kinds and use of, 13. Sphincters, dilatation of, 14. — — for cure of fissure, 157. for haemorrhoids, 97. Statistics of coexistence of fistula with phthisis, 47. with rectal diseases, 10, Strangulation of protrusion in cases of procidentia, 144. Stricture of the rectum, 166. without ulceration, 198. Syphilis, a cause of fissure of the rectum, 144. of stricture of the rectum, 190. TETANUS after ligature of haemorrhoids, 107. Tuberculosis a cause of ulceration of the rectum, 188. Tumor, villous, of the rectum, 239. ULCER, painful (see Fissure). rodent, of the rectum, 232. Ulceration and stricture of the rec- tum, 245. linear, rectotomy for, 176. and stricture of the rectum, opinions as to venereal causa- tions, 191. statistics of seventy cases of. 171. symptoms of, 166 treatment of, 193. twenty-nine cases of, in pri- vate practice, 177. Urine, necessity for examining be- fore operation, 12. retention of, after operations on haemorrhoids, 107. retention of, due to impaction of faeces, 162. Uterine diseases complicating fis- sure, 146. haemorrhoids, 81. Uterus, state of, as affecting rectal diseases, 12. VENOUS haemorrhoids, descrip- tion of, 72. Vemeuil, Prof., views of, as to causation of internal haemor- rhoids, 67. Villous tumor of rectum, 239. TTTHITE piles. Si> COLUMBIA UNIVERSITY LIBRARIES 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 library rules or by special arrangement with the Librarian in charge. DATE BORROWED ^DATE DUE DATE BORROWED DATE DUE i r ! C28(n49)lOOM Scytc^(Buyiq 1882 Allinrhara Fistula, haemorrhoids, painful '^ll^^'^^;^''^''^^^^. prolapsus, and other disease of the rectum. %t %(^f "TTSSrSEJ'