COLUMBIA LIBRARIES OFFSITE HEALTH SCIENCES STANDARD HX641 39204 HC864 .K29 The pathology, diagn RECAP i I I I I i: D c ■I III ■■ ■•-•-■ Columbia Wntowaftp int!jeCitprf3toSr a diagnosis. There is a train of symptoms common to almost all diseases of this part, and which infallibly points to trouble GENEKAL RULES REGARDING EXAMINATION", ETC. 61 of some kind, but they do not tell what that trouble is. The pain of a fissure is, perhaps, diagnostic of the fissure, but it does not tell what troubles may be associated with the fissure ; and so it is in every other affection. For this reason the practi- tioner who attempts to treat a case of disease of the rectum without first making a direct examination, uselessly risks his reputation as a diagnostician, and in my own practice I am guided by the simple rule that patients, male or female, who have not yet come to the point which makes them willing to submit to an examination, have not yet reached a point which admits of treatment. An examination, especially in women, is sometimes, though not often, difficult to obtain, and the dread of it keeps many sufferers from seeking relief ; but still the rule I have laid down is the only safe one, and the surgeon who allows himself to be persuaded into "recommending something for piles," will sooner or later have a mistake in diagnosis laid to his charge, nor will the fact that he was moved by considera- tion for the patient's sensibilities save him from blame. I have often found that the best way to secure an examina- tion in women who otherwise could not be brought to consent to it, was to resort to ether, with the understanding that whatever surgical procedure was thought advisable should be performed at the same time. In this way a patient's sensibilities may often be spared, while both diagnosis and treatment are included in one examination. Before, however, proceeding to make the physical examina- tion which is inevitable, certain questions and answers may give the surgeon a pretty clear idea of what he is about to find. It is generally a good plan to allow an intelligent patient to tell his or her own history, and then to supplement it with appro- priate questions as to the length of time since the trouble began ; the character of pain when present, whether constant or intermittent, and increased by defecation ; whether it comes with the stool, immediately or some time after, and its duration. The question of discharge should also be inquired into, its quantity and character, whether blood, pus or mucous ; also whether there is any protrusion of any kind, and its character. The answers to these questions, and to those which relate to the presence or absence of diarrhoea, constipation, and incontinence, will generally give the surgeon a fair idea of the nature of the case before him. 62 DISEASES OF THE BECTUH ABB ANUS. How. then, to proceed to make a rectal examination which shall be at the same time thorough and as free from pain as Fig 1*5.— The tame ready for use. bid Two things are necessary above all others, a good bed or table, and a good light. For a table, a strong four- GENERAL RULES REGARDING EXAMINATION, ETC. C: legged one. upholstered with hair and leather, answers every purpose. It should be hard, without springs, and about thirty inches in height. In place of this, any of the examining tables of the gynaecologists may be used. In my own office, I use the Archer Gynaecological Chair, shown closed and open in Fig. 15 and Fig. 16. Its great advantage is that, when not in use, it answers as an ordinary piece of furniture, and when raised it provides a firm. Fig. IT.— Lamp for Rectal Examination. 1 Lard, operating table of convenient height. Either natural or artificial light may be used, but the latter is on some accounts preferable, being always at command, and easily thrown up the bowel or concentrated upon a particular point. The lamp which I have found most convenient is a modification of To- bold* s laryngoscope, which has for many years been in use by Dr. Sass, of New York, and is shown in Fig. 17. It is not 1 Made by A. Keune r- Fig. 20.— Cup for Fusing Nitrate of Silver. ter of some importance. For mere inspection of the anus and % surrounding parts, the dorsal decubitus answers every purpose, and a digital examination of the rectum may be made either in this posture or with the patient on the side. For a speculum examination or the passage of a bougie, the patient should be T fij"- ■■-'/»,<*>; Fig. 21 . —Applicator. placed on the side, with the buttocks well elevated, the thigh which is uppermost strongly flexed on the abdomen, and the breast resting on the table. In this way the weight of the ab- dominal contents falls upon the front wall of the abdomen, and not upon the pelvis, and the lumen of the bowel is not so firmly GENERAL RULES REGARDING EXAMINATION", ETC. 65 closed, nor is the mucous membrane so firmly forced into the end of the speculum. Before commencing an examination, the bowel should be emptied, either by the natural effort of the patient or by an enema, and for this reason a water-closet in connection with the examining-room is indispensable to the practitioner in rectal dis- ease. In this way the patient may come directly from the closet to the table with the parts in the best condition for inspection; and great additional confidence is acquired, especially by women, that the examiner's frequent reiteration to "bear down" will not be followed by untoward consequences. The point may seem trivial, but the fear of an accident will frequently, in Fig. 22. — Case for Rectal Instruments, with sliding cover A A. women, result in a firmly closed sphincter, which no word of the surgeon can overcome, and a thorough examination cannot be made while the rectal pouch is filled with faeces. This is not merely a thing to be observed for the cleanliness of the exam- iner, for the act of defecation will bring internal hemorrhoids and prolapse to the light, and may greatly assist in the diagno- sis of other maladies. In examination with a speculum, it is indispensable to cleanliness. For facilitating this part of the examination I have arranged the injecting apparatus shown in Fig. 23. The water in the res- ervoir can be made of any temperature by means of the two stop-cocks, the force can be regulated by raising or lowering it ; 5 M DISEASES OF THE RECTUM AND ANUS. it is always ready for use, and where a practitioner has much of this work to do it will be found a great improvement upon a Davidson's syringe. It also answers for cleansing wounds, or for any other purpose for which a syringe is ordinarily used. It should be provided with a number of tips, one for an ordinary Fig. 23. — Apparatus for Injections. enema, one which will fit closely into a hollow, rectal bougie, and one very line one, preferably of glass, which can be intro- duced into the external opening of a fistula in case it is neces- sary to discover whether the latter communicates with the bowel. In connection with this apparatus the hard-rubber basin shown in Fig. 24 will be found very useful. ; GENERAL RULES REGARDING EXAMINATION, ETC. 67 A simple inspection of the anus and adjacent skin and mu- cous membrane is often sufficient for a diagnosis, though it should never be trusted to alone. External haemorrhoids and internal ones, when brought down by the use of the closet or enema, external fistulas, ulceration, skin diseases, many venereal affections, pin-worms, abscess, and fissure, may all be recog- nized in this way. A glance at the anus, too, may indicate to the practised eye the existence of serious disease within the rectum proper, for a discharge may flow from it which marks ulceration above, and it may be relaxed and patulous from over-distention or partial destruction of the sphincter. A Pig. 24.— Hard Rubber Pus Basin. sunken condition of the ischio-rectal fossae, and a retracted anus, surrounded by a profusion of soft, fine hair, may also properly excite a suspicion either of grave rectal disease or of some constitutional affection which is causing emaciation. By using gentle force in pulling the anus open with the fin- gers, the mucous membrane may be everted to a considerable degree, especially if the patient can be brought to assist by an effort at bearing down. In this way a fissure may almost always be brought into view without the use of a speculum of any sort, and the internal opening of the great majority of fistulae may be reached, with a good view of the radiating folds and lacunae. Dr. Storer, 1 of Boston, has described a method of examining the mucous membrane just within the anus, which is applicable only in women who have a lax sphincter. It consists in evert- ing the mucous membrane by pressing it out of the anus by the index finger in the vagina. In a case in which the manoeuvre 1 Lancet, May 31, 1873. 68 DISEASES OF THE RECTUM AND ANUS. can be practised successfully, and without too much pain, a small portion of the anterior wall of the rectum may be brought into view. The pessary of Gariel has also been used for the same purpose. It consists of a rubber ball, which is introduced empty into the rectal pouch, then inflated by means of a tube attached to it, and withdrawn with some force, the mucous membrane being prolapsed in front of it. But neither of these two procedures is of any great value. After having examined the anus in this way, the surgeon next proceeds to the more difficult task of examining the rec- tum, an operation which may be done skilfully and almost painlessly, or awkwardly and with great suffering. The rectum may be explored either by the touch alone, or by vision alone, or by both combined. The former is the simpler and more painless method, and with practice may be made to afford all the information which can be gained by the two combined. To practise the rectal touch, the nail of the index finger should be well trimmed, and the finger lubricated with some tenacious oil. Olive oil is much better than vaseline, the latter being too easily rubbed off by the sphincter. The condition of the sphincter muscle is first to be noted. Its resistance should be overcome by a slow and steady pressure with the ball of the finger, and not by a sudden exertion of force, for such an attack is always met by increased contraction. The force of the mus- cle will be found to vary greatly in different people. In the aged or debilitated it is lax ; in the strong and healthy it is the opposite, and the finger can scarcely be passed through it with- out great pain, and sometimes a slight laceration of the tender mucous membrane. "When inclined to spasmodic contraction, as it sometimes is in persons of nervous tendency, a satisfactory examination may be impossible without the use of ether, on account of the pain. Unless an obstruction is encountered, the finger ma}' be car- ried up the bowel its full length, and pressed as far as possible beyond this point. Additional distance may be gained by pass- ing the three remaining fingers backward along the inter-gluteal groove, instead of closing them in the palm, as is generally done, and pressing the knuckles against the soft parts ; for the knuckles prevent the fall passage of the index finger. An inch more may be gained by having the patient stand up and strain down upon the finger in the bowel. GENERAL EULES EEGAEDING EXAMINATION, ETC. 69 In this way three and a half or four inches of the rectum may be carefully explored, together with the prostate, the neck of the bladder, the uterus, and the anterior surface of the coc- cyx and lower part of the sacrum. With an exceptionally long finger it may even be possible to feel the vesiculse seminales and vasa deferentia. In other words, all that part of the bowel which is most subject to disease is brought within reach. But after this is done the examiner may be no wiser than before, for to appreciate fully the condition of the rectum by the sense of touch alone requires a facility in this method of exploration which most practitioners never attain. In the majority of cases a digital examination will be made to discover whether or not the patient is suffering from internal haemorrhoids, and in the majority of cases also the examiner will be no wiser on this point after than before, for a soft internal hsemorrhoid is a diffi- cult thing to detect by the ringer alone, being readily mistaken for the natural mucous membrane of the part, especially when the latter is abundant and gathered into folds, as it is apt to be. Ulceration is another condition which it is sometimes diffi- cult to detect, especially when superficial and not attended by much induration ; and so is the opening of a blind internal fis- tula ; and yet, so well educated may the finger become that other methods of examination may be almost completely dis- carded. To carry diagnosis to this point it is first necessary, by oft repeated examinations, to become perfectly familiar with the feel of the normal bowel. After this knowledge has been gained, a gentle sweeping of the ball of the finger over the whole inner surface of the lower three inches of the rectum will detect any change in it, however slight. I wish it were possible to describe plainly the different sensations which are conveyed by the different pathological conditions, but this is a thing each practitioner must learn for himself by practice. A stricture of small calibre cannot easily be mistaken, though one which admits the ringer without constricting it may easily be overlooked. A stricture small enough to engage the end of the index finger firmly, marks the limit of safe digital examina- tion, and the finger should not be forced through it for the sake of feeling what is above, for an attempt to do this has been fol- lowed by a fatal rupture of the bowel. In case of a tumor of any kind, advantage may be taken of conjoined manipulation 70 DISEASES OF THE RECTUM AND ANUS. through the vagina in the female ; but these are the troubles most rarely met with, and most easily diagnosticated when en- countered. The cervix or fundus of the uterus, when pressing upon the bowel, may be distinctly felt with the finger in the rectum, and may deceive the unwary into a diagnosis of a new growth. The prostate may do the same. The different varieties of ulceration have each their peculiar and often diagnostic feel. Q.TIEMANN SzCO. Fig. 25.— Soft Rubber Bougie. For examination by the sense of touch above the reach of the finger, recourse may be had to bougies. These are of all forms, sizes, and materials, and, in general words, the softer the instrument the better it is for examination. The black rubber instrument, with the blunt point (Fig. 25), which may readily be bent into a circle in the hand, is better than most others in the market, and the same instrument comes with a sharp point (Fig. 26), which sometimes answers a good purpose. These instruments are made in twelve different sizes, and for the purpose of diagnosis the medium-sized is the best. The old fashioned red, hard-rubber bougie is unnecessarily stiff and dangerous, and should be discarded, having no advantages over the softer ones either for the purpose of diagnosis or for that of treatment. The bougie a boule, made of hard-rubber with G.TJEMANN &.C0. Fig. 20. a flexible whalebone handle, is a favorite instrument with many. (Fig. 27.) For my own use I have had a kind of bougie made by Messrs. Stohlmann, Pfarre & Co., which I prefer to all others, for the simple reason that it is softer and more flexible than any in the market. It is made of the same material as the red soft- rubber catheters, and differs from them only in size and in the thickness of its walls. (Fig. 28.) It is essentially the same in- GENERAL RULES REGARDING EXAMINATION, ETC. 71 strument as that invented by Wales, except that it is more flexi- ble even than his. With such an instrument one is pretty cer- tain not to perforate the bowel, and for diagnosis it answers every purpose as well as the harder instruments. The better Fig. 27. fitted a bougie is for pushing its way through a stricture the worse it is for rectal exploration. Every bougie intended for exploration should be perforated so that a stream of water may be injected through it. Fig. 23. —Red Soft Rubber Bougie. These instruments are all used for the same purpose — that of feeling for a stricture located above the reach of the finger ; and with any of them the unpractised hand will generally de- tect an obstruction in the perfectly healthy bowel at about four 72 DISEASES OF THE RECTUM AND ANUS. inches from the anus. I have had patients in whom I have never been able to pass any sort of a bougie without first in- jecting the rectum, no matter what manoeuvring I resorted to ; and I have seldom told a student to pass a rectal bougie that he did not at once discover a stricture. To pass a bougie into the rectum is rather a more difficult operation than to pass one into the urethra, the triangular ligament in the latter being replaced by the curves, the folds of mucous membrane, and the promon- tory of the sacrum in the former. Independent of Houston's valves of mucous membrane, it is not improbable that a slight degree of invagination of the upper into the lower part of the rectum may often exist, and into the sulcus formed by this con- dition the point of the bougie may easily pass. For the sake of overcoming these folds of membrane the most minute direc- tions have been given as to how the bougie should be introduced and gently urged along each successive inch of the bowel 1 by changing its direction and manipulating the handle. But such rules are of little value, for the simple reason that the obstruc- tion is seldom of the same kind or in the same place in two dif- ferent persons. Esmarch 2 gives the good general rule that the patient should lie on the left side, as the chief and most con- stant fold of membrane, the plica transversalis recti of Kohl- rausch, projects from the right wall. The instrument should be passed gently, for force is never allowable here more than in the similar operation on the urethra ; and when an obstruction is met with the handle should be gently rotated, withdrawn, and again passed onward till by frequent repetitions of this manoeu- vre it is made to pass. If this does not suffice, a Davidson's syringe may be attached to the lower end of the bougie and a stream of warm water thrown into the bowel until it is moder- ately distended, when the bougie will generally pass with ease. For measuring the extent of a stricture, an ingenious instru- ment has been devised by Laugier, which consists in attaching a thin rubber glove-finger to the end of a perforated bougie. This is passed up the bowel empty, and then inflated and with- drawn till it reaches the upper limit of the obstruction. It is safer than the !><>ii(/ie d boule, for it may be allowed to collapse before being withdrawn, and all straining of the diseased tissues may thus be avoided. Houston: Dublin Hospital Reports, vol. v.. 1830. 5 Die Krankheiten des Mastdarmes und des Afters, Pitha und Billroth's Chirurgie. GENERAL RULES REGARDING EXAMINATION, ETC. 73 In case disease actually exists high up in the bowel, the at- tempt to pass an instrument is full of danger. A patient may easily recover from a false passage made in the urethra, but such will seldom be the case with the rectum, for here when the instrument leaves the bowel it enters the peritoneum. To under- stand this danger it is only necessary to remember that the bowel is generally ulcerated both above and below the seat of the contraction, and is sometimes weakened to such an ex- tent that it will allow a bougie to pass through it without the use of any appreciable force on the part of the surgeon. The bowel may also be lacerated without being directly perforated by the bougie, for the stricture may be pushed upward or dragged downward on the point of the instrument till the bowel gives way. Supposing, now, that a rectal bougie cannot be passed eight or ten inches up the bowel, is it safe on this account alone to make a diagnosis of stricture high up \ I should hesitate long before doing so, and should make many careful attempts to pass the instrument at different times, resorting to injection if neces- sary, carefully exploring through the abdominal wall for indu- ration, and watching for the usual signs of obstruction. There are one or two points worthy of remembrance in this connec- tion. The first is that the obstruction due to a stricture will always be at the same point in the canal ; and another is, that when a bougie has once become engaged in a stricture it is firmly grasped, and the resistance to its withdrawal is equal to that encountered in introducing it farther. The feeling con- veyed to the hand under these circumstances is diagnostic, and is like that which is felt when the effort is made to withdraw a sound from the grasp of a stricture in the urethra. Should it still be necessary for diagnosis, the speculum may be used and the inside of the rectum illuminated. I have post- poned any reference to this means of examination till the present, because it will generally be found useful only after the others have been tried. The thorough use of the speculum involves, almost of necessity, the administration of ether and the stretch- ing of the sphincter muscles ; to try to use it, except in certain cases for obtaining a view of a small portion of the rectum, with- out these adjuncts is almost to inflict useless pain upon the patient. I shall not attempt any description of the infinite number of instruments which have been invented for this pur- 74 DISEASES OF THE RECTUM AND ANUS. pose, or any judgment upon their relative advantages, but will merely say that the best vaginal speculum is still the best for the rectum — that of Sims, with a groove where the blade joins the handle for the sphincter to rest in, as suggested by Van Fig. 29. — Helmuth's Speculum. Buren, and a slight curving over of the end to keep out more of the mucous membrane, as suggested by Helmuth. (Fig. 29.) I have myself added one more to the number of these instru- ments, made after a pattern suggested to me by Dr. Sass, and shown in Fig. 30. It is one which I use especially for office work without an assistant, and it has certain advantages. It avoids the especial objection to all the two- or three-bladed in- struments, which is that the blades separate at almost an equal Fig. 30.— Author's Speculum, distance along their entire length, and that an equal amount of dilatation is therefore brought to bear both upon the anus and rectum, an amount which, when brought to a degree which is unbearable at the anus, has still done no good within the rectum. GENERAL RULES REGARDING EXAMINATION, ETC. 75 With this instrument the hinge is at the anus and the dilata- tion at the other end of the blades, and in a patient with a lax sphincter the instrument can sometimes be opened to a consider- able extent, and permit of an inspection of a considerable part of the bowel without stretching the anus enough to cause much suffering. The fenestrated blade must be made of steel to give Fig. 31. — Fenestrated Speculum. it sufficient strength. It is an instrument, however, much more useful for treating an ulcer within the rectum, the exact seat of which is already known, than for finding the ulcer in the first place. The fenestrated instrument, Fig. 31, is sometimes useful for inspecting the parts just within the anus ; and a long vaginal cylindrical speculum, with the end cut at such an angle as will best expose the mucous membrane, may sometimes be of service in bringing into view a small portion of the inner surface of the bowel high up. But, after all have been tried, none will be FlG. 32.— Bivalve Speculum. found better for any purpose than a small-bladed Sims' 1 s, and without ether all will be found eminently unsatisfactory. Almost the only other speculum besides these which I have found of any practical value is the bivalve shown in Fig. 32, but the same objection applies to this as to all the others, that the redundant mucous membrane prolapses between the blades 76 DISEASES OF THE RECTUM AND ANUS. to such an extent as to render it almost useless, and that when the attempt is made to dilate the blades sufficiently to over- come this, the sphincter is immediately stretched to a painful extent. With any speculum the wooden depressor, shown in Fig. 33, may be found a useful addition. Fig. 33. — Rectal Depressor. (Van Buren.) The idea of the endoscope has been applied to the rectum in the use of the instrument shown in Fig. 34. It is of little, if any, practical value, however ; its introduction beyond the point which can be reached by a long vaginal speculum being exceedingly difficult, and, in case of the diseases which it is supposed to enable the surgeon to see, not devoid of danger ; and the mirror quite useless. It is almost useless to attempt to see within the rectum with any kind of a speculum without first overcoming the sphincter muscle, and the only effectual way of doing this is by stretch- ing it. It is, therefore, my own practice to resort to this pro- Fig. 34. — Colonoscope of Bodenhamer. cedure in every case of doubtful character, nor was I led to this practice without many trials of the various specula? in the market, all ending in disappointment. The stretching of the sphincter is in itself an entirely harmless proceeding, but one which necessitates the previous administration of ether. It GENERAL RULES REGARDING EXAMINATION, ETC. 77 should not, however, be done, as was at one time the usual method, and as it is often done at present, by introducing the thumbs back to back, and forcibly and suddenly separating them till they touched the tuberosities on each side. In this way the mucous membrane is often lacerated at one or more points, and the paralysis is not as effectual as when the stretch- ing is done more gradually. A better way is to introduce first one finger, then two, and finally four, in the form of a funnel and gradually bore into the anus ; or to introduce two fingers, and make pressure on all sides of the opening till it becomes patulous. Instead of one or two seconds, this procedure should occupy five minutes, and should be done so gently as not to lacerate the mucous membrane. The dilatation should also be made to include the internal as well as the external muscle. If this dilatation be carried to a sufficient extent, the firm, cord- like feel of the external sphincter may be made to completely disappear. The paralysis induced in this way is always tem- porary, and I have never known it to be followed even by a temporary incontinence of faeces. After coming out of the ether, the patients are usually conscious of only a sense of sore- ness in the part, but are never incapacitated for their usual duties. This stretching of the sphincters is a necessary prelim- inary in almost all operations within the rectum. With the patient in the proper position on the side, under the influence of ether, with the sphincter thoroughly dilated, and with a good reflected light, the lower four or five inches of the rectum may be thoroughly illuminated and examined. As a rule, however, a speculum will be found of very little use in the examination of stricture, but is chiefly available for obtaining a good view of other morbid processes affecting the rectal pouch and for making applications to them or per- forming operations for their cure. By its aid the different va- rieties of ulceration may be inspected and thus differentiated, the internal openings of fistulse may be located, and the whole rectal pouch may be brought into view. From what has been said it may readily be seen that the diagnosis of stricture above the reach of touch or vision is a dif- ficult matter. So difficult is it in some cases that no less an authority than Syme has written that there is good reason to suspect the honesty of a man who pretends to detect such a condition. Such is, indeed, the case, for "strictures high up" 78 DISEASES OF THE RECTUM AND ANUS. are favorites among a certain class of quacks, and the passage of a bougie two or three times a week for an indefinite period is profitable business. In reality strictures above the rectal pouch are rare ; when they exist they are usually malignant, for this part of the bowel is not subject to the influences which, by ex- citing ulcerative action, result in the cicatricial contractions which so often affect the lower three inches of the rectum ; and malignant disease of the sigmoid flexure or descending colon will manifest itself by a well-marked train of constitutional and local symptoms, and can generally be felt better through the abdominal wall than per rectum. After the use of the bougie, which is at best an uncertain means of diagnosis for this condition, and after a study of the symptomatology, and a careful examination through the abdo- minal wall, there is still one other means of exploration open to the surgeon if he have a sufficiently small hand — the passage of the whole hand into the rectum. A hand which measures seven and a half inches in circumference can generally be passed easily ; one measuring more than nine is unfit for the purpose. With a small hand there is no danger of permanent incontinence of faeces, but the sphincter should be dilated gently and grad- ually, rather than forcibly torn open. 1 When the anus has been sufficiently dilated to allow the hand to enter the rectum, if the bladder is empty, the arch of the pubes may be felt above the prostate ; if full it will be easily distinguished at the same point. The uterus and ovaries are easily made out anteriorly, and the whole curve of the sac- rum may be followed posteriorly. The next point to feel for is the spine of the ischium on either side, and with this as a guide, 1 Dr. R. F. Weir (New York Medical Record, March 20, 1875) was led to the fol- lowing conclusion from his investigations of this subject. " A hand of less than 26 ctm. may be introduced 17-19 ctm. without inconvenience, but not more." His measurements showed the greatest circumference of the rectum to be at or 7 ctm. from the anus, where it may reach to 25-30 ctm. At the upper part of the middle third it is not more than 20-25 ctm., and thence it rapidly diminishes, being not more than 10-18 ctm. at the middle part of the superior third, while the narrowest part is at the commencement of the sigmoid flexure. For an early case of manual exploration see Medico-Chirurgical Transactions, vol. i. , p. 1 2!). Referred to by Copeland, Observations on the Principal Diseases of the Rec- tum and Anus. London, 1814. See also G. Simon, Ueber die kunstliohe Erweiterung des Anus und Rectum, Arch. f. klin. Chir., xv., 1, 1872 ; Dtsch. Klin. f. Chir., Novem- ber, 1882 ; W. J. Walsham : Some Remarks on the Introduction of the Whole Hand into the Rectum, St. Bartholomew's Hospital Reports, vol. xii. , 187G, p. 223. GENERAL RULES REGARDING EXAMINATION, ETC. 79 the greater and lesser sciatic notches may be outlined. The whole brim of the pelvis may be traced, and the external and internal iliac arteries followed with the lingers. All this may be done while the hand is in the rectal pouch, and it may be done upon almost any patient, male or female, though more easily upon the female, and with a small hand, without causing any unpleasant after-results. But in many persons this is all that can be gained by this method, for the anatomical reason that to pass the hand above into the sigmoid flexure is often at- tended with great danger from the narrowing of the bowel at this point. When the hand is met by a sense of constriction at about the level of the third sacral vertebra, where the lateral fold of Douglas is reflected from the bowel, the limit of examin- ation has been reached, and no force should be used to over- come the constriction, which can only be accomplished by a rupture of the peritoneal coat. In many cases, however, by carefully following the natural windings of the canal, and by a semi-rotatory movement of the hand, combined with alternate flexing and extending of the fingers, this point of danger may be surmounted, and the hand be passed fairly into the sigmoid flexure, and sometimes into the descending colon. Here the common iliacs, the bifurcation of the aorta, the left kidney, and, in fact, nearly all of the abdominal contents may be touched. By this method of examination, a stricture situated in the sigmoid flexure, or even in the descending colon, may some- times be discovered after all other methods of examination have failed ; but, as we have shown, the method is not always ap- plicable, and the diagnosis of stricture high up still remains one of the most difficult things in surgery. In the great majority of cases in general practice, in which such a diagnosis has been made, it may be proved false by the introduction of a full-sized bougie after a few trials, and in the remainder the diagnosis will be confirmed sooner or later by the well-marked symptoms of intestinal obstruction. Before attempting any surgical operation upon the rectum, the bowels should be thoroughly emptied by a cathartic. It is well to begin with three compound cathartic pills, or with five grains of mass, hydrarg. on the second evening before the oper- ation where the patient's general condition admits of these remedies ; to follow them with a slight saline or a dose of castor- oil on the night immediately preceding ; and finally to clear 80 DISEASES OF THE RECTUM AND ANUS. out the rectum with a simple enema on the morning of the day of the operation. After this the bowels may easily be confined for a week if desirable without inconvenience to the patient, and the passage ol* hard masses of faeces over a wounded surface is avoided. In all operations in which ether is used, three assistants will be necessary and four are preferable. Each assistant should have his place assigned to him — one for the anaesthetic, one to keep each leg of the patient in position and to hold the speculum, and one to assist the operator in whatever way may be necessary. A state of profound anaesthesia will generally be Fig. 35. — Paqnelin's Thermo-cautery. necessary, thongh with intelligent patients I have often taken advantage of the primary anaesthetic state which ether produces for opening abscesses, dividing fistulae, and cutting off external haemorrhoids. Accidents are not common in operations about the rectum, but there is one for which the surgeon should always be pre- pared—haemorrhage. For tliis reason a bottle of dry per- sulphate of iron, and a Paquelin's thermo-cautery should always be at hand. The thermo-cautery as now made, Fig. 35, is not at all cumbersome, and is exceedingly useful in many operations about the rectum. The bulb containing the sponge for the benzine should never be filled with an excess of fluid GENERAL RULES REGARDING EXAMINATION, ETC. 81 which may run down into the point and interfere with the working of the instrument ; and the platinum point should be thoroughly heated before the assistant begins to use the bulb to drive the air over the sponge. If proper regard be paid to these points the instrument is a most reliable one, and in every case where hemorrhage is to be apprehended it should be ready for use, and an alcohol lamp or gas jet should be ready to heat the point — which is sometimes forgotten. A haemorrhage seldom occurs from the rectum after a sur- gical operation — so seldom as to be almost unknown — which cannot be controlled either by the ordinary methods or by the cautery and by packing the rectum. The rectum may be packed with either sponges or lint, and these may be used either with or without the persulphate of iron. Most cases of bleeding may, however, be controlled by the use of simple ice- water and a moderate amount of pressure properly applied to the bleeding surface without the necessity for a systematic packing of the whole rectal cavity. It is not long since I was called in the middle of the night to stop the bleeding from an incision which I had made into an abscess of the ischio-rectal fossa about eight hours before. I found, as is too often the case, that the patient was thoroughly immersed in a mixture of blood and persulphate of iron, which covered him from the pubes to the middle of the back and had thoroughly permeated the bed. On entering the room I was informed that the wound had been carefully stuffed with lint and persulphate of iron "several times," and that the case was undoubtedly one of hemorrhagic diathesis. A case like this is easily managed. The treatment consists first of all in providing a good light, next in cleaning up the general nastiness, then in finding the bleeding point and making pressure upon it. In this case the bleeding came from a small, spouting, cutaneous vessel and was at once controlled by filling the incision I had made with picked lint thoroughly pressed home into the wound. Most cases of bleeding m&y be controlled in the same way, but where the haemorrhage is within the bowel it is not always easy to make pressure upon the right point without packing the entire rectal cavity. For this purpose Allingham 1 recommends the follow- ing procedure which is equally simple and effectual. 1 Op. cit., p. 154. 82 DISEASES OF THE RECTUM AND ANUS. Take a medium-sized bell-shaped sponge and pass a strong double ligature through the apex from within outwards and back again, so as to include a considerable part of the sponge in the bite of the ligature — enough so that when the cord is pulled upon strongly from below it will not tear out. After wetting the sponge and squeezing it out, it should be powdered with the persulphate of iron and passed as far up the rectum as possible with the aid of a rectal bougie, the apex being up- ward. The whole of the rectum below the sponge should then be carefully filled with pledgets of cotton-wool powdered over with the iron, each roll being carefully and firmly packed away. An exceedingly large quantity of cotton may be crowded into the rectum in this way, and when the cavity is filled the sponge should be drawn down by means of the string hanging out of the anus, so that the whole mass may be tightly compressed. If the bowel has been thoroughly emptied as recommended, such a plug may be left in for a week or more without causing any discomfort, and no bleeding can occur while it is in place. If, however, it is intended to leave the packing in for such a length of time, it is better to pass a large-sized, stiff rubber male catheter through the apex of the sponge and pack the cotton around it. In this way a chance is given for wind and fluid faeces to escape. By this simple means, when properly used, any hemorrhage after an operation upon the rectum may be controlled. After operations upon the rectum or anus, a suppository of one grain of opium may generally be placed in the rectum with advantage, and the surgeon should always be provided with them. Those made of gelatine by Mitchell, of Philadelphia, have given me great satisfaction. They are smaller, softer, and less irritating than those usually made of cacao butter, and they withstand the changes of temperature better. The usual dress- ing consists in placing a pad of lint and a soft towel over the anus, and fastening them in place with a T bandage. This form of bandage will generally be found the best in any case where a continuous dressing is needed. Lister's impervious dressing has been applied to wounds of the rectum in some of the more extensive operations, such as excision of cancer, by the German surgeons ; but it has not be- come popular, and the use of free drainage and plenty of car- bolic acid or some other disinfectant is generally considered all GENERAL RULES REGARDING EXAMINATION, ETC. 83 that is necessary or desirable in this line. Verneuil recommends the free nse of a solution of chloral as an antiseptic for this part. Wounds of the rectum will always heal more kindly when the patient is in the horizontal position than when standing or walking, there being less tendency to venous congestion in the former case. Almost any operation may result in a sluggish open sore if the patient be allowed' to disregard this rule. Retention of urine is of frequent occurrence after operations upon these parts, both in men and women, and it should always be in the mind of the surgeon. It is not generally of long dura- tion, and it may often be overcome by a bath and hot applica- tions, without having recourse to the catheter. The following case conveys a lesson in this matter which should never be for- gotten. Case. Death from Retention of Urine. — I was requested several years ago by a gentleman to make an autopsy on his brother, who had died very suddenly and unexpectedly after being confined to his bed about a week with an abscess near the anus. Before the abscess appeared the man had been in perfect health, and was apparently doing well up to the moment of his death, as the abscess had been opened on the day before, with great relief to pain, and was discharging freely. I made the autopsy, as requested, and found a bladder distended to the point of rupture, the urine dammed back upon the kidneys, which were gorged with blood, and the cerebral vessels greatly congested. The man had died very suddenly in a convulsion. A little questioning revealed the fact that from the first day of the disease there had been retention of urine with dribbling from the overflow ; and that for the pain arising from this con- dition opium had been freely given up to the day of death. Once during his sickness an old woman in the house had ap- plied a hot flannel cloth over the bowels, and the patient had passed an immense amount of urine. The condition of the bladder seemed to have entirely escaped the notice of his med- ical attendant, as it probably has escaped the attention of most surgeons at some time, though, fortunately, without, as in this case, a fatal result. CHAPTER IV. INFLAMMATION OF THE RECTUM. Cases of Proctitis. — Varieties : Acute, Chronic, Primary, Secondary, Localized, Gen- eral. — Symptoms and Course of each Variety. — Causes of Proctitis : Direct Prop- agation, Foreign Bodies, Drastic Cathartics, Gout, Pederasty, Gonorrhoea. — Treatment. The case which follows is not only interesting from its rarity, but as being a good example of the affection under consideration. Case. Inflammation of the Rectum. — Woman, married, aged twenty-three, mother of two children : youngest six months old. Patient has always been constipated, and for years has been in the habit of using purgatives whenever she desired an evacuation. For the past six months has noticed occasional discharge of blood and slime from the rectum. Now suffers great pain on defecation, and the amount of blood and muco- purulent matter is increasing so that while at first it only came away when at stool, it now comes several times a day. With this she has much pain in the rectum at all times, and is in poor general condition, having lost her ap]3etite, and being unable to sleep. A careful examination of the rectum showed it to be con- gested, hot, and painful, as far as the eye could see ; but nothing else was apparent. The amount of discharge suggested the idea of a gonorrhoea of the rectum, but there was no inflammation of the vagina, and careful questioning of the patient left no room for such a suspicion. The cause of the trouble in this case was not difficult to find, the patient having been in the habit of tak- ing large doses of patent cathartic remedies two or three times a week for a long time ; and as the trouble developed imme- diately after her last confinement, this may not have been with- out its influence as an exciting cause. The next case is one of simple congestion of the rectal mu- coua membrane, brought about by retained faeces and uterine disorder. INFLAMMATION OF THE KECTUM. 85 Case. Congestion of the Rectum. — Mrs. Gf , aged thirty- seven, mother of three children. The patient, a delicate and rather anaemic lady, had not been in good health for some time past, but had never had any trouble with the rectum until one month before consulting me. At that time she was surprised to find that she had passed a considerable quantity of blood while at stool, and this haemorrhage had been repeated at intervals of about a week up to the day before my visit. There had never been any pain in the rectum or anus, or any signs of haemor- rhoids, and a careful examination failed to reveal any source of the haemorrhage. The lady complained, however, of a good deal of discomfort in the back and pelvis ; had missed her last men- strual period, and was decidedly constipated. An examination showed a uterus enlarged and retroverted, and a considerable mass of faeces in the sigmoid flexure and descending colon, and treatment was begun for these conditions. The bowels were unloaded of many scybalous masses by means of frequent ene- mata, and the uterine condition was so far improved by treat- ment that the menses soon reappeared, and the pain and dis- comfort passed away. The bleeding from the rectum never recurred, nor has the patient ever again had her attention called to that part up to the present time — four years later. Here the congestion of the mucous membrane relieved itself by a discharge of blood from the over-distended veins. Had the conditions remained, other symptoms would in all proba- bility have soon developed, such as heat and tension at the anus, possibly a slight mucous discharge, pruritus ani, and, finally, haemorrhoids. There are various other causes of such a condition, besides impacted faeces or menstrual disorders, such, for example, as excess at table, prolonged horseback exercise or carriage riding, pregnancy, drastic purgatives, and, in short, anything which tends to produce hyperaemia of the pelvic viscera. In most cases of bleeding from the rectum a diagnosis of congestion alone would be an error, for a congestion sufficiently marked to cause haemorrhage is rare, and bleeding is in most cases a symptom either of haemorrhoids, polypus, or some more serious affection. But in this case there was no such cause, and the subsequent history of four years with no other rectal symptoms tends to strongly confirm the diagnosis. A proctitis may be either acute or chronic, primary or 86 DISEASES OF THE RECTUM AND ANUS. secondary, localized or general. The localized variety is gener- ally due to the injury inflicted by a foreign body, or to some irritation acting upon a small part of the rectal surface. In the acute form the inflammation does not extend deeper than the mucous membrane, which is congested and hyperaemic. In the chronic, the inflammation involves the submucous and muscular layers. The acute generally ends in resolution in from eight to fourteen days where the cause can be found and removed. It may, however, in severe cases go on to actual gangrene and ter- minate fatally. The chronic results in infiltration and consequent thickening of the rectal wall, and may end in ulceration, either superficial and confined to the epithelial layer of the mucous membrane, or deep and involving the whole thickness of the mucous layer. What is described a follicular ulceration (ulcer- ation affecting the mouths of the tubular follicles) may result from chronic inflammation, and these ulcers, which are very minute at first, may coalesce and gain in depth till they cause perforation of the bowel. When the perforation is above the peritoneal reflection a fatal peritonitis may result ; when lower down, an abscess or fistula (see Fistula). A chronic proctitis may in this way be a cause of stricture, and may result in the hypertrophy known as chronic parenchymatous proctitis. The symptoms of this affection have been partially detailed in the two cases which have been related. They are, in the acute form, a sensation of heat and weight in the part which may amount to actual pain, and may involve the bladder, uterus, and sacral region, and radiate into the loins and down the thighs. The anus also becomes painful, red and contracted, and in children the mucous membrane may become slightly everted from the swelling and tenesmus. The evacuations soon become painful and increased in number, and the fa3ces are streaked with mucus, blood, and pus. There is apt to be also a train of symptoms referable to the bladder and to the gener- ative organs, such as painful micturition, cystitis, and leucor- rhcea. With these local symptoms there may be, as in the case reported, more or less constitutional disturbance, fever, and loss of appetite. As the discharge from the inflamed surface in- creases in amount, the desire to empty the rectum produces more frequent evacuations, so that while at first the faeces only are stained with pus and blood, later the evacuations consist INFLAMMATION OF THE RECTUM. 87 entirely of the muco-purulent matter, and the anus may become excoriated by the discharge. In the chronic form the symptoms are all less marked. The diarrhoea may alternate with constipation, and the discharge will occur only at the time of defecation. This condition may last for years. An examination of the rectum during the acute stage of proctitis will generally cause considerable pain. The rectal mucous membrane will be found intensely congested, and the temperature, as shown by the thermometer or even by the finger, will be increased. In the chronic stage, the solitary glands may occasionally be recognized as small round promi- nences in the substance of the mucous membrane. Proctitis is generally found associated with stricture of the rectum and is secondary to it. In these cases the mucous mem- brane below the stricture will be found congested and covered with pus or bloody mucus, while above it is eroded and de- stroyed, sometimes only superficially, at others for its entire depth. In such cases the other layers will be found hypertro- phied, especially the circular muscular layer. The causes which may produce proctitis are numerous. It may result by direct propagation and continuity of surface from inflamed haemorrhoids or prolapsus, or from any erosion about the anus, such as a mucous patch or eczema. It may be, and often is, caused by the presence of foreign bodies, or of hardened faeces and indigestible remains of food which act as foreign bodies, and by irritating suppositories, injections, or medicinal applications. As in the case given above, it may be caused by the abuse of drastic purgatives such as aloes, gamboge, or even rhubarb in excess. It has been seen to result fro (i m prolonged sitting upon a cold or wet seat, and when founo^ An children it will generally be due to the presence of worms. V It may be a symptom of gout (Esmarch, Bushe) alternating with the mani- festation of the disease in its usual seat, and there may be a true diphtheria of the rectum, as there may be of the vagina, and the formation of a membrane similar to that seen in the throat. Again, the disease may result both in men and women from the habit of passive pederasty, and in such cases may be due either to mechanical violence or to the inoculation with gonorrhceal pus. A true gonorrhoea of the rectum, whether caused in this way or by direct inoculation in women by pus which is passing over the anus from the vagina, is very rare. 88 DISEASES OF THE RECTUM AND ANUS. Tardieu ' lias never observed a single case. Gosselin a saw only one case at Lourcine in three years. Rollet 3 reports a case caused by direct inoculation from the penis to the rectum in a patient who was in the habit of using a finger in the anus to provoke a passage. A. Boniere 4 found it very difficult to inoc- ulate the rectal mucous membrane with gonorrhceal pus placed upon it through a tube, though the anus was easily affected. On the other hand, Requin 5 believes it almost sure to follow passive pederasty with a person suffering from gonorrhoea. Thiery also believes in true gonorrhoea of the rectum and re- ports the following case : 6 Case. Gonorrlicea of the Rectum. — The patient, a clandes- tine prostitute, aged twenty-four, complained of weight and shooting pain in the pelvis, of pain in defecation, and of a con- stant thick discharge from the bowel ; also that walking was difficult. There was a well-marked funnel-shaped depression of the anus ; the anal folds were obliterated ; the sphincter weak and dilated. A vaginal speculum of ordinary size passed easily. The lower rectum was acutely inflamed, covered with thick discharge, studded with bright red points, and bled when wiped with wool. The rectal follicles were enlarged and dis- charging pus. The patient confessed to intercourse with dis- eased men. The treatment consisted of lotions of borax and red cinchona bark, and finally of injections of oak bark with sitz-baths and iron internally. A cure was effected in three weeks. The diagnosis of gonorrhceal proctitis will rest upon the amount and purulent character of the discharge, and upon the existence of gonorrhoea of the vagina in women ; or the confes- sion of unnatural intercourse with a diseased person, in men. The treatment of proctitis consists first of all in an endeavor to discover and remove the cause of the congestion, be it what it may. In the acute stage, the pain and tenesmus may be over- come by warm baths, and anodyne injections of starch-water with a few drops of laudanum. The bowels should be kept 1 Etudes Medico-k : gales sur les Attentats aux Moeurs, 4th ed., 1862, p. 179. s Arch. Gtn'l. de Med., 1854. 3 Diet. Enc. des Sci. Med., Art. Rectum. 4 R'Jcherches Nouvelles sur la Blennorrhagie. Arch. Gen'L de Med., April, 1874. 6 Elements de Path. Med. Rectite, t. i, p. 729. "Presae Med. Beige, No. 26, 1882. INFLAMMATION OF THE KECTUM. 89 open by laxatives, such as castor-oil, or preferably the saline cathartics in small doses. The patient should also be confined to the bed, and placed upon a diet chiefly of milk. In the chronic stage astringents are indicated, such as alum and tan- nin, and to these may be added suppositories of iodoform (gr. v.), and the same rules with regard to rest and diet should be observed. CHAPTER V. ABSCESS AND FISTULA. Abscess, divided into Superficial and Deep. — Superficial Abscesses. — Simple Furun- cles : Causes ; Characters ; Results ; Treatment. — Suppuration of External Hasmorrhoid. — Suppuration of Internal Hemorrhoid. — Diffuse Inflammation of Subcutaneous Tissue : Causes ; Symptoms ; Treatment. — Form of Incision. — Deep Abscesses. — Divided into Abscess of the Ischio-Rectal Fossa and of the Superior Pelvi-Rectal Space. — Description of Superior Pelvi-Rectal Space. — Causes of Deep Abscess. — Residual Abscess. — Symptoms and Cases of Deep Abscess. — Dangers of Deep Abscess. — Formation of Deep and Extensive Fistulas. — Horse-shoe Abscess. — Idiopathic Gangrenous Cellulitis. — Reasons why Abscesses do not Heal Spon- taneously. — Diagnosis. — Prognosis. — Treatment. — Incisions and Subsequent Treatment of Deep Abscess. — Danger of Incontinence. — Relief of Incontinence by Operation. — Fistula. — Generally due to Abscess. — Divided into Superficial and Deep. — Complete Fistula. — External Fistula. — Internal Fistula. — Description of Superficial Fistulas. — How to Detect an Internal Opening. — Location of Internal Opening. — Description of Track of Fistula. — Symptoms of Superficial Fistula. — Deep Fistula.— Fistula with Numerous External Openings. — Pelvic Fistulas. — Blind Internal Fistula. — Ulceration of Rectum Causing Internal Fistula. — Treat- ment. — Spontaneous Cure. — Advisability of Operation. — Fistula in Relation to Phthisis. — Contra-indicatioDS to Operation.— Treatment by Cauterization. — The Ligature. — The Elastic Ligature. — Galvano-Cautery. — How to Pass Ligature. — Incision. — Description of Operation. — Author's Knife for Fistula. — Division of Deep Tracks. — Treatment of Track running up the Bowel. — Treatment of Blind External Variety ; of Horse-shoe Variety ; of Fistula with Numerous External Openings.— Dressing after Incision. — Packing the Incision. — Hasmorrhage in Operation. — Treatment of Blind Internal Variety. — Incurable Fistulas. — Treat- ment of Deep and Extensive Tracks. — Fistula with Stricture. Abscesses in the region of the anus and rectum are best class- ified according to their anatomical location into superficial and deep. Of each of these there are several different varieties. Considering first the superficial variety, the simplest form will be found to be that which involves the skin of the margin of the anus alone, and which generally originates in one of thu minute glands of the part. Such an abscess or furuncle, for it is really only a furuncle, may be due to traumatism, or to any irritation, such as the use of improper paper after defecation, prolonged walking or horse-back riding, a menstrual discharge, or a discharge due to diarrhoea or dysentery. ABSCESS AND FISTULA. 91 This form of disease is always distinctly circumscribed, is generally about the size of an almond, is found by preference in robust persons, more often in men than women, seldom in old people, and almost never in children. It generally goes on rap- idly to suppuration, breaks spontaneously on the cutaneous surface, and heals without the formation of fistula, though in cachectic or phthisical patients it may pursue a contrary course, the skin over it becoming thin and violet colored, and finally rupturing, leaving a permanent subcutaneous fistula. The treatment of such an abscess consists chiefly in the at- tempt to avoid the formation of a fistula, and the best means for accomplishing this end is an early incision as soon as sup- puration appears inevitable. Resolution is hardly to be ex- pected, but it may be sought for by the use of laxatives, rest in the horizontal posture, and the application of a bladder of ice. The incision should be large enough to allow of the free exit of pus, and after it has been made, the part may be poulticed for a day or two, and the abscess cavity then dressed with lint, care being taken to keep the lips of the incision separated. Another frequent cause of superficial abscess is the acute inflammation and suppuration of an external hemorrhoid, which generally comes on after an attack of constipation and straining at stool, or may be due to the same causes as the last. The suffering caused by such a condition, as by the one last de- scribed, is out of all proportion to its apparent importance, and is sufficient to incapacitate a person of sensitive organization from all accustomed duties. The remains of former external haemorrhoids are always liable to this accident, and by the proper abortive treatment, the inflammation may sometimes be overcome without suppuration. If, however, suppuration ap- pears to be inevitable, a small sharp-pointed bistoury should be quickly passed through the little tumor. There is also a form of superficial abscess which lies nearer to the mucous membrane than the skin, and is due to the acute inflammation of an internal hemorrhoid, either just at the verge of the anus or within the sphincter. This is in reality a circum- scribed phlebitis in a venous pouch which is shut off from the general circulation. A circumscribed, tense, exquisitely painful tumor is formed, varying in size from a grape to an almond, which, after a few days of suffering, ruptures spontaneously, and allows the escape of a small quantity of pus. Such an ab- 92 DISEASES OF THE RECTUM AND ANUS. scess, when within the bowel, is always liable, as will be shown later, to result in the formation of a blind internal fistula if left to its own course, and should, therefore, be treated by early incision. There is still another variety of superficial abscess, more serious in its consequences than those already described, for the reason that it affects the subcutaneous tissue and not the skin, and is diffuse and not circumscribed. The causes of this variety of abscess are the same as of those already mentioned, though traumatism plays, perhaps, a more important role. Falls, kicks, horse-back exercise, and violence in the use of the syringe are its most frequent antecedents. Surgical inter- ference with the rectum, as in the removal of a hemorrhoid, may also be followed by this form of abscess, and it may arise from the perforation of the wall of the bowel just above the sphincter, by an ulceration of any kind, generally, however, that due to a foreign body. It has also been known to follow the suppuration of an internal hemorrhoid. The symptoms of this form of disease vary greatly in differ- ent cases. In cachectic persons, pus may form in large quan- tity, and break into the bowel, and a blind internal fistula may result. The diagnosis is generally easy. There will be the usual pain, tenderness, and swelling ; and if the pain be not too severe to admit of the attempt, fluctuation may be obtained by introducing one finger into the rectum, and making counter- pressure with the other hand outside. There is little use in hoping for resolution in an abscess of this kind, and alL active attempts to cause it will be found to do harm, rather than good. The proper treatment is an early free incision. If the incision be made early, it may in itself have an abortive action, and under such circumstances it need not be very large. If pus has already formed, or the skin has begun to grow thin over the abscess cavity, the incision should be free enough to allow of the easy escape of the contents, for in this way only can the formation of a fistula be avoided. In such a case, drainage should be resorted to after the incision, and every effort should be made to secure healing from the bottom of the cavity. When the incision is made in the early stage of such a tumor ;i- this, while the skin is yet hard and infiltrated, a free hemor- rhage from cutaneous vessels is not uncommon, nor on account ABSCESS AND FISTULA. 93 of its antiphlogistic action is it to be deprecated. Only when it has passed the bounds of safety need any steps be taken to ar- rest it, and this may always be done by a careful stuffing of the incision with picked lint. A word of caution against opening such abscesses as these in the surgeon' s office, and allowing the patient to walk home, may not be out of place ; for a small artery may commence spurting at any moment during the ac- tive exercise. Deep Abscess. — The deep abscesses of this region differ greatly from those already described, in their location, extent, and gravity. They may with advantage be divided into those of the ischio-rectal fossa and those of the superior pelvi-rectal space, which is thus defined by Richet. 1 See Fig. 65. "The superior pelvi-rectal space, contained between the superior aponeurosis of the levator, the peritoneum, the rec- tum, and the walls of the pelvis, has a variable extent in dif- ferent subjects, and especially varies according as the levator is or is not relaxed. Its greatest extent is reached when the mus- cle is in repose. In this condition the levator in its upper part is in contact with the ischiatic walls, the lower end of the rec- tum is much lowered, and the summit of the inf undibulum is as distant as possible from the peritoneum ; while the contractions of the muscle efface the rectal funnel and approach it to the point of reflexion of the peritoneum. At its anterior part the pelvi-rectal space is much less extensive than at the sides and especially behind, which is due to two causes ; the first is that the peritoneum, which is much lowered in front of the rectum to form the recto-vesical cul-de-sac, gradually rises behind to meet the sacrum ; the second is that the plane formed by the levator inclines in a reverse direction to the former, that is from the prostate to the coccyx. Therefore these two planes are sepa- rated in front by scarcely a few millimetres, while behind they are several centimetres apart. An abundant cellular tissue with large and lax meshes fills the whole space, and seems intended to favor the movement and expansion of the rectum ; rarely it is loaded with fat. In front and laterally this tissue communi- cates with that which fills the iliac fossae and the deeper regions of the abdomen through the intervention of the subperitoneal cellular layer of the pelvic walls, and, in women, it is continu- 1 Traito d. Anat. Med. Ohir., 8d Edit., p. 82S. 94 DISEASES OF THE RECTUM AND ANUS. ous with that of the broad ligament ; behind it is continu- ous with that found in the meso-rectum and the concavity of the sacrum, and it communicates with the gluteal region by the sciatic notch. It is traversed by the visceral branches of the hypogastric artery and vein ; the sacral plexus, and the ganglia of the great sympathetic against the sacrum, are cov- ered by it. 4 'In men the superior pelvi-rectal space is separated from the prostate, the seminal vesicles, and the bas-fond of the bladder by a cellulo-fibrous layer called prostato-peritoneal. In women it may be said not to exist anteriorly, because the rectum is applied without intervention to the posterior wall of the vagina. 1 ' An abscess of the ischio-rectal fossa is generally bounded by the levator ani muscle superiorly, and by the skin below, with the rectum on one side, and the adjacent portion of the pelvis on the other. An abscess of the superior pelvi-rectal space, on the other hand, originates in the lax connective tissue around the upper portion of the rectum above the levator ani muscle. It may assume vast proportions, blending laterally with the subperitoneal connective tissue of the iliac fossa, and burrowing in almost any direction in the true pelvis. The causes of deep rectal abscesses are various. Trauma- tism is perhaps the most frequent, and the injury is generally internal, rather than external, and is caused by the point of a syringe or a foreign body, rather than by kicks and falls. For- eign bodies, such as fish-bones, may pass entirely through the rectal wall, and be found loose in the cavity of the abscess they have caused. Such an abscess may also be due to the injury inflicted by the fcetal head in parturition, and in such a case, the diagnosis may be difficult to make from a puerperal inflam- mation due to blood-poisoning and involvement of the lym- phatics. They may also be secondary to diseases of the urinary organs, such as acute inflammation of the prostate, or a rupture of the urethra, and extravasation of urine ; and they may result from rupture, ulceration, or perforation of the rectal wall, in connection with stricture. Tli is explains partly, though not completely, the frequent coexistence of stricture and numerous fistula?, for a stricture may act as the exciting cause of a deep abscess by the impair- ment of vitality and nutrition which it causes, as well as by ABSCESS AND FISTULA. 95 producing a perforating ulcer above, as is proven by the fact that a great many fistulse have their internal openings below, and not above the constriction. Again, these abscesses may be due to a submucous inflam- mation, and production of pus, which first breaks into the rec- tum, and forms an internal fistula, and subsequently extends outward, forming a large abscess ; or they may be due to an acute phlebitis, or to faulty nutrition and a generally vitiated state. Finally, they may be in their origin entirely discon- nected with the rectum, and due to disease of some neighboring part, or to necrosis of some adjacent bone of the pelvis or spine. In the latter case they are generally of the variety known as cold abscess, and are apt to be preceded for a long time by pain at the point of disease in the bone. Finally, for lack of any known cause we are compelled to consider some of them as idiopathic, originating in an acute inflammation of the cellular tissue of the superior pelvi-rectal space. These generally form behind the rectum, where the space is the largest, and are attended by the formation of abun- dance of pus and gas, the latter being due to the decomposition of the pus and not to communication with the rectum. The inflammation may also have its point of origin in or around the prostate, and the abscess is then described as prostatic or peri-prostatic. There is still another variety of abscess, which occasionally occurs around the anus, and which has been very appropriately named by Paget the "Residual Abscess." It is an abscess arising in an old cicatrix. The following case is a good example of this form of disease. Case. Residual Abscess. — J. D , aged forty-five. The patient was a large, fleshy man, who was operated upon by me for fistula, with a good result, in June, 1882. The track was deep, but the wound healed kindly, leaving a deep cicatrix. In December of the same year, after an interval of several months of health, he applied to me again for pain at the seat of the former incision. An examination showed a puffy swelling of the old cicatrix, with a decidedly erysipelatous blush and a brawny swelling extending for a considerable distance over the buttock. An incision was at once made into the centre of this over the cicatrix, and a quantity of serous fluid was evacuated. The patient was confined to bed for a few days, the bowels 06 DISEASES OF THE RECTUM AND ANUS. were freely moved with a cathartic, and a lotion of lead and opium applied to the part, and in a few days the trouble had disappeared. He still, however, complains of an occasional tenderness in the part, though another year has elapsed. Symptoms. — In an abscess of the superior pelvi-rectal space the symptoms are often obscure and far from characteristic. There is more or less vague pain in the pelvis and lumbar region, which is seldom intense and is generally increased in defecation. Fever may be entirely absent, is seldom continu- ous, and chills are only occasionally met with when pus is formed. In addition there is more or less headache and general malaise, and the vesical symptoms (retention and incontinence of urine) are apt to be marked. The following cases will serve to illustrate the general char- acter and course of the disease. Case. Abscess of the Superior Pelvi-rectal Space opening into the Bladder. — Dr. M , aged fifty- three. The patient was in his usual good health until the morning of April 3d, when he experienced some pain in the rectum and some diffi- culty in micturition, with pain in the act, and frequency in the desire. This pain was shortly followed by a chill and high fever, the temperature reaching 103° F., and the pulse 120. The fever and pain lasted about one week, at the end of which, the difficulty in urination had become so great that he was obliged to use the catheter upon himself for one day. During this time he was also suffering greatly from constipation, and was forced to use cathartics and enemata to induce a motion. He also noticed that when the enemata were ejected they were always squirted off toward the right side and expelled with a violent spasmodic action. The pain had also become distinctly localized in the left side of the pelvis and near the bladder. Three weeks from the time of the first chill he passed a large quantity of pus from the bladder. The discharge was very free, amounted to many ounces, and lasted, with each act of urin- ation, for three days, after which it ceased entirely. After a short interval he began again to have fever and chills with the same rectal and vesical symptoms, and after two weeks of suffering there was another discharge of pus by the urethra, which this time lasted four days and then began to diminish gradually, so that at the end of six weeks it had again ceased. He had never recognized pus in the faeces, but there was ABSCESS AND FISTULA. 97 much mucus, and once something that seemed to him like a slough. An examination showed an indurated mass on the left side of the rectum, above and to the left of the prostate, which was not enlarged. This mass was painful to the touch, but I could not decide that it contained pus to any considerable amount. The patient was pale and thin, and showed the effects of the sickness and suffering ; but as there was no indication for opera- tive interference with the cure nature seemed to be effecting, I advised him to spend some time at the sea-shore and await further developments. A week later the patient brought me some long shreds of tenaceous mucus which he was in the habit of passing from the bowel. He locates most of his pain up under the rami of the pubes, and says that at times it is of that peculiar sickening character which comes when the testicle is wounded. Another examination was made but revealed, nothing new. The tender- ness was at a point three or four inches from the anus on the left lateral wall of the bowel, and at this point there seemed to be a central softening in the induration. He was advised to continue the same plan of treatment, which consisted in rest, change of air, laxatives, nourishing food, and suppositories of belladonna and iodoform ; and about a fortnight later he found himself greatly improved, and went on from that time to a complete recovery. Case. Abscess in the Pelvis. — Boy, aged twelve ; slight and of delicate build, but generally well. Has had pain in the abdo- men for the last forty -eight hours. Pain on urination and de- fecation, and tenderness all over the lower part of the bowels, but without localization at any one point. Temperature 103° F. Pulse 130. Two soft evacuations from bowels yesterday. Next day (third of disease) he "thought it hurt him more on the right side than on the left when he tried to stand up," and there was some dulness in the right fossa but no swelling. Has vomited his milk once. Fourth day. Temperature has continued to range between 101° in the morning, and 103° in the afternoon. Passed a very restless night and begins to show signs of suffering. There is flatulence, but not as much distention of the abdomen ; vomit- ing and vesical tenesmus continue. Has had no chill. The tenderness is now confined to the right fossa, and is greatest at 7 98 DISEASES OF THE KECTTTM AND ANUS. a point half-way between the anterior superior spine and the pubes, and above a line running from one anterior superior spine to the other, where a slight tumefaction can be made out by careful palpation. ~No superficial redness. Bowels have not moved since the first day. On consultation with Drs. Sabine and Bullard it was decided that an operation was not immedi- ately indicated, and the same treatment, quinia, morphia, wine, and fluid diet was continued. Sixth day. Marked relief of all symptoms ; less pain, less tenderness, four free fluid evacuations from the bowels in rapid succession, fall in temperature and pulse, appetite better, and had a good night's sleep. From the sixth to the thirteenth day there was little change. The bowels moved daily, but always with more or less pain, and the appetite and strength returned in a measure, so that he was able to leave his bed. But the temperature daily showed the same increase above the normal, never falling below 100° ; and the pain and tenderness did not diminish. For a day or two the parents had remarked a peculiar bubbling noise, which they heard at times at the seat of the tumor, and on the twelfth day a part of the dulness was found replaced by clear tympanitic resonance, and the diagnosis of a communication between the rectum and the tumor was made. On the thirteenth day he had a very free, fluid, and offensive discharge from the bowels, which the parents said contained pus, followed by a marked fall in temperature and diminution in the pain ; and for the next two days he was comparatively comfortable. Sixteenth day, evening. Complaining of great pain, rolling and tossing in bed, and screaming with agony. Found him lying on his right side, legs drawn up, sphincter ani relaxed, mucous membrane slightly protruding, and a small stream of clear mucus flowing from the anus, and staining the bed. The rectal tenesmus was very great. He had passed a small amount of faeces during the morning, and had passed most of the day sitting up in bed, enjoying his supposed convalescence. Digital examination of the rectum revealed a hard tumor pressing upon and almost closing it, situated on the anterior wall, to the right, and above the prostate. Large dose of mor- phia given to quiet him during the night. At my visit next morning he was more comfortable, and the tenesmus had in part ceased. Had passed nothing per rectum. ABSCESS AND FISTULA. 99 On turning him on his back I was surprised to see what ap- peared to be a greatly distended bladder reaching nearly to the umbilicus and plainly outlined against the abdominal wall. He had passed his water twice during the night, he said, and was not suffering from any desire to do so. Stupes over the abdo- men brought away only four ounces of urine (by measure) and caused the entire disappearance of the visible tumor. The dul- ness and the hardness to the touch still remained, however, and extended half-way from the pubes to the umbilicus. Under ether he was catheterized and three more ounces of urine with- drawn, thus entirely emptying the bladder, but causing no change in the tumor, which occupied the place usually occupied by a distended bladder. By careful examination the following condition was then made out : A firm, hard tumor in the pelvis toward the right side, the upper edge of which could be felt by deep pressure about half-way between the pubes and the umbilicus, and the lower surface of which could be felt with the finger in the rec- tum. The pressure upon the rectum was nearly sufficient to oc- clude it, and it was with difficulty that the limit of the tumor above could be made out in this way. The mass could not be made to fluctuate by this conjoined manipulation. A medium sized aspirator needle was thrust into the tumor from the ab- dominal wall, and a pint of fetid, greenish pus evacuated. The point of the needle was then used as a director, and could be felt by the finger in the rectum. It was cut down upon from the rectum and a free vent allowed for the contents of the ab- scess in this way at its most dependent portion. The end of the index finger passed through this incision into a large abscess cavity, the limits of which could not be determined. By a daily introduction of the index finger into the incision it was kept open; more or less pus was evacuated in the stools for some time, and the abscess finally healed very kindly. One year after the operation the boy was still in perfect health. An abscess of the ischio-rectal fossa may at its commence- ment be accompanied by the same symptoms as one in the pelvi-rectal space, but later, the skin becomes hard, red, and cedematous sometimes over a large portion of the corresponding buttock, the pain is very severe, and rectal touch impossible. The general symptoms are those of any acute inflammation. In abscess of the superior pelvi-rectal space, when the disease has 100 DISEASES OF THE EECTUM AND ANUS. extended to the cellular tissue of the iliac fossa, immense col- lections of pus may form, and this may burrow in any direc- tion. In men it generally follows the course of the bowel, in- volves secondarily the ischio-rectal fossa, and makes its way through the skin at some distance from the anus. In women it is more apt to pursue a contrary direction, and may appear on the surface in the region of the crest of the ilium or in the groin. An abscess of the ischio-rectal fossa may tend to discharge its contents upward toward the superior perineal region, being less confined by fascia and muscle in this direction. In this way the prostate and urethra may be implicated, and the signs of retention of urine may be joined with those which point more directly to the rectum. The pus from such an abscess, in time, generally breaks on the cutaneous surface and forms one or several permanent fistu- lous tracks. The pus from a pelvi-rectal abscess not infre- quently makes its way into the rectum and is discharged with each act of defecation ; before the faeces when the opening is near the anus, after them when it is above the rectal pouch. It may, however, rupture into the vagina, bladder, uterus, or per- itoneum, but these internal openings are not the rule, but the exception, for the pus generally finds its way to the cutaneous surface, and fistula? result as with ischio-rectal abscesses. Either variety may cause fistulous tracks upward into the true pelvis, downward into the perineum, or outward into the thigh. When the pus reaches the rectum it may burrow for a consid- erable distance in the submucous connective tissue of the bowel, and separate the mucous membrane from its attachment before perforating it. In this way two large abscess cavities may be formed communicating with each other by a narrow orifice. What is now generally known as the horse-shoe abscess or fistula is due to the formation of an abscess in each fossa and the communication of the two behind the rectum through the substance of the sphincter muscle at its attachment to the coccyx. Such an abscess generally has one opening into the bowel and two on the cutaneous surface, though the latter may be single also. By manipulation the pus may be made to cross from one fossa to the other, imparting a characteristic sense of fluctuation. There is a form of gangrenous cellulitis which sometimes af- fects the ischio-rectal region. It is a rare disease, and is gen- ABSCESS AND FISTULA. 101 erally idiopathic. In it there is no pus formed, but the cellular tissue and the skin over it become necrosed and slough in large, black masses. The adjacent portion of the rectal wall may be involved and the rectum be laid open for a considerable extent. The disease is attended with fever and great prostration ; the tendency to relapse and extension is marked, and the cavity left after separation of the slough closes very slowly. 1 This form of disease may be fatal. The reasons why abscesses in this region so seldom heal spontaneously are to be found in the anatomy of the part, and the fixedness or mobility of the walls of the abscess cavity. In the ischio-rectal variety the skin is hard, thickened and larda- ceous, and from its rigidity cannot yield its position to allow of healing. The walls of the abscess higher up in the pelvi-rectal space, on the contra^, move with the varying fulness of the ab- dominal or pelvic organs, with the incessant action of the levator ani, and with the fulness or vacuity of the abscess cavity, which depends on the intermittent discharge of pus through its small opening. Diagnosis. — The diagnosis of these conditions should be made with great care, for on a correct appreciation of the ex- tent of the disease will depend the prognosis and treatment ; and the class of fistulse resulting from these deep abscesses re- quires careful treatment, and may not always be suitable for any operative interference. An abscess in the ischio-rectal fossa will generally be mani- fest to any one making a careful examination of the parts and giving heed to the history, but one in the pelvi-rectal space can generally only be suspected from the history and found only by careful pelvic examination. The finger in the rectum may make the whole case plain, or the inflammatory hardness and tender- ness may be more manifest by deep pressure through the ab- dominal parietes. 1 A Clinical Lecture on Idiopathic Gangrenous Cellulitis around the Rectum. Fur- neaux Jordan, Brit. Med. Jour., January 18, 1879. Also, Jackson, Brit. Med. Jour., February 8, 1879. This disease is apparently the same as that denned by Dunglison under the head of Proctocace (Proctitis Gangrenosa, Mastdarmfiiule, Cacoproctia) and so named by Fuchs. " According to him (Fuchs) it is common in Peru, in the neigh- borhood of Quito and Lima, on the Honduras and Mosquito coasts, in Brazil, and on the Gold coast. It is called by the Portuguese Bicho and Bicho di Culo ; by the peo- ple of Quito, Mai del Valle, from its prevalence in the valleys ; and in Africa, Bitios de Kis. It is an adynamic, inflammatory condition, frequently ending in gangrene. It has been attributed to bad food and the use of spices." -Dunglison. 1 M 2 DISEASES OE THE RECTUM AND ANUS. A fistulous track communicating with a pelvi-rectal abscess may generally be recognized by its length and by the amount of tissue between it and the bowel, which may easily be esti- mated with one ringer in the rectum and a probe in the track. The probe does not approach the rectum, but either runs par- allel with it. or recedes from it. The now of pus from the opening is also apt to be intermittent and to occur at the time of defecation, being caused by the same muscular effort. Some- times, when the cavity has not been recently emptied, a soft tumor may be felt by rectal touch, and pressure upon it may cause a How of pus. With the pus bubbles of gas may also appear, but in a large abscess in the neighborhood of the bowel this is not a proof of an internal opening, but may be due merely to the proximity of the intestine. Prognosis. — The prognosis is necessarily grave. In the be- ginning the patient is exposed to all the dangers of pyaemia, peritonitis, and phlebitis : and should the abscess go on to a favorable termination in an external opening, there is still the dread that it may at any time seek another opening toward the peritoneum with a fatal result. The immediate results being favorable, the ultimate ones may still be disastrous : beinsr those which always attend upon prolonged suppuration — vis- ceral complications, amyloid degeneration of the liver and kid- D jys, and tubercular deposits. In the comparatively small number of cases of pelvi-rectal abscess in which healing occurs. the patient still has to meet the results of extensive cicatricial contraction. These may be stricture on the one hand, or incon- tinence on the other : with the subacute inflammatory tendency which is always apt to attend upon a cicatrix at the anus and cause p>ain and uneasiness. In females especially, such a cica- trix may be the cause of grave trouble with the genito-nrinary canal. Treat in'- nt. — It may be considered as a rule to which there are few exceptions, that an acute inflammation in this region will go on to suppuration : and hence that antiphlogistic meas- adopted with a view to securing resolution are useless. Early incision is. therefore, the only rational treatment, and, where properly performed, this may result in cure without the formation of fistula, as is illustrated in the following case. < -k. IscMo-Hectal Abscess treated by Marly Incision and cured without the Formation of a Fistula- — The patient. ABSCESS AND FISTULA. 103 a professional man, aged thirty-seven years, had been suffering for several years from large internal haemorrhoids which bled freely. For some weeks before sending for me he had been under the care of an irregular specialist, who had been follow- ing out some plan of local treatment for this condition, the na- ture of which the patient did not understand. Although there was some decrease in the amount of blood lost, his general con- dition became far from satisfactory. Though naturally a large, healthy man, and accustomed to hard mental work and abund- ant exercise, he began to suffer from lassitude, loss of appetite, and emaciation. Finally, a hard mass was felt in the right ischio-rectal fossa, which caused him a good deal of pain, and after this had lasted five days he sent for me. Examination. — A hard, brawny, painful swelling completely filled the right fossa. The skin over it was red and hot, but there was no fluctuation. There had been a chill, some fever, and complete loss of appetite, with a good deal of rectal te- nesmus. Operation. — The patient was etherized, and a deep incision made into the swelling. Although the cut was made over the most prominent portion of the mass, it failed to reach pus, being too far out upon the buttock. A longer, straight knife was again entered within half an inch of the margin of the anus and carried steadily upward, parallel with the bowel, about four inches. The blade was turned in its track occasionally as it was entered, to allow of the escape of pus as soon as it was reached, but none appeared till the depth mentioned was ar- rived at. After pus was found, the knife was withdrawn, making an incision fully three inches long at the surface, in an antero-posterior direction. Into the opening thus made the finger was passed till it reached the abscess cavity, and all par- titions were broken down. This part of the work was done very thoroughly, and the original incision was made still longer, so that future burrowing might be avoided. A solution of car- bolic acid was then injected into all parts of the wound, and the cavity was dressed with lint soaked in carbolized oil (1-12). After this the sphincter was dilated, and several large haemor- rhoidal tumors were removed. The dressing thus introduced was allowed to remain undisturbed for three days, when it was removed and a similar one replaced, after a thorough washing out of the wound and the introduction of the finger into all 104 DISEASES OF THE EECTUM AND ANUS. parts of it. The patient was kept strictly in bed, and the bowels confined for one week with medicine, at the end of which time they moved easily and painlessly after a dose of salts. The operation was performed July 5th. On September 15th he was entirely well, the wound having completely closed. This time might have been shortened a good deal had the pa- tient not been obliged to be up and about his business during the latter part of the time the wound was healing. He was seen two months later, and was "as well as he had ever been in his life.'' This case illustrates exceedingly well several points in rectal surgery. As to the causation of the abscess, it cannot be posi- tively stated whether it was the result merely of his general depreciated condition, whether it was the result of direct injury while undergoing some secret treatment for haemorrhoids, or whether it was purely idiopathic. Whatever its cause, the condition was one which certainly would have ended in a deep fistulous track opening high up into the rectum, above the in- ternal sphincter, had not this particular operation been per- formed. It is safe to say that had this abscess been left to its own course, or had it been opened in the usual way — that is, by making an incision just large enough to fairly evacuate its con- tents — the subsequent history of the case would have been en- tirely different. The case is one of a class which, left to the course of nature, often work irreparable injury — injury which may render the patient's whole subsequent life one of suffering in spite of any future surgical procedures — and yet, if treated promptly and efficiently, may be brought to a very happy ter- mination. It is the kind of case in which a single day's delay may be ruinous to the interests of the patient. In general terms the incision should radiate from the anus to avoid, as far as possible, the section of nerves ; and should be free enough to secure the escape of pus, not only at the time, but while the abscess is healing. If there be burrowing in any direction, the incision should be prolonged to correspond ; and the finger should be passed as far as possible into all parts of the cavity to break down all partitions. The wound should then !)"• stuffed with lint wet with carbolized oil, and a drainage- tube inserted. The secret of success will be found to lie in securing a free outlet for pus, and thus preventing burrowing. ABSCESS AND FISTULA. 105 These abscesses should not be laid open into the rectum — a point which is generally misunderstood in practice, because of the confounding of an abscess which may ultimately result in a fistula with fistula itself. The treatment is that of abscess, and not that of fistula, and is especially directed toward the preven- tion of fistula. Should the abscess have been neglected till it has opened externally, it is still essentially an abscess and not a fistula, and the treatment described may still be carried out with a fair prospect of success in avoiding an opening into the bowel ; and even should the abscess have already opened into the bowel, healing may still be secured in this way, with suitable means for keeping the rectum empty, and a laying open of the lower end of the rectum may be avoided. I wish to emphasize this point strongly, for I have seen very unfortunate results follow free division of both sphincters for deep fistulse, and it is a step which should always be avoided if possible. That it is possible in this class of cases I have occasionally proved to my own satisfaction, and I do not hesitate now to try every means with which I am acquainted, at any cost of time to the patient, be- fore resorting to the usual plan of dividing everything between the track and the bowel. When incontinence has resulted the case is not to be con- sidered as beyond the reach of help. I have seen marked benefit result in this sad condition from the persistent use of bougies and such other measures as are calculated to increase the power of the sphincters ; and I am much less inclined to despair of being able to afford relief in these cases than formerly. In the following case I tried a novel procedure for the relief of this condition with a very satisfactory result. Case. Operation for the Relief of Incontinence of Fceces. — The patient a man, aged twenty-seven, was originally sent to me two years ago by Dr. McCready, suffering from ischio-rectal abscess. Although this was at once operated upon, it did not stop the burrowing of pus, and eventually a fistula was formed, opening into the bowel well above the internal sphincter, and out on the buttock a considerable distance from the anus. This in its turn was divided with the knife, but the result of the division of so much of the bowel and of both sphincters was a consider- able degree of faecal incontinence, with all of its necessary at- tendant evils. Treatment of the incontinence by the passage of 106 DISEASES OF THE EECTUM AND ANUS. bougies, the use of cold, etc., resulted, after a year's continu- ance, in great benefit, so that the patient seldom soiled his clothing with faeces, except when the bowels were unusually loose ; but there was an occasional passage of a slight amount of faeces, a frequent escape of rectal mucus, and a constant annoying sense of insecurity in the patient's mind which made him anxious for any further relief which surgery could afford. The actual cause of the open condition of the anus lay not so much in any weakening of the power of the sphincter, which always contracted firmly around the finger in the rectum, as in the peculiar shape of the anal orifice, resulting from the con- traction of the cicatrix formed by the operation for fistula. This was situated on the left side, was firm, deep, and hard, and, by its contrac- tion, had resulted in a decided drawing of that side of the anal orifice over still more to the left, so that no amount of sphincteric contraction could close it. The condition may be seen by a glance at the diagram, in which C represents the cica- trix. fig. 36.-Operation for Re- To remedy tllis deformity, I made with lief of Incontinence of Faeces. _ a Paquelm cautery the burns represented by the lines 1, 2, 3, 4, and 5, and also removed two longitudinal strips of mucous membrane from the inside of the bowel, clamp- ing the tissue deeply with Smith's clamp, and using the cautery freely. The burns represented by the figures were also deep, going fairly down to the sphincter, and extending from well within the anus to the distance of an inch upon the skin, grow- ing deeper as they reached the lower end. The operation was followed by more pain and local distur- bance than I anticipated, and there was at one time a brawny hardness in the cellular tissue of the right buttock which made me uneasy lest the patient should have another deep abscess worse than the first ; but all this passed away, and, after three weeks' rest in bed, he was again able to attend to his work. At the time of writing, one year has elapsed since the operation. The sphincter contracts firmly upon the finger, the anus is closed, and the discharge has ceased. In other words, the patient is cured by the production of a stricture at the anus sufficiently tight to close the orifice, and I have no longer any ABSCESS AND FISTULA. 107 fear that I might have done too much in the operation and made his last state worse than the first by producing a stricture which would need constant future care. The burns seem to have been just sufficient to produce the desired effect, and this, it is evident, is the delicate point in the operation, and the one for which no rule can be laid down, but which must be judged of by each operator in each particular case. Incontinence depends more upon division of the internal than of the external sphincter, and is more apt to follow a double division of the fibres than a single one. For this reason the surgeon should always endeavor to leave a few fibres at least of the internal muscle in any operation, and the incision should always be directly and not obliquely across the fibres of the muscle. It is also well to remember that incontinence is always more apt to result from division of the muscles in the female than in the male. Fistula. — A fistula which is not due to a perforation of the rectal wall from within is the result of a previous abscess, and, therefore, in enumerating the causes of abscess those of fistulse have also been given. Like the abscesses from' which they arise, they may well be divided into superficial and deep ; or into those of the anus, which are subcutaneous, and involve at the most only a few fibres of the external sphincter, and those of the rectum and pelvis, which open into the bowel at a higher point. Both the superficial and deep may also be divided into the com- plete, or those which open both on the skin and into the bowel ; the external, which open only on the skin, and the in- terna], which have an opening only within the bowel (Fig. 37). Superficial Fistulm. — On account of the special laxity of the submucous con- nective tissue in this region, already no- ticed, abscesses show little tendency to spontaneous closure, and fistula is the common result when left to their own course. In the subcuta- neous fistula, the external orifice may be at some distance from the anus, or in the radiating folds. It may be so small as to escape the eye in a cursory examination, unless a drop of pus Fig. 37.— Varieties of Fistula (Gosselin). A, anus ; R, rectum ; B, complete fistula ; C, blind in- ternal fistula; D, blind external fistula. 108 DISEASES OF THE RECTUM AND ANUS. chance to be squeezed out of it by the pressure of the fingers in pulling open the parts ; and when discovered, it may not admit the end of an ordinary probe. The surgeon should, therefore, always be provided with a probe of small size and of pure silver, which admits of being readily bent, for using in these examina- tions. The presence of more than one external orifice is rare in sub- cutaneous fistula? ; and an internal opening will be found in the great majority of cases, if properly searched for. The only way to settle the question of the presence or absence of an internal opening in any doubtful case is by injecting milk through the external orifice. In the vast majority of cases the milk will be found in the rectum, and the internal orifice will be found just within the external sphincter. It may sometimes be felt in this location by the educated finger as a small tubercle, and in other cases it is marked by a distinct loss of substance. In some the internal opening will be found in the radiating folds entirely below the fibres of the sphincter, and in others it may be much higher up the bowel. 1 The internal orifice does not in all cases mark the superior limit of the fistulous track. This may run several inches up the bowel under the mucous membrane, when the internal orifice is just within the external sphincter (Figs. 38, 39). The track of a fistula is sometimes straight, extending di- rectly from one orifice to the other ; in other cases a track, prop- erly speaking, does not exist, and both orifices open directly into the original abscess cavity. If the external orifice be very small, the cavity may at any time become distended with pus and give rise to all the symptoms of a fresh abscess, till the pus finds an exit either through the old opening or a new one. The external orifice of a true, straight fistulous track is generally large, and sometimes free enough to allow of the escape of gas. The track is lined with lardaceous tissue the result of chronic inflammation, and in this may be found numerous blood-vessels of new forma- tion. This tissue, by preventing all contact of the walls, neces- sarily prevents healing. On the other hand, the track is some- times lined with healthy granulations which are capable of being formed into new tissue, and for this reason a fistula will sometimes heal spontaneously. 1 Ilibcs : Rechcrches sur la situation de 1' orifice interne de la fistule de 1'anus. Rev. MOd., t. i., 1820. ABSCESS AND FISTULA. 109 The history will sometimes afford valuable information as to the general character of the case. The history of a slight abscess and the escape of a small amount of pus generally means an insignificant fistula with external and internal open- ings near the margin of the anus ; while, on the other hand, the Fig. 38. Fig- 39. Fistulse with Double Tracks. (Molliere.) Fig. 38. — AB, deep submuscular track resulting from an ischio-rectal abscess. AI, submu- cous track running up and down the bowel. Fig. 39. — DE, Subtegumentary and submucous fistula with internal and external opening. DF, deep submuscular track, having same internal, but separate external opening. history of a prolonged inflammation and a free discharge of pus means a large abscess cavity mounting to a considerable height, and with its internal orifice at a correspondingly high point. The symptoms caused by this class of fistula? vary greatly. At first they are those of the abscess in which they originate. After that the one great symptom is the incessant discharge, sometimes slight, at others abundant ; sometimes purulent, at others serous ; always fetid ; sometimes containing faeces and gas. It is generally the stoppage of the discharge and the con- sequent filling of the track or abscess cavity which induces the patient to seek the surgeon. Besides the discharge there may be no symptoms at all, or there may be more or less uneasiness in the part, and pain on defecation, with the constipation which arises from the fear of a passage, and the symptoms to which it gives rise. Such a state of affairs may exist for many years 110 DISEASES OF THE RECTUM AND ANUS. -without aggravation, or without causing the patient to seek relief. Deep Fistula. — Deep or submuscular fistulse differ greatly in their extent and gravity from those last described. In them the track is large, and often double or branching, and the ex- ternal opening may be far away from the amis. The whole perineum and gluteal region will sometimes be found to be per- forated by openings. In a case sent to me by Dr. R. W. Taylor, of New York, I counted between twenty and thirty of these discharging points, and the whole perineum and surrounding region were hard, brawny, and infiltrated. The man, under the pressure of his sufferings probably, had become a confirmed opium-eater and was in a deplorable plight. Pelvic Fistula?. — The fistula resulting from an abscess of the superior pelvi-rectal space is generally of the blind external variety. The track is deep and the probe passed into it can hardly be felt from the rectum. The external opening may be far away from the anus, and there may be several tracks and openings which may branch off from each other, or all com- municate with a common abscess cavity above the levator-ani muscle. The track in some of these cases has been known to take a remarkably irregular course. Sir A. Cooper ' mentions an au- topsy where a fistula opened in the groin, followed the course of the spermatic cord, and ended in what seemed like an ordi- nary fistula in ano ; and cases in which the pus has burrowed under the gluteal muscles and finally opened in the thigh or even nearly at the popliteal space, are not uncommon. This form of disease is rather more common in males than in females. Blind Internal Fistula. — Fistula with internal openings alone have a somewhat special pathology. When caused by an abscess it is generally by one of the deep variety which has opened into the rectum high up and continues to discharge in this way. The abscess causing such a fistula may, however, be a small submucous one, or a large subcutaneous one, and the symptoms will then be pain, spontaneous discharge of pus from the bowel, and subsequently pain after defecation resembling that of a fissure. There is another, and perhaps more common class of internal fistula in which the oj>ening is not the result 1 Lecture on Principle and Practice of Surgery, with notes by Tyrell, t. ii., p. 326. ABSCESS AND FISTULA. Ill of the breaking of an abscess, but in which the opening is first formed by ulceration, and the track is a secondary consequence. This pathological fact was proved by the well-known investi- gations of Blbes, who believed that the internal orifice was always the first formed, but here he was undoubtedly in error. A circumscribed ulcer which shall perforate the mucous membrane and result in internal fistula may be due to several causes : to the inflammation of one of the lacunae just above the sphincter from the lodgement within it of a particle of hard faeces ; to rupture of an inflamed internal haemorrhoid ; to the application of strong acids to haemorrhoids ; to operations upon the rectum, generally for haemorrhoids ; and to the peculiar ulceration met with in tubercular patients, but not necessarily tubercular in its nature. Such a condition is a very painful one. The opening, which may be large enough to show a distinct loss of substance to the touch, catches and retains particles of faeces, causing a burning pain which may last many hours after defecation. As a result of the opening an abscess forms after a time, with the usual symptoms, the induration of which may be felt externally. When the abscess is small and the induration not extensive a speculum examination may reveal the ulcer ; but the fistulous tract and abscess may escape— a mistake which will render all treatment directed toward the cure of the ulcer of no avail. There may indeed be several ulcers, only one of which has a fistula connected with it. Treatment. — A fistula may heal spontaneously or after a very slight excitement to reparative action, such as the mere passage of a probe in making an examination. It has been mentioned that the track is sometimes lined with healthy granu- lations, and that these may result in new tissue which shall close it. I have the notes of one such case where a fistula of several years' standing closed spontaneously without even the passage of a probe to excite it to reparative action. Setting aside these cases, we are at once brought to the question which will often be asked by the patient, and which the surgeon may not always be able to answer to his own satis- faction, whether or not it is always best, or even safe, to try to cure a fistula. In certain cases of Bright' s disease, cancer, cardiac and hepatic affections, etc., all surgical interference may be plainly contra-indicated ; but the question is most apt 112 DISEASES OF THE EECTUM AND ANUS. to arise in connection with pulmonary affections. There can be little doubt that phthisical patients are especially predisposed to this affection, and the reason is probably in great measure a mechanical one, depending npon a loss of fat in the ischio-rectal fosse and a resulting loss of support to the hemorrhoidal veins. From this there results a venous congestion and final dilatation or rupture of the vessels, which, with the cough and concus- sion, leads eventually to abscess. I believe it to be a safe rule to operate on phthisical patients as upon others, being led by the idea that one exhausting dis- ease — phthisis — is better than two — phthisis and fistula. I have many times followed this rule with happy results as to im- proved general health after the cure of the fistula. Once only has it happened to me to see the cure of a fistula followed by a marked increase of the lung trouble, and even in such a case the relation between cause and effect cannot be established. There are several rules which should be carefully regarded in this class of cases, however. No cautious practitioner would think of operating either in a very advanced or a rapidly ad- vancing lung trouble. Cough, when violent and frequent, is also a decided contra-indication, interfering, as it does very cer- tainly, with the healing of the wound. The following case will perhaps illustrate the line of treatment to be followed in a gen- eral way. Case. Cure of Fistula in a Phthisical Patient. — A theo- logical student, aged twenty-eight, applied to me from a neigh- boring city for relief from a large subcutaneous abscess, with an internal opening within the sphincter, and an external one at some distance from the anus. The probe could easily be passed a considerable distance in every direction beneath the under- mined skin. The discharge was very profuse. This condition had existed for several months ; the patient was much re- duced in weight ; there was consolidation in the apex of one lung, with a history of phthisis and hemorrhages. The internal and external orifices were connected by an in- cision involving the external sphincter, and the abscess cavity was laid open for a distance of four inches along the perineum, and dressed with picked lint. After a fortnight's rest in his room, the patient being partially dressed most of the time, and spending his days on the lounge or easy-chair rather than in bed, reparative action seemed to come to a standstill, and with ABSCESS AND FISTULA. 113 careful directions as to dressing the wound, I sent him off into the mountains. He reported at my office after an interval of three months spent in the woods, during which time he had fre- quently been on horseback several hours at a time. The change in his general condition was very remarkable, he having gained nearly twenty pounds in weight. The abscess cavity was nearly, but not quite closed, and again he returned to the country, with the understanding that he should report in the city every fort- night. In just six months from the operation the wound was entirely healed, there had been no exacerbation in the lung troubles, and the patient was in better general condition than for years previous. In the former edition of this work I made the statement that I had yet to meet the first case of this kind which, under suit- able and careful general and local treatment, refused to heal after the operation. It is well, however, to give a guarded prog- nosis, and within the past year I have had one case in which, though the patient was greatly benefited by the operation, both as to the local trouble and his general condition, the wound has failed to cicatrize. The notes of it are as follows : Case. Blind Internal Fistula in a Phthisical Patient. — Mr. D , aged thirty-eight. The patient has had phthisis for three years, which has advanced to the formation of cavities in both lungs, and is accompanied by the usual general symptoms of that condition. About three weeks before consulting me he had the usual signs of an abscess on the left side of the anus, which resulted in a very profuse purulent discharge. Upon ex- amination I discovered, just within the margin of the anus, but hardly above the sphincter, a loss of tissue on the left side of the bowel into which the end of the finger readily passed. The corresponding buttock was infiltrated, and pressure over it caused a free discharge of pus from the anus, showing a con- siderable abscess cavity. This was freely incised under ether by entering a curved bistoury at the internal opening and cut- ting outward over the buttock. The cavity was scraped out with the finger, and dressed with lint and carbolized oil, and the patient was put to bed for three days. At the end of that time the wound was doing well but the patient was not, and I was obliged to let him sit up and take moderate exercise in the open air. The operation was performed January 7th. Twenty days 8 114 DISEASES OF THE RECTUM AND ANUS. later I made a note that the wound was closing nicely, and the patient in a fair way to recover. But, February 19th, I dis- covered that there had been some burrowing of pus, and it was necessary to slit up a small sinus which had formed. The wound looked healthy, but the patient's general condition was very bad indeed, and he objected most strenuously to being con- lined to his bed or even to his room. The following four months were passed in a long, patient struggle on my part and that of the patient to induce a complete closure of the wound. Every form of treatment which ingenuity could suggest was tried, and it would be useless to enumerate them. More than once we congratulated ourselves that the work was done, and that an- other week would end the case, when a fresh pocket would form, at first very slight but rapidly increasing, and the task had to be undertaken again. During all this time the patient was up and about, and improving in his general condition, so that in the early summer, when I last saw him, he had gained decidedly in flesh and the local trouble caused him so little dis- comfort that he had ceased to wear a bandage. But there were still two small pockets which needed to be laid open. He is now in a condition which would warrant the enforcement of the most important element of the treatment, and the only one which has never been practised — absolute rest in bed after opening the sinuses — and by this means I still hope to get a positive cure after his summer rustication has done all that can be done in that way. From the peculiar origin of this case, and once or twice from the peculiar appearance of the nearly cicatrized wound when it was reduced to a surface the size of the little finger-nail, I have been inclined to suspect that the starting-point of the disease might have been a deposit of true tubercle. This would fully account for the lack of success of the treatment, but I have never been able to convince myself of the fact. In cases of fistula in phthisical patients, the sphincters should be interfered with as little as possible, as they are apt to be weak at the best. The internal orifice is apt to be large and ragged, and the external may be the same. The tendency to undermine the skin is always marked, and the discharge is generally thin and watery. Cauterization. — It is not necessary even to enumerate the various substances which from time out of date have been ad- ABSCESS AND FISTULA. 115 vocated for this purpose. Among those for which good results have been claimed, iodine holds the first rank. 1 There is no doubt that by its use certain fistulae and abscesses may be made to heal, but the plan is uncertain and not very reliable. The operation consists in closing the internal opening with a finger in the rectum, and then injecting the fluid with a small syringe through the external orifice, using pressure enough on the track to bring the fluid into contact with every part. In the place of iodine, nitrate of silver either in solution or fused upon a probe, the tincture of iron, or carbolic acid, may be used. The galvano-cautery wire, or a simple hot iron, may also be employed to modify the track ; and a fine sea- tangle tent carefully introduced will sometimes set up reparative action. By any of these means failure will be the rule, but success may occasionally be secured after faithful trial. The Ligature. — Under the head of the ligature may be in- cluded also its different modifications — ecrasement lineaire, elastic ligature, and the galvano-cautery wire. The method of cure by the simple ligature consists in pass- ing a strong cord through the fistula from the external opening, through the internal, and out at the anus, then in tying the two ends, and tightening the loop from day to day till the tissue included is divided. The operation is generally effectual, but it is also painful, tedious, and uncertain. It is a substitute for the knife, a concession to the fear of being cut, and it is free from haemorrhage ; but it only accomplishes in the end, and sometimes after weeks of suffering, what the knife accomplishes in a moment ; and except for the single fact that by its use haemorrhage may be avoided, it would bear no comparison with the latter. If this mode of treatment is for any reason decided upon, there are certain modifications of the operation which are much to be preferred to the simple cord. The method of immediately cutting through the tissues by attaching the ends of the cord to the handle of an ecraseur {ecrasement lineaire) is a much better way of attaining the same end, which is due to Chassaignac. There are, however, two methods of dividing the tissues which are still better than this — one by the galvano-cautery wire, the other by the elastic ligature. The galvano-cautery wire has the 1 Boinet : Traitc d'iodotherapie. 116 DISEASES OF THE RECTUM AND ANUS. same advantage over the knife as the Ligature in preventing haemorrhage ; and it is not particularly painful in its applica- tion. In using it, as little heat should be used as is possible to slowly divide the tissue, or haemorrhage may occur and all its advantages be lost. On account of the expense of the appara- tus, and the skill required for its management, this method has never become very popular with the general practitioner, but it is very successful in the hands of a few. Probably the best of all methods next to the knife is that of the elastic ligature. The cord in this case is of solid rubber, which is drawn as tightly as possible — the tighter the better — and then held on the stretch by slipping a soft metal ring over the ends and squeezing its two sides together close up against the tissues. In the course of a few days the ligature will be found to have cut its way through the included tissues, the time depending on the quantity and quality of the mass to be cut. Various devices have been recommended for facilitating the passage of the ligature. The best known is Allingham's, Fig. 40. In using it, remember that it is intended to draw the cord from the rectum out of the external orifice, and not vice versa. Helmuth, of New York, has modified the instrument, and I think with advantage, Fig. 41, but the least elaborate and most effective instrument for the purpose in my own hands is a sim- ple silver-eyed probe which is threaded with the elastic cord and then passed from the external orifice through the track and out at the anus. I once had an awkward accident with Ailing- ham's instrument, which broke in my hand in a moderately deep and hard track. After the ligature is in place, the patient is allowed to go about his ordinary pursuits, and this is claimed as one great advantage of this method. I have never been able to under- stand why cutting with a string should permit of any more liberty than cutting with a knife. The patient, it is true, will generally get well if he goes about while the string is doing its work, and so he will after the operation with the knife ; but in both cases the healing will be facilitated by rest. The operation is said to be painless. I have not found it so. Both the pass- ing of the cord, and its tension for the first forty-eight hours, have been bitterly complained of in some of my own cases. The healing has already begun before the ligature comes away ; but ABSCE9S AND FISTULA. 117 with the dropping out of the cord there will sometimes be found a considerable slough in the line of strangulation which may require some days for its separation. The elastic ligature has undoubted advantages over the knife in cases where the latter is contra-indicated by the fear of «sH II PlG. 40. — Allingham's Ligature Carrier. Fig. 41. — Helmuth's Ligature Carrier. haemorrhage, as in a fistula running high up the bowel where haemorrhage may be a serious matter, or where the patient re- fuses to submit to a cutting operation. Of all the methods of cutting with a string it is the best ; but, after all, it is only a substitute for the knife, and for my own part I must plead 118 DISEASES OF THE RECTUM AND ANUS. guilty to a preference for cutting with a knife when cutting is necessary. Incision. — The operation for fistula by incision may be greatly facilitated by the observance of several minor details. In this as in other operations on the part, the bowels should be thoroughly emptied on the previous day. Care must be ex- ercised, lest in the endeavor to free the alimentary canal a diarrhoea be excited, for this will prove anything but an agree- able complication for the operator. In all cases in which the track is of any considerable depth, or in which, on account of sensitiveness of the patient, the surgeon has not been able to assure himself of the exact extent of the disease and the absence of any side tracks or diverticula, ether should be given and the anus gently and completely dilated before the operation. It is only in the simplest cases that the incision may be made with- out ether, and then the best chance of a thoroughly satisfactory exploration is missed, and the way is opened for an incomplete and therefore unsuccessful operation. With regard to position the operator may choose between placing the patient on the affected side or on the back. In women the former is generally preferable. A director with probe point should be passed through the external orifice into the bowel and brought out at the anus by the index finger of the other hand, which should in any case be passed into the bowel before the probe is inserted into the external opening. The track should now be carefully and thoroughly explored and its extent discovered. This should be done deliberately and without haste, and hence the advantage of an anaesthetic. When the patient is not etherized there is always a tempta- tion, when the end of the probe is felt against the finger in the rectum, to bring it out at the anus, follow it instantly with the bistoury, and quiet the sufferer with the cheering assurance that all is finished ; but a seemingly insignificant case may have a deep track connected with it which must be divided before a cure can be effect id. Having by careful examination decided just how much «ut ting is to be done, the choice of the instrument rests with each operator. In simple cases, where the track is superficial, I frequently use a knife of my own invention which (like most new inventions) I found after having it manufactured, exactly resembled those in use in the fourteenth and fifteenth century, ABSCESS AND FISTULA. 119 though somewhat smaller and less formidable in appearance." It is represented in Fig. 42, and consists of a flexible probe at the end of a curved bistoury. The probe point should blend as gradually as possible with the cutting edge, as anything like a shoulder at the junction of the two interferes greatly with its use. I have thought that in suitable cases the operation was rendered more speedy and less painful by the use of this com- bined instrument ; but it is not well adapted to those cases in Pig. 42.— Author's Fistula Knife. which the track runs any distance up the bowel ; and where the patient is etherized it has no advantages over the director on which the bistoury is generally passed. It is especially adapted for operating without ether. In subcutaneous fistulse the track should be divided from the external to the internal orifice. If there be at the same time any undermining of the skin with tracks leading off in different directions, these also should be laid open, so that all may be converted into an open wound. For deep fistulsB the Fig. 43.— Gorget. knife or scissors should be strongly made, for it is not a very difficult matter to break an ordinary scalpel in a deep fistula. A heavy steel director may also be snapped in an attempt to bring the end out of the anus preparatory to making the incision ; and should the internal orifice be high up, and the external at some distance from the anus, so that the amount of tissue to be 1 I am indebted to my friend, Dr. James L. Little, for calling my attention to the plates in Heister's Surgery, showing this instrument — the old-fashioned syringotome. 120 DISEASES OF THE RECTUM AND ANUS. divided is large, it is often better to use the wooden gorget to guard the opposite side of the rectum and dispense with the director after the knife has been passed. (Fig. 43.) The end of the knife may be firmly fixed into the wood and both with- drawn simultaneously, Fig. 44, or the incision may be made by Fig. 44. — Operation for Fistula with Gorget. (Bernard and Huette.) cutting on the gorget. Allingham prefers a pair of spring scissors, one blade of which runs in a director the groove of which is more than a semicircle, for cutting deep tracks. (Fig. 45.) Some difference of opinion exists among different writers as to the proper method of treating the track that will often be *e^ Fig. 45. — Allingham's Spring-Scissors for Fistula. found running along the bowel above the internal orifice, and directly contrary opinions are taught as to the necessity for its complete division. The operation is of course rendered more severe by the division of such a sinus in addition to the fistula, and the danger of haemorrhage is increased ; but one can never ABSCESS AND FISTULA. 121 be sure that the operation will be successful when such a track is left, though no doubt many cases have turned out well. With regard to haemorrhage in such cases, it will be found that the sinus has generally burrowed under the mucous membrane, and that the vessels have remained in the deeper layers of the bowel, so that the division of the sinus does not of necessity in- volve that of any large vessel, though it extend far up the bowel. Many of these sinuses may best be divided with the scissors, and the haemorrhage, if it be profuse, dealt with according to the rules already given. If, however, haemorrhage be feared beforehand, the track may be divided with the ecraseur, or a small canula may first be passed, through this a wire, and finally by means of the wire an elastic ligature. When no internal orifice can be found, but the mucous mem- brane feels undermined, and the probe can be felt by the finger in the rectum, separated only by a thin layer of mucous mem- brane, it is a good plan, when the fistula is not too deep, to force an internal opening and treat the fistula as though it were com- plete. When there are two internal openings, both should be included in one incision. When, after the incision, the diseased integument is found to overlap the cut, and hang into it, it should be cut away, and in old tracks the healing may be has- tened many days by thoroughly scraping out the lardaceous wall with the handle of the scalpel, or even scarifying it in sev- eral places, so that a healthy reparative action may be set up. In cases of horse-shoe fistula with two external orifices and one internal one, it is generally best to do the usual operation on one side only, and to dilate the opening on the opposite side, so as to allow of free escape of pus. Where the fistulous tracks exist in great numbers — twenty or thirty in some cases — two or three operations may be advisa- ble at intervals, rather than to attempt to do all at one sitting, lest the patient's reparative powers should be unequal to the task thrown upon them. In such cases there will often be found two or three tracks which may be considered as primary, into which the others run ; and each of these, with its branches, may be dealt with at a separate operation. Many of the tracks will be found to run away from the bowel under the skin of the buttock, or toward the scrotum, and these may be induced to heal by laying them open, without interfering with the sphinc- ters. It will sometimes be necessary to divide the sphincter 122 DISEASES OF THE KECTUM AND ANUS. several times, however, before the cure can be completed, and a certain degree of incontinence may be expected as a result. In such cases the anal region is generally greatly hardened and infiltrated, and free haemorrhage may be expected. The best weapon with which to meet it is the cautery of Paquelin. In the matter of dressings after the incision, much skill may be displayed. Immediately after the operation, a dressing of dry picked lint, or if there be an abscess cavity, of lint soaked in carbolized oil, is as good as any, and this should be kept in place by a T bandage. To save the patient as much pain and annoyance as possible, this should not be removed till suppura- tion has been established. Subsequent dressings may be of the same material, and should be changed daily. The wound should not be tightly packed with lint. It will heal from the bottom if its surfaces are kept apart or separated daily by the ringer of the surgeon. Care is always necessary to prevent an immediate union of the cutaneous edges of the incision. I have seen a remarkably well-pleased patient come to me and report himself as entirely cured a week after I had divided his fistula, in consultation with his medical attendant, and have found on examination that the incision had healed very kindly by first intention through its whole extent, and that the fistulous track was exactly as it was before the cut. Healing may be indefinitely delayed by too frequent dress- ings or by stuffing the wound tightly with lint, with the inten- tion of forcing it to heal from the bottom. Under such treat- ment, healthy granulations may entirely disappear, and the cut surface assume a mucous-membrane-like appearance, and so re- main. Standing or walking always delays, and may sometimes entirely prevent healing. During the treatment, the burrowing of pus and the forma- tion of a new pocket should always be carefully watched for, and met by incision. The 1 1 hemorrhage in an ordinary operation for fistula is sel- dom profuse enough to cause the surgeon any uneasiness, and is almost alwa3's easily controlled by packing the incision with lint, and making firm pressure with a compress held in place by a T bandage. A free arterial haemorrhage from a vessel well up the rectum may, however, be alarming, and if not controlled by the admission of air or the application of ice to the part, the rectum must be tamponed. ABSCESS AND FISTULA. 123 Fistulse of the blind internal variety can only be dealt with rationally by incision. A speculum should first be introduced and a silver director bent into the form of a hook passed into the orifice and brought down to the bottom of the track, with this as a guide the fistula may be opened into the bowel. The incision should always be continued through the sphinc- ter and the anus, so that the wound may be properly dressed and drained, otherwise the operation will merely serve to con- vert a small internal opening into a larger one. An operation of this kind is always more apt to be followed by a concealed haemorrhage into the rectum than one for a complete fistula, and this should be guarded against by a careful plugging of the wound and by the application of dry persulphate of iron if necessary. The abscess in connection with a blind internal fistula may sometimes be detected by the induration which may be felt through the skin of the ischio-rectal fossa. In such a case, after the director has been passed into the internal orifice, a counter- opening should be made into the abscess through the skin, using the director for a guide for the incision. In this way the blind internal variety is changed into the complete, and the usual operation of division into the bowel may be performed. After what has been said of the origin and extent of ab- scesses of the superior pelvi- rectal space, it is evident that there may result from them a class of fistulse which are not to be operated upon by any of the methods we have described — fis- tulse so deep and extensive as to contra-indicate all operative interference. And yet much may be done, even in the worst cases of this kind, and by proper treatment some may be cured. The first attempt of the surgeon should always be toward effect- ing a cure without cutting the track into the bowel. External and comparatively free incisions may be made, which shall not implicate the anus, and through them drainage tubes may be passed into the abscess cavity so that it may be freely emptied. Through the drainage tube stimulating injections maybe made, and the abscess treated as an abscess elsewhere would be, by rest and attention to the general health. A cure may some- times be effected in this way in a very unpromising case. When all these measures have been exhausted and it be- comes necessary to open the sinus into the bowel, the danger of haemorrhage may be overcome by the elastic ligature or the en- 124 DISEASES OF THE RECTUM AND ANUS. terotome. Of these the former is preferable, but if it be deemed advisable to use the latter, the form shown in Fig. 46, which has been invented by Richet for this purpose, is the most con- venient. Where the track has burrowed to great length, much may be accomplished by modified operations. In a track, for ex- ample, which has one opening near the anus and another in the middle of the thigh, a counter-opening may be made between the two, and the further extremity induced to heal while drain- age is maintained from the middle opening, by the use of injec- tions or caustic applications. Should these means not succeed, and should it appear that a free division is likely to result in a cure, the incision may be made according to the ordinary rules of surgery. Such operations have been done, and tracks of great length extending under the gluteal muscles have been FlG. 46. — Enterotome of Richet for Deep Fistulae. divided with the ecraseur with good results. I have myself fol- lowed a track directly across the perineum and exposed the membranous urethra in the incision, dividing in the operation the sphincters four different times. Such operations may some- times be necessary to save life, but they may be too great for the patient's powers of recuperation. An abscess between the prostate gland and the perineum, where the pus is confined by the perineal fascia, may result in both a rectal and a urethral fistula. The operation in such a case is the same as for other sinuses, that leading into the rec- tum being first divided, and the others which communicate with it, later. In fistula complicating stricture of the rectum, attention should always first be turned to the latter, for if this can be cured there is a prospect that the former may undergo sponta- neous closure, and if the stricture be not relieved it will be of ABSCESS AND FISTULA. 125 little avail to cut the fistula. Many awkward mistakes have happened to good surgeons by failing to detect this complica- tion of diseases. Throughout this chapter on the treatment of fistula I have endeavored constantly to keep before the eye of the reader the importance of the sphincter muscles. A permanen t incontinence of faeces is always considered by the patient a very poor ex- change for a fistula which was causing comparatively little suffering or annoyance. CHAPTER VI. HEMORRHOIDS. Definition. — Division into External, Internal, and Intermediate. — Differences between the two Varieties. — External Haemorrhoids. — Pathology. — Inflamed Haemorrhoids. — Treatment. — Means of Prevention. — Palliative Treatment.- — Excision. — Internal Haemorrhoids. — Division into Capillary, Arterial, and Venous. — Description of Capillary Variety, of Venous Variety, of Arterial Variety. — Symptoms of Internal Haemorrhoids. — Strangulation. — Diagnosis. —Treatment of Internal Haemorrhoids. — Palliative Treatment. — Constitutional and Local Means of Palliation. — Treat- ment of Strangulation. — Curative Treatment. — Haemorrhoids Associated with Uterine Disease. —Symptomatic Haemorrhoids. — Radical Cure. — Caustics. — Dan- gers of Nitric Acid. — Vienna Paste. — Treatment by Carbolic Acid Injections; Cases and Cures. — Advantages of this Treatment. — Treatment by Ligature. — Description of Operation- — Operation with Clamp and Cautery. Hemorrhoids may be defined as varicosities of the anal or rec- tal vessels. They may present themselves under various forms and conditions owing to changes in their substance ; but the first step in their formation is always an enlargement and dila- tation of the veins or arteries or both. Haemorrhoids, for convenience, may be divided into external and internal ; and these may always be distinguished from each other, though both may exist at the same time in the same patient. An external hemorrhoid originates in the subcuta- neous veins which surround the anus ; it is therefore entirely below the sphincter muscle, and though it may be partially covered by mucous membrane, it does not come from the rectum proper, nor can it be forced above the external sphincter mus- cle. An internal hemorrhoid originates, on the other hand, within the rectum, and may exist for a long time without ap- pearing externally. When it does show itself outside of the anus, it is a result of straining, of increase in size, or of a lax condition of the sphincter; and after long exposure outside the body it may become changed in character and appearance, till the mucous membrane covering it takes on something of the character of integument ; but it may still, with proper manage- PLATE q$mv. '• m«.%. <^ia/.A. S^xmywiAAuyxa/d . HAEMORRHOIDS. 127 ment, be returned within the bowel, though it may not remain there for any length of time. The distinction between an external and an internal hemor- rhoid is not, however, a purely arbitrary one, the one being below, and the other above the external sphincter. A different set of blood-vessels is implicated in each case. An external hemorrhoid is a varicosity of an external hemorrhoidal vein, and is, therefore, an affection of the general venous circulation. An internal hemorrhoid is a varicosity of the middle or internal hemorrhoidal veins, which are parts of the visceral venous sys- tem. A glance at the venous anatomy of the rectum and anus (pages 17 and 18) will show the arrangement of these two sets of veins, and will also explain how, from the free anastomosis which exists between them, it is improbable that one should be affected without influencing the other to a greater or less extent, and how, judged by this test alone, it may be impossible to tell whether a particular hemorrhoid belongs to one system or the other. For practical purposes, therefore, the first definition is the better one — an external hemorrhoid is one originating out- side of the external sphincter, and an internal one is one origi- nating within that muscle. Other secondary differences, which may arise from various causes, in the development and location of the tumors will be considered later. Intermediate Haemorrhoids. — A third class of hemorrhoids may with advantage be made to include those which are on the dividing line between the external and internal, partaking some- what of the characters of both. Plate II. , Fig. 1. External Haemorrhoids. — A person of middle age who has not at some time suffered from an external hemorrhoid is in- deed a great rarity, so common is this affection. In the major- ity of cases, it is allowed to run its own course, and only when the pain is unusually severe, or some untoward accident has happened, does the patient consult the surgeon. It is perhaps useless to seek for the causes of a malady which is so universal beyond a few which are well recognized and manifest. Amongst these are straining at stool, pregnancy, affections of the internal organs which interfere with the return of venous blood, and constipation. Outside of these cases where a manifest cause exists, external hemorrhoids will be found amongst all classes. Those who smoke and those who do not ; the high liver and the abstemious ; the laborer and the professional man ; those 128 DISEASES OF THE RECTUM AND ANUS. who stand and those who sit ; are all affected and about equally. An external hemorrhoid may appear in two different forms which bear little resemblance to each other. The first is a small, round or elongated venous tumor (Fig. 47) ; the second is a tag Fig. 47.— External Venous Haemorrhoid. (Smith.) of hypertrophied skin, sometimes improperly spoken of as a condyloma (Fig. 48). The second is formed from the first by changes soon to be described. The external haemorrhoid may arise in either of two ways, by the dilatation of a vein, or the rupture of a vein and the ex- travasation of blood into the adjacent tissue. The dilatation may not always be of the same character. In one case it may affect the whole calibre of the vessel, in another it may be in the form of a pouch springing out from one point in the circum- ference. A haemorrhoid resulting from the dilatation of a vessel is of gradual formation ; but it sometimes happens, particularly after a violent straining at stool, that the patient will feel a peculiar sensation at the anus, and an examination will reveal the presence of a tense, bluish, smooth tumor, the size of a pea or a grape, situated just at its verge. In this case, a previously HAEMORRHOIDS. 129 dilated and weakened vein has suddenly given way, and the tumor is the result of the extravasatiou of blood. Such a bloody tumor as this will cause much pain and dis- comfort, preventing the patient from sitting down, or even from going round with any ease. It may be freely incised by trans- Fig. 48. — External Cutaneous Haemorrhoids. (Esmarch.) fixing its base with a small, sharp, curved bistoury and cutting outward, the incision being in the direction of the radiating folds of the anus, and this operation is sure to give tempo- rary relief, by allowing the escape of a small clot of blood and putting an end to the tension which is causing the suf- fering. If the surgeon undertake this method of treatment, there are one or two hints which may be of value. The incision itself is G.TIEMANN-CO ITC Pig. 49. - Small, Sharp-pointed, Curved Bistoury. extremely painful, and should therefore be done with a sharp knife of the form shown in Fig. 49, and it should be done in- stantaneously. Whatever deliberation is required, is better ex- ercised before entering the knife. Again, care should be exer- cised to empty the clot entirely out of its bed, otherwise a small 130 DISEASES OF THE RECTUM AXD ANUS. wound remains which will not readily heal, because the sac is prevented from contracting, and the patient is obliged to wear a bandage, perhaps for a week or longer, to keep from soiling the linen with a sanious discharge. Under such circumstances also the pain is but little relieved by the operation. Again, I have in a few cases seen the incision heal by primary intention, and the sac again till with blood, thus leaving the patient in the same condition, as regards suffering, as before operation. This is best avoided by placing a shred of lint in the cut. These, however, are untoward accidents which may attend an insignifi- cant operation which usually gives relief to suffering, and al- lows the tumor to shrivel up and disappear except for a small tag of skin which may remain and form an external pile of the second variety. When left to its own course, a bloody tumor of this variety may gradually decrease in size from the absorption of the fluid elements of the clot, the pain decreasing at the same time; and after a week or ten days of discomfort, it is changed into a cutaneous hemorrhoid. Or the opposite course may be taken, and the tumor may show all the signs of an abscess (Plate II., Fig. 4), and finally rupture spontaneously with the discharge of a little blood and pus, and with an instantaneous ending to a week of suffering. For during this acute inflammatory process, the pain is often very severe, the discomfort constant, and there may be more or less febrile excitement, all of which will pass away the moment the tension is relieved. The treatment of such a case where the knife is not used will be described a little later. To return to the hemorrhoid which is due to the varicose vein, but not to the extravasation of its contents. In such a case there may be one considerable dilatation which shall cause a smooth, round, bluish tumor the size of a pea or a grape ; or there may be a number of veins included in a new growth of connective tissue which shall constitute a distinct, firm, hsemor- rhoidal tumor. For these dilated pouches are in themselves causes of irritation, and are subject to irritation from without ; and as a result an exudation takes place in their vicinity which finally ends in the production of new tissue. It is thus easily understood why on cutting into one external hemorrhoid a single large clot will be exposed contained in a distinct sac ; while in another, several smaller clots may be seen imbedded in HEMORRHOIDS. 131 the surface of the section, and why there is more or less connec- tive tissue in the tumor. Figs. 50 and 51. The formation of such a tumor is a gradual process due to the continuous action of the primary cause and to subsequent irritation from without. It may go on with little pain and suf- fering, so little that the patient will hardly care to ask for re- lief ; and it may undergo a spontaneous cure, leaving in its place only an hypertrophied tag of skin. Generally, however, during its course an attack of acute inflammation will be excited at some time, and this is very apt to bring the sufferer into the Fig. 50. — External Hemorrhoid with Increase of Connective Tissue. (Esmarch. ) Pig. 51. — External Hsemorrhoid after Injection of the Vein. (Eroriep.) hands of the surgeon. At such a time, if the inflammation has occurred in a fleshy pile the tag will be swollen, oedematous, and exquisitely sensitive. Suppuration may occur in it and a small marginal abscess and fistula be the result. Or, if the in- flammation has attacked a sanguineous tumor, it will be found hard and swollen and painful to the touch. The patient will often say that he has tried to replace the little grape-like tumor within the bowel, but has been unable, though the pressure has caused it to disappear for the moment and has given a tempo- rary relief. This is due to emptying the vein of its blood, but the blood returns the moment the pressure is removed. The pain is constant, often preventing sleep at night. The 132 DISEASES OF THE RECTUM AND A"NCTS. sufferer is "unable to sit or stand, and soon finds that he feels better in the recumbent posture. A motion of the bowels is feared and therefore avoided as long as possible. When after two or three da} r s of constipation the call can no longer be de- layed, the pain is greatly increased. It is astonishing how much pain and constitutional disturbance such an apparently trivial thing may cause. Such an attack in a sanguineous hemorrhoid may terminate in three ways : by resolution, by induration, and by suppura- tion. In the former case the resolution may be complete, espe- cially when the inflammation has been of moderate intensity, and no trace of the tumor may remain, or a cutaneous tag may be left to mark its former site, When the inflammation assumes a chronic type, and the tumor becomes cedematous, and is still somewhat painful on pressure or during defecation, though not to such a degree as during the acute stage, the inflammation is said to have terminated in induration. Such a tumor is always liable on slight provocation to a fresh attack of inflammation. When suppuration occurs, the tumor discharges its pus and then shrivels up and becomes a cutaneous tag. Treatment. — The surgeon will seldom be called upon to treat a case of external haemorrhoids unless during an attack of acute inflammation ; for at other times the annoyance caused by them is comparatively trivial. A cutaneous tag which is quiescent may as well be left undisturbed by the knife or scissors ; for the removal of it will not infrequently cause an amount of suffering disproportionate to the benefit gained. The whole thought of the surgeon may then be turned first to the prevention and second to the relief of an attack of inflammation. The means of prevention are very simple and yet very effectual. They con- sist In the avoidance of excess in eating or drinking, and in per- fect regularity in defecation ; for in a person affected with ex- ternal haemorrhoids a single heavy meal at an unusual hour, an evening spent iri smoking and drinking, or, worst of all, the neglect to have a motion of the bowels for a single day, will give rise to a sensation of heat, pressure, and itching about the anus, which warns him that trouble has commenced. Even under sucb circumstances the attack may be aborted by rest in the recumbent attitude, a light diet, abstinence from wine or liquor of any kind, and a laxative, preferably one of the mineral waters, repeated every night for three or four days. HEMORRHOIDS. 133 Should the attack go on and actual inflammation be excited, more active treatment will be required, and this may be either operative or medicinal. It is my own practice to try the latter first, and if it does not succeed, resort to the former. The me- dicinal treatment consists in keeping the sufferer on the bed or lounge, and applying a small bladder of pounded ice to the part. 1 This is generally very grateful to the patient and very effectual — much more so than warm poultices or applications of belladonna and opium ; but should it not prove so, the latter may be tried. A good formula is equal parts of the extract of belladonna and opium smeared freely over the anus. In most cases the attack will subside after forty-eight hours of this treat- ment, and the use of a daily laxative ; but should it not, a san- guineous tumor maybe incised in the manner already described, and a cutaneous tag may be seized with a sharp forceps and quickly snipped off with the scissors. Ether is not generally necessary for this operation, which, though very painful, re- quires but a moment ; and I have generally found that attempts at local anaesthesia with the ether spray were very delusive on this part of the body. If ether be employed at all, it is much better to take advantage of the primary anaesthesia produced by the first few inhalations, the patient holding the towel or bottle in his or her own hand. This is a favorite procedure of my own in this and many other operations about the anus, and one which I cannot too strongly recommend. The only caution necessary in cutting off an external haemor- rhoid is to remove neither too much nor too little tissue. If too much be removed, the wound will take a long time to heal, and if several tumors be removed, contraction to a disagreeable extent may follow ; if too little, a tag of skin will still remain after cicatrization and shrinking, and although this might be considered a matter of no importance in a male patient, I have seen ladies who did not so consider it. Internal Hcemorrhoids . — External haemorrhoids were de- scribed as varicosities of the external haemorrhoidal veins ; and internal haemorrhoids may also be similarly defined as varicosi- ties of the middle and superior haemorrhoidal veins, but they are more than this. An internal haemorrhoid is often an arte- rial tumor, as well as a venous, and the arteries may be of large 1 Nothing is so convenient for this purpose or causes as little pain as the rubber baudruche, which may now be procured at any druggist's. 134 DISEASES OF THE RECTUM AND ANUS. size (Fig. 52). Occasionally one will be met as large as the radial. In describing these tumors, we shall follow the division laid down by Allingham into capillary, arterial, and venous. The capillary hemorrhoid is in reality an erectile tumor, composed of the terminal branches of the arteries and veins and of the capillaries which join them. This form of tumor is never of large size, and never projects very far into the cavity of the rectum. To the naked eye and under the microscope they Fig. 52. — Internal Haemorrhoids showing Line of Junction of the Skin and Mucous Mem- brane. (Curling. ) strongly resemble an arterial naBvus. They may be situated high up in the rectum or low down by the sphincter ; their sur- face is granular, and the membrane covering them is always of extreme thinness. This accounts for the chief symptom which distinguishes them clinically from the other varieties— the free arterial haemorrhage which follows the slightest bruising of their surface even in the act of defecation. Such a tumor never appears outside of the anus unless accompanied by some other rectal affection, but it may sometimes be seen by a careful pull- ing open of the sphincter with the fingers, and from some part of its strawberry-like surface there is pretty sure to be a jet of ar- terial blood, coming per saltern. The disturbance caused by the HAEMORRHOIDS. 135 gentlest examination is sufficient to start this bleeding, and it almost always occurs at defecation. This is the form of haemor- rhoid to which the name of ''bleeding" most properly applies. In my own experience it is not as frequently met with as the varieties to be described later ; and this probably for the reason that after existing for a longer or shorter period in this form it is changed into one of the others ; and that patients do not seek relief till after such change has occurred. After a time, the mucous membrane covering such a tumor becomes thickened, and as a result of repeated irritation, there is an increase in the submucous tissue. The haemorrhage decreases in frequency and finally ceases as the capillaries become obliterated by the increase in the connective tissue, and the capillary tumor is suc- ceeded by the arterial or the venous one. The one symptom of a capillary haemorrhoid is the daily haemorrhage ; and as this haemorrhage occurs at the time of defecation, and there is no pain at any time, the patient may be entirely ignorant of the fact that blood is daily lost. This is particularly the case with the class of patients seen in public practice who give little attention to themselves. In the higher walks of life such a loss of blood seldom occurs without the knowledge of the patient ; but unfortunately it is often disre- garded, especially in women, who are in the habit of losing blood at every menstrual turn and who always shrink from an examination. It is not necessary to relate in detail the train of constitu- tional symptoms which may follow the daily loss of a con- siderable quantity of arterial blood. The anaemic look, the disturbance of the heart's action, the troubles with the digestive apparatus and with the sexual organs, the cessation of menstru- ation, are all well known. But it is curious that, as in a recent case in my own practice, a very intelligent medical man, who understood perfectly his own condition, should allow himself to be brought to a state of profound anaemia by a little haemorrhoid of this variety rather than have anything done for himself. In this case a single application of nitric acid to the bleeding surface worked a cure which has lasted for several years. The Arterial Hemorrhoid. — In this form of tumor the capillary network has disappeared and in its place is found a mass of freely anastomosing arteries and veins bound together 136 DISEASES OF THE RECTUM AND ANUS. by connective tissue. The arteries and the veins are tortuous, often varicose and dilated into sacs and pouches, and the arteries may be of large size, especially the one which enters at the base of the tumor, the pulsations of which may often be distinctly felt by the finger. Such a tumor is often of consider- able size ; it is firm to the touch and smooth ; it is liable to inflammation, erosion, haemorrhage, and prolapse. The haemor- rhage which occurs is arterial in character, and apt to be abun- dant. When the hemorrhoid has gained a sufficient size to become prolapsed in the act of defecation, the patient suffers the usual symptoms of the hemorrhoidal state. If the sphincter be not tight enough to strangulate the mass after it has come out of the body, the pain will not be very severe and the patient will return the tumor by a little gentle pressure and manipulation. The Venous Hemorrhoid. — This form of haemorrhoid may result from either of those already named or it may arise de novo. It consists at first of a simple dilatation of the large veins beneath the mucous membrane of the rectum ; later these veins undergo certain changes due to the hypertrophy and induration of the mucous membrane and submucous connective tissue, until finally a large, bluish, hard tumor is formed which is smooth to the touch, comes out of the body on defecation, and is covered by a mucous membrane which has assumed a par- tially cutaneous character from exposure. The three varieties of internal haemorrhoids thus described may all be present in the same person, and each be distinguish- able from the other. In other cases the line of distinction may not be so well marked. A venous haemorrhoid may contain a considerable number of arteries and may bleed per saltern, and it is not certain that an arterial haemorrhoid is always a later stage of the capillary variety. But the three forms are well marked and must be distinguished from each other in the matter of treatment. Symptoms.— Usually the first symptom of internal haemor- rhoids is the loss of blood during defecation, to which reference has already been made. This may be present for a long time before any other symptom is noticed by the patient, except perhaps an occasional feeling of discomfort in the rectum, and a sensation that the rectum has not been thoroughly emptied after stool. There is however a peculiar train of nervous HAEMORRHOIDS. 137 symptoms which are quite characteristic of the disease, and which may be well marked before either bleeding or protrusion has appeared. These are difficulty in micturition, diminished sexual power and desire, pain in the genitals, loins, and thighs, and formication in the lower extremities. A very marked case of this last symptom was sent to me not long since by Dr. Spitzka. The patient was himself a very intelligent physician, who had consulted Dr. Spitzka for supposed incipient locomotor ataxia, but no disease of the spine being found he was referred to me for rectal examination, under the suspicion that a disease of this part might account for the condition. Such was found to be the fact, there being well-marked hgemorrhoidal trouble wiiich had never manifested itself in any other way, except by a slight uneasiness after defecation. Pain in the rectum of a sharp lancinating character may be present as an early symptom, but it is not generally complained of until the tumor begins to descend within the grasp of the sphincter and appears at the anus at each act of defecation. If the sphincter be firm and strong, it is then apt to be very severe and the tumor may become strangulated, but after the disease has existed for any great length of time, and especially in per- sons past middle life, there is apt to be a loss of power in the muscle which, though it facilitates prolapse, decreases the pain attendant upon it. It will occasionally happen that internal haemorrhoids though fully developed and of many years' standing have never been known by the patient to cause any loss of blood though such a case is very rare. In ordinary cases, the patient will reduce the tumors when they come down on defecation. They may, however, become strangulated, and be entirely beyond the patient's power of manipulation. In such a case, after a period of rest, and after the relief which may follow a spontaneous escape of blood from the over-distended vessels, the haemorrhoids may return of themselves or be put back by the patient. If the strangulation be more intense, gangrene may set in and a part of the mass may slough ; or a part may suppurate and pus be discharged. Under these circumstances there will be great pain and more or less constitutional disturbance, with fever and loss of appetite. The gangrene is very evident to the eye from the greenish or blackish color and fetid odor of the 138 DISEASES OF THE RECTUM AND ANUS. part, and is rather a favorable termination to the trouble, as it generally results in a radical cure. Diagnosis. — It is not always an easy matter to discover an internal hsemorrhoid, even though it be far enough advanced to cause haemorrhage and more or less uneasiness. When it has become hard, it may be detected by the accustomed finger in a simple digital examination, but when soft and not over-dis- tended, it may escape detection. An examination should be made directly after the rectum has been emptied by an enema of warm water, when the water and the straining have brought it into prominence, and should be made with a speculum when there is any doubt. Under these circumstances it may gener- ally be brought plainly into view. An examination in a case of internal haemorrhoids should never end at the finding of the tumor. An inch or so higher up there may be a stricture, malignant or simple, which has given no sign of its presence except the haemorrhoids, and this is not a good thing to over- look. Treatment. — The treatment of this most common and dis- tressing malady may with advantage be considered under two different heads — (a) palliative, (b) radical. (a) Tlie Palliative Treatment of Internal Haemorrhoids. — In spite of all that the surgeon may say to his patient of the advantages of a radical cure, and the safety and facility with which it may be accomplished, he will still have many more chances in the way of palliation than will fall to him of using the knife. It is, therefore, of great advantage to know what can be done for a timid and reluctant sufferer without the knife ; and, indeed, most patients may be made greatly more comfort- able without any surgical interference whatever. The first thing to be done is to secure a daily natural evacu- ation of the bowels, and this without medicine, if possible. The diet should be plain and abundant. Highly seasoned meats, gravies, salads, old cheese, etc., all alcoholic drinks, and any- thing approaching excess in tobacco, should be strictly inter- dicted. If the bowels do not act daily with this diet, and with regularity in the time of going to the closet, a laxative must be added, and this may be either in the form of a mineral water in the morning, or of a small dose of compound licorice powder at night. This powder may now be bought under that name at most H^EMOKEHOIDS. 139 drug stores. The formula is, however, appended for the con- venience of any who may desire it : 3 . Fol. sennae 2 parts. Had. liquiritiae 2 parts. Fruct. foeniculi pulv 1 part. Sulphuris depurati = 1 part. Sacch. pulv 6 parts. If the haemorrhoids are in the habit of coming down when the patient has a passage, he must accustom himself for a time to the use of a bed-pan, and to having his passages while in the horizontal position. This will be considered a very objection- able remedy by most ; but it is one from which great benefit will be derived. The other treatment is local, and consists mainly in the use of astringents and of cold. A cold sitz-bath every morning is one of the best of all methods of preventing and relieving haem- orrhoids ; and after each passage cold water should be freely applied to the protruding mass. Even ice-water will do no harm, and if the" case is one attended with bleeding, this will be found a most valuable means of combating that symptom. The number of astringents which have been recommended for use under the circumstances we are now considering is very large. I shall content myself with naming one, the subsulphate of iron, which combines the advantages of all the others. This may be applied in the form of an ointment (3 ]'.-§].) to the haemorrhoids when prolapsed, or may be given in the form of a suppository (2-5 grs.) and allowed to remain in the rectum over night. It will be found to act simply as an astringent, causing no pain, and destroying no tissue. By these means, when followed with care and patience, the worst case of haemorrhoids ma} 7 be greatly improved, and when the sufferer will not submit to curative treatment, or when, from any reason, operative interference is contra-indicated, they should always be tried. Although they are given simply as palliative measures, and should be considered as such, I have had some cases where, after a few weeks of this treatment, the patients believed themselves cured, and were, at all events, so far relieved as to disappear from observation. Treatment of Strangulation. — The practitioner may at any 1-iO DISEASES OF THE RECTUM AND ANUS. time be called upon to treat this complication of internal haem- orrhoids, and the condition is an exceedingly painful one. He will generally find his patient in bed, complaining that his piles are "down," and that he has been unable to replace them. The prolapse may have occurred at the time of defecation, or during a momentary mental excitement or physical effort. On examination, the anus will be seen to be surrounded with a mass of haemorrhoids which are swollen, congested, livid, and more or less cedematous, and any attempt to replace them will cause exquisite pain. This is an excellent opportunity for in- ducing the sufferer to submit to a radical operation, and should consent be gained, ether may be given, and the usual operation, by the ligature, be at once performed. The operation, under these circumstances, does not seem to be contra-indicated, and I have never had occasion to regret performing it. But should an operation be refused, the mass must be re- duced. The patient should be turned on the face, with a hard pillow under the pelvis to raise the buttocks and allow of gravi- tation of the abdominal contents away from the rectum. The mass should then be well smeared with olive oil, and a gentle effort made to reduce it by the taxis. This may sometimes be done by introducing one finger into the anus and exerting press- ure with the others, gradually forcing the tumors, one by one, within the bowel ; at other times the mass may be replaced by a firm and continuous pressure, with the bulbs of all the fingers directly upon it, till the blood has been crowded back, and the diminished piles slip up together. Much gentleness is required for this manoeuvre, which is a very painful one under any cir- cumstances, and one man may succeed where another would fail. At times, however, replacement by the taxis is impossible. Under such circumstances, it is a not uncommon practice to re- sort to leeches ; and though I have never done it, I have seen it almost immediately successful with others, and the patient him- self will assure you that, if the piles would only bleed, they could be easily reduced. It is better, however, to apply cold, and to leave the patient in bed on his face, with the buttocks raised. The cold should be in the form of an ice-bag, and this will almost certainly give relief to suffering, and so reduce the (Edematous swelling as to render reduction possible on a second attempt. Should this also fail, there is nothing to do but to HAEMORRHOIDS. 141 wait for the condition to subside under the use of cold and ap- plications of belladonna and opium in the form of a soft oint- ment, with rest in the position named, and the administration of laxatives. After forty-eight hours of this treatment, the patient will generally succeed by himself in reducing the mass. (5.) Curative Treatment. — Before recommending anything in the way of a surgical operation, the surgeon must consider whether the case before him is one in which such a procedure is justifiable, and this brings us to the consideration of what have been called symptomatic haemorrhoids, as distinguished from those which are apparently idiopathic. Internal haemorrhoids may be symptomatic of disease in a number of the viscera. They often indicate structural changes in the wall of the rectum itself at a higher point, such as malig- nant and non-malignant stricture ; and, under such circum- stances, whatever is done in the way of relief must be done to the stricture, and not to the haemorrhoids. Again, they are often secondary to disease of the bladder, to enlarged prostate, or to stricture of the urethra, and in these cases where it is pos- sible to remove the cause it must always be done. If haemor- rhoids are dependent upon a calculus or a stricture of the urethra, they will probably disappear when these affections are cured. I was consulted not long since by a brother practitioner in regard to a very typical external sanguineous haemorrhoid — the size of a large pea — on the person of his four-year old child. The child had an adherent prepuce, and the pile was the result of the straining. The ordinary operation of circumcision cured the haemorrhoid. A man with enlarged prostate is never a very desirable subject for a surgical operation, and if such a man's haemorrhoids can be rendered endurable by the palliative treatment already described, the better way will be not to use the knife. In women haemorrhoids often depend upon disease of the uterus, and in every female patient this dependence should be carefully inquired into, and if found, removed before operation. The operator in rectal surgery may save himself much discredit by postponing his operation for piles till his patient has been cured of a uterine displacement ; for, as a rule, the co-existence of the latter disease will prevent a favorable issue to the opera- tion. Either the wounds will not heal readily, or the haemor- rhoids will speedily return. It will occasionally happen that a 142 DISEASES OF THE RECTUM AND ANUS. pregnant woman will suffer so severely from this complication as to demand surgical aid. Though it is better not to operate, except in a case where the haemorrhage or the pain renders it unavoidable, still, pregnancy is not an absolute barrier to sur- gical interference in this more than in many other affections. Haemorrhoids may also be symptomatic of disease of the liver, kidney, heart, or lungs. There are few liver affections which need prevent operative interference in a bad case, but such interference should be preceded by general treatment point- ing toward relief of the hepatic circulation. An excess of alco- hol in the daily diet should be stopped, and a blue pill may be given with advantage every other day for a week before the operation. Affections of the lungs, except in a very advanced stage, need not prevent an operation. The condition which most positively stays the hand of the operator is that of albu- minuria, whether dependent upon heart or kidney. Having decided to attempt a radical cure, the surgeon finds himself embarrassed with the number of operative procedures from which he may choose. It is safe to say that no one opera- tion is the best in all cases, and I shall make no attempt even to enumerate all of those which have, at different times, been advocated, but shall describe several which are to be relied upon, and which, together, will cover every case. T/ie Application of Caustics. — Chief among the caustics used for this purpose are nitric acid, pure carbolic acid, and Vienna paste. The capillary haemorrhoid may be cured by painting it once or twice with pure nitric or carbolic acid ; but large and old haemorrhoids are not curable by this means, though the haemorrhage from them may be stopped, and for a time they may cease to prolapse. When used upon a capillary growth, a speculum must be introduced. If used in a case of large tu- mors, they must first be brought outside of the body, carefully dried, and then thoroughly covered with the acid, applied with a small stick or glass brush. The end of a match makes an ex- cellent brush. The tumors should then be well oiled and re- placed. The application is not generally painful, unless the acid is applied to the wrong surface, viz., the skin. I have used this plan of treatment in many cases ; have seen an exhausting haemorrhage from a capillary tumor stopped for- ever by a single application, and have benefited old cases to an extent which convinced the patients they were radically cured HAEMORRHOIDS. 143 in spite of my own skepticism ; but it is never safe to promise anything more than temporary relief by this means. The capil- lary tumor is very likely to subsequently become the larger ar- terial one ; and the old and large hemorrhoid is more than likely to become prolapsed at some future date ; so that I no longer use it in these latter cases when the patient will permit me to follow my own judgment. There is one danger in the application of a strong acid to an old prolapsing hemorrhoid, and that is, the occurrence of a profuse secondary haemorrhage when the slough separates. Such an accident is not common, but it may be a fatal one, and it happens just often enough to worry the surgeon in every case in which he has employed this method on an old and debili- tated subject. The Vienna paste is a much more powerful caustic than nitric acid, and its application to the surface of a hsemorrhoid is very painful. This and the amount of tissue destroyed by it are the two great objections to its use. It has been employed to pro- duce deep, linear radiating cicatrices, each cicatrix running from the centre of the anus over the top of a prolapsed hsemorrhoid ; and three or four such cauterizations will undoubtedly cure an ordinary case of piles; but the Paquelin cautery will do it much better, and if the patient will submit to the latter, he will submit to something better still, and that is the ligature. Treatment by Injection. — The treatment of haemorrhoids by injection of certain substances, chief of which is carbolic acid, may now, I believe, be accepted as a surgical procedure of a certain definite value, and one worthy of a place among the recognized means of cure at our command. Originating as it did among the quacks, it has been looked upon with suspicion, and its adoption by the profession has been followed by the ac- cidents which generally attend a new remedy before its applica- bility is fully understood ; but this does not diminish its real value. I wish now to emphasize what I wrote in the first edition of this work in favor of this method of treatment. For the past year I have treated nearly every case of internal haemorrhoids for which I have been consulted by this method alone, and the favorable view I then held regarding it has only been confirmed by subsequent experience. The following cases, selected from dispensary and private 144 DISEASES OF THE RECTUM AND ANUS. practice in which this plan of treatment has been adopted, will illustrate some of its advantages and disadvantages. Case*. — Male, aged thirty-nine. This was an ordinary case of prolapsing internal haemorrhoids of about six months' dura- tion in an otherwise healthy man. The tumors were well de- veloped, bled freely at each motion of the bowels, and were usually reduced by the patient without much difficulty. In the course of three months four injections of carbolic acid were made into four separate tumors. Only one of them was fol- lowed by any pain or soreness, and this not very marked in character ; and after three months the man was discharged cured, there being no longer any bleeding or descent of the haemorrhoids at defecation. The man, who was a fireman, was at no time during the treatment unable to attend to the active duties of the service. Case. — Male, aged thirty-eight. In this patient anything like a cutting operation was out of the question. He had been a hard drinker for years, and was suffering from phthisis, cirrhosis of the liver, and albuminuria. The haemorrhoids were of long standing ; the whole circle of mucous membrane pro- lapsed with them ; and the sphincter had lost its contractile power. The man was under treatment three months, and dur- ing that time six injections of carbolic acid were made, and each one was followed by more or less pain and by sloughing of the haemorrhoid. The pain was not, however, so great as to coun- terbalance the relief the patient experienced from the cessation of the bleeding and the decrease in the protrusion, and the treatment was gladly persisted in by him, till in the end he considered himself as cured and ceased to attend. I have no doubt that in this case the sloughing of the tumor, which each time left a dirty sore after the introduction of the acid, was di- rectly due to the patient's condition ; but he was sustained with generous diet and suitable tonics, and, as I say, did very well — much better than he would have done by any other plan of treatment which it was safe to try; and, but for it, I should have confined myself strictly to palliative measures. Case. — Male, aged fifty-two. General health excellent. Haemorrhoids well developed and prolapsing. Having had con- siderable experience with this method of treatment by this time in dispensary practice, I ventured to try it in a private patient, and to promise an easy and painless cure. A single injection HAEMORRHOIDS. 145 was therefore made, and for the first forty-eight hours there was little trouble ; but at the end of that time I received a telegram from the gentleman that he was suffering great and constantly increasing pain — he having left me on the day following the in- jection to return to his home in a neighboring city. I went to him and found, to my disgust, that the injection had in his case also caused a slough, and that he was suffering intense pain at each act of defecation. Suitable treatment with laxatives and anodyne suppositories was at once instituted, but his sufferings continued for many days, and he finally went off to the moun- tains where he remained till the ulceration had healed. Need- less to say he refused to continue this "painless" method of cure, and I lost my patient and not a little reputation. Case. — Male, aged fifty-three. Also a private patient, and in fair general condition, but with old and severe haemorrhoids and partial prolapse, and weakening of the sphincter. I was first called to see him in the night, when he was suffering from strangulation of the entire mass, and a week later I began the use of the acid. This was followed very cautiously and with abundant intervals of rest after each injection, and in a very short time the relief was very apparent in the diminution of the size of the protrusion. There was no pain at any time during the treatment, and only a slight nipping sensation for an hour or so after each injection. In the end he was entirely cured, all haemorrhage and protrusion of the tumors having ceased, though the anus was still surrounded by the redundant circle of half skin and half mucous membrane which remained from the former condition of prolapse. Case. — Clergyman, aged forty-eight. This case and the following one were selected for treatment by injection for the simple reason that they were the worst cases of long-standing and advanced hemorrhoidal disease which had come to my office in months. This gentleman had been forced to retire from the active duties of his profession ; was nervous, excitable, and dyspeptic ; suffered from palpitation, loss of sexual power, and pulmonary disease ; and the tumors when prolapsed formed a mass fully as large as a large hen's egg. The treat- ment lasted about four months. The solutions were of varying strength, sometimes strong enough to cause sloughing of a considerable portion of a tumor, but generally weaker. When a strong solution was used and a slough produced the injection 10 146 DISEASES OF THE RECTUM AND ANUS. was not repeated for two or three weeks, until the part had healed and the disturbance subsided. The weaker solutions were used much more frequently, the patient coming to me twice a week and sometimes receiving two or three injections at each visit. The treatment was not entirely painless, for when a strong injection was used there was more or less subsequent suffering, and the patient was willing to follow directions and spend a considerable portion of the day on the lounge with a book ; but he was at no time actually confined to the house, nor was it ever necessary for me to visit him there, nor ad- minister anything more than an anodyne suppository. At the end of four months he was cured, and, I believe, as thoroughly cured as though he had been etherized and the tumors removed in any other way. Six months after the cessation of the treat- ment he reported at my office fully as well as w r hen the treat- ment was concluded. Case.— H. L , aged forty-two. Sent by Dr. W. M. Bill- iard. This man had been a constant sufferer for twenty-five years. The tumors surrounded the whole circumference of the anus, were large and pendulous, prolapsed easily, and bled freely. In eight weeks he pronounced himself cured, and there was neither pain, bleeding, nor protrusion. The cure was accomplished without a day's detention from business, and with only slight annoyance after one or two of the injections, which varied in strength from one part in six to one in twenty-five. At the end of six months he also had had no return of his trouble. These cases have been selected simply as illustrations, and it would be useless to multiply them. I have used this method of treatment now many times, and except in the third case re- ported here, have never had reason to regret using it, or to be dissatisfied with its results, as far as I have been able to follow them. The unfortunate result in that case was rather my fault than the fault of the treatment, and would not happen w r ere the solution properly selected ; but at that time the treatment was new to me, and all that I really knew about it was from the reports of patients who had been cured by certain irregular practitioners. Although I should be very slow to advocate any one treat- ment of this affection to the exclusion of all others, I now generally adopt this by preference, and as yet I have not known it to fail. Its advantages over all other methods, provided its HEMORRHOIDS. 147 results prove equally satisfactory, are manifest to all. The pa- tient is not terrified at the outset by the prospect of a surgical operation, is not confined to his bed, and is not subjected to any considerable suffering. The cure goes on almost painlessly and without his consciousness. There are no objections to this method which do not apply equally to others. I have once seen considerable ulceration result from it, but I have seen an equal amount follow the ap- plication of the ligature ; and I do not consider this as a danger greatly to be feared when injections of proper strength are introduced in the proper way. It is applicable to all cases ; is especially adapted to bad cases ; and may be used, as in the second case, where a cutting operation is inadmissible. It acts by setting up an amount of irritation within the tumor which results in an increase of connective tissue, a closure of the vascular loops, and a consequent hardening and decrease in the size of the hemorrhoid. Except when sloughing occurs, the tumors are not, therefore, removed, but are rendered inert so that they no longer either bleed or come down outside of the bod}'. In cases in which the sphincter has become weakened by distention, the injections will also have a decided effect in contracting the anal orifice, as do injections of ergot or strych- nine in cases of prolapse. I must confess that as my experience with the method has increased, the objections to it which are now generally made, and to which I at first attached considerable importance, have gradually lost their force. These objections are briefly four- pain, ulceration, embolus, and the uncertainty of the result. The first two are matters which depend in great measure upon the strength of the solution employed, and are, therefore, within the control of the operator. As for embolus I can see no more reason why the clot formed in this way should become detached and pass into the general circulation, than should the clot formed on the proximal side of the ligature. In my own prac- tice, as I have said, the results have been uniformly satisfactory, and when ulceration has been produced I have found it no more difficult to manage than that which follows the detach- ment of the ligature. The method requires some practice and some skill in manip- ulation in getting a good view of the point to be injected and in making the injection properly. In the first three cases reported, us DISEASES OF THE RECTUM AND ANUS. the solution employed was one part of pure carbolic acid to three of glycerine and three of water ; in the last the carbolic acid was decreased one-half, and this is a better solution to use. I have experimented with solutions varying in strength from five to thirty-three per cent., and am much better satisfied with the former figure than the latter, which will frequently cause sloughing. The results obtained by the weaker solutions are in the end as good as the others, and the amount of disturbance is I have also used solutions of tincture of iron and of ergo- less. tine, but I prefer the carbolic acid, the iron being much more painful. Twice I have had it cause fainting from the immediate suffering it caused. The amount injected each time should be Fig. 53. — Hypodermic Syringe for Injecting Haemorrhoids. about five drops. The instrument used is a hypodermic syringe such as is shown in Fig. 53, with a fine, long needle, through which the solution will readily pass. When the tumor to be injected is prolapsed, the needle may be thrust into it without difficulty, and after the injection is made the tumor should be gently replaced. If it be allowed to stay out of the anus for a few moments it will be seen to swell up and become black and hard with venous blood. There is seldom any haemorrhage from the operation, but occasionally a few drops of blood will follow l ho puncture. If the tumor is not protruded at the time of operation it may be seized with toothed forceps (Fig. 54), and drawn out and held while the injection is made, or a speculum HEMORRHOIDS. 149 may be used. The injection should be landed as nearly as pos- sible in the centre of the hemorrhoid, the needle being entered perpendicularly from the apex, and not passed upward under the mucous membrane in a longitudinal direction. If the acid be placed simply under the mucous membrane the latter will die and an ulcer result, but if placed more deeply the danger of an ulcer is much decreased. Used in this way and in the strength last indicated the acid will not be followed by any great amount of pain. Each injection should be followed by a day's rest in the horizontal position. No change need be made in the ordinary diet of the patient provided the bowels act regularly every day. Only one tumor should be injected at Fig. 54. — Forceps for Bringing Down Haemorrhoids. a time, and I seldom repeat the injections of tener than once a week. It will sometimes be found necessary to inject the same tumor two or three times when it is a large one. It will be observed that in the cases reported the length of time during which the patient was under treatment was in each case, except the second, between three and four months. I have no doubt that this could be much shortened, were it necessary ; but where the patient is at no time confined to the house, time is of little consequence, and I seldom repeat the applications of tener than twice a week, preferring to see the full effect of each one before giving a second. Still, were there any reason for haste, I should not hesitate to shorten this interval, and I know that in the hands of the quacks the time is considerably shortened. I believe also that with them it is the custom to produce a considerable sloughing of each tumor by the strength 150 DISEASES OF THE RECTUM AND ANUS. of the injection, and several times I have had patients come to me in this condition after a single injection. But no such use of the acid is necessary to effect a cure, and sloughing is a result which I try very carefully to avoid. I was sent for not long since in the middle of the night to see a gentleman suffering intensely with piles. A large, venous, ex- ternal hemorrhoid had formed suddenly two days before, and his physician had injected into it a few drops of carbolic acid while it was still tense, inflamed, and exquisitely tender. The puncture had bled continuously, drop by drop, ever since the operation, and the pain was exceedingly severe, but there seemed to have been no other effect. I merely mention the case to say that in this particular class of cases the simple incision is a much better plan of treatment than any injection ; and, generally, that the injections are for internal and not external hemorrhoids. Treatment by Ligature. — This is the method of treatment which has been brought to such perfection by Allingham, and which usually passes by his name. It consists in partially cut- ting through the hemorrhoid at its base, and tying the remain- der. It is performed in the following manner : As in all operations on the rectum, the bowel should be thoroughly cleared by a cathartic on the previous day and by an enema just before operating. The patient may be placed either on the side or in the lithotomy position ; personally I prefer the latter. The sphincter should be carefully dilated, as already described, and this is a step of great practical impor- tance, as the securing of complete paralysis of the muscle will do more than anything else to prevent pain and spasm after the operation. In cases where the tumors were large and prolapsed readily, I have seen this step in the operation omitted as un- necessary by good surgeons ; and I have seen a week of great suffering to the patient follow the omission. So important is this step in the operation, for the relief of pain, that in some cases in which the tumors were so extensive and the sphincter so dilated that they could easily be removed without it, I have first cut off the haemorrhoids and then stretched the sphincter. It is rather a reversal of the regular order, but it illustrates the fact that stretching the muscle should not be omitted. If the muscle is forcibly and suddenly torn apart by the operator, a fissure may result, and may require a subsequent operation for H^EMORKHOIDS. 151 its cure after recovery from the original operation. The tumors being thus brought into full view by the introduction of a spec- ulum, one is seized and drawn down with a toothed forceps. The selection of a good forceps for this purpose is a matter of considerable importance. In my own operations I use those shown in Fig. 55, though the instrument sold under Luer's name (Fig. 56) is an exceedingly good one. The hold is firm in either case, and the handle sufficiently long for the hand of the assist- ant to be out of the way of the operator in the subsequent steps. Fig. 55. Having secured a good firm hold on the tumor, the surgeon transfers the forceps to the left hand, and with a strong and long pair of straight scissors cuts the hemorrhoid away from its attachments for a certain distance, beginning from below and cutting upward. In this way the mass is entirely cut off except at its upper end, where the artery or arteries which feed it enter it from above. It is to prevent haemorrhage from these vessels that the ligature is applied instead of completely cutting Fig. 56. — Luer's Haemorrhoidal Forceps. off the mass ; and this is done by the operator after transferring the forceps to the assistant. The line of incision should com- mence at the j unction of the skin and mucous membrane, shown in Fig. 52. The ligature should be of stout hemp, something stouter than ordinary ligature silk being necessary. The string should be tied very tightly, and after it is secured the pile may be cut off to remove as much as possible of the dead tissue from the rectum. Each hemorrhoid is thus treated in succession, and 152 DISEASES OF THE RECTUM AND ANUS. after all are removed, a suppository of opium is introduced, and a T-bandage tightly applied over a compress of lint and a napkin. The after-treatment is a matter of a good deal of importance. It is not well to allow the bowels to be confined for more than two or three days, and the first passage should be assisted by a laxative. Much less pain will be caused by a soft passage on the third day after the operation than will result from confining the bowels for ten days or a fortnight, as is often done. Under the latter circumstances the suffering caused by the first pas- sage is often atrocious, and will not infrequently so tear the mucous membrane as to produce a fissure. It is not a good plan to try and introduce suppositories after the operation, and should morphine be necessary it is better given by the mouth or hypodermically. The ligatures will generally come away about the end of the first week, and the patient should be kept in bed or on the lounge for a week longer. This in an active person will sometimes be difficult to manage ; but no other course should be sanctioned by the surgeon, for the reason that when the ligature comes away an ulcerated spot is left ; and under cer- tain circumstances, the most effective of which is active exer- cise, these little wounds may grow larger instead of smaller. In this way a case of internal haemorrhoids may be turned by an operation into one of ulceration of the rectum, and the change is not to the advantage of the patient. One such case I have had in my own practice, in a debilitated patient in poor general health ; and a long course of careful treatment was necessary to effect an ultimate cure. Nothing has been said regarding primary or secondary haemorrhage, for the reason that it is not a complication to be looked for. The diet for the first few days should be chiefly fluid. This operation, thanks to Mr. Allingham, is now so well and so favorably known, that but little need be said in addition. It is as safe as any operation in surgery, and by it the surgeon may promise his patient an absolute and permanent cure of his troubles in every case. This is saying a great deal, but not too much. It has been followed by fatal results— but so has every other minor surgical operation; and the chance of such a ter- mination is so slight that it need not enter into the calculation HAEMORRHOIDS. 153 of the operator. So much may be said in its favor, but there are certain objections to it which it is well to bear in mind, es- pecially when recommending it to the patient and assuring him that it is merely a trifling affair. In a case operated upon in consultation with Dr. C. H. Avery, of New York, we came very near losing our patient (a strong man in good condition for operation) from what bid fair to be pyaemia. But excluding this complication, which may follow any wound, the operation itself is not a light matter, and the surgeon when he undertakes it can never be exactly sure of how much suffering his patient will have to endure before a cure is accomplished. There may be, and often is, severe haemorrhage at the time of the operation, which, though not dangerous, will require a moderate stuffing of the rectum with lint for its control ; and if this is resorted to an additional element of trouble will be found when its removal becomes necessary. Again, the constitutional disturbance is often severe. There will often be considerable nervous excite- ment, a frequent pulse, loss of sleep, pain sufficient to demand the use of morphine for days, obstinate retention of urine which may render catheterism necessary for a fortnight, swelling of the parts around the anus, and finally undue contraction after cicatrization which will entail the use of the bougie. That this picture is not overdrawn the experience of most men who have had a large number of these cases will, I think, prove. Operation with the Clamp and Cautery. — This is generally known as Smith's operation, because he has advocated it so forcibly and practised it with such good results. He claims no credit for introducing it, however, this being due to Mr. Cusack, of Dublin, and his own originality has been chiefly spent in im- proving the clamp, which is shown below. The operation consists, according to Dr. Smith's most re- cent description, in drawing down the tumor, embracing its base in the clamp, and removing it with the serrated and cutting cautery knives shown in the cut. (Fig. 57.) It is important to isolate the tumors well, so as to compress them easily and completely, and in some cases where the hemorrhoid runs, as it were, abruptly into the hypertrophied skin, Smith recommends the previous making of a slight groove with the scissors, so that the compression of the neck of tumor may be the more effectual. The base should not be divided too close to the clamp lest there be not enough tissue left for the 154 DISEASES OF THE RECTUM AND ANUS. proper application of the hot iron. The latter is to be applied very thoroughly and slowly at a black heat ; and the blades of the clamp may then be gradually released by the screw. Should any vessel not thoroughly cauterized bleed when the pressure is taken off, the clamp must be again screwed up and the cautery again applied. It may be necessary to do this several times. The advantages claimed for this operation by Smith over that of Allingham, with which it comes most naturally into com- parison, are greater safety to life, greater freedom from suffer- Fig. 57. — Smith's Clamp and Serrated and Cutting Cauteries. ing, and a more rapid recovery, with less danger of pyeemia, of ulceration, and of embolus, and less constitutional disturbance after the operation. With regard to the painlessness of the operation, a point on which I have asked further information from Mr. Smith, he very kindly wrote me as follows : "I mean by that to state that by very great care in selected cases, and by the use of the clamp well shielded by the ivory, and when no skin is to be removed, the operation, as I have often verified, is attended by very little pain. As a rule, in severe cases I use an anassthetic, and I never dilate the sphincter, but sometimes divide it." HAEMORRHOIDS. 155 The reader is, therefore, at liberty to choose between these two procedures. My own experience has been almost entirely, confined to the former operation where I desired to remove only a moderately large hemorrhoidal protuberance, and I have re- served Mr. Smith's method for cases of extensive disease where much tissue was to be removed, whether it were a case of severe haemorrhoids with prolapsus, such as is shown in Plate II., Fig. 3, or of prolapsus alone. The array of unfortunate cases, espe- cially of haemorrhage, given by Mr. Smith, in which he has per- formed the operation of Allingham, confirms very strongly what has already been said against that operation ; but I am unable to see why one should be any more fatal than the other, and the operation with the ligature may also be performed with lit- tle pain and without an anaesthetic in certain selected cases. I have done it several times in my office, tying off only one tumor at a time, however, where the sphincter was relaxed, and the tumors well separated from each other. Since adopting the treatment by injections I have had very little use for either operation, except in cases of prolapsus, and in them I decidedly prefer the clamp and cautery. With the means already enumerated every case of internal haemorrhoids may be cured where a cure is desirable, or relieved when radical cure is out of the question, and I shall not, there- fore, take the space necessary to describe the various others which either have been or are at present in favor, such as simple dilatation of the sphincters, crushing, the galvano-cautery wire, plunging the actual cautery into the substance of the haemorrhoid, and cauterizing the skin of the anus in radiating lines to cause contraction. It will sometimes be found that several of the methods de- scribed may be used with advantage on the same case. Thus, for example, a patient may present himself with one haemor- rhoid which seems particularly adapted for the ligature, with another strawberry-like growth which can be eradicated with a single application of nitric acid, and with others which may be cured by injections. All three methods may be used without confining the patient to his room or causing any great amount of suffering, as I have often proved, and by a combination of them all a radical cure may be reached more quickly and pain- lessly than by any one method singly. CHAPTER VII. PROLAPSE. Four Varieties. — First Variety: Prolapse of the Mucous Membrane Alone. — Second Variety: Prolapse of all the Coats of the Rectum. — Third Variety: Prolapse of the Upper Part of the Rectum into the Lower, or Invagination. — Fourth Variety : Invagination in the Continuity of the Bowel. — Prolapse of the Mucous Membrane Alone. — Causes. — Symptoms. — Treatment: Palliative and Curative. — Prolapse with Haemorrhoids. — Treatment by Injections. — Cauterization. — Description of Operation. — Smith's Clamp. — Dupuytren's Operation. — Prolapse of the Second Degree. — Pathological Changes. — Presence of Peritoneum. — Strangulation. — Ad visibility of Reducing Inflamed or Gangrenous Prolapse. — Excision of Prolapse after the Formation of a Slough. — Third and Fourth Varieties. — Differences be- tween Third and Fourth. — Degrees of Invagination. — Anatomical Appearances. — Pathology. — Relative Frequency. — Symptoms.— Physical Signs. — Acute and Chronic Forms. — Diagnosis. — Differential Diagnosis from Volvulus ; from Strict- ure ; from Internal Hernia ; from Obstruction by Pressure from without the Bowel ; from Foreign Bodies ; from Peritonitis with Perforation. — Treatment. — Replacement by Manipulation. — Treatment by Injections. — Treatment by Punc- ture. — Laparotomy. — Description of Operation. Of prolapse of the rectum and invagination there are four dis- tinct varieties. 1. Prolapse of the Mucous Membrane Alone. — This, which is sometimes spoken of as "partial" prolapse, because only a part of the wall of the rectum is involved in the descent, is well represented in Fig. 58. 2. Prolapse of all the Coats of the Rectum, including, when the Disease is of sufficient Extent, the Peritoneum. (Fig. 59.) 3. Prolapse of the Upper Part of the Rectum into the Lower, or Invagination. (Fig. 60.) 4. Invagination in the Continuity of the Intestine. — The same condition as the third variety, only occurring in a part of the bowel further away from the rectum. The first form is a mere everting of the mucous membrane of the lowest portion of the rectum, rendered possible by the laxity of the submucous connective tissue. It is seen as an ac- companiment of old cases of haemorrhoids, and its mechanism PROLAPSE. 157 may be studied at airf time upon the horse, in which it occurs naturally at the close of each act of defecation. The second variety is an exaggeration of the first, in which, after the submucous connective tissue has yielded to its utmost, Pig. 58.— First Variety of Prolapse. (Molliere.) the whole thickness of the rectum begins to descend, and finally protrudes. It follows, of necessity, that after this protrusion has reached a certain length, the peritoneal coat must also de- Fig. 59. — Second Variety of Prolapse. (Molliere.) scend outside of the body, and this condition is shown at a glance by reference to the plate. In both of these forms the protrusion begins first at the part of the rectum nearest the anus. In the third form, the part of 158 DISEASES OF THE EECTUM AND ANUS. the rectum higher up is passed through that nearer the anus, and what is known as an invagination occurs. This condition must, of necessity, cause a sulcus or groove to exist between the containing and the contained portion ; and at the bottom of this sulcus the mucous membrane of one is directly continuous with that of the other. The depth of this sulcus must depend upon the point at which the invagination occurs, but in the variety under consideration, its bottom can generally be felt by introducing the finger by the side of the protruding portion. In the fourth variety this sulcus also exists, but its bottom cannot be felt, the point at which the invagination has occurred being in the continuity of the bowel, too far away from the anus. In the first three forms of the disease there is always a protrusion of a portion of the bowel through the anus ; in the fourth, there may be no such protrusion, the lower end of the invaginated bowel being still within the rectum, or, perhaps, too far up the canal to be seen or felt. FlG. 60.— Third Form of Prolapse. (Bryant.) Having thus briefly defined the different varieties of prolapse and invagination, we shall consider each one in detail. Prolapse of the Mucous Membrane Alone. — This is, per- haps, the most common of all the varieties of the disease when we take into consideration its frequent coexistence with haemor- rhoids. It is found in children most often between the years of two and four, and in adults it is more frequent in women than in men. Its causes are various. Among them may be enumer- ated the following : a. Those which tend mechanically to draw down the mucous membrane, such as haemorrhoids, polypus, vegetations, and tumors, b. Those which tend to weaken or to destroy the action of the sphincters, such as ulcerations or in- cisions, c. Those which cause muscular spasm, such as fissures, worms, dysentery, phymosis, cystitis, calculus, stricture of the urethra, and enlarged prostate, d. Those which produce per- manent dilatation and weakening of the sphincters, such as PROLAPSE. 159 spinal paralysis, traumatism, chronic constipation, and sodomy. In this last connection, Molliere ' details a very interesting case from his personal observation in a woman suffering from vesico- vaginal fistula. Her husband, a brutish peasant, not daring to practise coitus in the ulcerated vagina of his wife, subjected her to unnatural intercourse daily for more than a year, with the result of producing a relaxation of the sphincter which showed itself by prolapse to an enormous extent, and by incontinence. To this lack of tonicity of the sphincters may be attributed the frequent occurrence of prolapse in feeble and badly nourished children, e. Those which produce oedema and swelling of the pelvic tissues, such as pregnancy, parturition, faecal accumula- tions, and hepatic lesions. . In this connection also, Molliere a details an instructive experiment which may easily be repeated on the cadaver. He says : "On the cadaver of a young girl, I introduced under the mucous membrane of the anus a blow- pipe, and fastened it with a ligature. By practising insufflation the air instantly spread in the submucous rectal tissue, and the mucous membrane escaped from the anus. I repeated the same manoeuvre at another point of the circumference of the anus, with the same result. By dissection I was able to assure myself that only the mucous membrane had been raised up. It was then sufficient in this case to cause tumefaction of the sub- mucous tissue to produce prolapse ; and, moreover, in this subject, the anus was still firmly closed." f. To these causes, it may be proper to add one anatomical one — the undeveloped sacrum in children, which, by its straightness, leaves the rectum comparatively unsupported. Symptoms. — This first form of prolapse always comes on gradually and never suddenly. It may be partial or complete as regards the circumference of the anus, being in some cases of hsemorrhoids confined to one side of the aperture, and in others involving the whole circumference. It presents itself as a scar- let or livid mass (depending upon the state of contraction of the sphincter) projecting from the anus, covered with the natural secretion of the bowel, directty continuous with the skin on one side and with the mucous membrane on the other, and ar- ranged in folds which radiate from the central aperture toward the circumference. It is at first spontaneously reducible, or at 1 Op. cit, p 202. i Op. cifc., p. 199. 160 DISEASES OF THE RECTUM AND ANUS. least easily replaced by a slight pressure, and remains reduced till the next act of defecation ; but as the amount of prolapsed membrane increases, the difficulty in reduction becomes greater. At first also there is no pain, but after a time the act of defeca- tion comes to be greatly dreaded by the patient, and the suffer- ing continues till the tissue is replaced. Treatment. — The first step in the treatment of prolapse of the rectum to which the surgeon will be called to attend will generally be to effect the reduction of the mass ; after this has been accomplished the treatment may be either palliative or curative. In children a prolapse may generally be reduced by laying the patient across the lap on its face and making gentle pressure on the protruded bowel with the fingers which have been well oiled, or with a soft greased rag. If this cannot be accomplished by a gentle taxis, and without bruising the parts, the child should at once be etherized and a curative procedure adopted. It is scarcely worth while in a child to stop to try the various methods of reduction which have been recommended where the taxis has failed, before resorting to this step. In an adult, however, ether and operative interference may both be declined, and the surgeon may have to tax his brain to accomplish the reduction without the aid of an anaesthetic. In such a case, after gentle taxis has been tried with the patient in the knee-elbow position, and failed, cold should be applied while the patient remains on the face in bed with a pillow under the pelvis ; and this maybe alternated with warm poultices and with plentiful applications of an ointment composed of equal parts of ext. of belladonna and ext. of opium. By these means, the most effectual of which is position, reduction maj^ almost always be accomplished. When by the action of the sphincter the prolapse has become gorged with blood and cedematous, the surgeon is often tempted to resort to leeches. They will gener- ally give relief, and may greatly facilitate reduction, but they are not free from the danger of a concealed haemorrhage within the rectum after the prolapse has been replaced. The palliative treatment is directed entirely toward dimin- ishing the frequency and the amount of the prolapse, and in children a cure may sometimes be obtained by these means without resorting to surgical interference. The act of defeca- tion is first to be regulated, and should be performed with the patient in the recumbent posture in bed, or while standing. PROLAPSE. 161 One buttock may also be drawn aside so as to tighten the anal orifice with advantage ; and any source of irritation which pro- duces frequent defecation and straining in the act must be re- moved. After the action of the bowels, if the prolapse has oc- curred, the bowel should be thoroughly washed with cold water and a solution of alum (3j. to fviij.) before it is returned. Another favorite wash is composed of the tincture of iron, twenty to thirty drops to four ounces of water. The patient should then be confined to the bed for some time, and pressure should be applied over the anus by a pad kept in place by a T-bandage in the adult,- or by a broad strip of adhesive plaster in children, applied so as to draw the buttocks into close ap- position. A rectal supporter may also be worn when the patient is up and about, and perhaps the best of these is the one made by Mathieu, and represented in Fig. 61. Fig. 61.— Rectal Supporter. After the bowel has ceased to come down with the act of defecation, an astringent injection may be given every night with advantage and allowed to remain in all night. The gen- eral health should be carefully attended to ; tonics should be administered where they seem to be indicated ; and if well borne, cod-liver oil may be used to fulfil the double indication of tonic and laxative. In children these measures may, as has been said, be curative, and in fact the disease often ceases spon- taneously at about the time of puberty ; but in adults they are not at all likely to be so, and more radical measures will gener- ally be necessary. Of these there are several which are effect- ual, and each of them has its supporters and advocates. In cases of prolapse attending old internal haemorrhoids, the operation for the removal of the latter by the ligature may easily 11 162 DISEASES OF THE RECTUM AND ANUS. be extended so as to cure at the same time the former condition. And here a little careful discrimination may be necessary to distinguish between piles and prolapsed mucous membrane. The piles are smooth, hard, and shiny tumors ; the prolapse is soft and velvety to the feel, and generally surrounds the whole margin of the anus without being divided into distinct tumors. In such a case the proper course to pursue is to divide the pro- lapse into several sections with the scissors, and tie off each one exactly as though it were an internal hemorrhoid. I have sev- eral times performed this operation with the happiest results, both as to curing the piles and the prolapse ; but caution must be exercised as to the amount of tissue removed, lest too great a degree of cicatricial contraction result. Since beginning the use of injections in the treatment of hemorrhoids, I have also in some cases effected a cure of this form of prolapse by the use of carbolic acid in the same way as for piles. The idea of using carbolic acid for this purpose is, I believe, my own, and came naturally from my trials of the remedy in haemorrhoids ; but both strychnine and ergot have been used for the same purpose for some time. At a meeting of the Therapeutical Society, December, 1879, reported in the Gaz. Hebdom. , January 2, 1880, Dr. Ferrand re- lated the case of a lady who had suffered three years from pro- lapse, the tumor being nearly the size of the fist, and descending even when she walked across the room, and causing great suf- fering. One gramme and twenty centigrammes of a solution, composed of glycerin and water aa fifteen parts, and alkaline l^drated extract of ergot two parts, was injected into the ischio-rectal fossa beside the prolapse. Considerable benefit resulted, and three other injections were practised at intervals of twenty days, ten days, and a month, with the result of ef- fecting a cure. The patient was seen after an interval of six months, and it was found that the prolapse was not reproduced even by such exertion as going up several flights of stairs. Vidal 1 also has recorded three successful cases of cure with ergotine. The first was that of a man, aged thirty-nine, who had suffered for eight years. After five injections of fifteen drops of a solution of ergotine, at intervals of two days, the mucous membrane scarcely protruded at all. After the eleventh 1 Paris Medical, Auguat 28, 1879. PROLAPSE. 163 injection it only came down during defecation and returned spontaneously. The whole number of injections was twenty- two, and the man remained perfectly well four years after. The second patient, a female, aged sixty-four, was cured after twenty-four days' treatment, and remained well two years and a half after. The third patient, a female, aged fort} r -five, was cured in fifteen days by six injections of twenty or twenty-five drops each. The solution used consisted of fifteen grains of Bonjean's ergo tine dissolved in seventy-five minims of cherry- laurel water. The injections were made at the distance of one- fifth of an inch from the anus. Acute pain always followed, and contraction of the sphincter lasting several hours. Several times an injection of twenty -five drops of the solution caused spasm of the neck of the bladder and retention of urine. In no case did the injections produce any local inflammation or abscess. Dr. Vidal has more recently expressed himself as preferring Yvon's solution of ergot to Bonjean's ergotine, as causing less pain. 1 The danger to be avoided in this method of treatment is the use of too irritating solutions, or solutions in too great quantity which shall excite a suppurative action and produce constitu- tional poisonous effects. Cauterization. — In children in whom milder measures have failed, a very effectual means of cure is the application of fum- ing nitric acid to the mucous membrane of the prolapsed part. The bowel should first be carefully wiped off with a towel or sponge, and the acid then applied by means of a small stick all over the mucous membrane, but not at all to the skin adjacent. After such an application the bowel should be replaced, a pad of lint firmly applied over the anus by means of broad strips of adhesive plaster, and the bowels confined by means of opium. Allingham speaks of stuffing the rectum with wool in addition, but I have always found the pad and straps sufficient when thoroughly applied, and the child kept on its bed. After three or four days the straps may be removed, and the bowels moved with castor-oil. In a large proportion of cases the cure will be found complete, though, in a few cases, I have seen a return of the disease after a few months. In any case, however, the benefit will be found to be very great, and should the disease 1 Gaz. Hebdom., January 2, 1880. 164 DISEASES OF THE RECTUM AND ANUS. return, a very careful search should be instituted for some ex- isting source of irritation, such as polypus, phymosis, or cal- culus. In case of a recurrence, a second application will be effectual in causing a cure. This treatment, though successful in children, is by no means so in adults. Allingham calls attention to the occurrence of deep sloughs in old persons with debilitated constitutions ; and, as a result of such a slough, he has seen an almost fatal haemorrhage. Stricture of the rectum may, without doubt, be caused by too free use of this remedy, but since it follows its abuse and not its proper use in appropriately selected cases, it can hardly be considered an objection. Linear Cauterization. — In adults this is undoubtedly the best means at our command for dealing with this affection, and the best means of applying it is that recommended by Van Buren, with Paquelin's cautery. The patient is at first etherized and placed in Sims' position. Van Buren reduces the prolapse, and applies the iron with the aid of a speculum. Allingham first applies the iron and then reduces the prolapse. In either case from three to six vertical stripes should be made upon the mucous membrane, with the iron heated to a dull red-heat. The cauterization should begin about three inches up the rectum, and end at the junction of the skin and mucous membrane. They should also be deeper at the end, where there is no danger, than at the beginning, where the bowel may be perforated. Van Buren recommends that the iron be bent at a right angle a short distance from the end, so that it may be the more thoroughly applied to the concavity of the rectum, and that, in mild cases, a small iron should be used, " no thicker than an ordinary probe." (Fig. 62.) Allingham, in bad cases, burns through the sphincter muscle at two opposite points, after reducing the bowel, and inserts a small pledget of oiled wool. By this burning through the sphincter, the patulous condition of the anus is overcome. The result of the operation is to decrease the circumference of the anal orifice, and in this way to effect a cure. The patient should be confined absolutely to bed till the wounds are entirely healed, so that a recurrence of the descent may be effectually avoided. For some time after the healing, and after the patient is allowed to be up and about, in fact, until the full effect of the PEOLAPSE. 165 operation has been obtained, a bed-pan should be used. The first operation, if thoroughly performed, will probably result in permanent cure. Should it not, it may be repeated. The only danger in connection with it is the occurrence of secondary haemorrhage when the sloughs separate, and of pri- mary haemorrhage from large veins at the time of the application of the iron. To avoid this, Allingham recommends the choosing of points for cauterization which are free from large venous pouches, such as may be visible on the surface of the tumor. In old cases of extensive disease the operation as thus described may not be effectual, and it may be necessary actually to produce a stricture at the anus to prevent recurrence of the trouble. There is, per- haps, no better means of accomplishing this than to apply the iron to the whole circumference of the anus circularly, instead of in longitudinal stripes ; but such an operation will seldom be called for. There is one other method of dealing with this affection, which, though not as simple as the cautery iron alone, is well worthy of trial, and that is Smith's operation with the clamp and cautery. We have already given a figure and description of the clamp and the operation in speaking of haemorrhoids, but the operation is even better adapted to cases of pro- lapse than to haemorrhoids, the mass being larger and more readily seized, cut off, and cauterized. Having thus described the most effectual means of dealing with this troublesome affection, it is scarce worth while to describe the various cutting opera- tions by which pieces are removed either from the mucous membrane alone, or from the sphincter muscle, with the object of accomplishing the same result that is more readily attained with the cautery iron. Dupuytren's operation consisted in removing F three elliptical folds of skin and mucous membrane pointed Cau- from the verge of the anus. The same idea has been more recently applied in Germany.' Eobert and Dieffenbach cut out wedge-shaped pieces, and approximated the edges with 1 Eine neue Methode der Operativen Behandlung des Mastdarmvorfalls. Deutsche Med. Woch., No. 33, 1880. 166 DISEASES OF THE RECTUM AND ANUS. deep sutures ; and the latter even went so far as to cut off the whole tumor — an operation now seldom practised, except in slight cases, such as those accompanying internal haemorrhoids. Prolapse of the Second Degree. — As already said, the second variety of prolapse differs from the first in the fact that it is composed of the whole thickness of the bowel, and, therefore, when of sufficient length, of peritoneum also. It is probable that every prolapse of more than two inches in length may con- tain peritoneum ; and it follows from the anatomy of the parts that' the peritoneum will extend lower on the front than behind. In the peritoneal pouch thus formed there may be located coils of intestine, an ovary, or a part of the bladder. (See Kectal Hernia.) In this form of prolapse there is no groove or sulcus, as is shown by the figure, and the absence of such a groove is, therefore, no proof of the non-existence of a fold of peritoneum in the tumor. ■■•■:■■■' ::&$' Fig. 63. — Prolapse composed of all the Coats of the Rectum. (Bushe.) It is a mistake to suppose that this second variety is not met with in children, for it is only an exaggerated form of the first, being the next step in the descent after the submucous connec- tive tissue has yielded its utmost ; and exaggerated cases of prolapse are often seen in children. It is distinguished from the first variety, first of all, by its size. (Fig. 63.) The first is never very large ; while the second, from the nature of the case, must be of considerable dimensions. Again, a prolapse of the first variety is seldom of long standing, while one of the second is generally so. The second generally follows the first, but a prolapse may be of this variety from the beginning ; resulting, in such a case, generally from violent straining, and coming on suddenly. The first variety is not firm and thick to the feel ; PROLAPSE. 107 the folds of mucous membrane radiate from the orifice to the circumference, and the opening is circular and patulous. In the second, the orifice is slit-like and is drawn backward by the attachment of the meso-rectum, or in females forward by the closer attachment to the vagina. The form of the tumor is con- ical, its walls are thick and firm, and when pressed between the fingers, the gurgling of gas in a contained loop of intestine may sometimes be detected, and a resonance may be obtained on percussion. If such a tumor be carefully dissected, the coats of the pro- truded bowel will be found enlarged, the mucous membrane will be seen to be thickened and dense in structure, especially at the free extremity ; and it will, also sometimes be found eroded and granular. The submucous areolar tissue will be seen to be infiltrated with albuminous deposit, and the muscu- lar layers will be hypertrophied. Owing to these changes, the bowel is actually increased in size, and becomes too large to be retained in its proper place ; which explains the difficulty often experienced in reducing it and in keeping it reduced, in spite of the constant straining and desire for defecation which it pro- duces. These changes in the mucous membrane may in rare cases result in the production of a foul, hard, bleeding, eroded mass, which may at the first glance strongly suggest malignant growth. The bleeding from a prolapsed rectum is commonly in the form of a general oozing, and applications of astringents may be necessary for its control. Strangulation is rare in infants and in feeble old people, but in a strong j3erson the sphincter may be sufficient^ powerful to produce such a result. A strangulation may be only temporary when met by the proper means, or it may continue long enough to cause ulceration and partial gangrene ; the latter, however, is rare. When it occurs, it is possible for it to end fatally from the contiguity of the peritoneum ; but it more often results in a spontaneous cure of the prolapse, and in a cicatricial stric- ture, the location of which will depend upon the length of the prolapsed portion and the point at which the sphacelus occurs. The causes of the second variety are the same as of the first, and need not again be enumerated. The symptoms also are the same, with the addition of more or less incontinence of faeces in old cases ; but the treatment is not the same in all respects, for 168 DISEASES OF THE RECTUM AND ANUS. certain measures which may be safe when a prolapse contains no peritoneum may be fatal under the opposite condition. In cases in which curative measures are out of the question, the haemorrhages and the erosions ma}^ be relieved by suitable applications, rest in bed, defecation in the recumbent posture, etc. Persulphate of iron is perhaps as good an application to the bleeding surface as any other ; and weak solutions of ni- trate of silver often have a good effect upon the erosions. The reduction of a prolapse of the second degree is by no means as simple a matter as that of the first. When the sphincter is tight and the tumor cedematous, it may be nearly impossible ; and in old cases, where the opposite condition of the sphincter obtains, it may be equally difficult to keep the parts within the body after placing them there. The latter may, however, gen- erally be accomplished by the means already enumerated, and the reduction in obstinate cases may generally be obtained through the influence of anaesthesia. Two questions may arise in this connection. Should reduc- tion be tried when the tumor is inflamed, and should it be tried in case of a circular slough? In answering the first question, the distinction must be made between a prolapse which is merely strangulated and one which is inflamed. The appear- ances may be much the same, but an old prolapse in an old person when found in this condition is much more apt to be inflamed than strangulated, for the sphincter muscle in such cases has generally lost the power of forcible constriction. The danger in returning an inflamed prolapse into the body is that the inflammation may extend and cause general and fatal peri- tonitis, and, as a rule, it is safer not to employ the taxis in such a case, but to put the patient in bed and treat it by local appli- cations and rest till the acute symptoms have disappeared. In answer to the second question, Molliere ' recommends ex- tirpation of the prolapsed portion rather than its reduction when there is a circular slough, on the ground that no matter how radical such a step may appear at first sight, it is better than leaving the case to nature. For a circular slough means inevitably a cicatricial stricture, and if the prolapse be exten- sive, a stricture situated high up in the rectum or sigmoid flex- ure beyond the reach of art. As preferable to this he recom- 1 Op. cit. , p. 240. PROLAPSE. 169 mends the complete ablation of the tumor with all the dangers which attend such a step. These dangers are easily understood to be haemorrhage, hernia of the intestines through the incision, and peritonitis. Each may be avoided where the surgeon is prepared beforehand for their occurrence, and Molliere relates one case where the operation was performed by himself with the hot iron, but the patient "died on the eighth day from the ef- fects of the chloroform ' ' so that he was unable to decide on the value of the operation. Excision with the surgeon's eyes open to the fact that he is dealing with peritoneum may perhaps be done with success under such circumstances. At all events it is a very different matter from excision of this variety of prolapse under the im- pression that it is the one previously described, and contains no peritoneum. In this form of the disease, the surgeon may find it better, after mature deliberation, not to attempt a radical cure, but to confine his efforts solely to palliation. Dr. Kleberg has utilized the elastic ligature in operating upon severe cases of prolapse ; and, it may be, that if the mass has to be removed at all, the method he describes (p. 208) is the pre- ferable one. Third and Fourth Varieties. — These two forms of invagina- tion will be described together because of the fact that they differ from each other not at all in their nature but only in ex- tent and location. It will be observed that the word prolapse is now dropped and invagination substituted, which more aptly expresses the condition. The essential difference between the disease now to be considered and the forms already described, consists in the fact that while in the latter the bowel begins to slip down from its lowest portion at the anus, in the former the lowest portion at the anus remains in its proper position and the bowel from above is telescoped within it. Under these circum- stances it is evident, as is shown in Fig. 60, that the affected portion of the bowel must consist of three different and distinct cylinders — an outer one, which contains the other two, and two included portions, one of which is the entering and the other the returning bowel. When the upper part of the rectum becomes invaginated in this way within the lower, the included portion will appear at the anus as in the cases of prolapse already described, and a 170 DISEASES OF THE EECTUM AND ANUS. distinct sulcus may be felt by the finger between the extruded portion and the mucous membrane which is continuous with that of the anus. (Fig. 64.) The bottom of this sulcus, or the point at which the entering portion becomes directly continuous with that into which it enters may also be felt by the finger if it is low enough down ; if not, it may be detected by the aid of a soft catheter. This is what is understood by the third variety of prolapse. When a portion of the bowel still further removed from the anus has become invaginated into that immediately Pig. 04.— Prolapse of Invaginated Intestine. (Esmarch.) below, the included portion mayor may not descend sufficiently Dear to the anus to be felt by rectal touch, and the sulcus may not be apparent. This constitutes the fourth variety, or what is now generally known as intussusception. It is evident that between a case of prolapse in which all the coats of the rectum appear through the anus, and in which a sulcus can be felt by the finger passed around the protruded portion, and a case in which the ileum is telescoped through theilio-csecal valve and ap- pears at the anus, the difference is one of degree and not of kind. PROLAPSE. 171 Of tins condition there are many degrees, and almost any portion of the bowel from the duodenum to the rectum may be- come invaginated into the portion next below. The caecum itself may be so loosened from its attachments as to follow the same course, and the orifice of the appendix vermiformis may be detected at the anus by the side of the orifice of the included bowel. In 763 cases of invagination collected by Bultean, 1 220 were of the small intestine, 151 of the large, and 392 ileo-csecal. The mesentery of the two included portions is drawn in with them, and by its attachment and traction gives to them a curve the concavity of which is toward the point of attachment of the mesentery. For this reason the lower orifice of the in- cluded portion is not found in the axis of the containing portion, but turned toward some portion of its circumference, and is, therefore, often difficult to detect by digital examina- tion. The immediate effect of an invagination is to interfere with the passage of fseces, but seldom to entirely prevent their pas- sage, for the fasces do pass, and in considerable quantity, forced down through the constriction by the contraction of the healthy bowel above. Another immediate effect which is due to constriction of the blood-vessels in the included mesentery and in the walls of the included portion, is the transudation of serum and consequent swelling of the intestinal walls. By this means the serous sur- faces become dark-colored, and the mucous surfaces become in- filtrated ; blood is effused between the mucous surfaces of the outer and middle layers, and lymph between the serous surfaces of the middle and internal layers, and after a time these become completely agglutinated. If the constriction be sufficiently severe, the included por- tions soon become gangrenous and slough away, the lumen of the bowel is again established, and a circular cicatrix is left. This is nature's method of cure, and though life is by it saved for a time, in the end the cicatrix thus formed may become a stricture which shall be more surely fatal than the condition from which it arose. The invaginated portion is at first of ne- cessity short ; but as the case advances, it may reach to several 1 De l'occlusion intestinale au point de vue du diagnostic et du traitenient. These de Paris, 1878. 172 DISEASES OP THE RECTUM AND ANUS. feet, and in one case ' there is reason to believe that about four yards of intestine came away, piece by piece, per anum. The disease is twice as common in males as in females, and is greatly more common in children than in adults. In adults the trouble will generally be found to involve the small intestine ; in children, the large. An invagination of the small into the large intestine begins generally at the ileo-csecal valve, which with the vermiform appendix is carried up the ascending, and along the transverse colon, till it may finally reach the anus and protrude through it, the valve all the time remaining the lowest portion. In these cases only the inner tube is made of small in- testine, the middle and the outer consisting of the large. Strangulation is much more frequent where the outer layer is composed of the small than where it is composed of the large intestine ; because of the greater tightness of the constriction. In the latter case the congestion may be only moderate in degree and the condition may last many weeks without gangrene or ulceration. This condition is known as chronic intussusception. If sloughing occur at all, it may happen at any time after the first week ; generally, however, it occurs within three weeks, though it maybe delayed for a much longer time. In one case" the separation of fragments of intestine extended over an inter- val of three years. In about one-half of the reported cases a favorable termina- tion has followed spontaneous separation, in the remainder death has occurred after a longer or shorter interval. Several pathological changes may occur. The peritonitis which serves to unite the serous surfaces of the contained portions may be- come general and cause death. The ensheathing portion may be- come ulceiated and perforated, allowing of the extravasation of fseces. The ulceration may perhaps be due to the lateral press- ure of the end of the contained portion against the side of the cylinder which contains it. 8 Separation by sloughing leaves the upper end of the ensheathing portion united with the lower end of the lnalthy bowel, and results in complete amputation of the contain< d portion. Extravasation may also occur from a defi- cienrv in this union at the time when separation occurs. The causes of invagination are not as yet perfectly under- stood. It is easy to understand how in the effort which the in- 1 Peacock : Path. Trans., vol. xv. s Peacock, loc. cit. 3 Aitken : Practice of Medicine, vol. ii. PROLAPSE. 173 testine makes to relieve itself of a polypus or other tumor by its vermicular action, not only the growth itself may be extruded, but also the portion of the bowel to which it is attached ; and polypus is one of the recognized causes of this condition. But in the great majority of cases no such palpable cause is to be de- tected. Except in the case of a tumor it is probably always an accident of sudden occurrence dependent upon some violent action in that part of the bowel. A collection of gas causing an undue dilatation in one part of the intestine, combined with a violent movement of the abdominal muscles, and a peristaltic movement in the portion just above that which is distended, might, it is easily understood, cause the accident. So, also, might any interference with, or undue violence in, the rhythmic action of natural peristalsis, by which the bowel in successive portions is first shortened and dilated by contraction of the longitudinal fibres, and then narrowed and elongated by the contraction of the circular fibres. Since the wave of peristaltic action is constantly passing from above downward, it may easily happen that a narrowed portion may under unfavorable circum- stances be caught in a dilated portion just below, and, once en- gaged, the exaggeration of the condition becomes natural and easily understood. It is to such explanations as this that we have to look in the absence of any palpable cause. Symptoms. — An invagination will cause a very different train of symptoms, according to the part of the bowel affected and the intensity of the constriction. As a rule, the symptoms are more acute and severe in invagination of the small intestine, and are more chronic in the large, because the constriction is more intense in the former than in the latter ; but an invagination of the small intestine may approach in symptoms and chronicity to one of the large, and vice versa. Wherever the constriction be located, its first symptom is generally a sharp attack of pain in the abdomen, coming on suddenly, and often in the midst of perfect health. There is nothing characteristic in this pain. It may pass off after a few hours and again return ; it may or may not be accompanied by vomiting at the start ; it is sometimes relievable by direct press- ure, and it is not at first accompanied by any tenderness of the abdomen. Change in the character of the evacuations is also a symptom common to the disease in any part. After the onset there will 174 DISEASES OF THE RECTUM AXD ANUS. still be a discharge of the contents of the bowel below the con- striction, and a certain amount of faeces may still leak through the invagination. Instead of the natural passages, however, the appearance of bloody stools is a very common occurrence, the blood coming, as has already been explained, from the con- gested and swollen mucous membrane of the outer and middle portions. There is also present at times a dysenteric discharge and a good deal of tenesmus. By careful manual examination, a tumor can generally be discovered in the abdomen, which may be characteristic enough to form a basis for the diagnosis ; but this may be concealed by the presence of much fat, or by a general distention of the abdomen with gas. The tumor is cylindrical, and may be movable under the hand from its own peristaltic action, or it may be seen to change its position from day to day as the in- vagination gradually advances, and more and more of the bowel becomes involved. The other symptoms depend in great measures upon the severity of the strangulation, and, as has been said, are more marked when the small intestine is implicated. In such cases, the symptoms rapidly increase in severity. There may or may not be considerable febrile action; the abdomen soon becomes tender to the touch ; there is almost complete obstruction, or else only the passage of bloody mucus ; the patient rapidly sinks, and the history ends either in death or in the sloughing of the included part. The latter is shown by a re-establishment of the calibre of the bowel, and, therefore of the passages ; by an abatement of all the worst symptoms, and finally by the appearance of larger or smaller pieces of gangrenous intestine in the passages. The existence and the early appearance of faecal vomiting have been given as points in favor of the diagnosis of intussus- ception of the small rather than of the large intestine ; but they point rather toward complete obstruction than to the particular s^at of the obstruction. In invagination of the large intestine, the general history of the case is that of a more chronic trouble. The pain is less severe and the paroxysms separated by longer intervals ; the faecal evacuations are larger, and the dysenteric symptoms are more pronounced ; vomiting is variable, and after a time often stercoraceous. This state may continue for several weeks before PROLAPSE. 175 death results from gradual exhaustion or from the supervention of acute strangulation. The history of a case of chronic invag- ination may at any time be cut short by the occurrence of a general acute peritonitis, and this is particularly apt to happen at the time of the separation of the slough. Diagnosis. — In any case in which the invaginated portion descends near enough to the anus to be felt by digital examin- ation, the diagnosis is easy to the surgeon of ordinary care and intelligence who has studied the symptoms which infallibly point in the direction of intestinal occlusion. But when such an examination has been made with a negative result, beyond the fact that occlusion exists, the surgeon may be completely at a loss. Under such circumstances the differential diagnosis rests between the following conditions: 1, Invagination; 2, Vol- vulus ; 3, Stricture ; 4, Concealed internal hernia ; 5, Pressure from without the bowel by tumors, etc. ; 6, Obstruction from foreign bodies, as calculi, indurated faeces, etc. ; 7, Peritonitis from perforation. It may be as well to state at once that in these cases the differential diagnosis will often be impossible, and then go on to throw what light upon the question modern science has made available. It is a good plan to divide all cases of intestinal obstruction into the acute and the chronic. An acute case will generally be either an invagination, a vol- vulus, or an internal hernia. Duplay ' also has called attention to the fact that a peritonitis from perforation may cause all the symptoms of an acute occlusion, and has given the chief points in the diagnosis of that affection. In peritonitis the vomiting seldom becomes faecal, but remains bilious to the end ; the constipation is less marked and the patient generally passes gas and liquid faeces or small quantities of solid matter ; the tympanites is also less marked, and the coils of intestine are less pronounced ; the pain begins with great severity at one point, and extends over the whole abdomen (the same tiling may happen in acute obstruction, but in such cases the other symptoms — faecal vomiting, absolute constipation, absence of the passage of gas per anum — are all equally severe, while in peritonitis they do not correspond in severity with the intensity of the pain) ; the temperature is elevated in peritonitis and normal or even less than normal in obstruction. 1 Dnplay : Du Traitement Chirurgical de l'Occlusic-n Intestinal. Arch. Gen. de Med., December, 1879. 176 DISEASES OF THE RECTUM AND ANUS. Having then excluded peritonitis from perforation, the diag- nosis in any acute case will rest between invagination, volvulus, and internal hernia. Invagination is indicated by the signs of partial occlusion, by the moderate tympanites, by the bloody stools mixed with mucus, the tenesmus, and the presence of the tumor. The diagnosis between volvulus and internal hernia will generally be impossible except as the history may point to antecedent peritonitis, or to a hernia which has ceased to come down ; or as the careful exploration of the abdomen by palpation and of the pelvis by rectal and vaginal touch may show the existence of an induration or resistance limited to one point. In other words, in any acute case of occlusion the existence of invagination may be decided by the presence or absence of its peculiar symptoms, and if excluded the diagnosis rests either with volvulus or internal hernia, but with Avhich it may be im- possible to decide. In a case of chronic intestinal occlusion, the diagnosis rests between invagination, occlusion by the pressure of solid or fluid tumors outside the bowel, stricture of the intestine, abnormal adhesions of the bowel, and obstruction by foreign bodies within the bowel, such as biliary calculi, indurated faeces, tumors, etc. The easiest of these to diagnosticate is that which comes from the pressure of a tumor without the bowel. Chronic invagina- tion may be made out by the symptoms already given. For the symptoms of stricture, we must refer the reader to the chapter on that subject, and these symptoms are much the same whether the obstruction be due to a narrowing of the cali- bre of the bowel by a deposit in its wall, or to the presence of a foreign body, or abnormal adhesions of the peritoneum which cause acute flexures and obstructions in its calibre. It will thus be seen that the differential diagnosis is shrouded in difficulty, and that the difficulty is rather greater in a case of chronic than of acute obstruction. A well-marked case of in- vagination, whether acute or chronic, is, however, the easiest of all the forms of occlusion to distinguish, and the diagnosis can generally bu made with sufficient approach to certainty to guide the surgeon in the selection of his plan of treatment. Treatment. — It is evident that the treatment of the conditions we have been describing must differ in every particular from that of those previously described. When the invagination has PROLAPSE. 177 occurred in the rectum, that is, when the upper part of the rec- tum has become telescoped into the lower, and has appeared as a prolapsed mass outside of the anus, the case may still be re- lievable by the methods of reduction and taxis. The mass must be replaced by a process exactly the reverse of the one by which it came down, the most dependent portion being first carried into the body, and the entanglement unfolded in this way. In a child, with the assistance of anaesthesia, the inverted position, and gentle manipulation with the fingers, or possibly with a soft bougie, this may sometimes be accomplished where the point of constriction is low down near the anus. Prall 1 reports a case where replacement was successfully accomplished by manipula- tion with the tube of a stomach-pump, though the mass could only just be felt in the rectum. In cases, whether of adults or children, where the constric- tion is still higher in the intestine, and manipulation with the hand or bougie is out of the question, various other mechanical means may be tried with a prospect of success. These consist in applying indirect pressure to the invaginated portion and to the constricting part by means of copious injections of water or air, but it should be understood that they are only applicable to cases affecting the large intestine alone, and the lower down in the large intestine the constriction may be, the better is the prospect of their success. In cases of this kind the mechanical treatment may be assisted by the previous administration of opium and belladonna in full doses, the one to quiet peristalsis, the other to relax the unstriped muscular fibres of the intestine. To these means may be added the reversal of position and an- aesthesia, and then the copious injection of large quantities of warm fiuid, or of air by means of a bellows, may in a few cases be successful. The following case illustrates the method of treatment by injection, and what, under favorable circumstances, may be accomplished hy it. 2 Case. — Invagination. — A well- nourished infant, seven months old, was in perfect health till noon of the day of attack, when she suddenly screamed, and immediately after- ward became pale, cold, and collapsed. She was put into a warm bath, after which she lay quietly in the nurse's arms for 1 Brit. Med. Journ., July 31, 1880. 2 Dr. N. P. Blaker, Brit. Med. Journ., January 11, 1879. 12 178 DISEASES OF THE RECTUM AND ANUS. an hour and a half, the bowels acting slightly once or twice. At 3 p.m. the child had become warmer, and was sleeping quietly, occasionally, however, waking up with a scream, and drawing up her legs with an expression of severe pain. There was occasional vomiting, and at 6 p.m. two passages of bloody mucus. At 11 p.m. a distinct but ill-defined oval tumor, about an inch and a half in its longest diameter, could be felt through the parietes, at a spot two inches to the left of the umbilicus. A considerable quantity (perhaps a drachm) of dark blood came away, and it was determined to distend the large intestine with thin gruel. The child was put thoroughly under the influence of chloroform, and placed on the table, with the nates well raised on a pillow. The gruel was slowly injected by means of a Hig- ginson's syringe, the upper part of the nozzle being pressed firmly against the anus to prevent any from escaping. After a pint or more had been injected, the abdomen became tense, and the distended bowel could be felt like a hard rope, an inch in diameter, across the upper part of the abdomen, almost as far as the right iliac region, and considerable force would have been required to inject any more of the fluid. When the nozzle of the syringe was removed, a portion of the gruel escaped, and soon afterward a much larger quantity. The child slept well at intervals during the night, took the breast well, and there was neither vomiting nor pain. Next morning the skin was a little hot and the pulse a little quick, and one small healthy motion had been passed. The tumor which had been felt in the abdomen had disappeared. At 1 p.m. all the feverish symptoms had disappeared, and the child had passed a copious motion of green color, and there had been no pain or spasm. At 4 p. m. there was another large motion of the same character. From this time the child appeared in perfect health, but the motions retained their unhealthy look for four days longer. The success of this treatment undoubtedly depended in a great measure upon the speed with which it was adopted before reduction became difficult from strangulation. Instead of warm gruel the enema may consist of simple water, or of soda-water from a siphon, or of a portion of a seid- litz powder, 1 the idea in the latter case being to gain the disten- tion by the gas as well as by the water. A good formula when 1 Case, Dr. Morton, Practitioner, July, 1875. PROLAPSE. 179 it is desired to make use of the pressure of gas is two parts of a solution of bicarbonate of soda, and one of tartaric acid in- jected separately. There are now many cases recorded in which these means have been successful, and the relief following such a procedure has been instantaneous ; but, as a rule, injections of fluid are more easily managed, the amount of pressure produced by them better gauged, and, therefore, they are safer. There is much to be said against the practice of trying to re- lieve the condition of distention by puncture of the intestine, though Broadbent reports a very successful case in which cure was affected by that means. The danger is that fsecal extrava- sation may occur, and to guard against this he offers the follow- ing suggestions : 1. To secure, if possible, absolute freedom from peristalsis by an extra dose of opium. 2. To select, if possible, a coil of intestine which shall contain only gas and not liquid. This will be found (if anywhere) in the jejunum, and therefore above and not below the umbilicus. An indis- pensable condition is that scarcely any food sliall ham been taken during the entire attack. 3. To pierce the coil exactly at its most convex part. The abdomen should be carefully watched for some time at every visit, and especially before the operation. In some cases where the walls are thin the outlines of various coils may be' traced even in repose ; but this will be more distinct when peristalsis is provoked by pressure or man- ipulation of any kind ; it will be seen also which coils shift and which keep the same position when contracting. The spot chosen for puncture should be as near as possible over the centre of a coil which does not roll about, and by preference in the linea alba. 4. To exercise great care and patience during the escape of gas. The needle should be held lightly, but rather firmly, perpendicular to the abdominal wall, and should not be allowed to follow too freely the rolling of the coil of intestine. As the gas escapes from the coil which has been punctured, it will collapse, and the flow from the needle will cease ; very soon, however, the air in the intestine will distribute itself and enter the empty portion, when it will again escape. This may be aided by gentle manipulation and pressure. Should the tube get blocked, aspiration may free it ; but it is safer to drive a little air through the tube into the bowel than to exert power- ful suction which may draw the mucous membrane against the point of the needle. 180 DISEASES OF THE RECTUM AND ANUS. Dr. Broadbent, in spite of the rules for its use which he has laid down, believes that puncture can relieve obstruction only very exceptionally. His own experience leads him to recom- mend it as a palliative, and he suggests that it may be a useful preliminary to inflation, manipulation, suspension in the in- verted position, etc., in the treatment of intussusception. The chief hope of relieving an invagination, however, lies in prompt and efficient surgical interference by opening the abdo- men. The propriety of such a course has in the last few years been the subject of much argument. In its favor have been ad- duced the rarity of ultimate recovery from the disease, even after sloughing of the included portion and temporary relief ; the fact that when the large intestine is affected the bowel may remain in a comparatively healthy state for weeks, and above all, the actual saving of life which has now sufficiently often followed the performance of the operation to attest its undoubted value. Against the operation still stand, however, the difficulty of positive diagnosis, especially early in the disease, the speedy formation of such adhesions as will prevent reduction even after the abdomen has been opened, and the early supervention of gangrene which renders reduction improper, and the compara- tive frequence of spontaneous recovery by sloughing. At the present time it is admitted that in cases of acute or chronic invagination, where the diagnosis is reasonably certain, and where the means of relief which have been enumerated have been tried and failed, the abdomen should be opened. The discussion at present has changed its bearings to the ques- tion of abdominal section where the diagnosis as to the form of obstruction cannot be arrived at. The surgeon having deter- mined to operate, no time is to be lost ; for success, if the oper- ation be successful, will depend more than anything else upon the time at which the operation is done. The operation of laparotom}^, or oj)ening the abdominal cav- ity, is to be performed as follows : The incision should be about five inches long, in the llnea alba, above the umbilicus. The tissues should be divided slowly, and all bleeding should be stopped before the peritoneum is ojDened on a director to an extent equalling the opening in the skin. The seat of the ob- struction is to be sought for by first noticing the condition of the caecum. If this be flaccid, the obstruction is in the small intestine, if it be distended it is in the large. If the caecum be PROLAPSE. 181 found undistended the hand is to be passed gradually along the small intestine till the obstruction is encountered ; if the oppo- site condition obtains, v the ascending transverse, and descend- ing colon are to be successively examined. When the invagination has been found, it should be un- folded, as Hutchinson suggests, rather by expressing the in- cluded portion out of its sheath from below upward, than by traction upon it from above. If the bowel should be found per- forated, or gangrenous in any part so that perforation seems probable, an artificial anus is to be formed by stitching the bowel to the lowest part of the abdominal wall. CHAPTER VIII. RECTAL HERNIA. Definition. —Generally a Complication of Prolapsus. — Cases. — Anatomy. — The Pelvic Diaphragm. — Relation of Pelvic Diaphragm to Rectal Hernia. — Varieties of Rec- tal Hernia. — Internal and External Hernia.— Hernia without a Sac. — Rupture of the Rectum usually a Result of Hernia.— Changes in Sac which lead to Rupture. — Location and Extent of Rupture. — Cause of Rupture. — Contents of Hernial Sac. . Hernia may be Reducible, Irreducible, Inflamed, or Strangulated. — Causes of Irreducibility. — Symptoms of Inflamed Hernia. — Seat of Constriction in Strangu- lation. — Diagnosis. — Treatment. — Method of Reduction. — Operations for Radical Cure. — Kleberg's Operation with Elastic Ligature. — Treatment of Inflamed Her* nia. — Treatment of Strangulation. — Incision into Sac. — Laparotomy. — Treatment after Rupture. — Reduction of Inflamed Intestine. Br rectal hernia (G-er., Mastdarmbruch ; Gr., Archocele, He- drocele) is understood a hernial protrusion of the pelvic or ab- dominal contents which has a pouch of the rectal wall for a sac. The sac of such a hernia is generally composed of all of the layers of the rectum, including the peritoneum. The protrusion may be from one side of the wairinto the cavity of the bowel where it is concealed, constituting what is known as an internal rectal hernia, or one which has not passed out of the anus ; or it may pass the sphincter and form an external hernia, the sac of which is simply an extensive prolapsus of the second variety containing peritoneum, as shown in Fig. 59. Under its proper title of archocele, or rectal hernia, this affection is seldom found described, and this fact might make it appear to be rarer than it really is. The external variety of it, however, which occurs as a complication of extensive prolapsus, is not particularly uncommon, and will often be found referred to in medical liter- ature under the head of "prolapsus containing loops of small in- testine." Such reference is generally limited to a casual mention of the possibility of the condition, and the condition itself has seldom (never in English) been described with any approach to completeness. Allingham, 1 for instance, says under the head of procidentia 1 Philadelphia edition of 1882, p. 88. RECTAL HERNIA. 183 recti : x( 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 opening of the gut being 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 the course of the following pages I shall be forced to dif- fer from Allingham in his statement that such a hernia must of course be in the anterior portion of the prolapsus ; and, as a matter of fact, quite a large number of all the reported cases have occurred in children, in whom its most frequent exciting cause, prolapsus, is so common. Van Buren ' says, also under the head of prolapsus : "I am especially anxious to impress you with the fact that there is always more or less of the peritoneal sac carried down with the bowel, and necessarily present in the tumor. I have reliable information of a case in which the removal of a ' complete pro- lapse,' of long standing, in a child, was quite recently undertaken by a hospital surgeon of mature years. The protest of a junior colleague led the operator to pass some deep sutures, in defer- ence to a fear expressed as to the probability of intestinal pro- trusion, but he was confident that the tumor consisted of mucous membrane alone, and proceeded to remove it. Not- withstanding the deep sutures, protrusion of several coils of small intestine did occur, and the child died, in collapse, within twenty-four hours." Molliere 2 also refers to the subject under the same head, quoting Cruveilhier, Allingham, and Uhde, and giving the case of Roche in full in a foot-note. He merely says, " if the exist- ence of the condition is therefore demonstrated, its history still remains entirely to be written." Esmarch 3 refers to the sub- ject, but adds little to it ; and generally, when it is mentioned by the standard writers, it receives but a passing notice. 1 Edition of 1881, p. 60. * Op. cit., p. 236. s Pitha u. Billroth, p. 154. 184 DISEASES OF THE RECTUM AND ANUS. Two articles have recently appeared, however, one by Quenu 1 and the other by Englisch, 2 which cover the ground more satisfactorily. These authors have considered the subject from different standpoints, the one writing upon "Spontaneous Rupture of the Rectum,-' and the other upon "Rectal Her- nia," and have made a careful collection of cases coming under each head. Since it is a fact that spontaneous rupture is gen- erally due to a previously existing hernia, Quenu' s cases have been included in the following list, the whole having been veri- fied as far as possible, and some others added. Case. 3 — The patient was a child one year and four weeks old, pale, bu t well developed, who had frequently suffered from prolapsus. Examination showed a tumor at the anus, 50 ctm. long, which plainly contained coils of intestine and reached far out upon the buttock. Four distinct rolls were distinguishable. The outer surface of the prolapsus was reddened, moist, and shiny, and there was no furrow at the anus. There was fever and undoubted collapse, and reposition was impossible, though a large amount of air and serous fluid were evacuated by punc- ture. The proposed operation — division of the prolapsus longi- tudinally, reposition of the protruded intestine, cutting off the prolapsus, and closure of the wound with sutures — was there- fore abandoned. On the evening of the same day gangrenous spots appeared on the protrusion, and the child died at one o'clock at night. Autopsy. — Rectum protruding, and the anterior portion of the swelling filled with the ileum, which had also displaced the neighboring small intestine and the transverse and descending colon. The anus was very wide. The contents of the hernia consisted of at least a third portion of the ileum and the sig- moid flexure. The hernial sac and abdominal contents were inflamed. Case. 4 — The patient was an emaciated female child, twenty weeks old, with severe diarrhoea, and a prolapsus which rapidly increased to the size of a "sausage," and had the appearance of a loop of intestine with the concavity turned downward. 1 Des Ruptures spontam'-es du Rectum : Rev. de Chir., March 10, 1882. 2 Ueber den Mastdarrabrueh : Med. Jahr., II. heft, 1882. 3 Uhde : Langenbeck's Archiv. fur klin. Chirurgie, 1867. Bd. 9, S. 1. 4 Brurm : Beobachtungon und Mittheilungen aus der Praxis 2. Mastdarmbruch, Casper's Wochenschrifte fur die gesammte Heilkunde Jahrg., 1833. Bd. 2, No. 40, S. 934. RECTAL HERNIA. 185 Reposition was impossible and death followed from, rapid ex- haustion in ten or fifteen hours. Autopsy. — The prolapse was not reducible and a longitudinal incision allowed several loops of the ileum, the greater part of which was in the pelvis, to protrude. The uterus was so drawn into the inverted rectum that it could only be pulled out with difficulty. The wall of the rectum was purse-shaped, inverted, and formed the hernial sac. The intestines were empty and inflamed ; the other organs normal. Brunn held that the strangulation, though possibly due to the sphincter, was more probably due to the levator ani. Case. 1 — This patient was a girl, seven years old, so thoroughly scrofulous and rachitic as to appear like a child one year of age. On November 12, 1821, a prolapsus began which in three days increased to the length of the finger, was 8" long, 3" thick, and had a blackish appearance. Simultaneously vomiting began with fluid and painful passages. Further examination showed widen- ing of the external sphincter, difficulty in replacing the prolap- sus, swelling of the protruded rectum, and on that part of the prolapse which had laid upon the bed, gangrenous spots. After a number of trials reposition was accomplished, the contraction of the sphincter not being the cause of the difficulty. The reposition was made in this way. The assistant took in his hands, one above the other, the protruded intestine. Pockels introduced his index finger into the intestine, and by means of the thumb pushed it back. During the strong downward pressure of the child, the finger was held quietly in the in- testine. While the thumb rolled in the edge of the protrusion, the index finger pushed the part up over the sphincter. During the reposition the examination with the finger showed a very much contracted pelvis. The prolapsus was held up by a T-bandage. Afterward when prolapse occurred it was always easily reduced. On December 9th the patient died from exhaustion. Autopsy. — Intestines in pelvis normal, with no signs of in- flammation. The transverse colon was drawn into the inverted rectum and the left ovary was within the grasp of the sphincter. The wall of the rectum was completely perforated at one point 1 Pockels : Catalog des collegium Anat. chirurg. Braunschweig, 1854 ; also Uhde, loc. cit. , S. 13. 186 DISEASES OF THE RECTUM AND ANUS. so that a bougie could be introduced through the opening into the abdominal cavity. Case. 1 — The patient was a woman seventy-two years old, who in the interval between her twenty-third and thirty-fourth years had six confinements without difficulty. The last one caused a rupture of the perineum which completely healed. Shortly after this she began to suffer from prolapsus, which was easily reducible by merely assuming the horizontal position. A slight prolapse occurred after each stool. A few months' stay in hospital, with the use of cold baths and injections, resulted in a decided improvement, and at the time of reporting the case the patient had returned for a second visit. She was poorly nourished, and showed when standing and after pressure a pro- lapsus 9 ctm. long, pear-shaped, 27 ctm. in circumference, and 30 ctm. in the largest part. A groove li ctm. deep surrounded the tumor, and there was an opening 2 ctm. long at the highest point. The tumor was vaulted on the anterior surface so that it measured 16 ctm. from the edge of the skin, while the measure- ment on the posterior surface was only 7 ctm. The ring sur- rounding the opening in the tumor exhibited a row of longitudi- nal folds diverging into a wide tract upon the outer surface. If the finger was pushed through the opening into the rectum, it came in contact posteriorly with the enclosed and enclosing portions of the rectal wall, and further on, against the point of the coccj 7 x. The further the examination was carried beyond the point of the coccyx the more the layers separated from each other. The outer surface of the tumor was covered with reddened and sometimes excoriated spots. The wall was about equal in thickness at all points. The outer surface seemed about equally stretched in the middle portion, but somewhat dis- tended at the higher points, and under strong pressure bulg- ings showed themselves. The consistence was soft, and such as to allow a decrease in size by pressure. The percussion sound was tympanitic in front. A vaginal examination showed the posterior wall to be unevenly stretched backward and down- ward, forming a shallow depression ; but the other parts had suffered no change. If an attempt was made to decrease the size of the tumor by pressure the twisting and gurgling of the 1 Englisch : Med. Jahr., 1882. II. Heft. RECTAL HERNIA. 187 intestine contained in it could be felt both in front and behind, especially in front. If the intestine was completely reduced there remained a slack prolapsed sac 5 ctm. long, which could also be reduced. When this was done the sphincter was seen to be dilated so that it admitted three fingers, and the lower part of the rectum was also stretched. When the hernia was not protruded the abdomen was soft and evenly distended ; but when the tumor was in the condition first described, the vaulting of the abdomen disappeared, especially in its lower part, the umbilicus was depressed about 1 ctm., and longitud- inal folds appeared in the lower abdominal region which di- verged from the umbilicus toward the symphysis. The curv- ing of the sacrum and coccyx was very slight, and both extended widely backward. The difficulty of which the patient complained was very trifling, being only that which naturally arose from the presence of the tumor in standing and walking, and the frequent burn- ing sensation which resulted from excoriation of the mucous membrane. There was no pain on defecation except during costiveness, and only occasionally any pain in the abdomen. Case. 1 — The patient was a middle-aged woman, who was suddenly seized, in the middle of the night, with nausea and pain in the abdomen. After making violent efforts at vomiting she discovered something unusual, which made her think she was about to have a miscarriage, and caused her to send for a midwife. For a time she was attended by a physician who dis- covered a large portion of the small intestine outside of the anus, and who finally sent her to Saint George' s Hospital. At this time not less than two yards of small intestine, with its mesen- tery, was protruding from the anus. The whole mass was greatly inflamed, and the loops were distended with gas and faeces. At two inches from the anus a transverse rent on the anterior wall of the rectum could be felt by the finger. At- tempts at reduction only succeeded in replacing three-fourths of the hernial mass, and most of this was pressed up into the rectum instead of into the peritoneal cavity, and remained there only as long as the pressure was maintained. Under these circumstances Brodie made an incision in the linea alba below the umbilicus, and by introducing the finger 1 Brodie : London Medical and Physical Journal, 1827, vol. lvii. 188 DISEASES OF THE RECTUM AND ANUS. effected the reduction of the hernia, closing the abdominal wound with sutures. After the operation the pulse was scarcely perceptible, the extremities were cold, and all nour- ishment was vomited immediately. The patient died in col- lapse eight hours after the operation. Autopsy. — The peritoneum was found much inflamed and covered in some places with coagulated lymph ; and there was a transverse wound in the anterior wall of the rectum with no trace of ulceration in the neighborhood. It was concluded that in this case the hernia was the result of an accidental rupture, and no mention is made whether the patient had or had not previously suffered from prolapsus. Case. 1 — The patient, a male, aged forty -five years, entered the Hotel Dieu October 21, 1879, in a state of collapse, but with intellect unaffected. On uncovering him an enormous mass of intestinal loops was seen protruding from the anus together with their mesenteric attachment. In spite of his prostration he was able to give the following history : He was well in the morning and went about his usual work. At seven o'clock he had a de- sire to go to stool, and during the efforts at defecation he experi- enced pain in the abdomen, became sick, passed a large quan- tity of blood, and finally the intestine. A doctor was called, and after an attempt at reduction the man was sent to the hos- pital. An attempt was made to discover if he had suffered from any previous rectal disease, and he affirmed that his health had been good, that there had been no emaciation, and no previous pain in the abdomen ; but during the past two months he had occasionally passed blood at stool, and two years before some- thing came down by the anus which he was able to reduce him- self without difficulty. He imagined that a similar accident had happened again. Pains were taken to find out from him whether he had had a fall, or whether he had not introduced something into the rectum, but he always answered in the negative. The suffering did not appear to be very intense ; the abdo- men was supple, flat, and only slightly sensitive ; at every mo- ment the patient, in spite of advice, made an effort as if in defe- cation. The intestinal loops which protruded from the anus were piled up one upon the other, and formed a mass the size of a man's head. An approximate measurement gave two metres 1 Qucnu : Revue de Chir., November 3, 1882. EECTAL HERNIA. 189 as the length of protruded small intestine, the serous surface of which forbade any idea of an invagination. The loops were cold and inert, moderately distended with gas, and without any vermicular movement. With regard to color, two different parts of the mass could be distinguished : one violet, ecchymosed, resting upon the clothes ; the other simply congested and ap- pearing to have come out more recently. The mesentery was infiltrated with blood, and there was blood upon the patient's shirt. The anus was large and the sphincter relaxed. There was no trace of rupture within reach of the finger. The reduction was commenced with those loops which ap- peared to have escaped last and were the least changed, and after twenty-live minutes it was accomplished. Then the whole hand was passed into the rectum and the rupture was found high upon the anterior wall. 'A single loop remained in the rectum, and its reduction was not insisted upon, in the hope that the vermicular movement of the bowel might suffice to reduce it. A large tampon of cotton and a T-bandage were applied. The patient was relieved by the reduction, but did not rally, and died two hours later without having vomited, and with the ab- domen still supple and not distended. Autopsy. — The loops which had been replaced could easily be distinguished by their color, and by the bloody infiltration of their walls. The large intestine was in its place and the loop which had been left in the rectum had returned to the peritoneal cavity. The abdominal cavity contained one litre and a half of uncoagulated blood. On the anterior surface of the upper portion, of the rectum there was a longitudinal wound through which the mucous membrane could be distin- guished. The rectum was empty and flat. The bladder was empty, and the lower end of the rupture was eight centimetres from the recto-vesical cul-de-sac. The rupture was to the left of the median line, and involved the coats of the rectum to differ- ent degrees ; the wound in the mucous membrane measuring 4.3 ctm., and that in. the peritoneum 10 ctm. Between these two the layers of the intestine had been dissected up by blood, but the separation had especially affected the mucous membrane, which was separated from the other layers to the extent of 3.4 ctm. above, 2.3 ctm. below, and from 1 to 2 ctm. laterally. The layer of circular fibres had been separated in some places in two planes, one of which remained adherent to the mucous membrane. All 100 DISEASES OF THE FwECTUM AND ANUS. the right half of the rectum, corresponding in extent to the rup- ture, presented a series of soft black protuberances due to an effusion of blood beneath the peritoneum. The meso-rectum showed no bloody infiltration. The veins of the rectal wall ap- peared more developed than normal ; there were traces of old haemorrhoids at the anus ; and the rectal mucous membrane was absolutely healthy and without a trace of ulceration to the naked eye ; but under the microscope it showed marked signs of severe inflammation, similar to those seen in the stomachs of tuberculous persons who have died with symptoms of gastritis. Case. 1 — The patient, a woman aged seventy- two years, had suffered for several years from an easily reducible prolapse. After a stool without unusual straining she observed, on return- ing the prolapse, the sudden appearance of intestine through the anus, attended with great pain in the region of the stomach. As a result of straining the hernia rapidly increased, and Adel- mann found five ells of small intestine prolapsed, the mass reaching the ground, and soiled with dirt and urine. The pro- trusion was dark colored and the mesentery was marked with dark spots. It lay in six loops, the lowest being longest and the shortest uppermost. The sphincter was relaxed. The rupture was on the right side of the rectal wall 2i" from the anus, running from behind forward and allowing only the front part of the sharp edge to be plainly seen. Its length was 2£". Reposition was undertaken in the knee-elbow position and proceeded with comparative ease till the pelvis was full, after which no more could be replaced, the abdominal cavity not having been accustomed for a long time to the presence of the intestine. A laparotomy was therefore necessary. An incision was made at the level of the umbilicus, 3" from the median line to the right, at the outer edge of the rectus, 4" long, extending downward to within three fingers' breadth of the pubes ; per- mit ting the entrance of the hand into the abdomen. Bypas- sing the hand along the mesentery to the rent the intestine could be drawn back with the help of an assistant. In this way 1£ ell was returned, and the rest was punctured with a broad needle to allow the escape of gas and contents. The dis- charge through the prolapsed mucous membrane was not at all free, and it was assisted by introducing a sound through the 1 Adelmann : Journal fur Chirurgie und Augenheilkunde, 1845. RECTAL HERNIA. 191 punctures. After removing the hand from the abdomen, the reposition could be carried no further, and a loop of intestine also appeared in the abdominal wound. After placing the patient on the left side the rectum was exposed and the rent, which had sharp edges through its whole extent, was united with seven sutures. The sutures in the middle of the wound were placed at some distance from each other, to allow of dis- charge from the pelvic cavity. Toward the end of the suturing, the contractions of the levator ani could be distinctly appreci- ated. After replacing the intestinal loop the abdominal incision was also closed. Three fluid passages occurred immediately after the operation was completed ; and the patient died ten hours later, and seventeen hours after the accident. Autopsy. — Six or eight ounces of sero-sanguinolent fluid in the peritoneal cavity without trace of coagulation. No peri- tonitis in the neighborhood of the rupture. The mucous mem- brane was inflamed and congested, and in some places eroded, and there were red spots on the visceral layer of peritoneum formed by an effusion of blood between the layers of intestine. Especial attention is called to the fact that the nail of the index ringer on the patient's right hand was sharp, and it was thought that in the efforts at replacement this might have lacerated the bowel, and thus caused the rupture of the hernial sac. Case. 1 — The patient, a woman fifty years of age, had suffered for many years from severe prolapsus. Being engaged in a fight with another woman she was thrown upon her back, and the prolapsus was injured by the feet in the struggle. Immediately after she wished to go to stool, and after some straining she passed a considerable quantity of blood and some loops of small intestine. The hernia, which was at first the size of the fist, constantly increased by the straining of the patient, and she died in collapse twelve hours after the accident. Autopsy. — The intestine was found inflamed ; all of the larger bowel was contained in the pelvis, and the stomach was forced downward into a vertical position. The prolapsed bowel was 12' 10" long, and included the whole ileum beginning 2" from the ileo-csecal valve ; and also a part of the jejunum. The rupture was on the posterior wall 1" from the anus, and four 1 Pyl : Pyl's Aufsatze und Beobachtungen, zweite abtheilung, p. 133; or Adelmann, loc. cit. 192 DISEASES OF THE KECTUM AND ANUS. fingers' breadth long. The abdomen also contained extra- vasated faeces. Case. ' — The case was that of a woman, aged forty-six years, who about twelve years before, a short time after a difficult labor, had begun to suffer from prolapse which came down daily at the time of defecation, and was easily reducible. She was seen by the doctor at a time when the tumor had been down nearly twenty-four hours, and had resisted all the efforts of herself and female friends at replacement. She had passed a restless night and was much fatigued by her journey in an old cart, but had experienced no bad symptoms referable to the stomach or bowels. The doctor found at the anus a tumor larger than the fist, round, red, and covered with bloody mucus. The prolapse was directly continuous with the margin of the anus, in such a manner as to render the introduction of a sound between them impossible. At the extremity of the tumor there was a rounded aperture which admitted the finger without ob- stacle. To accomplish the reduction the woman was placed on the bed with the thighs separated ; the tumor was seized in the palms of the two hands and the ends of the fingers, and a gen- tle circular compression was exercised in order to diminish its volume and cause it to go up by an operation similar to the taxis. The resistance being great, a few moments were allowed for rest, and after a quarter of an hour the same manoeuvre was repeated after having enveloped the tumor in a cold cloth. "After a few moments I felt," says the narrator, "during a violent effort of the patient, the tumor distend under my fin- gers, and at the same time I heard a noise similar to that made by tearing parchment. At the same time the tumor suddenty disappeared of itself, and syncope, nausea, and a marked change in the expression of the face supervened. " When the patient came to herself she complained of severe colic. I then found outside of the anus a loop of intestine which I easily replaced, and on introducing the finger into the rectum I recognized at a considerable height an irregular longi- tudinal rent, the extent of which I was unable to determine. I placed a tampon of lint over the anus and kept it in place with a T-bandage and compress. I sent the patient to her home, ordering that nothing be disarranged. As the case was very 1 Eoche : Revue Mud.-Chirurg., 1853. RECTAL HERNIA. 193 serious, I requested a neighboring confrere to come and aid me with his advice. At our arrival, six hours after the accident, I found the patient sitting by the corner of the fire, without the dressings. Between the separated thighs were exposed, in the midst of the ashes, the large and a considerable part of the small intestines, distended with gas, cold, and in several spots livid. The face was Hippocratic, the pulse thready and much accelerated, the voice feeble ; and to this was joined colic and continual vomiting. After having placed the woman in bed and raised the intestines, the mass was replaced within the body, the former dressing was applied, and the woman died in a few hours." Case. 1 — A woman, thirty years of age, wishing to lift a heavy vase, and stooping over to accomplish it, suddenly caused a very considerable intestinal hernia to appear through the anus which could not be reduced even by the introduction of the whole hand within the rectum. Stein thought he might be able to effect the reduction by raising the pelvis, but this manoeuvre failing, he cut the intestine to empty it of its contents, hoping at the same time to establish an artificial anus. Death followed on the sixth day from general peritonitis. Autopsy. — Rupture 10," long in the anterior wall of the rec- tum, through which several feet of the small intestine and two inches of the caecum had protruded. Case. 2 — In this case, which is reported by Fiedler from the practice of Ohle, and copied by Ashhurst, the patient, a man, gave a past history of haemorrhoids, obstinate constipation, bloody stools, difficulty in micturition, and, finally, the develop- ment of a tumor filling the anus. Without known cause he was attacked with fever, vomiting, and great pain in the abdomen. An examination revealed the presence of a swelling at the anus, 3" in diameter, and this was incised on the diagnosis of an at- tending physician. It contained one of the appendices epi- ploicse and a piece of small intestine. To replace this Ohle made an incision on the left side from the tip of the tenth and eleventh costal cartilages to the anterior superior spine, 5£" long, parallel to the linea alba and 3£" from it. Through this the transverse colon was drawn outward, the intussusception reached, and the 1 Stein : Pitha und Billroth Chirurgie. '- Ohle. Fiedler : Magazin der gesammten Heilkunde von Rust, Bd. 2, S. 253, 1817; Ashhurst: Amer. Jour, of the Med. Sciences, 1874, vol. ii., p. 48. 13 194 DISEASES OF THE RECTUM AND ANUS. small intestine drawn out of the wound in the 'rectum, while an assistant made pressure from without. The patient died of peri- tonitis. Case. 1 — The patient was an old woman who had borne three children without difficulty. Following the second birth there was a prolapse of the vagina, and after the third a prolapse of the rectum accompanied by alternate diarrhoea and constipa- tion. For the last ten years the prolapse had been increasing in size and had remained out of the body when the patient was in the horizontal position. At the same time inflammation had occurred so that she was obliged to take to her bed. This in- flammation suddenly became increased, the patient had a chill with severe colicky pain in the lower pelvis radiating from the rectum and the genitals, and high fever. Later there was vom- iting, and after eight days a rupture of the weakened hernial sac and death from peritonitis. Autopsy confirmed the diagnosis of rectal hernia. Case. — The same author reports another case, in a woman forty years of age, who had never borne children. In her child- hood she had suffered from a prolapsus which, however, had always been reducible. This again developed later, and was only reducible with difficulty and undoubtedly contained intes- tine. Case. 2 — In 1835 a feeble child, one year old, was brought for treatment who had a prolapse 3" long and of unusual thickness. The examination showed an undoubted interval between the two layers of the inverted rectum in front, and intestine between them. Reposition was impossible, and the weakness of the patient rendered operation out of the question. The child died on the same day. No autopsy. Case.' — This surgeon observed in 1844, in a child two years of age who suffered with the symptoms of volvulus, a swelling in the rectum which occluded it so completely that the finger could not be made to pass. After death, which soon followed, a large coil of intestine was found in the swelling. No more ac- curate description of the case is given, but from the author's few words it would seem to have been one of the class of internal rectal hernia? shown in Fig. 4. 1 Schreger: Chirurgiscbe Versuche, Nurnberg, 1818, Bd. 2, p. 186. 2 Baum : See case of Uhde, loc. cit. * Dieffenbach : Operative Chirurgie, Bd. 2, S. 631, Leipzig, 1848. RECTAL HERNIA. 195 Case. 1 — This was a case of prolapsus the size of the fist, in a woman, which evidently contained intestine. After replacing the hernial protrusion the prolapsus was cut off with an ecra- seur, and with it the hernial sac lying in the anterior part. On the day after the operation both the folds of peritoneum became loosened and a large mass of small intestine appeared. The patient died of peritonitis. Case. 2 — The patient, a woman aged forty-five years, had had several children, the last confinement being twenty-two years be- fore, and all having been without difficulty. Eleven years before she felt a good deal of uneasiness about the anus with difficulty in defecation. One morning, when getting out of bed, she felt a tumor projecting from the anus. It was about the size of a walnut and became larger on exertion. After awhile it always came down when she went to stool, and she could not defecate without passing the hand into the rectum and pushing the sub- stance aside. She had a good deal of pain about the umbilicus and was always constipated. During the last ten months the prolapse had increased till it had reached the size of a cocoa- nut, and was always down when she was at work, though she was comparatively comfortable when in the horizontal position. Operation. — It was discovered that the anterior fold of the protruding bowel contained a large globular body which could easily be encircled at the base by the finger and thumb. On passing the forefinger of one hand into the vagina and that of the other hand into the rectum, their points could easily be ap- proximated above the tumor. On rubbing the ends of the fin- gers together in this position a cord feeling precisely like the spermatic cord in the male, with its vas deferens, could be felt rolling between them. It was concluded that this cord was the Fallopian tube and that in all probability the tumor was an ovarian cyst. An incision was made on the anterior aspect, a small ovarian tumor was turned out, the pedicle was tied with a strong hempen ligature, the tumor removed, and the wound closed with the uninterrupted suture. There was considerable bleed- ing from the wall of the rectum, requiring one or two ligatures, and the prolapsus was left outside of the sphincter. After 1 Streubel : Handbuch der Chirurgie von Pitha und Billroth, Bd. 3, Abth. 2, S. 336, Schmidt, Hernien. 2 Stocks : British Medical Journal, June 1, 1872, p. 584. 196 DISEASES OF THE RECTUM AND ANUS. healing of the incision this could be returned without pain, and the patient made a good recovery. Case. 1 — As this case seems to have been beyond the reach of both Quenu and Englisch, both of whom refer to it without having been able to obtain it ; and as it is short and very im- portant we transcribe it in full. " An Account of a very RemarTcable Case of a Boy, who, not- withstanding that a Considerable Part of his Intestines toere forced out by the Fall of a Cart upon him, and afterward cut off, recovered and continued well. Read June 12, 1755. "On January 3, 1755, I was called to John, the son of Lancelot Watts (a day laborer living in Brunsted), a servant- boy to Mr. Pile, a farmer in Westwick, near North Walsham, Norfolk, aged thirteen years. He was overturned in a cart, and thrown flat on his face, with the round, or edge of one side of the cart (bottom upward) whilmed (sic) across his loins, the upper part of the body lying beyond the wheel at right angles. In this helpless condition he continued some time, and was found with a very large portion of the intestines forced out at the anus, with part of the mesentery (and some loose pieces of fat which I took to be part of the omentum) hanging down below the hams double, like the reins of a bridle, very much distended and inflamed. He had a continual nausea, and vio- lent Teachings to vomit, and threw up everything he took. The pain of the stomach and bowels was exquisite, attended with convulsions ; his pulse low and quick ; and frequently he fell into cold sweats. After using an emollient and spirituous fomentation I reduced the parts, though to no purpose ; the vomiting immediately returned, and forced them out again. Next day the fever increased, the nausea and Teachings to vomit continued, the parts appeared livid and black, with all signs of a mortification. On the third day the mortification increasing, I cut off the intestine with the mesentery close to the anus. He had had no food from the time of the accident, but soon after the operation there was a very large discharge of blackish and extremely offensive faeces which continued several days, lessen- ing by degrees. He soon grew easy and the nausea and vomit- ing abated. I gave him Tinct. Cort. Peruv., simpl., twice a 1 Nedbam : Philosoph. Trans., vol. xlix., 1755, p. 238. RECTAL HERNIA. 197 day ; and, as he complained at times of griping pains, lie took now and then Tinct. Rhubarb vinos., and had recovered a good state of health. For some time he had six or seven, or more- stools a day ; at present commonly three or four, all loose, which come soon after eating ; and frequently he is obliged to hurry out to ease himself during his meals. " I have three times lately tried if I could discover a passage through the coats of the rectum with my finger, and I think I have always felt an opening, just above the sphincter, toward the spine, the circumference of which was full, and protuber- ated, seemingly as large as my finger, the lower edge of which was harder than the rest ; he complained of pain when I pressed the upper part. "The intestine cut off measured fifty-seven inches, by a string applied to the outer surface. "On May 7fch, the boy came walking from Brunsted to North Walsham (seven miles), and dined with me, was per- fectly well, and walked back again that afternoon. "John Nedham. "Witness, E. Brooke, Surgeon. " Nobth Walsham, Norfolk, "May 28, 1755." Case. 1 — "The patient was an elderly man who had a pro- lapsus as big as a cocoa-nut always coming down, and render- ing his life a burden. He had already been operated upon twice by a hospital surgeon, but in vain. The patient was then sent to me, and, formidable as the case looked, I determined to undertake it. I applied the clamp deeply in three different directions. There was a great deal of bleeding and I had to ap- ply the cautery over and over again before I could stop it ; and then, just as I was finishing the operation, a most untoward event occurred — severe vomiting, as the result of the anaes- thetic, took place. The prolapsus was forced still further down, and before I and my assistants could return the parts, the violent action of the abdominal muscles was such that the weakened coat of the bowel gave way, and a knuckle of small intestine actually protruded through the rent thus made. I carefully returned this as soon as the vomiting ceased, and anxiously waited the result. Our house-surgeon, Mr. New- 1 Henry Smith : Lancet, March 15, 1880. 198 DISEASES OF THE KECTUM AND ANUS. march, watched the patient with great care and treated him with great skill, keeping him constantly under the influence of opium, and locking up his bowels for several days. The result was not a single bad symptom of any kind. On the first action of the bowels there was no protrusion, nor afterward, and as soon as the man was fairly recovered I removed three longitud- inal folds of skin from the anus, so as further to tighten the parts. The man was completely cured. Now, the lesson this case teaches is this — not to employ an agent which could cause vomiting ; because, of course, in such a terribly severe case as this it is absolutely necessary to clamp deeply, and thus weaken the bowel. It was a most unlooked-for accident, not likely to occur again ; in fact, it is hardly reasonable to expect to meet with another such a case for operation. I have, however, been called to cases as bad or worse, but where no operation could be recommended." Anatomy. — To properly understand the anatomical forma- tion of a rectal hernia a knowledge of the structure and rela- tions of the pelvic diaphragm is absolutely essential. This dia- phragm, which forms an adequate support for the pelvic and abdominal contents and completely closes the outlet of the pelvis, is a funnel-shaped, musculo-aponeurotic sheet stretched across the pelvis with its apex pointed downward. Through the apex passes the rectum, to the circumference of which the diaphragm is closely attached by a commingling of muscular fibres. Between the rectum and the symphysis pubis lies the prostate which may also be said to help close the mouth of the funnel and to which the diaphragm is also closely adherent. The pelvic diaphragm, which has been diagrammatically rep- resented in Fig. 65, is composed of several layers. These may be enumerated from above downward as peritoneum, recto-vesi- cal fascia, levator ani muscle, and anal fascia. The peritoneum and its loose cellular attachment to the recto-vesical and pelvic fascia? needs no particular description in this connection, except as the drawing happens to show what Richet ' has so well de- scribed as the superior pelvi-rectal space, the space between the p'-rironeum and the recto-vesical fascia. This space extends laterally and posteriorly from the rectum to the pelvic wall on all sides. It is filled with loose connective tissue containing 1 Traits d'Anat. Med. Chir., 3d Edit., p. 828. RECTAL HERNIA. 199 little fat in its meshes, and continuous through the intervention of the general sub-peritoneal connective tissue with that filling the concavity of the sacrum and the iliac fossae. It also com- municates with the genital region through the sciatic notch, and in this way is explained the extensive burrowing of pus in some of the deep varieties of fistula. The pelvic fascia (1) divides into two layers (2 and 5), and the line of division is shown on the cadaver by a tendinous cord stretching antero-posteriorly on each side of the pelvis from the symphysis pubis in front to the spine of the ischium behind. After the bifurcation the upper layer (2) which is known as the recto- vesical division of the pelvic fascia, or simply as the recto- FiG. 65. — Diagrammatic View of the Pelvic Diaphragm as seen in a Lateral Vertical Sec- tion through the Pelvis on a Line with the Rectum. R, rectum ; 1, undivided pelvic fascia ; 2, recto-vesical division of the pelvic fascia ; 3, anal fascia lining the under surface of the levator ani ; 4, levator ani muscle ; 5, obturator division of the pelvic fascia ; 6, superior pelvi-rectal space of Richet ; 7, ischio-rectal fossa ; P, peritoneum. vesical fascia, follows the superior surface of the pelvic dia- phragm down to the rectum, the prostate, and the bladder, all of which it encases to a greater or less extent before it is finally lost in a thin layer upon them. From this layer of fascia the anterior and lateral ligaments of the bladder are formed. The outer layer of the divided pelvic fascia (5) is known as the obturator fascia and covers the inner surface of the obturator internus muscle ; forming also the outer boundary of the ischio- rectal fossa. The thin layer of fascia (3) which lines the under surface of the levator ani and is known as the anal fascia, is a supplementary division of the general pelvic fascia. The remaining layer of the pelvic diaphragm is a muscular 200 DISEASES OF THE RECTUM AND ANUS. and tendinous one, the levator ani. We say muscular and tendinous because the muscular fibre is in some places exceed- ingly thin, and in others entirely wanting, its place being sup- plied by aponeurotic septa and the tendinous fibres of origin and insertion, which are very thin and yet possess considerable strength. This muscle, including the ischio-coccygeus, which is really only a part of the levator ani, has already been described. What the abdominal wall is to an inguinal hernia the pelvic diaphragm is to a rectal ; and for this reason it has been dwelt upon to such length. It is evident that no protrusion of the pelvic or abdominal contents, except in the form of intussuscep- tion, can occur into the rectum and out of the anus which does not either pass directly through it or carry it before it as one of the layers of the hernial sac. IP R 5 5 Fi G . 66. — Same Section as Fig. 65, showing the Commencement of the Formation of the Hernial Sac. H, Hernial sac lined by peritoneum and composed of all the coats of the rectum. It happens as a matter of fact that the hernial contents do pass this barrier in several different ways, giving rise thus to several distinct varieties of the affection. The most frequent form is that represented in Fig. 66, where the rectum is seen at the commencement of the formation of a prolapsus which itself forms the sac of the hernia. The inversion of the rectum is here shown as beginning just at the point where the pelvic diaphragm surrounds the bowel ; and the neck of the hernial sac in such a case is formed by the levator and the pelvic diaphragm. The sac itself is composed of all the layers of the rectal wall, and the peritoneum is in part that which covers the rectum and in part that of the pelvic dia- phragm, but chiefly the former because of its more ready dis- placements. RECTAL HERNIA. 201 Fig. 67 shows the advanced condition of prolapsus, and the full development of the hernial sac; and explains why the previous existence of a complete prolapsus is the most common cause of rectal hernia. Whether or not such a sac contains a hernia is in great measure a matter of accident. As is the case in one form of congenital inguinal hernia, the prolongation of the peritoneal layer which lines the hernial sac is there waiting for some unusual strain or the gradual increase in its size to complete the process and fill the sac with a loop of intestine. The peritoneal sac has been drawn both in front and behind the rectum, and on this point the drawing is directly opposed to the statement of Allingham, that from the anatomy of the part the hernia must of course be perineal. There is no doubt that Fig. 67. — Sac of Rectal Hernia. in most cases the sac is anterior, but there seems to be no anatomical impossibility in its being posterior, and that it sometimes is posterior is a matter of clinical experience. In the case of Englisch, particular attention is called to the coils of intestine in the posterior part of the prolapsus, though they were more marked in front. Another way in which the hernial sac may be formed is shown in Fig. 68. Here the protrusion has occurred between the rectum and uterus, and the hernia is the direct cause of whatever prolapsus there may be, instead of as in last case, the prolapsus being the exciting cause of the hernia. The neck of the hernia in this case will be formed by a direct perforation of the pelvic dia- 202 DISEASES OF THE RECTUM AND ANUS. pliragm in all of its layers except the peritoneal, which is car- ried forward into the hernial sac ; and the sac is formed from the front or side of the rectal wall. The protrusion may occur at any other point in the rectal wall, as well as at the recto- vesical cul-de-sac, obviously at the point behind marked by a star, or at a point higher up in the rectum ; and such a hernia may remain entirely within the bowel, constituting what has been referred to as an internal rectal hernia, or it may pass be- yond the external sphincter and constitute the external variety. Fid. 68.— Internal Rectal Hernia. R R, rectum laid open laterally ; H, empty hernial sac with its neck at Douglas's pouch, protruding into and filling the rectum ; . . . . Peritoneum. In the internal variety the hernial sac may be composed of all the layers of the rectal wall minus the muscularis, which has been ruptured, and allowed the protrusion to be carried through it, instead of being spread out over its surface. Another variety of rectal hernia is that in which there seems to be no hernial sac, but in which the coils of intestine lie loose in the cavity of the rectum or have passed bej^ond the sphinc- ter. These are the cases described by Quenu as spontaneous rupture of the rectum, to distinguish them from the results of EECTAL HERNIA. 203 direct traumatism, such as might be caused by a foreign body puncturing the rectal wall or the pelvic diaphragm. Many of these cases are undoubtedly the result of the rupture of a pre- viously existing hernial sac, and are therefore merely complica- tions of the varieties already described. In the case of Brodie, no previous prolapsus is mentioned, and the rapture is believed to have been the result of an accidental tearing of the rectal wall. In the case of Quenu, the history of previous prolapse was carefully sought for and not obtained ; still there is no proof that both of these cases might not have been complica- tions of previously existing internal hernise. Quenu' s patient gave a distinct history of former rectal trouble and bloody pas- sages ; and had once, two years before the rupture, suffered from some kind of a protrusion from the anus, which he had reduced himself. In the cases of rupture reported by Adelmann, Pyl, Roche, and Schrager, the previous existence of prolapsus is distinctly stated. In the case of Stein, no data are given upon which to base an opinion. It is possible, however, that rupture of the rectum may occur as a result of severe straining where there has been no previous hernia, but it does not seem probable that such rupture ever occurs without the existence of previous disease which has weakened the wall of the rectum at the point where the rupture takes place, except in cases of direct traumatism, as in childbirth or the introduction of foreign bodies ; or in the case of an accident such as is reported by Nedham. In the case of Quenu the rectal wall seemed to the naked eye to be perfectly healthy, and yet an examination with the microscope showed the signs of inflammation and infiltration of the wall with white globules. In Brodie' s case the mucous membrane is said also to have been healthy, but no microscopic examination is reported, and the statement cannot, therefore, be allowed much weight. In all the cases of rupture compli- cating previously existing hernise a change in the hernial sac of a character to render rupture easy may be taken for granted, if not distinctly stated to have been present. In Adelmann' s case the mucous membrane is said to have been congested, inflamed, and eroded in spots. In Roche' s case the prolapsus had been down twenty-four hours and " had resisted all the attempts of the patient and her fem,ale friends at replacement." Besides these direct statements we know the changes which occur in an 204 DISEASES OF THE RECTUM AND ANUS. old prolapsus, and especially in an irreducible one. These are a thickened, eroded, granular, and cedematous condition of the mucous membrane ; a deposit of albuminous material in the submucous connective tissue ; and the final production of a foul, hypertrophied, eroded, and bleeding mass. Quenu has studied this point very thoroughly and lays great stress upon the dilatation and alteration of the veins. The straining causes the rupture of a vein, and the infiltration of blood among the diseased tunics of the prolapsed rectum causes their rupture. There is an oedema of the hernial sac, a catarrh of the mucous membrane, a dilatation of the veins of the mucous and sub- mucous tissue ; the wall of the vein becomes infiltrated with leucocytes, and the predisposition to rupture is established. An effort at abdominal expulsion increases the tension of the blood in the dilated vessels rendered feeble by inflammation ; a vein ruptures as in a varix of the extremities ; the blood percolates the layers of the sac all the more readily as the infiltration of white corpuscles has prepared the way ; and the walls of the bowel, dissected up by the blood and already altered, finally give way. The rupture may occur at any point in the hernial sac, or in the rectal wall when no hernial sac is discoverable. Thus in Quenu' s personal case it was in the anterior wall of the up]:>ei' part of the rectum a little to the left of the median line, its lower end reaching to within 8 ctm. of the recto-vesical cul-de- sac. In Adelmann's case the rent was longitudinal, 2%" above the anus. In Pyl's case it was on the posterior wall an inch from the anus; in Stein's case on the anterior wall ; in Roche's case it was longitudinal at a "considerable distance from the anus ; " in Brodie's case it was anterior, 2" from the anus. The length of the rupture ma}' also vary greatly. In Adel- mann's case it was 2£" long ; in Stein's 10" ; in Roche's its ex- tent could not be determined without an autopsy ; in Pyl's, four fingers' breadth ; in Quenu's it was 4.3 ctm. in the mucous mem- brane, and 10 ctm. in the peritoneum. The rupture is probably always due to force applied from within the hernial sac or from the direction of the abdominal toward the rectal cavity, and not vice versa, and the peritoneal coat, on account of its greater tenuity and slight elasticity, is probably th»> first to give way. The immediate cause of the rupture is probably an over-distention of the sac with loops of RECTAL HERNIA. 205 intestine filled with gas and faeces, and then a straining on the part of the patient by which fresh coils of intestine or more air and faeces are forced into the sac. Brodie's occurred during an effort at vomiting; Stein's while lifting a heavy weight; and those of Quenu and Adelmann during the act of defecation ; Pyl's case occurred also during defecation, but the patient had just previously been thrown upon the floor and the hernia was probably injured in the fight. In the cases of Streubel and Ohle, the opening in the hernial sac was due to surgical inter- ference ; and in Roche's case the rupture occurred during the surgeon's forcible attempts at reduction. The contents of the hernial sac are generally loops of small intestine ; quite frequently, however, portions of the colon and sigmoid flexure have been found ; in Stocks' s and Pockel' s cases an ovary ; and in Brunn's and Englisch's cases the uterus. The size of the hernia ma} 7 be so small as to lead the unwary into the belief that it is a simple prolapse composed entirely of mu- cous membrane, or it may reach the dimensions of an adult head. After the rupture of the sac the intestine may escape to the length of several yards. A rectal hernia, like one into the scrotum, may be reducible, irreducible, inflamed, or strangulated. A rectal hernia which has previously been reducible with proper manipulation, may become irreducible from a variety of circumstances. The obstacle to reduction may be at the neck of the hernia outside of the sac, or within the hernial sac. As is the case in any hernia of the intestine, it may be reducible when the coils of intestine filling the sac are empty, and irredu- cible when they by chance become distended with gas or faeces. Or the neck of a hernial sac which will allow the passage back and forth of a certain amount of intestine, may not allow of the return of an unusual quantity which has been forced through it by some unusual pressure. Bat probably a more common reason for the irreducibility of a rectal hernia which is not strangulated will be found in an inflammation of the sac, which lias united the peritoneal lining with the peritoneal covering of the contained intestine. A chronic inflammation of a rectal hernia is by no means uncommon. This is generally the con- dition of the mucous membrane covering the sac, and it is due to its exposed position, and the frequent slight injuries it re- ceives. 206 DISEASES OF THE RECTUM AND ANUS. If the injury be more severe, as a kick or a blow, or if the sac be exposed to cold or wet, there may supervene an acute peritonitis starting in the sac and possibly extending to the general cavity of the abdomen. Such an inflammation will generally be ushered in by a chill and more or less pain in the hernia and abdomen. The inflammation is shown by the dark, brownish, ecchymosed appearance of the mucous membrane, by its dryness or the presence of a muco-purulent or bloody dis- charge ; by the loss of elasticity in the sac which results from the infiltration of its different layers and by its increased fri- ability, and the constant spasm of the sphincter. There may be an increase in the size of the hernia from distention of its con- tents with gas as the peristaltic action ceases under the inflam- mation ; and finally, the signs of intestinal obstruction with general peritonitis. Such a condition may result in gangrene and in perforation. Brunus case was one in which inflamma- tion of an irreducible hernia ended fatally, and in Uhde's case gangrene and death were the result. When perforation results an artificial anus is formed. If the perforation happen to be outside of the sphincter the con- dition is easily diagnosticated by simple inspection. If the her- nia be an internal one, or if a fistulous communication be es- tablished between the small intestine contained in the hernial sac and the cavity of the rectum above the point which can be reached by a digital examination, it may entirely escape diag- nosis. Another condition which may render a hernia irreducible is strangulation, and in this as in abdominal hernise the constric- tion will be found at the neck of the sac, in other words at the level of the pelvic diaphragm. It is possible that if a mass of intestine, with or without a hernial sac, has been forced out of the anus, where there has been no pre-existing prolapsus, strangulation may be caused by a contraction of the sphincter muscle ; but in general the power of this muscle has been so weakened by previous stretching that it is incapable of causing strangulation, and the constriction will be found at the level of the levator ani, and on the front, back, or side of the rectum, wherever the neck of the hernia may chance to be. Diagnosis. — Nothing need be said upon the diagnosis of a rectal hernia in which the coils of intestine protrude from the anus uncovered by any hernial sac. In such a case a mistake RECTAL HERNIA. 207 would seem to be well nigh impossible. In an internal rectal hernia (one which has not passed the anus) the diagnosis will lie between it and an intussusception ; but a careful examina- tion with the finger, or the whole hand if necessary, should re- veal the presence of a sac containing loops of intestine which can be pressed out of it into the general peritoneal cavity ; of a pedicle to the tumor thus formed ; and of an opening in the wall of the bowel which constitutes the mouth of the sac. In ordinary cases of hernia which have become external, the diagnosis will lie between hernia and prolapsus without hernia. Often the different coils of intestine within the prolapsus can be felt between the fingers, the index finger being passed up into the rectum and the thumb remaining outside. The coils may also be reduced from the sac with a gurgling noise, and the sac may be tympanitic on percussion, especially in front. The thickness of the mass and its pear-shape are also points of im- portance, and the peculiar enlargement in circumference which it undergoes when the patient strains, instead of the mere lengthening which occurs under similar circumstances in a simple prolapsus. A careful examination here also may enable the surgeon to trace the pedicle up into the pelvis, and the po-^ sition of the opening into the rectum as it is turned back toward the coccyx by the bulging of the anterior portion of the tumor, is worthy of notice. The diagnosis is always compli- cated by the condition of irreducibility, but even here tym- panitic resonance on percussion, and gurgling of air on palpa- tion, remain to assist the examiner. The flattened appearance of the lower abdomen, the sinking in of the umbilicus, and the folds of the abdominal wall radiating from it, may also indicate that the abdomen has lost a part of its natural contents. Treatment. — The treatment of rectal hernia at once divides itself into curative measures for the uncomplicated condition, and the treatment of the complications — inflammation, strangu- lation, and rupture. In reducing a rectal hernia the same accident may happen as in other hernise, and the sac and its contents may be pushed above the sphincter en masse. This is best avoided by keeping a firm hold upon the sac while the intestinal loops are expressed from it. A reducible rectal hernia may, after reduction has been ac- complished, be treated as would an old and extensive prolapsus *208 DISEASES OF THE RECTUM AND ANUS. without hernial contents, and it is unnecessary to recall the various measures in the hands of the surgeon for dealing with this condition. But rectal hernia is a more serious condition than prolapsus, and certain more radical measures may be justifiable in the treatment of it than would be in dealing with an affection which, however disagreeable, does not generally en- danger life. In cases where free and extensive cauterization lias failed to keep the hernia within the anus, nothing remains but the ablation of the sac, an operation fraught with the greatest danger to the life of the patient. A glance at the table of cases will show that Uhde abandoned the idea on account of the strangulation of the hernia and the collapse of the patient ; and that Streubel cut off the sac with the ecraseur and the hernial contents protruded through the wound on the following day with fatal result. The case mentioned by Van Buren ended in much the same way in spite of the sutures which were in- troduced to prevent the escape of the hernial contents. Smith operated in a similar case with his clamp and cautery and had the same accident, though the case terminated favorably. These results seem to point to the advantages of any method which will more certainly insure the avoidance of an appearance of coils of intestine through the wound, and the following case by Kleberg' was more successful. Case. — Operation for Rectal Hernia. — In this case the pro- lapse was about a foot in length and six inches in diameter. The mucous membrane was spongy, bleeding, excoriated, and ulcerated. The patient had been sick for two years, had been bed-ridden for two months, and was waxy pale. On the previous day a dose of castor-oil was given, and on the morning before the operation an enema of lukewarm water was administered high up the bowel. Immediately before, a glass of wine and one grain of opium were given. After the patient had pressed down the gut as far as he could he was placed on the operating table in the lateral position with the pelvis raised and shoulders turned downward. Chloroform was then ad- ministered. In two cases Kleberg has operated without chloro- form because the patients were in such a miserable condition that he was afraid to narcotize them thoroughly, and an incom- plete narcosis has all the dangers of profound anaesthesia and 1 Ueber die Anwendung der elastischen Ligatur zur Operation sehr echwerer Falle von Prolapsus Recti. Arch, fur Klin. Chirurg., vol. xxiv., p. 840. EECTAL HERNIA. 209 none of its advantages. After the chloroform, he says, "I care- fully examined about the rectum, at the junction of the skin and mucous membrane, in order to discover the sphincter ani — a procedure that was more difficult than one would think, be- cause it had become so stretched and atrophied that I could only make it out by feeling under the fingers the coarser fibres running across the longitudinal axis of the bowel. Of anything like the normal muscle there was nothing to be discovered. "An assistant, at this point, surrounded with all the fingers the prolapsus from above, the points of the fingers being di- rected toward the free end of the prolapsus, and pressed as hard as possible into the gut at a point perhaps half an inch below the supposed sphincter. Immediately in front of the ends of the assistant's fingers I then placed a good, fresh, unfenestrated drainage-tube of rubber, one and one-half line in diameter, around the prolapsus, and drew it only as tight as seemed nec- essary to stop the circulation. The elastic ligature was brought to the necessary tension by means of an easily-untied slip-knot of silk thrown under it. " The assistant now had both hands free ; and from this time on the operation was performed under the carbolic spray. A few lines beneath the ligature I now made a longitudinal in- cision two inches long through the prolapsed gut, and in this way opened the sac formed by the drawing down of the peri- toneum. Then I seized the elastic ligature with the forceps and fixed it firmly. It was thus an easy matter to push back into the peritoneal cavity a protruding loop of intestine without the slightest bleeding taking place into the wound or any air enter- ing the peritoneal cavity ; because the elastic pressure follows so rapidly all the movements that no opening can exist any- where. "After I had convinced myself that the peritoneal sac was empty, and that no invagination of the intestine was present, but, on the other hand, only that part of the gut which was to be removed lay in front of the ligature, I thrust the largest size Luer's pocket trocar through the prolapsus, immediately below the elastic ligature, from before backward, and passed through the canula two elastic drainage-tubes of one and one-half line in diameter, and after removing the canula, tied them as tightly as possible, one on the right side, the other on the left. These knots were secured against slipping by means of the knot of 14 210 DISEASES OF THE RECTUM AND ANUS. silk. The first provision against haemorrhage — the elastic liga- ture applied after Esmarch's plan — was then removed and the prolapsus cut off with the scissors one inch in front of the per- manent ligatures. After a few minutes' time, during which I kneaded the parts which still remained and lay above the liga- tures thoroughly, and as far as possible removed the fluids from them, I covered the parts around the stump with cotton, and soaked the part of the prolapse which still remained above the ligature with a solution of chloride of zinc, dried it, squeezed the soft parts once more, thoroughly applied the chloride of zinc again, and then covered the whole with dry cotton-batting, giv- ing the patient instructions to remove this as soon as it became moist and to replace it with dry, and to give the air all possible access to the parts." No fever followed the operation, and the pain was bearable, with the aid of an occasional opiate. On the next day the parts had so far shrunk as to leave a concavity at the anus where be- fore there had been a bulging. There was no bleeding, no peri- toneal irritation, and only slight tenesmus. On the fourth day the first ligature cut out, and the second on the fifth. The rec- tum was irrigated twice a day with water and permanganate of potash, and on the seventh day a dose of castor-oil was followed by a large evacuation while the patient was on his back, without pain or haemorrhage. The passage, however, was involuntary. On the fourteenth day the wound was healed, the general con- dition of the patient excellent, and the evacuations regular but still involuntary. The sphincter at this time began to be ap- preciable, and there was no protrusion of the bowel, the patient going about and wearing a bandage. One month later he had control of solid faeces, but there was still a slight discharge of mucus ; and after another month he was entirely well. Another case by the same surgeon and the same method ended fatally, but can hardly be considered a fair test of the dangers of the operation, on account of the exceedingly bad condition of the patient ; still the operation is one of extreme gravity, and its results so far have not been encouraging. The existence of an irreducible rectal hernia, even without any signs of acute inflammation, justifies the division of the con- striction and its reduction ; for such a hernia, unlike one in the scrotum, is constant^ subject to influences which may at any moment excite a fatal peritonitis. RECTAL HERNIA. 211 In cases of inflamed rectal hernia, the treatment should be directed toward reducing the inflammation by rest, local anti- phlogistic measures, and opium. If reduction be possible it may be performed. If reduction be impossible and the hernia acutely inflamed, it must be treated, as a strangulated hernia elsewhere would be, by operation tending to divide the constric- tion causing the strangulation. If the constriction seems to be at the sphincter ani it can easily be overcome by stretching without a cutting operation and without opening the peri- toneum. If it be at the neck of the sac the same manoeuvre may be possible. Various methods of subcutaneous section of the constriction have been recommended, but none of them rest upon any clinical experience. If the constriction cannot be overcome by stretching with the fingers, and if reduction cannot be accomplished by this means joined with anaesthesia, nothing remains but a longitu- dinal incision into the hernial sac as near the neck as possible, and the division of the neck with the hernia knife as in an ordinary case of strangulated hernia. In case a rupture of the sac or of the rectum has already occurred and the intestines have escaped through the rent, there is still much for the surgeon to do, although the prognosis is almost fatal. Smith's case recovered, but here the accident occurred directly under the eye of the operator, and the bowel was immediately replaced before it had been long exposed to the air or had become inflamed. In Streubel's case, where a somewhat similar accident occurred on the day after the opera- tion, the result was fatal. It will be noticed that in every case but one where the rupture has been due to violence, death has been the conse- quence ; and also that in every case but that one (Nedham's) an effort has been made at reduction, even though laparotomy were necessary for its accomplishment. There is no doubt that the first duty of the surgeon is to replace the mass witliin the abdomen after cleansing it, and this is seldom an easy matter. The amount protruded is often enormous, it is also generally distended with gas and faeces ; the rent through which it must be returned is more or less con- cealed from vision and touch ; and the intestines constantly tend to pass upward into the rectum above the rent, rather than into the peritoneal cavity. As Quenu, who has thoroughly 212 DISEASES OF THE RECTUM AND ANUS. handled this branch of the subject, suggests, those loops which have descended last, and are therefore the last changed in ap- pearance, should first be returned. A part of the contents of the bowel may be pressed back into the abdomen by gentle manipulation, and punctures may be made to evacuate the re- mainder. The reduction, however, has seldom been completely accomplished without recourse to laparotomy. After the reduction has been accomplished the rent must be closed by sutures — in itself an exceedingly difficult task, but one which is rendered easier by the abdominal wound already made ; and which might be still further facilitated by a pos- terior enlargement of the anus by incision. After the rectal wound has been sutured the abdominal one may be closed, a tampon applied to the rectum, and opium with fluid diet ad- ministered ; but the chances of a favorable termination of the case are very slight, the patient generally dying of collapse or peritonitis. If the protruded bowel be greatly inflamed, and approach- ing gangrene in appearance, the surgeon must choose between replacing it and cutting it off. Nedham's fortunate result is attributed by most writers to a lucky chance ; but it cannot fail to strike the reader that had he insisted upon opening the abdomen and replacing the mass of inflamed bowel, instead of cutting it off as he did, the chance of recovery might have been much less. These cases in the future must be studied and treated in the light of the recent results of intestinal resection. CHAPTER IX. NON-MALIGNANT GROWTHS OF THE RECTUM AND ANUS. Polypus. — Definition. — Hypertrophy of Villi. — Characteristics. — Villous Tumor. — Adenomatous Polypus. — Fibrous Polypus. — Structure; Characteristics. — Symp- toms of Polypus —Diagnosis. — Diagnosis from Malignant Disease. — Treatment. — Vegetations. — Definition. — Description. — Microscopic Appearances. — Relation to Syphilis. — Symptoms of Vegetations. — Diagnosis. — Treatment. — Condylomata. — Distinction between Condylomata and Vegetations. — Description. — Syphilitic and N on syphilitic Condylomata. — Benign Fungus. — Gummata. — Rarity and Lit- erature. — Anorectal Syphiloma. — Definition of Fournier. — Fibromata. — Lipo- mata. — Characteristics. — Enchondromata. — Cysts. — Dermoid Growths. — Charac- ters. — Pilo-Nidal Sinus. — Hydatids. — Fcetal Inclusions. — Spina Bifida. — Congen- ital Cysts. Under this head will be included polypus, vegetations, condy- lomata, benign fungus, gummata, ano-rectal syphiloma, fibro- mata, lipomata, enchondromata, and the various forms of cysts. Polypus. — A polypus may be defined as a benign tumor composed of one or more of the normal elements of the wall of the rectum ; an hypertrophy either of the mucous membrane or of the submucous connective tissue. Those which are composed of the elements of the mucous membrane are known and gen- erally spoken of as " soft" polypi ; while those into which the submucous connective tissue enters are known as the "hard" or fibrous. In many works the former class are spoken of as the polypi of childhood, and the latter as those of adult age — a classification of little practical value. The mucous membrane, as has been shown, is composed of villi, of the follicles of Lieberkuhn or tubular glands, and of oc- casional closed or solitary follicles. A polypus composed of an hypertrophy of the villi is well represented in Fig. 69. A polypus of this variety may reach the size of a pigeon's egg, it is soft to the feel, and has a shaggy or cauliflower sur- face. On section the cut surface is of grayish-red color, the substance of the growth homogeneous, and the fluid which may be forced from it by pressure will be found to be full of cylin- 214 DISEASES OF THE RECTUM AND ANUS. drical epithelium. A microscopic examination shows it to be composed of long fine papillae bifurcated at their extremities and covered by cylindrical epithelium. 1 Although these polypi are generally small, Dr. Goodsallhas reported a case from St. Mark's Hospital, 2 in which the tumor attained the size of an orange. It was rough and tuberculated on the surface, and was attached to the rectal wall by a pedicle long enough to permit of its extrusion from the anus without pain. It was attended by a frequent, copious, watery discharge, Fig 69.— Rectal Polypus. (Esmarch.) but never by any very free hasmorrhage at one time, and the patient showed no emaciation. Villous Polypus (granular papilloma, Gosselin ; villous tu- mor, Curling; villous polypi, Esmarch; "peculiar bleeding tumor," Quain). — Fig. 70. It is a question whether this form of growth should be clas- sified with the polypi already described or with the warty growths, whose description is to follow. It consists of an hy- pertrophy both of the villi and of the follicles of Lieberkuhn, 1 Liicke : Die Geschwulste. Handbuch der allgemeinen und speciellen Chirurgie. Pitha u. Billroth, p. 250. 5 Lancet, May 21, 1881, p. 828. NON-MALIGNANT GEOWTHS OF THE EECTUM AND ANUS. 215 with a centre of connective tissue and generous vascular supplv. According to the description given by Dr. A. Clark ' of a speci- men in the London Hospital Museum, the tumor is " essentially an outgrowth of dense areolar tissue, permeated by blood-ves- sels, and assuming a papillary form, the papillge being flattened and curled so as to represent hollow cylinders, and being clothed with layers of epithelium, the free layers being cylindrical." Pig. 70.— Villous Polypus. (Bryant.) These tumors are very rare ; they have the feel of a large warty polypus with cauliflower surface ; are of red color ; bleed easily ; are of relatively slow growth, existing in Rowland's case several years. They adhere to the wall of the rectum by a pedicle, sometimes composed chiefly of mucous membrane, and at others large, short, and fleshy. The pedicle may be absent (Curling) ; and the growth will vary in structure according to the proportion of its different 1 Curling, op. cit., p. 85. 216 DISEASES OF THE EECTUM AND ANUS. elements. It may reach the size of an orange ;' it is found only in adults or in old persons, and the symptoms are the same as those caused by other polypi, viz., discharge and haemorrhage ; but the haemorrhage is not a constant symptom, and varies greatly in frequency and amount in different cases. Glandular Polypus. — The adenomatous polypi, or those de- veloped from the glands of the mucous membrane, are well shown in Fig. 71. These may be due either to an hypertrophy of the follicles of Lieberkuhn or to an hypertrophy of the closed follicles. FlO. 71. —Glandular Polypus. (Esmarch.) They occur most frequently in young persons ; are generally of the size of a small plum, rarely reach that of a pear, and yet Esmarch reports one weighing four pounds." They are very vascular tumors, and, therefore, of reddish color ; they are sometimes smooth on the surface, but oftener mammillated, like a strawberry, and are attached by a pedicle, most often to the posterior wall, but occasionally to the sides of the rectum, and at a point generally within reach of the finger, but some- times higher up. They may indeed occur anywhere along the large intestine as high up as the ileo-caecal valve. 1 Syme : Diseases of the Rectum, 2d ed., p. 82. a Op. cit.,pp. 170, 177. NON-MALIGNANT GROWTHS OF THE RECTUM AND ANUS. 217 The pedicle is generally large and short, and not long and. slender as in the case of the fibrous polypi soon to be described ; but there are frequent exceptions to this rule, and these tumors will sometimes be spontaneously expelled by rupture of the slender pedicle in defecation. The pedicle is also sometimes double (Smith). It consists of mucous membrane covering the vessels which carry the blood to the tumor, and return it again — an artery and generally two veins, but when the tumor is very large, sometimes two arteries and a collection of veins. Polypi which consist of an hypertrophy of the closed fol- licles of the rectum are often found in considerable numbers. Fochier ' removed several hundred of them from a patient aged eighteen, and Richet 2 from sixty to a hundred in a man aged twenty-one. Van Buren 3 speaks of the same condition, adopt- ing Broca's name of "polyadenomata." To this variety of polypus belong also certain cysts (closed follicles), distended by viscid and transparent fluid ; and Bathurst Woodman has reported one such case in which the cyst was lined by a mem- brane similar to peritoneum. On section these adenomatous polypi are found to contain much viscid fluid, full of cylindrical epithelium and rudi- mentary glandular tubes. Under the microscope a vascular stroma of connective tissue will be found, in which there are enlarged glandular tubes, sometimes branching at their extremi- ties, and also cystoid spaces filled with reddish viscid fluid (Esmarch). The microscopic appearances of a section of such a polypus are shown in Fig. 72. Fibrous Polypus. — The hard or fibrous polypus (sarcoma- tous polypus, Esmarch), which is composed primarily of the elements of the submucous connective tissue, is much rarer than the soft variety, and is most commonly found in adults, where it may be isolated or multiple. It is chiefly composed of fibrous tissue, and resembles the uterine fibroid ; but it may contain both muscular and glandular elements. When the glandular elements are filled with fluid which resembles glue, these tumors have been known as colloid, and when cysts are found filled 1 Molliere, p. 362. Note. 2 Traite Prat. d'Anat. Med.-Chirurg. 4th ed., Paris, 1873. 3 Op. cit. , p. 103. 21S DISEASES OF THE EECTT7M AND ANUS. with jelly-like substance, the name myxoma lias also been ap- plied. These hard or fibrous polypi vary greatly in their degrees of hardness to the feel, according to their turgescence and their composition. They may creak under the knife on section, and look very much like hypertrophied and oedematous skin, or they may resemble the better-known nasal polypus in their consistence. The connective-tissue fibres are generally irregularly dis- posed, and cross each other in every direction, though a regular r*> ,*"^' V : TT ».? ' T f T f I T I T ' * ' ' T '?^M ^^(C2rj»J Fig. 72— Vertical Section of Glandular Polypus. (Esmarch.) stratification, such as is seen in uterine myxomata, may be present (Esmarch). When seen in the rectum before removal, the surface is generally red from their vascularity; but after re- moval they are pale, and generally smooth, though sometimes uneven and irregular in surface, and covered with hypertrophied papilla?. The mucous membrane is generally easily stripped off, though if there has been local inflammatory irritation it maybe firmly attached. The vascular supply is abundant, and dis- tributed both to the substance and surface of the tumor. This accounts for their rapid development. NON-MALIGNANT GEOWTHS OF THE EECTUM AND ANUS. 219 The pedicle is generally very slight, and is formed mechani- cally by the traction of the growth on the mucous membrane beneath which it is located. It is composed, as in the soft variety, simply of mucous membrane and blood-vessels. There may, however, in a case where the pedicle has been formed by traction upon and prolapse of all the coats of the bowel by a tumor located primarily above the reflection of the peritoneum, be a peritoneal cul-de-sac within the pedicle. An hypertrophy and increased vascularity of the mucous membrane at the attachment of the pedicle has been noted in certain cases. If left to its natural course, the pedicle gradually becomes longer and more slender, and finally ruptures in the act of de- fecation, and in this way a patient may relieve himself of the growth. These tumors are benign in character, and when once re- moved do not generally return at the same point. They may, however, recur, if not at the same point, at one very near it, and the same patient may be relieved of a succession of them. Quite recently I was called upon to remove three of these growths from the rectum of a brother practitioner, in whom t\\Qj had been growing nearly twenty years. At each act of defecation two of them were protruded, one the size of a hen s egg and the other not much smaller. They were hard to the touch, very painful when handled, perfectly white, and with- out an}^ trace of vascularity on the surface, and attached by large and strong pedicles, one on each side of the rectum, about an inch above the anus. The third one was much smaller, and was attached posteriorly. Under the microscope they were found to consist chiefly of fibrous tissue arranged irregularly, though in parts the sarcomatous element was well marked. The mucous membrane which originally covered them had en- tirely disappeared, though they were described as having at one time been very vascular on the surface — so much so that when extruded in defecation the blood spirted from little papillae in numerous jets. Symptoms. — A rectal polypus may exist for many years, and give no sign of its presence. The two chief symptoms which it is apt to excite are haemorrhage and discharge. The haemorrhage may be a daily occurrence, or may be present only at long intervals, and it may vary in amount from a few drops 220 DISEASES OF THE RECTUM AND ANUS. to a quantity which shall cause grave disturbance and alarm. When the mucous membrane covering the tumor has once be- come ulcerated, the haemorrhage will be frequent, and the dis- charge will be more or less fetid. The vessels are apt to bleed freely when opened, because of their being embedded in fibrous tissue, and of their inability to contract. When the tumor is so high and the pedicle so short as to be beyond the grasp of the sphincter, there is no suffering ; but after prolapse once begins to take place, the suffering may be very severe. The sphincter may become dilated and relaxed, or the pedicle may be firmly grasped by it after the act of defecation, and a cure may result from the strangulation thus caused. The discharge from the rectum which a polypus may cause is sometimes extreme in amount and constant, escaping not only at the time of defecation, but at frequent intervals be- tween, and being of an excessively fetid character. This dis- charge may, by its irritating qualities, cause secondary conges- tion of the rectal mucous membrane, erosions around the anus, vegetations, constant diarrhoea, and tenesmus ; and, joined with the loss of blood, the condition of the patient may be easily mistaken for that of chronic dysentery or even malignant disease. There are several points worthy of attention in examining a patient for this disease. It is a good plan, as suggested by Chassaignac, to first administer an enema of water before mak- ing the examination, that the polypus may float freely in the distended rectum. The finger is, in the vast majority of cases, all that is necessary for the examination ; and as Molliere sug- gests, the examination should be made from above downward, and not, as is usually the case, from below upward. In the former case, by passing the finger up along the anterior wall and withdrawing it along the posterior, the tumor may easily be caught in the descent after the pedicle has been put upon the stretch, while in the latter case it may easily be carried up the bowel and escape detection altogether. Diagnosis. — Haemorrhage from the rectum in a child, with or without pain on defecation, generally means polypus ; and it often means the same in an adult, though it will oftener in- dicate haemorrhoids. The secondary symptoms, which seem to point to dysentery, must never cause the original disease to be overlooked. There is, in fact, but little difficulty in the diag- NON-MAUGWANT GROWTHS OF THE RECTUM AND AXES. 221 nosis of a polypus in the vast majority of cases ; but once in a ■while, where the attachment is broad and the pedicle not well marked, the question of benign or malignant growth may arise and be difficult to solve except by the subsequent history and development of the case. In the chapter on cancer attention will be called to the fact that the distinction between epithelioma and a benign polypus of the adenoid variety cannot always be made by the micro- scopic examination ; and we here emphasize the fact that the diagnosis must rest rather upon the clinical history and gross appearances than upon histological iDvestigation of the growth when removed. In children malignant disease is so rare that the chances are greatly in favor of benignity. Malignant growths, moreover, do not tend to spontaneous extrusion, and are not pedunculated, and the presence of a pedicle is therefore greatly in favor of benignity. Bat given an adult with an adenoid polypus which has ulcerated, and which is not pedun- culated, and the diagnosis between it and malignant disease may be impossible, either by the microscope or the clinical history ; for the ulcerated and bleeding tumor may cause a wasting and cachexia which strongly resembles cancer. A soft polypus may also be mistaken for an internal hsernorrhoid when no pedicle is present, but the point of attachment is different in the two cases. Treatment. — The treatment of polypi is generally a simple matter, and consists in their extirpation, after which they rarely return. There are two dangers to be considered ; the first is that the pedicle, when a pedicle exists, may contain large vessels ; the other is that it may contain peritoneum. The extirpation of a polypus, which has come down from its attachment in the sigmoid flexure, has been followed by death from wounding the peritoneum, at the hands of no less a sur- geon than Broca. "Where the pedicle is long and slender, the polypus may generally be twisted off by simple torsion without danger. It is generally safer, however, first to apply a ligature, and then cut away the tumor. Should there be no pedicle, the mass must be extirpated as any tumor would be, and the haemorrhage which occurs must be treated upon general sur- gical principles. Vegetations. — These growths, known also by the names of warts and papillomata, may be denned histologically as an hy- 222 DISEASES OF THE RECTUM AND ANUS. pertrophy of the papillary layer of the skin and of the papillary layer only. They are composed of the connective tissue, the epithelial covering, and the blood-vessels, which, in their natural quantities, form the papillae of the derma. The gross appearances of these warty growths are repre- sented in Fig. 73. PlG. 73. — Vegetations. (Esmarch.) Under the influence of any of the exciting causes which will soon be mentioned, little tumors resembling ordinary warts ap- pear, and grow rapidly till they reach two or three millimetres in size. The extremity of the tumor shows a decided tendency to branching and bifurcation, and when there are many of them their branching extremities may fuse together and form a large NON-MALIGNANT GROWTHS OF THE RECTUM AND ANUS. 223 flat tumor, which will be attached to the skin, however, by numerous little pedicles, so that, if shaved off, the skin will not be wounded except in numerous small points where the pedicles have had each its independent attachment. When the wart is isolated it is dry, but when several are united they become macerated in the secretion of the part, which decomposes between them and gives rise to inflammatory phe- nomena. The tumor then becomes moist and fetid, and all the adjacent parts become irritated. According to the size of the growths, the condition of the patient, the abundance of the se- cretions, and the irritation to which they are originally due, these vegetations take on various shapes, and have been de- scribed as cock's- combs, cauliflower excrescences, etc., etc. ; but the elementary structure of them all is the same — an hyper- trophy and branching of the papillae of the derma. On placing a longitudinal section of one of these warts under the microscope the following structures will be seen. In the centre, a framework of connective tissue composed of a pro- longation of the papillary bodies of the derma ; in the centre of this a vascular loop ; the whole covered by one or more layers of epithelium, the form and size of which are variable, and de- pend apparently on several conditions, such as the moisture and dryness of the parts, and the amount of pressure to which the growths are subject. When the connective tissue is abundant and the epithelial layer relatively thin, the vegetations are dry and hard. When the conditions are reversed, they are moist. When the vascular network is greatly developed, the tumors are red and turgescent, and bleed easily. The growth occurs from the cells of the proliferating zone, between the summit of the papilla and the epithelial covering. The intercellular substance of the connective tissue becomes less abundant, while the cellular elements increase, and mingle above with the epithelial layer, and below with the connective tissue. Similar proliferating zones may be seen on the lateral surfaces of the ramifying warts, and, through their medium, the ramifi- cations develop at the extremity of the wart, while on the level with the proliferating zones, the capillary loops grow and de- velop by which the afferent and efferent vessels communicate (Rindfleisch, Molliere). These vegetations were formerly considered as proof positive of the existence of syphilis, and even of sodomy, and were 224 DISEASES OF THE RECTUM AND ANUS. treated as such. Molliere ' relates how, at the time of Dionysius, there was a special hospital at Rome for the treatment of these growths ; and Dionj'sius himself tells how the surgeons spared neither the iron nor the fire, and were not moved to pity by the cries of the patients, inasmuch as this disease was the result of unnatural intercourse between man and man. The same false idea has lasted until the present time, and is even now far from unpopular ; and yet the independence of these growths upon syphilis would seem to be beyond question, except to the extent that any syphilitic sore in this neighbor- hood may, by the irritation of its discharge, cause their pro- duction. They owe their growth, in the first place, as pointed out by Diday, 3 to a special predisposition to the formation of wart}^ growths on various parts of the body in the individual, and this predisposition is assisted by the presence of any irrita- tion of the part. Thus the discharge from a gonorrhoea or a leucorrhcea, or any disease of the rectum or genitals, may cause them to grow, and they may appear in persons appar- ently perfectly healthy and cleanly. Pregnancy has an un- doubted influence upon their production, and they sometimes disappear spontaneously after delivery. From what has been said, it is evident that these growths are neither contagious nor inoculable, and that anti-syphilitic treatment can be of no avail. Symptoms. — These vegetations may occur at any age from infancy to adult life, though they generally belong to the latter period. They may vary in size and quantity from a single en- larged papilla at the verge of the anus to a mass such as is rep- resented in the plate, and which weighs as much as a pound. The symptoms, in any case, will vary with their size, number, location, and the amount of the secretion. When they grow from one side of the intergluteal fold, and are large enough to press with their moistened surface upon the corresponding point of the opposite side, a second patch may be developed at the point of contact. The irritation from any other source would have the same effect. The development of the growths may be slow or rapid, and when the tumors are of large size, the patient is constantly troubled by the feeling of a foreign body, by a sanious and foul-smelling discharge, and by fresh erosions and superficial ulcers in the adjacent parts. Great 'Op. cit., p. 506. 5 Exposition critique et pratique des uouvelle3 doctrines sur la syphilis. Paris, 1858. NON-MALIGNANT GROWTHS OF THE RECTUM AND ANUS. 225 pain in defecation may be produced by a small wart situated just at the verge of the anus, and such a little tumor may give rise to all the characteristic symptoms of a painful fissure, in- cluding a slight discharge, and an occasional drop or two of blood. They are not very infrequent on the line of junction of the mucous and cutaneous surfaces, just within the verge of the anus. They may, also, spring entirely from the mucous mem- brane, above the sphincter, though they are generally confined to the first inch of the canal, and, in such cases, give rise to a much more aggravated train of symptoms, and to much dif- ficulty of diagnosis. There they are generally smaller and harder than when on the cutaneous surface, and cause a serous discharge, which may be so profuse as to escape from the anus between the acts of defecation, and cause much suffering from pruritus and rectal tenesmus. On examination in such a case the mucous membrane will be found dry and glistening, as a rule, though sometimes there may be a more or less extensive proctitis ; and the little, hard, tender, warty excrescence, which is the cause of all the grave train of symptoms and of so much suffering, may easily escape detection. The only treatment for such a condition is to seize the little tumor with the toothed forceps, and excise the mu- cous membrane to which it is attached. It may, however, re- turn many times. 1 Diagnosis. — The diagnosis of these growths is not generally difficult, though care is necessary when they are small and located within the grasp of the sphincters. The mistake most commonly made is to consider them as syphilitic condylomata ; and, indeed, they may not always be easily distinguishable from the raised mucous patch or flat condyloma which is a manifesta- tion of true syphilis. A careful examination of a raised mucous patch can scarcely fail, however, to show the difference between its general character and that of a cauliflower growth which has sprung up from the surface like a shrub, and is attached to it by numerous little pedicles. The two may exist simultaneously, the wart being caused by the irritation of the discharge from the other. There is little danger of mistaking these vegetations for malignant growths, though they have been known to assume a semi-malignant epithelial character, and to return frequently after removal. 1 Des Verrues de l'intestiu rectum. Rognetta, Gaz. med. de Paris, June, 1835. 15 226 DISEASES OF THE RECTUM AND ANUS. Treatment. — The surest, most rapid, and in every way most satisfactory way of curing these vegetations is by simple ex- cision with the knife or scissors. The ligature is often inap- plicable, and cauterization is not always easy to limit in its action. The growths may, however, often be induced to dry and shrink up by applications of powdered alum or tannin, and by washing with astringent lotions, such as Labarraque's solution. Condylomata. — The term condyloma has been applied to many different growths around the anus, as well as to the raised mucous patch already spoken of, and to the remains of external haemorrhoids. It will be used here to refer to the non- syphilitic growths of skin frequently seen around the anus, which are attached by a broad base, are pinkish in color, soft, fleshy, glistening, moist, and irregular in shape, flattened where two are pressed together, or where one is subjected to the press- ure of the buttocks, and which generally give out a slight se- cretion. They generally have one of the radiating folds of the anus as their point of departure, and they differ from the class of vegetations last described in that they consist of an hyper- trophy of the whole thickness of the skin, and not alone of the papillae. The epithelial element in them is not as marked as in the warts, and the blood-vessels are also less developed. They are merely the result of a localized chronic inflammation and thickening of the skin, and often follow an external haemorrhoid or any local irritation such as has been spoken of in connection with vegetations. They are generally isolated and few in number ; but it may happen that after the irritation to which they owe their origin has ceased, the growth may continue, becoming harder and more movable, and resembling a true fibroma. Such a hard tumor may, under sufficient irritation, take on an ulcerative and suppurative action, its size all the while increasing, until a foul, painful, indurated mass results which strongly resembles malignant disease. Paget ' once said that without considering these growths as absolutely and al- ways syphilitic, they are so rare without it, that, as yet, he had not seen a case. They are a very common accompaniment of any ulcerative process within the rectum, and hence of stricture, and many a stricture has been untruly stamped as syphilitic 1 Medical Times and Gazette, vol. i., 1865, p. 279. NON-MALIGNANT GROWTHS OF THE RECTUM AND ANUS. 227 because the discbarge from the anus had caused a development of these fleshy tags. They are indeed common in syphilis of this part, but they are not syphilitic. These condylomatous tumors occasionally reach a large size, as in a case recently reported by Dr. Barnes. 1 The tumor in his case was the size of an ordinary orange, and had been pro- truded from the anus during labor. It proved to be a dense growth attached to the margin of the anus, the rest of the anal circumference being surrounded by piles more or less indurated. At one point the tumor was greenish, as if about to sphacelate. It was removed by galvano-cautery. It had a broad base, and Dr. Barnes looked upon it as an outgrowth from a hsemor- rhoidal tumor. Dr. G-oodhart reported it as, for the most part, composed of loose fibro- cellular tissue, covered by a tough and altered mucous membrane ; the deep parts were, however, cavernous in structure. He was of opinion that it originated in some chronic overgrowth of connective tissue round a pile. The diagnosis of these growths is generally easy. They can scarcely be mistaken for aught except a syphilitic gummy de- posit or malignant disease, and they are not apt to be con- founded with either. I have seen malignant deposit, however, mistaken for simple condyloma, and treated by mercurials, ablation, and the hot iron, it is needless to say without benefit. The necessity for distinguishing between the syphilitic and non-syphilitic condylomata around the anus has already been referred to. There is a variety of mucous patch situated upon the skin near the anus which is often spoken of as condyloma lata, or vegetating condyloma. The syphilitic condyloma first manifests itself as a red spot and by a slight effusion beneath the epidermis, which is soon rubbed off by friction, exposing a raw surface, generally covered by a grayish pellicle. This surface is subsequently elevated by an upward growth, and by branching of the papillae, with for- mation of connective tissue, and dilatation of the blood-vessels. Where this development of the papillse has reached a consider- able extent, the cauliflower appearance is the result, and what was at first a simple mucous patch may become a large pe- dunculated wart surrounded by other vegetations which have sprung up around the original lesion, and which are due to 1 British Medical Journal, April 12, 1879. 228 DISEASES OF THE RECTUM AND ANUS. the irritation of its presence (Bumstead and Taylor, Keyes, Baumler). It may be impossible to distinguish this form of syphilis from the simple vegetation already described, except by the history, the fact of its infectiousness, and the results of treat- ment. Under the microscope both are composed of an hyper- trophy of the papillse of the derma. It ought not, however, to be difficult to distinguish between this syphilitic mucous patch and the simple hypertrophy of the skin, such as is seen at the Fig. 74. — Condyloma Lata, or Vegetating Condyloma. (Bumstead and Taylor.) site of an old external pile, to which we here limit the name of condyloma. This loose and undefined use of the word condyloma is much to be regretted, but is so common as to make any change out of the question. It is used here to denote only one form of growth, the simple non-syphilitic lrypertrophy of the whole skin. What is usually called the syphilitic condyloma is here referred to as the raised or vegetating mucous patch. The only treatment necessary in cases of condylomata is their simple excision, after which there will generally be no return. Benign Fungus. — Under this title Molliere 1 describes a granular condition of the mucous membrane of the lower end 1 Op. cit, p. 524. NON-M ALIGN ANT GROWTHS OF THE RECTUM AND ANUS. 229 of the rectum occasionally seen in children as a result of pro- lapse. It is composed of soft, friable, vascular tissue, identical with the granulations of a cicatrizing wound. The surface of the mass is red and uneven, the base is marked by dilated veins. After defecation the tumor may remain prolapsed, but it is easily reducible, and when prolapsed is not painful, which is a distinguishing mark between it and polypus. The haemorrhage attending this form of growth is always abundant and may cause much wasting. On account of this haemorrhage the growth is best treated by cauterization and astringents. Gummata. — These also may affect either anus or rectum, though their rarity in the latter may best be judged by the statement of Fournier ' that he has never seen one, and only admits their existence on the testimony of Verneuil, who has seen one. However, their presence, a fortiori probable, has been demonstrated by other observers than Verneuil. Esmarch 2 admits it ; Zeissl 3 reports a case in a male, and Zappula * an- other ; Molliere 6 has seen one starting at the anus and extend- ing into the ischio-rectal fossa ; and Fournier 6 himself met one in a young woman starting in the left buttock, and secondarily involving the anus and then the rectum. Ano-rectal Syphiloma. — This affection is defined by Four- nier 7 as " an infiltration of the rectal walls by neoplasm, whose initial structure is still undetermined, but susceptible of degen- erating into retractile fibrous tissue, and of constituting in this way more or less extensive intestinal strictures." He speaks of it as "hyperplastic rectitis, becoming later a fibro-sclerous rectitis," and as identical, or at least analogous, to other lesions of the same order developed in different viscera, as the liver or testicle. He particularly emphasizes the fact that this process begins in the submucous layers, and that the mucous membrane is only secondarily destroyed, being at first entirely free from ulceration or cicatrices. Its point of predilection is the rectal pouch, but it may be found below. He has never seen it above. Sometimes only two or three centimetres of the wall are in- volved, but when it begins at the anus it may reach seven or eight centimetres up. It forms a cylinder around the whole 1 Lesions tertiaires de 1'Adus et du Rectum, p. 8. Paris, 1875, 2 Op. cit. 3 Vrtljschr. f. Dermatol, u. Syph., 1876, H. ii. 4 Ann. Univ. de Med., ccxiii. Milan, 1870. 5 Op. cit., p. 645. c Op. cit. 1 Lesions tertiaires de l'Anus et du Rectum. Paris, 1875. 230 DISEASES OF THE RECTUM AND ANUS. circumference of the bowel. In the initial stage the rectum is only stiffened and thickened, but not contracted. When the infiltration is limited to the vicinity of the anus, it is not uni- formly diffused around its circumference, but forms irregular masses which are at first covered by healthy tissue. These are painless unless inflamed, but are liable to erosion and ulcera- tion. The disease is more common in females than in males — eight to one. Unfortunately the specific character of this ulceration cannot be proved under the microscope, there being nothing distinctive in its structure. The theory advanced by Fournier has held its own, however, and has gained adherents. Duplay 1 adopts it, and Van Buren has distinctly recognized this form of disease, and has also " seen it disappear under anti-syphilitic treat- ment," though Fournier says distinctly the anti-syphilitic treatment exercises no curative influence on confirmed syphilitic retraction, and this he explains on the ground that the contrac- tion is less a syphilitic lesion than the ultimate consequence of a syphilitic lesion, just as a cicatrix is the ultimate consequence of a wound. The remainiug tumors which occur in this part of the body are very rare, so rare as to be rather curiosities than otherwise ; and yet, as they may be met with at any time, it will not be a waste of time to enumerate them and say a few words concern- ing each in turn. Fibromata. — True fibrous tumors may develop outside of the anus. Curling 2 gives a description of one such case re- moved by Mr. Hovel, of Clapton, which had been growing for seven years and weighed upward of half a pound. It was composed of fibrous tissue arranged in several lobes, was pen- dulous and attached to the margin of the anus by a narrow neck. The surface was ulcerated from friction. He remarks that they seldom exceed the size of a chestnut, and that their surface is generally irregularly lobulated. Lipomata. — Of these fatty tumors there are only a few scattered cases in literature from which to derive a general knowledge of their characteristics in this part of the body. Esmarch' speaks of two cases, one observed by Weiss, the other by Bose. The former occurred in the surgical clinic at Prague, 1 Le Progrea Med., Novembre 30, 1876. » Op. cit., p. 188. 3 Op. cit, p. 154. NON-MALIGNANT GROWTHS OF THE RECTUM AND ANUS. 231 its size was that of a plum, and it had caused an invagination of the sigmoid flexure into the rectum and a prolapse nearly four inches in length. After extirpation of the tumor and ligature of the pedicle, the prolapse was reduced and the invagination overcome by forced injections. The second case was somewhat similar and occurred in Langenbeck's clinic. Molliere ' gives two cases in full. One from CI. Bernard 2 in a woman eighty- three years of age, who complained of obstinate constipation and dyspepsia, and a sensation as if of the weight of a foreign body in the rectum. By making a digital examination upon herself she could feel the tumor, and she soon succeeded in evacuating it. It weighed twenty grammes, was about the size of a pigeon's egg, was composed entirely of fat, and had a dis- tinct and slender pedicle. The other case, 3 reported by Castilain, occurred in a man aged forty-three, who complained of the same symptoms of constipation and dyspepsia, and this also was expelled spontaneously by the straining of the patient. The doctor at first supposed the mass to be a ball of hardened faeces, but a closer examination proved it to be an ovoidal tumor measuring twelve centimetres in length by six in thick- ness. The consistence was firm, and the section reddish in color. The tumor showed numerous lobules and was enveloped in a resisting envelope. At one end there was a distinct pedicle two or three centimetres long, and slender. Spencer Wells 4 has also reported a large lobulated fatty tumor, weighing two pounds, which he removed from the recto-vaginal septum. Fatty tumors may also occur in the region around the anus and encroach upon it to a greater or less extent. Molk, 5 in his well-known thesis, gives several such examples. They may be divided into the pedunculated and non-pedunculated. The former occurs especially in children, and are easily removed by knife, scissors, or galvano-cautery wire, and generally without great danger. The non-pedunculated variety is much rarer. Molk relates one, in a still-born child, which filled the pelvis, 1 Op. cit. , p. 525 et seq. 2 Azefou : Bull, de la Soc. anatomique, seance du Mars 26, 1875. 3 Gaz. hebdomadaire, Mai, 1870, p. 318, et Bull. Med. du Nord de la France, Mars, 1870. * Transactions London Pathological Society, vol. xvi. , p. 277. 5 Des tumeurs congenitales de l'extremite intVrieur du tronc. These de Stras- bourg, 1868, No. 106. 232 DISEASES OF THE RECTUM AND ANUS. and descended to the calves of the legs. Robert ' has recorded another in which the tumor sprang from the ischio-rectal fossa, and was at first mistaken for a perineal hernia. It occurred in a riding-master, forty-five years of age, and measured ten centimetres by seven. The operation at first consisted in cut- ting down upon the tumor, layer by layer, as in the case of a hernia ; but as soon as its true nature was evident it was fol- lowed into the ischio-rectal fossa and extirpated. The patient was well in a fortnight. Virchow 2 has made a study of these intestinal fatty tumors from which the following general facts may be derived. The fatty tissue of which they are composed is apt to undergo in- flammatory' changes by which the general appearance of the tumor is changed, so that when it appears at the anus it may seem like a hard fleshy tumor of dark-red color on section. Another result of the irritation to which they are exposed is the formation of a hard crust on their surface, which may finally become cartilaginous and cause them to be confounded with faecal calculi. Instead of an inflammatory hardening, a central softening may occur, and a cavity be formed containing free liquid fat. Cretaceous masses may also be found in the centre of the tumors. In general these tumors are attached high up the bowel, and hence the pedicle may contain peritoneum. They are very apt to cause invagination, as in Esmarch's case, and this coinci- dence should always be borne in mind when one is found pre- senting at the anus. Enchondroma. — Cartilaginous tumors of the rectum proper are of exceeding rarity, and when found they are generally the result of a secondary change in a tumor primarily glandular, and do not therefore present the well-known characteristics of the typical enchondroma. M. Dolbeau has reported 3 a case of enchondroma of the lower part of the rectum, removed from a young man aged twenty- seven. The tumor was the size of a hazel-nut, was hard and movable, and located at the entrance of the anus, where it caused no pain except when a sound or syringe was used. Around the tumor the mucous membrane 1 Lipome de l'anus simulant une hernie pcrinc-ale. Annales de therapeutique, Octobre, 1844. 2 Pathologie des Tumeurs, Translation par Aronssohn, vol. i., chap. 14. 3 Bull, de la Soc. Anat., second series, t. v., p. 6. NON-MALIGNANT GROWTHS OF THE RECTUM AND ANUS. 233 was eroded. The microscopic examination showed a predomi- nance of the fibro-cartilaginous element with glandular culs-de- sac, in the proportion of one to four. M. Dolbeau did not believe that the tumor was developed from the glands of the rec- tum, and Robin thought that the glandular elements of the tumor were of new formation. Cysts. — Cysts in the neighborhood of the rectum and anus may be of many varieties. Of the dermoid there are several recorded examples. At a meeting of the London Pathological Society, May 18, 1880, Dr. Port 1 showed a tumor he had re- moved from the rectum of a girl aged sixteen. It was mainly composed of fibrous tissue inclosed in an integument like ordi- nary skin, covered with long hair, and containing abundant in- voluntary fibre like that seen in the normal cutis. Growing upon it also was a well-developed canine tooth. The author refers to a somewhat similar case, recently reported in Ger- many, in which the tumor contained not only a tooth but brain substance. Danzell 2 reports a case in a woman, aged twenty- five years, in whom a lock of brown hair, the size of the finger, protruded from the anus occasionally after defecation. In the front wall of the rectum, about two and a half inches from the anus, a hard tumor could be felt about the size of a small apple. This was extirpated by introducing the whole hand into the rectum, after Simon' s method, death following some months after from localized peritonitis. The hair growing from this tumor was from twelve to eigh- teen centimetres long. The tumor itself, when extirpated, measured 4.5 ctm. in length, 4 ctm. in breadth, and 3.5 ctm. in thickness, and the microscopic examination showed the usual cyst- wall and contents. Perrin 3 gives an account of three cases of these tumors, which may be briefly extracted. Case. Congenital Tumor. — Woman, aged thirty years. First noticed small tumor at point of coccyx a few months after confinement. Tumor round, elastic, well defined, firmly adher- ent to point of coccyx, painless to the touch, but more sensitive 1 British Medical Journal, May 29, 1830, p. 811. 2 Geschwulst mit Haaren im Rectum. Arch, fiir Clin. Chirurg., 1874, p. 442. 3 De la Glande coccygienne et dea tumeura dont elle peut ctre le siege. Stras- bourg, 1860, These No. 530. 234 DISEASES OF THE KECTUM AND ANUS. at menstrual epochs, and when the patient was in sitting pos- ture. At this time it was the size of a small nut, but a year later it had increased considerably, and extended from the anus to the sacrum ; it gave a sense of fluctuation to the touch, and was unattached to the skin. Defecation painful. The sac of the tumor was extirpated, after its steatomatosis contents were emptied, without difficulty. It was adherent by fibrous tissue to the point of the coccyx, but not elsewhere. The examination after removal showed it to be about the size of a hen's egg, with the large extremity turned toward the anus. It was composed of an envelope and contents. The envelope was composed of two distinct layers ; the outer, fibrous and elastic, and showing the elements of cellular tissue under the microscope ; the inner, thin, transparent, and resembling a very thin layer of cartilage. Under the microscope this transparent layer was composed of flattened, transparent, polygonal epithelial cells about one-for- tieth mm. in diameter. The contents of the sac consisted of whitish matter, dis- posed in layers at the circumference, but mingled in a tallowy mass in the centre ; seen under the microscope to be composed of epithelial cells filled with fatty matter. Cure. Case. Congenital Tumor. — Woman, aged twenty-seven years. This tumor had been growing for five years. It first appeared as a small tubercle about one-third of an inch in size, very hard and painless, at the left side of the coccyx. For the first three years it was painless, but during the latter two had caused more uneasiness when struck or pressed upon. After a time the pain was increased, and became continuous, with re- missions and exacerbations, and the size began to increase, while the surrounding parts took on an inflammatory action. The pain followed the course of- the sciatic nerve on the side of the tumor, and after a while it became impossible to lie on the back or to walk. At this time the tumor had increased to the size of a child's fist, and rested on the left sacro-sciatic liga- ment. The skin and subcutaneous tissue over it were healthy and not adherent. The tumor itself was hard and somewhat elastic, and adherent to the subjacent parts. The tumor having been completely separated by enucleation and dissection from surrounding parts, was cut away with curved scissors, care being taken to cut the osseous portion as much as possible in a longitudinal direction. The excised por- NON-MALIGNANT GROWTHS OF THE RECTUM AND ANUS. 235 tion presented a fibrous shell, like that of a cyst, containing in its upper part a caseous, grayish substance which increased in consistence in proportion as it neared the base, where it was of fibrous hardness and appearance, then became fibro-cartila- ginous, and at the base, where it was adherent to the bony outgrowth from the coccyx, it was almost cartilaginous. The interior of the tumor was perforated with spaces inclosing a liquid matter resembling pus. Cure. Case. — Man, aged twenty-four years. Fibrous cyst, size of a pigeon's egg, filled with liquid contents. Cure. Molliere also reports one case of his own, in a young girl in whom the tumor, the size of a small almond, was covered by healthy skin. Walzberg 1 also reports an interesting case of operation. The patient was a woman, aged twenty-six years, from whom a con- genital tumor the size of the two fists was cut. A prolongation was found extending so far into the pelvis that it could not be followed to the bottom. The patient recovered from the opera- tion with a deep pelvic fistula remaining. From these cases, the general characters of these tumors may be deduced. They are generally soft, pasty, indolent, covered by healthy skin to which they are not adherent, and firmly attached to the sacrum or coccyx. They occur most frequently in adults, and seldom attain any size larger than that of a hen's egg. They grow slowly for a longer or shorter time, until an inflammatory action is excited, when acute symptoms supervene, and they demand attention. They may contain sebaceous matter, hair, or teeth, and may be located even within the rectum, which is very rare, or in the ano- coccygeal region, which is more common. While speaking of tumors containing hair, etc., it may be well to refer to an affection which Dr. Hodges, 2 of Boston, has described under the name of "pilo-nidal sinus " (pilus, a hair ; nidus, a nest), and which has for some time been known in French literature by the name of the posterior umbilicus. The affection is simply a ball of hair and dirt in a sinus between the anus and the tip of the coccyx. The sinus is a deep, sym- metrical, somewhat conical dimple of congenital origin, repre- senting an imperfect union of the lateral halves of the body, 1 Deutsch Z'tsch. f. Chir., t. x , Nos. 5 and 6, November, 1878. 2 Boston Med. and Surg. Journal, November 18, 1880. 230 DISEASES OF THE RECTUM AND ANUS. involving the integument alone, in which, as life advances, short hairs and other particles accumulate. These, by their irritation, cause a purulent discharge from the fistulous open- ing of the cavity, and when the case comes under the observa- tion of the surgeon, it is usually mistaken for fistula-in-ano. The hair being removed, the sinus closes by granulation. This affection is never found in children, never in men who do not have a large amount of hair about the nates, and so rarely in women that the records of the Massachusetts General Hos- pital included but a single instance, and in this patient there was, for a female, an unusual growth of hair. For the develop- ment of the affection there are necessary a congenital coccygeal dimple, an abundant pilous growth (hence adult age, and al- most of necessity the male sex), and insufficient attention to cleanliness. The affection is, therefore, met with in persons of' the lower class, and in hospital rather than private practice. Hydatids. — The number of hydatid cysts of the pelvis which have been reported is by no means inconsiderable. F. Villard ' has collected thirteen of them in women, and the standard surgical writers mention their occasional occurrence. Bryant mentions removing a " basinful " of secondary cysts from one in this position. These swellings are to be recognized by their tense, globular, and elastic feel, and by the fact of their causing no symptoms except those due to pressure, except in cases of suppuration after the death of the entozoon. The cyst has laminated walls lined with a granular layer, and is usually sur- rounded by a connective tissue capsule formed from the part in which it is imbedded. It may be of any size, and contains a clear, watery, albuminous fluid, in which may be found parts of the entozoon. Foetal Inclusions. — In these congenital cysts, any foetal structure may be found. They are not so rare but that several very complete studies have been made of them. Molk a gives numerous examples ; Verneuil " has collected ten cases ; and Paul 4 has written exhaustively on the subject, his article being founded on a study of twenty-eight cases. That variety which 1 Considerations cliniques sur les Kystes hydatiques du petit bassin chez la femme. Annales de Gynecologie, 1878, p. 101. • Surgery, p. 152, American edition. * Arch. Gen. de Med., 1855. 4 Etude pour servir a l'histoire des monstrositcs parasitaires de l'inclusion foetal situe dans la region Bacro-perineale. Arch. Gen. de Mul., t. xx., 1862. NON-MALIGNANT GROWTHS OF THE RECTUM AND ANUS. 237 is located in the sacro-perineal region is the most frequent of all. (Fig. 75.) The sac is composed of three layers, cutaneous, fibrous, and serous. The skin is thinned from distention, is violet or bluish in color from congestion, and an inflammation or a spontaneous rupture may cause perforation of the sac and the escape of the fluid contents. The fibrous layer may be more or less resistant. It is sometimes composed of a simple hypertrophy of connective tissue ; at others it is aponeurotic in character. When the sac communicates with the spinal canal, this fibrous layer is a direct extension of the dura mater of the cord. The serous layer is smooth and covered by pavement Fig. 75. — Congenital Tumor of Ano-perineal Region. epithelium, and to one side of it the included foetus will be found attached. This may also be a continuation of the arach- noid of the cord. These cysts contain a serous fluid and foetal contents in the form of an irregular mass, hard and soft in spots. Any and every part of a foetus may be discovered in this mass. The tumor is ovoidal in shape, resembling an egg when small, or the scrotum when larger. The size is generally equal to that of the head of the foetus which bears it, but sometimes equals that of the head at term, and may be larger. The tumor may be biloc- ular ; its contents generally give fluctuation and are irreducible except where there is a communication with the spinal canal. There is no pain unless inflammation has supervened. The diagnosis is generally made by discovering a hard mass of foetal 238 DISEASES OF THE RECTUM AND ANUS. elements in the midst of a serous cyst. When the cyst com- municates with the spinal canal, the differential diagnosis be- tween it and a spina bifida may be impossible. Such a cyst may cause death by obstructing labor, or by the development of a gangrenous inflammation after birth. As a rule, operations for their removal have not resulted successfully when undertaken during the first three years of life. One oper- ation practised at a later date has, however, been crowned with success. Spina Bifida. — Concerning this variety of cyst little need be said except as regards its diagnosis. It should be borne in mind that a tumor due to a deficiency of the spinal bones may be entirely within the pelvis, in which case it would present great difficulties in diagnosis. Such a case is the following. 1 Case. — Woman, aged thirty-six ; single. The patient stated that ten years before she detected a swelling as large as a goose egg in the right iliac region, her attention having been called to it by shooting pains through the abdomen starting from this point. The size of the tumor increased slowly, had once caused retention of urine, and now caused oedema of the right leg. The patient was cachectic and emaciated. The abdomen was uniformly enlarged and tympanitic. On making a vaginal examination, the cervix uteri could be scarcely reached, situated as it was above the pubes, while a mass was felt behind in the cul-de-sac, extending to the right, apparently an ovarian cyst. But from a digital examination in the rectum it was evident that the rectum was pushed forward by a large, soft, fluctuating tumor behind it, which filled up the hollow of the sacrum to within a short distance of the anus. The patient was placed under ether, and a fine trocar was introduced into the sac, about three inches beyond the anus, by which an ounce or more of its contents were aspirated by Dieu- lafoy's pump. This fluid was serous in character, perfectly clear and limpid, resembling hysterical urine. It contained no albumen, and the microscope revealed nothing more than a few oil-globules, which had, beyond question, been attached to the instrument before its introduction. Autopsy, nine and a half hours after death. On opening the abdomen, the colon was so much distended as to fill the whole 1 Emmet : Prin. and Prac. of Gynecology, first edition, p. 773. NON-MALIGNANT GROWTHS OF THE RECTUM AND ANUS. 239 cavity, and reached to a level of the fourth rib, being filled with 11a tus and f feces. ... A cyst which contained some three quarts of fluid was found behind and to the right of the rectum, filling completely the cavity of the pelvis, and extending up to a line with the second lumbar vertebra. . . . The rectum was greatly constricted in its upper portion. ... In attempt- ing to discover the attachments of the cyst in the hollow of the sacrum it was ruptured. The sacrum was removed and a spina bifida found, the three lower bones of the sacrum being defi- cient on the right side. A funnel-shaped opening communi- cated directly with the spinal canal, from which projected por- tions of the cauda equina an inch or more in length. . . . Although the posterior portion of the bones were wanting, no external bulging of the sac could take place posteriorly in con- sequence of the dense ligamentous structures bridging it over. The diagnosis of spina bifida can generally be made by the reducibility of the tumor, the signs of pressure on the brain and spinal cord which are produced by pressure on the tumor, the fluctuation at the fontanelles, and the chemical character of the fluid which may be withdrawn for the purpose of diagnosis. The fluid of a spina bifida contains both sugar and urea, as does that of the cerebro -spinal canal, and though both these sub- stances may be found in cysts entirely independent of the cere- brospinal canal, they will always be found in spina bifida. There still remains a class of congenital cysts which are neither connected with the spinal canal (spina bifida) nor para- sitical (containing foetal remains). These are often of large size at the time of birth, and may consist of a single cyst or be mul- tilocnlar. They are generally attached by a pedicle near the tip of the coccyx, though the cyst or cysts may have prolonga- tions in the perineum or the ischio-rectal fossae. The cyst- wall in these cases is fibrous, and when many cysts are present it sends prolongations between them. The integument covering it is thin and generally marked by large veins. The cyst is filled with a yellowish, tenacious, gelatinous fluid, transparent to light as is a hydrocele. It will be seen at once that the great difficulty in diagnosis lies between this form of cyst and a spina bifida, and though the diagnosis may not always be possible, it will generally turn upon the presence or absence of the signs of communication with the spinal canal when pressure is made upon the tumor. 240 DISEASES OF THE RECTUM AND ANUS. The treatment of these growths is by extirpation. Injec- tions of iodine, etc., have in them the element of danger from prolonged and extensive suppuration. When extirpation is at- tempted it should be complete ; and where the cyst is multi- locular it should be followed into the perineum and ischio- rectal fossae if necessary, in order that no parts of it may remain to undergo subsequent development. 1 These cystic formations, unless of sufficient size to cause death during labor, are not in- compatible with life. 1 Buneau : Bull, de la Soc. Med. de la Suisse romande (Molli^re). CHAPTER X. NON-MALIGNANT ULCERATION. Varieties. — Simple Ulcers. — Generally due to Traumatism. — Various Forms of Injury to which Rectum is Subject. — Sodomy. — Injury of Rectum in Labor. — Ulcers due to Surgical Interference. — Fissure or Irritable Ulcer. — Nothing Distinctive in the Ulcerative Process. — Characteristics of Irritable Ulcer. — Theories concerning this Form of Ulcer. — Description. — Herpes. — Tubercular Ulceration. — Distinc- tion between True Tubercular Ulcer and a Simple Ulcer in a Tuberculous Person. — Description of Each. — Scrofulous Ulceration. — Esthiomene. — Rodent Ulcer. — Dysentery. — A Cause of Stricture. — Venereal Ulceration. — Gonorrhoea — Chan- croids. — Chancroidal Stricture. — Discussion. — True Chancre. — Secondary and Tertiary Syphilitic Ulcerations. — Diagnosis of Syphilitic Ulcers. — Ano-rectal Syphiloma as a Cause of Ulceration. — Ulceration Secondary to Stricture. — Gan- grene. — Symptoms of Ulceration. — Gravity of the Disease. — Diagnosis. — Treat- ment. — General and Local Measures. — Treatment of Fissure. — Fissure Compli- cated with Polypus. — Treatment by Rest, Fluid Diet, and Incision of the Sphincter. — Local Applications. The many different varieties of non- malignant ulcers which are met with at the anus and within the rectum may best be clas- sified, from the stand -point of etiology, into the following groups : 1. Simple. 2. Tubercular. 3. Scrofulous. 4. Dysen- teric. 5. Venereal. 6. Those due to stricture. 7. Those due to gangrene around the rectum. Simple Ulcers. — These are almost always of traumatic origin, and the most frequent traumatism to which the rectum is sub- ject is, perhaps, that arising from the presence and passage of hardened faeces. From this cause alone, or from this combined with their extrusion from the anus, the surface of projecting hemorrhoidal tumors may become ulcerated for a considerable extent ; and, by this means, a fissure is often produced within the grasp of the sphincter. The latter I have known to happen on the first evacuation of the bowels after an operation for haem- orrhoids (the bowels having been confined by medicine for several da}^s), rendering necessary the usual operation for its cure at a subsequent time. Another frequent cause of direct injury is the presence of foreign bodies, either fish-bones, date-stones, etc., 16 242 DISEASES OF THE KECTUM AND ANUS. which have been swallowed, or larger substances which have been intentionally introduced per anum. The presence of such substances may excite extensive ulceration which will lead to subsequent stricture. An infrequent cause of direct violence to the rectum, and of subsequent ulceration due to the direct injury, and independent of any venereal disease, is sodomy, either attempted or accom- plished. Burgeon ' describes the rectum of an idiot, who for a considerable time had practised this vice, as much dilated and infundibuliform in shape, the mucous membrane as blackish, swollen, and ulcerated in spots, and the submucous and mus- cular layers as hypertrophied to four or five lines in thickness. It is doubtful whether passive pederasty should be included among the causes of stricture, as the injury done does not gen- erally reach to this extent, and, indeed, the anus is not often dilated to any such extent as in this case. Ligg 2 describes a deaf-mute, thirty-live or forty years of age, the victim of this habit, whose anus offered no trace of traumatism, and was well closed, being marked only by the absence of the radiating folds. The mucous membrane of the rectum also was normal. I have also had a patient come to me for supposed rectal trouble in whom the rectum and anus were both perfectly normal, who voluntarily confessed to having practised this vice for years. The habit is one to be looked for in negroes, and in sailors when upon a long voyage. This absence of the radiating folds, to- gether with the presence of spermatozoa in the rectum or in the mucous discharge from it, are given as the best medico-legal proofs of the vice. 3 An injury to which women alone are subject, and which is believed by many to go far toward accounting for the greater frequency of ulceration and stricture in them than in men, is bruising of the rectal wall between the head of the foetus and the sacrum in parturition. Most of the standard authors men- tion such cases. An ulcer of the rectum is a not infrequent result of surgical interference with diseases of this part. -Although in certain subjects a wound made by the surgeon may refuse to heal under 1 Bull, de la Soc. Anat., ia30, p. 80. s Corr. Bl. f. echweiz. Aerzte, No. 3, p. 71, February 1, 1879. 3 See Lecons sur les Deformations Vulvaires et anales Produities par la Masturba- tion, etc. Martineau, Paris, 1884. NON-MALIGNANT ULCERATION. . 243 the best of treatment, ulceration from this cause will generally be found to be due to careless or ignorant manipulation, rather than to the unfortunate constitutional state of the patient. Two cases occur to me now : one of a large ulcer, with hard and elevated edges, looking much like a true chancre, which re- sulted from the persistent application of caustics to a simple fissure ; and another, of three separate ulcers which marked the former site of three internal haemorrhoids which had been re- moved by ligatures. The patient suffered only slight discom- fort from the operation, and was allowed to go to his business on the following day — a thing which may sometimes be done with apparent impunity, but which should never be counte- nanced by the operator. The application of nitric acid to prolapse is said to have been followed by disastrous ulceration and stricture, but such need not be the case, nor is any such use of the acid necessary to effect a cure in any case where its use is indicated at all. Prolapse is not, however, a rare cause of stricture, due to the strangulation and sloughing of the prolapsed portion, and to the subsequent cicatrization. Irritable Ulcer, or Fissure. — An injury due to any of the causes already mentioned may, in certain persons, and when located at the verge of the anus, assume the characteristics of an affection which has been elevated into a separate class, and is known as fissure, or irritable ulcer. The irritable ulcer dif- fers in no respect from other simple ulcers in the same locality, except in the fact of its irritability. There is nothing peculiar in the ulcer itself. It may be due to a slight rent in the mucous membrane from hard faeces ; to a congenital narrowness of the anal orifice and a naturally over-powerful sphincter ;'' to the irri- tation of a leucorrhoeal discharge in women ; to an herpetic ves- icle, or to the venereal sore which it so strongly resembles — the soft chancre. Any sore which is fairly in the grasp of the ex- ternal sphincter is apt to become an irritable or painful one ; and a fissure may be painless at one time and painful at an- other in the same person, or painless in one person and painful in another. For this reason Gosselin 2 has divided these ulcers into two distinct varieties, the tolerant and intolerant — a classification 1 Molliere : Sarremone, These de Strasbourg, 1861, No. 555, p. 134. ' Diet, de Mud. et de Chirurg. Prat , art. Anus. 244 DISEASES OF THE RECTUM AND ANUS. which Molliere ' still further improves by suggesting the words tolerable and intolerable. An ulcer associated with contracture, spasm, irritability, and sometimes with actual hypertrophy of the sphincter is what is known as an irritable one ; and without this condition of the muscle it will not properly come under this classification. This contracture of the muscle may be temporary or per- manent, and is due to the irritation of the sensitive nerve fila- ments on the surface of the ulcer by the passage of faeces, and to the reflex action excited thereby ; and to many slighter causes, such as laughing, coughing, sneezing, or position. It may even come on spontaneously in persons of a highly nervous organization, or with such slight provocation as to appear to be spontaneous. There are two well-known theories regarding the causation of this little sore. According to Boyer, a the foundation of the trouble is a spasm of the sphincter muscle, and the fissure is merely a secondary lesion due to the passage of faeces through the spasmodically contracted anus. Trousseau, 3 on the other hand, reverses the relation, and very properly, holding that the fissure exists first, and that the spasm of the sphincter and the resulting pain are reflex, being specially apt to occur in persons of neuralgic tendency, and being in many cases merely the local manifestations of a general nervous state. Although these ulcers are generally stated to be due to an actual laceration of the mucous membrane, or to its abrasion from some irritation, they not unfrequently originate within the sinuses of Morgagni, and a true fissure may be entirely con- cealed from view within one of these pouches, as in the follow- ing instructive case reported by Dr. Vance, 4 which for brevity I will slightly condense. Case. Inflammation of one of the Sinuses of Morgagni. — A lady, aged eighteen, had suffered for more than a year from all the symptoms of fissure, had been frequently examined to no purpose, and was reduced to a very miserable state. On ex- amination the integumentary folds were congested, thickened, and oedematous, doubtless as a result of constant scratching, but there was no trace of anything like a fissure. The lining 1 Op. cit, p. 149. 5 Traitii des Maladies Chirurg., t. x., p. 105. 3 Clin. M'd., t. iii., art. Fissure. ' Medical and Surgical Reporter, August 14, 1880. NON-MALIGNANT ULCERATION. 245 membrane was searched with the utmost care, but no lesion of any sort was revealed except slight hypertrophy of the sphinc- ter. A second painstaking review of every part of the rectum gave the same result, and the author was about to abandon the hope of finding any local lesion, when as a matter of form— for there was no evidence of disease about them — he determined to pass a probe into each of the pouches. The prObe could not be forced into the first one, and with the second he fared no better, but with the third, after an ineffectual attempt, the probe passed into the saccnlus. No sooner had the probe entered, however, than the patient screamed with pain, and there was a spasmodic retraction of the levator ani and sphincter muscles and the part was forcibly withdrawn from view. The site of the sacculus felt as if a buck- shot had been imbedded in the tissues, so hard and swollen was the part. A small probe-pointed tenotome was carefully passed along the canal, and as soon as the sensitive point was touched, the handle was brought down and the edge of the knife made to sever the inner wall of the sacculus and expose the diseased point. This done the cause of the suffering was revealed. On the left side of the anus, and at a point where there had been no unusual sensibility, an indurated ulcer had formed within one of the little pouches. When the sacculus was opened and the ulcer exposed, it seemed very much like an ordinary fissure of the anus, but before cutting it open there was no evidence whatever, save the symptoms the patient complained of, to in- dicate the existence of such a lesion. These ulcers are generally situated at the posterior commis- sure, but may be found anywhere on the anal circumference. They are generally single, but there may be two or three, more especially when of venereal origin. They are more common in women than in men, because constipation is more common in the former and because the skin is finer. • They are confined to no age and are by no means relatively rare in infants. They are generally oval in shape with their long axis vertical, and involve both skin and mucous membrane, being situated just at the junc- tion of the two. In some cases they have the appearance of a simple erosion, in others of an old ulcer with grayish base and in- durated edges which has involved the whole thickness of the mu- cous membrane and extended fairly down to the muscle beneath. In the majority of cases they are not attended by suppuration or 246 DISEASES OF THE RECTUM AND ANUS. the discharge of pus. They may exist for years without gaining in surface or depth. Allingham ' has pointed out how commonly they are attended by small polypi situated at their upper end or on the opposite side of the rectum ; and they will often be found in conjunction with haemorrhoids and condylomatous tags, the dragging upon which in the act of defecation has seemed to me in some cases to account mechanically for a slight tearing of the mucous membrane. An eruption of herpes around the anus, similar to what is seen on the lips, may result after rupture of the primary vesi- cles in numerous small superficial ulcers of a reddish color and secreting a little pus. These may coalesce at their edges and form a serpiginous sore. They are apt to be accompanied by similar eruptions on other parts of the body, and must be care- fully distinguished both from mucous patches and soft chan- cres. The ulcerations which result from acute and chronic eczema and from pruritus present no special characteristics. They are generally due to the injury inflicted by the nails of the sufferer. From what has been said of the etiology of these simple ulcers it is plain that they must present many variations in ap- pearance ; yet the diagnosis of each from the other, and of the whole class from those which are to follow, will not generally be found difficult if proper attention is given to the history, the appearance of the lesion, and its course. The disease is gener- ally of a healthy type, and tends to self-limitation and sponta- neous cure rather than to increase. The ulcerative action is generally superficial, and tends to extend on the surface rather than in depth. It is generally surrounded by the signs of re- parative action, and with proper care will undergo cicatrization, which, when extensive, will result in stricture. Tubercular Ulcers. — There are two varieties of ulceration met with in persons of the tubercular diathesis ; one due to the actual deposit and softening of tubercle, the other a simple ulceration containing no tubercular deposit, but modified in its course by the patient's general condition of malnutrition. The former may properly be called tubercular ulceration, and the latter is better known as the ulceration of the tuberculous. The former is very rare. It may occur in the rectal pouch or indeed 1 Op. cit., p. 19?. NON-MALIGNANT ULCERATION. 247 anywhere along the course of the alimentary canal, but its favorite site is at the verge of the anus, where it may exist before any general manifestation of tuberculosis. The characters by which such an ulcer may be recognized are its pale -red surface covered with a small quantity of serum, but devoid of healthy pus and appearing as if varnished ; the absence of all surrounding inflammation and of the granulations which exist in a healthy sore ; its tendency to spread in depth rather than on the surface ; the absence of any marked pain ; the regular outline ending abruptly in healthy skin ; and above all its chronicity and the utter failure of all remedies to affect its steady course. The diagnosis may be confirmed by the microscope ' and the disease is analogous to tuberculosis of the larynx, which, however, has been studied much more thoroughly. Fig. 76. Whether such an ulcer is ever a cause of stricture is doubt- ful, it being doubtful whether a truly tubercular ulceration in this place ever heals, or, in other words, results in the forma- tion of contractile tissue. It is exceedingly difficult to induce them to take on a healthy reparative action ; and if cicatrization begins, the process is generally incomplete, and the cicatrix easily breaks down. Sands, 2 however, relates a case of stricture in a boy aged eighteen, due to tubercular deposit, both in the rectum and peritoneum, for which he performed colotomy, the deposit being on the anterior wall at the level of the pubic symphysis, and the rectum being so nearly occluded as not to allow of the passage either of an instrument or an injection. On autopsy, a portion of the small intestine seven feet long, was also found to be so narrowed as to admit of the passage only of a full-sized bougie, but the narrowing in both cases seems to have been due 1 In the excellent monograph of Pean et Malassez, Etude clinique sur les Ulcera- tions anales, Paris, 1872, there may be found the history of a case of this kind with the microscopic report and drawing of Cornil. Gosselin also gives a clinical lecture on a similar case in the Gaz. Med. de Paris, March 27, 1880, calling attention to the main points in the diagnosis and treatment ; and Allingham speaks of cases in which the diagnosis was confirmed by Paget, and remarks parenthetically that the disease is not as rare as is generally supposed. Other literature on the subject may be found in Habershon, On the Diseases of the Abdomen, p. 302 et seq., London, 1862; in Mol- liere, Traite des Maladies du Rectum et de l'Anus, Paris, 1877 ; Spillmann, De la tuberculization du tube digestif (These d'agrigation en Medecine, 1878); and Lion- ville, Bull. Soc. Anat., 1874. 5 N. Y. Med. Journ., April and December, 1865. 248 DISEASES OF THE RECTUM AND ANUS. rather to the encroachment of the tubercular mass than to cica- trization and subsequent contraction. A tubercular ulcer starting in the wall of the rectum may end in perforation and fistula (fistula with large internal open- ing), and, as a matter of course, the usual operation in such a case would be followed only by disappointment. Such an ulcer has also been known to cause sudden death from haemorrhage in a child, aged four years, the subject of acute general tuber- culosis. 1 Fig. 76. — Tubercular Ulceration. (Esmarch.) The treatment is, therefore, only palliative, though Molliere 1 propounds the interesting question whether, if such an nicer were completely extirpated or destroyed, before general symp- toms of tuberculosis had shown themselves, it might not be possible to prevent the general manifestation of the disease, as may be done in cases of tubercular testis. He bases the ques- tion on a case in which such an ulcer existed nearly four years before any other sign of tuberculosis was apparent. ' Ashby : Trans. Manchester Med. Soc, Brit. Med. Journ. , July 31, 1880. 'Op. cit., p. 651. NON-MALIGNANT ULCERATION. 249 The other variety of so-called tubercular ulcer is a simple sore in a phthisical patient, modified in its course and charac- teristics by the general condition. It may result from any of the causes already mentioned, and any of the varieties already described may, under the proper conditions, assume its charac- teristics. It may occur either within the rectum or at the anus, and may vary in size from a mere spot a quarter of an inch in diameter to a sore covering the whole lower part of the rectum. It may extend in depth as well as on the surface, may perforate and cause abscess and fistula, or be attended by thickening of the wall without decrease in calibre. It is often accompanied by numerous polypoid growths ; it is generally painful, and the discharge is purulent. It neither extends rapidly nor heals easily, and yet it is surrounded by a healthy reparative action, and, unlike the true tubercular sore, it may be induced to heal, and is one of the causes of grave stricture. The process is essentially a chronic one, and several of the cases of "chronic ulceration of the rectum " reported by Curling come properly under this category. It may easily be distinguished from true tubercle, but may readily be confounded with some of the varieties which are to follow. Scrofula. — Allied to the class of ulcers last named are those in which the scrofulous taint manifests itself, as it may do either in follicular ulcers of the rectum and large intestine, in lupus or esthiomene, and in rodent ulcer. The last two affect primarily the anus and perineum. Follicular ulceration is due to a chronic inflammation and fatty degeneration of the follicles of the rectum. These which, when first affected, appear as small caseous nodules, break and leave small, deeply excavated ulcers, which, being multiple, may coalesce and leave larger ones of the chronic variety, capa- ble of subsequent healing with the formation of cicatricial tissue. They may perforate the bowel or form fistulse of the blind internal variety when low down, or cause peritonitis when higher up. They may be only one of many manifestations of the scrofulous tendency in the same patient, and they fre- quently co-exist with pulmonary disease. Under the title of esthiomene (lupus exedens of the ano- vulvar region) a number of phagedenic ulcerations, complicated with more or less hypertrophy of the nature of elephantiasis. *250 DISEASES OF THE RECTUM AND ANUS. have probably been described ; but, in spite of the confusion of statement, this would seem to be a rare manifestation of scrof- ula, which may precede any others in its development. It commonly starts from the external organs of generation in the female, and invades the anus, rectum, and vagina secondarih\ It is almost never seen in men. Its favorite starting-point is in the perineum, and instead of being superficial, it may be per- forating and produce great loss of tissue, turning the rectum and vagina into one cavity. At this stage other ulcers are apt to appear in the rectum and colon, causing diarrhoea and some- times peritonitis ; but whether these are of the variety just de- scribed as follicular, or are due to further deposits of lupus, has not yet been positively decided. The ulcer is irregular in outline, with a granular base of a violet-red color, and there is a slight sanious discharge. The edges are but little elevated, and are not undermined, and there is more or less hypertrophy of the surrounding tissue which, in some cases, is exceedingly well marked. The ulcer may cica- trize in part, the cicatrix being thin and white, at the same time that the ulcerative process is extending in the opposite direc- tion. At a little distance from the ulcer there is often a path- ognomonic appearance of slight, reddish, hard nodules of tu- bercular lupus, separated from the primary sore by healthy skin. With this amount of disease the constitutional disturb- ance is often not sufficient to confine the patient in the house. The diagnosis is not generally difficult, though the disease may be confounded with cancer, phagedenic chancroid, and with elephantiasis with secondary ulceration. It is best dis- tinguished from cancer by the cicatricial bands which it leaves behind in its ineffectual attempts at healing, and from chan- croid by the surrounding tubercles which in lupus develop in the thickness of the derma, and ulcerate secondarily ; while the ulcers which sometimes surround a chancroid are ulcerous from the first, being due to secondary inoculation. Van Buren ad- vances the theory that most of these ulcerations are due to the grafting of the syphilitic poison upon the scrofulous diathesis in women of improper lives. The duration of the disease is in- definite, and it seldom leads to fatal results. It is best treated by destructive cauterization and raclage. 1 1 See also Huguier. Mm. Acad, de Med. . 1849; Harday, Scrofule et Scrofulides, p. 80 ; and Pcan et Malasscz op. cit. NON-MALIGNAXT ULCERATION. 251 Rodent Ulcer is very closely allied to epithelioma, and may;, in fact, be considered one of its varieties ; but it is distin- guished from it clinically by the fact that it does not infiltrate surrounding tissue, does not involve the lymphatics, and does not become generalized. It is the same disease met with upon the face, and is exceedingly rare at the anus, being seen only twice in four thousand consecutive cases at St. Mark's Hospital. According to the classical description of Allingham, it is found by preference at the verge of the anus, and extending from this point upward into the rectum. It is irregular in shape, and its edges end abruptly in healthy tissue. Its sur- face is red and dry ; it destroys superficially, attacking mucous membrane rather than skin, and undergoes rapid but only partial cicatrization under proper local and constitutional treat- ment. It never entirely heals, and is not to be included among the causes of stricture. It is at first generally mistaken for a late syphilitic manifestation, but is distinguishable from it by the powerlessness of all treatment to prevent its steady prog- ress. It is one of the most painful of all the ulcerative affec- tions of this part, and ends fatally, unless some other disease cuts short the history. It is best treated by complete excision, and this, in one case of Allingham' s, secured immunity for a period of four years during which the patient was under obser- vation. Dysentery. — In dysenteric ulceration, the diseased portion of the lower bowel becomes infiltrated with fibrinous exuda- tion, and, as a result of the compression which this exercises, is necrosed and sloughs. When the slough is cast off, there results a loss of substance, and if this is superficial, the mem- brane may regain its former state ; but, if deep, the usual callous cicatrix is produced in its place, and stricture is the result. The ulcers resulting from this process vary much in size, location, and appearance. They may be minute circles, but are generally large, and, though their favorite site is the rectum or sigmoid flexure, they may be found anywhere in the large in- testine. They may extend so as to coalesce and leave only islands of mucous membrane between the extensive patches. The" process usually involves only the mucous coat, but may ex- tend in breadth, and result in perforation and its attendant evils. The coats of the bowel may become sinuous abscesses, so 252 DISEASES OF THE RECTUM AND ANUS. that, on dividing the prominent portion of mucous membrane between two ulcers, several drachms of pus may escape (Ha- bershon). Although all the symptoms of dysentery may result from ulceration due to other causes, as in Annandale's case, 1 there is no doubt that in this country the disease is one of the causes of chronic ulceration and stricture, and Habershon con- cludes that the disease is more common in our climate than is generally supposed. In the "Medical and Surgical History of the War of the Re- bellion," 5 Dr. "Woodward remarks that stricture resulting from dysenteric ulceration seems to have been much rarer than might have been supposed, and that no case has been reported at the Surgeon-General's office, either during the war or since ; that the Army Medical Museum does not contain a single specimen ; nor has he found in the American medical journals any case substantiated by post-mortem examination in which this condi- tion is reported to have followed a flux contracted during the Civil War. In the Amer. Journal of the Medical Sciences for April, 1881, I published a case which I then believed came under that category, and the subsequent history of which has only the more convinced me of the correctness of the diagnosis. Venereal Ulcers. — Gonorrhoea of the rectum has already been spoken of under the head of proctitis. Without attempt- ing to decide upon the specific character of the inflammation which may follow the contact of gonorrheal virus, it may be well to call attention to the severity of that inflammation and to the fact that it may cause ulceration, and, probabty, subse- quent stricture. During the height of the process the rectum is hot, red, swollen, and granular, and there is an abundant purulent discharge issuing from the anus, from time to time, in clots. The irritation of this may cause erosions and fissures which may reach a considerable size ; or a previously existing fissure may become inoculated in this way and spread in extent. Chancroids. — One of the most frequent of all the superficial ulcerations at the anus is the soft chancre. It is said by Pean and Malassez to have constituted nearly one-half of all the ulcerations in this region examined at the Lourcine in 1868. It is much more common in females than in males, consti- tuting one in nine cases of chancroids in the former and one in 1 Brit. Med. Journ., p. 681. 1872. * Part II., vol. i., Med. Hist. NON-MALIGNANT ULCERATION. 253 four hundred and forty-five in the latter. 1 To account for this greater relative frequency only two things are necessary : the frequency of accidental contact of the male organ in coition and the facility of auto-inoculation which is due to the proximity of the vulva and vagina. These ulcers are seen either on the skin around the anal orifice, or just within the canal (Plate I.), and show a decided tendency not to pass above the upper border of the internal sphincter. So marked is this trait that their existence in the rectum proper has been denied, and the mucous membrane supposed to furnish no suitable ground for their imoculation. They may be single or multiple, may be situated at any point in the anal circumference, or may completely surround it. In one case of my own, the anus was completely surrounded by a group of these sores, and the ulceration extended from the posterior commissure backward in the intergluteal fold its whole length, as far as the base of the sacrum, being superficial, however, in the whole of its course. In such a case the pain is apt to be severe ; a careful examination is impossible without ether, and there is often free haemorrhage. The bleeding at the time of defecation was the chief cause of alarm to the patient in the case mentioned. These sores have the same charac- teristics as the soft chancre in other parts of the body. The class of women in whom they occur is always an aid to the diag- nosis, and if suspicion as to their nature exists, the test of auto- inoculation may always be tried. Sores of this variety tend to spontaneous cure with cleanli- ness, and, if necessary, with judicious cauterization ; and no matter how completely they may have involved the anus or the skin around it, they seldom leave any traces of their former existence. On the other hand, the cure may be delayed even for months, and the sore may assume a chronic type, due either to the existence of other disease in the rectum, as haemorrhoids, or to a syphilitic or scrofulous taint in the patient. They may be complicated by a chronic oedema of the surrounding parts, and resemble the lupus exedens already mentioned, or by the gangrenous process known as phagedsena, generally of the chronic variety, and advancing in one place while healing in another. 1 Fournier: Diet, de Med. et Chirg. Prat., Art. Chancre, p. 72. 254 DISEASES OF THE RECTUM AND ANUS. And now we come to the debatable ground upon which so much has been said and written, and about which much still remains to be learned. Do these soft chancres ever cause strict- ure of the rectum, and are they the most common cause of those grave strictures so often met in women who have had syphilis, and which are generally known as S3 7 philitic % In the light of our present knowledge, and yet subject to such modifi- cations of opinion as future experience may teach, we shall an- swer yes to the first of these questions, and no to the second. That a soft chancre may extend into the rectum and cause great destruction of tissue, cicatrize, and leave stricture, is be- yond doubt. Van Buren ' says, "I have certainly seen this in several cases, but only in women;" Bumstead and Taylor" speak in the same way ; Molliere 3 says, "Nevertheless, the soft chancre of the rectum does exist, and has even been seen to as- sume frightful proportions in this deep region ;" and Bridge's 4 case is generally considered as conclusive, though its authority rests much more upon the well-known character of the men who pronounced judgment upon it than upon its history as it stands recorded ; for there is at least a strong suspicion of syphilis, and there is no account of the crucial test of auto- inoculation. Dr. Mason's 5 paper to prove the chancroidal nature of this kind of ulceration and stricture has this great advantage over the similar one of Gosselin, 6 that he leaves the reader in no doubt as to what he means by chancroid, and unhesitatingly adopts the dualistic theory. That this is not the case in the latter article the reader may readily convince himself by a careful perusal ; and, for my own part, I am unable to see where in this justly celebrated article the non-syphilitic nature of the affection in question is taught, for the author leaves us in absolute ignorance as to which of the two at present well-known varieties of "chancre" is, in his opinion, the primary cause of the stricture ; and it is rather by inference than otherwise that his "chancre" is interpreted to mean chancroid. The idea left on the mind of the reader is not that the dis- ease is not syphilitic, but that it is neither a primary, secondary, 1 Op. cit., p. 243. a Venereal Dis., Philadelphia, 1879. 3 Op. cit, p. G77. * Arch, of Dermatology, January, 1876. 6 American Journal of the Medical Sciences, January. 1873. « Arch. Gen. deMed., 1854. NON-MALIGNANT ULCERATION. 255 nor tertiary manifestation of syphilis, as such are generally un- derstood, but something developed in the neighborhood of the primary sore. Gosselin, though he comes nearer to it than had ever been done before, just missed enunciating the chancroidal nature of these strictures, though Bassereau had distinguished between the two chancres two years before. What he does assert is, that they are not to be considered as manifestations of constitutional syphilis, but that they are of local character, " due to a special modification of the vitality of the tissues contaminated by the virus of the chancre, comparable to the lengthening and hyper- trophy of the prepuce with contraction of its orifice, which fol- lows a chancre on its under surface, in which the disease is evidently neither an oedema, nor a specific induration, nor a constitutional affection, but a local lesion, due to the presence of the chancres, and consecutive, to the inflammation which they have caused." In the same class of lesions he places hypertro- phy of the labia, condylomata, and other vegetations. The weight of the evidence, then, is decidedly in favor of the occasional causation of stricture by the chancroid. But that all of the many so-called syphilitic strictures are not due to this cause is rendered certain by the fact that many of them occur in women above the suspicion either of a chancre or a chan- croid, and many more are developed late in the course of true syphilis, but are not preceded by any iilceration, chancroidal or otherwise, at the anus, and have their starting-point well above the sphincter muscle. Of the true nature of these we shall speak later. Chancre. — True chancre at the anus is not very uncommon. Though Pean and Malassez saw only one case at the Lourcine in 1868, they explain the fact by the slight local disturbance which the sore causes — so slight that the sufferers do not seek treatment. They give the proportion in this place as compared to chancres in other parts of the body as one in sixty-eight, and as much more frequent in women than in men (one in thirteen in the former, to one in one hundred and seventy-seven in the latter). These are about the same figures reached by Jullien. In the female, a sore in this locality is easily accounted for by accidental inoculation ; in the male, it means sodomy. They are most likely to be mistaken for simple fissures, but have a hard, raised outline and indurated base, are less painful, and 256 DISEASES OF THE RECTUM AND ANUS. devoid of the healthy surface of the former. In any case of suspicion constitutional treatment should be delayed till the diagnosis is completed by the appearance of general symptoms. True chancre within the rectum is very rare indeed. Ricord, Fournier, and Vidal de Cassis each report a single case, and in the latter the induration is said to have been so great as to cause stricture. 1 Molliere carefully analyzes the evidence on this point up to date, and concludes that though a true chancre may exist within the rectum, it never causes stricture, for the reason that it does not produce any great amount of ulceration, and that the induration tends to spontaneous resolution, or, at least, rapidly yields to the influence of mercury. The diffi- culties surrounding the diagnosis of such a sore are manifest. Its mere appearance would scarce be conclusive, and in women the absence of any other sore which might cause secondary symptoms would need to be absolutely proved — a very difficult thing to do. Secondary and Tertiary Syphilis. — One of the secondary manifestations of syphilis is to be looked for at the anus and rectum — the mucous patch, not an infrequent sign in the former locality, and one liable to assume ulcerative action from local irritation or inoculation with the virus of the chancroid. Gen- erally, however, they are devoid of symptoms, and disappear spontaneously without treatment, or simply with cleanliness and the use of an astringent wash. That the mucous patch may appear in the rectal pouch also is rendered probable from analogy with the fauces, and such cases have been reported ; a but as they never form cicatrices, they must be counted out of the etiology of stricture. Tertiary Syphilis. — Well-marked cases of tertiary syphilitic ulceration in the rectum, such as are seen in the mouth and throat, are seldom mentioned ; and yet that they may exist and may cause extensive destruction is not only probable from anal- ogy, but clinically true. Smith 3 says, "I am strongly im- pressed with the view that stricture of the rectum is produced either directly by the specific ulceration in the part affected, or by contact of the discharge from the surrounding parts" — a sentence of which the last clause weakens the first, for the ques- tion is not whether ulceration may be set up in the rectum of a 1 Van Buren. * Molliere, p. 641. 3 Diseases of the Rectum. NON-MALIGNANT ULCERATION. 257 syphilitic person by the irritation of a discharge from the sur- rounding parts, but whether there is such a thing as true ter- tiary syphilitic ulceration of the rectum. Curling ' describes a case presented by the late Mr. Avery at a meeting of the London Pathological Society, 8 which he says clearly showed the connection of the lesion with syph- ilis. " Immediately within the anus, which was surrounded by a circle of vegetations, the ulcer commenced extending three inches upward, and occupying the whole of the internal surface of the rectum to that extent. The edges were rough and un- even above, and below soft and rounded, the whole surface was smooth, exhibiting the muscular fibres of the intestine quite bare. The patient died with numerous indelible marks of syph- ilitic eruption on the limbs and trunk." Paget 3 also describes a case very fully and gives the main points by which syphilitic ulcers may be distinguished from tubercular. He says: "The whole mucous membrane is de- stroyed except one small patch, which is thickened and opaque. The exposed submucous surface has a lowly tuberculated, un- dulating, uneven appearance, and is thickened by infiltration. In the early stages the tissue is soft, as it is from recent inflam- matory effusion or oedema ; but as the infiltration organizes it hardens, becoming callous, with fusion of the mucous and sub- mucous coats, and then contracts and thus brings about the stricture. The affection commonly extends from the anus, as if by continuity with the excrescence (condylomata), to about five inches up the rectum ; but it is rarely so marked in the first inch of the rectum as it is higher up." In the case spoken of there were also ulcers in the colon, which, as the patient died of phthisis, had to be carefully dis- tinguished from tubercular disease. He says : " On the mucous membrane of all parts of the colon there are ulcers, of regular round or oval shape, from one-sixth to two-thirds of an inch in diameter, with clean, sharply cut, scarcely thickened edges, surrounded by healthy or only too vascular mucous membrane. Their bases are for the most part level, flat, or with low granu- lations resting on the submucous tissue, nowhere penetrating to the muscular coat, with no marked subjacent thickening or 1 Diseases of the Rectum, p. 112. 2 Transactions of the Pathological Society, vol. i., p. 94. 3 Medical Times and Gazette, 1, p. 279. 1865. 17 258 DISEASES OF THE RECTUM AND ANUS. hardening. On some of them are ramifying blood-vessels ; on some few there is at the centre of the base a small island of mucous membrane, giving to the ulcer an evident likeness to the annular syphilitic ulcer of the skin." In a few places they had coalesced so that the annular shape was less distinct. In the colon they were continuous with those in the rectum which '" £0$ ; cp Fir;. 77.— Syphilitic Ulceration of Colon. (Huet.) a, swollen follicles with gummy infil- tration ; b, commencing ulceration of follicle ; c, ulcer showing submuoous connective tissue ; d, ulcer exposing muscular layer. Paget conjectures to have been originally of the same shape. Fig. 77. The diagnostic marks are thus given: "These ulcers were limited to the large intestine and decrease in size and number from the rectum upward — conditions which I think are never observed in tubercular disease. There is not a trace of tubercle, i.e.. of circumscribed, crude, or softening tuberculous deposit, NON-MALIGNANT ULCERATION. 259 in the submucous or any other tissue of the intestine, none in a Peyer' s patch,' or at the base or edge of any ulcer, or in the sub-peritoneal tissue below an ulcer. The shape and other characteristics of the ulcers are quite unlike those of intestinal tuberculosis ; they are regular, with sharp, even, well-defined edges, with level bases ; they are not excavating, nor do they extend through the submucous tissue ; their edges are nowhere eroded or undermined, sinuous, thickened, or brawny or infil- trated ; the subjacent and intervening structures appear healthy except at the rectum. These ulcers are not grouped, and where by extension or coalescence they have lost their firgt shapes they have acquired one altogether irregular, and have in no in- stance even tended toward that girdle -like shape, encircling the canal of the intestine, which is so characteristic in the large coalesced tuberculous ulcer. Thus by negative as well as by positive characters, these ulcers are clearly distinguished from the tuberculous, and, as I have said, there is no other form of intestinal ulcer to which they bear even a remote resemblance." I have seen two cases of ulceration in syphilitic women where I could find no more satisfactory explanation of the cause than the presence of this constitutional state. In both the disease began well within the rectum and not at the anus, which is rare but which proves that they were not an upward extension of a chancroidal ulcer at the anus ; and in both it began as an ulcer of the mucous membrane, and was not at all similar to what has been described as ano-rectal syphiloma. In one it coincided with a late syphilitic eruption, but though the eruption promptly yielded to general treatment, the rectal dis- ease did not. A strong argument in favor of the syphilitic origin of many cases of ulceration and stricture is found in the fact that a large proportion of them all, nearly one-half, occur in persons with an undoubted syphilitic history. Both Smith and Paget remark on the occurrence of large condylomatous tags of skin around the anus in these cases as a sign of value in the diagnosis of syphilis ; and the former re- marks that he has more than once made the diagnosis of syphilitic stricture from their presence alone. As a sign of ulceration and probable stricture they are of value ; but they can hardly be said to point to the character of the ulceration. The ano-rectal syphiloma of Fournier (see non-malignant 260 DISEASES OF THE RECTUM AND ANUS. growths) is not primarily an ulceration, but like the gummata it leads to ulceration, and according to him it is the most common cause of that form of stricture which is called syphilitic and which we have spoken of in connection with the chancroid. It is primarily an infiltration of the wall of the rectum by a new deposit of peculiar, doughy, inelastic feel, covered by shiny, livid integument, which is prone to break down into ulceration ; and it causes stricture, not by a process of ulceration and sub- sequent cicatrization, but by an actual blocking up of the outlet of the canal. Stricture. — Not only is ulceration a common cause of strict- ure, but any form of stricture is liable by its obstructive action to set up ulceration in the wall above. At first there is dilatation of the rectal pouch and hyper- trophy of its walls, due to the effort to overcome the obstruc- tion. In this way the coats may become double their natural thickness. Next an ulcerative action is set up in the mucous membrane, probably due to the irritation and traumatism of fjeces. Beginning as a simple congestion, it advances to com- plete destruction of the tissue over the whole circumference of the bowel, and sometimes for several inches above the stricture. As a result of this process the muscular layer may be entirely denuded, and even perforated at a point high above the original disease. 1 Gangrene. — The gangrene which sometimes follows the con- tinued fevers and is particularly liable to affect the female genitals, and the more severe forms of abscess in this region may by their extensive sloughing end in subsequent deform- ity and stricture. The following case 2 shows the extent of the ravages which may be caused in this way. Case XVIII. Gangrene. — Colored woman, aged eighteen years, stated that six days before she had been taken in labor at full term, and was delivered of her first child after an easy labor of less than twelve hours. She was left after delivery in a soiled condition upon the filthy bed for three or four days, when she experienced some uneasiness and felt some pimples upon the vulva. On examination on admission to the hospital, the labia were found swollen, black, and sloughing ; and escap- 1 See Molliere, p. 294; Gosselin, loc. cit.; Lancereaux, Bull, de la Soc. Anat., 1859; Malassez,T>ict. Encyc., p. 728. 8 Dr. Sparkman, Trans. South Carolina Med. Ass., 1879. NON-MALIGNANT ULCERATION. 261 ing between them was a purulent discharge of intensely foetid odor, mixed with the urine which constantly trickled away. With this local condition there was associated a slight fever and small, quick pulse. Eight days after admission, the whole vulva and vagina, which had separated at its junction with the uterus, were thrown off, leaving a deep excavation, five inches from above downward, two and a half inches across, and three inches in depth. The greater portion of the back of the cavity was filled with a globular body, red and bleeding when touched, which was taken for the bladder. In the lower por- tion of the cavity a remnant of the posterior wall of the rectum which had suffered in the general destruction could be seen. The slough which came away was nearly eight inches in length and two or three in thickness. This disease is not to be confounded with the idiopathic gangrenous cellulitis already spoken of under the head of abscess, and which is also, when recovery takes place, very apt to result in subsequent deformity and stricture. Symptoms. — The symptoms of what is known as the irrita- ble ulcer or fissure are so well marked as to render its diagnosis in most cases easy. The chief is the peculiar pain, which may be constant, but is always increased by defecation. The act of defecation itself may not be notably painful, but after the act, sometimes almost immediately, sometimes after a short interval, the characteristic suffering begins and may last in mild cases an hour or two, or in severe ones nearly all of the twenty-four hours. The pain is described by the sufferers as dull gnawing and aching rather than lancinating, and with it there will often be associated neuralgic pain in the loins and down the thighs. As a result of this suffering, at first periodic and later con- stant, a very miserable general condition is often developed. The sufferer soon learns to dread the act of defecation and to postpone it as long as possible, till a state of chronic constipa- tion is produced which is overcome at long intervals by purga- tives ; and in this way the whole digestive apparatus is thrown out of order. In women also there is apt to be reflex irritation of the bladder with tenesmus ; and in men there may be spas- modic stricture of the urethra. In women, also, it is not un- common to find uterine trouble combined with that at the anus. It is sometimes a matter of amazement to the physician to see how long a woman will suffer from a simple sore of this kind, 2G2 DISEASES OF THE RECTUM AND ANUS. and to what a condition of invalidism she will allow herself to be reduced before she will seek for aid. The struggle between feminine modesty and the desire for relief may last for many years before common sense finally gains the victory. It will sometimes be found that as great suffering may be caused by a simple erosion at the anus as by more extensive and deeper ulceration, and indeed the amount of pain is not at all indicative of the depth or extent of the sore. The element upon which the pain directly depends is probably the exposure of nerve-filaments. Moreover, the susceptibility to pain varies greatly in different people, and a woman of high nervous or- ganization may be completely invalided by a sore which would not prevent a laboring man from attending to his daily avoca- tions. It must be remembered in this connection that all fissures or ulcers in this part are not painful, that many heal sponta- neously, and many more exist for years without causing any particular trouble. Ulceration within the rectum is also attended by a certain train of symptoms which render its existence extremely prob- able, and which in themselves are sufficient to denote the pres- ence of an ulcerative process, though throwing little light upon its nature. These have been so well described by Allingham that we cannot do better than give them in his own words : "In the majority of these cases the earliest symptom is morning diarrhoea, and that of a peculiar character, in my opinion, quite indicative of the disease [ulceration], and can only be confounded with 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 dis- charge resembling 'coffee-grounds' both in color and consist- ency ; occasionally the discharge is like the ' white of an un- boiled egg' or 'a jelly-fish,' more rarely there is matter. The patient in all probability has tenesmus, and does not feel re- lieved ; there is something of a burning and uncomfortable sensation, but not actual pain ; before he is dressed very likely ]i<- has again to seek the closet ; this time he passes more motion, often lumpy, and occasionally smeared with blood. It also may happen that after breakfast, taking hot tea or coffee, the bowels will again act ; after this, he feels all right, and NON-MALIGNANT ULCERATION. 263 goes about his business for the rest of the day, only perhaps being occasionally reminded by a disagreeable sensation that he has something wrong with his bowel. . . . After this condition has lasted for some months, more or less, as influ- enced by the seat of the ulceration and the rapidity of its ex- tension, 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 wearying, described as like a dull toothache, and it is induced now by much standing about or walking. At this stage of the complaint, the diarrhoea comes on in the even- ing 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 anoma- lous pains in the back, hips, down the legs, and sometimes in the penis." We need scarcely call attention to the extreme gravity of this condition, or to the certainty with which, if untreated, and sometimes indeed in spite of the best treatment, it will end either fatally, or in stricture which will require the gravest surgical procedures for its relief. The picture is unfortunately a familiar one to every general practitioner, and a case of severe or extensive ulceration of the rectum, is perhaps one which calls for as much skill in treatment and yields as poor results as any- thing in the range of surgery. Diagnosis. — The diagnosis of the existence of ulceration is generally easy with sufficient care. A small ulcer within the grasp of the external sphincter, or partially concealed within one of the saccnli, may easily escape a cursory examination, but no ulceration within four inches of the anus is beyond the reach of actual touch and vision, and none need, therefore, escape detection when the examination is properly conducted. In many cases the diagnosis is plain, the sphincter will be found destroyed, and the rectum and vagina will present one common cavity of foul appearance, from which issues a foetid purulent discharge. In other cases, by a careful and gentle pulling apart of the lips of the anus and a gentle straining down on the part of the patient, a small ulcer within the grasp 2G4 DISEASES OF THE RECTUM AND AXES. of the sphincter, or at least its lower edge, will be brought into view without the use of the speculum or ether. In others, a digital examination will reveal an eroded painful spot within the rectum, and when the finger is withdrawn, it will be found stained with blood. In all such cases the diagnosis is easy ; in others, there is but one way to make a diagnosis, and the secret of success will be found in the two words — ether and the specu- lum. This is the way. I am sorry to say, which is least often followed by the general practitioner. It is much easier to give a lady a diarrhoea mixture and trust in Providence for a cure than to gain her consent to take ether and be thoroughly exam- ined, and for this reason many a case of curable disease has been allowed to reach an incurable stage before its existence has been certainly determined. The existence of a chronic diarrhoea, or of a discharge of any kind from the rectum, is always a good and sufficient reason for a thorough physical examination, and with ether, a dilated sphincter, and a good speculum, no one need be in doubt as to the existence of ulceration in the lower part of the rectum. The existence of ulceration being decided, its nature remains to be determined. We have already, in speaking of the differ- ent varieties, given some of the chief points in the differential diagnosis, and to these we must again refer the reader. In every case the history must be taken into account, as well as the appearance of the lesion. Of the many varieties we have mentioned, some may almost certainly be excluded from their great rarity. Amongst these are the true chancre, the tuber- cular deposit, lupus, and rodent ulcer. In the majority of cases, after excluding syphilis, the ulcer will be of the simple variety first described, modified more or less by the general condition of the patient, or it will be malignant. TreaJbment. — In speaking of the treatment of ulceration of the rectum and anus, we will first deal with the simplest form, the irritable ulcer, and then with the more severe, postpon- ing the question of stricture, which is the most frequent result of severe ulceration, to a separate chapter. The treatment of fissures at the anus should in the first place be preventive in those persons in whom the skin of the part is sensitive and liable to cracks and small sores ; and for such there is nothing better than the daily washing of the part with cold water and a soft sponge, and the avoidance of anything NON-MALIGNANT ULCERATION. 265 which may tend to irritate it, such as the use of printed or rough paper after defecation. When fissures really exist, but before the sphincter has be- come irritable, they may often be cured by a nightly applica- tion of Goulard's liniment on a pledget of lint, or by gently touching the surface with a solution of nitrate of silver to coat the sore (gr. v. or x. — |j.). Allingham strongly recommends the following ointment for use in such cases, to be applied sev- eral times during the day. B Hyd. subchlor gr. iv. Pulv. opii , gr. ij. Ext. belladonnas gr. ij. Ungt. sambuci 3 j. I have been surprised, in my own practice, at the remarkable results which can be obtained in simple fissures with applica- tions of weak solutions of nitrate of silver, and I have the notes of many cures by this means, some of them by a single applica- tion, combined with a light laxative to ensure easy passages. The occasional light application of the solid stick of nitrate of silver will sometimes effect a cure, but cauterization should be used with great caution. ■ An ointment of the oxide of mer- cury ( 3 ss. — fj.) will sometimes prove effectual, and I have myself been very well satisfied with the results obtained by the occasional passage of a simple hard bougie well oiled, and al- lowed to remain a few minutes within the anus. "With these means at my disposal I now seldom find a fissure which can- not be cured by milder means than stretching the sphincter. With these local measures must always be combined the greatest possible amount of rest, and the daily administration of a mild laxative to insure a soft evacuation. If there is already considerable pain after defecation, it is a good plan to have the bowel emptied before going to bed at night, and to ad- minister an opium suppository or enema after the motion, by which means a quiet night may often be obtained. An oint- ment of ext. belladonna may also be used for the same purpose. The method of cure which at the present time has succeeded all others in these cases, and which is so invariably successful as to leave little to be desired, consists in temporarily paralyzing the sphincter muscle by stretching it, the patient being under 266 DISEASES OF THE EECTUM AND ANUS. ether. This is an outgrowth of the original operation of Boyeiy which consisted in completely dividing the muscle with the knife. Syme saw that this was unnecessary, and substituted for it the division of those fibres of the muscle which formed the base of the ulcer, an operation equally effectual and in every way preferable to the other, involving no danger of per- manent loss of power of the muscle, inasmuch as its fibres are not completely divided. Dumarquay 3 also proposed another substitute, which he believed would succeed where other meas- ures failed, and which consists in a subcutaneous section of the muscle by passing the knife first between the mucous mem- brane and the muscle and then catting till the muscle gave way, very much as the tendo Achillis may be felt to do when sim- ilarly operated upon. The objections to this procedure are the occasional occurrence of suppuration in spite of the greatest care ; and the risk of a concealed haemorrhage, which may be none the less severe and infiltrate the parts with blood. The operation of stretching was originally performed by Recamier, and as performed by him consisted rather in a thor- ough kneading of the muscle with the fingers than in stretch- ing ; and this was once again improved upon by Maisonneuve 3 who brought it to essentially its present condition. This oper- ation has been already described. In fissures complicated with polypi, the polypus must always be removed at the time of the operation ; and in women suffer- ing from the union of uterine and vesical trouble with painful ulcer, the uterus must be treated as well as the ulcer, or the operation on the latter will be apt to fail. In cases where the patient refuses to take ether, the opera- tion of drawing a sharp knife through the ulcer and muscular fibres directly beneath it may sometimes be performed quickly, and with only momentary pain. It is customary to use a fenes- trated speculum in such an operation, but it may easily be dis- pensed with when a straight, blunt-pointed knife is used. The knife should be very sharp, and the operation must be skilfully done, but when properly done it is usually successful. It is not necessary to cut entirely through the sphincter, and yet those fibres of it which form the base of the ulcer should be 1 Traitc des Maladies Chirurg., etc., t. x., Paris, 1831. 2 Arch. Genl. de Mod., 1840. 3 Clin. Chirurg., t. ii., p. 1864. NON-MALIGNANT ULCERATION. 267 fairly divided, for it is by putting an end to the contractions of these fibres that the operation works its cure. The operation should always be extensive enough to produce a certain amount of relaxation of the muscle. The most frequent cause of failure in any of the procedures commonly employed for the cure of fissure is the presence of a small polypus or an external hemorrhoidal tag in connection with the sore. These should always be searched for with great care, hence with a speculum, and should always be removed when found. Otherwise neither stretching nor division of the sphincter will be of much avail. Note.— Kjellberg (Nordiskt Med. Arkiv, Bd. VIII. , Heft 4) has called attention to the comparative frequency with which fissure is met with in children, which he believes to be much greater than is generally supposed. In 9,098 children brought to the Polyklinik of Stockholm, it was found 128 times ; 60 of the cases were boys and 68 girls. The majority were under one year of age, and 73 under four months. The symptoms resemble those in the adult, but are less severe, and the treatment is the same, care being taken to remove anything which may act as a cause of the trouble, such as constipation, worms, rectal catarrh, etc The treatment of ulceration within the rectum is a much more difficult matter than the treatment of that at the anus, and yet in principle they are the same. In both we give the ulcer rest, and try to assist nature in her own methods by avoiding anything which shall interfere with the process of re- pair. The treatment of ulcer of the rectum may therefore be summed up in two words, rest in bed and fluid diet. I do not think I exaggerate when I say that these alone will cure most cases that are curable, and that without them no treatment is likely to be of much avail. The rest in bed must be absolute, and is not such rest as is usually considered by ladies to be compatible with a morning bath, a rather elaborate toilet while standing before the mirror and walking round the room, and a final sitting down to com- parative quiet in an easy-chair or on a lounge for a part of the day till the reverse of the performance is repeated. Rest in these cases means rest in bed for weeks at a time, and the line should be drawn on exercise at just what is necessary for the use of the commode which is brought into the room and placed by the patient's bed when necessary. After considerable ex- perience I have found it easier to begin right in these cases than to waste a couple of months while the patient is half resting, 268 DISEASES OF THE RECTUM AND ANUS. and then have to come to it in the end ; and have again and again been surprised to see how quickly reparative action will begin in the one case, and how long it may be delayed in the other. An hour's walking and standing around the sick-room will undo more than the other twenty- three can gain. This point being carried to the surgeon's satisfaction, the milk-diet need not be so absolute; but may be varied with soups and easily digested solids, as bread and crackers ; care being taken to secure soft and unirritating passages. With such diet as this it will sometimes happen that a movement of the bowels every two or three days will be all that nature re- quires, and, as long as such a condition causes no uneasiness, I am not accustomed to interfere with it by laxatives. In cases where it is well borne, cod-liver oil may be adminis- tered both as food and laxative, often with excellent effect upon the general condition and the local trouble. In the way of local applications suppositories answer the best purpose. The menstruum should be of some substance which may be easily dissolved at the temperature of the body ; and in the way of drugs I have had more satisfaction with bismuth and iodoform than with anything else. The practice of introducing local remedies in this form has many advantages over that of applying them by means of a speculum, because a speculum examination of an ulcerated rectum, repeated two or three times a week, is apt to do more harm by its mere intro- duction than the remedies will do good. The utmost gentle- ness must be used in all cases, and the greatest care is neces- sary to keep from irritating the part. I have also found it well to mix about the tenth of a grain of morphine with the supposi- tory, and administer this at night and morning. It certainly ministers to the local rest of the part, and it renders rest in bed much more endurable in persons of a nervous tendency. Certain good results may be gained by applications to the ulcerated spot by means of enema ta, and when the disease is situated high up, the amount of fluid injected should be large. Three pints of water may be thrown into the upper part of the rectum, the sigmoid flexure, and the lower part of the colon, if the proper means be adopted, without causing any uneasiness at the time or any subsequent desire for an evacuation. Long, flexible, soft-rubber tubes may now be obtained from any of the surgical instrument-makers, which are suitable for this purpose. NON-MALIGNANT ULCERATION. 269 The tube should be small and the opening in it just large enough to hold securely the smallest end-piece of an ordinary David- son's syringe. The injection should be given with the patient on the side, and given slowly. The drug from which the best results may be expected when used in this way is the nitrate of silver, and the solution should vary in strength from twenty to forty grains to three pints of water. This plan of treatment has recently been very successfully employed in cases of dysen- teric ulceration. Dr. Mackenzie ' reports five cases of cure by it, and in one of them, where the disease had lasted two years and a half, the cure followed a single injection. The knife may serve a good purpose under several circum- stances. Where the sore is of small dimensions and well-limited in outline, even though it be above the external sphincter, it is sometimes of advantage to draw the knife across the muscular fibres which form its base, and secure rest for it in this way. The operation is one of delicacy, but is also one which may assist greatly in the cure. In cases of more extensive diseases above the sphincter and at its level, where the latter by its action causes constant pain and suffering (and indeed ulceration of the rectum is seldom very painful unless the sphincter is involved, and in advanced cases, where it has been entirely destroyed, may be almost painless), I am in the habit of freely dividing that muscle in the median line posteriorly by a single incision through all its fibres. In this way relief is given to suffering, more perfect rest is obtained than is otherwise possible, and a way is opened for such further local treatment as may be necessary. The operation may be followed by incontinence, though it is not apt to be if the incision is in the median line, so that the nerves are not implicated, and if the internal sphincter be not involved in the incision. The operation is preferable to that of stretching the muscle, simply because its effect is more perma- nent ; and, indeed, is a substitute for colotomy in the same class of cases. Of this operation I shall say more in the next chapter, when speaking of the most frequent secondary effect of ulcera- tion — stricture. The application of strong nitric acid to a circumscribed ' On the Treatment of Chronic Dysentery by Voluminous Enemata of Nitrate of Silver. The Lancet, April 22, 29, 1882. 270 DISEASES OF THE RECTUM AND ANUS. ulcer of the rectum is often attended by the happiest results, as seen in the following case : Case. Ulceration of the Rectum cared by Nitric Acid. — The patient was a man, aged thirty-one, with a full syphilitic history, who for two j^ears had suffered from the usual signs of ulceration of the rectum. He had bloody diarrhoea in the morn- ing, passed a good deal of mucus, suffered constantly from pain in the rectum and bowels, and had tried a thorough course of constitutional treatment without benefit. On examination under ether, three distinct ulcers were found in the lower four inches of the bowel, and each of these were thoroughly cau- terized with nitric acid. The patient was then put to bed for a month, and confined to milk diet. After the first few days there was a marked relief to all symptoms, and the diarrhoea and pain disappeared entirely. The subsequent treatment consisted in the daily administration of a laxative, and of suppositories of iodoform (gr. v.). At the end of six weeks all signs of the disease had disappeared. In treating these cases by local applications the surgeon must be prepared to ring all the changes between a two-grain solution of nitrate of silver and fuming nitric acid, or pure carbolic acid. They are cases which require the utmost care, both as to the diagnosis, in the first place, and the treatment ; and many of them will end unhappily in spite of all that can be done. And yet, when they present themselves in their earlier stages, before irreparable injury has been done, they are capable of being cured by the treatment which has been outlined. CHAPTEK XL NON-MALIGNANT STKICTURE OF THE RECTUM. Strictures Divided into Congenital and Acquired. — Table of Subdivisions. — Complete and Partial Congenital Stricture. — Acquired Stricture. — Stricture due to Pressure from "Without. — Spasmodic Stricture. — Non-Veneieal Strictures. — Dysenteric Stricture. — Simple Inflammatory Stricture. — Stricture due to Enlargement of Valves of the Rectum. — Traumatic Stricture. — Venereal Stricture. — Divided into Cicatricial and Neoplastic. — Cicatricial Venereal Stricture. — Neoplastic Venereal Stricture. — Pathological Anatomy. — Changes in Rectal Wall above and below the Stricture. — Changes in Parts around the Stricture. — Symptoms. — Value of Flattened Passages as Symptom. — Signs or Obstruction. — Obstruction with Strict- ure of Ccnsid rable Calibre. — Diagnosis. — Dangers to be Avoided in Examination. — Difficulty when Disease is Situated high up in the Bowel. — Use of Bougie for Diagnosis. — Treatment. — Advisability of Anti-Syphilitic Medication. — Palliative Treatment. — Medicinal Treatment of Threatened Obstruction. — Surgical Meas- ures. — Dilatation, Gradual or Sudden. — Rules for Gradual Dilatation. — Divulsion, Dangers of, and Methods of Performing. — Treatment by Free Division. — Descrip- tion of Operation. — Collection of Cases. — Results of this Treatment. — Comparison with Colotomy. — Cases from Author's Practice. — Knife for Operation. — Excision of Non-Malignant Stricture. — Colotomy. — Restrictions to the Operation. — General Considerations Regarding it. — Treatment of Stricture High Up. For convenience of reference the following table of the differ- ent varieties of stricture of the rectum has been prepared. Congenital. Acquired . STRICTURE OF THE RECTUM. 1. Complete. 2. Partial. 1. Pressure from without. 2. Spasm. fa. Dysenteric. 3. Non-venereal. -[ b. Inflammatory. ^ c. Traumatic. 'a 4. Venereal. 5. Cancer. Cicatricial. (From Chan- croid. From Secondary and Tertiary Ulceration.) Neoplastic. (Gummata. Ano - Rectal Syphiloma. Inflammatory.) 272 DISEASES OF THE RECTUM AND ANUS. Congenital Strictures. — The congenital narrowing of the rec- tum, both complete and partial, which is sometimes seen, has been already described in speaking of the malformations of this part, p. 37. Acquired Strictures. 1. Stricture due to Pressure from without. — A stricture of the rectum may be due either to a change in the wall of the bowel or to pressure from without. A tumor of any kind in the pelvis will not infrequently press upon the rectum so as to obstruct its calibre. An abscess in the ischio-rectal fossa may be accompanied by an amount of in- flammatory deposit around the rectum sufficient to obstruct it, and a pelvic inflammation in women may be accompanied by an exudation which in the form of bands across the bowel shall partially close it, and at the same time lead to compensatory muscular hypertrophy of the rectal wall. Medical literature is full of cases of this nature, and here it is only necessary to refer to them as a not infrequent cause of obstruction both of the rectum and of other parts of the canal. 2. Spasmodic Stricture. — Much has been written in times past upon the question of spasmodic stricture of the rectum, but at present the condition is looked upon by the best author- ities with great doubt, if not with, absolute unbelief. Spas- modic contraction or stricture of the external sphincter is not an unusual condition, and cases of it from my own practice and that of others will be reported further on, but spasmodic strict- ure of the canal above this point has always been a matter of belief and assertion rather than of demonstration. Allingham upholds its existence, in connection with organic stricture, as a complication of the latter, and gives the follow- ing case as proof. He says : " There are, no doubt, many cases of stricture in which there is very little deposit and much spasm, and there are, on the other hand, cases where much ob- struction exists, but very little spasm. A patient under my care at St. Mark's had a stricture so tight that I could not make the point of my little finger enter it ; on putting her under the full influence of chloroform, I could get two fingers through without difficulty." This case, if it be admitted, as it generally will be on so good authority, actually proves more than lias ever been proved be- fore with regard to this question, and is about the only one which really proves anything. I have already referred to the NON-MALIGNANT STRICTURE OF THE RECTUM. 273 difficulty which often exists in passing a rectal bougie from the natural conformation of the parts. It is upon this difficulty that nearly all the arguments for, and the supposed cases of, spasmodic stricture rest. When the bougie cannot be passed, a spasmodic stricture is supposed to be the cause. When, af- ter numerous trials, by a lucky manipulation an entrance is effected, the spasm has been overcome. To this may be re- duced nearly all the reported cases of this affection which from time to time have appeared in the writings of those who have devoted attention to the subject. Molliere, 1 with his usual happy style, has gone very nearly to the bottom of this question. He says that at a not very re- mote period there flourished by the side of Ashton, Curling, and the surgeons of St. Mark's Hospital, certain specialists as expert in finding strictures in the rectum as are our laryngolo- gists in discovering polypi in the larynx. These estimable practitioners gave themselves up to the daily exercise of dilata- tion by bougies, and to facilitate the practice one of them had invented a pair of pants of a special pattern, dressed in which novel livery his patients came daily to have a sound introduced into the anus. This whole question of spasmodic stricture has been very ably discussed by Van Buren, 2 and if the reader wishes to fol- low it further, he can scarcely do better than to consult that article. Uncomplicated spasmodic stricture of the rectum is a thing whose existence is not admitted by the best authorities, and which will seldom be found by a skilful examiner. It is, perhaps too much to say that it never exists ; but a well-marked case of it within easy reach of the finger, which could be plainly detected by an ordinary examination, and which disappeared under chloroform, is what those who do not believe in its exist- ence are calmly waiting to see. Non - Venereal Strictures. — a. Dysenteric. Dysenteric strict- ure and ulceration have also been already described. Stricture due to this cause is, perhaps, more often multiple than when due to any other. b. Inflammatory. Proctitis, whether acute or chronic, when 1 Loc. cit., p. 320. 2 On Phantom Stricture and Other Obscure Forms of Rectal Disease. Amer- ican Journal of the Medical Sciences, October. 1 879. 18 274 DISEASES OF THE RECTUM AND ANUS. attended by sufficient changes in the structure of the coats of the rectum may result in stricture. There is another form of stricture which may be considered as on the dividing-line between the congenital and the inflam- matory, and which consists in an enlargement and thickening of the folds of mucous membrane which are normally present in every one. Quain, 1 under the head of impaction of faeces, describes the case of a man, aged forty years, who died with a large accumu- lation which was evidently due to the presence of two crescent- FiG. 78. — Longitudinal Section of Stricture of the Rectum at the Plica Recti Inferior. (Kohlrausch.) a, mucous membrane; b, circular muscular layer entering into the fold of the stricture ; c, cellular tissue ; d, longitudinal muscular layer passing over the stricture. shaped shelves of mucous membrane projecting into the rectum, one attached opposite the prostate and the other about four inches higher. Each of these was more than an inch in breadth, and into each the circular muscular fibres fully entered, while even the longitudinal layer dipped slightly inward at their bases. Kohlrausch also describes an analogous case, in which he made an autopsy on a criminal who had been executed. (Fig. 78.) He found an enormous dilatation of the rectum above the spot at which he locates the plica transversalis. At that point he 1 Diseases of the Rectum, p. 273. London, 1854. NON-MALIGNANT STRICTURE OF THE RECTUM. 275 discovered an undoubted stricture which, from its hardness and extent, he at first considered cancerous. It presented, however, nearly the same anatomical condition as the one just described ; the mucous membrane was sound and formed a considerable duplicative, the circular muscular fibre entered into this dupli- cature and formed a hard, hypertrophied, muscular ring several lines in thickness. The longitudinal fibres passed directly over the affected spot in this case, however, and were not unusually thick or firm, and the space left between the outer and inner muscular layers by the bending inward of the latter was filled with connective tissue. A stricture was in this way formed without degeneration of the mucous membrane — a condition, however, which led to no less serious results. Such a state furnishes in itself the ground for constant aggravation, for the longitudinal fibres passing entirely over the fold must, by each contraction and by the necessary increase in their normal func- tion, augment the substance of the fold more and more, and thus decrease the lumen of the gut. Nelaton, indeed, has writ- ten that valvular retractions of the rectum are most often only an hypertrophy of his superior sphincter, and that the projec- tion formed by it into the cavity of the intestine is the point at which foreign bodies are most frequently arrested, as well as that at which invaginations in young children generally begin, and in all these points he is borne out by Velpeau. 1 Sappey a says " at the level of this band most of the organic contractions of the rectum are situated ; its study, therefore, offers no less interest in a pathological than in a physiological stand-point." This idea of the pathological relations of the mucous folds and muscular bands in the causation of organic strictures may be traced through the works of Arnold, Tanchou, Hyrtl, and Houston, and has its foundation in the fact that, as these folds are the most subject to injuries, so they may be the most fre- quent starting-point of those contractions of the rectum which are due to injuries, especially those from foreign bodies intro- duced per anum or swallowed, and from masses of hardened freces, intestinal concretions, etc. c. Traumatic. A simple traumatism may result in stricture, either by causing ulceration and cicatrization or by exciting a chronic inflammation in the submucous connective tissue. 'Velpeau, Anat. Chir., 3d ed , p. 39. 1837. 2 Anat. Descript., t. iv., p. 222. 276 DISEASES OF THE RECTUM AND ANUS. Amongst these traumatisms may be enumerated operations upon haemorrhoids, applications of strong acids, the perform- ance of some surgical operations, foreign bodies, kicks and falls, and the injury produced by the head of the child at birth. 4. Venereal Stricture. — a. Cicatricial. — In the chapter on ulceration stricture has been frequently referred to as a not in- frequent consequence of that process, and the various forms of ulceration which by subsequent cicatrization were capable of producing this result have been mentioned. In a general way it may be said that any ulcer which destroys even the thickness of the mucous membrane to any extent will, when healed, leave a cicatrix, and if such a cicatrix be at all extensive it will by its contraction cause subsequent diminution in the rectal calibre. It has been shown that many of the more severe forms of rectal ulceration are of venereal origin. The venereal sores capable of producing a stricture are the chancroid, and the later syphilitic ulcers. We shall leave out of consideration the true chancre, and the mucous patch, for the reason that their influ- ence in the causation of stricture is still rather a matter of sur- mise than of proof, and the same thing may be said regarding gonorrhoea of the rectum. For a description of these ulcerative venereal processes the reader may again refer to the chapter on ulceration. b. Neoplastic. — There is a class of venereal strictures which are not primarily ulcerative and, therefore, not cicatricial ; these we have denominated neoplastic. In this class are to be placed the gummata ; the ano-rectal syphiloma, which differs from gummy deposit rather clinically than microscopically, both of which have already been described ; and a third late manifesta- tion of constitutional syphilis, which is an inflammation of the rectal wall. This inflammatory change may involve a large portion of the rectum. It begins in the muscular fibre, the in- terstitial tissue of which becomes filled with round cells which ultimately form a connective tissue, and this connective tissue by its hardening and consolidation finally causes the complete destruction of the muscular element. This is not to be con- founded with the ano-rectal syphiloma in which there is an actual deposit of large masses of new material in the rectal wall —masses which it may be very difficult to distinguish from cancer. In these various ways venereal disease, and especially syphilis, NON-MALIGNANT STRICTURE OF THE RECTUM. 277 may result in rectal stricture, and this accounts for the fact that in about fifty per cent, of all cases of stricture there is a syphilitic history. Pathological Anatomy. — In studying the pathological an- atomy of stricture, there are several points to be observed, for changes will be found not only at the stricture itself, but both above and below it, and in the surrounding parts. From what has been said already, it will be inferred that a stricture which is not the direct result of a deposit of new material in the rectal wall will be composed either of cicatricial tissue, such as is found in other parts of the body, or else of connective tissue which is firm and dense, and creaks under the knife on section. All the connective tissue in the rectum at the diseased point, whether submucous, subperitoneal, or intermus- Fig. 79. — Stricture of the Rectum showing Hypertrophy of the Connective Tissue. (Bushe. ) cular, will be found to have increased in quantity, and this ac- counts for the increased thickness of the rectal wall. (Fig. 79.) The mucous membrane at the seat of stricture will generally be found destroyed, and replaced by granulation tissue on this fibrous base, which bleeds easily when scraped. Above the constriction a process occurs which will be found to be almost constant. This begins by a dilatation of the bowel and an hypertrophy of the muscular layer, with, at first, a thickening of the mucous membrane. Later, the mucous mem- brane, due, probably, to the irritation of retained faeces, will show all the stages of ulceration, from simple congestion in some points to a complete destruction in others, and an expos- ure of the muscular tissue beneath. This ulcerative process may extend for several inches up the bowel. The wall of the •278 DISEASES OF THE RECTUM AND ANUS. bowel above the stricture may be as thin as paper in spots, and at such points perforation is apt to take place. In a case re- ported by Goodhart, 1 the changes of which we are speaking had gone on to actual gangrene, extending in spots along the trans- verse and descending colon, and were undoubtedly due to the intensity of the inflammatory action caused by the retained ir- ritant matters. The bowel is also generally distended with gas and faeces, and the latter are more often fluid than solid, though faecal tumors, with their well-known characteristics, will some- times be met. The dilatation above the stricture may reach an enormous size, and may ultimately result in a cul-de-sac or pouch which will All a large portion of the abdomen, and dip down below the point of constriction, and an ulceration in this pouch may re- sult in its perforation and the establishment of a fistulous out- let for the faeces. Such an opening may be into the rectum, either above or below the stricture, or into the ischio-rectal fossa, with the necessary result of abscess. An opening may also be made into the bladder in either sex, and in females, into any part of the genital tract. As showing what efforts nature is capable of making to overcome the occlusion caused by stricture, the following ac- count of the post-mortem appearances found in the body of Talma, the tragedian, is of great interest. The whole history of the case may be found in Quain. 2 In the examination of the body the intestines were all found largely distended with air and faecal matter. . . . The pelvis was filled with an enormous sac— the upper part of the rectum largely dilated. When the sac was raised a circular narrowing of the gut was discovered. This was the stricture. It was at the distance of six inches from the anus, and proved, upon close examination, to be wholly impervious. It was, in fact, a solid fibrous cord, but on the surface irregular, and hav- ing the appearance of a purse, drawn tightly and puckered, with the strings tied around it. The great dilatation of the bowel at its lower end, dipped down below the level of the stricture in the form of a dependent sac, in which was an open- ing about an inch in diameter, and from this opening issued a fluid, the same as that diffused through the abdomen. The Med. Times and Gaz., February 28, 1880. ' Op. cit., p. 190. NON-MALIGNANT STRICTURE OF THE RECTUM. 279 rectum below the stricture was no more than the size of a child's intestine, and upon it, close to the stricture, was an ulcerated surface with a narrow opening, to which the edges of the aperture above the stricture had been adherent. A new com- munication, but an imperfect one, had thus been established between the two parts of the gut — severed one from the other by the stricture. But the connection had given way, doubtless in consequence of the violence of the expulsive efforts, and thus the contents of the bowel had escaped a short time before death. The cellular tissue in the ischio-rectal fossae around a stric- ture may also become hard and lardaceous, as a result of chronic inflammation ; and this change may extend to some distance from the original starting-point along the sacrum, as high as the promontory, and into the subperitoneal tissue of the iliac fossae. Abscess is always liable to occur in the neighborhood of the stricture, probably from lowered vitality in the parts, and this accounts for the relative frequency of fistulse in this disease. These may be both numerous and extensive, and may make communications between the rectum and any of the adjacent organs. For this reason a fistula should always lead the surgeon to think of stricture and to examine for it. Allingham has also called attention to the frequent existence of a low form of peritonitis in connection with stricture, an in- flammation marked by tympanites, vomiting, and pain, espe- cially on walking or moving, and attended by thickening of the peritoneum and old and recent adhesions. Below the stricture the rectum may sometimes be found unchanged from its normal condition, but it will generally be ulcerated as it is above, or else there will be hsemorrhoidal tumors, excoriations, and vegetations and condylomatous tags of larger or smaller size. These cond}domatous growths are the result simply of irritation of the discharge from the process above. Most strictures are located in the lower part of the rectum, and hence their presence is easily detected in the majority of cases. They are far more frequent in females than in males, because many of the causes which produce them operate chiefly in females. Age has little influence upon their frequency after the period of adult life. A stricture may or may not involve the whole circumference of the bowel ; and the contraction may be so slight as not to be apparent till the bowel is dis- tended with the speculum, when a falciform band may spring 2S0 DISEASES OF THE RECTUM ATJD A1NTCS. out from one side. In more extensive disease, there is still usually a passage for the faeces, but this may be very slight. The most extensive disease will be found to be due generally either to syphilitic deposit, syphilitic sclerosis, or dysentery ; and in such cases the calibre of the bowel may be lessened for a space of several inches. Symptoms. — Where stricture is the result of ulceration, the signs of ulceration will at first mask those of the stricture, and the patient will complain of pain, discharge from the anus, excoriations, and warty growths, together with the failure of the general health, gastric and intestinal disturbance, and wan- dering pains. The one sign of a stricture is the obstruction, and this may show itself in several ways, generally at first by alternate at- tacks of constipation and diarrhoea. The constipation is me- chanical, and is due to the accumulation of faeces above the constriction. The diarrhoea is secondary to the accumulation, which, in time, begins to act as a foreign body, setting up a catarrhal inflammation, as a result of which sufficient fluid is poured into the bowel to soften the hardened mass, and large quantities are discharged, only to be followed by a fresh ac- cumulation. It has often been asserted that a well-marked lessening of the rectal calibre must, in the nature of things, produce a change in the shape of the fasces, but this is not quite true. The flattened, tape-like stool is a sign of value when present, and should always lead to careful exploration, but it may not be present even in the worst cases of stricture, and it may exist without stricture ; in the latter case generally being due to an irregular spasmodic action of the sphincters, or to pressure from without the bowel. This point, to which attention was called by White ' as long ago as 1815, has again recently been 1 "With regard to the lessened diameter of the fasces, just noticed, which must necessarily he the case whenever a permanently contracted state of the gut takes place ; yet it has happened in some instances where that change had been observed, that, in a more advanced period of the disease, freces of a natural size had occasionally passed. The knowledge of this circumstance I consider of some importance, inasmuch as. if properly attended to, it will prevent the practitioner from hastily concluding there is no stricture merely from an examination of the evacuations, when symptoms may otherwise indicate the presence of the disease." — Observations on Stricture and other Affections occasioning a Contraction in the Lower Part of the Intestinal Canal, etc. Bath, 1*1'). NON-MALIGNANT STRICTURE OF THE RECTUM. 281 made the subject of discussion. In an able article on " Annu- lar Stricture of the Intestine ; its Diagnosis and Treatment," in the Britisli Medical Journal for Maj^ 31, 1879, Mr. Stephen Mackenzie wrote : " The fact that full-sized, properly formed faeces are occasionally passed, of course shows that there can be no organic stricture." Under criticism, he withdrew the statement in the issue of the same journal for May 15, 1880, with the explanation that it was founded on his personal ob- servation, which had since been supplemented and corrected by that of others. In a case which I once saw in consultation with Dr. De Long, of Brooklyn, I had a long-wished-for opportunity to observe, in the presence of a number of physicians, the actual mechanism by which tape-like stools are produced. The woman suffered from a stricture one inch above the anus, which was of suffi- cient calibre to admit the ends of two fingers easily. She had never noticed any deformity of the faeces. While under the in- fluence of ether, and after the sphincter had been very thor- oughly dilated, an O'Beirne tube was passed through the rec- tum, which was empty, into the sigmoid flexure, which was full. After resting there a few moments, it provoked a movement of the bowels. The stricture was instantly crowded down into view, appearing at the anus, and taking the place of the anus, which, owing to the complete dilatation, ceased to have any action, and was simply a patulous ring. Through the stricture there came a long, tape-like evacuation, the mould which gave it its peculiar form being the stricture pressed to the surface of the perinseum, and greatly lessened in calibre by folds of mu- cous membrane, which were crowded into it from above. While remarking to those present on the peculiar mechanism of its production, the straining ceased, the stricture rose, the mucous membrane was relaxed, and a passage of natural formation was the result. This alternation was repeated several times. At each violent effort the stricture was forced down to the anus, the membrane above it was crowded into it so as to greatly les- sen its calibre, and a flat passage was the result. When the effort was less violent, there was still a passage, but the stric- ture having risen to its place, and not being so tightly filled with the mucous membrane, the passage was natural. The les- son to my own mind was this : that a stricture of large calibre might, as a result of straining, cause a passage of very small 2S2 DISEASES OF THE RECTUM AND ANUS. size ; and that, to get this peculiar shape, the stricture must be crowded down so as to actually take the place of the external sphincter, and be the last contracted orifice through which the soft substance is expressed. It is well known that, with the closest stricture high up, the faeces may be reformed in the rec- tum below, and be passed normal in size. At the bedside but little importance is to be attached to the statements of patients concerning this matter. After a stricture has existed for a certain length of time, signs of obstruction will be manifest by abdominal palpation and inspection. The transverse and descending colon can be felt partially distended with masses of faeces, and will be dull on percussion, tender to the touch, somewhat movable, and pitting on firm pressure. After an attack of diarrhoea, or after a brisk purge, these accumulations may disappear, only to form again in a short time. Generally complete obstruction does not occur without ample warning in this way. It is preceded by eructa- tions of fetid gas, the abdomen swells and becomes very tender on pressure, the coils of intestine are visible through the ab- dominal wall, and their visibly violent peristalsis gives proof of the effort nature is making to overcome the obstacle. After a short time the patient is exhausted, and, unless surgical aid is given, dies. Complete obstruction has been seen to occur very suddenly, forming almost the first intimation of serious disease; and this is more apt to be the case where the stricture is high up in the rectum or at the junction with the sigmoid flexure. It comes on with the usual signs of acute intestinal strangula- tion — pain, swelling of the abdomen, bloody passages, etc., and it may be caused by some indigestible substance which has been swallowed and refuses to pass the stricture, or merely by hard- ened faeces or prolapse of the bowel above into the constriction. The following case is one of quite a large class : "The patient, a middle-aged woman, was admitted into St. Bartholomew's Hospital with symptoms of sudden obstruction. She stated that she had enjoyed good health up to the onset of the attack, nor had she previously been troubled with consti- pation. The attack commenced suddenly while at work, and was followed by obstinate vomiting and constipation. The symptoms having existed for some days, and the case appear- ing urgent, while the sudden onset of the symptoms suggested mechanical strangulation, it was deemed advisable to open the NON-MALIGNANT STRICTURE OF THE RECTUM. 283 abdominal cavity. This being done, Mr. Marsh felt a hard cancerous mass in the walls of the bowel, which caused the obstruction. The bowel was opened above the obstruction and stitched to the sides of the wound, the patient making a good recovery." ' There is one important element in the obstruction due to stricture which must not be forgotten. It will sometimes hap- pen that fatal obstruction will occur even when, on post-mortem examination, the calibre of the stricture is found to be large enough to permit the passage of the finger, showing that the obstruction could not have been due merely to the contraction of the new growth. John Hunter remarked a fact of this sort, as is proved by the following account : " On introducing the pipe by the anus, it was found to come butt against one side of the upper part of the cavity of the tumor, where there was a bend in the passage ; but why a crooked pipe did not pass when attempted to be passed by turning it to all sides, I cannot conceive, or why a bougie which was slightly bent did not hit the hole, is not easily ac- counted for ; but, what is more extraordinary than either, why a clyster did not pass freely up ; or why did not the wind or soft excrementitious matter that did yet lay [sic] pass readily down, while I could pretty readily pass the end of my finger down from the gut above into the tumor? The folds of the contracted part did not appear after death to have been suffi- cient for an entire stoppage of this sort." 2 Notwithstanding the statement that the folds of the part did not appear after death to have been sufficient to produce the stoppage, it seems that a prolapsed fold of mucous mem- brane is the only thing likely to give rise to it. In cases of ad- vanced disease a spasmodic stricture (if such ever occurs) would seem out of the question, whereas partial or complete invagina- tion in this part is known to be of frequent occurrence. As shown by Rokitansky," the paralysis above the stricture is also an undoubted element in the production of the occlusion. Diagnosis. — The first means of diagnosis in stricture is the examination with the finger, and as the great majority of stric- 1 Cripps : Cancer of the Rectum, p. 107. s Hunterian MS. Cases and Dissections, No. 59, in Descriptive Catalogue, etc., vol. iii., p. 98. From Mayo, op. cit., p. 249. ! Manual of Path. Anat., vol. ii., translated by Sieveking. 284 DISEASES OF THE RECTUM AND ANUS. tures are confined to the lower portion of the rectum this is in itself generally sufficient. It is the best and safest and least painful of all the means of diagnosis when properly executed, and yet it may be the immediate cause of death to the patient when roughly practised. There is an inborn tendency on the part of many, when the index finger comes in contact with a tight stricture, to bore through the narrow passage which is left and feci what is on the other side — a tendency to be strug- gled against and overcome. If the surgeon has deliberately de- termined to practise divulsion, this is one way to do it, but at present we are speaking of diagnosis, and forcible dilatation is not diagnosis, but a very grave surgical procedure. The finger should therefore be passed slowly up to the stricture, and unless the calibre admits of it without straining, it should not be passed further. The condition of the parts below may also be appreciated, the amount of induration estimated, and a general idea formed of the nature and extent of the disease. In women the vaginal touch will generally be found of the greatest value and should never be omitted. As a rnle all can be learned in this way that can be learned in any other where the disease is within reach of the finger, and nothing is to be gained by a painful speculum examination or the use of the bougie — means of diagnosis which, however valu- able where the stricture cannot be felt by the finger, are of little use for the lower four inches of the rectum. When a stricture is situated high up in the rectum or in the sigmoid flexure, the confidence in diagnosis which comes from actual contact of the finger with the disease is entirely lost, and there is perhaps nothing in the whole range of surgical diagnosis which requires more skill than the detection of stricture in this part, and nothing attended with more uncertainty. The symp- toms of stricture of the upper part of the rectum are not the same as when the disease is lower down, for the nerve-supply is not the same, nor is the sphincter muscle involved. For this reason the patient is much more apt to suppose himself suffer- ing from chronic constipation and dyspepsia than from hemor- rhoids. Pain in the abdomen, not always localized at the left side, pain in the loins and down the legs,' obstinate constipation and occasional diarrhoea, are the things usually complained of, and in these there is nothing upon which to base a positive diagnosis. The faeces may never present any peculiarity, for NON-MALIGNANT STRICTURE OF THE RECTUM. 285 tlie reason that they are accumulated in the rectal pouch below the obstruction and passed in the natural shape. They are apt to be lumpy and unformed rather than misformed, but they may be streaked with blood or slime, which is always a valuable sign and one calling for careful physical exploration. A stricture in the locality in question must be examined for with the greatest care and gentleness, and the examination will often be negative in its results. The attempt to decide the question by the use of bougies is altogether unsatisfactory and by no means free from danger. It is unsatisfactory because an obstruction will generally be encountered in trying to pass an instrument of any considerable size through this part of the bowel, and the passage of an instrument of small size, which is much easier, proves nothing. It is dangerous because, with the ordinary rubber rectal bougies, a diseased bowel may easily be ruptured with what may seem to the operator to be no more force than is justified in attempting to overcome the natural ob- structions to this part of the passage. The bulbous-pointed bougie on the flexible stem appears d priori to be the most suitable for the exploration, but it has two objectionable fea- tures. It is not at all an easy instrument to pass, and if passed through an obstruction too much force is required for its with- drawal after the abrupt shoulder is in contact with the stricture. O'Beirne gives the following description of the way to pass his tube: "A gum elastic catheter of the largest size was in- serted into the anus, and passed to the height of about two inches up the rectum, where its further progress was felt to be opposed by strong expulsive efforts, which lasted but a few seconds, then relaxed, and again became renewed. By first yielding somewhat to these efforts, and then taking advantage of the succeeding relaxation, the instrument was gradually passed to the height of seven or eight inches. At this point the resistance was sensibly felt to be much greater than at any former, but, instead of allowing it to yield, the instrument was pressed more firmly upward. Having steadily continued this pressure for about one minute, the resistance suddenly gave way, the tube passed upward as if through a narrow ring," etc. Even with the softest instrument, the moment when the ob- struction suddenly gives way, and the instrument passes for- ward, will be an anxious one for the surgeon, and the life of the patient may be sacrificed to desire for certainty of diagnosis. 286 DISEASES OF THE RECTUM AND ANUS. A bougie intended for this purpose should always be hollow, and the opening at the lower end should be of a size to admit the small tube of a Davidson syringe, which should be fitted to it before the attempt to pass it is begun. Then with a basin of warm water close at hand the bougie may be introduced, and at the first obstruction the bowel should be filled with water until it is moderately distended. In this way the folds of mucous membrane are drawn out of the way by the distention of the whole bowel, and one great obstacle is eliminated. The next is the promontory of the sacrum, which is much more easily passed by a soft than by a stiff instrument. Without these precautions, and sometimes with them, the inexperienced examiner will find a stricture in the rectum of nineteen persons out of twenty, no matter how healthy they may be ; and for this reason it is seldom safe to rest the diagnosis of stricture on the fact that a bougie cannot be made to pass. Moreover, a bougie of good size will often pass a stricture small enough to produce great trouble. In certain cases information may be gained by the use of a long cylindrical speculum with the patient bending over the table or chair and straining down to bring the parts into view. Fortunately, however, we are not limited to either of these means for a diagnosis, for, if the stricture be cancerous and of any size the mass may be felt through the abdominal wall by careful palpation ; and if not, and the symptoms warrant it, the sphincter may be stretched or incised sufficiently to allow of introducing the hand into the rectal pouch. Passing the whole hand into the rectal pouch, and then the finger into the sigmoid flexure as far as possible, is a very different affair from trying to pass the whole hand into the flexure, and is free from danger, because the distention by the hand is not carried to the point where danger is located, at the reflection of the peritoneum. Though seemingly a much more serious matter, it is really safer than any forcible use of the bougies, and by it the diagnosis maybe rendered certain for all that part of the bowel at present under consideration. I know of no other way than this by which a stricture in the sigmoid flexure, which cannot be felt by external manipulation, can certainly be recognized. Treatment. — The treatment of stricture of the rectum is both constitutional and local, medicinal and operative. The first question to be answered is as to the advisibility of anti- NON-MALIGNANT STRICTURE OF THE RECTUM. 287 syphilitic medication. In recent cases where syphilis is to be suspected this should never be omitted. It is well to exercise caution in this matter, however, and the cases in which the patient should be submitted to this form of treatment should be carefully chosen. The practitioner who considers the majority of strictures as syphilitic, and indiscrim- inately uses mercury and iodide of potash, will be mistaken about as often as he who looks upon most of his cases as can- cerous and therefore incurable. The general condition of a patient with a stricture is never up to the normal, and an un- necessary course of medication may do great harm. instead of good. Cicatricial tissue, though the result of specific disease, is be- yond the reach of specific treatment, but where the case can be seen clearly enough, much improvement can be gained by a thorough course of mixed treatment, and a gummatous deposit or a syphilitic sclerosis may be checked. Mercury and iodide of potash should both be given, neither being relied upon alone. Mercury in the form of an ointment or the oleate may also be administered by the rectum, and the full constitutional effects of the drug may be gained in a very short time by this method ; it is, however, an irritating application, and in cases of much ulceration and sensitiveness it may not be well borne. M. Trelat * has seen good effects follow internal medication in cases of ano-rectal syphiloma, though Fournier speaks so positively as to their uselessness. He gives two cases in which the disease was of long standing, but yielded to a considerable degree to the use of mercury and iodide of potash internally, with glycerin applied locally. Van Buren 2 has also seen good effects in a case of this kind from the use of the modified Zitt- man's decoction, in mild doses, guarded by bismuth, combined with inunctions of the oleate of mercury. The following case taken from Zappula 3 is worth reproducing entire, proving as it is supposed to do that a syphilitic stricture which is so extensive as to give rise to the diagnosis of malig- nant disease may be made to completely disappear by specific treatment. The author says : " The patient who is the subject 1 Le Progres Med., June 22, 1878. 5 On Phantom Stricture, etc. The American Journal of the Medical Sciences, Oc- tober, 1879. 3 Annali universali de Medicina, vol. cexvii., p. 137. 288 DISEASES OF THE RECTUM AND ANUS. of this case is one of my colleagues and an intimate friend, a man thirty-six years of age and of nervous temperament. The family history is good. The patient has always enjoyed good health with the exception of some attacks of malaria, a gonor- rhoea contracted in 1851, and some months after an ulcer in the balano-preputial fold, which was followed by a painful adenitis in the right groin which, however, did not suppurate. The ulcer was of considerable size, lasted about forty days, and ended by healing under the influence of repeated cauterizations. Nothing more is known of the character of that ulceration, and it is impossible to establish any connection between it and the disease under consideration. But it is certain that the patient used in inunctions more than one hundred grammes of mer- curial ointment, and that an examination of the former site of the ulcer shows now no trace of its existence. "The first symptom of the present disease was pain which started from the right side of the anus, extended as far as the tuberosity of the ischium on the corresponding side, or some- times took an opposite course, but always was confined to the ano-rectal region. The pain was of neuralgic character, inter- mittent, returning with more or less frequency, but always very severe and accompanied by the phenomena of spasm. Defe- cation became a little less frequent, but was painless except once, when there was a sharp pain about the anus. A fissure was suspected, and though it was impossible to discover it, a suitable injection of laudanum and rhatany was administered. "The pain disappeared from the ischio-rectal fossae, but symptoms of impaction followed which purgatives in large doses failed to relieve, and which on the contrary led to still more alarming accidents. It was under these circumstances that I first saw the patient, on the 24th of September. He had suffered for one month and his condition seemed to be very serious. Three large faecal tumors occupied the left iliac fossa, the epi- gastrium, and the right flank. Severe colic starting from the left iliac fossa extended over the whole abdomen and reached to the anus. The abdomen was swollen and painful to the touch, and pain was also caused by pressure in the ano-ischiatic region, where, however, no trace of organic disease could be discovered. An examination of the anus led to the discovery of a stricture so tight that only the end of the little finger could be introduced without causing great pain. NON-MALIGNANT STPJCTURE OF THE RECTUM. 289 " Such was the group of symptoms the patient presented when I first examined him : retraction of the anus and probably of the rectum ; absolute necessity of causing the disappearance of the obstacle to the exit of faeces, and of exciting intestinal contraction. But it was impossible for me to know whether the contracture was due to ragades located immediately within the anus, to the neuralgic symptoms described above, or to some neoplasm in the lower part of the rectum. Nevertheless I attacked the symptom of contracture by the method of Recamier, and it may be imagined how painful this proceeding was while the state of the sufferer did not permit me to give ether. However, during the operation I discovered an enor- mous dilatation of the lower portion of the rectum, from which escaped a considerable quantity of glairy matter. Twice after- ward I administered large doses of purgatives, but the patient vomited them almost immediately, and the abdominal meteorism increased. Then the vomiting became spontaneous, the fever increased, and the symptoms of strangulation became so intense that the life of the patient seemed to me about to be sacrificed, when again, under the influence of two inunctions of croton-oil on the abdomen, there followed a tumultuous expulsion of faeces. More than twenty hard, round, faecal masses came away, and after this relief all went well. But the patient's ease only lasted a few days, for the faeces very soon accumulated afresh, without forming tumors, however ; the passages were made with difficulty ; and purgatives administered from time to time caused the expulsion of hardened masses mixed with mucus and sometimes with blood. However, the suffering con- tinued, and was especially violent after the administration of purgatives, even in small doses ; the abdominal pain became more and more severe ; the ischio-rectal pain, together with the neuralgia which he had at the commencement, returned and resisted the most powerful local anodynes; but the anal spasm did not return. In spite of these frightful sufferings there was as yet little loss of flesh. " But the organism could not long withstand such sufferings and emaciation supervened ; there was fever at irregular inter- vals, always preceded by a chill, and a pale-yellowish tint to the skin. An examination of the rectum, which had been de- layed on account of the repugnance of the patient, was ex- tremely painful ; but instead of finding as before a considerable 19 290 DISEASES OF THE RECTUM AND ANUS. dilatation of the lower extremity, I found the tissues soft and uneven, giving to the finger the sensation of folds and anfractu- osities, in a way that without a speculum examination would have led one to believe in the existence of condylomata and ex- tensive destruction of tissue ; but by the aid of that instrument I was able to prove that we had to deal with an hypertrophy of the mucous membrane, which was mammillated. " This condition was found completely surrounding the rec- tum and reaching as high as the eye could see. The sensation which my finger experienced could not, therefore, be due to a duplicature of the hypertrophied mucous membrane. A sound introduced into the rectum passed freely eleven centimetres, but, arrived at that point, it was arrested by an insurmountable obstacle, and caused great pain. A second examination, prac- tised about a fortnight later, permitted me to observe a small tumor on the right side of the intestine, four centimetres above the anus. This tumor was the size of a hazel-nut, spherical, smooth, somewhat elastic, and indolent even to pressure. It was absolutely immovable, and did not seem adherent to the mucous membrane beneath which it lay. But all these details were very difficult to appreciate well on account of the hyper- trophy of the mucous membrane and the irregularities of its surface. "The retraction of the rectum was then an evident fact, re- vealed not only by the rational symptoms, but by the physical examination and the hypertrophic thickening of the mucous membrane. But the diagnosis of the nature of the constriction still remained doubtful, for the data furnished by direct exam- ination seemed insufficient. We were therefore reduced to making a diagnosis by exclusion, and rejecting successively the valves of mucous membrane, strictures due to ulceration or simple inflammation, excluding also the idea of a spasmodic or venereal stricture, tubercular stricture, polypus, and haemor- rhoids, we were naturally led to the conclusion that we were dealing with a cancer. However, we had no pathognomonic sign on which to base this diagnosis ; and the origin and evolu- tion of the disease were not those of cancer, the march of which is slow and rarely takes such an exceptionally rapid course. Tims, hesitating to admit a cancer, I thought of syphilis. But it was necessary to know for certain whether our patient was suffering from syphilis. It was necessary to be able to estab- NON-MALIGNANT STRICTURE OF THE RECTUM. 291 lisli by well-observed facts that a syphilis may remain latent nearly nineteen years without causing any species of manifes- tation. The emaciation, the coloration of the skin, the daily fever, all seemed to indicate the presence of cancer, and to ex- clude the idea of syphilis. "However, the powerlessness of art in the presence of a heteroplastic lesion determined me to attempt an anti-syphilitic treatment, which I commenced by administering large doses of iodide of potash. After twelve days of this treatment the pa- tient experienced relief of all the worst symptoms. The first to yield was the ischio-anal pain, which for some time had been exceedingly severe. The anal tumor diminished little by little, the mucous membrane subsided, there were several normal pas- sages, the colic became less frequent and less severe, and disap- peared finally after some violent pain which the evacuation of a considerable quantity of hard faecal matter provoked. From that time the passages were daily and easy, the local symptoms became definitely better. The flesh returned, the fever disap- peared, with it disappeared the yellowish tint of the integument, and at the end of three months the patient was completely cured." This case is also quoted by Molliere ' in full, as proof of what may be accomplished by anti-syphilitic treatment in syphilitic stricture. He remarks that one sucli case seems to him to pass all comment, and to prove what caution should be used in the diagnosis of organic disease. That nothing, in fact, was more improbable than the syphilitic character of the lesions of this patient, and that specifics saved him from certain death. He asks : "Is not one authorized, in the presence of one such extraordinary fact, to lay down the absolute rule that iodide of potash should be employed in all neoplastic lesions of the rectum ?" To my own mind the case conveys a very different lesson from the one intended. It seems to me to prove nothing with regard to the effect of internal medication in syphilitic stricture, and to be one more example of a diagnosis of stricture based upon the fact that a bougie met with an obstruction at a point beyond the limit of touch and vision. It may be a case of syphilitic stricture cured by treatment, but the history does not prove it. 1 Op. cit , p. 306. 292 DISEASES OF THE RECTUM AND ANUS. There are various means by which the comfort of these suf- ferers may be greatly increased without recourse to operative treatment — and since in many cases the surgeon is limited to these means in his efforts to afford relief, it is well that th^y should receive careful attention. The most effectual of them will be found to be a careful regulation of the diet, the admin- istration of laxatives on occasion, and rest. The diet should consist mostly of fluids, preferably milk. If milk is complained of, soups may be substituted. A certain amount of farinaceous food may also be allowed, such as toast, crackers, and mush ; but milk is the basis of the diet, and the other things are only intended to make that diet endurable. Many patients will as- sert from the outset that they cannot take milk, but nearly all can take it, and considerable quantities of it daily for an in- definite period, if a little care is exercised in its administration. The bowels should move daily without straining. Should any medication be necessary to secure this daily evacuation a mild laxative will be found all-sufficient. The mineral waters, or Rochelle or Glauber's salts answer every purpose. Purga- tives are always contra-indicated in stricture of any variety, because they cause straining and tenesmus, increase the ten- dency to congestion and its consequences, and because where obstruction actually exists or is threatened, they may do great harm by exciting violent peristaltic action in an already weakened and ulcerated bowel. The opposite condition of diarrhoea is more difficult to meet and often cannot be controlled by direct medical treatment, depending as it does on the ulcera- tion associated with the stricture. It is best met by diet, rest in the recumbent posture, and bismuth with morphine. The general strength of these patients is to be supported in every possible way, and in all of them where it can be borne cod-liver oil will be found to answer a good purpose. When obstruction actually exists, much may be done in the way of general treatment before resorting to operation. Food -hoi ild be almost absolutely suspended ; opium should be given in large doses, to allay the peristaltic action of the intestine, and large poultices covering the abdomen will be found to give great relief to fclie suffering. Dr. Norman Kerr has derived great benefit from the administration of the extract of bella- donna in doses of one or two grains at short intervals, in this condition, but the rationale of its operation is not understood. NON-MALIGNANT STRICTURE OF THE RECTUM. 293 No purgatives should be administered, and the bowel should not be tapped with the aspirator. The dangers of this measure have already been pointed out. By these means, combined possibly with gentle dilatation, the life of a patient may be prolonged in comfort. I have often been agreeably surprised at the happy results of such measures, where operative interference was either declined or contra-indi- cated, and they can never be dispensed with, though an opera- tion be performed. The various surgical procedures at our command for over- coming stricture of the rectum may be considered in the follow- ing order : 1. Dilatation. 2. Division. 3. Colotomy. 1. Dilatation. — This may be either gradual or sudden, par- tial or complete. The use of bougies for gradual dilatation is an example of a good practice originating in false ideas. It was first adopted with the idea of destroying the stricture by the effect of medicinal substances applied in this way ; experience, however, soon proved that simple bougies were not less effica- cious than medicated ones, and the improvement was then sup- posed to be due merely to the mechanical stretching of the part, and the instruments were introduced as often, and allowed to remain in, as long as possible, an idea still very popular. But as Syme 1 pointed out, "it is the effusion of organizable matter in the cellular texture of the part which causes the stricture, and it is the absorption of this deposit which removes the disease. The bougie, by its pressure, excites the action of absorption ; and if the pressure be too great, too long continued, or too frequently repeated, there will be a great risk of causing more than sufficient irritation for the purpose, and of inducing again the very condition it is desired to counteract, the consequences of which must be a confirmation and increase of the disease." The rules which should guide the surgeon in this method of treatment are now well understood and generally admitted. The dilatation should be intermittent, and not constant. At- tempts at constant dilatation by means of a bougie of any sort which shall remain permanently in place, generally result either in failure or actual disaster. They are not well borne by the patient, and when their use is persisted in, in spite of the pro- test which nature is pretty sure to make, the rectum becomes : Op. cit., p. 120. 294 DISEASES OF THE RECTUM AND ANUS. irritable, the suffering is greatly increased, and the patient is exposed to the risk of peritonitis and cellulitis. The dilatation should never be forced. A bougie should be chosen which will readily pass the obstruction without stretch- ing, and if there be any doubt in the operator's mind as to the proper size of the instrument to be used, let one be selected which is too small rather than too large. The instrument should seldom be passed more than every alternate day, and once a week may be often enough. Little is gained by allowing it to rest for any length of time within the constriction. Practised in this way, much good may be done by this treat- ment. The patient may be greatly relieved, and made very comfortable ; but it must be continued indefinitely. For this reason, I suppose it is not infrequently used under false pre- tences in cases of hypothetical stricture in hypochondriacal patients ; and most of the reported cases of cure will be found reported by the laity. It has happened to me more than once not to be able to find any stricture after a patient had sub- mitted to a long course of supposed dilatation, and there is but one way of convincing the patient under such circumstances. It consists simply in passing a full-sized instrument its whole length into the bowel. In cases where the stricture is associated with much ulcera- tion, dilatation by bougies is very apt to make matters worse instead of better, and in such cases I seldom employ it in my own practice, and have seen much suffering caused by it in the practice of others. The treatment by gradual dilatation, perhaps on account of the recent great advances which have been made in the treat- ment of stricture, has, to a certain extent, been superseded by more radical measures. It is not long since a well-written article on rectotomy in one of our periodicals was begun by the statement that the treatment of stricture by dilatation was ac- knowledged to be a failure. This is by no means the case. The measure may not be curative, but it is, perhaps, as valuable a palliative as is at the command of the surgeon. It need not always be done with a bougie ; for the patient's own finger or thai of a careful nurse is often better than any instrument. It is applicable to all structures, malignant or benign, which are within reach of the anus. When the disease is high up, it is not free from danger, and can scarcely be recommended, NON-MALIGNANT STRICTURE OF THE RECTUM. 295 on account of the uncertainty and difficulty of its applica- tion. I have said that this treatment by gradual dilatation was not curative, and must be continued indefinitely. I have seen no exceptions to this rule, though many of them are reported. In years gone by, this treatment and that of forcible dilatation or divulsion were about the only means of dealing with this affection. Now we have better ones which will shortly be de- scribed. Divulsion. — The dilatation, instead of being gradual, may be sudden and complete. For this purpose various instruments have been invented, all of them with the idea of tearing open the constriction by the use of a considerable amount of force. One of these is shown in Figure 80. More recently, advantage Fig. 80. has been taken of fluid pressure, and an instrument has been invented by Wales, which is shown in Figure 81. Of all the instruments for forcible dilatation, this is perhaps the best. There are now several cases on record where forcible stretching with the fingers, either with or without previous nicking with a knife, has been followed by immediate relief to obstruction and faecal accumulation. 1 What may be accomplished by this method is well shown in the following successful case from Smith. 2 " I was called by Dr. Vine to see a military officer, aged forty, who had returned from India in the most miserable plight. He had suffered for several years from chronic diarrhoea, and had not got relief from any measures, and six months previously he had been recom- mended by a medical board to go by sea to England. On his arrival at Southampton, on his way to Edinburgh, his native town, he was so ill that he determined to stop in London, and when he arrived there he sent for Dr. Vine, who, on hearing 1 Smith, op. cit. Dr. J. M. Matthews, of Louisville, Ky., has recorded one re- markably successful case of this kind. 2 Surgery of the Rectum. 296 DISEASES OF THE RECTUM AND ANUS. his history, at once suspected something wrong with turn, and making an examination, found an obstruction his rec- I was 5 Fig. 81.— Wales's Dilators. requested to see him, and I found the patient exactly in the condition of one suffering from strangulated hernia ; he was NON-MALIGNANT STRICTURE OF THE RECTUM. 297 constantly vomiting, complaining of pain, and the countenance was anxious, and he was much emaciated ; the abdomen was immensely distended, and it was clear that, if some relief were not soon given, this gentleman would die. "In conjunction with Dr. Tine, I made a most careful ex- amination, and I found, on introducing the finger into the bowel as far as possible, that it met with an obstruction, but after some time I discovered what appeared to be the opening of the stricture, more like a dimple than aught else. I was en- abled to introduce through this a No. 10 gum-elastic catheter, and through this instrument some faecal matter and air came. I was thus made to see that I had got beyond the stricture. " On the following day the patient was placed under chlor- oform, and I guided a long, straight, probe-pointed knife very carefully along the' side of my left index finger, and fortunately got its point into the orifice of the stricture. I nicked this on either side, and then got the point of my finger into the obstruc- tion, and dilated the orifice as much as I could, whereupon an enormous quantity of faecal matter was emitted, deluging the bed, and placing myself and my assistants in a most unenviable position. The abdomen became quite flat, and the patient be- came at once immediately relieved. No bad results followed this operation ; in three days we commenced dilatation by bougies, and I was soon enabled to pass a full-sized rectum- bougie through the stricture. In a fortnight I took my leave of the patient, recommending Dr. Vine to pass the bougie daily. I heard a few weeks afterward that the patient had gone to Edinburgh convalescent, and able to introduce the bougie for himself." In spite of a few such successful cases as the one above, this method of treatment has but few upholders, because it has been found to possess no advantages over more gradual dilatation, and to be in itself by no means devoid of danger. The dangers are haemorrhage, laceration and rupture of the bowel, periton- itis, and abscess. The relief obtained is not permanent, and the operation involves the subsequent use of gradual dilatation to preserve the calibre gained. Even when applied to the lower three inches of the bowel, the operation is rough, uncertain, and unsurgical, and above this point it is scarcely admissible. Nevertheless, it has occasionally served a good purpose, and a few happy results are recorded in cases of linear contraction. 298 DISEASES OF THE RECTUM AND ANUS. Division of the Stricture. — The practice of nicking a linear stricture in two or three places as a first step in the treatment by dilatation is a good one, and generally devoid of danger. It can usual]} 7 be done entirely by the sense of touch with a straight, blunt-pointed bistoury passed along the left index finger as a guide. The operation of internal proctotomy consists in dividing the whole of the stricture tissue in the median line, either an- teriorly or posteriorly. It is called internal because the inci- sion is confined within the rectum and does not involve the sphincter, and it is generally performed with the knife in pref- erence to the cautery or ecraseur. Regarding this operation there is not very much to be said. It involves no new principle of treatment, and would seem to rank rather with the older procedures, such as nicking and dilatation, than as a substitute for colotomy. There have been many unpublished cases, especially in New York, and I should probably express the general feeling of the profession were I to say that it is not looked upon with very great favor. Though at first sight it might appear less serious than the external operation, it is probably the more dangerous of the two — the sphincter preventing the free discharge from the wound and in- creasing in this way the liability to pelvic inflammation. This muscle should at least be stretched as a primary step in the operation, and when possible, a large drainage-tube should be left in. The danger of haemorrhage is not very great when the incision is confined to the median line, but, should there be trouble from this cause, the advantage of a free external wound in controlling it will at once be manifest. When the cut is an- terior as well as posterior, the anatomical relations must be borne in mind, lest the peritoneum in the female, or the bladder in the male, be wounded. The following case represents my entire experience with the operation, which I abandoned after once trying, being convinced of the advantages of the external excision, next to be described. Case. Internal Proctotomy. — Mrs. , aged twenty-six. This patient was a woman with a syphilitic history. The stric- ture was of eiglit years' growth, and had previously been treated both by nicking and by gradual dilatation. As a result of this treatment, she describes an attack of " inflammation of the bowels," which made her very dangerously sick. The NON-MALIGNANT STRICTURE OF THE RECTUM. 299 stricture was two and one-half inches from the anus, was of just sufficient calibre to engage the end of the index finger, and did not involve more than one inch of the bowel, though there was the usual amount of ulceration above it. I divided the stricture by a single, deep, posterior incision, which did not implicate the sphincter, and the operation was followed by an attack of pelvic peritonitis, which very nearly cost the patient her life. This may have been due to the opera- tion, or it may have been due to attempts at subsequent dilata- tion, which was begun early and followed with perhaps too great vigor ; but it was certainly excited by the patient leaving her bed, going down-stairs, indulging freely in wine, and submit- ting to the embraces of her lover. Three months after the operation, I completely lost track of the case. At that time the calibre of the stricture was so much increased as to permit of easy digital examination of the parts above. The increased size seemed due entirely to a deficiency in the old cicatricial tissue at the point of incision, the rest of the circumference of the part having much the same feel as be- fore the operation. The act of defecation was much less pain- ful, and her condition was altogether much better. I never counted the case as proving anything concerning the value of the operation until a few months ago, and more than four years after its performance. In fact, I had little doubt that the contraction had returned, and supposed that the pa- tient had either succumbed to the disease or submitted to colo- tomy. At that time, however, the woman was in perfect health and spirits, and since then I have thought better of the opera- tion. I would have given much for a rectal examination after so long an interval, but it could not be obtained. Other cases of similar operations have been reported in this country with equally good results. 1 External proctotomy involves not only the division of the 1 Whitehead — Old fibrous stricture ; anterior and posterior incision with bistoury, followed by dilatation. Two months later, much improved ; passages large and nat- ural ; dilatation continued. Amer. Jour. Med. Sc, Jan., 1871. Lente — Fibrous stricture and fistula ; incision followed by dilatation. Three months later, much re- lieved, with prospect of entire cure by continuing the use of bougies. Amer. Jour. Med. Sc, July, 1873. Beane — Probably syphilitic; incision both anterior and pos- terior, followed by use of dilators. Seven months after, cure of ulceration and of many bad symptoms, but tendency to recontraction. Amer. Jour. Med. Sc, April, 1878. 300 DISEASES OF THE RECTUM AND ANUS. stricture, but of all the parts below, including the anus. This is the operation usually accredited to Nelaton, and more re- cently advocated by Verneuil, Panas, and others. It may be performed in several ways, and with the knife, galvano-cautery, or ecraseur. The operations with the galvano-cautery and ecraseur were invented by Verneuil, 1 and have been practised by him more than by any other surgeon. The operation, as performed by him, consists in passing the left index finger through the stricture as a guide, and then plunging a trocar from a point in the median line, just in front of the tip of the coccyx, into the rectum, on to the tip of the finger above the stricture. After drawing out the trocar a fine bougie is passed through the canula into the rectum, and brought out at the anus. Removing the canula, the bougie is replaced by the chain of the ecraseur, and the operation is com- pleted. The same section may be accomplished by repeated strokes of the galvano-cautery or thermo-cauteiy knife. Both these measures are intended simply to prevent haemorrhage, and have no other advantage over the knife, and by any of the methods all of the stricture tissue and the parts below may be divided. Nelaton's method was the simplest of all, and was to intro- duce the left index finger as far as the stricture, and with this as a guide, to pass in a blunt bistoury, and divide all the soft parts below the stricture as nearly as possible in the median line. By pulling open the lips of this incision, the stricture comes plainly into view, and may be divided by a second in- cision. In performing this operation either the knife or the cautery may be used. Formerly I preferred the knife, and had one especially adapted for the purpose, which is shown in Fig. 82. It is simply the lithotomy knife of Blizard, made heavier in the back and at the handle, for with an ordinary bistoury there is great risk of breaking the blade in the midst of the stricture tissue, which is often as hard as cartilage, and thus having an awkward accident. The blunt point on the end of the blade is 1 Verneuil : Dch r<'-tr : ci88ement8 de lapartie inferietire du rectum, etde leur traite- ment curatif on palliatif par la reetotomie lineaire, ou section longitudinale de l'intes- tin a l'aide de l'ccraseur. Gaz. des Hop., October 2(5, 29 ; November 7, 9, 12, 1(5, 19, 1872. Traitement palliatif du cancer du rectum au moyen de la reetotomie lineaire. Gaz. Ilebdom., March 27, 1874. NON-MALIGNANT STRICTURE OF THE RECTUM. 301 a great convenience in passing the knife along the index finger, avoiding, as it does, all risk of wounding the operator. The best position for the patient is the lithotomy position, and the whole incision may be made at one stroke. The blade should be passed fairly through the stricture before the cutting- is begun, then the stricture is divided completely, as near as possible in the median line posteriorly, and finally the incision is continued downward and outward, growing deeper as it approaches the perinaeum, till all the soft parts are severed between the anus and the tip of the coccyx. In this way a large triangular wound is made, the apex being within the rec- tum, above the stricture, and the base at the skin, and all the stricture tissue is completely cut through. There will generally be a free gush of blood when the cut is made, and the rectum should at once be packed in the manner already described, without waiting to try any other method of Fig. 82. — Proctotomy Knife. stopping the bleeding. This is a precaution which should never be omitted. It was this haemorrhage, and the trouble of removing the lint with which it was almost always necessary to stuff the rec- tum, which first led me to operate with the thermo-cautery, which I now greatly prefer. The bleeding is absolutely noth- ing, and the wound is dressed by its own eschar, thus saving much distress to the patient. This operation may be modified in various ways to fulfil any special indication. In extensive cancerous disease I have some- times made two such cuts, and taken out a considerable mass of the growth between them, merely for the purpose of opening the canal. It may be asked, Why should so large an incision be made, and so much tissue be divided below the actual disease ? The answer is simple. In the first place, this incision provides for free drainage and discharge in the most effectual of all ways, by furnishing a dependent gutter-shaped opening which cannot be- come closed. This is better than any number of drainage-tubes, and it is this alone which makes the external operation a safer one than the apparently slighter internal incision. 302 DISEASES OF THE RECTUM AND ANUS. In the second place, by this incision the sphincter is com- pletely divided, and another great point is gained. The opera- tion we are now considering, it should be remembered, is noth- ing less than a substitute for colotomy in the same class of severe cases for which that operation is generally considered the only relief. One point which is exceedingly well brought out by a study of these cases is the important part played by the sphincter muscle in tlie sufferings accompanying severe cases of stricture and ulceration, and the relief which may be obtained by its simple division without interference with the stricture itself. In one case of Verneuil's, for example, there was a stricture high up, and yet, under a mistaken diagnosis of spasmodic stricture at the anus, the sphincter was cut through with the galvano-cautery, while the real cause of the trouble was un- touched, and yet there was entire relief from suffering. The same experience has been repeated often enough to establish the general principle, that free division of the sphincter is not only a justifiable therapeutic measure for the relief of the pain at- tendant upon either benign or malignant stricture or ulceration, but is often the best means at the surgeon's command for allay- ing suffering. By the external operation, then, the obstruction is divided, and one great cause of suffering is abolished, and both are ef- fected by the same stroke of the knife. The after-treatment of the incision is very simple. When the rectum has been tightly packed with picked lint, it will usually cause more or less uneasiness on the following day, unless the patient be under the influence of opium. For this reason, I generally remove enough of it on the following day to give the patient ease, and the remainder is allowed to remain imtil suppuration has commenced. It may usually all be picked out by the third or fourth day without causing any pain. The subsequent treatment of the incision itself consists wholly in cleanliness, which may be obtained by gently syringing the part with warm water and a little carbolic acid. No particular attention need be given to regulating the passages. The first one after the operation will often be the only comfortable one the patient has experienced for years, and unless there is some special reason for interference, they may be left entirely to nature. NON-MALIGNANT STRICTURE OF THE RECTUM. 303 The cases which follow will give a very fair idea of what may be hoped for from this method of treatment. Case. External Proctotomy . — Mrs. , aged thirty-five, mother of one child twelve years old. The patient had always suffered from obstinate constipation, and several years ago was relieved artificially of impaction of faeces. Her husband, a phy- sician, assures me that there is no venereal history, nor is there any reason to suspect any such. The symptoms of rectal trouble began six years after marriage, at which time she was operated upon for large internal haemorrhoids. Soon after this she began to suffer with the usual symptoms of ulceration of the rectum. The examination revealed advanced ulceration of the whole circumference of the rectum, with a stricture about an inch and a half up, which just admitted the end of the index finger. In connection with the stricture there were two fistulas. For this condition the patient had submitted to the usual treatment by dilatation, but without relief. Her general condition was such as is usually seen in advanced rectal disease. She had lost flesh and appetite, and the suffering was extreme. What she most dreaded was an action of the bowels, so great was the pain at- tendant upon it. The operation which I have described was performed. One of the fistulae was also cut, but the other was left to the chance of spontaneous closure, since it communicated with both rectum and vagina, and the usual operation for recto-vaginal fistula would have been necessary had any interference been practised. The operation was attended with considerable haemorrhage, which was controlled by stuffing the rectum with picked lint, after the ulcerated surfaces both above and below the stric- ture had been renovated by scraping them with the handle of a scalpel. The subsequent treatment consisted merely in absolute rest in bed and milk diet, with a dressing of the wound by the in- troduction of picked lint. No attempt was made at passing a bougie, and the stricture was left entirely to itself. The imme- diate effect of the operation was a most marked and satisfactory relief of the most painful symptoms. The passages were invol- untary, but were painless and always preceded by a warning sensation, which gave the patient ample time to prepare herself. At the end of six weeks she had improved greatly in general condition, and was more comfortable than at any time since the 304 DISEASES OF THE RECTUM AND ANUS. trouble began. The passages were of normal shape and oc- curred painlessly once a day. They were under the control of the will, but there was incontinence of wind. In this condition the patient returned to her home in the West under the care of her husband. Six months later she again came to New York for treat- ment, not from any return of the pain, but because of the dis- charge from the bowel, and the occasional annoyance which arose from the incontinence of wind. Her general condition was excellent, and, except for the two things mentioned, she would have considered herself in perfect health. An examina- tion showed a very marked decrease and softening down in the stricture tissue ; the wound made with the knife had never en- tirely healed, the patient having exercised freely and constantly while at home, and there were two distinct lines of ulceration within the anus : one on the anterior surface, superficial, about half an inch broad and an inch and a half long ; the other, at the site of the cut behind, deeper, and running further up the bowel. Otherwise the old ulceration was entirely healed, and its site marked by a thin, shining bluish- white cicatricial surface. Attention was at once turned to the treatment of this ulcera- tion. The patient was put upon almost absolute milk diet, and after a while was also confined absolutely to her bed. The remnant of the old incision was induced to heal by daily dress- ings of lint and balsam of Peru, and the ulceration above was treated by applications of bismuth, opium, nitrate of silver, balsam of Peru, iodoform, and oxide of zinc, alone and in com- bination. At the end of a couple of months she was so nearly well that attention was turned to the recto-vesical fistula. The openings into the rectum and vagina were both small, but there was a considerable abscess cavity in the recto-vaginal wall which discharged into each canal. This cavity was freely laid open into the rectum. At the end of three months the ulcera- tion on the anterior wall of the rectum had entirely healed, that on the posterior wall had nearly healed, the incision had cica- trized, and the abscess cavity had closed except an exceedingly fine and fcortnous canal leading from the rectum into the vagina. The discharge from the rectum had practically ceased, and in llii< condition, which certainly warranted a prognosis of com- plete and speedy recovery, she returned to her home to continue the treatment for a few weeks longer, till she should be entirely NON-MALIGNANT STRICTURE OF THE RECTUM. dOo well. Four years later I again heard from her, and the report was most favorable. This case is certainly worthy of a careful consideration. When the lady applied to me, all the supposed resources of rectal surgery had been exhausted except colotomy. I do not think I exaggerate when I say that most surgeons would have at once decided in favor of colotomy, and would have been jus- tified, of course, in so deciding, for colotomy is still the recog- nized mode of treatment in these cases. In my own mind, colo- tomy was always present as the dernier ressort, but having tried proctotomy in several instances, and been more or less satisfied with its results, I determined to make this a test case. The re- sult was most happy, and yet there is nothing exceptional in that result, though the great tractability of the patient, and her determination to do all that was asked of her, alone rendered it possible. Case. External Proctotomy. — Mary P , aged thirty-five, widow, two children. The patient was sent to me for operation by Dr. Abbe, of New York. She had been under his treatment for various syphilitic manifestations for several years, and for at least five years, to his knowledge, had suffered from stricture of the rectum, which had been treated in various ways. At the time of the operation she was suffering from a constant dis- charge of blood and mucus from the anus, and never had an evacuation from the bowels without previously taking medicine, which she did twice a week regularly. Her general condition was fair, and there was not much pain when she used the laxa- tives and kept the bowels open. The ostium vaginae was much deformed by condylomatous growths, which had caused a good deal of hypertrophy of the labia. The urethra was ulcerated and partly destroyed, so that the little finger easily entered the bladder. The stricture began about three-fourths of an inch from the anus, extended higher than the index finger could reach through the vagina, and was so small that the finger could not be passed through it. The whole mass of cicatricial tissue was divided in the median line posteriorly, the incision reaching several inches up the bowel and well above the disease, and including all of the perinseum between the anus and the tip of the coccyx, which was exposed in the wound. The haemorrhage was free, and was controlled by packing the rectum with lint. 20 306 DISEASES OF THE RECTUM AND ANUS. The patient did well in spite of adverse circumstances. The bowels moved for the first time on the seventh day after the operation. At the end of two weeks she was having comforta- ble, painless, well-formed passages without medicine, and with sufficient control of the sphincter for cleanliness. Four weeks after the operation the patient was able to attend to her usual work, and expressed herself as perfectly satisfied with her con- dition, which was better in every way than for j^ears before. On examining this patient three months after the operation, I was surprised to find a considerable degree of recontraction, although the patient was decidedly more comfortable than be- fore and was well satisfied with the result. The contraction was found to be due to a rapid closure of the incision through the stricture tissue, and this gave way very readily to the pass- age of the finger, again opening the canal. One year after the operation the patient was still very comfortable, but obliged to continue the use of bougies to prevent recontraction. Case. External Proctotomy. — E. A. B , patient operated upon in consultation with Dr. Rand, of Newark, N. J. The patient, a man, aged about thirty-eight years, had a distinct syphilitic history, and had suffered from stricture of the rectum for ten years, and from fistula for two years. For some months past he had noticed also a decided failure in sexual power, which he attributed to the rectal trouble. The fistula had once been cut without any relief, and the stricture had recently be- come so tight that he was afraid of its complete closure. To avoid this, he was in the habit of taking a very hard bougie, resting it upon the floor, and then, by sitting down upon the sharp end of it, forcing it into the bowel by the weight of his body. There was great trouble in securing evacuations from the bowels, and a constant muco-purulent discharge, with oc- casional escape of fa3ces involuntarily. On examination, an exceedingly tight and firm stricture, which would allow of the passage of nothing larger than a lead pencil, was found just within the external sphincter. The fis- tula was in the median line posteriorly, and was a trivial affair, having its internal opening just below the stricture, and being subcutaneous for its entire course. This was first divided, and then the stricture, which proved, after it had been cut suffi- ciently to admit the finger, to be nearly annular in form. The bowel was comparatively healthy above. NON-MALIGNANT STRICTURE OF THE RECTUM. 307 Eighteen months after the operation there had been no re- contraction and the patient was exceeding well satisfied with the result. Case. External Proctotomy for Cancer. — Mrs. H , aged fifty-four, mother of seven children. Family history good. This case, when first seen by me in consultation with Dr. Prior, of Connecticut, had been suffering with cancer for about two years, and had recently been relieved by him of an attack of faecal obstruction which was very nearly fatal. On my first examination I found the anterior wall of the rectum fully in- volved in the disease as far up as the fold of peritoneum. This I easily made out by vaginal examination. Just within the sphincter my finger came in contact with the growth, and the lumen of the bowel at this point was just sufficient to engage the end of the index without allowing it to pass. The examin- ation of the posterior wall of the bowel was, therefore, unsatis- factory ; but the idea I gained was that the disease was limited in that direction, and could probably be removed from that point almost completely without much danger. I began the operation with this idea of particular extirpation in my mind. The stricture readily admitted the small cautery- knife and was quickly cut through, but above it I came in con- tact with a mass of disease completely surrounding the bowel, and forming a stricture through which no opening could be discovered. To burn through this solid wall of cancerous disease without any guide as to the direction of the channel for the faeces was a task of considerable difficulty, and not without danger of open- ing into the peritoneum. It was, however, happily accom- plished after a considerable time, and the lumen of the bowel was largely restored by the destruction of such portions of the growth as were most easily attacked with the cautery and sharp scoop of Simon. On the tenth day, when the sloughs separated, a free secon- dary haemorrhage occurred, the patient losing about a pint of blood and fainting twice. This ceased spontaneously, and when last heard from she was having easy evacuations of the bowels and progressing favorably. In an analysis of cases made some time since, I found that in eighteen cases of non-malignant stricture treated in this way, all the patients were greatly relieved as to general health, or 308 DISEASES OF THE RECTUM AND ANUS. local condition, or both. In eight, kept under observation for a period of from three months in one case to four years in three cases, the cure was absolute, there being no return of the con- traction, and in some a disappearance of all induration. A tendency to recon traction is mentioned in four, due in two to the fact that all of the stricture was not divided. Brief notes of some of these cases are given below. External Proctotomy with the Knife. 1. Panas. — Female, aged thirty-three. Syphilitic stricture, very dense and painful ; eight years' duration. Incontinence for three months after operation. Eighteen months later, described as completely cured. — Gaz. des Hop., December, 1872. 2. Whittle. — Hard annular stricture, very close ; one fis- tula. Operation as for ordinary fistule. Haemorrhage trouble- some and controlled by thermo-cautery. . Three weeks later, " general health completely restored and local condition greatly relieved." — Lancet, June 1, 1878. 3. Pan as. — Woman, aged forty. Stricture probably syphi- litic. Two previous operations by slight internal incision, and two attempts at cure by dilatation. Patient very feeble ; suffer- ing from abdominal distention ; signs of approaching occlu- sion ; ovarian tumor ; diarrhoea and vomiting. Operation followed by relief of pain and by great comfort ; no tendency to return ; vomiting and diarrhoea continued till death, some time after, from exhaustion. Post-mortem examination showed the complete success of the operation, and the division in the fibrous tissue. — Gaz. des Hop., December, 1872. External Proctotomy with the Ecraseur, Galvano- Cautery or Thermo- Cautery. 1. Tuelat. — Ano-rectal syphiloma, of several years' dura- tion, with great thickening, ulceration, and fistula?. Operation (kind not stated) five years before, unsuccessful. Galvano- cautery. Nine days after operation, pneumonia and facial erysipelas. Death in three weeks without local accident. — Prog. Med., June 22, 1878. 2. VEBNEUIL. — Stricture of several years' duration ; great induration and tumefaction, and twenty fistulous tracks. Three operations : first, on one-half the fistula? ; second, on re- NON-MALIGNANT STRICTURE OF THE RECTUM. 309 mainder ; and third, on the stricture with ecraseur. Four months later, "wound healed and functions of the rectum en- tirely re-established." — Gaz. des Hop., 1872, p. 1028. 3. Verneuil. — Previous syphilis ; great constitutional dis- turbance ; scrotum enlarged to three times its natural size hy fistulous tracks, of which there were twelve. Ecraseur through one of the fistula — others operated on a month later. Two 3 r ears later, parts had regained their suppleness, and all traces of disease had disappeared. — Log. cit. 4. Verneuil. — Patient in bad general condition. Two oper- ations with ecraseur at six weeks' interval. First, posterior proctotomy with division of posterior fistula? ; second, anterior proctotomy with division of anterior fistula?. Incontinence lasted only a few days. There was marked tendency to recontraction, due to the fact that the stricture was so extensive that the chain was not carried to its upper limit, and a distinct zone of cica- tricial tissue was left. — Log. cit. 5. Verneuil. — Woman, reduced to last degree of marasmus, with hectic. Stricture complicated with much ulceration above and below, and three or four fistula?. Operation followed by great relief of all symptoms. After several years, again ex- amined ; general condition still good, but a very appreciable re- contraction of a year's duration. — Log. cit. 6. Verneuil. — Stricture very close and hard ; previous dil- atation without effect. Phlegmon existing on one side, and old fistula on the other. Abscess laid open and chain passed through it into gut above stricture. Four years later, died of phthisis, having been entirely free from symptoms in meantime. Before death, stricture admitted two fingers easily. — Log. cit. 7. Verneuil. — Constriction very hard and close ; also fis- tula. It was found almost impossible to pass trocar beyond the contraction, on account of its great hardness, and this was finally accomplished only by boring a track with a pair of curved scissors. The ecraseur required three-quarters of an hour to cut through. Several months later, general state very satisfac- tory ; rectal wall had partly regained its suppleness ; no diffi- culty in defecation, but a still appreciable contraction, due to the fibres, which were too high up for the chain. — Log. cit. 8. Verneuil. — Previous syphilis. General condition bad. Stricture consisted of a limited contraction of the posterior and upper fibres of the sphincter, and disappeared on prolonged 310 DISEASES OF THE RECTUM AND ANUS. pressure with the finger. Two previous operations, one by in- ternal incision, the other by nicking and dilatation. Division by trocar and ecraseur ; incontinence for a few days ; after three weeks, passages natural and all symptoms relieved. Three years after, again examined, and found suffering from rectal syphiloma developed since operation, together with ter- tiary eruptions. — Loc. cit. [History completed by Tison in These de Paris.'] 9. Verneuil. — Previous syphilis ; stricture annular ; much constitutional disturbance, great pain, diarrhoea, colic, and dis- charge of pus. Operation of internal proctotomy with thermo- cautery, followed by phlegmon. Abscess opened and external operation" done with thermo-cautery through abscess cavity. One month later, relief of all symptoms ; return of suppleness in parts; stricture admitted two fingers easily; tendency to recontraction in posterior part of rectum ; anterior part healthy. — Tison, TTtese de Paris. 10. Verneuil. — Rectal syphiloma ; anaemia and loss of flesh ; great tenesmus. Thermo-cautery. Incontinence for three weeks. Reported completely cured after three months. — Tison. 11. Verneuil. — Stricture, probably inflammatory, with sev- eral fistulse. Thermo-cautery. Incontinence for three weeks. After five weeks, appetite and strength returned ; passages easy and painless. — Tison. 12. Gosselin. — Syphilitic. Forced dilatation three years before. General condition very bad from excesses of all kinds ; passages very frequent and painful. Thermo-cautery, followed by temporary relief. Four months later, condition same as be- fore, with signs of commencing phthisis. — Tison. 13. Tillaux. — Valvular stricture, posterior, with ulceration ; anterior portion healthy ; several fistulffi. Galvano-cautery. Three j^ears later, complete cure, and no return. — Tison. 14. Tillaux.— Old stricture, probably syphilitic, with gen- eral cachexia — so great as to resemble that of cancer. Ecraseur. Four years later, remained completely cured. — Tison. 15. Tillaux.— Probably syphilitic ; previous rupture of perinpeum ; enormous dilatation of anus; incontinence of fluid faeces ; general condition exceedingly bad ; signs of occlusion ; operation undertaken without hope of cure, but to relieve worst symptoms. Galvano-cautery, from without inward, with cau- NON-MALIGNANT STRICTURE OF THE RECTUM. 311 tery knife. Life prolonged five months, with freedom from suffering. 16. Verneuil. — Dysenteric contraction high up, twelve cen- timetres from anus. Under mistaken diagnosis of spasmodic stricture of the sphincter, that muscle was divided with the cautery. Entire relief from pain, but continued symptoms of retention. — Tison. 17. Labbe. — Probably syphilitic; much pain; abscesses; fistulae. Division with gal vano- cautery, followed by considera- ble haemorrhage and tampon. After a time, slight return of contraction at margin of anus, the rest of gut remaining supple. Second operation by Verneuil with thermo-cautery, followed in the course of six months by prolapse of the rectum, which was cured by cauterization of the posterior edge of the anus. Con- siderable amelioration of suffering. — Tison, quoted from Cerou, These de Paris. 18. Verneuil. — Syphiloma of long standing ; great anaemia ; intolerable pain ; constant purulent discharge ; previous dilata- tion unsuccessful. Ecraseur. followed by dilatation. Four years later, absolute cure. JN"o induration ; sphincter acting well. — Tison, These de Paris. 19. Fochier. — Stricture of many years' standing. Patient feeble and emaciated ; great gastro-intestinal derangement ; two fistulae. The constriction was first divided with a bistoury cache to admit the finger, and operation completed with ecra- seur. Control of sphincter after the first few days. Left hos- pital ten days after the operation, with appetite and digestion good, and general health much improved, having soft passages of the size of the finger. — Lyon Med., February 20, 1876. Cancers. 1. Verneuil. — Cancer. Ecraseur, followed by immediate re- lief ; decrease in induration ; recovery of appetite and strength. Death from subsequent operation of excision. — Oaz. des Hop., 1872. 2. Verneuil. — Cancer reaching beyond point of finger ; sphincter continually in contraction, and violent pain caused by slightest touch ; attempts at dilatation followed by phlegmon and fistula ; constant pain and tenesmus, with bloody passages ; insomnia ; rapidly approaching fatal termination. The opera- tion consisted merely in dividing the sphincter with ecraseur 312 DISEASES OF THE RECTUM AND ANUS. without touching the cancer, and the relief was so great that the patient left hospital believing himself cured. — Gaz. des Hop., November, 1872. 3. Verneuil. — Cancer, with all the usual symptoms, and approaching occlusion, ficraseur ; death on the ninth day from peritonitis. — Gaz. des Hop., November, 1872. 4. Verneuil. — Cancerous stricture high up, and very close ; constant suffering from discharges of gas and pus. Ecraseur passed as high as possible, but not high enough to divide upper portion. Considerable relief ; cessation of pain ; passages easy for several months. Death finally from progress of disease. — Gaz. Hebdom., March 27, 1874, p. 196. 5. Verneuil. — Epithelioma involving right half of rectum, and reaching too high for extirpation ; ulceration ; loss of flesh and strength ; great pain on defecation ; retention. Sphincter divided with chain on left side in such a way as not to involve the cancer. One year later, freedom from pain ; general state good ; incontinence following operation disappeared ; difficulty in passage of solids overcome by seltzer ; gradual advancement of cachexia. — Gaz. Hebdom., March 27, 1874, p. 196. 6. Verneuil. — Cancer high up, involving prostate and vesi- cular seminales. Continued diarrhoea and incontinence, and bad general condition. A double posterior external operation was done with the chain, and the portion included between the two incisions cut away, with the idea of relieving pain and retention and opening a j>assage for the subsequent application of eschar- otics to the cancer. Operation followed by immediate relief of worst symptoms. — Gaz. Hebdom., March 27, 1874. 7. Nelaton. — Operation done with bistoury. Relief con- tinued till death, eighteen months after, from extension of ma- lignant disease to the pelvis. — Panas : Gaz. des Hop., 1872, p. 1149. 8. Fociiier. — Cancer of posterior part of rectum, reaching to height of ten centimetres. Great pain and tenesmus ; foetid and bloody discharge ; loss of sleep. Complete division with ecraseur. Left hospital ten days after, believing himself cured. After two months, had no more pain and no incontinence, ex- cept when suffering with diarrhoea. Had two regular passages daily, and complained only of not regaining his strength. In t)ii- case, the section extended to the unusual height of twelve centimetres from the anus. — Lyon, Med., February 20, 1876. NON-MALIGNANT STRICTURE OF THE RECTUM. 313 I have performed this operation in various other cases be- sides those of my own detailed above, and have every reason to be satisfied with its results. In malignant or non-malignant stricture and ulceration, I have never seen it fail to give imme- diate relief to suffering, and, as a means of relieving the pain of the disease, I believe it to be fully equal to colotomy. It also fulfils the other great indication for colotomy, the overcoming and prevention of obstruction. Too much must not be expected of the operation, however. I have seen several cases, one in my own practice, and several where I have advised the operation in consultation with others, which have led to disappointment for this very reason. An old stricture of the rectum with extensive ulceration is a well-nigh incurable disease. Proctotomy may be relied upon with cer- tainty to relieve the pain and prevent fsecal obstruction even in the worst cases, and in more favorable ones it may effect a prac- tical cure by opening the canal, causing a diminution in the in- duration, and allowing the ulceration to heal ; but it will not cure them all. Nothing at present known to surgery will. A rec- tum which has once been diseased to tins extent is never again a healthy one, though it may be made a very comfortable one. Another point which must not be overlooked is that after proctotomy, as after colotomy, there is still a diseased rectum which must be treated by every possible means, and that the incision may be only the first step in the cure. The stricture is easier to overcome than the ulceration which accompanies it. In one of the cases given above I succeeded ultimately by long and patient effort in curing that also, but it cannot be done in every case. In many of these cases the ulceration must be treated as ulceration with the same results, both good and bad, as usually attend the treatment of that most painful, obstinate, and often incurable condition. But the chances of curing it, and at all events of relieving it, are infinitely better after the operation than before. It is understood that I do not advocate the operation in cases of disease high up in the bowel, though it may be safely done at a considerable distance from the anus, and where an incision involving the anterior wall would be unjustifiable, for the ana- tomical reason that the peritoneum extends so much lower in front than behind. For other literature upon this subject, the reader is referred to the bibliography given below. 314 DISEASES OF THE BECTUM AND ANUS. Bibliography. Panas : Du traiternent des retrecissements du rectum par la rectotomic ex- terne, Gaz. des Hop., December, 1872, p. 1148. Mttron, A. : Des retrecissements de Texti-emite inferieure du rectum, et de leur guCrison par la rectotomie lineaire. Gaz. Med. de Paris, January 4, 1873. Fochier, A. : Sur l'application de la rectotomie lineaire aux retrecissements tres-etendus du rectum. Lyon Medicale, February 20, 1876. Pinguet : Des retrecissements du rectum ; appreciation des diverses metho- des therapeutiques. These de Paris, 1873, No. 17. Tison : Nouvelles considerations sur la rectotomie lineaire. These de Paris, 1877. Tuegis: Foreign Body in Bectum. Bull, de la Soc. de Chir., tomeiv., No. 10, 1878, p. 789. Cekou : These de Paris, 1875, No. 390. Whitehead, W. B. : Case of Fibrous Stricture of the Bectum Believed by In- cisions and Elastic Pressure, with Bemarks. American Journal of the Medical Sciences, January, 1871. W hi ttjjE, G. : Stricture of the Bectum Divided by the Knife. Lancet, June 1, 1879, p. 788. Lente, F. D. : Beport of a Case of Non-Malignant Stricture of the Bectum, and Bemarks on the Surgical Treatment of this Disease. American Journal of the Medical Sciences, July, 1873. Beane, F. D. : Case of Specific Stricture of the Bectum ; Antero-Posterior Linear Bectotomy ; Becovery ; Bemarks on the Operation. American Journal of the Medical Sciences, April, 1878. Discussion sur les retrecissements du rectum.— Bull, de la Soc. de Chir., p. 83. Paris, 1873. Verneuil, et al. : Bectotomie et colotomie (Soc. de Chir., Paris). Prog. Med., January 7, 1882. Excision. — The operation of excision, which is generally ap- plied only to cancerous strictures, and which will be fully de- scribed under that head, has also been applied to simple strict- ures ; and, though I have never done it myself, I have seen a few cases which seemed particularly adapted to it. One such case is reported by Dr. Lowson ' in which the result was com- paratively good, though no better than that obtained by proc- totomy. The operation performed by him consisted in dividing the external sphincter posteriorly, so as to arrive at the stricture, pulling it down through this wound when possible, dividing the bowel above and below it, dissecting it out from its attachments, 1 Caae of Stricture of the Rectum, treated by Excision of the Stricture. Lancet, April 12, 1870. NON-MALIGNANT STRICTURE OF THE RECTUM. 315 and uniting the two ends of the bowel by sutures. In this case there was considerable difficulty in the subsequent union of the parts, and after healing had occurred there was considerable contraction, but the condition of the patient was greatly im- proved. Colotomy. — This is the last resort of surgery in dealing with ulceration or stricture of the rectum. In ulceration it may be a curative measure ; in stricture it is only palliative, and it should therefore not be undertaken until other measures have failed. It is intended to fulfil two important indications, the re- lief of pain and preventing or overcoming obstruction, and we have already seen how both of these may be met in many cases by other means which, even when only partially successful, are much preferable. When none of the methods already pointed out serve to assuage the suffering, and when it is probable that the suffering is not due to an irritable sphincter muscle, or to pressure on neighboring nerves from the mass of the deposit, cancerous or otherwise (in which latter case colotomy cannot be expected to afford relief), and when none of the means already described for preventing or overcoming obstruction can be applied, colotomy may be resorted to. There is, however, but one class of cases in which obstruction may not be overcome by attacking the stricture itself, instead of the bowel above it, and that is where the stricture is too high to be safely reached by the knife, and where, even then, dilatation is too painful or too dangerous to be admissible. Judged by these rules, colotomy would be limited to a small proportion of cases. It would be tried after division of the sphincter and of the stricture had each failed to give relief in disease near the anus ; and practically w r ould be limited to dis- ease high up in the bowel. Such restrictions as these would greatly limit the number of operations, especially in the United States, and I am not sure that this might not be done with ad- vantage. We seldom see in the reports of this operation in cur- rent literature any other reason given for its performance than the mere existence of obstructive or painful disease ; and yet I doubt if the mere presence of a stricture of the rectum, malig- nant or benign, is a justifiable reason for the performance of this repulsive and serious operation any more than a stricture of the urethra justifies the operation of cystotomy. It has yet 310 DISEASES OF THE RECTUM AND ANUS. to be proved that colotomy delays cancerous growth, though it certainly prolongs life by diminishing pain and overcoming ob- struction. But the relief to the pain may be and often is only partial, for a small amount of faeces which has passed the arti- ficial anus may cause as much suffering and tenesmus as the natural quantity. In almost direct proportion as the operations of proctotomy and of partial or complete excision of strictures have become popularized and their advantages in suitable cases have become manifest, the operation of colotomy has been limited and the natural objections to it, both by patient and surgeon, have been allowed more weight in influencing the treatment. Especially is this the case in France, the birthplace of the operation, and in Germany, while England, as represented by Allingham, is plainly following in the same course. In this country alone does colotomy still hold its sway — partly for the reason that its substitutes have never been so thoroughly tried here as on the other side of the water. It would be easy at the present time to collect a much larger table of cases of this operation than was accessible to Mason when he published his paper on this subject, but I do not know that anything would be added to our general knowledge of the subject by such a labor. Allingham had operated at the time of his last edition twenty seven times. His best result was obtained in a man with a scirrhous growth filling up the pelvis, in whom life was prolonged four and a half years after the operation. Another case, a woman, lived nineteen months, twelve of them in wonderful comfort. Only three of his pa- tients died within a fortnight of the operation, one from phleg- monous eiysipelas, another from exhaustion ; and the third, in nine days, in whom there was complete obstruction at the time of the operation, and in whom paracentesis abdominis was per- formed immediately after the colotomy, acute pleurisy being the immediate cause of death. Curling has performed the oper- ation eighteen times with seven fatal results ; two from chloro- form, one from already existing peritonitis, another from peri- tonitis arising independently of the operation, but immediately succeeding it, one from pyaemia, and two from exhaustion, one on the sixth, and the other on the twelfth day. Bryant records fifteen operations of his own, four for vesicointestinal fistula ; two for pelvic tumor ; and nine for stricture, cancerous and NON-MALIGNANT STRICTUEE OF THE RECTUM. 317 otherwise. Of these latter, one lived eighteen months in com- fort, dying at last supposably of cancer of the liver ; two lived two and four months respectively ; one lived thirteen days, and two three days ; in these cases the operation having been under- taken too late to prolong life. One died of peritonitis due to the operation, and three were alive at periods varying from one to three years. Bulteau ' has collected one hundred and forty -two cases of lumbar colotomy from the statistics of Doliger, Mason, Haw- kins, and Heath. Of these ninety-two recovered and fifty died. These figures are about the same as those reached by D'Erck- elens. 2 These figures show as well as would a more elaborate collec- tion of cases, the general results of the operation itself, the dangers which attend it, and especially the danger of postpon- ing its performance till the patient is at the point of death. These patients sometimes sink with unexpected rapidity at the end, and when seemingly no worse than for weeks before, are often very near death. In my own experience I have had a patient die in the night upon whom I intended to operate in the morning. Although an artificial anus is justly regarded as being only a substitute for death itself, and although many patients will deliberately choose the latter to the dangers and results of the former, it is astonishing how comfortable a patient may be with one where the retention of faeces is good. Bridge's case, 3 in which the prostitute followed her customary avocation after its performance, is certainly an exceptionally favorable one, but it illustrates what may be done. Still we have Allingham's 4 testimony that "this operation, though doubtless it may pro- long life, should not be resorted to without due consideration, because one cannot fail to see in many cases the remedy proves a most objectionable one ; an opening in the left loin through which the faeces escape is very harassing, 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 after years the patients get used to the discomforts and loathsomeness of their 1 De l'occlusion intestinale au point du vue du diagnostic et du traitement. These de Paris, 1878. 2 Arch, fur Klin. Chirurg., vol. xxiii., 1 Heft, 1878. 3 Loc. cit. 4 Loc. cit. , p. 253. 318 DISEASES OF THE RECTUM AND ANUS. condition. My patients who have lived long seem to have had some pleasure in life ; indeed, two women were married after the operation ; but with all that I entertain repugnance to the operation greater than I formerly used, and latterly have mostly performed it as a last resource or for total obstruction." The operation has already been described. A free discharge of faeces may follow the opening of the bowel, or there may be only a slight escape of fluid. It is better for the patient that the evacuation should be postponed till the edges of the wound have become agglutinated, as in this way the danger of extrava- sation is diminished. Morphine should be given hypodermic- ally to keep the bowels as quiet as possible till cicatrization is complete. Only the simplest dressings and perfect cleanliness are necessary in the way of local treatment. The sutures may be left in till they commence to cause suppuration. If the bowels are slow to empty themselves, an enema may be admin- istered, or a scoop used through the new opening, and a purga- tive may be given by the mouth. No change is necessary in the ordinary diet after the second day. The patient should be kept in bed for two or three weeks till cicatrization is complete, and then a pad must be arranged to cover the new anus and prevent leakage of faeces and prolapse of the mucous membrane. Bry- ant says some of his patients have found great comfort from the use of an india-rubber ball with one of its sides cut away suffi- ciently to cover the new opening. It holds any little faeces which may come away, besides preventing the escape of flatus and serving as a pad. Annoying prolapse is not as apt to occur with the oblique in- cision as with the old vertical one ; nevertheless, it may be ex- pected in some degree, and the patient should be taught to exercise the greatest regularity in relieving the bowels early in the morning. Should faeces pass by the artificial opening, as they are apt to do, they must be removed by enemata, for a very small quan- tity will cause great pain and a constant demand for their re- moval. It will at once be seen that the treatment of a stricture high up in the rectum or in the sigmoid flexure must be conducted on entirely different principles from one within reach of the finger. In the latter case, the disease itself may be directly attacked with the bougie or the knife ; in the former, both are NON-MALIGNANT STRICTURE OP THE RECTUM. 319 nearly out of the question, and the surgeon is in reality limited to attempts at warding off the natural effects of the malady ; in other words, to preventing the occurrence of intestinal obstruc- tion, and forming an artificial outlet for the contents of the bowel when obstruction is threatened. The medicinal means of preventing obstruction, and of overcoming it when actually im- pending, have already been referred to in the chapter on pro- lapse and invagination. In cases of cancerous disease, atten- tion must be given to cleanliness as well after as before the operation, and this is best secured by frequent injections of an unirritating disinfectant, as the permanganate of potash or chloral. In cases of non-malignant ulceration, the diseased sur- face may be treated after the operation as before. CHAPTER XII. CANCER. General Characters of Malignant as Distinguished from Benign Growths. — Malignant, Semi-Malignant, and Benign Adenoma. — Encephaloid. — Colloid. — Melanotic Can- cer. — Osteoid Cancer. — Age at which Cancer occurs. — Symptoms. — Diagnosis. — Treatment. — Excision : History and Results of Operation. — Conclusions Regarding Excision. — Modes of Performing the Operation. — Excision of Cancer of the Sig- moid Flexure. — Palliative Treatment. In a general way it is undoubtedly true that new growths in the rectum, when benign, increase slowly, tend to grow away from the wall of the bowel, to form pedicles for themselves, and to project into the calibre of the canal, to remain movable, and not to involve surrounding parts ; while with cancerous forma- tions the tendency is just the opposite. In this way the diag- nosis between a benign polyp and a cancerous nodule in the wall of the rectum is generally easy. But there is a class of tumors which occupies the border line between the benign and the malignant, in which the diagnosis, either clinically or with the microscope, may be difficult and even impossible. In fact, recent careful study of these rectal tumors goes far to break down the lines between the varieties which are usually drawn, and Cripps, 1 who has done such care- ful and valuable work in this department, is inclined to group nearly all of them under the single head of adenoma, holding that all are primarily affections of the glandular element. The true nature of the growths may perhaps best be gleaned from a comparison of Fig. 83 with Fig. 72, the latter being a benign polypus, and the former a malignant growth, but both being- adenomata. According to Cripps the names malignant, semi-malignant, and simple adenoid will cover both the benign and cancerous 1 Cancer of the Rectum, London, 1880. Also, Adenoid Disease of the Rectum. Trans. Path. Soc. of London, 1881. CANCER. 321 growths of this part of the body, except possibly the form of colloid. Generally, but not always, it is possible to distinguish between them both clinically and microscopically. After speaking of the innocent growth, which is soft, has a fairly marked pedicle, and projects into the cavity of the bowel, he says: "In the more malignant varieties, the«new growth frequently spreads as a thin layer between the muscular and mucous coats. In this form it often occupies several square inches of the bowel, while its thickness does not exceed a quarter of an inch. At first the mucous membrane lies intact over such a layer, but eventually it gives way by ulceration. This ulceration sometimes begins at more than one point, so that the mucous membrane becomes honeycombed, and portions of the subjacent growth may even sprout through it. The de- Fig. 83. — Cancer of the Rectum — Malignant Adenoma. (Stimson.) structive process not only destroys the mucous membrane over the surface of the growth, but after a while the new growth is itself destroyed by ulceration. While destruction is proceeding toward the centre, the growth is advancing toward the circum- ference. In this way a crater-like mass of disease is produced, the centre of which consists of dense fibrous tissue belonging to the muscular coat of the bowel, which appears for long to resist the ulcerative process. The margin of the crater consists of the mucous membrane of the bowel, heaped up by the extending growth beneath it, tucking it over in such a manner as to overlap the healthy membrane. The border is at times so irregular as to represent a series of nodules rather than a continuous line." Stimson ' has also made a careful study of these growths. He ' A Contribution to the Study of Cancer of the Rectum. Archives of Medicine, August, 1879. 21 322 DISEASES OF THE RECTUM AND ANUS. says : " If it is admitted that cancer of the rectum is essentially a glandular or epithelial affection, one having its origin in the mucous membrane, the borders of the growth, as being the freshest, most recent portions, must be examined, as in car- cinoma of other organs, for evidences of primary changes and mode of development. These changes consist of hypertrophy of the mucosa by hypertrophy and hyperplasia of its epithelial elements, together with an abundant development of embryonal connective tissue between the tubules. They are the same as those found in a variety of neoplasm of recognized benign char- acter known as polyp of the rectum or polypoid adenoma. The formation of a pedunculated growth with a tendency to isola- tion in the one case, and of a flat growth with a tendency to spread laterally and into the underlying tissue in the other, may be explained partly by mechanical causes and partly by the degree of intensity of the changes in the submucous connec- tive tissue. If the primary change occupies a limited area upon a natural fold of the mucous membrane, and if the muscularis mucosae remains unbroken until the young embryonal cells produced below it, in consequence of the neighboring irritation, have had time to develop into adult fibrous tissue, the natural retraction of this new tissue narrows the base of the fold, giving it at once a polypoid form and opposing by its greater density a stronger barrier to the extension of the epithelial formation in this direction. The pedicle once formed, the neoplasm increases in the direction open to it, that is, into the lumen of the canal in all its diameters, and the dragging to which it is subjected by the constantly recurring passage of the fseces lengthens its pedicle and tends toward its final separation. "On the other hand, if a broader area is occupied by the primary change, or if the processes are more intense and rapid, the pedunculation is absent or less perfect, and the epithelial growths of the mucosa break through immediately, or after an interval spent in overcoming the greater resistance offered by the partial pedunculation, into the submucous tissue. Once established in that region the spread of the disease is easy, and its ultimate generalization a question only of time. "The second and final barrier to generalization is presented by the muscular coat of the intestine, but it is a barrier in which are many gaps, large ones along the lines of the vessels, and in- numerable small ones in the line meshes of connective tissue caistcer. 323 which separate the muscular bundles and are continuous with the submucous tissue on one side and the para-rectal tissue on the other. Here, too, the intensity of the process materially affects the rapidity of its extension, for if the proliferating con- nective tissue, which is most easily implicated while it is in the formative stage, is allowed time to reach its full development, to become fibrous, it forms, as it were, a second line of defence capable of offering a certain resistance after the first line has been carried. 7 ' With a full appreciation of the importance of the conclu- sions which Cripps has reached, it may still be well, in a work of this kind, to call attention to some of the clinical characters of some of the different forms of malignant disease as found in this part of the body. Of all the varieties of true cancer, the one most frequently met with is epithelioma, and this presents itself, here as else- where in the body, under two forms distinguishable with the microscope and clinically. The first (cancroid, lobulated epi- thelioma) contains the characteristic onion-like nests of squam- ous epithelium, and is the same form so commonly seen in the lip, though rarely about the anas. It has its point of origin at the anus, and not within the rectum, and begins as a hard, dry, warty nodule. It is slow in progress, covered at first with firm epidermis, and only begins to ulcerate late in its course. It seldom spreads far up the rectum, but tends rather to involve the integument, which it may destroy to an extent similar to that sometimes seen in the same variety of disease about the face. In the other variety (cylindrical epithelioma) the cells are columnar, and the growth resembles in minute structure the mucous membrane from which it springs. This variety, on the contrary, chooses the rectum proper for its development, and is found above the internal sphincter. It is easily distinguished from the former, but not so easily from a scirrhus which has be- gun to ulcerate. It is softer than the other, more vascular, and therefore more prone to bleed and undergo extensive degenera- tion and ulceration, and it rapidly infiltrates surrounding tis- sues. Early in its course it is movable on the subjacent tissues, but it is seldom seen by the surgeon at this stage. At a later period it presents itself as a soft, friable mass seated on a hard, infiltrated base ; ulcerated in spots, the edges of the ulcers being hard and raised. At this stage the growth will yield on press- 324 DISEASES OF THE KECTUM AND ANUS. lire the well-known cancer jnice containing cells and nuclei, and it may be difficult to distinguish it from a tumor- which began in the submucous tissue as a hard mass, and subsequently underwent degeneration. Next to epithelioma, scirrhus, or hard cancer, is the variety most frequently met with in the rectum. It arises, not like epi- thelioma, in the mucous membrane, but in the submucous con- nective tissue ; therefore, in the early stages of its growth the membrane is found normal and movable over the hard mass be- neath. When cut into it shows the characteristic, raw-potato- like hardness of scirrhus, and there is no distinct line of demar- cation between it and the adjacent tissues. From the original tumor are often seen, and sometimes felt, hard fibrous bands spreading out in various directions, generally longitudinally in the bowel — the processes or claws from which cancer takes its name. These tumors may soften down in parts and slough or ulcerate away. When ulceration has begun, a cavity with an irregular outline is formed in the midst of the hard cancer tis- sue, from which issues a foetid discharge mixed with more or less blood and pus. Although a large part of the growth may die in this way and be discharged, the steady increase in the disease is not checked. Indeed, the growth often seems to be most rapid in the bed of the part which has been destroyed. This form of cancer is said to be most apt to show itself first on the anterior wall of the rectum, near the prostate, 1 and " to increase most on the side of the chief arterial supply, and in that toward which, by lymphatics and veins, its constituent fluids most easily filter." 2 It spreads by infiltrating all the adjacent parts, eventually involving all the coats of the bowel, and extending both in surface and thickness till, instead of apjjearing as a hard, movable spot under the mucous membrane, it involves a great part or the whole of the circumference of the rectum, inclosing it in a dense, contracting sheath. The hard- ness and contractility of this form of disease are the chief clinical facts upon which a diagnosis rests ; and yet, leaving out of consideration the history of the case, it will often be impossi- ble to distinguish between the gross appearances of scirrhus and those of simple fibrous stricture. I have now under treatment, at the Infirmary for Diseases of the Rectum, a case of stricture Allingham, Molliore. 2 Moore. See Bryant's Surgery. CANCER. 325 which I believe to be dysenteric in origin, in which the extent of the disease is fully as great as in any hard cancer I have ever met with, and yet which has been eighteen years in developing. Enceplialoid has its primary seat in the glandular tissue of the mucous membrane. It is inclosed in a capsule of connect- ive tissue, from the internal surface of which spring trabecule which divide the mass into lobules. On section, it may be comparatively firm or nearly fluid, and almost white or stained red with blood. It is often very vascular ; large vessels may sometimes be seen on its surface, and large blood extravasations may be found in its interior. The name fungus nematodes has been applied to a variety of this disease in which, after the cap- sule has burst, the mass has protruded. The material compos- ing it may resemble brain tissue (from which it is named), or it may be more spongy and shreddy, like placenta. On squeez- ing a section of the tumor a large amount of juice may be ob- tained, and this, when thrown into a vessel of water, is uni- formly diffused through it, giving it a milky hue. This is given by Paget as an exceedingly valuable rough test of the nature of the growth. These cancers are rapid in their increase, and may attain an immense size, fairly filling the pelvis. They quickly affect the neighboring lymphatics, and, when enucle- ated, speedily recur. The results of removal are, however, particularly favorable for a short time, as shown by the imme- diate improvement in the general condition of the patient, and the disappearance of the cancerous cachexia. The extreme soft- ness of the tumor, and the deceptive sense of fluctuation im- parted to the finger, may cause a mistake in diagnosis, which may be avoided by the use of the aspirator, or even the hypo- dermic syringe. When the fluid thus obtained is examined under the microscope, it will be found to contain cells and nuclei, with more or less blood. In colloid cancer (alveolar cancer) the structure is essentially the same as in the last variety, except that the alveolar meshes are filled with a jelly-like material, which in its most natural state is glistening, translucent, and pale yellow. This variety of cancer has its origin in the follicles of Lieberkiihn, or the crypts which surround the rectum. It is not very rare in this part, and appears in the. shape of large, lobulated, fungus-like tumors, which are soft and easily broken down. Under the microscope, the mucous contents of the alveoli will be seen to 326 DISEASES OF THE EECTUM AND ANUS. contain cells of various forms, the most characteristic being large, round, and flat, with a nucleus and concentric laminae. The growth rapidly infiltrates the surrounding tissues, and secondary deposits will often be found in the neighborhood of the original mass, the whole tending to undergo cystic degener- ation. The malignancy of these tumors varies in degree, some of them being comparatively benign ; they do not always recur after removal, nor do they readily infect the lymphatics and viscera, being in this respect about on a par with epithelioma. The term colloid is used without much exactness, being applied to almost any growth which consists in part of large, cellular spaces filled with glue-like material. The following description of a case illustrates very perfectly the general characteristics of colloid : Case. — "The patient was an old woman, and the case was peculiar, in that the colloid material was contained in cysts of various sizes, pressed firmly one against the other, so that the disease might be called multiple cystic colloid degeneration. The anus was surrounded with a large number of tumors of unequal size, of which several, larger than the rest, were sur- mounted by smaller ones in such a way that the anus occupied the bottom of an extremely deep infundibulum. Two super- ficial ulcerations were to be seen at the margin of the anus. The finger recognized at a short distance above the anus an ulcera- tion in the form of a zone, which was deep, had destroyed all the thickness of the rectum in a part of its circumference, and communicated with fistulous tracks, which penetrated into the substance of the diseased skin adjacent to the anus. "The degeneration, which had given the rectum an enor- mous thickness, ceased abruptly nine or ten centimetres from the anus. Immediately above, the rectum presented considerable hypertrophy in the muscular layer. This affection, which had all the characters of colloid degeneration, presented an arrange- ment in its upper two-thirds which I had never before met with, and which I will try and describe. Let one imagine a number of acephalocysts of unequal size (some of them as large as pigeons' eggs) squeezed firmly one against the other, and held in a fibrous network, and one will have an exact idea of the change. Only these were not acephalocysts. The covering of each cyst was fibrous, very thin, and yet very strong ; the mat- ter contained in them exactly resembled currant jelly, on the CANCER. 327 surface of which had been deposited a cretaceous matter exactly similar to that which sometimes covers the excrement of birds. This cretaceous matter contained calcareous concretions. In the centre of the jelly-like substance two or three blood-vessels were to be seen, similar to those which form in a hen's egg — vessels without walls, ending in an enlargement of one ex- tremity. " The fibrous network in the midst of which these cysts were inclosed was evidently made up of the transformed coats of the rectum. I could recognize the longitudinal fibres of the rectum. There was also adipose tissue, an evident proof that the de- generation had not only invaded the rectum, but had developed at the expense of the adipose tissue of the pelvis. " The lower third of the rectum presented no sign of a cyst, but an areolar tissue, with fibrous meshes, which occupied all the circumference of the anus ; this tissue was filled like a sponge with colloid matter, which could easily be pressed out, and the tissue itself was approaching erosion or ulceration. The areolar and gelatiniform degeneration appeared to me to penetrate into the thickness of the skin of the anal region ; while an extremely thin, almost epidermic, pellicle had resisted and covered the swellings on its surface. In the vicinity of the circular ulceration of the rectum, the colloid matter had not undergone degeneration, only it was permeated by an increased number of blood-vessels. Behind the rectum was a colloid al- veolar mass, all the areolae of which contained blood-vessels. This mass had evidently been formed at the expense of the cir- cum-rectal adipose tissue." ' Cruveilhier draws this distinction between colloid and en- cephaloid. The colloid degeneration is not susceptible, as is the encephaloid, of inflammatory action producing gangrene ; more- over, if the sanguineous centres are not absolutely foreign to it, it is certain that they are incomparably rarer in colloid than in the cancerous degeneration, properly so called, where effu- sions of blood are so often met with — apoplectic centres some- times so large as to conceal the true nature of the morbid tissue. Colloid alveolar degeneration shows only one mode of de- struction — by encroachment in successive layers ; this encroach- 1 Cruveilhier : Traite d'Anatomie Path. Gen., t. v., p. 67. 328 DISEASES OF THE RECTUM AND ANUS. merit, sometimes rapid when it occurs in the alimentary canal, permits of the re-establishment of the flow of faeces, tempo- rarily interrupted by the undefined and often very rapid in- crease in the degenerated parts ; so that, to the gravest signs of faecal retention, there sometimes succeeds a more or less rapid separation, with and without diarrhoea. 1 Melanotic carcinoma, or black cancer, is by some classed among the true cancers, and by others among the sarcomata. It belongs to the class of soft or medullary cancers, and its dis- tinguishing feature is the development of pigment. What- ever may be said of the microscopic characters of melanoma, it is clinically a very malignant growth, running a very rapid course, and very likely to become generalized. Its clinical his- tory, as relates to the rectum, is to be studied from ten cases only, which have been given in full in an exhaustive study by Nepveu, read before the Societe de Chirurgie (1880). 2 The cases are reported by the following observers: Schilling, 3 Kopp, 4 Moore, 5 Maier, 6 Virchow, 7 Ashton, 8 Gross, Meunier, 10 G-ussen- bauer, 11 and Nepveu. 12 From the six of these cases which are reported with an ap- proach to completeness, several facts of interest are to be gath- ered. The age of all of the patients was advanced, ranging be- tween forty-five and sixty-four years. Five were in men, one only in a woman. In the microscopic examinations which were made in five of the cases, the tumor is in every case described as a sarcoma. There is nothing in the symptomatology to dis- tinguish this form of disease from others, except that in one case the stools were colored black from mixture with the pig- ment — a point which might aid in diagnosis were the tumor so high up as to be out of sight. In rectal examinations it was 1 Cruveilhier : Traite d'Anatomie Path. Gen., t. v., p. 69. 5 Memoires de Chirurgie, Paris, 1880. 3 Mentioned by Eiselt, obs. v., Prag. Viertelj., Bd. 70 u. 76. 4 Denkwurdigkeiten in der iirztlichen Praxis, Bd. iv., Frankfort, 1838, pp. 305-313. 5 Medical Times, March, 1857. 6 Berichte iiber die Verhandlungen der Naturforschenden Gesellschaft zu Frei- burg, 185s, No. 30, p. 516. 1 Pathologie des Tumeurs, Paris, 1867, t. ii., p. 281, note. 8 Ashton, T. J.: Prolapsus, Fistula in Ano, etc., 3d edition, London, 1870, p. 162. • System of Surgery, Philadelphia, 1872, vol. ii., p. 589. ,0 Bull, de la Soc. Anat. de Paris, 1875, p. 792. 11 Ueber die Pigmentbildung in melanotischen Sarcomen und einfachen Melanomen dor Haut. Virchow's Arch. f. path. Anat. u. Phys., lxiii. , 1875. )2 Op. cit. CANCER. 329 also noticed that the finger was colored in the same way. The location of the disease was once in the sigmoid flexure, twice in the rectum above the sphincter, and four times at the anus. The size of the growth was generally considerable, surrounding the bowel and projecting into its cavity ; sometimes it was firm enough to cause tight stricture, at others ulcerated and broken down in parts. The course of the disease is marked by second- ary deposits in the adjacent glands or in the viscera, while the original growth may spread in neighboring organs, and by ulcer- ation cause a foul discharge mixed with blood and pigment. To these may be added the usual signs of incontinence and ob- struction. The duration of the disease in no case exceeded three years, but it was generally fatal in a much shorter time. The diagnosis is easy if the growth can be seen, and is some- times assisted by the secondary black deposits. In four cases the tumor was removed, but in none was the return long de- layed. Osteoid Cancer. — Either a sarcoma or a carcinoma in any part of the body may become ossified, and hence pathologists speak of osteo.-sarcoma and osteo-carcinoma. It is rare that such a formation is found in any structure except bone or peri- osteum ; and there seems to be but one case on record of bone- cancer of the rectum, which, because of its great rarity, I will quote in part : Case.— The preparation was removed from the body of a lady, aged about fifty-four, who died January 18, 1869, under the care of Mr. Collambeli, of Lambeth. The history of the case pointed to the existence of disease in the rectum for about twenty years (during which time she had occasionally com- plained of pain, irregularity of the bowels, and a discharge of blood and mucus). . . . The specimen includes the whole pelvic viscera. The rectum is laid open posteriorly, but rather on the right side, and shows a cancerous mass projecting into its interior at a distance of about four or five inches from the anus. The principal mass, of about the size of a walnut, is sit- uated directly at the back, and occupies nearly the whole cali- bre of the rectum, but the disease involves, more or less, the entire circumference of the intestine upon a level rather above the larger mass. A small opening, large enough to admit a goose-quill, is found in the sigmoid flexure, about twelve inches above the cancerous growth, and communicates with a circum- 330 DISEASES OF THE RECTUM AND ANUS. scribed abscess cavity within the peritoneum, above the pelvic viscera and behind the pubes, and this again communicates with the rectum immediately below the obstruction. At the time of the post-mortem this peritoneal abscess contained very little fluid, but what there was was pus discolored with faecal matter. There is also a large, foul, burrowing abscess, situated in the submucous tissues, almost completely surrounding the rectum at the seat of the disease, communicating freely with its cavity and directly continuous with the intra-peritoneal abscess. When first laid open, the surface of the cancer generally presented a nodulated, red appearance, but the larger or pos- terior mass was roughened in its lower half by numerous sharp spicules of bone which projected from its surface. The cut sur- face showed the growth involving the thickened muscular coat as a hard, contracting mass, and from its base firm fibrous bands ramified into the neighboring fat, just as from the base of an ordinary scirrhous tumor. That portion which projected into the cavity of the rectum was softer, and its lower part was occupied throughout by numerous spicules of true bone. On the surface, the softer structures having sloughed away, the bony constituents were exposed. The growth did not extend to the sacrum, which was perfectly healthy, and the other bones of the pelvis were also free from disease. The other viscera were examined and appeared healthy. The lymphatic glands were not carefully examined, but in the parts which were removed there was no glandular enlargement to be found. The ulceration in the sigmoid flexure seemed to be of a simple character ; there was no evidence of malignant deposit elsewhere than in the obstructed portion of the rectum. On examining the growth in the rectum it was found to be firm in the deeper parts, where it involved mucous and sub- mucous tissues, but nearest to the surface, where the spicules of bone were evident, it had the appearance and character, to the naked eye, of a fibro-fatty structure. In the deepest parts, however, where it was firmest, it had not any very great hard- ness. The parts involved in the ossification lay exposed in the rectum, and seemed, from their shreddy, softened appearance, to have been recently sloughing. Upon section, a quantity of juice was readily obtained, and showed under the microscope an immense number of free nuclei and cells of all shapes and of variable sizes, though the greater number were elongated or CANCER. 331 oval, and about half the size of the columnar epithelium of the neighborhood. There was a large quantity of molecular matter and oil, and the nuclei were indistinct. The solid portion of the growth was composed of cellular and muscular structures imbedded in a granular matrix. Bands and fibres, composed almost altogether of nuclei, ramified in the growth, and could be traced as continuous with the osseous portions. It appeared that the nuclei became darker, granular, and harder in outline as the examination was carried toward the ossified parts ; the intervening matrix became more fibrous, and the processes of bone branched out into this. The bony spicules contained num- erous lacunae, whose size was about that of the ordinary nuclei of the growth. They were of various forms, generally branch- ing, and were arranged with no regularity, but in the manner usually found in adventitious bony deposits in tumors. The matrix was granular. The interest of this case lies chiefly in the fact of bone being found ramifying through parts of the structure ; and that this bone was the result of ossification of the scirrhous growth seems evident from the manner in which it could be traced under the microscope. That it was not an original formation apart from the scirrhus must be admitted, for its histological characters show its definite relation to the elements of the tumor, the lacunae replacing the nuclei, and the rest of the bone occupying the place of the intervening matrix. And a primary bone tumor in this position is difficult to imagine. The occurrence of true bony deposit in medullary tumors is not altogether infrequent, but then it is found in the deeper parts, and is almost always in connection with some bone. In scirrhous growths, however, I do not find any mention of ossification occurring, except where starting from bone. I have no history of any case of any kind of tumor of the rectum in which bone formed an element of a primary growth. 1 These are the rarer forms of cancerous disease in the rectum and their recognition presents little difficulty. Most malignant growths are included under Cripps' classification of adenoma or under the older terms of epithelioma and scirrhus. Hecker 2 found twenty-one cases of epithelioma in thirty-four cases of cancer. Cripps says: "I have failed to discover" (in the rec- 1 Wagstaffe : Trans, of the Path. Soc. of London, vol. xx., p. 176. 2 Schmidt's Jahrbucher, 1870. 332 DISEASES OF THE RECTUM AND ANUS. turn) "any growths or tumors consisting entirely of the char- acteristic structure which pathologists designate as scirrhus or medullary cancers, or as belonging to the various varieties of sarcoma. Considering the eminence of many careful observers who have applied such names to these growths, it would be quite unjustifiable to assume that such distinctive structures never form the entire bulk of the tumor ; but I feel bound to state that with, perhaps, a more than average opportunity of examining such growths from the rectum, I have been unable mj^self to discover tumors composed entirely of the distinctive features appertaining to these diseases." Cancer of the rectum, like cancer elsewhere in the body, generally occurs in middle life or old age. There are, however, some interesting exceptions to this rule. ' Allingham ' reports a case of encephaloid in a boy of seventeen, under his own care, and another (variety of cancer not stated) under the care of Mr. Gowland, in a boy not thirteen ; Mayo 2 speaks of one at the age of twelve, and Godin 3 of one at fifteen years ; Quain 4 quotes one, reported by Busk, at sixteen; and Despres 6 reports an epithelioma in a child of six. After the age of twenty the cases increase rapidly in number. With regard to the relative fre- quency in the sexes, different statements will be found in the works of different writers, according to the experience each has had, and considerable reasoning has been indulged in to explain why the disease should be more common in the one sex than in the other. In a collection of one hundred and seven cases, I have found fifty in males and fifty-seven in females. The locality in which the disease first appears varies. Quain 8 sa}^s : "I have most frequently met with the lower margin of the deposit at the distance of from two to three inches above the orifice of the bowel. The part between that just in- dicated and the anus is next in order of frequency as the seat of the disease, and to this succeeds the lower end of the colon." This perhaps expresses the facts of the case as well as they could 'be stated in a few words, f The upper limit of the rectum, where it joins the sigmoid flexure, is a common site of the disease, and 1 Diseases of the Rectum, London, 1809, p. 265. - Injuries and Diseases of the Rectum, London, 1833, p. 188. 3 Molliere : Trait' des Maladies du Rectum etde l'Anus, Paris, 1877, p. 580. 4 Proc. of the Path. Soc. of London, 1846-47. ■ Gaz. des. Hop., November 2, 1880. ' Op. cit. CANCER. 333 here it runs a more rapid course than elsewhere, and is more apt to be suddenly fatal on account of the increased liability to obstruction which the anatomical condition favors. The symptoms of cancer of the rectum may be classified as follows : pain ; those due to contraction, to ulceration, to inva- sion of neighboring parts ; and, lastly, the generalization of the disease and the cachexia. A cancer of the rectum may, and often does, begin so insidi- ously that its existence is not suspected by the patient till it has made irreparable progress. This will be the case particu- larly when the disease is well up in the bowel beyond the reach of the sphincters. The slight sensitiveness of the mucous membrane of the rectum proper which permits the existence of extensive ulceration, and the application of escharotics and the performance of surgical operations without pain has been already referred to. On the other hand, cancer of the rectum is usually attended with great pain, and the suffering in itself may be made of great assistance in diagnosis, as in the follow- ing case. Case. Cancer Jiigli up in the Rectum. — The patient, a gentleman slightly over fifty, was sent to me by his family physician, as a case of internal haemorrhoids. He was a man of good habits, had never had venereal disease, and was in good flesh. He gave a history of dysentery some years since, but upon what authority the diagnosis rested I do not know. For several months before consulting me he had been troubled with what he supposed to be dyspepsia, pain in the bowels, loins, and more recently in the spermatic cords and inguinal regions. With this he had been having three or more slimy and bloody passages daily. At the time of his visit he complained of but one thing which he considered of any importance, a steady, wearing pain in the lower bowel, sufficient to keep him awake at night, and to unfit him for work during the day. A most careful examination was entirely negative. A full- sized bougie was passed its whole length without meeting any obstruction. The history may be much condensed. The pain never left him except when under the influence of opium, though the bloody passages soon yielded to treatment. Emaciation soon began to show itself and steadily increased. Six months after his first visit, the diagnosis of cancer which I then made be- 334 DISEASES OF THE IiECTUM AND ANUS. came only too evident from his personal appearance, and the mass could be distinctly felt in the left iliac fossa through the abdominal wall. The presence of a steady, severe pain, and the absence of anything else except bloody passages and rapid emaciation may seem but slight grounds for the diagnosis of a fatal disease, and so they are, but they are sometimes enough. The strongest point in the case was the absence of stricture or of any of the ordinary painful affections of the rectum. The patient was also an ex- ceedingly intelligent man (which assisted greatly in reaching a conclusion), and he described his sufferings in no uncertain terms, although rather inclined to make light of them. In a case recently seen with Dr. Templeton, of North Carolina, the history was very similar, but the diagnosis was dysentery and not cancer. In his patient there was also pain and bloody discharge with emaciation ; but the history covered several years, the pain was of an intermittent character, and the disease could be felt just at the limit of digital examination. There was no distinct tumor, though there was thickening of the rectal wall, and this absence of distinct new growth after so long a period of disease decided us in the diagnosis of dysentery rather than cancer. Attention has been called to the point in diagnosis that the existence of pain or cramp in the lower extremity in cancer of the rectum is a bad sign, suggesting a direct encroachment upon some of the neighboring nerves, either by implication and press- ure of the glands, or by direct extension of the original disease. 1 In the later stages of cancer the pain is often the most impor- tant symptom to be met by treatment. It may then be due to the irritation of faeces upon an ulcerated surface, to the involve- ment of the anus in the ulceration, or to direct pressure on ad- jacent parts, and each of these is to be met by a different and appropriate treatment. The symptoms directly referable to contraction of the bowel are often slight, and differ in no way from those caused by the simple, fibrous stricture of the same part. It is often astonish- ing to the surgeon to meet with an advanced case of scirrhus in which iIm' calibre of the bowel is so nearly occluded as scarcely to permit the passage of the end of the finger, and yet in which 1 Hilton : Rest aDd Pain, p. 1G3. CANCER. 335 the patient lias never had sufficient uneasiness to call for a direct rectal examination. The haemorrhage from an ulcerated rectum in cancerous disease is seldom profuse enough to be dangerous, though by frequent repetition it may become an important factor in the ultimately fatal result. Above the contraction there often develops an ulceration which is not to be confounded with the breaking down of the cancer itself. When the cancer itself once begins to break down and ulcerate, its extension is limited by no tissue of the body. The bladder may be opened and a permanent fistula re- sult, in which case the passage is generally from that viscus into the rectum ; but the opposite may be the case — and the pain caused by the entrance of fseces into the bladder and their discharge through the urethra is one of the best of all the indi- cations for colotomy. The prostate and seminal vesicles in the male and the recto- vaginal septum in the female may each be destroyed ; in fact, any part near the disease may be implicated. Smith 1 has recorded a case in which the disease opened into the hip-joint, and Molliere 2 another in which it invaded the soft parts in the loin. There are two sets of lymphatics which may be involved in malignant disease of the rectum, one coming from the anus and going to the glands in the groin ; and one coming from the rec- tum proper and going to the glands in the hollow of the sacrum and lumbar region. The proper place, therefore, to feel for glandular involvement in disease within the sphincter is along the spine, deep in the pelvis — a simple point which may decide the surgeon for or against operative interference. This impli- cation of the lymphatics is sometimes shown by pressure effects at points quite remote from the original disease, as in the fol- lowing case from my own case-book. Case. — J. B , aged sixty, has always been strong and well until within a few weeks past, when he has been troubled with obstinate constipation. All he desires now is some "pills" to move his bowels. On closer questioning, he refers casually to the fact that he has considerable pain in the right thigh, and some swelling in the right leg and foot, but "nothing to speak of." On examination, nothing was to be detected by rectal 1 Surgery of the Rectum, London, 1871. 2 Op. cit., p. 565. 33 G DISEASES OF THE HECTUM AND ANUS. touch, but the pelvis at its upper part was partially filled by firm, nodular masses, which extended deeply down into the right iliac fossa. The patient had no conception of any trouble beyond constipation and "rheumatism," though the whole lower extremity on the right side was oedematous. By careful diet and laxatives the threatened obstruction was avoided, and the man gradually sank with all the signs of the cancerous cachexia, and died three months from the first examination. Unfortunately no autopsy could be obtained. From what has been said, it is evident that there is little in the history which the patient will give of cancer of the rectum to distinguish it from ulceration and stricture of any other vari- ety, and that the diagnosis must chiefly rest upon a physical examination. To make such an examination thoroughly, and yet safely, requires great care and gentleness, and to properly interpret the conditions which may be found, no little experi- ence and knowledge. It requires many years of practice to reach the point Allingham has reached when he says: "There is something peculiar about the feel of cancer which the prac- tised finger rarely mistakes even for simple indurated ulceration. I think it is many years now since I mistook the one for the other." In the majority of cases the diagnosis may be made by the history and by physical examination with the finger alone. Cancer in this locality is a disease of rapid growth, and when a patient says that stricture has existed any considerable number of years the idea of malignancy may be abandoned. Something also may be learned from the general appearance of the patient, but most of all from the digital examination. When the dis- ease is seen in its earlier stages, the hard, more or less distinctly circumscribed new growth which has infiltrated the wall of the bowel is diagnostic. (Fig. 84.) The great difficulty is to distin- guish between an advanced case where the rectum is partially occluded by hard masses of disease, and an old case of stricture and ulceration which is not malignant. This may sometimes be impossible except by the microscope, and syphilitic disease of the rectum is not infrequently mistaken for cancer. When a f time is decisive. Some operators, 'Op. cit., p. 1GG. CANCER. • 339 however, report better results than these, and some have not been so successful. Curling 1 gives one case of removal of an epithelioma in which there had been no return in the rectum after seven years, though for one year there had been " a doubt- ful tumor of the pelvis." Velpeau and Verneuil each report cases in which the cure has seemed permanent, and Chassaignac gives several in which there had been no return after six years. Dieffenbach's thirty cases in which the patients lived many years without a return are generally looked upon with sus- picion. Allingham, 2 on the contrary, considers the partial re- moval of the circumference of the bowel as unsatisfactory. In all of his thirteen cases in which he was able to follow the prog- ress of the case for one year, there was either a return of the growth in the rectum or the glands in the groin became affected, and there ensued disease in the internal organs. In four cases the disease did not return in the bowel, but in the inguinal glands, proving that it was not due to an incomplete operation. With regard also to his ten cases of total extirpation, he speaks very cautiously. He believes that a cure is very uncommon, and not generally to be expected, and he does not commit him- self even on the question of the prolongation of life. The mor- tality, as a direct result of the operation, is generally about twenty-five per cent. 3 Billroth 4 reports thirty-three cases. Thirteen died of the operation, and the remainder all died within two years, most of them of recurrence. The deaths immediately following the operation were in- variably due to retro-peritoneal suppuration, characterized by acute septic symptoms. Most of them died within from four to eight days. Since then, in certain cases, we are justified in expecting re- covery from the operation itself, and such a length of life as would not result were the disease left to its natural course, we may ask: 1. What are the dangers, and what is the mortality of the operation ? 2. In what class of cases is it applicable ? 3. What are its results as a curative and as a palliative mea- sure, and how do these results compare with those of lumbar 1 Diseases of the Rectum, ed. of 1870, p. 164. 2 Loc. cit., p. 277. 3 Molliere: Traite des Maladies du Rectum et de l'Anus, Paris, 1877, p. 627. 4 Clinical Surgery. Extracts from the Reports of Surgical Practice between the Years 1860-1876. By Th. Billroth, New Sydenham Society, 1881. 340 DISEASES OF THE KECTUM AND ANUS. colotomy ? 4. What are the results as regards the subsequent condition of the bowel, and the control of the faecal evacuations ? 5. What is the best method of its performance % For the purpose of arriving at a knowledge of what expe- rience has already taught in this matter, I collected, several years ago, 1 the reports of operations up to that time as far 1 For the full literature of the cases upon which these conclusions are based, the reader is referred to the following bibliography : Ag.new.- Phila. Med. Times, June 23, 1877. Allingham. — Diseases of the Rectum, 3d ed. , London, 1879. Briddon.— Med. Record, January 6, 1877. Bushe. — Treatise on Diseases of the Rectum, New York, 1837, p. 294. Byrne. — Annals of the Anat. and Surg. Soc, May, 1880. Batjmes.— Bull, de l'Acad. Roy. de Med., t. x., p. 936. Chassaignac. — Traite de l'ecrasement lineaire, Paris, 1856. Cripps. — Cancer of the Rectum. Crosse (quoted by Mayo). — Observations on Diseases and Injuries of the Rectum, London, 1833, p. 210. Curling. — Observations on Diseases of the Rectum, London, 1851. Med. Times and Gaz., March 14, 1857. Dennonvilliers. — Gaz. des. Hop., 1844. Desgranges (quoted by Molliere). — Maladies du Rectum, etc., Paris, 1877, p. 627. Dieffenbach. — Die operative Chirurgie, Leipzig, 1845. Dolbeau. — These de Fumouze. Duplav.— Gaz. Med. de Paris, 1872, p. 486. Dupuy.— Bull, de la Soc. Anat., Paris, 1872. 2me s., xvii., p. 242. Emmet. — Principles and Practice of Gynecology, 1st ed. , Philadelphia, 1879, p. 511. Ewart. — Lancet, June 21, 1879. Fenwick. — Montreal Gen. Hosp. Reports, vol. i. Gay.— Lancet, June 28, 1879. Gosselin.— Gaz. des. Hop., 1879, p. 921. Holmer.— Hospitals-Tidende, March 31, April 7, 14. 1880. Holmes. — Trans, of the Clin. Soc. of London, 1878, p. 113. Holt (quoted by Curling), op. cit. Keyes.— Arch, of Med., August, 1879. King.— Brit Med. Jour., June 21, 1879. Kumab.— Wiener Med. Woch., 1878. p. 1070. Labbe.— Gaz. des Hop., June 4, 18, 1880. Levis.— Arch, of Clin. Surg., February, 1877. LlBFBANC. — These de Pinault, 182".). Majsonneuve. — Union M ; d., 1805. Also These de Cortes, 1860. Mandt.— Revue M<'d., 1886, p. 204. March.— Trans, of tin: N. V. State Med. Soc, 1868 ; also Med. and Surg. Reporter, June 9, 1877. Mayo. — Observations on Diseases and Injuries of the Rectum, London, 1883, p. 212 Moore.— Med. Times and Gaz., March, 1857. CANCER. 341 as tliey were then attainable. The list at that time included one hundred and forty cases, and I arrived at the following general conclusions concerning the operation, which subsequent study of the question has led me in no way to alter. 1. AWiough there ham been a few cases of excision in loliicJi the cancer has not returned in a number of years, such a result is so rare as not to justify the exposure of the patient to the risk of immediate death which attends the attempt to re- move extensive disease. Regarding the question of radical cure, we find difficulty in establishing exact dates, and have to take into consideration the reputation of the reporter. We find, however, that in one hundred cases (deducting those immediately fatal, and seven- teen which passed out of observation immediately after opera- tion) we have five cases of reported permanent cure, in which there had been no return for at least ten years. Three of these are reported by Volkmann, and two by Velpeau. March, of Albany, has been credited with another case of radical cure, but the author is much indebted to the present Dr. March for a letter stating that the case of supposed radical cure reported by his father passed out of observation at the end of one year. There are some other cases which have been included in the MoLLlfeRE. — These de Carcopino, 1879. Nussbatjm. — Aerztlich. Intelligenzblatt, 1863. O'Hara. — Phila. Med. Times, vol. viii. Paget (quoted by Cripps), op. cit. Peters. — Arch, of Med., August, 1879. Pital du Cateau.— L'Experience, t. vi. , p. 27. Polaillon. — Gaz. des Hop., 1879. Post.— Med. Record, July 31, 1880. Recamier. — These de Masse, 1842. Roddick. — Montreal Gen. Hosp. Reports', vol. i. ScnuH. — Abhandlung der Chir. und Operationslehre, Wien, 1867. Siebold (quoted by Curling), op. cit. Simon.— Lancet, 1851, ii., 1882. Simon, of Rostock.— Deutsche Klinik, 1866. Stimson.— Arch, of Med., August, 1879. Terrillon.— These de Carcopino, 1879. Van Buren.— Arch, of Med., August, 1879. Van Derveer.— Med. Record, September 20, 1879. Velpeau.— Nouveaux Elemens de Med. Operatoire, Paris, 1839, vol. iv., p. 814. Verneuil (quoted by Marchand).— Etude sur l'Extirpation de l'Extremite In- ferieure du Rectum. Volkmann.— Klin. Vortriige, March 13, 1880. 342 DISEASES OF THE RECTUM AND ANUS. category of permanent cures — cases in which the disease had not returned in four or five years — but the great majority recur within the first year and are fatal within two. 2. The operation is chiefly valuable as a palliative measure, and as such it compares favorably with colotomy both in pro- longing life and relieving pain. The treatment of cancer of the rectum by excision has not yet been accepted by the surgical world as a substitute for other measures, even in cases best adapted for the operation, although it cannot be denied that a radical cure has sometimes been ob- tained, and that in many other cases life has been prolonged beyond what could have been hoped for by any other means of treatment. It is no less true that the operation is one of great danger, and that there are not lacking those whose experience has led them to believe that life was rather shortened than lengthened by it. By these it is claimed that in lumbar colot- omy we have a safer method of relieving pain and delaying the progress of the growth, and in both these ways prolonging life. American and British surgeons hold rather to this latter idea, while the French and the Germans favor excision. Excision can scarcely be judged in comparison with colot- omy, being applicable properly only to an entirely different class of cases. In cancer above four inches from the anus, colotomy or colectotomy are about the only means of relief. In cancer within four inches of the anus almost any other plan of treatment is preferable. This leads me to call attention to another point — the opera- tion of excision as a palliative measure. In cases properly chosen, where the disease is not so extensive as to render its removal one of the capital surgical operations, we know of nothing better, and this fact cannot fail to be deeply impressed upon the reader of these cases. The statement that all suffer- ing was relieved is almost invariable. In almost every case at- tention is called to the great improvement in general health, the loss of pain, and the increase in strength. Patients go away believing themselves radically cured, return to their employ- ments, and are reported by the French surgeons as "parfaite- ment gueries," a few weeks after the operation. It has been claimed ' against this operation that even when a good immediate result is obtained, it may shorten life by 1 Labbe: Gaz. Hebdom., June 4, 18, 1880. CANCER. 343 hastening the return and final progress of the disease. Unfor- tunately, it is difficult to tell in any particular case how long a patient would have lived had the disease been left to its course ; but, accepting as a basis for comparison Allingham's estimate of the average duration of life in cancer of the rectum as two years or less, we are justified in concluding that in all cases where life was prolonged more than one year and a half after the time of operation (the operation generally being done late in the disease), this length of life may fairly be attributed to the surgical interference. This estimate is manifestly a small one, for a study of the cases makes it evident that many who did not live eighteen months after the operation yet gained a con- siderable length of comfortable existence ; and there is nothing to prove that in any case the operation hastened the natural course of the disease. I have carefully searched the record of cases in which a re- turn of the disease within six months of the time of operation is reported, to discover whether here also there was any marked relation between this result and the nature or extent of the disease at the time of operation ; but it is especially at this point that the table fails us. A proper answer to this question involves not only a careful report of the extent of the disease, but a microscopic study of its character, and such data are given only in a relatively small proportion of cases. I believe, however, that the cases show a marked relation between the rapidity of the growth before operation and the speedy return after removal. We can trace no connection between the time of the return and the extent of the disease removed when the removal has been complete ; and the microscopic reports are too few for gen- eral conclusions to be drawn from them. I know of no writers, except Stimson and Holmer, who have made a careful study of the specimens excised and have given the results ; and, so far as the clinical reports of the German operators go, they would seem to give support to their practice of removing everything involved, no matter how extensive, in the hope that the local return may be long delayed. 3. When the disease readies above three inches from the anus, or involves neighboring parts so as to render its entire removal without injury to the peritoneum questionable, the operation is contra-indicated. 3-14 DISEASES OF THE RECTUM AND ANUS. The Germans have apparently no limits to the applicabil- ity of this operation. They perform it in cases of the most ex- tensive disease, opening the peritoneum, exsecting the sacrum when necessary to reach its upper limit, and removing the pros- tate and base of the bladder when they are implicated, balanc- ing the risk of immediate death from the operation against the chance of radical cure, or prolonged immunity from return. Conservative surgeons will hesitate long before accepting this view, for, although very satisfactory results have been obtained in such cases, they can hardly be considered other than excep- tional, and a study of cases shows that the frequency of the fatal result is in direct proportion to the extent of the operation attempted. The rules for the selection of cases laid down by Lisfranc were these : -when the bowel is movable, in other words, when the disease has not involved surrounding parts, the oper- ation should be undertaken. When, on the other hand, the disease is more extensive and reaches higher, he leaves the question to be decided by future experience. I believe that experience has now decided against it. In deciding for or against the operation, an examination of the glands in the hol- low of the sacrum and in the loins is of great value, for these receive their lymph directly from the rectum, and may be en- larged, while those in the groin, which are supplied from the skin around the anus, may still be uninvolved. I shall not stop at this time to again discuss the question as to how much of the anterior wall of the rectum is uncovered by peritoneum, but must refer the reader to the chapter on anat- omy. The height to which it is safe to go cannot be definitely stated for all cases, the reflection of the serous coat upon the rectum being at a variable point. Fochier ' reports a case in which he used the ecraseur at twelve centimetres without harm, and Allingham, 2 who is always a safe guide, has seen all but the lower two inches of the bowel covered by peritoneum in a female, has opened into it in a male when not more than three and one-half inches were removed, and has taken away fully five inches in a male without bringing it into view. There is an old rule for applying the trephine, that in every instance the operator should remember that some skulls are very much thinner than others, and he should act on the sup- 1 Lyon Med., February 20, 1870. s Op. cit., p. 275. CANCER. 345 position that the particular point upon which he is operating is the thinnest part of the thinnest skull ever seen. Something of the same kind might be said of the peritoneum over the rectum ; and everybody who has studied the anatomy of the part knows how various are the opinions of different authorities on this point. Nevertheless, a line of danger can be marked out, and that line is about three inches from the anus. It is true that more than this amount of the rectum has been removed without encountering the peritoneum, and it has been opened below this point ; but I should not, for my own part, hesitate to try to remove three inches of the bowel for a cancer, and I have refused to attempt to extirpate in an otherwise suitable case because the disease passed this line. The index finger is a good guide. What is well within its reach in a hand of good length it is safe to try to remove, provided it does not involve surrounding tissues to an extent which renders its complete removal impossible. Whatever may be said of the impunity with which the periton- eum may be opened in other parts of the body does not seem to apply here ; for I have been able to find but three cases in which that accident was not followed by a fatal result. Unfortunately, the disease is but rarely seen at a stage when extirpation is justifiable ; that is, when it is limited to a circum- scribed spot within three or three and a half inches of the anus, when it is movable on the muscular coat, has not invaded the deeper tissues, and before there has been any glandular en- largement. Although there is a very evident relation, which is shown by a study of the statistics of the operation, between the extent of the operation attempted and the favorable or unfavorable results obtained, a fatal result will often follow the extirpation of disease which is comparatively slight in amount. The three great dangers of the operation are peritonitis, pelvic cellulitis, and septicaemia. Haemorrhage may fairly be dropped out of consideration, for the operation may, if desired, be rendered almost bloodless by the use of the ecraseur or galvano-cautery. 4. The operation is not followed by any annoying after- consequences which are of sufficient gravity to contra-indicate its performance. In a small proportion of cases there will be complete incon- tinence, in a greater number there will be partial control over the evacuations, and in a majority the control will be sufii- 346 DISEASES OP THE RECTUM AND ANUS. ciently complete to prevent the occurrence of any annoying accident. Stricture to a troublesome extent is also rare, and when it exists it may generally be overcome by the introduction of bougies. In one case reported by Verneuil, a special plastic operation was performed to relieve this condition, an account of which may be found in the work of Marchand. 1 Regarding the best way of performing the operation, the surgeon has his choice of several. The first case of extirpation of the rectum of which we have any record was by Faget, in 1739, and was not for cancer, but simply a removal of the lower portion of the bowel, which had been completely surrounded and denuded by an abscess beginning in one ischio-rectal fossa, and subsequently extending into the other. From that time until 1826 the operation, as a means of treatment of cancer, will occasionally be found mentioned in surgical literature ; generally, however, only in condemnation. In 1826 Lisfranc performed the first successful operation for cancer ; and three years later his student, Pinault, in a these reported nine cases, and gave to the procedure a permanent place in literature and practice. In 1833 Lisfranc himself embodied the same ideas in a paper read before the Acad. Royale de Medecine, 2 and from that time the operation became widely known. Since then it has had its advocates and opponents, and has been subject to many modifications in its performance. For a long time it was coolly received by British surgeons, but within the past decade it has received a new stimulus from the Germans, and at the time of writing it seems to have been fairly tried by the surgical world, and can now be judged on its merits. Almost every surgeon whose name is prominently associated with the operation has had his own favorite way of performing it ; and we shall, therefore, speak in detail only of those which have proved most acceptable, and first of those described by Volkmann in his Klinisclie Vortrage for March 13, 1880. He describes three different operations, depending on the location of the disease. The first is for the removal of a circumscribed spot only. This is accomplished by dilating the anus, dragging down the disease, and excising it in such a way that the wound 1 Etude sur 1' extirpation de rextremito inferieure du rectum. Marchand, Paris, 1873. 1 Mem. de l'Acad. Roy. de Med., 1833, iii., p. 296. CANCER. 347 shall not cause subsequent stricture. When the growth in- volves the anus, the edges of the wound are carefully brought together, stitched with catgut, and a drainage-tube inserted between them. When the growth is entirely within the sphinc- ter, the edges are brought together with equal care, but the tube is inserted through a track made for it, which communi- cates with the wound above, and perforates the healthy skin at a point outside of the border of the sphincter. When dilata- tion does not suffice, the anus is freely divided down to the coc- cyx, and this wound is subsequently carefully closed under the antiseptic precautions. In the second class of cases where the growth involves the whole circumference of the bowel, but not the anus, the latter is divided forward into the perinseum, and backward to the tip of the coccyx, when necessary, to give room for manipulation. The latter of these two incisions is carried as far into the bowel as the lower border of the disease, which, is then removed. The mucous membrane above is stitched to that below, the prelim- inary incisions carefully closed, and a drainage-tube left in the posterior one. In the third class, where the disease involves all, or nearly all, of the anus and of the circumference of the rectum, the entire tube is separated and removed in a cylinder. The same preliminary incisions may be made as in the second class, and the anus is surrounded by a circular cut, which runs outside the sphincter. From this as a starting-point, the dissection is carried parallel with the bowel till the upper portion of the dis- ease is passed. By the use of knife, scissors, and fingers the bowel is completely freed, then drawn down to the anus, and cut off above the disease, the healthy upper end being stitched to the margin of the skin. In case the peritoneum is opened, the wound is at once stuffed with carbolized sponge, and after- ward carefully closed with catgut. The coccyx and part or nearly all of the sacrum are removed when necessary to make room, as a preliminary step. The risk of haemorrhage is one of the great objections to this operation, and later on we shall describe another procedure, which is preferred by many, in which the knife is supplanted by other and bloodless instruments. It is no doubt true that the deep dorsal incision is the key to the operation, and greatly facilitates the securing of bleeding vessels, yet the heemorrhage 348 DISEASES OF THE RECTUM AND ANUS. ma} 7 be so great as to impede the operator and endanger the life of the patient. It will be seen that, at every step in this operation, union by first intention is aimed at. and Listers methods are carefully followed. If the elements of success in Listerism are, as I believe, cleanliness and drainage, these are certainly better met by a deep posterior wound, which is left open and syringed out frequently, than by carefully closing that safety-valve with cat-gut sutures and inserting a drainage- tube. It will also be observed that the bowel is always brought down and stitched to the free edge below. To do this much dissecting is necessary, and but little permanent good is gained, as the stitches soon tear out. Maisonneuve described, in L^Urtion mkllcale of 1860, an operation which he named the procede de la ligature exteinpo- ranee, and which differs from the preceding in being almost entirely bloodless, although it differs little from the operation previously described by Chassaignac, under the name Vecrase- ment lineaire. In the latter, the rectum is divided into two lateral halves by the chain ecraseur, and each half of the dis- ease is then attacked in the same way and removed. In the operation as done by Maisonneuve, a strong cord is substituted for the chain, and the disease is removed in the following manner. The skin and subcutaneous tissue are divided by a circular incision which completely surrounds the anus. The operator is provided with several strong curved needles, each of which is to be threaded through the point as often as used, with a strong silk ligature about a foot in length. One of the needles with the ligature in its point is then passed from the ex- ternal incision into the bowel above the growth, going wide of the gut to clear the tumor. The loop of string in the eye of the needle is seized within the rectum and drawn out of the anus, while the needle is drawn back out of its own track. The result of this is a double uncut ligature, passing from the point where the needle entered the external incision, outside of the tumor, into the rectum above it, and then out of the anus, and this manoeuvre is repeated eight or nine times at points around the circumference of the anus equidistant from each other. A strong whip-cord or bow-string is the next requisite — about two yards long — and to this all the loops hanging from the anus are attached at points nine inches distant from each other. Each of the original ligatures is then withdrawn by the same course CANCER. 349 it ■ entered, carrying a loop of the whip-cord with it. When all are drawn out, the rectum above the disease is surrounded by a series of loops of strong cord, and the ends of each loop hang oat from the original incision. The ends are then attached to an ecraseur, and each loop made to cut its way out in turn. After all have been cut out, the lower end of the bowel and the diseased mass are of necessity completely separated from their attachments. The operation performed by Cripps is a modification of the two preceding ones, and would seem to possess several advan- tages in facility of performance. The preliminary dorsal incision is made from within outward, by passing a strong curved bis- toury into the rectum, bringing its point through the skin at the tip of the coccyx, and cutting all the intervening tissue. The buttock is then drawn away from the anus to put the tis- sues on the stretch, and a lateral incision made from the pre- liminary cut behind, around the rectum to the median line in front. The site of this incision, whether inside or outside the anus, will depend upon the location of the disease, and whether or not the anus is implicated. The cut itself should be made boldly, and deep enough to reach well into the fat of the ischio- rectal fossa. The forefinger in this incision will readily sepa- rate the bowel from the surrounding tissue, except at the at- tachment of the levator ani muscle, which should be divided with the knife or scissors. A piece of sponge is pressed into this cut to restrain the bleeding, while the opposite side is treated in the same way. The anterior connections give more difficulty, and the dissection in the male is aided by having a sound in the urethra. The knife and scissors replace the finger in this part of the operation. When the dissection has been carried to a point above the disease, the bowel is drawn down and held while the wire ecraseur is passed over it, and the sec- tion made at the required level. After this there may be free but seldom serious haemorrhage. The vessels divided in the first steps of the operation all come from the wall of the bowel, and if ligatured when first cut, are again opened with the ecraseur. When the disease is located to one side of the bowel, the operation is modified accordingly. The preliminary dorsal cut is the same, and the lateral incision is made on the affected side. At the farther end of this lateral incision, away from the dorsal 350 DISEASES OF THE KECTUM AND ANUS. one, a needle carrying a cord in its point is passed around the disease and into the rectum above it. The loop of cord is brought out of the anus, attached to the chain of the ecraseur, and withdrawn as it entered. The chain is then made to cut its way out, and a rectangular piece of the rectum is thus included between two longitudinal incisions, one posterior with the knife and one lateral with the chain. In this rectangle is the cancer, and it is dissected upward from below, and separated above by again using the ecraseur. Instead of the chain or wire ecraseur, the wire of the gal- vanic cautery may be used, heated to a dull red, and not a white heat, if the desire is to avoid haemorrhage. Or again, in- stead of the wire the galvanic cautery knife may be used, and the operation performed with bloodless incisions. This is the operation favored by Verneuil. The rectum is first divided into lateral halves w T ith the ecraseur, as in the method of Chassaig- nac, the cut dividing both the anterior and the posterior walls. Then with the galvanic cautery blade the lateral halves are separated from their attachments stroke by stroke, until a point is reached above the level of the disease. The chain is again slipped over the end of each, and the final section made. An ingenious and simple method applicable to certain cases has been recorded by Emmet. 1 The growth in the case in which it was used was an epithelioma the size of a hen's egg, situated on the posterior wall of the rectum an inch above the sphincter, with considerable surrounding infiltration. The sphincter was stretched, and the mass seized with a double tenaculum and drawn well down by an assistant. " A steel groove director, as the most convenient instrument for the purpose, was pushed through the skin in front of the coccyx and just behind the outer edge of the sphincter, into the cellular tissue of the pelvis, and then made to puncture the rectum, in healthy tissue, just beyond the upper edge of the tumor. The end was turned out of the gut, and pushed far enough forward to rest on the perin- eum while the other end was over the coccyx. Then a second director was pushed around from the outer side of the muscle on one side, through the cellular tissue into the rectum, across to the other side, through the cellular tissue and skin again to the opposite side of the muscle. So that the mass, with a por- 1 Principles and Practice of Gynaecology, e'd. 1879. CANCER. 351 tion of the rectum above, was now brought through the anus and fixed by the two directors, which had been passed behind the mass at right angles to each other, with their ends resting outside on the soft parts. The chain of an ecraseur was placed behind these two instruments and slowly tightened till the whole mass, as transfixed, was cut through along the course of the directors. By this means I removed the entire sphincter muscle, about three inches of the posterior wall of the rectum, and about an inch and a half of the rectal surface of the recto- vaginal septum. The immediate result was a most formidable opening in the connective tissue of the pelvis, about three inches in diameter, and cone-shaped from below. 1 ' Dr. Rouse ' has recently called attention to a simple method of avoiding a wound of the sphincter, which is applicable to some of the slighter cases. A curved incision is made parallel with the outer border of the sphincter, and on a line with its outer limit. By introducing the finger through the rectum, the growth may be everted through this incision, and removed with the part of the rectal wall to which it is adherent. Perhaps the best of all the operations we have spoken of is the combination of the ecraseur and galvano-cautery knife, as used by Verneuil. But the operator is at liberty to choose from among them all the one he considers easiest of perform- ance, and most free from the risk of haemorrhage or of wound- ing surrounding parts. A wound into the vagina, though always to be avoided when possible, may often be necessary in order to fully remove the disease. When the fistula thus made is not too extensive, it may be closed immediately after the operation. If large, it must be left. A wound of the urethra in the male, when slight, is to be treated as though the patient had submitted to an ex- ternal urethrotomy, by the frequent passage of the sound, to prevent contraction. When a large piece has been taken from the urethral wall, a permanent recto-urethral fistula is the nec- essary result, and the danger of fatal inflammatory action is greatly increased from the presence of the urine in the rectal wound. As for the cases reported by Nussbaum and others, in which the whole neck of the bladder, the greater part of the prostate, and the seminal vesicles have been removed, and the 1 Lancet, October 2, 1880. 352 DISEASES OF THE RECTUM AND ANUS. patients have lived for years in comfort, they are merely curi- osities of literature. That such a thing may happen has been proved, but that the operation should ever be undertaken in any case where such a result is necessary for the entire removal of the disease, has yet to be proved. It is with this operation much the same as with proctotomy — by trying to save too much, discharge is impeded and life may be lost. Cases where the whole of the sphincter is re- moved, together with the skin of the anus, do better than those in which an attempt is made to save the sphincter and drain the wound with drainage-tubes. The operation of excision has, with the recent advances in abdominal surgery, also been applied to cancer of the sigmoid flexure and descending colon. This operation, to which allusion has already been made and to which Mr. Marshall 1 has very properly applied the name of " colectomy," has now assumed a definite place in surgery and marks another of the great ad- vances of the present century. It dates from the time of Reybard, of Lyons, 2 who in 1833 re- moved a tumor the size of an orange from the sigmoid flexure of a man aged twenty-eight years. In this case the tumor could be felt through the abdominal wall in the left iliac fossa, and the incision was made parallel with Poupart's ligament and the crest of the ilium. The tumor was drawn out through this wound and excised with three inches of the adjoining intestine. The two ends of the bowel were stitched together and replaced within the abdomen and the abdominal wound was completely closed. There was considerable local trouble for a few days, but on the thirty-eighth day the wound had entirely healed and the natural passages were restored. Death occurred ten months after from recurrence of the disease. This case was subject to considerable discussion in the academy, but was finally admitted as authentic. The operation thus inaugurated in 1833 has been modified in two essential particulars by subsequent operators, one in the choice of location of the incision, the other in the subsequent disposal of the ends of the divided intestine. Since the first case by Reybard, the operation has been performed at least seven times. 1 Clinical Lecture on Colectomy, Lancet, May 6, 13, 1882. 2 Bull, de l'Acad. do Med., vol. is., 1843-44. CANCER. 353 Gussenbauer, of Liege,, has done it twice. The first time, in 1877, ' was upon a male patient aged forty-two years. The tu- mor, which was associated with the usual symptoms of obstruc- tion, could be felt in the left side, but an attempt was made to remove it through an incision in the median line of the abdo- men. This incision, proving insufficient, was enlarged by cut- ting laterally as far as the lumbar fascia. Another complica- tion arose from the attachment of the growth to the small intestine, which was opened, and faeces were allowed to escape into the peritoneal cavity. All the intestinal wounds were closed with sutures, the bowel was replaced within the abdo- men, and the abdominal incision sewed up. In this case death followed in fifteen hours. Gussenbauer's second case was per- formed in 1879, 2 and there had been no return of the disease two years later. Baum, of Dantzic, 3 operated between these two dates (1878) upon a male patient, aged thirty-four years, in a case of doubt- ful nature. He first opened the small intestine to relieve the symptoms of obstruction, and seven days later he discovered the seat of the obstruction in the right hypochondrium. A second operation w T as then performed. The abdomen was again opened, this time by a longitudinal incision over the tumor, two and a half inches to the right of the median line, and this incision was afterward enlarged by another running toward the right. The growth was situated at the junction of the trans- verse with the ascending colon, and was removed, together with a piece of the mesentery which contained an enlarged gland. The divided ends of the bowel were invaginated and united, the intestine replaced, and the abdominal wound closed. There was considerable discharge of faeces from this opening, however, up to the time of death on the ninth day. The next case was by Martini, of Hamburg,* in 1879, and was performed with the deliberation and consequent success which arise from a certainty in diagnosis of the character and location of the tumor. The growth was situated in the sig- moid flexure and could be felt both through the abdominal wall and the rectum. The incision was made over the tumor, 1 Arch, fur klin. Chirurg. , Bd. xxiii. , 1879. - Ztschr. fur Heilk., Prag, 1880. 3 Centralblstt f ur Chir.. 1879, Bd. ii., p. 169. 4 Vierteljahrschrift fur Heilk., Bd. i., 1880. 23 354 DISEASES OF THE RECTUM AND ANUS. the intestine below was cut between double ligatures, the meso- colon was divided and the affected glands excised, and finally four inches of the bowel were excised together with the diseased mass and two inches breadth of mesocolon. After the removal of such a section it was impossible to approximate the divided ends of intestine. The rectal end was, therefore, invaginated upon itself, closed with sutures and allowed to drop into the pelvis. The upper extremity was attached to the incision in the abdomen to form an artificial anus. There were no bad symptoms, and in a few weeks the man was able to return to his business. Czerny, of Heidelberg, reported the next successful case in I860, 1 in a female patient aged forty-seven years. In this case also the growth could be felt through the abdominal wall on the left side, and the diagnosis was therefore positive. After open- ing the abdomen over the tumor, the bowel was found to be im- plicated at two points, one at the transverse colon, and the other at the sigmoid flexure which curved upward to an abnor- mal degree and was involved in the same disease through a fold of the great omentum. Two and three-fourths inches of the sigmoid flexure, and four inches and a half of the transverse colon were excised and the cut ends of each portion were united. The peritoneum was washed out, a drainage-tube in- serted, the abdominal incision closed except for the drainage- tube, and the whole dressed antiseptically. For a time there was a discharge of faeces through the abdominal wound, but this finally closed and the patient was well in four months. The return of the disease was, however, very rapid, and death was caused by it in about, seven months after the operation. Billroth operated next in order, in 1881, 2 on a male patient twenty-eight years of age. The operation was done antisepti- cally, and the incision was the usual one for left inguinal colotomy. The tumor involved the lower half of the sigmoid flexure, and there was considerable involvement of the adjacent mesentery and of the tissue behind the bowel. The upper sec- tion of the bowel was used for the formation of an artificial anus. The patient died in about thirty-six, hours from incipient diffuse peritonitis. Bryant's case' is next in order, and is peculiar in the fact ' Berliner klin. Woch., 1880, No. 45. ' Wien. Med. Wocb., March 5, 1881. 3 Lancet, vol. i., 1882. CANCER. 355 that the incision was the usual one for left lumbar colotomy. This, in fact, was the operation attempted, but after the bowel had been opened, the obstruction was found to be above the opening made. It was then determined to excise the disease, and this was successfully done through the original incision. The two ends of the bowel were attached to the wound, the upper in the usual manner for forming an artificial anus. The patient recovered, and was well at the time of the publication of the case. The disease constituted a cylindrical stricture of limited extent. The patient in Mr. Marshall's 1 case was a woman, aged forty-nine years, and no positive diagnosis as to the seat of the obstruction could be made. The difficulties attending the diag- nosis may best be gathered from his own description. " The wasting and rapid ageing of the patient, although she took food tolerably well, suggested the presence of a malignant stricture, probably epitheliomatous ; but it was difficult to say how far the symptoms were referable merely to the pain and vomiting which she had suffered ; but whatever the nature of the obstruction, its seat was obscure. The chronicity of the case pointed strongly to the large intestine, but the abdomen was not broad in shape ; no tumor or scybala could be felt in either iliac fossa, or elsewhere along the course of the large gut, though both fossae could be well examined under chloroform. There was no dulness in either loin to indicate a full colon, and no "colonic" note to show that the bowel contained gas. Rectal examination revealed nothing. The long tube passed one foot, and an enema of three pints was easily given, and seemed, from an accompanying diminution of resonance in the left flank, to have entered the descending colon. But as the patient was lying on the left side, it was possible that fluid contents had gravitated into the small intestines lying over the descending colon — a source of movable dulness which, as re- marked by Mr. Boyd, is often overlooked. The amount and uniformity o£ the abdominal distention were sufficient to prove that the obstruction, if in the small intestine, was near the lower end. If, however, the suspicion were correct that the cause of the obstruction was an epithelioma, the probability of its seat being in the large intestine, somewhere beyond the caecum, was greatly increased." 1 Lancet, May 6, 13, 1882. 356 DISEASES OF THE RECTUM AND ANUS. On account of the uncertainty in diagnosis, the incision in this case was an exploratory one in the median line, and the growth was found in the descending colon, between the lower end of the kidney and the iliac crest. As it was impossible to bring this part of the bowel to the median line, the first incision was abandoned, and a second one made over the tumor, parallel with the last rib, and one inch and a half above the posterior part of the iliac crest. The growth was cut out with the scissors, together with an inch of the bowel above and below, between double ligatures. The open end of the upper section of the bowel was attached to the abdominal wound to form an arti- ficial anus, and the lower end was left projecting from the lower and hinder part of the wound with the strong catgut ligature drawn tight upon it. The patient died of peritonitis on the third day. The latest case is that reported by Lammiman. 1 The patient, a woman aged fifty-four, though in good condi- tion when the signs of obstruction first showed themselves, ob- stinately refused to have any operation performed until she had passed seventeen days without nourishment by the stomach. The usual incision was made on the left side. The writer says : "I dissected, as quickly as possible, down to the fascia trans- versalis, but having to deal with very free haemorrhage, ray progress was somewhat slow, as I had to tie many vessels as I went on. Then, having cleared the fascia through the whole length of the wound from muscle and fat, I divided the fascia trans versalis upon the director and my forefinger. Now, hav- ing scraped away a large quantity of sub-colic fat, I came upon the intestine, not a distended but a collapsed one, and speedily found the stricture itself just at the bottom of my incision, now some inches deep. My colleagues assisted me in raising the gut to the surface, but it was not an easy matter, for it did not leave its bed as I had hoped it would ; it required much pa- tience and gentle force to accomplish this. At last, having freed enough of it, I opened the intestine above the stricture, fastened it to the skin, and having placed a very stout ligature of carbolized catgut around the gut below the stricture, I cut the latter completely away. Having to our satisfaction con- cluded that all haemorrhage had ceased, I cut off the ends of the ligature short, and returned it into the abdominal cavity 1 The Lancet, August 4, 1883. CANCER. 357 with the lower end of the intestine, fastened up as much as seemed necessary of the wound, and placed the patient in bed." In the course of an hour or two a large amount of fsecal matter passed through the wound, but the patient was so weak from her starvation that it required several hours to rally her from the operation, and she sank and died forty-eight hours later. The disease was scirrhus. 1 Of these ten cases five have been immediately fatal from the operation itself, and live have recovered. Of these latter one died in seven months, one in ten months, one was alive two years later, the history of one ends with the recovery from the operation, and Mr. Biyant's was alive at the .time the case was published. In deciding upon the propriety of interference in any partic- ular case, it would seem advisable to consider how long a life the patient is likely to have if not operated upon. For exam- ple, it would hardly seem good surgery to subject a patient to an operation the mortality of which is fifty per cent., and then have him die of a recurrence in seven months, when he might have lived seven months without an operation. The amount of actual obstruction caused by the disease must in many cases decide the propriety of surgical interference. Within a few months I have found it necessary to decide this question in the case of a personal friend, a man whose every day of life was important both for himself and family. The diagnosis seemed plain, the man was in good condition for operation, and in many respects the case seemed favorable for excision. But there was little or no actual obstruction,' the constitutional disturbance was great, while the local difficulty was slight ; I feared that the growth which could be felt through the abdomen was so diffused as to make the excision of other parts than mere intestine a probable necessity, and there seemed little to be gained and much to be lost by operation. As pointed out by Marshall in his instructive resume of the operation, the result undoubtedly depends in a great degree upon the certainty with which the diagnosis is made, or, in other words, upon the exact adaptation of the operation to the 1 A peculiar case of excision has been reported by Nicolaysen (Nordiskt, Medi- cinskt Arkiv., 1882). A cancer of the descending colon became invaginated into the rectum, was pulled through the anus, and cut off. The patient recovered, and there was no return for two and a half months. 358 DISEASES OF THE RECTUM AND ANUS. end to be attained. In most of the successful cases, the diag- nosis as to the seat of the obstruction was made before the operation was begun, and in all of them only a single incision was necessary to reach the tumor. In three of the four fatal cases, two incisions were made — one in the median line, and, subsequently, another to reach the disease. In this way the severity of the procedure was greatly increased. There seems to be little difference in the mortality whether the ends of the divided intestine be united and the abdominal wound closed, or one end be brought to the surface for the formation of an artificial anus. The latter is the simpler pro- cedure ; the former, when successful, gives the better result. A great difference in the size of the two ends will sometimes render their union difficult ; the upper one being frequently hypertrophied and dilated, and the lower contracted. The study of these cases leads plainly to the following con- clusions : — 1. In cancer of the descending colon, sigmoid flexure, and upper part of the rectum, when the disease is still movable, an attempt at its removal through the abdominal wall is justifiable. 2. In cases of obstruction where the symptoms point toward this part of the bowel as the affected part, even when the diag- nosis is not certain, it may be well to make the exploratory in- cision in the left groin instead of in the median line, having in mind the possible extirpation of the disease and the formation of an artificial anus. 3. In cases of intended colotomy, also, it may be found pos- sible, after the incision has been made, to substitute colectomy, and this constitutes another reason for choosing the inguinal to the lumbar incision in that operation, though, as in Bryant's case, colectomy may be done through the loin. 4. The operation of colectomy compares very favorably with colotomy in malignant disease, and while the latter may be the more suitable in an advanced case, the former may give better results when the disease is in its incipiency. The palliative treatment of malignant stricture of the rectum is in many points the same as of non-malignant. The relief of pain is perhaps a more marked indication in most cases. The juiiii depends on two classes of causes— those which make cancer a painful disease wherever met with in the body, and those which are due solely to its situation at the outlet of the bowel. CANCER. 359 Among the first, we liave pressure upon adjacent parts and in- volvement of neighboring organs and nerves ; and among the second, the passage of faeces over an ulcerated surface and spasm of the sphincter muscle from irritation caused by its direct implication in the cancerous growth, or by the passage over it of irritating sanious discharges from the sore. From this it is easy to understand why cancer is in one person at- tended by excruciating suffering, while another may hardly be conscious of its presence ; and why the pain is in some paroxys- mal and particularly aggravated by a movement of the bowels, and in others dull and constant, radiating through the loins and down the thighs. For the relief of this symptom we have at our command : a. Regulation of the passages, diet, and the recumbent posture ; b. Anodynes locally and by the mouth ; c. Partial destruction of the growth by means of the curette, cauterization, or partial extirpation ; d. Division of the sphinc- ter ; e. Lumbar colotomy. The passages should be kept soft but not fluid, as any ap- proach to diarrhoea always aggravates the suffering. This may be done partly by the choice of food, which needs to be reg- ulated with great care on account of the tendency to gastric disturbance, more or less of which is always present ; and by the administration of the mineral waters, which are generally suflicientry laxative for the purpose. Rest in the recumbent posture is a means of palliation of great value, sometimes giving more relief than anodynes. These latter may be given both by the mouth and in enemata, and if possible should be pushed to the point of relieving suffering. This seems so plain a duty which the surgeon owes to his patient, that we need not stop to discuss any possible moral bearing it may have. If the agony of this incurable malady could always be relieved by the ad- ministration of opium, the question of operative interference would arise much less frequently than it now does. But, un- fortunately, the constant administration of this or any other narcotic will sometimes cause gastric and mental disturbance, harder to bear than the disease. By using the finger-nail, a curette similar to the one used in the uterus, or a scoop such as is used for submucous uterine tumors, the pain may in some cases be greatly relieved by a removal of a part of the growth when of the soft variety. The same may be done by the appli- cation of chemically destructive agents or the actual cautery, 360 DISEASES OF THE RECTUM AND ANUS. and even b} r the partial excision of the mass, merely as a means of relief and where there is no question of cure. I have already called attention to division of the sphincter muscle as a pallia- tive measure in the treatment of rectal disease, and all that was said regarding the treatment of benign stricture applies equally well to cancer. The dernier res sort of surgery for the relief of pain is lumbar colotomy. We have already attempted to limit the scope of this operation. In any case in which the suffering is due to the direct contact of faeces with the diseased surface, and is not due to a spasmodic action of the sphincter muscle, and cannot therefore be relieved by the permanent division and paralysis of that muscle, and is not due to the extension into and press- ure of the disease upon neighboring parts, the operation may be tried. There may be such cases, but they are not common — not nearly as common as is lumbar colotomy for cancer. Let it be remembered, however, that after colotomy faeces will still find their way to the tender point, and that the amount of suffering from a small mass of faeces may be as great as from the entire quantity. "With regard to husbanding the sufferer's powers and prolong- ing life, much may be done by careful nursing and medication. Milk is by far the best diet, and cod-liver oil in small doses the best medicine where it can be borne, for it has a laxative as well as a tonic action. Cleanliness is best obtained b}^ frequent washing out of the rectum with disinfecting fluids, as perman- ganate of potash, carbolic acid, and chloral. The means of overcoming obstruction in malignant disease are also much the same as in benign stricture, and to what has already been said on that subject we must again refer the reader. Before commencing to treat the obstruction as such, it is well to remember that an exceedingly small outlet to the alimentary canal may, with proper care, be made to answer all the calls oC nature. We see this constantly in cases of stricture, both simple and malignant, where the finger cannot be forced through the obstruction, and yet there is no retention ; and in such cases, by the judicious administration of laxatives, life may be made so comfortable that the question of surgical inter- ference shall be postponed indefinitely. AVhen, however, ob- struction is actually threatened, much may be done by the medical means already pointed out. CANCER. 361 When dilatation becomes necessary, it should be of the gentlest kind. The cases of fatal accident from perforation of the bowel where the coats have been weakened by ulceration are already numerous enough to serve as warnings for all future time. The best of all dilators in cancerous disease is the finger, either that of the patient or the nurse, passed daily, and none of the mechanical means with which we are acquainted equals this for safety and comfort. When the disease is beyond the reach of the finger, a bougie must be used, but the dangers are greatly increased, and it may be better at once to make an artificial anus than to incur the risk of fatal accident which the use of a bougie high up the bowel certainly entails. The frequency with which the bougie may be used will depend upon the result of its trial. Should much irritation, tenesmus, or haemorrhage follow its employ- ment, the patient will soon refuse to submit to its continuance ; while, on the other hand, should the result be favorable, it may be employed daily. The softest bougie is the best, and a candle often answers admirably. If dilatation be found too painful or ineffectual, as it some- times will, recourse may be had to division or partial destruc- tion of the cancerous mass. A double proctotomy maybe done in case of malignant disease, and the section of the growth be- tween the two incisions be removed, in this way opening once more the calibre of the bowel and overcoming the obstruction. I have performed this modified operation with great relief, and I have also found that, after making a single free division of the cancerous mass, large pieces adjacent to the cut could be excised with great facility and without danger. The latter operation is rather the preferable one. Relief both to pain and obstruction may sometimes be gained in this way by a partial destruction and extirpation of a cancer- ous growth, where its entire removal is out of the question, and its local return may be expected with certainty. By such measures the evacuations may be made less painful, the spas- modic action of the sphincter and the rectal tenesmus may be allayed, the cancerous look may for a time disappear, and the patient recover sufficient strength to resume the ordinary occu- pations of life. I have seen as good results follow this opera- tion as ever follow colotomy. A growth may be attacked in this way, either with the 302 DISEASES OF THE RECTUM AXD ANUS. knife, cautery, linger, or curette. I have been exceedingly well satisfied in several cases with a modified operation, which con- sists in first dividing the stricture posteriorly, together with the parts between the disease and the skin, with the cautery knife, next removing considerable portions, if they could be isolated, with the wire ecraseur (Fig. 85), and finally resorting to the sharp scoop of Simon (Fig. 86.) By these means combined a large portion of the disease may be removed, the lumen of the Fig. 85. — Wire Ecraseur. bowel may be almost completely re-established, and yet the patient is spared the risk of a complete extirpation, as well as the objectionable artificial anus. In only one such case have I experienced any trouble from this operation, and in that one the patient nearly died of secondary haemorrhage on the tenth day — about the time of the separation of the extensive sloughs caused by the free application of the cautery. Caustic applications are of no use, except in cases where a fungous mass has protruded from the anus. This may, at times, be removed, with great advantage to the sufferer, by the application of a paste of arsenite of copper, mixed with mucil- G.TIEMAN.J &C0 Fig. 86. — Simon's Sharp Scoop. age. The operations for removing a part of the growth with the finger, scoop, or curette may give great relief in the soft varie- ties of the disease. The sphincter should first be thoroughly dilated, the anus held open with a speculum, and as much of the diseased tissue as possible torn and scraped away. Ha3m- orrhage, of course, is to be expected, but this is less where the growth is boldly attacked in its deeper parts, than when the surgeon is timid and attacks merely the superficial portions, CANCER. 363 and may be controlled either by plugging the wound with lint and styptics, or by the actual cautery. Allingham relates a case in which he entirely enucleated an immense encephaloid with his hand, with the happiest results. As a substitute for partial destruction of the growth in this way, the operation of crushing with an instrument similar to the enterotome of Dupuytren has been proposed. The proceed- ing is only applicable to a certain class of cases, in which the stricture is anular and not too extensive to be grasped by the instrument, and has no advantages over the other methods. There is no obstruction within four inches of the anus which may not be overcome by some one or other of these means. What, then, remains for lumbar colotomy? Simply those above the reflection of the peritoneum. It will often be difficult for the surgeon to decide for or against colotomy in these cases. Two factors enter into the question : 1st, Whether or not the patient is likely to survive the operation itself ; and, 2d, if this is decided in the affirmative, whether sufficient is to be gained to pay for the risk. The gen- eral condition of the patient, the extent of disease as regards secondary deposits, and the amount of pain due to defecation, all have to be taken into consideration. The operation may be indicated to relieve this pain when there is not much chance of actually prolonging life, and it may be indicated to prevent or overcome obstruction where there is no great amount of pain, lam inclined, for myself, to limit the operation to those cases where the pain of defecation is great, and where the disease is still circumscribed, and should not for the choice between death from obstruction and death a few weeks later from exhaustion always have recourse to this extreme measure, but should rather trust to securing a comparatively easy passing away of the patient under the influence of opium. Indeed, many patients will decide the question in this way for themselves when it is explained to them in all its bearings. It is a curious fact that, by relieving the over-distention of the bowels by colotomy, the obstruction also will sometimes cease, and passages will again pursue their natural course. Such a case is reported by Goodhart, where three successive operations for opening the colon above the. stricture were re- sorted to to relieve obstruction, and after each one the passages were again restored to the natural outlet. CHAPTER XIII. IMPACTED F-El'ES AKD FOREIGN EODIES. Impacted Faeces. — Intestinal CkmcxetifHia — Diagnosis and Treatment of Impaction. — Foreign Bodies Swallowed. — Results which may Follow the Swallowing of a For- eign Body. — Ulceration and Abscess. — Foreign Bodies Introduced per Anum. — Ca-es. — Prognosis. — Treatment. — Dangers of Attempts at Removal. — Laparotomy for Removal. — Cases successful. Impaction of Faces. — The impaction of f feces may be due to several causes, but is most generally a symptom either of in- testinal atony in old some paralytic affection such as locomotor ataxia. It not infrequently occurs in women as a result of the entire neglect of the function of defecation, for which they are perhaps unjustly celebrated ; and it may follow a partial paralysis of the rectum from the long-continued use of large enemata. or the pressure of the total head in child- birth. It may also result as a consequence of a painful affec- tion, such as a fissure, which renders each act of defecation an agony to be avoided by every possible means. The disease is generally one of old people, of hysterical girls, and of ca: women; but it has I a in children, and as a result of im- proper diet may occasionally be encountered in young and healthy men. Intestinal concretions may be composed entirely of hardened and stratified or clayey masses of feces, or they may contain within them as a nucleus a biliary calculus, or indigestible Bnbstances which have been hastily swallowed, such as peach- pits, cherry-sl oes, etc. Molliere rails attention to the pres- ence of magnesia, which favors the aggregation of frecal mat- ters, and which also may act as the nucleus of a scybalus : and the frequency of impaction during the famine in Ireland in 1846, when potatoes, and those of a very poor quality, were the IMPACTED FAECES AND FOREIGN BODIES. 365 only article of diet, is a well-known historical fact. 1 In Scot- land, where oatmeal is a favorite article of diet, fsecal accumu- lations are said to be of frequent occurrence. Certain other drugs besides magnesia, such as chalk, sulphur, and powdered cubebs, have been blamed as the cause of intestinal concretions. Intestinal calculi have been seen which were composed of pure cholesterin, or of a biliary calculus coated with cholesterin. The usual location of a mass of impacted faeces is the rectal pouch, but it may be situated anywhere between the caecum and this point. The symptoms to which it gives rise are gener- ally sufficiently well marked to enable the practitioner to reach a correct diagnosis if he be on his guard. The pains which it causes will generally be obscure and may be located anywhere in the abdomen or in the lower extremities ; and the signs of disturbance in digestion are not in themselves sufficiently marked for diagnosis, but the one symptom which is characteristic is diarrhoea. Just as the practitioner has to learn that incontinence of urine may be a sign of a distended and not an empty bladder, so he may have to learn by a disagreeable error in diagnosis that a diarrhoea is sometimes a result of an overfilled and ob- structed rectum. This diarrhoea is peculiarly foetid in charac- ter, and the matters discharged may be entirely free from faeces and consist entirely of mucus. In some cases there may be an approach to a daily natural evacuation. The act of defecation is always attended by straining and pain as the faecal ball is pressed down against the perinaeum and rises again when the muscular effort ceases. To these symptoms Allingham adds a peculiar ringing, barking cough, morning vomiting (particularly in women), and night-sweats. Of course errors in diagnosis are easy in such a condition as this, and a mass of faeces in the colon may be mistaken for any and every sort of tumor in the pelvis or abdomen. Liver, spleen, stomach, uterus, and ovaries have again and again been supposed diseased in these cases when a simple digital exam- ination of the rectum, or in women even of the vagina, could not fail to make the diagnosis clear. Unfortunately for diag- nosis, the general practitioner is not fond of making rectal examinations, and these cases are not infrequently treated with bismuth and opium as a consequence. 1 For description of these cases see article by Dr. Papham in the Lancet, 1850. 366 DISEASES OF THE RECTUM AND ANUS. The following instructive case was reported by Dr. 'Griffith. 1 In the autumn of 1876 I was hurriedly summoned to an old lady, who had within a few days of my seeing her met with a severe accident in the city, having been knocked down by a hansom as she was crossing the street. All her friends had given her up to die. She was so powerless to move, so pros- trated, and so large a tumor, they stated to me, had made its appearance since her injuries. Her age (eight}*) seemed to ex- clude all hope of recovery ; and I was asked to see her — more that it should not be said she had died incapable of making her will and to witness her signature to it, than with any idea that I could benefit her. I examined the abdomen, and while doing so learned from her that she thought she had been larger on the left side for some time before the accident. I found considerable enlarge- ment of the entire abdomen from flatulent distention, and on the right side a tumor, hard and apparently irregular, extend- ing from the left hypochondriac into the left iliac fossa, and passing a little way to the right of the median line. At first, I thought it might be enlarged spleen, or a left ovarian dropsy, or an extrauterine fibroid, which had been unnoticed, and was now observed solely because attention was directed to the left side, where the patient had been struck by the vehicle. I could not at this, my first visit, make a veiy minute examination, owing to the extreme prostration and depression ; but at my second visit, having in the interval built her up and cheered her all I could, I examined very carefully per vaginam, and with equal care explored by the rectum. I then came to the conclu- sion that there was neither ovarian nor uterine tumors, and that I had to deal with an accumulation of faeces — even though the bowels were moved every day, as the attendant informed me, and that the accumulation had commenced previous to her acci- dent ; forming, no doubt, the enlargement which she told me she had noticed before her injury, and which, as the accumula- tion increased, culminated in the enlargement I found. I swept out the bowels by free purgation, kept up for some days, while I sustained her with light and easily digested nutrients, allow- ing as stimulant only good tea and coffee. The next case is also from the same author : 1 Faecal Accumulations Stimulating Utero-Ovarian Tumors. Edinburgh Medical Journal, May, 1877. IMPACTED F^CES AND FOEEIGN BODIES. 367 Mrs. G , aged twenty-five, mother of three children ; the last being about four months old when I was first in attendance. I was called up to her on the night of June 18, 1876, "as she was suffering acute pain in the left side, which she could endure no longer." On examining the abdomen, I found a hard, irreg- ular, exceedingly tender tumor, from which she was enduring great agony, and which was almost as large as an infant's head. I made no further examination that night, contenting myself with ordering her one-half grain morphia suppositories, to re- lieve not only the pain, but likewise the tenesmus and the passing of mucus. The discharge from the bowels was quite fluid, but distinctly fffical, occasionally a scybalous mass mak- ing its appearance. Next day, the morphia having taken good effect, I examined with the finger by the vagina, but could make out neither ovarian nor uterine tumor ; the sound in utero enabled me to make certain that there was no intrauterine growth ; but move- ment of the uterus with the sound in the interior of it was at- tended with the movement of the mass, which I found lay out- side the womb, yet connected to the left and upper portion of it — in fact, attached to it. I gave it as my opinion that, whatever the mass was, it was outside the uterus, and was adherent to it, and that it was not ovarian. I did not, however, express the opinion at which I arrived after the above examinations and after thoroughly exploring by the rectum, viz., that it was a case of impacted and accumulated faeces, which, having set up great irritation, had occasioned inflammation, effusion of lymph, and matting or gluing of the bowel to the left and upper por- tion or cornu of the uterus, that organ being still enlarged, its involution after delivery being not yet completed, probably owing to the irritation, inflammation, and subsequent adhesion to which I have referred. Taking this view of the case, I purged freely and continuously for some days, till at length, after the lapse of six weeks, I had the satisfaction of hearing from my patient — for I did not attend her continuously during this period — that the tumor was all gone, and she was quite well ; facts I verified by careful manipulation when she last visited me. The iodide of potassium had been combined with the aperients, as had also anodj^nes— the former in hope of dis- solving adhesions, the latter with a view to ease pain. I would add, to show the difficulties which sometimes behedge the 368 DISEASES OF THE RECTUM AND ANTTS. diagnosis in these cases, that this patient had previously had pronounced to her by three medical men that operation alone (gastrotomy) could do her any good ; and of this she had a mortal dread, so that all through I buoj^ed her up with, the hope that the knife might never be required. The swelling had commenced to be noticed about twelve or fourteen days after the birth of her child, was chiefly confined to the left side, though sometimes it seemed to enlarge, and to extend higher up and across the middle line toward the right, and was so large that it was as though she was at her full time, and when walking, even across her room, she required a towel to support the abdomen ; at other times it would subside, pre- serving, however, the same shape ; these alterations in size were synchronous with the action of the bowels, and gave me a val- uable clue. The agony had been very great, and she told me nothing had relieved her for any length of time till she had used the morphia suppositories. At no period was there a dis- charge of matter indicative of any internal abscess ; nor any iiux of water either into the abdominal cavity or into the blad- der, or any way externally, which would demonstrate the exist- ence and rupture of an ovarian or other cystic growth ; there- fore, the only diagnosis at which I could arrive was that the bowels had become blocked during the confinement period, had not emptied themselves fully, that an accumulation occurred and became greater and greater, being, however, occasionally partially lessened by the aperient action of the bowels them- selves, which accounted for the diminution of and subsidence that had been noticed in the swelling. The treatment of impaction is simple, and consists first of all in the entire removal of the mass. In cases of paralysis, where the accumulation has not been allowed to reach any very great amount, and the scj^bala are small and not very hard, this may sometimes be accomplished by the use of injections with a long tube and the assistance of the finger of the opera- tor. In women very effectual aid may be rendered under simi- lar conditions hy pressure from the vagina, by which small masses may be extruded one after another, eacli with a certain amount of pain, bat without laceration of the mucous mera- brane at the anus. This plan of treatment will often constitute one of the regular duties of the attendant upon a case of paral- IMPACTED FAECES AND FOREIGN BODIES. 369 ysis— a disagreeable duty which must be attended to at certain regular intervals. In cases of longer standing, however, these means may be entirely inadequate, and all injections, no matter what their supposed solvent virtues, will be of no avail even if they are not at once ejected. In such cases the operation of breaking up and removing the mass must be begun by the administration of ether and dilatation of the sphincter. This accomplished, the mass may be attacked with the fingers, an iron spoon, a pair of lithotomy forceps, or the scoop shown in Fig. 87, and removed piece by piece. When this has been done, an injection may be administered through the long tube and more matter will gen- erally come down from the sigmoid flexure. The impacted mass is often as large as the fist, and sometimes as a foetal head, and the amount in the sigmoid flexure and colon may be much greater though not as hard, so that at a single sitting an enor- mous amount may be removed. Fig. 87. — Scoop for Removing Impacted Faeces. After such an operation as this, the patient must be treated by injections and a daily laxative, as will be described in speak- ing of constipation, till the over-distended rectum has recovered its tone. This may require a considerable time. Foreign Bodies which have been Swallowed. — Medical liter- ature is full of curious cases in which foreign bodies have been swallowed, either accidentally or by design, and have in some cases passed the full length of the alimentary canal, and been safely voided with the faeces, or in others have become entan- gled in the mucous membrane, and given rise to much trouble. Every practitioner is familiar with cases of peach-stones and coins which have been accidentally swallowed, and knows how generally such substances take care of themselves, and cause no symptoms after once passing the oesophagus. Much larger substances, such as whole or partial sets of false teeth, and the various things with which performers in travelling shows enter- tain an audience, may also be passed in safety. To show what nature is capable of in this line, it may be well to enumerate the substances which were swallowed and 34 370 DISEASES OF THE RECTUM AND ANUS. safely voided by a certain lunatic now become famous. The patient stated that she had been swallowing nails, etc., and a dose of castor oil brought away two pieces of faience, one or two centimetres long and about the same breadth, two nails, and a pebble. During the following six weeks she passed nineteen large pointed nails, a screw seven centimetres long, numerous fragments of glass and china, a piece of a needle, two knitting- needles, fragments of whalebone, etc., amounting in all to three hundred grammes. During all this time the patient ate and drank as usual, and seemed in ordinary health. 1 Prof. Agnew "saw in the dissecting-room of the Philadel- phia School of Anatomy, a female subject, afterward learned to have been insane, in whose intestinal canal from jejunum to rectum were found three spools of cotton partially unwound, two roller bandages, one of them two and a half inches wide and one inch thick, the other was partially unrolled, one end being in the ileum, the other in the rectum ; a number of skeins of thread, a quantity being packed tightly in the csecum ; and finally a pair of suspenders." Prof. Gross records the "case of a man who swallowed a bar of lead, ten inches long, upward of six lines in diameter and one pound in weight, whilst performing some tricks of legerdemain," which was removed by gastrotomy and the patient recovered in two weeks. He also mentioned another case in which a teaspoon was swallowed, whilst the patient was in a paroxysm of delirium, which was removed from the ilium by enterotomy, recovery taking place in a few weeks. 2 " Henrion, called Cassandra, born in Metz, in 1761. Not satis- fied with the various trades which he followed in his youth, he began to force himself, at the age of twenty- two years, to swal- low pebbles. Sometimes he swallowed them whole and with- out any preparation, and sometimes he broke them between his teeth, after having first heated them red-hot and then suddenly plunged them into cold water. In this manner he palmed him- self off as an American savage. For several years he had fixed his residence nt Nancy, and there continued the same habits which lie had not interrupted, swallowing daily a large number of pebbles, sometimes as many as thirty or forty. The largest pebbles equalled in volume a large nut, but they were usually 1 Lancet, 1860. vol. i., p. 2:!. 'Randolph Winalow: Maryland Medical Journal, March, 1880. IMPACTED FJECES AND FOREIGN BODIES. 371 smaller, and Henrion demonstrated their presence in the stom- ach by the collision which he obtained by percussing the epi- gastric region. With the aid of salts he passed them in twenty- four hours, and often made them do duty for the next day. He also swallowed live mice, though only one in the course of a day, as well as crabs of moderate size, after their claws had been cut. When the mice were introduced into the mouth, they threw themselves into the pharynx, in which they were soon suffocated, and their deglutition was then facilitated by that of a nail. Upon the following day it was passed from the rectum, flayed, and covered with a mucous substance. At another time three large pennies were successively put to the same use, and Henrion found them later, scraped clean and mixed with fsecal matters. "He continued this calling until 1820. At this time he swallowed some nails, and then a plated iron spoon measuring five and a half inches in length and one in breadth, for a mod- erate sum. He died seven days later." ' Napoleon relates a case of considerable historic interest where the alimentary canal was used for the purpose of secret- ing despatches. ' ' When I commanded at the siege of Mantone, shortly be- fore the surrender of this fortress, a G-erman was arrested while endeavoring to enter the city. The soldiers, who suspected him of being a spy, searched him without success ; they then threat- ened him in their own language, which he did not understand. Finally a Frenchman was called who spoke German slightly, and who threatened him, in bad German, with instant death if he did not at once disclose all he knew. He accompanied this threat with furious gestures, drew his sword, placed the point of it upon his belly, and said he was going to slit him open. The poor German, frightened and not understanding the jargon of the French soldier, imagined, when he saw him threatening his belly, that his secret was disclosed, and cried out that it was unnecessary to slit him open, and that if he waited a few hours it could be obtained in the natural manner. This gave rise to fresh questions ; he stated that he was the bearer of des- patches for Wurmser, and that he had swallowed them as soon as he found himself in danger of being captured. He was car- ried to my headquarters, whither several physicians were sum- 1 Arch. Gen. de Med., 3e Serie, 1839, p. 353 (Poulet). 372 DISEASES OF THE RECTUM A15TD ANUS. moned. It was proposed to administer a purgative, but they stated that it was best to await the operation of nature. He was then confined to a room under the surveillance of two staff officers, one of whom was constantly near him. After several hours the expected object was found. It was inclosed in wax, and was as large as a nut. When opened it was found to be a despatch written in the hand of the Emperor Francis, and which requested him not to be discouraged and to hold out a few days longer, when he would aid him with a strong column." Napo- leon, upon these indications, left with his troops and completely defeated Alvinzi at the Passage of the P6. 1 It would be beyond the scope of a work such as this to at- tempt to deal with the whole question of foreign bodies in the alimentary canal, and the accidents which may attend them. In a general way, the prognosis is good unless the foreign body be a very ragged one or a large sharp one like a fork ; and the treatment consists in giving a diet like bread and fruit, which will cause copious stools, with little drink, and the avoidance of exercise such as walking. If complications arise, they must be treated on general surgical principles ; and at the present day no patient would be allowed to die from the effects of a foreign substance in the stomach or intestines without a sur- gical operation for its removal, provided only the diagnosis were clear. The complications which may attend the detention of such substances in the rectal pouch just above the internal sphincter are ulceration with perforation, hemorrhage, and abscess. Ul- ceration may be caused by the pressure of a large body, and may cover a considerable space, or it may be caused by the pressure of the sharp ends of a smaller body, in which case the spots of ulceration will be smaller, and may be located at two opposite points in the rectum. As a result of ulceration, there will be more or less pain, purulent discharge, and perhaps also a sharp haemorrhage from the erosion of a vessel. When per- foration of the wall of the bowel has occurred, inflammatory action is almost sure to be excited in the surrounding parts, and this may vary greatly in its extent and gravity. If the injury be above the point of reflection of the peritoneum, it may cause either a localized or a general peritonitis. A general peri- tonitis caused in this way will be fatal, as it is also generally ' Memorial de Sainte Helene, t. ii., p. 468 (Poxilet). IMPACTED FJECES AND FOREIGN BODIES. 373 accompanied by more or less extravasation of faeces. A circum- scribed peritonitis with formation of an abscess is a less fatal complication. Under these circumstances the usual signs of pelvic abscess will be present — fever, pain on pressure, tympa- nites, painful defecation, and urination — and by careful exami- nation a tumor may be discovered, either through the rectum or at the bottom of the iliac fossa. Such cases, when the tumor is on the right side, are often mistaken for cases of perityphlitis, but the tumor is not in the same location. It is deeper and nearer the median line. Such an inflammation may terminate in resolution, provided the cause be discovered and removed ; but the usual termination is in suppuration, and the pus, if not removed by the surgeon, may find its way into the general peritoneal cavity or into the bladder or rectum. Abscesses of the superior pelvi-rectal space have already been described, and those which are due to foreign bodies in the bowel do not differ from them in general char- acters. When the focus of inflammation is located below the reflec- tion of the peritoneum, the prognosis is less grave. Phlegmon- ous abscess may form in the ischio-rectal fossa, and must be treated according to the rules already laid down ; but here the difficulty is well within the reach - of the surgeon, and a cure may confidently be looked for by proper care. Foreign Bodies Introduced, per Anum. — A classification of these cases is useless. The foreign bodies may be introduced through traumatism : by the patient in an honest endeavor to relieve himself of piles or prolapse ; by the surgeon for the pur- pose of relieving rectal disease. They are often introduced in a spirit of revenge or of trickery ; and most often of all they are lost in the practice of an unnatural vice. Edward II. is said to have met his death by having a red-hot iron thrust into the rectum. "We seized the king," said one of the murderers, "and threw him forcibly upon the couch, and, whilst I kept him there by the assistance of a table, with a pillow on his face, Gurney inserted through a horn-tube a red-hot iron into his bowels." Gross, vol. ii., p. 627. The case of the prostitute into whose rectum the students of the University of Gottingen introduced a pig's tail, butt end first, is as follows : " Some students had formed the plan of playing a practical 374 DISEASES OF THE EECTUM AND ANUS. joke on a prostitute ; they determined to push into her anus a frozen pig's tail. They cut the hairs very short in order to make them sharper and rougher, then dipped it in oil, and forcibly introduced it into the woman's anus, with the excep- tion of a portion three fingers' breadth in length, which re- mained outside. Several attempts were made to extract it, but, as it could only be withdrawn against the hairs, the bristles en- tered against the mucous membrane, and gave rise to excruciat- ing pain. In order to relieve it, various oily remedies were given by the mouth, and the attempt. was made to dilate the anus with a speculum in order to extract the tail without vio- lence, but it was unsuccessful. Severe symptoms developed, violent vomiting, obstinate constipation, very high fever, and intense pains in the abdomen. Marchettis was summoned on the sixth day. This physician, having been informed of what had happened, invented a very simple and ingenious device. He took a hollow reed, one end of which he prepared so that he could easily introduce it into the anus, and completely inclosed the pig's tail in this reed, in order to withdraw it without pain. For this purpose he attached to the tail, by the end which pro- jected from the anus, a stout wax thread which he passed into the reed. With one hand he pushed this form of canula into the rectum, and held the cord in the other, to prevent the tail being pushed in still further. He succeeded in completely in- closing the tail, and promptly relieved the patient." ' A punishment for adultery among the Greeks is said to have been the introduction into the rectum of a peeled radish, cov- ered with hot ashes ; and cases in which patients have fallen upon sharp and fragile objects, such as the wooden pickets of a fence, which have broken off and remained in the rectum, are on record. The list of foreign bodies which have been lost in the rectum by ignorant persons, in attempts to check a diarrhoea or to pre- vent the descent of piles or prolapse, is a very long one, and in- cludes such substances as bottles, sticks of wood, and round stones, some of them of a size relatively enormous ; and the use of the rectal pouch by criminals for the purposes of conceal- ment is well known to the police. In the Museum of Anatomy and Pathology at Copenhagen is alongish, oval, fiat stone, about 6f incheslong, 2| inches wide, 1 Hevin, p. 339. IMPACTED FAECES AND FOREIGN BODIES. 375 1^ inch thick, and weighing nearly two pounds, which a patient in Bornholm introduced into his rectum to prevent prolapse, from which he had for a long time suffered. The stone was ex- tracted by a surgeon, Frantz Dyhr, in 1756. ' Reali operated in 1849, in the hospital at Orvieto, on a peas- ant who nine days previously had introduced a piece of wood into the rectum for the purpose, he said, of economizing his food, and preventing it from passing out too quickly. He had violent pain. On exploration, the linger could feel the base of the piece of wood lying in the hollow on the sacrum, and sur- rounded by the broken mucous membrane. As repeated at- tempts at extraction led to no result, Reali made an incision in the right iliac region, and found that the foreign body lay in the sigmoid flexure, which it had dilated and pushed to the middle line nearly as far as the umbilicus ; he incised the in- testine, removed the foreign body, and closed the intestinal wound by Jobert' s method. The patient was treated by pur- gatives (!) and had entero-peritonitis and abscess in the iliac fossa, but recovered, and two years afterward was in perfect health. The foreign body was a piece of chestnut wood of the shape of a truncated cone, 10 inches long and about 3^ or 4 inches in diameter. A little case with very ingenious housebreaking and other thieves' instruments was found by Dr. Closmadeuc at the ne- cropsy of a man in the prison at Vannes. The man had died of acute peritonitis, from which he had suffered seven days. During his illness a hard, rather large body was felt in the left side of the hypogastrium ; he said that it was a piece of wood containing money, which he had introduced into the rectum ; this, on exploration in the meantime, was found empty. On section, the case, which was cylindro-conical in form, lay in the transverse colon, with its apex directed toward the caecum ; it was of iron, and was wrapped in a piece of lamb' s mesentery ; it weighed about 23 ounces, was about 6| inches long and 5i in circumference, and contained thirteen tools and some coins. 2 "A monk, desiring relief from a severe colic from which he was suffering, was advised to introduce into the rectum a bottle of Hungary water, in the cork of which there was a small open- 1 Bull, de la Soc. de Chir., 1878, p. 660. 2 London Medical Record, December 15, 1878. Abstract of Studsgaard's paper read before Soc. deChir., Paris, October 9, 1878. 376 DISEASES OF THE RECTUM AND ANUS. ing, through which the water gradually distilled into the intestine (these bottles are usually long). He pushed it so far that it en- tered the rectum altogether, whereat he was greatly astonished. He could neither have an evacuation nor receive an enema ; in- flammation and death were apprehended. A midwife was con- sulted in order to see whether she could introduce her finger and extract the bottle, but she was unable to do it. Forceps, a ripping-iron, and anal speculse were useless. It could not be broken ; this would have been more disastrous, as the pieces of glass would have wounded him. Finally, a little boy, eight or nine years old, was found, who introduced his hand, and had sufficient address to cure the good monk." ] A depraved sexual appetite has been mentioned as account- ing for the presence of many foreign bodies. It is known that sexual orgasm may be excited by stimulating the reflex power of the rectum, and it is probable that at the moment when the orgasm is at its height, the body used to produce it is allowed to escape from the hand and is lost within the bowel. This is a habit which will never be acknowledged by its victims, but which may often be assumed to exist by the surgeon in de- praved patients. The bodies used for this purpose are generally smooth, long, and round, such as glass bottles and pieces of wood. The following case is one in point, and the age of the patient is suggestive, for this vice is said to be more common in old men than in others — men whose physical powers have not kept pace with their desires. " On the afternoon of March 1, 1848, a young man consulted Parker with regard to his father, whom he had brought into the hospital. After beating around the bush and manifesting con- siderable shame and embarrassment, he stated that his father, named Loo, who was sixty years old, had passed the previous night in a house of prostitution. Overcome by drink and opium, the old debauchee conceived the strange notion of push- ing a goblet, two and a half inches in diameter and three and a half inches long, into the vagina of his partner. During the night, while Loo was completely intoxicated, the woman at- tempted to revenge herself. She carefully introduced the bottom of the goblet into the rectum, placed the end of the opium pipe, which was a foot and a half long, into the goblet, and pushed it into the rectum. The goblet disappeared and 1 Mem. de l'Acad. de Chirurgie. IMPACTED FAECES AND FOEEIGN BODIES. 377 had been retained twenty-four hours. A piece of the edge, about half an inch long, had been broken off by the friends in attempts at extraction. The glass was firmly fixed, and it was very difficult to pass the finger between it and the rectum. Parker, determining to break it, employed a cephalotribe and removed it in pieces, taking care to protect the parts with cotton. The most difficult part was the extraction of the glass, which was very irritating. It was done, but not without diffi- culty, by making it see-saw from side to side. Considerable haemorrhage occurred, which was arrested with sulphate of copper and alum. The man recovered in two weeks." 1 It would be interesting to enumerate the foreign bodies which have been removed from this part of the body, and the list would be startling from the strangeness of the different articles ; but enough has been said to indicate that almost any- thing, from a conical stone to a club or a coffee cup, may be en- countered by the surgeon, and to indicate the size of the body which the sphincter will allow to pass. Among them may be mentioned beer glasses, mushroom bottles, wooden pepper boxes, wine bottles of all kinds, lamp chimneys, and a part of the wooden handle of a baker's shovel twenty-two centimetres in length. A foreign substance may remain in the rectum for a con- siderable time and finally be expelled spontaneously, as in the following case reported by Weigand. 2 " A farmer, aged sixty-eight years, of a robust constitution, but somewhat stupid, introduced into the anus a cylindrical piece of wood for the purpose of relieving his obstinate consti- pation. However, he performed the manipulation so unskil- fully that the piece of wood broke and remained partly within the rectum. All attempts made to remove the foreign body failed ; two days later he suffered from abdominal and lumbar pains, dysuria, and constipation. Weigand being consulted by the physician, recognized the symptoms of enteritis. As the introduction of a finger into the rectum did not demonstrate the presence of a foreign body, he restricted himself to combating the inflammatory symptoms and pain (calomel, enemata, nar- cotics, leeches). On the eleventh day a purulent, sanguinolent, foetid fluid was evacuated, after which the patient felt remark- 1 Am. Journal of the Medical Sciences, 1849, p. 409. 2 Schmidt's Annalen, 113, iv., p. 95, 1862. 378 DISEASES OF THE RECTUM AND ANUS. ably relieved ; but it was impossible to discover any trace of the piece of wood. Weigand then expressed serious doubts as to whether a foreign body was really contained in the rectum ; but as the patient resolutely maintained that he continued to feel the piece of wood, renewed search was made, until the finger being introduced far in, encountered a rough, hard object which it was impossible to seize for want of proper instruments. As circumstances did not indicate a necessity for more active treatment, Weigand contented himself with giving the patient from time to time two or three spoonfuls of castor-oil, which always produced the discharge of a small amount of muco- sanguinolent faeces. At this time the lumbar and abdominal pains again appeared more frequently, and, on the other hand, the patient's former appetite being gradually restored, he walked about and attended to light domestic duties. On the thirty-first day after the accident, after having taken three spoonfuls of castor-oil, he stated that he had an intense desire to go to stool, when, in addition to blood and pus, the piece of wood made its appearance, 0.1357 m. long, 0.027 thick, cylin- drical, serrated at the broken end, and roughened on the cylin- drical surface ; in fact it was the end of a pole with which bean- vines are propped. The patient recovered entirely without having been subjected to any further treatment" (Poulet). Prognosis. — The prognosis in cases of foreign bodies will de- pend greatly upon their size and nature. A long body like a piece of wood may go so far up the bowel as to do fatal damage before its removal ; and a fragile body like glass may cause fatal injury in the attempt to remove it. Again the prognosis depends in great measure upon the surgical ability of the one in charge of the case. A little bungling in the treatment may at any moment change a case which promises well into a fatal one. Finally, much will depend upon the length of time during which the body has remained in the rectum ; and it is not very uncommon for patients who have met with an accident in the practice of this secret vice to conceal the real nature of the trouble which they well understand till they are forced by suffering to confess. In this way a week' s valuable time may be lost and a fatal amount of injury be done. Treatment. — Each case of foreign body must be treated by itself, and besides a few general principles which apply equally to all cases, the surgeon will be left entirely to his own ingen- IMPACTED FAECES AND FOEEIGN BODIES. 379 uity. The one guiding principle should be to avoid doing fresh injury in the attempt at removal. Only the smaller and least friable of bodies can be removed without a previous dilatation of the sphincter under ether, and in most cases it will be advis- able to incise the anus in the median line down to the tip of the coccyx as a preparatory measure to all treatment. This step will sometimes render a body movable which before was absolutely immovable, and thus open the way for its extrac- tion. Having opened the way to the body, it may sometimes be removed by passing the whole hand into the rectum and seizing it. At other times forceps may be used with advantage, and these may be of any shape which seems best to answer the purpose intended, including the obstetric forceps, which have been found useful in many cases. If a bottle has been intro- duced with the mouth downward a string may be secured around the neck for the purpose of traction, but, unfortunately, in almost all cases the position will be reversed. In cases of long bodies the lower end is not infrequently firmly wedged in the hollow of the sacrum — so firmly as to resist all efforts at dislodgment. Under such circumstances fatal injury may easily be done by the operator by persistence in the attempt. Above all things the surgeon must avoid breaking such a substance as a cup, for experience has proved that after this has happened, removal without causing great injury is almost impossible. Certain complications may at any time arise in the treatment of these cases, one of which is recorded by Desault. 1 A man, aged forty-seven years, entered the Hotel Dieu on April 17, 1762, in order to have a crockery vessel extracted from his rec- tum, which he had introduced a week previously in order to overcome, as he said, his obstinate constipation. This vessel was a preserve jar, the handle of which was broken and the bottom detached. It was conical in shape and three inches long ; it had been introduced by the smaller end, which was two inches in diameter. When the patient presented himself at the hospital, he had already made efforts to extract the foreign body, but an escape of blood and the excessive pains had compelled him to suspend his efforts. The upper part of the rectum was infolded and in- 1 Journal de Chir., t. iii., p. 177 (Poulet). 380 DISEASES OE THE EECTUM AND ANUS. vaginated in the vessel, and formed a very hard tnmor, which filled it completely. The surrounding parts were inflamed, and this fact rendered the extraction more difficult. Desault made the patient lie upon the side, and then, separating the intestine from the walls of the vessel, he succeeded in seizing the latter with a strong extractor, which he pushed up as far as possible and which was held by an assistant. By means of this point of support, and with another extractor introduced in the same manner, he succeeded in breaking the vessel and in extracting it in small pieces without wounding the rectum. The operation was neither long nor painful, though it was necessary to intro- duce the extractors a large number of times. After all the pieces had been removed, Desault pushed back the inverted portion of the rectum by means of a charpie tampon six inches long and two and a half in diameter, which he pushed in altogether after having covered it with cerate. Below this were placed a large amount of charpie, several compresses, and a triangular bandage which supported the whole dressing. The dressing was renewed twice a day on account of the relaxation, which did not cease till the sixth day. Then the intestine no longer protruded when the patient went to stool, and such large tampons were not required. They were discontinued entirely after the tenth day, when the ruptures had cicatrized, and the man left the hospital entirely cured two weeks after the operation. In cases where a long body has become firmly wedged into the lower end in the hollow of the sacrum, the proper treatment consists in opening the abdomen, and this should be done after an attempt to remove it per anum has been continued a reason- able time, and before injury has been done in such an attempt. It is not necessary to describe the operation of laparo-entero- tomy in this connection. The incision may be made either in the median line or in the groin. In the "Surgical History of the War of the Rebellion," Vol. II., p. 322, there is a history of one such operation performed upon a sailor who had introduced a stone five and a quarter inches long by three wide. The colon had been perforated and the stone was removed from the peritoneal cavity by an incision near the umbilicus. The man recovered. The oldest known case 1 was reported by Realli in 1 For this and maDy other interesting facts in connection with this subject the reader is referred to Poulet's work on Foreign Bodies in Surgery. Wood's Library of Standard Medical Authors, 1880. IMPACTED F.ECES AND FOEEIGTT BODIES. 381 the Bull, de Soc. Medich., and Gaz. Med., July, 1851, and being the one which has served as a guide for all subsequent ones, we give it in full : Case. Foreign Body. — "On December 18, 1848, a peasant was brought in the hospital of Orvieto in a condition of extreme weakness. Mne days previously, having hit upon the ingen- ious idea that, if he prevented the discharge of food he could limit the quantity to be swallowed, he introduced a piece of wood into the rectum ; all his attempts at removal only served to push it in still further. The ringer could only touch the end of the object, and it was firmly fixed in such a manner as not to yield to any tractions which could be made upon it with such a slight purchase. "After the failure of all attempts at removal, the foreign body completely obliterating the intestinal cavity, and the pa- tient being threatened with death from his atrocious sufferings, Realli decided to operate. After having cut the abdominal walls on the left side, he could distinctly feel the stake in the descending colon. He desired to push it down to the anus, but the attempts proved unsuccessful, and he was compelled to in- cise the intestine. Only after this was done could he remove the body, which was ten centimetres long and more than three centimetres in diameter at the base. The point was rounded and very soft. Ko fseces were retained above the plug, but the mucous membrane was blackish, the peritoneal coat strongly injected, and the thickness of the intestinal wall markedly in- creased. " The wound in the intestine was united by a suture, which was applied according to Jobert's plan. The lips of the wound in the abdomen were united by means of an interrupted suture. Cold, and then iced applications were made over the operated region. Two doses of castor-oil were administered. There was a purulent discharge from the anus. During the first few days, the tumefaction of the walls of the intestines prevented the ad- vance of freces, and caused meteorism and vomiting. Three bleedings, two applications of leeches, and a few doses of castor- oil put an end to these symptoms, which had acquired an alarm- ing character. The evacuations from the bowels were again passed on the fifth day. Toward the fourteenth day, the wounds had cicatrized. Two years later, the health remained perfect." 382 DISEASES OP THE RECTUM AND ANUS. In a paper read before the Soc. de Cliirurgie, 1 Studsgaard, of Copenhagen, reports the following similar case : Case. Foreign Body. — "J. F., footman, aged thirty-five years, was admitted on January 10, 1878, to the Copenhagen Hospital, and left cured on April 16, 1878. The night before entering he had introduced an empty mushroom bottle into the rectum, the neck of the bottle being uppermost, in order, as he stated, to relieve a rebellious diarrhoea, and on the morning of January 10th he was obliged to call a physician, acute pains being experienced in the abdomen. "He was anaesthetized with chloroform, but the bottle, which, previous to the narcosis, had been felt in the rectum, slipped further up. He was exhausted by the passage and the increasing pains ; vomiting of mucus. The bottle could be felt through the somewhat tense abdominal wall along the median line on the left side, the bottom being near the horizontal ramus of the pubis. In the evening, profound narcosis and posterior linear rectotomy ; the hand was introduced as far as the third sphincter, which was not forced, on account of its resistance. The bottle was then pressed from the outside down into the pelvis, but it descended in a loop of the intestine in front of the rectum. Immediately afterward, antiseptic laparo-enterotomy, through the median line, by an incision ten centimetres long, commencing at the umbilicus. A loop, which was thought to be the sigmoid flexure, was extracted, and the bottle was then slowly removed through an incision four centimetres long, which was made upon the orifice and upper part of the neck. The entire circumference was protected by sponges and com- presses between the faeces, and the intestinal incision was closed by twelve to fourteen catgut sutures, according to Lambert's method, the peritoneal surfaces having been freely washed. In order to be on the safe side, the sutures were tied with three knots ; the intestines were then introduced, and the abdominal wound united with eight silk sutures, tied alternately with knots and the figure of eight. The operation lasted an hour. " The bottle was seventeen centimetres long, the diameter of the bottom was five centimetres, that of the neck three centi- metres ; the opening contained a notch, which was evidently of old date, about half a centimetre long, and presenting cutting edges. The recovery occupied a long time, and the prognosis 1 Bull, de la Soc. de Chir.,1878, p. 662. IMPACTED FAECES AND FOREIGN BODIES. 383 was uncertain for a very protracted period, on account of a local peritonitis with abscess formation, which I incised both upon the median line and through the rectum, upon the pos- terior wall of which it projected. Gas began to pass two days after the operation ; from the ninth day on, he had spontaneous evacuations, which were well formed, and contained no traces of pus." One other case of this kind has been placed on record l by Verneuil. Case. — A man, aged forty-five, had been in the habit of stopping up his rectum to overcome an incontinence of faeces which had resulted from two previous attacks of dysentery. For this purpose he used various large bodies, taking the pre- caution to tie to them a piece of cord, the ends of which were left hanging outside. But one day he had no cord, and a cyl- indrical piece of wood, ten centimetres long and about eight in diameter, escaped into the upper part of the rectum, and could neither be forced down nor reached with the finger. All the efforts which were immediately made by a physician of the place only forced the body further from the anus. In this condition the patient entered the service of M. Ver- neuil. There were few signs of retention, but the finger could not be made to reach the foreign body ; only with the hand on the abdomen could it be felt in the left iliac fossa. It was so high that linear proctotomy could give no assistance, and there- fore laparotomy was decided upon. The plan of operation was the following : Through a small abdominal incision to search for the sigmoid flexure, in which the body was probably lodged ; to draw the sigmoid flexure outward, and, if healthy, to incise it, remove the body, sew up the gut and replace it in the abdo- men. If, on the contrary, it was diseased, to stitch it to the abdominal wall, and make an artificial anus. But the foreign body was so fixed in the upper part of the rectum, with its long axis from behind forward, as to be immovable, and by reason of this immobility of the rectum, the former plan of operation had to be abandoned. Fortunately, it was possible to dislodge the body from this fixed position, and M. Lucas Championniere, who at that mo- ment practised the rectal touch, received it upon the end of his finger. While an assistant fixed the body by pressing on the 1 Prog. Med., May 15, 1880. 384 DISEASES OF THE RECTUM AND ANUS. abdomen, M. Verneuil endeavored to seize it with the forceps of Muzeux, or to tix it with a gimlet, but without success. Linear proctotomy was then resorted to, and M. Yerneuil succeeded in moving the body with one of the blades of a lithotomy forceps, bringing it down, and seizing it with another pair of strong for- ceps. The instrument slipped many times on the bark of the wild cherry wood, and it was only after many long and painful attempts, practised with a very defective stock of tools, that the foreign body was finally withdrawn. It was followed by a discharge of very foetid faecal matter and a little blood. The result of the operation, thanks to the precaution taken during the manoeuvres and the treatment subsequently employed, sur- passed all expectations. The abdominal wound healed by first intention under Lister's dressing, and a soft-rubber catheter, kept permanently in the rectum, through which chloral was in- jected every two hours, prevented any complications in that part. These four cases indicate with sufficient clearness the general rules which should guide the practitioner. The operation is applicable only to bodies high up in the rectum. The point of incision may be in the median line, over the sigmoid flexure in the left loin, or over what seems to be the most prominent point of the foreign body, wherever that may be. If the intestine is healthy, it may be closed and returned into the body. If not, an artificial anus should be made at the point of incision. It is worthy of note that all of the cases thus far recorded have ended in recovery. Note. — The following cases have come to my notice within the past year: Russell, G. — Case of intestinal obstruction caused by a wine-bottle; removal by abdominal section ; death. British Medical Journal, May 28, 1881. Gentiliiomme. — Corps etranger du rectum deplace et arrete dans l'S iliaque ; ex- traction par l'abdomen, suture de l'intestin; guerison. Union Med., Septembre, 1881. BrLLROTii. — Foreign body in the sigmoid flexure. Laparotomy. Enterorraphy. Death. Wiener Med. Woch., Nos. 3, 5, 7, 1881. In this case the foreign body (a pencil, 7 ctm. long) had been in the body three weeks, and the patient was in collapse from perforation at the time of the operation. CHAPTER XIV. PRURITUS ANI. Pruritus generally a Symptom of some other Disease. — Description. — Causes. — Rela- tion of Internal Haemorrhoids, Fistula, Worms, Parasites, and Eczema to Pruri- tus. — Treatment of Eczema. — Herpes and Erythema. — Constitutional Conditions causing Pruritus. — Dependence upon Constipation. — Treatment of Constipation. — General Treatment of Pruritus. Pruritus ani — itching at the anus — is generally a symptom of some other disease such as haemorrhoids or eczema, but it is often present in a marked degree when no cause for its exist- ence can be discovered. It is an exceedingly painful and an- noying affection, and one which will often tax the powers of the surgeon to the utmost for its cure. It is met with in both men and women, and seems to be dependent upon no particular gen- eral state, being found in rich and poor, the overfed and under- fed, the professional man of nervous constitution and the la- borer, alike. The disease is marked by an itching at the anus which is more or less constant, but is generally worse after the sufferer has become warm in bed at night. The itching causes an at- tempt at relief by scratching, and the scratching, though it may be controlled during the day, is generally practised uncon- sciously during sleep to an extent which causes laceration of the skin. The itching in bad cases, even when constant, is marked by exacerbations and remissions, and may cause an amount of suffering which is simply unbearable. The disease is attended by certain changes in the appear- ance of the parts. The skin becomes thickened and parchment- like (Fig- 88), or else eczematous and moist from exudation. It may be red from the scratching, or there may be quite a char- acteristic loss of the natural pigment of the anus. In the latter case the skin becomes of a dull-whitish color, and this will oftener be noticed where the disease is of long standing and severe. The exudation may be very marked where the itching 25 .°»86 DISEASES OF THE RECTUM AND ANUS. is slight, and maybe attributed by the patient to trouble within the rectum instead of to its real source. Associated with the changes in the skin it is not at all uncommon to find one or several fissures. Causes. — The cause of pruritus may sometimes be easily discoverable, and in such cases a cure rapidly follows its re- moval. For example, pruritus is often a symptom of internal haemorrhoids, and is easily and effectually cured by their re- moval. Again it is often a symptom or complication of a fis- tula with a small external opening, such as may easily be over- looked in a cursory examination ; and is cured by the ordinary ^P^^fe Fig. 88. — Thickened Condition of the Skin in Pruritus. (Esmarch.) operation and the consequent cessation of the discharge upon which it depends. It is often dependent upon the presence of the oxyuris vermicularis in the rectum, and in every case these should be carefully looked for. If they are present they may generally be seen like small pieces of white thread between the radiating folds at the margin of the anus, especially at night when the itching begins. They may generally be eradicated by certain simple measures, the best known of which is an enema of lime-water, or of carbolic acid, 3 j. ; glycerin, | j. ; and water, 3 vij., injected after each passage. Turpentine and tincture of iron may be used for the same purpose, and are both very effectual ; but the parasites are much more easily removed in children than in adults, and I have had one case which was ex- PRURITUS ANI. 387 ceedingly intractable, and in which I have never been able to keep the worms from returning for any great length of time. A single examination should never be considered as proof of the absence of this parasite in an obstinate case of pruritus. Instead of a parasite located within the rectum, pruritus is occasionally easily accounted for by the presence of pediculi. In such a case the diagnosis and cure are alike easy. Again the parasite may be vegetable instead of animal, and the itching may be due to the disease known as eczema mar- ginatum. In this case the diagnosis will rest upon the finding of the spores under the microscope in the epidermis scraped from the edge of the affected spot and moistened with glycerine. The most effectual remedy for this condition is a wash of equal parts of sulphurous acid and water frequently applied with a soft cloth, and gradually increased in strength, if necessary, up to the pure acid, which latter is, however, generally a painful application, and one which will readily blister. The acid, even when diluted to a considerable extent, will blister if covered with a cloth. Strong tincture of iodine applied with a brush is also an effectual remedy in eradicating the plant. Pruritus may also be dependent upon other skin diseases, among which chronic eczema is perhaps the most common, and this is to be treated exactly here as elsewhere in the body, first by general measures directed to the constitutional state, and second, by local applications. The congestion and the thicken- ing of the skin must first be remedied, and for this purpose very hot water, compound tincture of green soap, and if necessary a solution of caustic potash, may be applied. The water, to be of any use, must be as hot as the fingers can bear, and should be applied to the part with a soft cloth and held there till it begins to cool. This may be repeated half a dozen times, but all rubbing should be carefully avoided both during the applica- tion and in drying the parts after it. This is a favorite remedy with most dermatologists ; it should be used just before going to bed, and is often in itself sufficient to insure a good night's sleep. If there be thickening of the skin from effusion, a stronger application than hot water will be necessary ; and for this the compound tincture of green soap is a good remedy ; or the so- lution of potash (gr. v.- § i.) or liquor potassse may be resorted 3S8 DISEASES OF THE RECTUM AND ANUS. to with caution. The formula for the compound tincture of green soap is the following : IJ . Saponis viridis, Olei cadini, Alcohol aa . 3* j. M. It is a much stronger preparation than the simple green soap, and also a much more disagreeable one, but it is very effectual and should be well rubbed into the part once a day. These remedies should be followed at once by soothing ointments, or lotions. A good ointment is the ordinary oxide of zinc made soft and applied gently, and one which is pretty certain to' allay itching is that made of chloroform ( 3 j.- 3 j.). This soon loses its power by the evaporation of the chloroform, and should on this account be kept in a wide-mouthed glass bottle, tightly corked, and should be frequently renewed. Another favorite application, and one which is very generally effectual, consists in a lotion of carbolic acid. The formula is : IJ . Acid, carbolic! § ss. Glycerinse 3 j. Aquas 3 iij. M. This may be applied at night, and if found to be too strong may be diluted by the patient. In a more dilute form it may also be continued for a considerable time after all symptoms have ceased. For the sake of those who have never encountered an obsti- nate case of this disease, but who are pretty sure at some time to have both knowledge and ingenuity taxed to the utmost, I will give one or two more formulas which have been found re- liable. The following comes from Allingham, and by it alone he has "seen a bad case cured in forty-eight hours : " I£. Liquoris carbonis detergens (Wright's), Glycerime aa. § j. Pulv. zinci oxidi, ( lalamin. prep aa. § ss. Pulv. sulph. precip 3 ss. Aqiue purse ad . 3 vi. M. PRURITUS ANI. 389 The part affected is to be thickly painted over with this once or twice a day and allowed to dry. The white precipitate oint- ment made soft with vaseline or glycerine is also a good appli- cation, and the following lotion, also from Allingham, will often work well in allaying irritation : IJ . Sodse biboratis 3 ij. Morph. hydrochlor gr. xvi. Acidi hydrocyanic, dil 1 ss. Glycerinse 3 ij- Aquae ad. fviij. M. This should be applied to the part four or five times in the twenty-four hours. Dr. Bulkley 1 has also recommended the following as being useful, and I have often found it so : # . Ungt. picis 3 iij. " bellad 3 ij. Tr. aconit. rad 3 ss. Zinci oxidi 3 j- Ungt. aquae ros 3 iij. M. The following prescription has also been very efficient in my hands. I am indebted for it to Dr. Salisbury : $ . Menthol 3 j. Simple cerate % ij. Oil sweet almonds % j. Carbolic acid > 3 j- Pulv. zinci ox 3 ij. M. Apply morning, noon, and night, after cleansing the parts. An ointment of chloral and camphor, a drachm of each to the ounce, is also at times effectual in allaying itching. There are two other skin diseases either of which maybe the cause of pruritus — herpes and erythema. Herpes at the margin of the anus is the same as when seen on the lips. In the latter case it heals spontaneously, in the former a dressing may be necessary. This may consist simply of a dry powder such as zinc or bismuth, or of one of the lotions already mentioned. 1 The Medical Record, December 18, 1880. 390 DISEASES OF THE RECTUM AND ANUS. Erythema will be found chiefly in fat people, where it is due to contact of the opposing cutaneous surfaces. It also is best treated by the application of diy powders, and by separating the opposed surfaces by a la} 7 er of dry sheet lint or old muslin. These are the most palpable, and perhaps also the most com- mon causes of pruritus, but there are many cases in which the cause is not so easily discoverable, because it is -a constitutional and not a local one. Where no local cause can be detected, a careful inquiry must be instituted with regard to the patient's general health and habits. If chronic constipation be present, this must first of all be overcome, for this is in itself an efficient cause for the disease. The treatment of chronic constipation is by no means a simple matter. It may be begun with a purga- tive such as three compound cathartic pills, for the sake of opening the way for future treatment, but here the administra- tion of purgatives should end, for their repeated administration is calculated to do harm rather than good, by substituting an occasional over-action for the daily one which indicates a healthy state of the intestinal tract. The following suggestions may be found of use in the treatment of this condition, which is one that must be overcome at the commencement of the treatment of any rectal affections with which it may be asso- ciated. Constipation may be due to deficient action of either the small or the large intestine, and this deficient action in either case may be the result either of deficient secretion or deficient nerve power. . Deficient secretion is very apt to be associated with hepatic disturbance, and is marked by dull headache, bad taste in the mouth, viscid secretion from the buccal glands, etc. This is a condition pretty sure to be aggravated by cathartics, for the ■ n that the temporary increase in secretion which they cause is followed by a corresponding decrease, which serves only to make the patient worse than before. For the purpose of increasing the natural secretion of the small intestine, the fruits containing citric acid, such as oranges, and other fruits, such as figs and apples, when the patient can digest them, all serve a good purpose. Water is also an excellent remedy, and two tumblerfuls of it taken in the morning will often be very beneficial. To it may be added a slight saline, which decreases its capability for absorption ( 3 ss.-O.i.), and, therefore, increases PRURITUS ANI. 391 the peristalsis ; and the addition of a single grain of quinine is said to greatly increase the effect. 1 This treatment, if patiently persisted in for a few weeks, will generally be followed by a good result. Deficient innervation will be found in most cases of consti- pation in old people, people of sedentary habits, and those who have little exercise. It is generally attended by deficient action of the skin and a sallow complexion. In such cases water will be found only to weaken the digestive power, unless it can be combined with a different mode of life and abundance of out- door exercise. Cold bathing, however, cold against the spine and abdomen, plenty of exercise in the open air, and nux vom- ica, will generally be found to give relief. In constipation dependent upon the large intestine, the trouble will generally be found to be due to deficient innerva- tion rather than to any lack in the secretion. It is best treated by keeping the rectum empty, by nux vomica, or belladonna in doses sufficient to cause dryness of the throat, and by electric- ity. The latter should be in the form of the Faradic current, one pole being placed over the spine and the other passed up and down along the track of the colon. Infantile constipation may be due, as pointed out by Jacobi, to the disproportionate length of the sigmoid flexure. In chil- dren it is not unusual to find two, or even three, flexures in the lower part of the colon, in which the fseces may remain until they become hard and friable, and when such an anatomical formation is associated with a deficiency of the intestinal secre- tion, a very obstinate constipation, and even impaction, may result. In such a case oatmeal is to be given in preference to tapioca, rice, or barley, and with it an abundance of water. Purgatives should never be administered except in extreme cases, enemata being preferable. 8 Faecal accumulation is not very uncommon in young children. In chronic constipation, the patient should first of all be in- structed to have a regular time for the daily evacuation, and the best time for this purpose is immediately after breakfast. The time being fixed, the patient is to go to the closet whether the desire for a passage be present or not, and pass a certain time upon the commode. I generally recommend the time imme- 1 Thompson, New York Medical Record, May 5, 1877. 2 New York Medical Record, September 25, 1880. 392 DISEASES OF THE RECTUM AND ANUS. diately after the morning meal for this purpose, because the breakfast itself often acts as a stimulant to this function, espe- cially in those in the habit of taking a morning cup of coffee. If the patient be a man in the habit of smoking, the first few whiffs of smoke often act in the same way ; and there are many men to whom the morning cigar or cigarette is an essential to the daily evacuation. In such a case it must be a very decided opponent of the weed who would object to its continuance in moderation. If the plain cold water taken in the morning has no effect, the mineral waters may be tried in its place with great advan- tage ; and the patient may select the one most agreeable to the taste and which most effectually accomplishes the desired end. The morning meal may consist of whatever the patient most desires, but a dish of oatmeal or coarse cracked wheat and milk should alwaj^s be an essential part of it. A laxative bread may be made of equal parts of coarse Scotch oatmeal, whole wheaten flour, and coarse ordinary flour, with yeast or baking powder. This may be eaten once or twice daily. 1 I have almost always found that where perfect regularity in the daily life with regard to eating and exercise can be estab- lished, the function of defecation will also be performed regu- larly, provided the diet be plain and rather coarse in quality. To have a copious, well-formed evacuation, it is necessary, first of all, that the diet should be composed of substances which leave a considerable quantity of waste, and chief among these are the coarser grains and the vegetables. In women a certain regulated amount of daily out-door exercise should be insisted upon, in spite of all excuses and professions of disability. If necessary, this may be small at first, and gradually increased ; and in a woman who has lost the habit, and, perhaps, almost the power of walking, considerable tact and firmness on the part of the physician may be required to carry out this part of the treatment, but it will be found to be care well spent. In addition to these dietetic and hygienic rules, certain med- ication may and often will be found necessary. This should be of the mildest possible kind which will accomplish the object. A pill which I have found to act very effectually and pleas- 1 W. H. Taylor, Lancet, May 31, 1879. PRURITUS ANI. 393 antly under these circumstances is made after the following formula : # . Pulv. aloes soc gr. iss. Ext. nucis vom gr. ss. M. Ext. belladonnas gr. One of these should be taken at bedtime, and will generally be followed by an easy passage on the following morning. If this does not w T ork satisfactorily, various other remedies may be substituted, amongst the best of which is the compound lic- orice powder, the rhubarb and soda mixture, or the dinner pill ; the object being to find one among the many laxative prepara- tions which, without causing pain or diarrhoea, will give an easy and natural evacuation of the bowels once every day. The use of enemata for chronic constipation should not be commenced till all other means have failed, for the reason that when once the bowel has become accustomed to this form of stimulus it will be found very difficult to discontinue its use. In some cases, however, their employment may be a necessity, and they are always much less harmful than purgatives. In- stead of the ordinary enema of soap and water, the introduction of a harmless foreign body into the rectum will sometimes ex- cite peristalsis. Small fragments of soap or of candles are pre- ferred by many for this purpose to fluid injections. In cases where enemata have lost their power from prolonged use, my own practice is to resort to the use of a long rectal tube two or three times a week ; but this should not be trusted to the patient for fear of accidents. Most patients will find it impossible to introduce them easily, and will not care to make the attempt. With a long flexible tube of small calibre a pint or more of water may easily be thrown into the sigmoid flexure and colon, and the bowel be thoroughly emptied. Another not infrequent cause of pruritus is derangement in the function of the liver. This may or may not be associated with the constipation which we have just considered. It must be treated by general dietetic measures, the dilute mineral acids, occasionally by doses of podophyllin, active out-of-door exer- cise, and cold and friction applied to the hepatic region. In women uterine disorders must be looked for and cured before very much will be accomplished in the treatment of pruritus ; 394 DISEASES OF THE EECTUM AND ANUS. and in women also the urine must be examined for sugar in obstinate cases, for diabetes will sometimes give rise to incura- ble pruritus. In case none of these causes can be found to account for the itching, errors of diet must be searched for, and corrected when found. Anything like excess in smoking or in alcoholic drinks will keep up the disease, and in men these habits must be care- fully regulated if indulged in at all. The disease will some- times be encountered in stout full-blooded persons who live well and perhaps incline to the gout, and who show no other signs of disorder. In such, active exercise and plainer living, with cold bathing of the part at night and morning, and the use of a lotion of carbolic acid, will often effect a speedy cure. On the other hand, the disease may be present in exactly the opposite class of persons, the overworked and worried professional or business man, and it is in this class of cases alone, where the itching seems to be purely a nervous symptom, that arsenic is indicated. It may be combined with quinine and cod-liver oil, and carried up to its full physiological effect. As a relief for the intolerable itchings at night, Allingham recommends the introduction of "a bone plug shaped like the nipple of an in- fant's feeding bottle, and with a circular shield to prevent its slipping into the bowel." Its benefit is explained by the pres- sure it exerts upon the terminal filaments of the blood-vessels and nerves of the anus. In this way then the physician must undertake the cure of a case of pruritus ani ; and not by the administration of any single lotion or ointment to allay the itching, which is but the symptom of some local or general condition. In every case the cause must be found and removed if success in the treatment is to be gained. I know of no disease of the rectum or anus in which there is a better chance for the practitioner to show his general knowledge and skill. If a case be undertaken in this way, and the treatment be intelligently followed by both doctor and patient, a cure may generally be effected ; sometimes in a veiy few days, but at others only after prolonged effort and many discouragements. The prognosis should, therefore, be guarded at the outset lest the patient be led to expect a too speedy relief, and in some cases, in spite of the best of care, the disease will frequently return and the patient can scarcely at any time consider himself as perfectly cured. CHAPTER XV. SPASM OF THE SPHINCTER.— NEURALGIA.— WOUNDS.— HEMORRHAGE.— RECTAL ALIMENTATION. Spasm without other Disease. — Cases. — Authorities. — Symptoms. — Treatment. — Neuralgia. — Cases. — Diagnosis. — Treatment. — Wounds. — Complications. — Spon- taneous Rupture. — Treatment of Wounds. — Haemorrhage from the Rectum. — Naevus of the Rectum. — Alimentation. — Physiology of Absorption. — Nutritive Enemata. — Nutritive Suppositories. Spasm of the sphincter without the presence of any other rectal affection is undoubtedly rare. Its general character may per- haps best be shown by the citation of the following cases. Case. Spasm of the Sphincter. — Physician, aged twenty- eight. The patient was a man decidedly given to thinking about his own health, and though generally well, not at all robust. He came to me complaining of a sense of discomfort about the rectum, accompanied by difficulty in defecation. The discomfort seldom amounted to actual pain, and he had noticed that when he was away on his summer vacations he was always better and in fact perfectly well. Nevertheless, the trouble in defecation had increased so markedly during the past few months that he was fully convinced that he was suffering from actual stricture. An attempt at digital examination caused the most exquisite suffering, forcing the patient to cry out in agony, and yet there was entire absence of any lesion. The treatment was based upon the fact which he had himself noted, that when his general condition was improved the local trouble ceased ; and the patient was cured by purely general measures looking toward the building up of the system. Case. Spasm of the Sphincter. — Professional man. Aged thirty. In this case also the only symptom complained of was pain on defecation, sometimes severe, sometimes slight. The history given pointed so strongly toward the existence of a fissure that 396 DISEASES OF THE RECTUM AND ANUS. I etherized the patient, fully expecting to cure him by stretch- ing the sphincter. He was entirely cured by stretching the muscle, but, to my surprise, a most careful examination re- vealed no disease ; and, being dubious myself about the exis- tence of spasm without fissure, the examination was a very thorough one. This patient was also a man of sedentary habits and of rather a nervous character. The following case is taken from Syme, and is characterized by him as a remarkable instance of the affection. 1 "I was asked to see a gentleman, about sixty years of age, who stated that, a few weeks before, after sitting out a long debate in the House of Commons, he had felt extreme difficulty in evacuating the bowels, having previously for several years experienced more or less uneasiness from this source ; that he had consulted a physician and surgeon in London, who prescribed laxatives without affording relief ; and that his complaint had continued so as at length to confine him to bed. I proposed an enema, which was at once objected to on the ground that the anus would not admit the smallest-sized tube. Suspicion being thus excited, the anus was examined and found to present the char- acteristic features of spasmodic stricture. Having explained my views of the case, I gently insinuated the narrow sheath of a bistoury cache, which I happened to have with me, and then expanding the blade, withdrew it, so as to make an incision on one side of the orifice. A copious stool immediately followed, and the patient was at once completely relieved from his com- plaint." With regard to this much disputed affection, a citation of authorities may be useful. Syme 3 believed that spasm existed as an independent condition without morbid change ; that, though there could be no doubt that spasm and fissure fre- quently existed together, it was not reconcilable with the facts met with in practice, that spasmodic stricture was always of secondary origin and dependent upon the fissure. He says : " In a considerable number of cases, I have found the sphincter firmly contracted without any perceptible fissure or abrasion of the surface." Mayo describes spasm of the sphincter as a kind of cramp which often comes on suddenty, sometimes at night daring 1 Diseases of the Rectum. Edinburgh, 1838, p. 138. 2 Loc. cit., p. 134. SPASM OF THE SPHINCTER. 397 sleep. The paroxysms may occur daily or two or three times a year; and the attack may come gradually and cause uneasiness for two or three days, and then pass away, or its coming and going may be sudden. He says: "There are cases in which the disease produces long-continued and permanent suffering ; in which the anus becomes permanently contracted and hard- ened, constituting, therefore, a permanent stricture, and gen- erally combining both permanent and spasmodic contraction. The motions are passed with an effort and with pain, and all the common symptoms of stricture of the rectum are pres- ent." Allingham * says : " Spasm of the sphincter has been said to be the 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 im- paction, spasm of the sphincter always exists ; in some in- stances to such a degree that, when the patient strained, I have observed the anus protruded like a nipple, and an injection re- turned in a fine stream as if coming out of a squirt. I have certainly met with cases of idiopathic spasm of the sphincter usually in elderly, nervous single women, and though no im- paction was present, costiveness was." Quain 2 concludes that "where pain, brought on by faecal evacuations and continuing after them, happens to be pres- ent, the fault — the morbid condition — is not in the sphincter, but in the skin or mucous membrane covering it, and that the division of the muscle is not required in order to remove the patient's suffering." In other words, that spasm is always de- pendent upon fissure. Boyer 3 treats of "constriction with fissure" and " constriction without fissure." Dupuytren* says: "The gravity of this affection (fissure) depends chiefly on the painful spasm of the sphincters ; the fissure is only an accident, as is proved by the existence of painful spasm without fissure, which, according to well-known surgical authorities, is found in proportion to the other of one to four." And, " the spasmodic constriction is the true lesion, 1 Op. cit., p. 210. 2 The Diseases of the Rectum. London, 1854, p. 167. 3 Traite des Maladies Chirurg., etc., fourth edition, t. x. , p. 139. 4 Legons orales de Clinique Chirurg., t. iii., p. 284. 308 DISEASES OF THE RECTUM AND ANUS. and the fissure only an epiphenomenon." Sir B. Brodie 1 held the same views. The symptoms of spasm of the sphincter are pain on defeca- tion and for a time after ; more or less uneasiness about the anus, especially when sitting ; fulness in the perineum ; often more or less trouble with the bladder, as shown by frequent micturition, sometimes attended by smarting in the urethra and constipation. The disease is generally attended by exacerba- tions and remissions. A digital examination of the anus is always painful, and the contraction may be so great as to leave hardly a trace of the anal orifice. Any anxiety or distress of mind, a generally irritable nervous condition, and everything which has a tendency to irritate the rectum, or the parts around, will aggravate the complaint. It may easily be confounded with the affection next to be described, neuralgia, but is gener- ally distinguishable from it by the marked dependence of the pain upon the act of defecation, which is not seen in neuralgia without spasm. The treatment consists in attention to the general health of the patient, in allaying any nervous excitement, in the admin- istration of a cathartic to empty the bowel when the spasm is present, and in anodyne injections, such as, for example, twenty drops of laudanum in an ounce of water. Suppositories may cause renewed irritation. Even in the more aggravated form, the disease will often yield to such measures as this, but if it does not, a cure may always be effected by forcible dilata- tion of the sphincter under ether. If the patient will not sub- mit to this, the next best thing will be found to be the introduc- tion and retention of a bougie. Neuralgia. — Neuralgia of the rectum is generally met with in nervous people, especially females, such as are subject to neuralgia in other parts of the body. The following cases show its general character. Case. — Professional man, aged forty-nine. The patient was slight and pale from sedentary habits, but was generally well. Thirteen months before consulting me he was operated upon for fissure, and after the operation he had for some time been entirely well, but he now has what he describes as a dull, wear- ing pain in the rectum, coming on while at his daily work, last- 1 Lectures on Diseases of the Rectum. London Medical Gazette, vol. xvi., p. 26. SPASM OF THE SPHINCTER. 399 ing a longer or shorter time, sometimes all day, but generally passing away after lie has reached his home and become quiet and rested. He has noticed that the pain has a direct connec- tion with the state of his general heath, and that, when he is away from his work and rusticating, he is entirely free from it. The pain is no greater at the time of defecation than at any other, and is never so severe as to be unbearable. A careful ex- amination of the part failed entirely to show any lesion. Case. — Woman, aged sixty-five, married. This patient had been treated for fissure, for ulceration, and for coccygodynia, and had ref used to submit to excision of the coccyx. Her gen- eral health was fair, but there was decided gastro-intestinal dis- turbance. The pain of which she complains has been present for about eighteen 'months. She suffers chiefly when sitting, sometimes finds it impossible to lie upon her back, and is apt to have a sharp twinge when she starts suddenly from her chair. The pain is no worse at defecation, is not increased by pressure upon or movement of the coccyx, and is entirety unconnected with any lesion of the rectum or anus. The greatest sensitive- ness to touch seemed to be located well within the sphincter, upon the posterior wall of the bowel. There was enlargement of the womb and misplacement. From these cases, which are both good examples of mild forms of the affection, it is evident that the disease may vary greatly in its severity. In some persons it will cause the same suffering as the most intense neuralgia elsewhere. The pain is apt to be paroxysmal, but may be continuous, and is indepen- dent of the act of defecation. In cases of well-marked period- icity, a malarial element should be looked for, and the disease may be a. manifestation of the gouty diathesis. In the former case, quinine, and in the latter, colchicum maybe of the greatest service. In all other cases the treatment will often be found unsatisfactory, and is to be conducted on general principles. The first care should be for the general health, the second for the regularity of the bowels, and after this, local applications of cold water, ointment of belladonna (3 ]'•- ! j.), and blistering over the sacrum may be tried. Besides this local treatment the case must be managed exactly as would be a case of neu- ralgia in any other part. The diagnosis from coccygodynia and from spasm must both be made with care. 400 DISEASES OF THE RECTUM AND ANUS. Wounds of the Rectum. — Wounds of the rectum may be either contused and lacerated, or incised. The latter most fre- quently result from surgical operations, and may be intention- ally inflicted, as in the operations for fistula or for the removal of tumors, or the result of accident, as in the operation for stone. Contused and lacerated wounds are generally the result of accident, and perhaps the most frequent cause of such an in- jury is the perforation of the bowel with an enema tube, a bougie, or a urethral sound. The gravity of this accident will depend upon two factors — whether the perforation of the bowel is above the peritoneum, and whether the enema has been deposited in the perirectal tissues. The latter complica- tion will be followed by abscess and peritonitis, and will re- sult either in death or in stricture and fistula. If the wound be uncomplicated by the injection, the mere puncture may heal spontaneously. It is oblique from below upward, and this greatly favors spontaneous healing without faecal extra- vasation. Esmarch has met with four cases of this injury, none of which were fatal though attended by much local trouble. Vel- peau describes eight cases, six of which ended fatally. Passa- vant observed five cases, one fatal. Chomel has had two fatal results. There are two preparations in St. Bartholomew's Hos- pital showing the results of this accident, one in a man, the other in a child ten years of age (Esmarch). Besides these most common injuries, many others may be enumerated. The person may fall upon a sharp body, as the point of an umbrella (Bushe 1 ), may be caught upon the horn of an animal (GJ-undrum, 3 Ashton), or may be impaled upon a spike (Esmarch :, j. In such cases, the accident may be immediately fatal from collapse, and the wound in the rectum may be complicated by a wound of the peritoneum, or of any of the adjacent organs. The body which has done the injury may also be so firmly im- planted as to require great force and an anaesthetic for its re- moval. The rectum is not infrequently lacerated in childbirth, and although such wounds are generally of slight extent, Bushe 4 relates a case in which the child's head was passed through the 1 Op. cit., p. 80. '■'Detroit Lancet, October, 1879. 'Op. cit., p. 43. 'Op. cit., p. 80. SPASM OF THE SPniNCTEPw 401 arms. It has also happened that in a violent effort to expel a mass of hard faeces, the rectal wall has given away. Mayo ' re- lates one such case in a woman of forty, in whom the rupture was in the recto-vaginal septum, about two inches within the bowel. Ashton 2 reports a similar case, and Bushe 3 another. Such a rupture may be either vertical or transverse, will be marked by sharp pain at the moment of the accident, and will be followed by a discharge of blood. It is doubtful whether it ever occurs without previous disease of the wall of the bowel. The consideration of gunshot wounds comes more properly within the scope of military surgery. They are always compli- cated with injuries of other parts, and are generally fatal from extravasation of urine or faeces. The complications which may attend a wound of the rectum have already been hinted at. They are hemorrhage, either primary or secondary ; faecal infiltration ; purulent infiltration ; peritonitis ; emphysema ; hernia ; invagination ; and later, stric- ture and fistula. When faeces are forced out of the rectum into the adjacent tissue, diffuse inflammation and gangrene will probably result, and the condition must at once be met by free incisions and free drainage, as has been described in the chapter on abscess. The danger of faecal infiltration may be lessened by a diet which shall prevent fluid passages, and by the free use of opium. A dilatation or a free division of the sphincter is also to be recommended, so that a free outlet may be accorded to the contents of the bowel. Emphysema, as a result of a perforation, is generally con- fined to the perinaeum, but may be diffuse. 4 It is very apt to be fatal from diffuse inflammation and septicaemia, due to the putrid nature of the gas, and is to be met by free incisions. Wounds of the bladder or urethra communicating with the rectum are to be met by providing for the free issue of the urine. This may be done by catheterism, by aspiration, or by free division of the sphincter. Where none of these complications exist, a fresh wound of the rectum may close by first intention, and an effort should always be made to secure this by rest in bed, by emptying the bowel, and keeping it empty by frequent washings with water, and by the use of opium. Healing by granulation will, how- •Op. cit., p. 13. 2 0p. cit., p. 152. 3 Op. cit., p. 69. * Lancet, January, p. 89. 1860. 26 402 DISEASES OF THE RECTUM AND ANUS. ever, be the rule. In some cases, such, for example, as lacera- tion in childbirth, sutures may be at once applied. HcBmorrliage. — Bleeding from the rectum, as has already been shown, is a very common symptom of disease of the part and is usually easily controlled ; but the following cases illus- trate exceedingly rare forms of trouble. Case. Ncevus of the Rectum. — Mr. E. T. Barker reported, at a meeting of the Royal Medical and Chirurgical Society, 1 the following case of naevus of the rectum in an adult, which proved fatal from repeated haemorrhages. The case was the only one known to the author, though in the discussion Mr. Howard Marsh spoke of another in a girl, aged ten, under his care, in the Children's Hospital. In Mr. Barkers case the earliest symptom was an attack of diarrhoea accompanied by great loss of blood, and the whole history of the case was marked simply by these two symptoms alternating with occa- sional constijDation, there being no particular pain or discharge at any time. The diagnosis was made by artificial light and a large vaginal speculum. The mucous membrane of the bowel was seen to be marked by smooth longitudinal folds, mottled with a peculiar purplish tint, and upon these were three shallow ulcers from which the blood flowed freely. The patient died finally from repeated haemorrhages, and the autopsy revealed a thickened condition of the lower four inches and a half of the bowel, which was due to the naevoid growth, on the rugae of which were the three shallow ulcers mentioned. In Mr. Marsh's case the child had suffered, since the age of two, from repeated severe haemorrhages. Examination revealed a naevoid growth completely surrounding the lower end of the bowel. This was treated by several applications of Paquelin's cautery, which relieved but did not cure the condition. "While speaking of haemorrhage from the rectum, it may be well to refer to two cases of bleeding which have recently been reported in the New York Medical Record. The first (New York Medical Record, September 27, 1879) is by Dr. Manley, of Law- rence, Mass. It occurred in an apparently healthy infant, three days old, and ended fatally. A post-mortem examination showed that the blood came from an opening in one of the rectal veins about three inches from the anus, which admitted of the introduction of a bristle. 1 The Lancet, April 14, 1883. SPASM OF THE SPHINCTER. 403 The second case (New York Medical Record, January 17, 1880) is reported by Dr. McGuire, of Salem, Ohio, and is very similar, the child being about the same age. Notwithstanding- suitable treatment by styptic applications, this also terminated fatally ; but no autopsy was obtained, and the precise source of the haemorrhage is unknown. Alimentation by the Rectum. — The fact that certain sub- stances may be absorbed into the general circulation through the mucous membrane of the rectum has been abundantly proved by physiological experiment and clinical experience. The close anatomical resemblance between the inverted folli- cles of the rectum and the intestinal villi render an analogy in function extremely probable without experimental proof ; but such proof is easily obtainable. A solution of salt, in the pro- portion of one part to eighty of water, injected into the rectum, will disappear completely in the course of an hour — so com- pletely that an evacuation at the end of that time will be found to contain no more than the usual quantity. 1 The fluid extract of rhubarb may be detected in the urine in about an hour after being injected into the rectum, by the characteristic red color caused by the addition of caustic potash. 2 Bouisson, 3 after injecting beef-tea into the rectum, found the lacteals charged with fluid. Savory, 4 in his experiments on the relative rapidity of this absorption by the stomach and rec- tum, found that strychnia in solution acts more quickly by the rectum, but that in powder the relation was reversed. Quinine should be given in larger doses by the rectum than by the mouth, while chloral and belladonna are readily absorbed by the former. Curare, on the contrary, acts more quickly by the rectum (CI. Bernard). Cubebs and copaiba both act equally well by the rectum ; and water charged with sulphuretted hy- drogen gas is rapidly eliminated in the dog by respiration, as may easily be proved by the usual test with a salt of lead. The fact of absorption being admitted, the next question is as to the power of digestion before absorption, and upon this 1 Liebig : Animal Chemistry. 2 Smith : Supplementary Rectal Alimentation, and Especially by Defibrinated Blood, as Applicable to a Large Range of Cases in which Nutritive Enemata have not heretofore been Employed. Read before the New York Academy of Medicine, Feb- ruary 20, 1879. 3 Diet. Encyc, Art. Rectum. * Gaz. Med., 1864. 404 DISEASES OF THE RECTUM AND ANUS. point there has been considerable discussion of late, and much difference of opinion. The theory that the follicles of Lieberkuhn may take on a vicarious action, and secrete a digestive fluid under the stimulus of albuminous food placed in contact with the epithelium, has its upholders, but has never been absolutely proved. 1 Another theory is that food introduced into the rectum ex- cites secretion by the gastric and intestinal follicles, and that, in the absence of food in the stomach, the digestive fluids thus secreted pass down into the rectum and there act upon the in- jected materials. 2 Still another theory is that, instead of digestive fluids de- scending to act upon the food, the latter ascends to be acted upon by the fluids in the small intestine, and is there fitted for absorption. 3 This theory has grown out of certain facts which have recently come to light regarding the reversed peristaltic power of the bowel. Injected matters, such as blood and milk colored with madder, may be found, on post-mortem examina- tion, evenly distributed over the coats of the intestine for a considerable distance above the rectum, and this is in itself a simple argument in proof of a reversed action of the bowel. But there are are many stronger ones. Dr. Battey, in an arti- cle on the "Permeability of the entire alimentary canal by enema, with some of its surgical applications," 4 details some experiments of his own by which he succeeded, in the cadaver, in passing an injection from the rectum through the whole length of the digestive canal, and out of the mouth. He also 1 C. H. Stowell : Is Food Digested in the Rectum ? The Medical Advance, Janu- ary, 1879. * A. Flint: Trans. N. Y. Acad, of Med., February 20, 1879, and "Cases Illustrative of Rectal Alimentation, with Remarks," Amer. Practitioner, January, 1878. 3 H. F. Campbell : Rectal Alimentation in the Nausea and Inanition of Pregnancy — Intestinal Inhaustion an Important Factor and the True Solution of its Efficiency. Trans. Gynaecological Soc. , 1879. 4 Virg. Med. Monthly, vol. v., 1878. Dr. Battey makes a claim to priority in having established the " entire permeability of the canal to enema." which, though no doubt perfectly just as far as his own experiments go, is refuted in the Med. and Surg. Hist, of the War, Med., vol. ii., p. 836, foot-note, by the following references: A. Guaynerius: Tractatus de fluxibus. Cap. 2, Lyons Ed., 1534. History of a man who vomited suppository placed in the rectum. J. Matthias de Gradibus : Practicia de iEgritudinibus stomaci. Cap. 5, devomitu, fol. 213, Venice Ed., 1502 ; History of girl who constantly vomited her suppositories, even after they had been tied with a string to keep them in the rectum. Morgagni, references to numerous similar cases. SPASM OF THE SPHINCTER. 405 gives certain cases in which what he has accomplished on the dead subject has been done by nature in the living patient. In this way he accounts for the undoubted fact that patients will often complain of tasting in the mouth a substance like castor- oil which has been administered by the rectum ; and for the fact that the ingredients of an enema, or a suppository, have occasionally been actually vomited. Dr. Harris, of Milledge- ville, Ga., 1 has recentty reported a case in which clear beef-tea enemata were vomited after an operation for ovariotomy. Jaccoud records a case of faecal vomiting which occurred in his wards at the Lariboisiere, in 1867, in a young woman who was admitted with hysterical convulsions. For eight days this person, at least once, and sometimes twice, in the twenty-four hours, vomited veritable faeces, dense, solid, cylindrical, of a brown color, and with the normal fsecal odor, coming evidently from the large intestine. Jaccoud witnessed the act himself, and so also did Dieulafoy, and he characterizes it as actual defecation by the mouth. Apart from the passing disgust which followed the act, the patient ate as usual, and continued in her ordinary health, except in the absence of normal action of the bowels. All possibility of deception seems to have been rigor- ously excluded. Within a fortnight the woman was seized with grave typhoid fever and died. Careful examination of the body disclosed no mechanical obstruction whatever in the intes- tinal canal. The ileo-caecal valve was normal. 2 Fsecal vomiting is not necessarily a sign of intestinal obstruc- tion, as has been shown by Leduc. 3 In seventeen cases which he observed there was no obstruction. He believes it to be simply a sign of paralysis of the bowel, either reflex in origin or due to an extension of inflammation from the serous surface to the muscular tunic. This he thinks, taken with the action of the diaphragm, is sufficient to account for the reflux of the faeces into the stomach and their rejection by the mouth in an effort at vomiting. By one of these three explanations it is attempted to over- come the obvious physiological objections to rectal alimenta- tion which arise from the facts that albumen is not diffusible, or 1 Quoted by Campbell, loc. cit. 2 Van Buren : On Phantom Stricture, etc. Amer. Journal Med. Sci., October, 1879. 3 Du Vomissement Fecaloi'de dans les affections du peritoine (sans obstacle meca- nique au cours des matieres). These de Paris, 1881. 406 DISEASES OF THE EECTUM AND ANUS. if so at all, only very slowly and in very small quantity ; and that to be absorbed it must first be changed by digestion into albuminose. Another and very practical way of overcoming the obstacle has been suggested by Dr. Chadwick, 1 which consists in placing the enema directly into the small intestine by means of an aspirator — a procedure which might be considered as not unattended with danger. Michel 2 has found the obstacle in- surmountable and has, therefore, come to a conclusion unfavor- able to the absorption of the nutritive matter of the substances injected. The theoretical difficulty of the digestion of albuminoid sub- stances has been practically overcome in a very simple manner, which is nothing more or less than artificially digesting such substances, either before or after their administration, by mix- ing with them a certain quantity of pepsin or freshly prepared pancreas. Catillon 3 has performed the following instructive ex- periments in this connection. He fed two dogs for two months with injections of eggs. The first had eggs only and lived with difficulty and with considerable loss of weight ; the second had glycerine and pepsin mixed with the eggs and lived in an ap- parently normal manner, the weight and temperature remain- ing constant. After thirty-seven days the pepsin was stopped, when the animal began to lose weight and the temperature fell 3° Fahr. The conclusion is plain that for nutrition the diges- tive ferments must be associated with the food, or in other words, that they must be transformed into peptones. In an- other series of experiments the same author has demonstrated that the same result is obtained by peptones prepared artifi- cially. There would seem to be no doubt, in the light of the abun- dant clinical evidence which has now been accumulated, that life may be supported indefinitely, without loss of weight, by the proper administration of properly prepared enemata. Flint * refers to one case in which life was so sustained for fifteen months, and in which the feeding had been mainly of this kind for five years. For the convenience of the practitioner, the following for- 1 Amer. Jour, of Obstet., viii., November, 1875. 2 Gaz. Hebdom., 1879. 3 Meeting of French Ass. for Advancement of Science at Rheims, 1880. Abstract in Brit. Med. Jour., p. 485, September 18, 1880. 4 New York Med. Record, p. 56, 1878. SPASM OF THE SPHINCTER. 407 mulse for nutritive enemata have been collected. The first is the one used by Mayet ' and approved by Brown-Sequard. 2 Take of fresh pancreas of the ox from one hundred and fifty to two hundred grammes, and of lean meat from four hundred to five hundred grammes. Bruise the pancreas in a mortar with tepid water at a temperature of 37° C, and strain through a cloth. Chop the meat and mix it thoroughly with the fluid which has thus been strained after separating all the fat and tendinous portions. Add the yolk of one egg. Let stand for two hours and administer at the same temperature after having cleansed the rectum with an injection of oil. This quantity is estimated by Brown-Sequard to be sufficient for twenty-four hours' nourishment, and should be administered in two doses. Where the pancreas cannot be readily obtained, the follow- ing formula may be found useful. 3 To a basin of good beef-tea add half a pound of lean, raw beefsteak pulled into shreds. At about the temperature of the body add one drachm of fresh pepsin and half a drachm of dilute hydrochloric acid. Place the mixture before the fire and let it remain for four hours, stir- ring frequently. The heat must not be too great or the artifi- cial digestive process will be stopped altogether. It is better to have the mixture too cold than too hot. Sometimes a little more pepsin may be needed, which may be ascertained by stir- ring with a spoon. If alcohol is to be given, it should be added at the last moment. Eggs may also be added, but should be previously well beaten. This preparation is said to be well borne for a long time. The formula of the late Dr. Peaslee was as follows : Crush one pound of beef-muscle fine, and add to it one pint of cold water. Allow it to macerate three-quarters of an hour and then raise gradually to the boiling-point. Allow it to boil two minutes and no more. The favorite injection of Dr. Flint is milk §ij., whiskey §ss., and the half of an egg. This head- ministers every three hours, day and night. But these simple enemata, no matter what their merits may be or may have been in the past (and we are inclined to wonder whether all at- tempts at alimentation, before the admixture of pancreas was thought of, have been as useless as Catillon's experiments 1 Gaz. Hebdom., November 21, 1879. 2 Ibid., November 14, 1879. 3 Rennie : Case of severe cut throat ; with some remarks on the administration of nutritive enemata. Lancet, October 22, 1881. 408 DISEASES OF THE RECTUM AND ANUS. would indicate), are now generally replaced by those of artifi- cialty digested meat. In the } r ear 1878 many experiments were made in New York with defibrinated blood as an enema, and the conclusions reached were embodied by Dr. A. H. Smith in the paper al- ready referred to, and were as follows : " 1. That defibrinated blood is admirably adapted for use in rectal alimentation. "2. That in doses of sixty to one hundred and eighty grammes (two to six ounces) it is usually retained without any inconvenience, and is frequently so completely absorbed that very little trace of it can be discovered in the dejections. "3. That administered in this way once or twice a day it produces, in about one-third of the cases, for the first few days, more or less constipation of the bowels. "4. That in a small proportion of cases the constipation persists, and even becomes more decided the longer the enemata are continued. "5. That in a very small percentage of cases irritability of the bowels attends its protracted use. "6. That it is a valuable aid to the stomach whenever the latter is inadequate to a complete nutrition of the system. "7. That its use is indicated in all cases not involving the large intestines, and requiring a tonic influence which cannot readily be obtained by remedies employed in the usual way. "8. That in favorable cases it is capable of giving an im- pulse to nutrition which is rarely, if ever, obtained from the employment of other remedies. "9. That its use is wholly unattended by danger." However useful and nutritious these enemata may be, there is one practical objection to them which I have occasionally met and have been unable to overcome. The sight of the blood, its administration, and its subsequent voiding are not calcu- lated to impress the mind of a nervous and delicate lady pleas- antly — on the contrary, they sometimes excite the most pro- found disgust. No one form of enema should be continued for too long a linn, and as a rule, patients will be found to thrive best upon an alternating diet of milk and egg, with preparations of beef and pancreas, alcohol being given as it is indicated. The rec- luni proper will seldom accommodate more than six ounces of SPASM OF THE SPHINCTER. 409 fluid, and this is the usual quantity for an enema ; but the sig- moid flexure will hold much more than this ; and for myself, I much prefer what may be called the colonic to the rectal method, because the injections are better retained, cause less irritation, ■ may be given in larger quantity, and hence need not be so often repeated. The best apparatus for this purpose is a small- sized, soft-rubber, flexible rectal bougie, the end of which will accommodate the smallest end-piece of the ordinary Davidson syringe. This should be well oiled, and the fluid to be injected should be forced through it once or twice till it is well warmed and the air is entirely forced out. The tube is introduced into the sigmoid flexure after the syringe has been connected. In this way, all over-distention of the rectum and consequent desire of the patient to immediately evacuate what has been ad- ministered is avoided. The enema should be administered slowly, and by the physician himself rather than the nurse or relative of the patient, for the operation is one requiring judg- ment and skill, and on the success of the method depends the life of the patient in most cases. It is always well to empty the bowel by a simple enema before administering nutriment, at least once a day. With proper care in using the syringe, the rectum and sigmoid flexure will generally be found to submit kindly to this method of treatment ; but when once they become irri- table, unless the injections can be intermitted for a day or so and suppositories of opium be substituted, the treatment is practically at an end. In a few cases I have succeeded in re- establishing a tolerance by rest and careful treatment, but it is much better so to manage the case from the first that no irrita- tion be excited. An enema, for this reason, should never be administered at a lower temperature than that of the body. Dr. Spencer * has described a suppository which he recom- mends in the place of enemata. It consists of the extracted product of artificially digested meat, from which the insoluble matter has been removed, mixed with a little wax and starch. Twenty ounces of meat thus prepared may be made into five suppositories, one of which should be given every four hours. 1 Practitioner, February, 1882. INDEX. Abscess, 90 cure without fistula, 103 deep, 93 deep, causes of, 94 due to stricture, 279 early incision of, 102 horseshoe, 100 pelvic, 97 residual, 95 simulating distended bladder, 99 symptoms of superficial, 92 treatment of superficial, 92 varieties of, 91 Absence of anus, 38 of large intestine, 44 of rectum, 43 Absorption by rectum, 403 Acquired strictures, 272 Adenoma, malignant, 320 semi-malignant, 320 simple, 320 Adenomatous polypus, 216 Alimentation, rectal, 403 Allingham's ligature carrier, 117 operation, 150 operation compared with Smith's, 155 operation, objec ions, 152 spring-scissors, 120 Ampulla, 2 Amussat, operation of, 47 Anatomy, minute, of rectum, 8 of anus, 5 of external sphincter, 12 of internal sphincter, 12 of ischio-coccygeus, 13 of levator ani, 13 of recto-coccygeus, 12 of retractor recti, 12 of rectal hernia, 198 of rectum, 1 of tensor fasciae pelvis, 12 of third sphincter, 23 of transversus perinei, 15 Ano-rectal syphiloma, 229, 260 Anus, absence of, 38, 40 anatomy of, 5 attempts to establish, after colotomy, 53 closed by diaphragm, 37 development of, in embryo, 30 erectile tissue of, 5 examination of, 59 imperforate, colotomy for, 48 malformations of, 36 Anus, muscles of, 11 normal, rectum imperforate, 39 Apparatus for injections, 66 Applicator for rectum, 64 Archer chair. 62 Arteries of rectum, 16 Artificial anus, closure of, 55 Arterial hseuiorrhoid, 135 Author's speculum, 74 Barker, closure of artificial anus, 56 Benign fungus, 228 Bistoury for external haemorrhoids, 129 Bladder, rectum ending in, 42 relations of, to rectum, 4 Blind internal fistula, 110 Blood, defibrinated, for rectal alimentation, 408 Bougie, Laugier's, 72 Bougies, 70 danger of, 73 rules for passing, 72 Bodenhamer, classification of congenital malformations, 37 colonoscope, 76 Bread, laxative, 392 Brodie, case of reflex pain, 21 Brush for rectum, 64 Bushe, on valves of rectum, 27 By id, cases of colotomy, 54 Byrd's operation for closing artificial anus, 57 Calculus, projecting into rectum, 4 Callisen, operation of, 49 Cancer, 320 age of patients, 332 alveolar, 325 cases of excision, 340 colloid, 325 colotomy for, 360 diagnosis, 333, 336 diagnosis from benign polypus, 221 difficulty of distinguishing, 320 excision, 338 excision, after consequences, 345 excision, Cripp's method, 349 excision, history of, 346 excision, Maisonneuve's method, 348 excision, Volkmann's method, 346 excision, when justifiable, 345 excision without wound of sphincter, 351 forms of, in rectum, 323 412 INDEX. Cancer, general characteristics, 320 location, 332 melanotic, 328 of sigmoid flexure, excision of, 352 osteoid, 329 palliative treatment. 359 partial excision of, 361 rules for excision, 343 symptoms, 333 treatment, 337 with secondary ulceration above, '335 Capillary haemorrhoids, 134 Carbolic acid for haemorrhoids, 143 Case for rectal instruments, 65 Cauliflower excrescence, 223 Caustic treatment of haemorrhoids, 142 Cauterization of prolapse, 164 Cautery, Smith's, 154 Cellulitis, gangraenous, 100 Chadwick, on third sphincter, 25 Chair, gynaecological, 62 Chancre, 255 Chancroids, 252 Clamp and cautery, Smith's, 154 Cloquet, on valves of rectum, 26 Coccyx, excision of, in proctotomy, 47 Cock's-comb, 223 Colectomy, 352 conclusions regarding, 358 indications for, 357 statistics, 357 Colloid cancer, 325 Colon, guide to, in colotomy, 49 Colonoscope, 76 Colotomy, description of, 49 for cancer, 360 for imperforate anus, 48 histoi-y of, 48 inguinal, 48, 52 lumbar, incision for, 50 results, 315, 318 statistics, 317 Coluinnae recti, 10 Concretions, intestinal, 364 Condyloma as proof of syphilitic ulcera- tion. 259 lata, 228 vegetating, 228 Condylomata, 226 syphilitic, 227 Congenital malformations, 36 tumors, 2-'>'-> Congestion of rectum, 84 Constipation, 890 infantile, :;'.»! treatment, 390 Cup for fusing nitrate of silver, 64 CurveR of rectum, 2 Cntaneoua hemorrhoid, 129 Cysts, :.':;:; DEEP abscess, 93 causes of, 94 fistula, 110 Deep treatment, 123 Defecation, physiology of, 23 Dermoid cysts, 233 Diagnosis, difficulties of, 59 Diaphragm closing anus, 37 of pelvis, 198 Dilatation of stricture, 293 Distance of peritoneum from anus, 7 Divisions of rectum, 3 Divulsion of stricture, 295 Douglas's cul-desac, 6 Dupuytren's operation, 56 Dysenteric stricture, 273 Dysentery, 251 Eczema marginatum, 387 Elastic ligature for fistula, 116 Elephantiasis, 249 Emphysema of rectum, 401 Encephaloid, 325 Enchondromata, 232 Enemata for rectal alimentation, 406 Enterotome for fistula, 124 of Dupuytren, 56 Epithelioma, 323 Erectile tissues of anus, 5 Ergotine, injections for prolapse, 162 Erythema, c89 Esmarch, classification of congenital mal- formations, 37 Esthiomene, 249 Ether, use of for diagnosis. 61 Examination, importance of, 61 light for, 63 of rectum, 59 Excision of cancer, 338 of coccyx, 47 External haemorrhoids, 126 haemorrhoids, treatment, 132 haemorrhoids, varieties of, 128 sphincter, 12 FAECAL vomiting, 405 Faeces, control of, after destruction of sphincter, 34 diaguosis of impaction, 365 impacted, 364 Fascia, superior pelvic, 14 Ferrand, ergotine injections for prolapse, 162 Fibromata, 230 Fibrous polypus, 217 Fissure, 243 in children, 267 incision of, 266 symptoms of, 261 treatment of, 264 Fistula, 107 and phthisis, 112 cauterization of, 114 deep, 110 ' deep, treatment, 123 dressing after operation, 122 horse-shoe, 100 INDEX. 418 Fistula, internal, 110 internal treatment, 123 knife, 119 operation with gorget, 120 del vie, 110 perineal, 124 subcutaneous, 109 submucous, 109 submuscular, 109 superficial, 107 symptoms of, 109 track of, 108 treatment by incision, 118 treatment by ligature, 115 with double tracks, 109 with two internal openings, 121 Foetal inclusions, 236 Follicles of Lieberkuhn, 11 Forceps for haemorrhoids, 149, 151 Foreign bodies, injury caused by, 372 introduced per anum, 373 laparotomy, 380 prognosis, 378 swallowed, 369 treatment, 378 Foster, on physiology of rectum, 31 Fournier, on syphiloma, 229 Fungus, benign, 228 Gangrenous cellulitis, 100 Gangrene, 260 Gelatine suppositories. 82 Glandular polypus, 216 Gonorrhceal proctitis, 87 Gorget, 119 Gosselin, on third sphincter, 29 Gower, on action of sphincter, 20 Gummata, 229 Gunshot wounds of rectum, 401 Granular papilloma, 214 Green soap, formula, 388 Hemorrhage from rectum, 402 in operations, 81 Hasmorrhoid, arterial, 135 capillary, 134 external cutaneous, 129 external, varieties, 128 venous, 136 Hasmorrhoidal forceps, 149, 151 Hasmorrhoids, 126 Allingham's operation for, 150 caustic treatment, 142 curative treatment, 141 external, inflammation of, 132 external, treatment, 132 intermediate, 127 internal, 126 operation with clamp and cautery, 153 palliative treatment, 138 reduction of, 140 sloughing of, 137 Smith's operation, 153 symptomatic, 141 J Hasmorrhoid*, symptoms of, 136 treatment by carbolic acid, 143 treatment by ligature, 150 treatment when strangulated, 139 varieties, 126 Helmuth's ligature carrier, 117 speculum, 74 Henle, on third sphincter, 24 Hernia, internal rectal. 202 Kleberg's operation for rectal, 208 rectal, 182 rectal, .anatomy, 198 rectal, cases, 184-197 rectal, contents, 205 rectal, diagnosis, 206 rectal, incision of the sac, 211 rectal, inflamed, 205 rectal, irreducible, 205 rectal, sac of, 200 rectal, strangulated, 206 rectal, treatment, 207 rectal, treatment after rupture, 211 Herpes, 246, 389 Horse-shoe abscess, 100 fistula, 100 fistula, operation for, 121 Houston, on valves of rectum, 25 Houston's valves, conclusions regarding, 35 Hydratids, 236 Hyrtl, on third sphincter, 24 Impacted fasces, 364 treatment, 368 Impaction of fasces, diagnosis of, 365 Imperforate anus, colotomy for, 48 rectum, 39 operations in perinasum, 46 Inclusions, foetal, 236 Incontinence of fasces, operation for, 105 Inflamed external hasmorrhoids, 131 Inflammation of rectum, 84 Inflammatory stricture, 273 Inguinal colotomy, 48. 52 Injecting apparatus, 66 Injections into hasmorrhoids, 143 of iron in hasmorrhoids, 148 Instrument case, 65 Intermediate haemorrhoids, 127 Internal fistula, 110 fistula, treatment, 123 hasmorrhoids, 126 sphincter, 12 Intestinal concretions, 364 obstruction from stricture, 280 treatment, 292 Intestine, absence of, 44 Intussusception. 170 Invagination, 170 causes, 172 diagnosis, 175 laparotomy for, 180 statistics, 171 symptoms, 173 treatment, 176 414 INDEX. Iron, treatment of haemorrhoids by injec- tions of, 148 Irritable ulcer, 243 Ischio-coccygeus, 13 Kidney, wound of, in .colotorny, 51 Kleberg's operation for rectal hernia, 208 Knife, for fistula, 119 Kohlrausch. on valves of rectum, 27 on valvular stricture, 274 Krause, nerves of rectum, 20 Laparotomy for invagination, 180 Laugier's bougie for measuring strictures, 72 Laxative bread, 392 Levator ani, 13 coccygis, 13 Licorice powder, 139 Lieberkuhn. follicles of, 11 Ligature of haemorrhoids, 150 Light for examinations, 63 Linear cauterization of prolapse, 164 Lipomata, 230 Littre, operation of, 48 Luer's hemorrhoidal forceps, 151 Lund's colotorny needles, 51 Lupus exedeus, 249 Lymphatics of rectum, 22 Malformations of rectum and anus, 36 treatment of, 44 use of trocar, 45 Malignant adenoma, 320 Manual exploration, 78 Measurements of rectum, 78 Melanotic cancer, 328 Mitchell's suppositories, 82 Molliere, classification of congenital mal- formation, 37 Mucous membrane of rectum, 9 Muscularis mucosae, 10 Muscles of anus. 11 of rectum, 11 N^kvus of rectum, 402 Narrowing of rectum or anus without complete occlusion. 37 Nelaton, on third sphincter, 23 Nerves of rectum, 19 Neuralgia of the rectum, 398 Nitric acid applications for prolapse, 163 for ulceration, 270 Non-malignant stricture, 271 excision. :!1 I ulceration, 241 Non-venereal stricture, 273 Xussbaum's cases of excision of the rec- tum, 851 O'Beirne, on defecation. 2 i, 30 Occlusion of rectum or anus, 37 Operating chair, 62 Operation for incontinence of fasces, 106 in congenital malformations, 44 Operation of Amussat, 47 of Callisen, 49 of Littre, 48 Operations, after-treatment, 82 Osteoid cancer, 329 Owen, cases of imperforate anus, 53 Paget, on syphilitic ulceration, 257 Pain, reflex, in rectal disease, 21 Papendorf, classification of congenital malformations, 37 Papilloma, granular, 214 Papillomata, 221 Paquelin's thermocautery, 80 Parturition, as cause of ulceration, 242 Pathological anatomy of stricture, 277 Pederasty, 6 Pelvic abscess, 97 diaphragm, 198 fascia, 14 fistula, 110 Pelvirectal space, 15 description of, 93 Perineal fistula, 124 Peristalsis, reverse, 404 Peritoneum, distance of, from anus, 7 relations of, to rectum, 6 Peritonitis caused by stricture, 279 Petrequin, on third sphincter, 24 Phthisis and fistula. 112 Pilo-nidal sinus, 235 Polyadenomata, 217 Polypus, 213 adenomatous, 216 benign, distinguished from cancer, 221 connected with fissure, 246 containing peritoneum, 219 diagnosis, 220 fibrous, 217 glandular, 216 hard, 213 sarcomatous, 217 soft, 213 symptoms, 219 treatment, 221 villous, 214 Position for examination, 64 Posterior umbilicus, 235 Proctitis, 84 acute, 86 causes, 87 chronic, 87 gonorrhoeal, 87 localized, 86 symptoms of, 86 treatment, 88 Proctoplasty, 47 Proctotomy, external, 299 internal, 298 knife, 301 literature of, 314 Prolapse, 156 causes, 158 cauterization, 103 INDEX. 415 Prolapse, changes in coats of, 167 extirpation of, 168 first variety, 157 of mucous membrane only, 158 of second degree, 1 66 operation for, 161 operation with elastic ligature, 169 operation with Smith's clamp, 165 reduction of inflamed, 168 second variety, 157 strangulation, 167 symptoms, 159 third and fourth varieties, 157, 169 treatment, 160 treatment by injections, 163 varieties, 156 with circular slough, 168 with rectal hernia, 201 Prostate, relations of, to rectum, 4 Pruritus ani, 385 causes, 886 changes in the skin, 386 prognosis, 394 treatment, 387 Purgatives causing proctitis, 87 Pus basin, 67 Rectal absorption, 403 alimentation, 403 alimentation, rules for applying, 409 bougies, 70 depressor, 76 digestion, 403 enemata, 406 hernia, 182 hernia, anatomy, 198 hernia, cases, 184-197 hernia, contents, 205 hernia, diagnosis, 206 hernia, incision of the sac, 211 hernia, inflamed, 205 hernia, internal, 202 hernia, irreducible, 205 hernia, Kleberg's operation, 208 hernia, sac of, 200 hernia, strangulated, 206 hernia, treatment, 207 hernia, treatment after rupture, 211 hernia, varieties, 182 supporter, 161 touch, 68 valves, conclusions regarding, 35 Recto-coccygeus, 12 Rectum, absence of, 43 anatomy of muscular coat, 8 arteries of, 16 circular muscular fibres, 8 congestion of, 84 curves of, 2 development of, in embryo, 36 divided into four sacs, 40 divisions of, 3 emphysema of, 401 ending in bladder, 42 Rectum, ending in blind pouch, 38 ending in fistulous track; 40 ending in urethra, 43 examination of, 59 excision of, different methods of, 346 glands of , 11 gunshot wounds of, 401 haemorrhage from, 402 haemorrhage in operations, 81 imperforate, anus normal, 39 imperforate, operations in perinaeum, 46 inflammation of, 84 injection of, for exploration, 72 injury in childbirth, 400 length of, 1 longitudinal muscular fibres, 8 lymphatics of, 22 malformations of, 36 manual exploration, 78 mucous membrane of, 9 muscles of, 11 naevus of, 402 nerves of, 19 neuralgia, 398 Nussbaum's cases of excision, 351 opening in perineum, 40 opening in sacral region, 40 packing of, 82 position of, 1 relations of, 4 rules for operations, 79 rupture of, 203 submucous coat of, 9 upper limit of, 2 valves of, 25 veins of, 16 Weir's measurements, 78 wounds of, 400 Relations of rectum, 4 Residual abscess, 95 Retention of urine after operations, 83 Retractor recti, 12 Reverse peristalsis, 404 Richet, superior pelvi-rectal space, 15 Rodent ulcer, 251 Rupture of rectum, 203 Sac of rectal hernia. 200 Sappey, on third sphincter, 24 Sarcomatous polypus, 217 Scirrhus, 324 Sclerosis, syphilitic, 276 Scrofula. 249 Secondary syphilis, 256 Septa in rectum, 40 Sigmoid flexure, malposition of, 3, 52 Sinus of Morgagni, inflammation of, 244 pilo-nidal, 235 Smith's clamp and cautery. 154 ovjeration compared with Allingham's, 155 operation for haemorrhoids, 154 Sodomy as a cause of ulceration, 242 416 IXDEX. Space, superior pelvi-rectal, 15 Spasm of sphincter. 395 Spasmodic stricture, 272 Spina bifida, 238 Specula?, use of, 73 Speculum, author's, 74 Helmuth's, 74 Sphincter, external, 12 external, nerve control of, 20 forcible stretching-, 266 internal. 12 spasm of, 395 stretching of, 77 third, 23 third, conclusions regarding, 35 Sponge-holder, 64 Stethoscope, used over anus, 39 Stricture, acquired, 272 cause of abscess, 279 cause of obstruction, 282 cause of peritonitis, 279 cause of ulceration, 260 cicatricial venereal. 276 congenital of rectum or anus, 37 diagnosis, 73, 78, 283 division of, 298 dysenteric, 273 examination for, 68, 285 from hypertrophy of rectal valves, 274 general treatment, 286 how to measure length of, 72 inflammatory, 273 neoplastic venereal, 276 non-malignant, 271 non-malignant, treatment when high up, 318 non-venereal, 273 pathological anatomy, 277 secondary effects, 279 shape of fasces, 280 spasmodic, 272 symptoms, 280 treatment by dilatation, 293 treatment by divulsion, 295 traumatic. 275 varieties of, 271 Subcutaneous fistula, 109 Submucous fistula, 109 Submuscular fistula, 109 Superior pelvi-rectal space, 15, 93 Suppositories, Mitchell's, 82 nutritive, 409 Suskenator tunicas mucosas, 10 Syphilis, secondary, 2J6 tertiary. 256 Syphilitic sclerosis, 276 ulceration of colon, 258 Syphiloma, ano-rectal, 229, 260 Talma, case of, 278 Taxis for haemorrhoids, 140 Tensor fasciae pelvis, 12 Tertiary syphilis, 256 Thermo-cautery, W Third sphincter, 23 conclusions regarding, 35 Transversus perinei, 15 Traumatic stricture, 275 Trocar, use of, in malformations, 45 Tubercular ulcer, 246 ulceration of colon, 257 Tumor, peculiar bleeding, 214 villous, 214 Tumors, congenital, 233 Ulcer, irritable, 243 rodent, 251 simple, 241 tubercular. 246 venereal, 252 Ulceration, caused by parturition, 242 caused by sodomy, 242 caused by stricture, 260 characters of syphilitic, 257 diagnosis of, 263 diagnosis of syphilitic from tubercular, 257 division of sphincter for, 269 follicular, 86 non-malignant, 241 symptoms of, 262 syphilitic of colon, 258 treated bv nitric acid, 270 treatment of, 264, 267 tubercular of colon, 257 Umbilicus, posterior, 235 Ureters emptying in rectum, 43 Urethra, rectum ending in, 43 relation of, to rectum, 4 Urine, retention after operations, 83 Uterus, emptying in rectum, 43 Vagina ending in rectum, 43 Valves of rectum, 25 conclusions regarding. 35 Van Buren, on imperforate rectum, 46 Vegetating condyloma, 228 Vegetations, 221 diagnosis, 225 non -syphilitic. 223 symptoms, 224 treatment, 226 Veins of rectum, 16 Velpeau, on third sphincter, 24 Venereal cicatricial stricture, 276 neoplastic stricture, 276 stricture, treatment, 287 ulcers, 252 Venous hasmorrhoid, 136 Vidal, ergotine injections for prolapse, 162 Vienna paste for haemorrhoids, 143 Villous polypus, 214 Vomiting of faeces, 405 Warts, 221 Weir's measurements of rectum, 78 Wounds of rectum, 40J THE PUBLICATIONS OF WILLIAM WOOD & COMPANY, NOS. 56 & 58 LAFAYETTE PLACE, NEW YORK Anatomy. 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Illustrated in various Discourses and Essays. To which are added Miscellaneous Writings, chiefl}' on medical subjects. Latest edition, enlarged. One volume, 12mo, 407 pages, muslin.Price, $1.25. Hooper's PHYSICIAN'S VADE MECUM : A Manual of the Principles and Practice of Physic ; with an Outline of General Pathology, Therapeutics, and Hygiene. Tenth Edi- tion. Revised by William Augustus Guy, M.B., Cantab.^F.R S., and John Harlet, M.D., Lond., F.L.S. Volumes I. and II. Illustrated by wood- en- gravings. Sold only by subscription. See page 52. Curtis, Edward, A.M., M.D., MANUAL OF GENERAL MEDICINAL TECHNOLOGY, INCLUDING PRE- SCRIPTION WRITING. One volume, 32mo, 334 pages, fine muslin. Price, $1.00. Wood's Pocket Manuals. " The metric system is explained in a man- ' patience. It is what many want and most ner at once lucid and attractive, and -will no need. " — St. Louis Medical Journal, January, doubt accomplish much in the way of render- 1884. ing this method less distasteful to those who " A very important feature of the work is have given it but little attention. " — The Medi- its clear exposition of the relations of the Eng- cal Bulletin, Philadelphia, Pa., January, 1881. ' lish apothecaries' weights and measures to the "This little manual is a tersely composed metrical forms now so often seen in the recent treatise on the subjects referred to alone, in a text-books and medical periodicals." — The convenient and authoritative sort of way that Medical Herald, Louisville, Ky., February, renders it a handy conservator of time and > 1884. Roosa, D. B. St, John, M.D., Professor of the Diseases of the Eye and Ear in the University of New York. A YEST-POCKET MEDICAL LEXICON. Being a Dictionary of the Words, Terms, and Symbols of Medical Science. Collated from the best authorities, with the additions of words not before introduced into a Lexicon. With an Appendix. Third revised and enlarged edition. One volume, 64mo. Price, roan, 75c, or tucks, $1.00. EJ5P*° This is just what its title-page would indicate, a very neat and convenient medical dictionary, so small that the student can carry it in his pocket with perfect ease. This little book has received the warmest commendations from very many of the best medical teachers in the United States. "The Lexicon measures three and one- fourth inches in length, by two and three- e ghths in breadth, and is three-fourths of an inch thick. The whole work is well done." — New York Teacher. "This is the smallest of books, albeit an ex- tensive Lexicon. As its title implies, it can nestle snugly in the vest pocket. To any one who would like to carry about his person a dictionary of medical words it is the very thing." — Pacific Medical and /Surgical Jour- nal, 10 PUBLICATIONS OF WILLIAM WOOD & COMPANY. Manuals, Cyclojxedice, etc. Tidy, Charles Meymott, M.D., F.C.S., Master of Surgery, Professor of Chemistry and of Forensic Medicine and Public Health at the London Hospital, .Medical Officer of Health for Islington ; late Deputy Medical Officer of Health and Public Analyst for thr City of London, etc. LEGAL MEDICINE. Volume I. With two colored plates. Contents: Evidence— The Signs of Death — Identity — The Causes of Death — The Fost-morteni. Sold by subscription only. See page 54. LEGAL MEDICINE. Volume II. Contents: Expectation of Life — Presumption of Death and Survivorship— Heat and Cold — Burns — Ligaturing —Explosives — Starvation — Sex — Monstrosities — Hermaphrodism. Sold by subsdrijjtion only. See page 54 LEGAL MEDICINE Volume III. Contents: Legitimacy and Paternity— Preg- nancy. Abortion — Eape, Indecent Exposure — Sodomy. Bestiality — Live Birth, Infanticide — Asphyxia, Drowning — Hanging, Strangulation — Suffocation. Sold by subscription only. See page 52. Castle, Frederick A., M.D., New York. WOOD'S HOUSEHOLD PRACTICE OF MEDICINE, HYGIENE, AND SURGERY. A Practical Treatise for the Use of Families, Travellers, Seamen, Miners, and others. By Various Authors. In two volumes, royal 8vo, 819 and 942 pages, illustrated by six hundred and thirty-five fine wood-engravings. Price, per vol- ume, muslin, $5.00; leather, $6.00; half morocco, $7.50. Sold by subscrip- tion only. Ziemssen, H. Von, M.D., Munich. CYCLOPAEDIA OF THE PRACTICE OF MEDICINE. By Various Authors. Coni- plete in twenty volumes, royal 8vo. Price per volume, in muslin, §5.00 ; in leather, $0.00 ; in half morocco, $7.50. Sold by subscription only. See page 63. Peabody, George L., M.D., New York. SUPPLEMENT TO ZIEMSSEN'S CYCLOPEDIA OF THE PRACTICE OF MED- ICINE. By Various Authors. In one royal 8vo volume, 844 pages, bound to correspond. Price, in cloth, $6.00 ; in leather, $7.00 ; in half morocco, $8.00 ; also extra muslin (not corresponding), $6.00 ; and in red leather, $7.00. E5F* The aim of this work is to take up each subject treated of in Ziemssen's Cyclopedia, and to bring it down to date. Many of the articles will, therefore, embrace the progress of it some, relating to the later volumes of Ziemssen, begin at a more recent period ; tin- whole, however, forms a complete resume of the progress of medicine mostly for the past five years. Carpenter, Wesley M , M.D., Bellevne Hospital ; Tnstructorin the Pathological Laboratory of the University of the City of New York ; Secretary of the- Medical .Society of the County of New York ; Secretary of the New York Pathological s.>ciuty, etc. !\'hi;\ OF THE PRACTICE OF MEDICINE. Sold only by subscription. i*>4. Flint, Austin, M.D. COMPENDIUM OF PERCUSSION AND AUSCULTATION AND OF THE PHYS- [CAL DIAGNOSIS OF DISEASE8 AFFECTING THE LUNG AND HEART. (no- volume, L8mo, 48 pages, muslin. Price, 50 cents. Paul, Dr. Constantino, tli. Faculty of Medicine of Taris. etc. DIAGNOSIS AND DISEASES OF THE HEART. Illustrated by numerous fine Sold only by subscription. See page 52. PUBLICATIONS OF WILLIAM WOOD & COMPANY. 11 Practice, Fevers. Loomis, Alfred L., M.D., LL.D., Professor of Pathology and Practical Medicine in the Medical Department of the University of the City of New York ; Visiting Physician to Bellevue Hospital, etc. A TEXT-BOOK OF PRACTICAL MEDICINE. One handsome 8vo volume of over 1,100 pages, illustrated by two hundred and eleven engravings. Price, in cloth, $6.00; leather, $7.00. " The work before us is a complete compre- hensive treatise on general pathology and practical medicine. The arrangement and classification is that which the author has ob- served in teaching, and is based on advanced pathological knowledge." — Louisville Medical Nt ws, November 22, 1884. " A careful examination of the book creates the impression that it is the work of one who speaks that which he himself knows. It is not, as is too often the case in such works, a mere revamping of statements which have been perpetuated through a long series of treatises ou the practice of medicine." — Medical Age, Detroit, October 25, 1SS4. " The work traverses the usual field of in- ternal pathology considered in text-books upon the practice of medicine ; but it does so with evidences of such unusual discretion and skill as to present the subject in a fresh light, and to constitute a most acceptable addition to medical literature. The illustrations are abundant, original, and, as a rule, neatly drawn, and well illustrate the text, in which the subjects are discussed in the light of the most recent additions to our knowledge of pathology and therapeutics." — The Philadel- phia Medical Times, December 27, 1884. " It is an elaborate work of 1,102 pages, with a full index, and is issued in the publisher's best style. It must be rated as one of the standard works on the theory and practice of medicine in this country, and should have a preference over those emanating from Europe, even if re-edited in this country." — The Ther- apeutic Gazette, November, 1884. LECTURES ON DISEASES OF THE RESPIRATORY ORGANS, HEART AND KIDNEYS. One volume, 8vo, 591 pages. Price, muslin, $5.00 ; leather, $6.00. "It is clear in style, convenient in arrange- ment, very definite and practical in its teach- ings."*— Philadelphia Medical Times. " We like the systematic method in which these lectures are arranged, and regard them as excellent in every way." — Cincinnati Lan- cet and Observer. "In the one before us the reader may look confidently for the last words on the subject, and may rest assured that what the author has here committed to the press is the result of much learning, sound judgment, and thor- ough experience." — American Practitioner. "We have no hesitation in pronouncing it one of much value to the profession, and highly creditable to the author." — New York Medical Journal. "While the views presented are fully up to what is actually known on the subjects treated, the doctrines are judicious and safe. At the same time they are presented with un- usual clearness, and with sufficient positive- ness to command confidence." — New Orleans Medical and Surgical Journal. "By all means buy Loomis' work and study it." — Ohio Medical and Surgical Reporter. LECTURES ON FEVERS. One volume, 8vo, 403 pages. Price in muslin, $4.00. " We have before us, therefore, a book con- taining statements of practical facts relating to certain diseases, and the theories regarding their nature, mode of origin, and propagation, and arranged so as to be easily comprehended by the medical student. We also believe they will be read without weariness by the daily practitioner. ... It contains much prac- tical knowledge, and cannot fail to be read by a very large proportion of the medical profes- sion ; for a concise statement of facts — with only such qualifications as can be safely in- dulged in without endangering perspicuity — is always acceptable." — The Medical Rec- ord. "This last work of Professor Loomis 1 is a valuable contribution to medical literature. His treatment of the subject is mainly practi- cal, and is in strict conformity with what the author has himself observed at the bedside. The general management of fever is justly re- garded of greater importance than the admin- istration of drugs. It is a book that will well repay careful study." — Western Lancet. " The work is clearly and concisely written, and will be useful and acceptable to both stu- dent and practitioner." — New York Medical Jour no 1 , " In this interesting volume, which contains the lectures on fevers delivered by Professor Loomis to his class during the last year, we have a concise and impartial review of the lit- erature concerning fevers which has been pub- lished since 1850, with reference to a few older books, 'because they contain many of the so-called new theories and modes of treat- ing fevers.' In this are embodied the results of the author's own extensive clinical expe- rience, which has led him to form opinions in certain respects at variance with those of some other observers ; and the weak points of theories and modes of practice which have not stood the test of time are clearly set forth." — Lotito7i Medical and Surgical journal. la PUBLICATIONS OF WILLIAM WOOD & COMPANY. Diseases of Throat and Chest, of the Rectum. Corson, John W., M.D., Late riiysician to the class of " Diseases of the Chest and Throat" in the New York and Eastern Dis- pensaries; formerly Physician to the Brooklyn City Hospital ; Physician to the Orange Memorial Ho*pital, etc. ON THE TREATMENT OF PLEURISY. With an Appendix of Cases, showing the Value of Combinations of Croton Oil, Ether, and Iodine, as Counter-irritants in otlier Diseases. One volume, 16mo, 31 pages, muslin. Price, 50c. Ingals, E. Fletcher, A.M., M,D., Lecturer on Diseases of the Chest and Physical Diagnosis, and on Laryngology in the Tost-gradnate Course, Rush Medical College ; Clinical Professor of Diseases in the Throat and Chest, Woman's Medical College : Physician and Surgeon for Diseases of the Throat and Chest, Central Free Dis- pensary, Chicago. LECTURES ON THE DIAGNOSIS AND TREATMENT OF DISEASES OF THE CHEST, THROAT, AND NASAL CAVITIES. With one hundred and thirty- five illustrations. One volume, 8vo, 437 pages, muslin. Price, $4.00. " In bringing within one pair of book covers a concise epitome of affections of the chest and the entire respiratory tract, Dr. Ingals has recognized the interdependent relations of a group of anatomical regions falling together naturally, both in histology and pathology. His volume aims thereby at an objective com- pleteness which has not hitherto been attained, to our knowledge, in any single work of physi- cal diagnosis, or on any disease of the chest and air -passages. " — American Journal of the Medical Sciences. "For good, practical, and correct teaching, this book has ne superior. There is no volume which would be more useful in the general practitioner's daily life." — American Medical Wi ■ Irly. " This forms a valuable aid, both to the student and practitioner, in the study of its subject. It is clear and concise in style, sys- tematic and thorough in the consideration of each detail." — Chicago Medical Journal and Examiner. '• Both as to the matter and arrangement of the book, it must be of great service to the or- dinary physician as well as to the specialist." — Virginia Medical Monthly. "The work is of the most practical charac- ter ; it avoids theoretical and unsettled ques- tions ; the subjects are presented in a lucid and compact style. We predict for this work a wide field of usefulness because it seems to us to be exactly adapted to the use of the phy- sician in active practice." — Maryland Medical Journal. Kelsey, Charles D., M.D., Surgeon to ?t. Paul's Infirmary for Diseases of the Rectum ; Consulting Surgeon for Diseases of the Rectum to the Harlem Hospital and Dispensary for Women and Children, etc., etc. THE PATHOLOGY, DIAGNOSIS, AND TREATMENT OF DISEASES OF THE RECTUM AND ANUS. One volume, 8vo, 430 pages, illustrated by two chromo lithographic plates and many wood-engravings. Price, in cloth, $4.00, ''The aim of the author has been to make this boob a Bafe guide for the student and gen- Mai practitioner, and to furnish that informa- tion which is bo difficult to obtain without special advantages, such as are obtained by clinic,, i fcc." " In oonclnaion, we will add that the author has sue-, i ded admirably in giving us a book which will greatly advance the domain of rec- tal Burgery, and encourage many a practitioner who baa heretofore shrunk from this distaste- ful and unsatisfactory branch of surgery, to it again with renewed confidence." — North Carolina M> dual Journal. " It forms the best recent work on a class of disease which, although claimed by surgery, has more medical relation than most physi- cians are aware." — The College and UlinieRec- ord. " The work is an excellent one, and will be highly appreciated." — The Physicians' and Surgeons' investigator. '"The student and busy practitioner will find here in a condensed form all that is posi- tively known, and much that has not before been recorded, concerning diseases of the rec- tum and anus." — The Medical Bulletin, Phil- adelphia, Pa. si.S OF THE RECTUM AND ANUS. j a e 54. Sold only by subscription. See PUBLICATIONS OF WILLIAM WOOD & COMPANY. 13 Diseases of the Hectum and Anus, Therapeutics. Bodenhamer, William, M.D., Professor of the Diseases, Injuries, and Malformations of the Rectum, Anus, and Genito-Urinary Or- gans. TREATISE ON THE HEMORRHOIDAL DISEASE. Giving its History, Nature, Cause, Pathology, Diagnosis, and Treatment. One volume, 8vo, over 800 pages, illustrated by two chromo-lithographic plates and many wood-cuts. Price, mus- lin, $3.00. " It is a practical discourse on both the surgical and medical treatment of hemorrhoids, and if well studied will enable any medical man of ordinary capacity to manage all such cases." — Therapeutic Gazette, December, 1884. A PRACTICAL TREATISE ON THE AETIOLOGY, PATHOLOGY, AND TREAT- MENT OF THE CONGENITAL MALFORMATIONS OF THE RECTUM AND ANUS. " Necessitas medicinum invenit experientia perfecit" (Hippoc- rates). Illustrated by sixteen plates and exemplified by 287 cases. One vol- ume, 8vo, 368 pages, muslin. Price, $4.00. ''Must be considered by far the most valuable, if not the only text-book on this subject." — Boston Medical and Surgical Journal. PRACTICAL OBSERVATIONS ON THE ^ETIOLOGY, PATHOLOGY, DIAGNO- SIS, AND TREATMENT OF ANAL FISSURE. Illustrated by numerous cases and drawings. One volume, 8vo, 199 pages, muslin. Price, $2.25. "The treatise is throughout carefully pre- pared, and we recommend it as a valuable, practical book, worth the place in any work- ing library." — Medical and Surgical Reporter. "This is the most complete and extensive treatise on this very painful and troublesome disease. The work is really a history of the disease, comprising an accurate description of its symptoms and pathology, together with the plan of treatment. As is the case with all specialties, when treated in a separate volume, we get the subject in an extended and minute form." — St. Louis Medical Reporter. ' ' It will be perused with interest and profit by all." — Detroit Review of Medicine, etc. "We believe that the subject has received full justice at the hands of the author, and. that the work will be the standard on the subject." — Buffalo Medical and Surgical Jour- nal. THE PHYSICAL EXPLORATION OF THE RECTUM. With an Appendix on the Ligation of Hemorrhoidal Tumors. Illustrated by numerous drawings. One volume, 8vo, 54 pages, muslin. Price, $1.25. AX ESSAY ON RECTAL MEDICATION. One volume, 8vo, 58 pages, illustrated, muslin. Price, $1.00. ISf 3 In the employment of an official therapeutic remedy, it is not only important and necessary to know in what case, in what dose, in what form, but also by what channel it should be administered. Ringer, Sidney, M.D., Professor of the Principles and Practice of Medicine in University College ; Physician to University College Hospital. A HANDBOOK OF THERAPEUTICS WITH DIETARY AND INDEX OF DIS- EASES. Tenth edition. Price, $5.00. " Upon the appearance of that now indis- pensable work, ' Ringer's Handbook of Thera- peutics.' my attention was particularly at- tracte I to the frequency with which he recommends small doses of medicines that we have been accustomed to use in much larger doses for entirely different diseases. Some of these remedies were recommended so strongly, the opportunity of further testing them in numerous cases of adults." — Dk. Desseau in Medical Record, July 28, 1877. " The author has selected everything of sub- stantial value among the recent advances in therapeutics. It is a practical work, replete with interest and reliable information, and will be found to be one which can be consulted that I was induced to give them a trial, more | by the practitioner with much benefit. We especially as my practice among children com- would advise every young physician to pro- pels me, for. many reasons, to administer as cure and read the book. It fills all the author little unple.isant-tasting medicines as possible, r claims for it in letter and spirit, and is written Their use with children first having been in such a clear and simple style that all who found satisfactory, my position in connection read it will do so with pleasure." — Western with the New York Dispensary afforded me Lancet. U PUBLICATIONS OF WILLIAM WOOD & COMPANY. Materia Med lea, Therapeutics. Eothergill, J. Milner, M.D., Member of the Royal College of Physicians of London ; Senior Assistant Physician to the City of Lon- don Hospital for Diseases of the Chest (Victoria Park) ; late Assistant Physician to the West Lon- don Hospital ; Associate Fellow of the College of Physicians of Philadelphia. INDIGESTION, BILIOUSNESS, AND GOUT IN ITS PROTEAN ASPECTS. Part I. Indigestion and Biliousness. One volume, 12mo, 320 pages, muslin. Pi ice, $2.25. " The relation of digestion to habits of life, i four chapters are devoted to its functions and to methods of living, and to the perfect nutri- j their disturbances. In referring to the in- tion of the body, are treated in a masterly | fluence of mental strain and worry, Dr. Foth- ergill says: 'Talking one day with 3Ir. Van Abbott, whose biscuits for diabetic; have such a well-deserved renown, I asked him, "Who are your diabetics mostly?" The reply was very significant. "Business men, compara- tively old and gray for their years ; men who look as if they had a deal on their minds.'' This was the response. It stands in sugges- tive relationship to the fact of acute diabetes manner, and abound in practical hints of the greatest possible utUity to the practising phy- sician. Altogether, the work is a remarkably comprehensive study of a subject which is too little understood by the majority of medical men." — New York Medical Record. " Dr. Fothergill's writings always command attention ; they are sprightly and full of in- structive facts, drawn mostly from his own large experience. This volume is written j being set up by shock or other mental pertnr from a physiological standpoint, and begins ! bation, or of its artificial production by the puncture of the floor of the fourth ventricle.' The whole book is practical and interesting reading." with an account of natural digestion, by way of introduction or antithesis to the main topic of the book. As the liver is the great store- house of supplies for the use of the system, Phillips, Charles D. F., M.D., F.R.C.S.E., Lecturer on Materia Medica, Westminster Hospital, London. MATERIA MEDICA AND THERAPEUTICS. Inorganic Substances. Adapted to the United States Pharmacopoeia by Lawrence Johnson, M.D. Volumes I. and II. Sold only by subscription. See page 54. MATERIA MEDICA AND THERAPEUTICS. Vegetable Kingdom. Revised and adapted to the U. S. Pharmacopoeia by Henry G. Piffard, A.M., M.D.. Pro- fessor of Dermatology, University of the City of New York ; Surgeon to the Charity Hospital, etc., etc. This practical book forms a volume in this series of 327 pages. Garrod, Alfred Baring, M.D., F.R.S., Fellow of the Royal College of Physicians, etc., etc., THE ESSENTIALS OF MATERIA MEDICA AND THERAPEUTICS. One hand- some Svo volume, 439 pages, extra muslin. Price, $4.00. "The author of this book has succeeded i " We have here a brief resume of materia admirably in placing in concise form what is medica, all non-essential parts being omitted. sury to be known of materia medica and It might be called a commentary on the Pbar- thcrapeutics, leaving it to larger works to j macopoeia, as it somewhat resembles Phillips' enter into details. ... If our estimate commentary on the London Pharmacopoeia, of the work is a correct one, and we think it is, it will not be long before another edition will be called for." — Medical and Surgical Reporter. though more extended in its description of the action and uses of remedies." — Eclectic Medi- cal Journal. Trousseau, A., M.D., Pn >f ' a x of Therapeutic* of the Faculty of Medicine of Paris ; Physician to the l'H&tel Lieu, etc., etc. THERAPEUTICS. Translated by D. F. Lincoln, M.D., from the Materia Medica and Therapeutics. Ninth French Edition, revised and edited. Volume I., II., and III. Sold by subscription only. See page 56. Any work by Trousseau needs no introduction to the medical profession— his profound iity of imparting instruction, and his delightful style commend nam.; to their best consideration. This work is said to be superior to any i.ject, and one which will long continue to be a standard. The edition from which this translation is made has been thoroughly revised and edited by Dr Paul, and brought down to the present year. PUBLICATIONS OF WILLIAM WOOD & COMPANY. 15 Therapeutics, Gholera, Diagnosis. Binz, C, M.D., Professor of Pharmacology in the University of Bonn. THE ELEMENTS OF THERAPEUTICS. A Clinical Guide to the Action of Medi- cines. Translated from the Fifth German Edition, and Edited, with Additions, in conformity with the British and American Pharmacopoeias, by Edward I. Sparks, M.A., M.B., Oxon. , Member of the Royal College of Physicians of London, Officier de Sante (Alpes Maritimes), France, formerly Radcliife Travel- ling Fellow. In one handsome 12mo volume, 345 pages. Bound in extra mus- lin. Price, $2.00. "Fully up to the times as a therapeutic guide." — Toledo Medical and Surgical Jour- nal. "We are much mistaken, however, if the work in its present shape does not become a general favorite with both students and prac- titioners. It will also help, we think, to ad- vance the movement to establish an universal Pharmacopoeia." — New Remedies. ' ' The work appears to have been written with great care, and bears the impress of re- liability, and is a volume that we do not he»i- tate to recommend in the strongest maimer." — The Medical Record. Wendt, Edmund C, M.D., Curator of St. Francis' Hospital ; Pathologist and Curator of the New York Infant Hospital, etc. A TREATISE ON CHOLERA. Edited and Prepared in Association with John C. Peters, M.D., New York, John B. Hamilton, M.D., Surgeon-General U. S. Marine Hospital Service, and Ely McClellan, M.D., Surgeon U. S. Army. Illustrated with maps and. engravings. Sold only by subscription. See page 51. __ ' Availing themselves of the history and experience of cholera epidemics to the present day, together with the new light thrown upon its mode of propagation, spread, and treatment the past year through the investigations of Prof. Koch and others — the knowledge concerning preventive measures, quarantine, etc. , so recently acquired in France and Italy — the learned authors of this work aim to produce a book which may at least serve to prepare the profession of America successfully to combat this dreaded scourge, should it unfortunately gain an en- trance into our country this year. Burrall, F. A., M.D., ASIATIC CHOLERA. One volume, 12mo, 155 pages, muslin. Price, $1.50. " It is a special merit of Dr. Burrall's timely volume, that it so states facts as to instruct the reader most impressively and acceptably in all that relates to preventive measures and prophylaxis. We have met with no writing on cholera in our language that has more happily achieved this chief end of medical research. For this reason, no less than for the scholarly excellencies of this brochure, it is sure to com- mand the attention and regard of the profes- sion." — Medical Record. Brown, Harvey E., M.D., Assistant Surgeon United States Army. REPORT ON QUARANTINE on the Southern and Gulf Coasts of the United States. One volume, 8vo, 117 pages, muslin. Price, $1.25. Delafield, Francis, M.D. ; and Stillman, Charles F., M.D. A MANUAL OF PHYSICAL DIAGNOSIS. Illustrated with superimposed and transparent lithographed plates. One volume, 4to, 30 pages, muslin. Price, $2.00. "The- want of conciseness in ths ordinary i "We cannot imagine any way in which the manuals on physical diagnosis affects the aver- ; practical study of ph ysical' diagnosis can be age student, and they never learn it until com- made more easy than by the aid of this su- pelled to. This work is an exception to this perb work." — Pacific Medical and Surgical rule." — Ohio Medical Recorder. ' Journal. 16 PUBLICATIONS OF WILLIAM \YOOD & COMPANY. Diagnosis. Ranney, Ambrose L., A.M., M.D., Adjunct Professor of Anatomy and Late Lecturer on the Surgical Diseases of the Genito- Urinary Organs and on Minor Surgery in the Medical Department of the University of the City of New Tork : Late Surgeon to the Northwestern and Northern Dispeu saries; ltesident Fellow of the New York Acad- emy of Medicine ; Member of the Medical Society of the County of New York, etc. A PRACTICAL TREATISE OX SURGICAL DIAGNOSIS. DESIGNED AS A .MANUAL FOR PRACTITIONERS AND STUDENTS. Third Edition. One volume of 638 pages, illustrated by 31 plates, handsomely bound in muslin. Price, §4.50. "Useful on account of its systematic ar- rangement." — Cincinnati Lancet and Clinic. ■ • We are at a loss to see how more informa- tion could have been condensed in fewer •words.' - — Chicago Medical Journal and Ex- it,-, int r. "The system and arrangement of the vol- ume are highly commendable, and the author has carried them out well." — Southern Prac- titioner. "A very good aid to surgical diagnosis for both advanced surgeons and beginners. As a text-book for surgical lectures it is quite val- uable." — St. Louis Clinical Record. "With the exception of Macleod's 'Out- lines,' published simultaneously in England I and in this country, in 1864, this is, so far as , we know, the first monograph ever issued on I surgical diagnosis." — Philadelphia Medical Times. " The chief source of perplexity in the prac- ' tice of medicine and surgery is to find out what is the matter with the patient. Uncomfort- able, indeed, is the reflection of a practitioner when he has left a case bandaged and dressed for a fracture, when, perchance, it may be a dislocation. Dr. Ranney has given us a book to assist us in all such states of uncertainty, and he has done well ; for in presenting the symptoms of disease in marked contrast, it makes the diagnosis of similar troubles really ' easy." — Toledo Med. and Surg. Journal. Guttman, Dr. Paul, Privat-Docent in Medicine. University of Berlin. k HANDBOOK OF PHYSICAL DIAGNOSIS: COMPRISING THE THROAT, THORAX, AND ABDOMEN. Translated from the Third German Edition by ALEX. Napiee, M.D., Fellow of Faculty of Physicians and Surgeons, Glas- gow. American Edition, with a colored plate and numerous illustrations. Sold only by subscription. See page 56. Loomis, Alfred L., M.D., Professor of the Institutes and Practice of 'Medicine in the Medical Department of the University of New York : Physician to Bellevue and Charity Hospitals, etc. LESSONS IN" PHYSICAL DIAGNOSIS. One volume, 8vo, 240 pages, illustrated, muslin. Price, $3.00. " The previous editions of this volume have ■ tv well received, and, from their ready gale, appear to meet a well-recognized want. We find the plan of the work excel- nd, within the limits proposed by the v rv well lurried out. It would bo to point out many omissions ; complete- ness to ■> cei tain degree ex- clude each other ; bul in the space assumed it would ix- difficult to include a greater variety and amount of sound teaching. Tin- style is ■ ar. positive, and exact. It i- Er< e from all irrelevant b; nothing is al- lowed to disturb or confuse the distinct image of olil ... The book i« very •• and industrious author ; and wl ! practically master its con- cannot fail to l» ;i discriminating' and well- furnished diagnostician." — The Medical /•'■ ■ ord. Lenta it is the best work on physi- cal diagnosis that is published." — Ditroit lie- v'n w of Medtcint . "This is a work already well and favorably known to the profession. In the present edi- tion the original text has been entirely revised and enlarged by the addition of five new les- sons." — Chicago Medical Examiner. "Students of medicine and practitioners will find this just the work to meet, their wants on the s-ubjects of which it treats. Its instructions are full and very plain." — Cincin- nati Medical X< ws. "The previous editions of the work, con- fined to an exposition of the subject of physi- cal exploration of the chest and abdomen, we have regarded as among the very best works on the subject extant, and hence recommended ' Loomis on Physical Diagnosis ' to our classes ; and it gives vs pleasure to repeat, in this form, our hearty commendation of the book." — Michigan University Medical Journal. PUBLICATIONS OF WILLIAM WOOD & COMPANY. 17 Botany, Climatology, and Physiology. Johnson, Laurence, A.M., M.D., Lecturer on Medical Botany, Medical Department of the University of the City of New York ; Fellow of the New York Academy of Medicine, etc. MEDICAL BOTANY : A Treatise on Plants used in Medicine. Illustrated by nine beautifully colored plates and very numerous fine wood-engravings. Sold only by subscription. See page 52. Bell, A. N., A.M., M.D., Editor of " The Sanitarian ; " Member of American Medical Association, American Public Health Asso- ciation, Medical Society of the State of New York ; Honorary Member of Connecticut Medical Soci- ety ; Corresponding Member of the Epidemiological Society of London ; formerly P. A. Surgeon U. S. Navy, etc. CLIMATOLOGY OF THE UNITED STATES AND ADJACENT COUNTRIES, and of sucb Foreign Ports and Places as bave intimate Commercial Relations with the United States, with special reference to Health Resorts, and the Pro- tection of Public Health. Sold only by subscription. See page 51. rp^= This work has been written expressly for Wood's Library, by one whose training and stud}- have been for many years in this line. Fothergill, J. Milner, M.D., Physician to the City of London Hospital for Diseases of the Chest (Victoria Park) ; Hon. M.D. Rush College, Illinois ; Associate Fellow of the College of Physicians, Pennsylvania. THE PHYSIOLOGICAL FACTOR IN DIAGNOSIS. A Work for Young Practi- tioners. Second edition. 8vo, 256 pages. Bound in muslin. $2.25. "Skill consists of foundation of common-sense and a superstructure of special education." Ashby, Henry, M.D., Physician to the General Hospital for Sick Children, Manchester ; Lecturer on Animal Physiology to the Evening Classes, the Owens College ; formerly Demonstrator of Physiology, Liverpool School of Medicine. MEMORANDA OF PHYSIOLOGY. Third edition. Thoroughly revised, with ad- ditions and corrections by an American editor. 18mo, 319 pages, muslin. Price, $1.00. (Wood's Pocket Manuals.) " This valuable addition to the popular se- ries, Wood's Pocket Manuals, was originally compiled for the use of the students of the Liverpool School of Medicine, when preparing tions embrace concise data on Physiological Chemistry, Physiological Histology, The Blood, The Circulation, Lymphatic System, Respiration, Animal Heat, Food, Digestion, for the primary examination of the College of | Absorption and Nutrition, The Liver, The Kid- Surgeons. The author was induced to bring I neys, The Ductless Glands, Nervous System, them out in print, in the hope that they might : The Senses, Speech, and Organs of Generation ; prove useful to a wider class of students. I and the Appendix ; Ingesta and Egesta, Metric Qiain's and Gray's Anatomies and Foster's j System, and Thermometer Scales. A 'com- ' Text-book of Physiology ' were the sources plete index makes the usefulness of the little upon which much of the information contained ! book readily available." in the work was founded. The seventeen sec- Comstock, J. C. ; and Comings, N., M.D., PRINCIPLES OF PHYSIOLOGY : Designed for the Use of Schools, Academies, Colleges, and the General Reader. Comprising a Familiar Explanation of the Structure and Functions of the Organs of Man. Illustrated by comparative ref- erences to those of the inferior animals. Also an essay on the Preservation of Health. With fourteen quarto plates and over eighty engravings on wood, making in all nearly two hundred figures. One volume, 4to, 110 pages. Price, in muslin, uncolored, $2.25. 2 IS PUBLICATIONS OF WILLIAM WOOD & COMPANY. Physiology. Kirkes' Handbook of Physiology. HANDBOOK OF PHYSIOLOGY. By W. Morrant Baker, F.R.C.S., Surgeon to St. Bartholomew's Hospital and Consulting Surgeon to the Evelina Hospital for Sick Children ; Lecturer on Physiology at St. Bartholomew's Hospital, and late Member of the Board of Examiners of the Royal College of Surgeons of Eng- land, and Vincent Dormer Harris, M.D. Lond., Demonstrator of Physiol- ogy at St. Bartholomew's Hospital. Eleventh edition. In one volume, with a colored • plate and five hundred illustrations. Price, muslin, $4.00; leather, $5.00. | ; = Kirkes' Physiology has long enjoyed a high reputation, as one of the best and most practical works of its kind, and in this new edition, just completed by Drs. Baker and Harris, is probably as acceptable a book on the subject as could be presented to the practitioners of America. ". . Fully up to the latest developments in the science of which it treats. The illus- trations are well selected and will be found very helpful to the student in his efforts to comprehend and master even the most intri- cate portions of the subject." — The Jlahne- mannian, Phdadelphia, Pa., July, 1885. " Indeed, the order of subjects and arrange- ment of matter throughout the volume are most excellent, and, as a handbook, the ab- sence of all controversial argumentation on settled points is an additional recommendation of its value. The illustrations can hardly be called beautiful, but they are well drawn and instructive, and this is the chief end of a pict- ure in a work on physiology." — The Amer- ican Practitioner, Louisville, Ky., June, 1885. " The book before us is a revision and im- proved edition of Kirkes' Physiology. It is a very excellent work. . . . To those of us who, in our student days, paid reverence to the teaching of Kirkes, this book comes as a pleasant reminder of an old friend, and pre- sents us with all the additional discoveries in this branch of onr science which have been made up to the present time. We very cor- dially endorse this book." — The Southern Clinic, Richmond, Va., April, 1885. " This old standard work has been thor- oughly revised and brought up to the times. It has long been one of the finest books for the student and practitioner and will long con- tinue such. This edition has been enhanced in value by the addition of a large number nf most excellent woodcuts and the text has been largely rewritten." — New England Medi- cal Monthly, April, 1885. Lambert, T. S., M.D., "As a guide for the student, and ready ref- ■ erencefor the practitioner, this work is not ex- celled by any other in the English language for the clearness of statement of established i facts in the science of which it treats." — The Sanitarian, New York, April, 1885. "The Messrs. Wood do not intend to forget the juniors and give them therefore the best works at a nominal price. There is hardly a ! practitioner of some years who did not learn the principles of physiology from Kirkes, and I any work which reaches an eleventh edition, | shows its intrinsic value." — The North Amer- ican Journal of Homoeopathy, Philadelphia, May, 1885. "Kirkes' Handbook has been a popular text-! ook of physiology for so many years that its eleventh edition hardly calls for an extended notice, much less a review. It is enough to say that the editors, who are now practically the authors, have maintained the high character of the work, and have kept ful- ly up to the times in the science of physiology, which has made such vast progress within the last few years." — GaillarcVs Medical Journal, May, 18S5. "On carefully looking through the last edi- tion of Kirkes' Physiology, which is, however, really Kirkes', it seems to us, only through the courtesy of the editors, we can tind scarcely anything to criticise. It seems thoroughly up to the time, and while moot points in physi- ology have not been entirely omitted, they are stated in such a way as to render them easily comprehensible to the youngest student of medicine." — The Therapeutic Gazette, May, 1885. PRIMARY SYSTEMATIC BUMAN PHYSIOLOGY, ANATOMY, AND HYGIENE. A new and Improved method <>f analysis and classification, both simple .and complete, practical and interesting. Adapted to the use of young scholars. One volume, l»mo, L 78 pages, illustrated, muslin. Price, 85c. Brodie, Sir Benjamin, Bart., D.C.L., hi "I the Rival Society. MEND AND MATTER; or, Physiological Inquiries in a Series of Essays, intended to illustrate the mutual rotations of the physical organization and the mental faculties. With additional notes bv an American editor. One volume, 12mo, 379 pages, muslin. Price, $1.25. lid be found in tin- library of both the physician and the naturalist." — New Jersey ifedi aX and Surgical Reporter. PUBLICATIONS OF WILLIAM WOOD & COMPANY. 19 Physiology. Harris, Vincent, M.D., Member of the Eoyal College of Physicians ; Demonstrator of Physiology at St. Bartholomew's Hos- pital, etc. ; and Power, D'Arcy, M.A., Oxon., Member of the Royal College of Surgeons ; late Assistant Demonstrator of Physiology at St. Bartholo- mew's Hospital. MANUAL FOR THE PHYSIOLOGICAL LABORATORY. pages, forty illustrations, muslin. Price, $1.50. One volume, 8vo, 214 "The present little volume, although of modest pretensions and narrow in scope, is a reliable guide-book for the student who desires to learn something of the rudiments of histo- logical methods and histo-chemistry." — Medi- cal Record, September 3, 18S1. " The prominence given to laboratory work in all well-equipped medical schools has cre- ated a demand for such books as the volume under notice, which is in every way fitted to serve the needs of any who may desire, through manipulative study, to familiarize themselves with the essentials of histology, histo-chem- istry, and physiology." — Louisville Medical Mm, October 28, 1882. " This little book is a useful aid to work in the physiological laboratory. Its main strength lies in the directions given for conducting mi- croscopic examinations of tissues." — Phila- delphia Medical Times, October, 1881. Satterthwaite, Thomas E., M.D., President of the New York Pathological Society ; Pathologist to the St. Luke's and Presbyterian Hospi- tals, etc. A MANUAL OF HISTOLOGY. Edited and Prepared by Thomas E. Satter- thwaite, M.D., of New York. In association with Drs. Thomas Dwight, J. Col- lins Warren, William F. Whitney, Clarence I. Blake, and C. H. Williams, of Boston ; Dr. J. Henry C. Snnes, of Philadelphia ; Dr. Benjamin F. Westbrook, of Brooklyn ; and Drs. Edmund C. Wendt, Abraham Mayer, R. W. Amidon, A. R. Robinson, W. R. Birdsall, D. Bryson Delavan, C. L. Dana, and W. H. Porter, of New York City. New edition, with appendix. In one handsome 8vo volume, profusely illustrated, 490 pages, muslin. P^ice, $4.50. " It will find a ready welcome from all workers in this department, as being a trust- worthy and valuable epitome of the subject according to the light of the most recent in- vestigations, and as being by far the best English text-book, as adapted to the wants of the student and busy practitioner ; as such we heartily recommend it." — American Journal of the Medical Sciences. "This book is what it purports to be, a manual in the true sense of the word, and will meet the wants of the busy practitioner, as well as the student who is just commencing study in this important department." — Medi- cal Times. "We commend it to the teachers of histol- ogy in our colleges as a fitting class-book ; one to be studied, and not as one of reference." — Therapeutic Gazette. " In every respect it is a book that we can heartily commend to all who desire to study this most attractive and useful branch of medi- cine. " — iVas7iville Journal of Medicine and Surgery. "Few medical works on any subject have had the advantage of such a galaxy of co- workers, and no subject is of more interest or I more necessary to physicians who would keep ' abreast with medical progress. The work is alike creditable to the editor — as he is pleased to call himself — his collaborators, and the I medical profession in the United States." — j The Sanitarian, New York City. "We would recommend the 'Manual of Histology ' to any physician or student who ! desires to be proficient in the medical sciences." j — Chicago Medical Journal a?id Examiner. " This is really a superb work, and will be ■ sought for by those engaged in histological work. Such a work as this should be studied i in conjunction with physiology, whether the student is able to follow along with the micro- t scope or not." — Cincinnati Medical JVevjs. " It may be said that Satterthwaite's ' Man- . ual ' worthily represents the histological knowl- j edge of to-day, and it may be safely used as a I guide-book by students and practitioners." — Medical Record. "The appendix contains whatever has been recently added to our knowledge of the lymph- atic system and the salivary glands. Those who have toiled through the histological fogs of some other work willappreeciate this book. " — Virginia Medical Monthly. Thudichum, J. L. W., M.D., A MANUAL OF CHEMICAL PHYSIOLOGY, Including its Points of Contact with Pathology. One volume, 8vo, 195 pages, muslin, illustrated. Price, $2.25. '20 PUBLICATIONS OF WILLIAM WOOD & COMPANY. Physiology, Pathology, and Therapeutics. Strieker, Prof. S., Of Vienna, Austria. A MANUAL OF HISTOLOGY. Written in co-operation with Th. Meynert, P. Von Recklinghausen, Max Schultze, W. Waldeyer, and others. Trans- lated by Henry Power, of London ; James J. Putnam and J. Orne Green. of Boston ; Henry C. Eno, Thomas E. Satterthwaite, Edward C. Segtjin, Lrcrrs D. Bulkxey, Edward L. Keyes, and Francis E. Delafield, of Kew York. American translation edited by Albert H. Buck, Assistant Aural Surgeon to the New York Eye and Ear Infirmary. One volume, imperial 8vo, 1,106 pages, four hundred and thirty-one illustrations. Price, muslin, $9.00; leather, $10.00. "At once the most extended and valuable treatise on Histology which has yet appeared." — American Journal of the Medical Sciences. ' ' The translation of Mr. Powers covers 406 pages of the present edition ; but the remain- ing articles are translated by the American gentlemen above named. Nearly two-thirds, therefore, of the book are translated by Amer- icans, who are physicians especially interested in the departments which they have under- taken. In this there is evident advantage, as one who is already familiar with a subject is the more likely to grasp obscure points, which are perhaps rendered still more obscure by be- ing couched in a foreign idiom. There is also likely to be more freshness about an article thus translated than if it form, in the original, one of a large number, and by different au- thors, translated by a single individual ; for the weariness which must necessarily grow upon the translator of so large a volume, is not re- lieved by the increasing familiarity which he must acquire if the papers are all by the same author. " This series of papers, edited and in many instances written by Prof. Strieker, consti- tutes at once the most extended and most accurate treatise on Histology extant. And as the stud}' of Histology is a subject which admits only the latest and most accurate in- formation to its aid, this work must necessa- rily supersede all others. It becomes, therefore, absolutely indispensable to every histologist and physiologist in the world, as well as to all Griesinger, "W., M.D., physicians and surgeons who would pursue their departments with all the light of modern science." — Philadelphia Medical Times. '' The need of a work of this kind has been felt for some time past. The last edition of Kolliker contains points which he himself has altered in his later editions, which have not been translated. The publication of this work is destined to give increased zest to the study of minute anatomy, a study which is becom- ing a necessity to any one who desires to be a thoroughly educated physician. "We believe this book to be indispensable to any physician who desires to understand the present position of medical science, and to know, if not to find out for himself, the present knowledge of the minute anatomy of the human body. The authors, as remarked before, are men who have devoted themselves to these studies, and do not limit themselves to communication of the facts, but in many places treat of the methods of obtaining good specimens for self-study. "As for the book itself, it has been pub- lished in good style. The type is clear, the wood-cuts are equal to those of the German edition, and there are but few typographical errors."' — The Medical Record. " Every medical student and every scientific practitioner should study this work, as, better than any other in the English language, it ex- hibits what has been demonstrated respecting the minute structure of the body." — Detroit Review of Medicine. at of Clinical Medicine and of Medical Science in the University of Berlin : Honorary Member of the Medico-Phyaiolotrical Association; Membre Associe Etranger de la Societe Medico-Pbysiolo* de Pari*, etc., etc. MENTAL PATHdLOGY AND THERAPEUTICS. Translated from the German by C. LO( kji\i:t Robertson, M.D. Cantab., Medical Superintendent of the Sus- Lunatio Asylum, Hay wards Heath, and JAMES RUTHERFORD, M.D., Edin- burgh. Sold only by subscription. See page 54. Wood's Pocket Manuals. THE PBESOEIBEE'S MEMOEANDA. Price, $1.00. me of the compiler of this little work is iot given on the title-page. There is face, no introduction, and no claim to led l a want long felt.' This un- usual modesty caused ns to look over the book OUghly, anil we say that it is one o) thi a] little books of this cbarac- rhich lias appeared." — Buffalo Medical md Surgical Journal^ November, 1881. One volume, 32mo, 300 pages, muslin. "A convenient little pocket manual; dis- eases and accidents arranged in alphabetical order, and favorite prescriptions of well-known physicians given under each head." — Obstetric Oazette, November, 1881. " This is a convenient little book for hasty reference." — Therapeutic Gazette, November, 1881. PUBLICATIONS OF WILLIAM WOOD & COMPANY. 21 Microscopy. Brocklesby, John, A.M., Professor of Mathematics and Natural Philosophy in Trinity College, Hartford. THE AMATEUR MICROSCOPIST ; or, Views of the Microscopic World. A Hand- book of Microscopic Manipulation and Microscopic Objects. Illustrated with two hundred and forty-seven figures on wood and stone. One volume, 8vo, 144 pages, muslin. Price, $1.75. " A little book full of curious and interest- ing facts regarding the microscopic world." — Our Young Folks. "Published in very beautiful shape." — Evening Mail. '" It treats of the microscope, how to use it, and how to prepare microscopic objects for examination. . . . There are about two hundred and fifty illustrations beautifully ex- ecuted. " — Illinois Teacher. " The book is finely gotten up, and will be found useful to all teachers who desire to ex- tend their knowledge into this most interest- ing domain." — Kansas City Journal. Frey, Heinrich, Professor of Medicine in the University of Zurich. THE MICROSCOPE AND MICROSCOPICAL TECHNOLOGY. A Text-book for Physicians and Students. Translated and Edited by Geo. R. Cutter, M.D. , Surgeon New York Eye and Ear Infirmary ; Ophthalmic and Aural Surgeon to the St. Catherine and Williamsburg Hospitals, etc. , etc. Illustrated by three hundred and eighty-eight engravings on wood. One volume, Svo, 660 pages. Price, muslin, $6.00; or colored leather, $7.00. "In many respects we think this the best work on the microscope." — Detroit Review of Medicine. " A complete exposition of the subject, thoroughly indispensable to the practical mioroscopist. " — Chicago Medical Journal. " The work is presented very modestly, yet we find it not only very accurate in all its de- tails of process, but complete as regards varie- ty of topics treated. The condensed style of the author, the fairness of his nature, together with his understanding of histology, permit an unbiassed discussion of nearly all questions of microscopic anatomy, and many of obscure pathology. The rules for testing and select- ing an instrument are especially valuable to one about to purchase." — New York Journal of Medicine. "We conceive this work, of all others, par- ticularly fitted by its completeness and ar- rangement to serve the student, whether be- ginner or one far advanced. The best and most recent methods are here given in detail. The additions of the editor make this part of the work complete to the present time. Each tissue and organ is treated with a complete- ness limited only by the present progress of microscopic art. The translator and editor deserves the gratitude of the medical profes- sion for placing before an English reading public Dr. Frey's work, rendered still more valuable by his own judicious brackets." — Broion-SequarcVs Archives of Scientific and Practical Medicine. " Those who are familiar with Prey's admi- rable manual will feel grateful to Dr. Cutter for his very readable translation, which ena- bles our American and English students who are unacquainted with the German tongue to participate in the instructions of the renowned Zurich professor. These directions for inves- tigation possess an especial value to the Amer- ican observer, on account of the explicit manner in which are described the manifold improved methods of demonstrating the vari- ous structures in their healthy or diseased conditions. To sum up all, we think that this handsome volume is one which the working microscopist cannot afford to do without. " — Philadelphia Medical Times. "We advise all commencing the study of microscopy to purchase Frey on the Micro- scope." — Buffalo Medical and Surgical Jour rial. " It is a pleasure, indeed, to call the atten- tion of the profession to this very superior work With this excellent work the beginner and the expert possess all that can be desired for the prosecution of their studies and inves- tigations." — Richmond and Louisville Medical Journal, Carpenter, Wm. B,, C.B., M.D., LL.D. THE MICROSCOPE AND ITS REVELATIONS. Sixth Edition.. Volume I. Illustrated by one colored and twenty- six plain plates, and five hun- dred and two fine wood-engravings. Volume II. Illustrated with twenty-six plates and five hundred and two fine wood-engravings. Sold only by subscription. See page 53. 22 PUBLICATIONS OF WILLIAM WOOD & COMPANY. Foods, Poisons, Surgery. Pavy, F. W., M.D., F.S. A TREATISE ON FOOD AND DIETETICS. Second Edition. Sold only by sub- scription. See page 55. Blyth, A. W., M.R.C.S. THE ANALYSIS OF FOODS AND THE DETECTION OF POISONS. With il- lustrations. One volume, 12mo, 463 pages, muslin. Price, $1.00. ''This work consists of two. parts. One devoted to the Analysis of the principal arti- cles of Diet in daily use ; the otiier to the Detection and Estimation of Poisons, organic and inorganic. In the first portion the author has endeavored to give a clear and concise account of the various Foods and Beverages, with the best and most recent Methods for the Detection of any Adulterations. A few of the more important legal cases are detailed, where their bearing on the subject renders them helpful ; and to every article is appended a Bibliography of the works and papers con- sulted. In the Second Portion, the arrangement of the Organic Poisons is simply that which sug- gests itself naturally into methodical investi- gation — the more volatile Poisons, those that are obtained by processes of distillation, being considered first ; and in the second place, those extracted by alcoholic or ethereal sol- vents. The Inorganic Poison*, finally, are taken in the order in which they may most conveniently be sought." — Extract from Pref- ace. "Will be used by every analyst." — The Lancet. " A work full of great interest . . . the method of treatment excellent." — Westmiu-- ster Review. " Stands unrivalled for completeness of in- formation. ... A really practical hand- book. " — Sanitary Record. " The whole work is full of useful practical information. " — Chemical News. Hamilton, Frank Hastings, A.M., M.D., LL.B., Professor of the Practice of Surgery, with Operations, and of Clinical Snrgery, in Bellevue Hospital Medical College ; Visiting Surgeon to Bellevue Hospital ; Consulting Surgeon to Bureau of Surgical and Medical Relief for the Out-door Poor, at Bel'evue Hospital ; to the Central Dispensary ; and to the Hospital for the Kuptured and Crippled ; Fellow of the New York Academy of Medicine, etc. THE PRINCIPLES AND PRACTICE OF SURGERY. Illustrated with four hun- dred and sixty-seven engravings on wood. One volume, royal 8vo, 954 pages. Price, in muslin, $7.00, or in leather, $8.00. "Has evidently been prepared with the greatest care, both on the part of the author and his publishers ; and as a text-book for the student it reflects the highest credit upon its well-known and gifted writer. As a text- book for the student, or one of reference for the busy practitioner, it undoubtedly is one of Che beat and most modern that has yet ap- peared." — The Medical Record. "A valuable addition to our list of text- books, an excellent work of reference, a credit to our professional literature." — New York .)/. dical Journal, " It will be found an excellent and common- nense volume. " — London Medical I'imes and ■ tie. "This is one of the best text-books upon surgery which we have ever seen, and we rec- ommend it highly to the profession." — Chicago Mi dical Examiner. "Professor Hamilton's latest work is one that will add to his already high reputation. . . . It is full of valuable practical sug- gestions and directions." — American Journal of the Mednal Sciences. "American in plan, scientific in method, written in clear, concise, classical English, Professor Hamilton's Surgery is a noble lega- cy to the medical student, an honor to the profession, and an ornament to our native tongpe. " — Detroit Review of Medicine. Keetley, C. B., F.R.C.S., K.-nior Surgeon to the West London Hospital ; Surgeon to the Surgical Aid Society. AX INDEX OF SURGERY. Being a Con, is,. Classification of the Main Facts and Theories 7 pages. Price, muslin, $4.00 ; leather, $5.00. " Successful as the work has been at home guagee. We congratulate the author upon and abroad, we were not prepared to see it this high compliment paid to his labors in the achieve a success exceedingly rare in the his- still new field of uterine pathology, where so tory of American medical authorship, viz., a many struggle vainly for reputation. " — Atner- tiion into the French and. German Ian- ■ ican Medical Times. Garrigues, Henry Jacques, A.M., M.D., Obstetric Sturgeon to the Maternity jlospital ; Physician to the Gynecologicnl Department of tbe Ger- man Dispensary; Fellow of the American Gynecological Society; Fellow of the New York Obstet- rical Bode) I DIA GNOSIS OF OVARIAN CYSTS BY MEANS OF THE EXAMINATION OF Til Kill CONTENTS. One volume, «vo, 112 pages, illustrated, muslin. Price, $1.26. PUBLICATIONS OF WILLIAM WOOD & COMPANY. av Diseases of Women. Verrier, E., M.D. PRACTICAL MANUAL OF OBSTETRICS. Fourth edition, enlarged and revised, with four Obstetric Tables of Professor Pajot. First American edition, with re- vision and annotations by Edward L. Partridge, M.D., Professor of Obstetrics in the New York Post-Graduate Medical School. One volume, 8vo, 420 pages, illustrated by one hundred and five wood-engravings. Fine muslin binding. Sold by subscription only. See page 52. Braun, Dr. Carl R., Professor of Midwifery, Vienna. THE UREMIC CONVULSIONS OF PREGNANCY, PARTURITION, AND CHILDBED. Translated from the German, with notes, by J. Matthews Dun- can, F.R.C.P.E., Lecturer on Midwifery, etc. One volume, 12mo, 182 pages, muslin. Price, $1.00. lv It contains, in a condensed form, the most complete and reliable history of this affection yet published." — New York Journal of Medi- cine. "We advise all who feel interested in the subject to procure it, as it will fully repay the perusal." — St. Louis Medical and Surgical Journal. "A most valuable essay, and one that will not be easily rivalled for its completeness and erudition." — Dublin Medical Press. Byford, William H., A.M., M.D., Professor of Obstetrics and Diseases of Women and Children in the Chicago Medical College, etc., etc. ; author of ''The Practice of Medicine and Surgery applied to the Diseases and Accidents incident to Women ; " " Chronic Inflammation of the Unimpregnated Uterus," etc., etc. A TREATISE ON THE THEORY AND PRACTICE OF OBSTETRICS. Illus- trated with one hundred and fifty wood-engravings. One volume, 8vo, 469 pages, muslin. Price, $3.75. " Professor Byford has been long and favor- | art in the most available form. It is complete, ably known to the professional public by his though not large ; it is full and perfect, and numerous communications to the medical press, his previously published elaborate books, and by his widely extended private and con- sultative practice. . . . Professor Byford's book is fully up to the times, and a successful exposition of the subject." — Chicago Medical Journal. " Byford's Obstetrics affords the student and practitioner the science and practice of the still is compressed into comparatively small space. It contains what is known, and com- mends itself to the profession, and especially to medical students, by its plain, well-con- sidered, complete teachings. Everything that can be said in favor of any work on this sub- ject can be said of it." — Buffalo Medical Jour- nal. Klob, Julius M., M.D., Professor at the University of Vienna. PATHOLOGICAL ANATOMY OF THE FEMALE SEXUAL ORGANS. Trans- lated from the German by Joseph Kammerer, M.D., Physician to the German Hospital and Dispensary, New York ; and Benjamin F. Dawson, M.D., As- sistant to the Chair of Obstetrics in the College of Physicians and Surgeons, New York. One volume, 8vo, 299 pages, muslin. Price, $3.50. Chapman, Edwin Nesbit, M.D., Late Professor of Obstetrics, Diseases of Women and Children, and Clinical Midwifery in the Long Island College Hospital. HYSTEROLOGY : A Treatise, Descriptive and Clinical, on the Diseases and the Displacements of the Uterus. Illustrated with superior woodcuts. One volume, 8vo, 504 pages, muslin. Price, $4.50. " His book is well worth reading. It is emi- i " He has contributed valuable clinical cases, nently clinical." — London Medical Times and and his treatment appears satisfactory in most Gazette. \ instances. '' — Buffalo Med. and Surg. Journal. 28 PUBLICATIONS OF WILLIAM WOOD & COMPANY. Diseases of Women. Emmet, Thomas Addis, M.D., Surgeon-in-Ch:ef of the New York State Woman's Hospital, etc., etc. VESICOVAGINAL FISTULA FROM PARTURITION AND OTHER CAUSES ; with Cases of Recto vaginal Fistula. Illustrated with wood-engravings. One volume, 8vo, 250 pages, muslin. Price, $2.75. '■ A careful and painstaking record of many ' " No work of its size has so much enriched cases of vesico-vaginal fistula, arising from all the literature of gynecology as this one." — sorts of causes. The operations necessary in Medical Record. each case are clearly described." — Medical] "As to the physique of the book, if we Times and Gazette. have any fault to find, it is with the elegance "Certainly no one is more competent to of its workmanship and costume, in which re- give an opinion in the matter than Dr. Emmet, spect it puts to blush its shelf- companions." — for his experience has been great indeed" — ■ Pacific Medical and Surgical Journal. Cincinnati Medical Repertory. Brown, W. Symington, M.D., Member of the Gynaecological Society of Boston ; Fellow of the Massachusetts Medical Society, etc. A CLINICAL HANDBOOK ON THE DISEASES OF WOMEN. Illustrated with wood-engravings. One volume, 8vo, 247 pages, muslin. Price, $2.50. " The author writes with great simplicity | a master of his subject, and chooses, off-hand, of diction, his style much resembling that of a the shortest route to the understanding of his clear-headed and ready clinical lecturer who is | hearers." — Louisville Medical News. Tilt, Edward John, M.D. A HANDBOOK OF UTERINE THERAPEUTICS AND DISEASES OF WOMEN. Fourth Edition. Sold only by subscription. See page 55. Tait, Lawson, M.D. DISEASES OF WOMEN. A new edition, with considerable additions, prepared by the Author expressly for Wood's Library. This very compact, \iseful book makes a volume of 204 pages, with illustrations. Sold only by subscription. See page 57. Fritsch, Heinrich, M.D., Professor of Gynecology and Obstetrics at the University of Halle. THE DISEASES OF WOMEN. A Manual for Physicians and Students. Trans- lated by Isidore Furst. Illustrated with one hundred and fifty fine wood- engravings. Sold only by subscription. See page 53. Savage, Henry, M.D., Fellow of the Boyal Colloge of Surgeons of England, one of the Consulting Medical Officers of the Sa- maritan Hospital for Women. THE SURGERY. SURGICAL PATHOLOGY, AND SURGICAL ANATOMY OF THE FEMALE PELVIC ORGANS, in a Series of Plates taken from Nature, with Commentaries, Notes and Cases. Third Edition, revised and greatly ex- tended. Sold only by subscription. See page 56. Hart, D. Berry, M.D., Lecturer on Midwifery and Diseases of Women, School of Medicine, Edinburgh, etc., etc. ; and Barbour, A. H., M.D., -tant to the Professor of Midwifery, University of Edinburgh. MANUAL GE GYNECOLOGY. Volume I. Illustrated with eight plates, two of which are in colors, and one hundred and ninety-two fine wood-engravings. Sold only by subscription. See page 58. Volume II. Illustrated with a lithographic plate and two hundred and nine fine wood-engravings. Sold only by subscription. See page 53. PUBLICATIONS OF WILLIAM WOOD & COMPANY. 29 Diseases of Children, etc. West, Charles, M.D. HOW TO NURSE SICK CHILDREN: Intended especially as a Help to the Nurses at the Hospital for Sick Children ; but containing directions that may be found of service to all who have the charge of the young. One volume, l8mo, mus- lin. Price, 50c. " Should be in the hands of every one who has charge of children." — Western Lancet. "It is beyond value. " — Nelson's American Lancet. Smith, Eustace, M.D., Fellow of the Royal College of Physicians ; Physician to his Majesty the King of the Belgians ; Physi- cian to the East London Children's Hospital, and to the Victoria Park Hospital for Diseases of the Chest. A PRACTICAL TREATISE ON DISEASE IN CHILDREN. pages. Price, in cloth, $5.00; in leather, $6.00. One 8vo volume, 868 "No medical writer has written so well upon the wasting diseases of children as Dr. Smith. These affections are exceedingly common, and often baffle the best efforts of the physician. "In preparing a fourth edition of this work for the press, the text has been revised and many alterations and additions have been in- troduced. Every care, however, has been taken to maintain the practical character of the book, so that it may continue to be a safe guide to the management of some of the com- monest, but not the least fatal, maladies of hance its practical worth. The subjects con- sidered are : — Simple Atrophy from Insuffi- cient Nourishment— Chronic Diarrhoea, Chron- ic Vomiting — Rickets — Inherited Syphilis — Worms — Chronic Pulmonary Phthisis — Casea- tion of Lymphatic Glands — Diet of Children in Health and Disease. Some reviewers have criticised the chapter on diet as being "too elaborate " but we consider it not elaborate but complete." — Chicago Medical Times, July, 1S85. "The author is a clear, concise writer, and early life. Every physician should have a j leaves no doubt about the idea he intends to copy of the work in his library." — The Cincin- ' convey. One of the most valuable chapters in nati Medical News, June, 1885. I the book is that upon inherited syphilis. This " Dealing with a comprehensive group of disease is so prevalent, and especially in cities, diseases characterized by wasting, it becomes that a full discussion of this subject is at all an invaluable aid to diagnosis in those often obscure cases. It is especially valuable to the times valuable. " Dr. Smith has spoken in such language as practitioner in large cities, or perhaps we might | to leave no mistake about the diagnosis of the more truly say to the practitioner wherever he J disease, and this is a point which cannot be may be located, who has to deal with infant overestimated, as the difficulty of making a constitutions which have been wrecked by city diagnosis of the disease is often very great, life. The book is full of subsidiary informa- ... There is no better book of the kind in tion, and, dealing as it does with diseases the English language, and we advise our friends characterized largely by mal-nutrition, con- to procure it at once, as it is fully abreast of tains the most carefully elaborated and sue- the times and a most valuable contribution to cessfully tested systems of feeding." — The a library." — The Medical Herald, Louisville, Therapeutic Gazette, Detroit, Mich., July, Ky., July, 18b5. 1885. " The great importance of the subject " This is a standard work. . . . It is treated, the sound judgment exhibited in the the book to which the author owes, in a large ; directions as to treatment, and the charming measure, his great reputation in pediatric medi- style of writing, render it, in our opinion, the cine, and if he had written no other, would have been sufficient to support his fame. . . . Each section of the work is developed with con- scientious attention to every essential detail, and while nothing relative to the pathology and clinical history of the affections named is omitted, the great question of constructive therapeutics is kept ever in the foreground, and discussed in all its bearings after the manner of one who has mastered this difficult problem in infantile medicine." — Louisville Medical News, July 11, 1885. most interesting and useful book of the kind that has ever been published." — The Canadian Practitioner, Toronto, August, 1885. "The chapters devoted to nursing and diet are exceptionally rich in valuable suggestions drawn from a wide and intelligently observ- ant experience." — The Ncvj England Medical Gazette, August. 1885. ". . . full of facts pertaining to the lat- est development of this portion of medicine, all expressed in the language of a master of this study and an excellent teacher. The por- " This edition does not depart from the tion pertaining to infant feeding cannot be practical character of the former editions, but read too often or too carefully." — Detroit Lan- whatever has been added is calculated to en- ' cet, August, 1885. Ellis, Edward, M.D. A PRACTICAL MANUAL OF THE DISEASES OF CHILDREN, with a Formu- lary. Third Edition. This standard book makes a volume of 225 pages. Sold only by subscription. See p ige 57. 30 PUBLICATIONS OF WILLIAM \YOOD & COMPANY. Diseases of Children, of the Eye, Anatomy. Henoch, Dr. Edward, Director of the Clinic and Polyclinic for Diseases of Children in the Royal Charite Hospital, and Pro- fessor in the Berlin University. LECTURES ON DISEASES OF CHILDREN. A Handbook for Physicians and Students. Translated from the German. Sold only by subscription. See page 54. Routh, C. H. F., M.D. INFANT FEEDING, AND ITS INFLUENCE ON LIFE ; or, The Causes and Pre- vention of Infant Mortality. Third Edition. This unique work forms a volume of 286 pages in Wood's Library. Sold only by subscription. See page 57. Dwight, Thomas, A.M., M.D., Instructor in Topographical Anatomy and Histology in Harvard University ; Fellow of the American Academy of Arts and Sciences ; Snrgeon at the Carney Hospital. FROZEN SECTIONS OF A CHILD. Fifteen full-page lithographic plates, draw- ings from nature by H. P. Qdincy, M.D. One volume, royal 8vo, 66 pages, muslin. Price, $3.00. " This book possesses the great merit nowa- | gans are no longer those of an infant, and not days i if originality. The plates are pen draw- I yet those of an adult. The sections from ings from sections of the body of a girl said to which these drawings are made begin at the be three years old, and are beautifully and neck, and continue, about and inch apart, graphically executed. They possess peculiar through the trunk. For the student and for attractions to the anatomist from the fact, : the practitioner this book will prove interest- stated in the preface, that at three years of ing and practically useful." age the proportions of the body and of the or- j Mauthner, Ludwig, Royal Professor of the University of Vienna. THE SYMPATHETIC DISEASES OF THE EYE. Translated from the German by Warren Webster, M.D., Surgeon United States Army, and James A. Spauldixo, M.D., Member of the American Ophthalmological Society ; Ophthalmic Surgeon to the Maine General Hospital. One volume, 12mo, 220 pages, muslin. Price, $2.00. "In eo far as regards the subject of this reliable description of the multiform symp- monograph, we may truly say that it is one of toms, and the treatment of sympathetic the most important with which the oculist is ophthalmia, so that they may at once recog- i vex I'oncerneA Upon his correct judgment nize its presence, and treat it from the outset will generally depend the future vision of the appropriately and effectually. Although cases patient. Much more orgeat, therefore, must of this nature are comparatively rare, their -ity for general practitioners in importance is sufficiently great to account for the country, and for medical officers of the the appearance of this excellent work in an army and navy, to have at hand a clear and English version." Noyes, Henry D., M.D., Profe or of Ophthalmology and Otology in Bellevuc Hospital Medical College ; Surgeon to the New Fork Bye and Bar Infirmary, i DISEASES OF THE EYE. Illustrated by two chromo-lithographs and numerous > l-<'Ogravings. Sold only by subscription. See page 55. I This treatise will be written with a special view to the needs of the general practi- tioner, and treats the subject in a very plain, practical way. Foote, John, M.D., Surgeons In London ; Corresponding Member of the Pharmaceutical and formerly Surgeon to the Cholera Hospital at St. Ilelier's, Jersey. OP HTHA LMIC MEMORANDA : RESPECTING THOSE DISEASES OF THE EYE WHICH AIM-; MORE FREQUENTLY MET WITH IN PRACTICE. One vol- ume, 18mo, 135 pages, muslin. Price, 50 cents. PUBLICATIONS OF WILLIAM WOOD & COMPANY. 31 Diseases of the Eye. Stellwag (von Carion), Dr. Carl, Professor of Ophthalmology in the Imperial Royal University of Vienna. TREATISE ON THE DISEASES OF THE EYE, INCLUDING THE ANATOMY OF THE ORGAN. Translated from the fourth German edition, and edited by D. B. St. John Roosa, M.D., Clinical Professor of the Diseases of the Eye and Ear in the University of the City of New York ; Surgeon to the Manhattan Eye and Ear Hospital ; Charles S. Bull, M. D., formerly Assistant Surgeon to the Manhattan Eye and Ear Hospital ; Clinical Assistant in the New York Eye and Ear Infirmary, etc. ; and Charles E. Hackley, M.D., Clinical Professor of the Diseases of the Eye and Ear in the Woman's Medical College of the New York Infirmary ; Surgeon to the New York Eye and Ear Infirmary. One volume, imperial 8vo, 915 pages, illustrated by wood-engravings and chromo-lithographs. Price, muslin, $5.00 ; leather, $6.00. " It should be in the hands of every medical man, and no one can safely practise ophthal- mology who does not regard the subject from a standpoint at least as high as Stellwag occu- pies." — New York Medical Journal. " This is one of those complete, exhaustive, magnificent monographs which we may look for in vain outside of Germany. All that modern science has lent to the diagnosis, all that the most careful observation has con- tributed to the treatment, and all that the most patient research has furnished to the pathology of diseases of the eye, are gathered together in this comprehensive volume." — Philadelphia Medical and Surgical Heporter. '*' We must reluctantly content ourselves with a simple indorsement of this book, as the most complete and trustworthy compen- dium of ophthalmology that has been offered to American physicians since the appearance, many years ago, of the great, but now, in many respects, obsolete works of Mackenzie and Lawrence." — St. Louis Medical and Sur- gical Journal. "' Of the work, as a whole, it is scarcely necessary that we should speak. A third edition of a book of such magnitude means in Germany very much what it would mean in England, that the ordeal of criticism had been passed successfully ; and the translators are fully justified in calling it ' a text-book which is regarded as one of the best in the German language.' It deals fully and accu- rately with every branch of the subject to which it relates." — London Lancet. "The rapid advance, by the united laborsv of Graefe, Helmholtz, Donders, Stellwag, and others, the science has made in the last six- teen years, very naturally led us to look to Germany for the first appearance of a system- atic treatise which should embody the pres- ent'advanced stage ot ophthalmic medicine and surgery. Prof. Stellwag has furnished us with such a treatise. It is a library in itself, and should be in the hands of every man." — Detroit Review of Medicine and Pharmacy. " It is indeed a great work, and will take its place as a standard authority in every medical library." — Pacific Medical and Surgical Jour- nal. " We have no hesitation in saying that this work, as a whole, is far the best which has yet appeared in English ; and as a book of refer- ence for the consultation of authority in mat- ters pertaining to the eye, is probably without its superior, even if it has its equal in any lan- guage." — American Journal of the Medical Sciences. Roosa, D. B. St. John, M.D., and Ely, Edward T., M.D. OPHTHALMIC AND OTIC MEMORANDA. One volume, 18mo, 298 pages, mus- lin. Price, $1.00. (Wood's Pocket Manuals.) " It must prove an extremely useful work to general practitioners, containing, as it does, the cream of the subject." — Clinic. "This small book, though containing only 280 pag»'S, gives most of the important points in both ophthalmology and otology. Its style is very concise, though not devoid of clear- ness." — Lancet and Observer. "Asa concise treatise on the diseases of the eye and ear, the ' Memorandum ' is all that could be desired. It fulfils all that its authors promise."— Western Lancet. "We have rarely seen so small a book em- bracing so much." — Philadelphia Medical Times. Knapp, H., M.D., Late Professor of Ophthalmology, and Surgeon to the Ophthalmic Hospital in Heidelberg. A TREATISE ON INTRAOCULAR TUMORS. FROM ORIGINAL CLINICAL OB- SERVATIONS AND ANATOMICAL INVESTIGATIONS. With one chromo- lithographic and fifteen lithographic plates, containing very many figures. Translated by S. Cole, M.D., of Chicago. One volume, octavo, 323 pages, muslin. Price, $3.75. 32 PUBLICATIONS OF WILLIAM WOOD A COMPANY. Diseases of the Eye and Ear. De Wecker, L., M.D., Trofessor of Clinical Ophthalmology, Paris. OCULAR THERAPEUTICS. Translated and Edited by Litton Forbes, M.A., M.D., F.R.G.S. , Late Clinical Assistant Royal London Ophthalmic Hospital. One volume, 8vo, 552 pages, illustrated, muslin. Price, $4.00. "Dr. De Wecker has written a very in- I undoubted genius of the author, his great teresting volume, and Dr. Litton Forbes has operative skill, his vast experience, and the done good service in rendering it into excel- many advances in the treatment of eye affec- lent English. At whatever page it is opened ; tions which have undoubtedly had their source the reader will find something to interest him i in the originality and inventive power of Dr. — something novel, or some new application of ! De Wecker. Coming from such a pen, care- old knowledge. In their chatty and agreeable ; fully revised and condensed, these lectures style these lectures remind us strongly of those will be read with avidity by all workers in this of Trousseau." — The Lancet. j branch of surgery, and hence it is not a matter 4 ' We do not exaggerate the importance of i for surprise that already they have been trans- this work when we assert that it marks an era lated into Italian and Spanish, and are about in opbthalmological science. The rapid ad- to be issued in Germany." — Dublin Journal vauce in this special field, especially on the of Medical Sciences. Continent, within the past few years, renders " Here we have the fruits of an exceptionally the appearance of this translation of Dr. ; large experience, and the matured judgment of Forbes peculiarly opportune ; and this is one one who has contributed largely to the recent of the peculiar attractions of this work, that advances made in this branch of medicine." — it is written with a terseness and perspicuity Glasgow Medical Journal. which render it easy of comprehension to the " We do not know that we ever read a work general practitioner, while it must prove of on any suhject with greater pleasure or more equal utility to the special worker, dealing as it does with many of the questions of practical interest which have agitated the minds of oph- thalmic surgeons for some time past ; and this value is heightened when we remember the Buck, Albert H., M.D., profit. It is a splendid rhume of modern oph- thalmological science. It sheds still greater lustre on the name of its illustrious author, while it reflects the greatest credit on the able translator." — Dublin Medical Journal. Instructor in Otology in the College of Physicians and Surgeon?, New York , Aural Surgeon to the New York Eye and Ear Infirmary ; Editor of Ziemssen's Cyclopaedia of the Practice of Medicine ; Editor of Reference Handbook of the Medical Sciences ; and Editor of " A Treatise on Hvgiene and Public Health. - ' DIAGNOSIS AND TREATMENT OF DISEASES OF THE EAR. subscription. See page 56. Sold onlv bv Allen, Peter, M.D., Fellow of the Royal College of Surgeons, England : Aural Surgeon to and Lecturer on Aural Surgery at St. Mary's Hospital ; Aural Surgeon to the Royal Society of Musicians; Late Surgeon to the Metro- politan Ear Infirmary, Sackville Street. LECTURES ON AURAL CATARRH ; OR, THE COMMONEST FORMS OF DEAF- NESS AND THEIR CURE. (Mostly delivered at St. Mary's Hospital.) One volume, 12mo, 277 pages, illustrated, muslin. Price, $2.00. " Full of valuable information for the gen- eral practitioner. We find here an explanation of manv conditions which are often overlooked or misinterpreted by others than those who de- mote themselves to the specialty of aural dis- American Journal of Insanity. " It forms one of the most reliable manuals Aural Catarrh that can be placed in the hands of the practitioner. ... It will be of immense service to the general practitioner, enabling him to treat the most ordinary cases of deafness with confidence, and to prevent the more serious ones from attaining that con- dition which eventually renders them insus- ceptible of amelioration, even by the most in- telligently directed efforts. It is a work, then, admirably adapted to the requirements of gen- eral practice, and one which we especially recommend to the student in otology and to the busy practitioner." — The Medical Iiecord. " Aural Catarrh in all its various forms, and in its complications with the throat, is treated of in a manner at once interesting and satis- factory. It is quite up to the improvements of the present day." — Cincinnati Lancet. Helmholtz, H., Professor of Physiology In the University of Berlin, Prussia. THi: MECHANISM OF THE OSSICLES OF THE EAR AND MEMBRANA TYM- I'A NT. Translated from the German, with the Author's Permission, by Albert II in ik and NOBHAND Smith, of New York. One volume, octavo, 69 pages, illustrated, muslin. Price, $1.25. PUBLICATIONS OF WILLIAM WOOD & COMPANY. 35 Diseases of the Ear, Throat and Nose. Roosa, D. B. St. John, M.D., Professor of Diseases of the Eye and Ear in the University of the City of New York ; Surgeon to the Man- hattan Eye and Ear Hospital ; Consulting Surgeon to the Brooklyn Eye and Ear Hospital ; formerly President of the Medical Society of the State of New York; Corresponding Member of the Medico- Chirurgical Society of Edinburgh ; Member of the Medical Society of the County of New York, etc. A PRACTICAL TREATISE ON THE DISEASES OF THE EAR, INCLUDING THE ANATOMY OF THE ORGAN. Sixth Edition. One volume, 8vo, 740 pages. Illustrated by 140 wood-engravings and chromo-lithographs. Price, muslin, $5.50; leather, $6.50. "If any one has the right to speak authori- tatively upon otological matters, it is Dr. Roosa, for it is he who, more than any one else, has made known to the American medi- cal profession the general principles of treat- ment of aural diseases ; and it is safe to say that no book upon any special subject has been more widely distributed throughout the country than has his admirable treatise. If this work be carefully studied, it will be seen that two main ideas run through the whole of what has been written ; first, that a skilful treatment of ear-troubles involves a consum- mate knowledge of general medicine ; second, that the measure of success is determined by the thoroughness which the practitioner brings to the examination of his cases, before apply- ing his simple armamentarium. "It is carefully inculcated that nothing is to be done without a knowledge of what is re- quired, and that practice ' in the dark ' (tenta- tive practice) is less justifiable in this branch of medicine than in any other." — The Medical Record. Bosworth, Franke Huntington, M.D., Lecturer on Diseases of the Throat in the Bellevue Hospital Medical College, and Physician in Charge of the Clinic for Diseases of the Throat in the Out-Door Department of Bellevue Hospital : Fel- low of the New York Academy of Medicine, of the American Laryngological Association, and Mem- ber of the Medical Society of the County of New York. A MANUAL OF DISEASES OF THE THROAT AND NOSE. One volume, octavo, 448 pages. Illustrated with, wood-engravings. Muslin. Price, $3.25. "The author has done his work well, and in j "A work On this subject, intended more clear and expressive language gives the result especially for the general practitioner than the of his by no means small experience. . . , The i specialist, is what is wanted, and Dr. Bos- work, like most emanating from the other side of the Atlantic, is well gotten up, paper, type, and woodcuts being excellent." — Edinburgh Medical Journal. " The book is an excellent specimen of book making, and Dr. Bosworth has honored him- self and the profession by writing it." — The American Practitioner. " The author gives us a book as instructive as it is interesting, not alone to the specialist, but to the general practitioner as well." — St. Louis Clinical Record. worth has been fortunate in the manner in which he has approached the subject. His handling of it, moreover, has been both able and judicious — a statement which an examina- tion of the book is sufficient to substantiate." — Michigan Medical News. 1 ' There are a thousand excellent hints in this volume, which is an eminently practical! manual, equally creditable to author and pub- lisher, well illustrated, altogether a work to be recommended to both student and practi- tioner." — The Canada Lancet. Van Troeltsche, A. DISEASES OF THE EAR IN CHILDREN. Price, $1.50. Salter, Henry Hyde, M.D., Fellow of the Royal College of Physicians; Physician to Charing Cross Hospital, and Lecturer on the Principles and Practice of Medicine, at the Charing Cross Hospital Medical School. ON ASTHMA : ITS PATHOLOGY AND TREATMENT. Sold only by subscription. See page 54. See, Germain, Member of the Faculty of Medicine; Member of the Academy of Medicine; Physician to the Hotel Dieu. etc., Paris. DISEASES OF THE LUNGS, OF A SPECIFIC, NON-TUBERCULOUS NATURE. Acute Bronchitis, Infectious Pneumonia, Gangrene, Syphilis, Cancer, and Hy- datids of the Lungs. Translated by E. P. Hurd, M.D., Member of the Massa- chusetts Medical Society ; Vice-President of the Essex North District Medical Society ; One of the Physicians to the Anna Jaques Hospital, Newburyport, Mass. With an Appendix by the Translator on the German Theory of Disease, and on the Tubercle Bacillus. Sold by subscription only. See page 51. $W One of the most valuable works on the subject of recent times, fully up to date. 3 34 PUBLICATIONS OF WILLIAM WOOD & COMPANY. Diseases of the Xas-al Cavities, Larynx, etc. Semeleder, Dr. Friedrich, Physician in Ordinary to his Majesty, the Emperor of Mexico ; Member of the Royal Medical Society of Vienna and of the Medical Society of Pantheon in Paris ; Formerly Member of the Medical Faculty of the University of Vienna, and Surgeon to the Branch Hospital at Gumpendorf. RHINOSCOPY AND LARYNGOSCOPY ; THEIR VALUE IN PRACTICAL MEDI- CINE. Translated from the German by Edward T. Caswell, M.D. With woodcuts and two chronio-lithographic plates. One volume, octavo, 191 pages, muslin. Price, $3.25. . . . " In a somewhat careful reading of this of the professional public to whom it comes." book, we have found much that is of practical — New York Medical Journal. value, and we believe this will be the verdict I Mackenzie, Morell, M.D., London. DISEASES OF THE PHARYNX, LARYNX, AND TRACHEA. Illustrated by 112 fine wood-engravings. Sold only by subscription. See page 56. Robinson, Beverley, A.M., M.D. (Paris), Lecturer upon Clinical Medicine at the Bellevue Hospital Medical College, New York; Physician to St. Luke's and Charity Hospitals, etc. A PRACTICAL TREATISE ON NASAL CATARRH. One volume, 8vo, illus- trated Price, muslin, §2.50. "Among the man)- recent contributions to "The author presents, in good readable the literature of the above subject this seems style, his opinions as to the diagnosis and to be superior to them all." — Southern Clinic, treatment of this stubborn and disheartening "The book is well written, concise, clear, disease. Aside from the more distinctly pro- and freely illustrated." — Chicago Medical fessional suggestions, he gives excellent com- X' W8. mon-sense advice in regard to matters not "Its teachings are mainly original, but a usually dwelt upon in treatises on disease of free comparison of the methods of other au- the nasal cavity. " — American Specialist. thors are discussed in relation to treatment, etc." — Arkansas Medical Monthly. James, Prosser, M.D. LARYNGOSCOPY AND RHINOSCOPY IN DIAGNOSIS AND TREATMENT OF DISEASES OF THE THROAT AND NOSE. Fourth edition, enlarged, one volume, 8vo, 223 pages. Illustrated with wood-engravings, and five hand-col- oivd plates, muslin. Price, $2.25. Jacobi, A., M.D., Clinical Professor of Diseases of Children in the Collru'.- of Physicians and Surgeons. New York ; Phy- sician to Bellevne, Mount Sinai, and the German Hospitals, etc. A TREATISE ON DIPHTHERIA. One volume, octavo, 252 pages, muslin. Trice, $2.00. " We regard Dr. Jacobi's work as one of the to thoroughly appreciate it, it should be read, most valuable which has recently appeared on For this reason, we commend it to the profes- the subject." -Michigan Medical hew*. sion, and we guarantee no one will be disap- "The subject is handled by a master, and pointed." — Therapeutic Gazette. Ross, James, M.D., Hetnbex of the Royal College <■! Physicians, London; Assistant Physician to the Manchester Royal [nflrmary; < aysiclan to the Manchester Southern Hospital. A TEE \TI-i: ON THE DISEASES. OP THE NERVOUS SYSTEM. Second Edition, d and enlarged. Illustrated with Lithographs, photographs, and three hundred and thirty-two w leuts. Two volumes, 8 vo, 1,044 and 1,057 pages, muslin. Price, $15.00. "A full and accurate account of the Bub- and not a mere clinical digest. It is an en - bowing the author's mastery of the cyclopaedia of facts and of references to the whole domain of nervous maladies. " — The literature oi France, Germany, England, and Medical Net America. This work may be considered a "Indeed, it is a great treasure-house of mirror of the most authentic literature of this sta, and one which would be department."— New York Medical Journal. a positivi addition to any library. As a " It may be alleged that the student of ner- work of reference it is very valuable."— OaiU vous diseases will nowhere else find all the :/, dical Journal. facts brought together in a form so convenient La that of a history or an essay, and serviceable." — The Medical News. PUBLICATIONS OF WILLIAM WOOD & COMPANY. 35 Diseases of the Nervous System. Rosenthal, M., M.D., Professor of Diseases of the Nervous System at Vienna. A CLINICAL TREATISE ON THE DISEASES OF THE NEEVOUS SYSTEM. With a Preface by Professor Charcot. Translated from the Author's Revised and Enlarged Edition by L. Putzel, M.D., Visiting Physician for Nervous Diseases, Randall's Island Hospital ; Physician to the Class for Nervous Dis- eases, Bellevue Hospital Out-door Department, and Pathologist to the Lunatic Asylum, Black well's Island. Illustrated. One volume, 8vo, 555 pages, muslin. Price, $5.50. " For a treatise on diseases of the nervous system, there is no work better arranged or more scientifically executed. The author is identified with the more advanced discoveries and researches in this most difficult field of medical science, and we may safely assert that no other book will give more benefit or infor- mation on nervous diseases." — Atlanta Medi- cal and Surgical Journal. " Among the merits of this book worthy of special mention are its uniformity of plan and S3 r stematic divisions and subdivisions ; the well-chosen amount of space and attention which are devoted to each disease, the careful presentation of the subject of symptomatology, diagnosis, and prognosis, and the numerous concise reports of original pathological and his- tological observations." — Philadelphia Medi- cal Times. " The book has many merits, and much to commend it to the attention of the profession. This is especially true in regard to the classi- fication, thedescription of many diseases, and, on the whole, in regard to treatment." — Ar- chives of Medicine. " It is systematically arranged, and is writ- ten in a style that is plain, clear, and forci- ble ; is devoid of hypothetical speculations, and startling and remarkable cures." — The Missouri Dental Journal. "The great advances that have been made in the diagnosis, pathology, and treatment of nervous diseases of late years, have been noted in this treatise, and we cheerfully commend the book to the profession." — Southern Clinic. ' ' The work is one which neurologists will scan with interest." — Medical and Surgical Reporter. " This work of Rosenthal's has been a stand- ard on the diseases of the nervous system in Germany and Austria for a number of years, having gone through several editions. It has been translated into French, and received the commendations of French Neuro-pathologists, especially Professor Charcot, who is the au- thor of a preface to the American translation. The work is, as it purports to be, a clinical one, being especially full in the practical de- partments of symptomatology and treatment. The pathological descriptions are also made prominent, and axe unusually clear. The data furnished by clinical observations and patho- logical anatomy are explained as far as possi- ble by physiology, but Dr. Rosenthal devotes very little space to theories regarding physio- logical mechanism, differing in this respect from most recent writers on nervous dis- eases." — Toledo Medical and Surgical Jour- nal. Beard, George M., A.M., M.D., Fellow of the New York Academy of Medicine, of the New York Academy of Sciences ; Vice-President of the American Academy of Medicine; Member of the American Neurological Association, of the American Medical Association, the New York Neurological Society, etc. A PRACTICAL TREATISE ON NERVOUS EXHAUSTION (NEURASTHENIA^, ITS SYMPTOMS, NATURE, SEQUENCES, TREATMENT. New Edition. One volume, 8vo, 198 pages, muslin. Price, $1.75. " The book is written in the author's usual lucid style, and exhibits the results of original research in a most interesting department of medicine. The medical world owes to Dr. Beard its warmest admiration for the really good work which he has done in this special investigation, made in the neutral space be- tween clear physiological and pathological condition. " — Medical Record. "Dr. Beard has, more than any other writer of the day, contributed to establish the fact that grave appearance of local disease may exist without, in fact, having a local organic habitation, or requires a name dissevered from the general nervous system." — Alienist and Neurologist. "The merit incontestably belongs to Dr. Beard, of having proved, on a scientific basis, the existence of neurasthenia, and having de- fined the difference between this form of ner- vousness and that which is the expression of organic changes in the various departments of the nervous system. We can most urgently recommend to all physicians, and to nervous specialists, in particular, the work here briefly reviewed as the result of abundant practical experience, and of sharp critical observation." — Allgemeine Wiener Mcdiz. Zeitung. "The book is full of original research and observation, and all the points as to symp- toms, etiology, and treatment, are amply il- lustrated by cases which have come under the author's own observation." — Canada Medical and Surgical Journal. "The present work treats of the diseased condition which has, in the last decades, be- come so disseminated, not only in America, but also with us, in Germany, that every prac- titioner encounters it on his rounds, several times daily." — From the Preface of the Ger- man Translator. 30 PUBLICATIONS OF WILLIAM WOOD & COMPANY. Diseases of the Nerves, Apoplexy. Gowers, W. R., M.D., Assistant 1'rofessor of Clinical Medicine in University College ; Senior Assistant Physician to Univer- sity College Hospital ; Physician to the National Hospital for the Paralyzed and Epileptic. EPILEPSY AND OTHER CHRONIC CONVULSIVE DISEASES. Their Causes, Symptoms, and Treatment. Sold by subscription only. See page 51. DIAGNOSIS OF THE DISEASES OF THE BRAIN AND SPINAL CORD, by subscription only. See page 51. Sold Bramwell, B., DISEASES OF THE SPINAL CORD. Price, $5.00. Putzel, L., M.D., Visiting Physician for Nervous Diseases, Randall's Island Hospital ; Physician to the Class for Nervous Diseases. Bellevue Hospital Out-door Department ; and Pathologist to the Lunatic Asylum, Black- weirs Island. A TREATISE ON COMMON FORMS OF FUNCTIONAL NERVOUS DISEASES. Sold only by subscription. See page 56. Lidell, John A., A.M., M.D. A TREATISE ON APOPLEXY, CEREBRAL HEMORRHAGE, CEREBRAL EM- BOLISM, CEREBRAL GOUT, CEREBRAL RHEUMATISM, AND EPIDEMIC CEREBRO -SPINAL MENINGITIS. One volume, 8vo, 395 pages, muslin. Price, $4.00. "To all friends of ours who are engaged in the study or treatment of cerebral diseases, we cordially commend this work as the most com- plete and satisfactory of any that we have seen. The mechanical execution of the work is excellent." — Detroit Review. " We think the modest hope of the author, as expressed in the preface to this excellent monograph, that it will prove interesting and useful to those who read it, will be fully real- ized. . . . We heartily recommend the work of Dr. Lidell to the profession as one of very great value. ,: — Philadelphia Medical Times. Erichsen, John Eric, F.R.S., Surgeon Extraordinary to the Queen : Emeritus Professor of Clinical Surgery in University College, and Consulting Surgeon to the Hospital : Ex-President of the Royal College of Surgeons of Eng- land, and of the Royal Medical and Chirargical Society, etc. ON CONCUSSION OF THE SPINE, NERVOUS SHOCK, AND OTHER OB- SCURE INJURIES OF THE NERVOUS SYSTEM IN THEIR CLINICAL AND MEDICO-LEGAL ASPECTS. One volume, 12mo, 344 pages, muslin. Price, $2.25. The distinguished author in his preface ex- i railway collisions, they were not peculiar to plains the origin of this hook, as having been them, but might be the consequence of any of six lectures on certain obscure injuries of the the more ordinary accidents of civil life. As nervous system commonly met with as the re- : the work is now presented, it includes eight suit of shocks to the body, received in colli- additional lectures and has been expanded in hions on railways, His objects in the publica- scope to embrace a wider range of subjects. turn were to direct the attention of surgeons In view of the medico-legal aspects of this to a class of injuries that had hitherto been large, obscure, and important class of injuries I. it little Doted; to endeavor to throw some of the nervous system, this work is highly light on their true characters; and, lastly, to valuable, show that though they commonly arose from Eichet, Chas., A.M., M.D., Ph.D., Former Interne of the Bospita] of Paris, PHYSIOLOGY AND HISTOLOGY OF THE CEREBRAL CONVOLUTIONS; ALSO, POISONS OF THE INTELLECT. Translated by Edward P. Fowler, .Ml). One volume, 8vo, 170 pages, illustrated, muslin. Price, $1.50. "This is a wry thorough and eomprehen- I ebral convolutions goes, and more attention siv« treatise on the subject of which it treats, than usual is given to their structure." — thorough and complete as fara> the knowledge Michigan Medical News. of the arrangement and morphology of the cer- PUBLICATIONS OF WILLIAM WOOD & COMPANY. 37 Diseases of the Brain, Idiocy, etc. Benedikt, Moriz, Professor at Vienna. ANATOMICAL STUDIES UPON BRAINS OP CRIMINALS. A CONTRIBUTION TO ANTHROPOLOGY, MEDICINE, JURISPRUDENCE, AND. PSYCHOL- OGY. Translated from the German by E. P. Fowler, M.D., New York ; De- partment of Translation, New York Medico-Chirurgical Society. Illustrated with wood-engravings. One volume, 8vo, 185 pages, muslin. Price, $1.50. ' It is strictly scientific philanthropy, and lack of the sentiment of wrong, though with a clear perception of it, constitute the two principal psychological characteristics of a class to which belongs more than one-half of condemned criminals. "He shows deficiencies in the cerebral con- stitution of criminals, viz. : deficient gyrus development, and a consequent excess of fis- sures, which are fundamental defects. These defects are evident throughout the entire extent of the brain. The work is of great value." — Western Medical Reporter. reaches to the scope of true humanizing, Comprehending as it does the psychology of our existence, it lays hold on facts most per- tinent to the welfare of society, individually and collectively. In fact, it opens up a very broad and entirely neglected source of infinite study, and should awaken new research into mental phenomena. " Dr. Benedikt is of opinion that an inabil- ity to restrain themselves from the repetition of a crime, notwithstanding the full apprecia- tion of the superior power of the law, and a Charcot, J. M., Professor in the Faculty of Medicine of Paris ; Chief of the Salpetriere Hospital ; Member of the Aca- domie de Medecine, of the Clinical Society of London; President of the Societe Anatomique ; for- mer Vice-President of the Societe de Biologie, etc., etc. LECTURES ON LOCALIZATION IN DISEASE*S OP THE BRAIN. Delivered at the Faculte de Medecine, Paris, 1875. Edited by Botjrneville. Translated by Edward P. Fowler, M.D. , New York. Illustrated with forty-five fine wood-engravings. One volume, 8vo, 133 pages, muslin. Price, $1.50. " We heartily commend the book to all stu- i a model both of scrupulous exactitude in ren- dents of nerve disorders. In these lectures the ; dition of the original meaning, and as a clear matter is considered in the direction pointed j andunexceptional style of English." — Ameri- out by normal anatomy and experimental phys- can Journal of the Medical Sciences iology. But as supplementary to this, there is added clinical and pathological research." — Detroit Lancet. "Issued in excellent style, and with illus- trations so good that he may run that reads the lessons which they teach. Dr. Fowler's translation is endorsed by Charcot himself as Medical Record, " Anything from the pen or lips of M. Char- cot is at once treasured by the profession. This author has labored so assiduously in the field of cerebral localization, both alone and in collaboration with M. Pitres and others, that he is in a position to speak ex cathedra.' 1 '' — Hamilton, Allan McLane, M.D., One of the Consulting Physicians to the Insane Asylums of New York City, and the Hudson River State Hospital for the Insane. TYPES OF INSANITY. AN ILLUSTRATED GUIDE IN THE PHYSICAL DIAG- NOSIS OF MENTAL DISEASE. Price, $2.50. £2F" A collection of ten large plates from photographs of selected cases, with description, text, and an appendix, which will contain directions for the examination and commitment of patients. This work is a very fine series of studies, beautifully made, mounted on tinted hoard, and inclosed in a portfolio envelope. Seguin, Edward, M.D. IDIOCY AND ITS TREATMENT BY THE PHYSIOLOGICAL METHOD. One volume, 8vo,*457 pages, muslin. Price, $5.00. "This work is well worth the perusal and " Twenty years ago, Dr. Seguin published fn Paris a treatise on the treatment of idiots, which has since been the best work of author- ity on the subject. He has now published an- other work on idiocy, embodying in it our present knowledge of the malady, expounding the physiological method of educating idiots, and setting forth rules of practical treatment ; study of those, and they are many, who have never given the subject a thought. To what extent physiological and moral treatment can go in improving the condition of the idiot is here shown, and we think it is a source of in- finite delight to watch the progress from mere animal life to almost the intelligent being and finally, pointing out the direction to be I has been here shown in this treatise." — St. given to future scientific effort." — London Louis Medical Journal. Lancet. \ .">> PUBLICATIONS OF WILLIAM WOOD & COMPANY. Diseases of the Urinary Organs. Bartholow, R., A.M., M.D. SPERMATORRHOEA : Its Causes, Symptoms, Results, and Treatment. One vol- ume, 8vo, l'J8 pages, illustrated, ruuslin. Price, $1.25. Harrison, Reginald, F.R.C.S., Surgeon to the Liverpool Royal Infirmary. Formerly Lecturer on Anatomy and Surpery at the School of Medicine, and Surgeon to the Liverpool Northern Hospital. LECTURES OX THE SURGICAL DISORDERS OF THE URINARY ORGANS. Delivered at the Liverrjool Royal Infirmary. One volume, 8vo, 399 pages, illustrated with lithographs and wood-engravings, muslin. Price, $4.25. "This edition of Mr. Harrison's lectures orders of the bladder are quite fully treated has been considerably enlarged. The work of in the latter half of the book, and L-r. Bige- treats of stricture and the various methods of low's operation, litholapaxy, favorably corn- treating it, the author taking exception to Dr. mented on. Injuries and surgery of the kid- Otis' method upon retention of urine, injuries , neys are considered in Chapters 25 and '.'.G. to the urethra, perineal fistuke, etc. The dis- | The work concludes with a full index." Coulson, W. J., F.R.C.S. OX THE DISEASES OF THE BLADDER AXD PROSTATE GLAXD. Sixth edition, revised. One volume, 8vo, 393 pages, handsomely illustrated. Sold by subscription only. See page 55. Neubauer, C, M.D., Professor, Chief of the Agricultural-Chemical Laboratory, and Docent in the Chemical Laboratory in Wiesbaden ; and Vogel, J., M.D., Professor of Medicine in the University of Halle. A GUIDE TO THE QUALITATIVE AXD QUANTITATIVE AXALTSIS OF THE URIXE. Designed for Physicians, Chemists, and Pharmacists. With a Preface by Professor Dr. R. FPvESENlUS. Translated from the seventh enlarged and revised German Edition by Elbridge G. Cutler, M.D., Physician to Out-Patients of the Massachusetts General Hospital, Pathologist at the Boston City Hospital, and Assistant in Pathology in the Medical School of Harvard University. Revised by Edward S. Wood, M.D., Professor of Chemistry in the Medical School of Harvard University. In one superb 8vo volume. 551 pages. Profusely illustrated with engravings and four fine chromo-lithographic plates. Pri.-e, muslin, $6.00; leather, $7.00. ''The work, as a whole, supplies an actual want to the profession of this country. The subjects treated of arc destined to take a more and more prominent place in the estimation lessly the most complete and comprehensive work of its kind in any language. The micro- scopic illustrations are unsurpassed in perfec- tion. In mechanical execution the book is a of the coming doctor. The bookie a credit beautiful specimen of art. We seldom see a to the publisher in its typography and bind- book of any kind with so excellent and gab- ing." — Toledo Medical and Surgical Journal. stantial a binding." — Pacific Medical andSur- •• Thi- monnmenl of the learning and labori- goal Journal. oub industry of German physicists, is doubt- j Belfield, W. T., M.D., County Hospital; Surgeon to the Gcnito-TXrinary Department, Central Dispen- lan to the Oakwood Betreat, Geneva, \Vi<. DISEASES OF Till; I'kl.WKY AM) MALE SEXUAL ORGAXS. Sold by sub- scription only. See page 52. Milton, J. L., M.D., M.R.C.S. THE PATHOLOGY AXD TBEATMENT OF GONORRHOEA. One volume, 318 pages, illustrated, muslin. Sold by subscription only. See page 52. PUBLICATIONS OF WILLIAM WOOD & COMPANY. 39 Diseases of the Kidneys and Urinary Organs. Gouley, John W. S. M.D., Late Professor of Clinical Surgery and G-enito-Urinary Diseases in the Medical Department of the Uni- versity of the City of New York: Surgeon to Bellevue Hospital : Fellow of the Sew York Academy of Medicine : Member of the New York Pathological Society, of the Medical Society of the County of New York, etc. DISEASES OF THE URINARY ORGANS ; INCLUDING STRICTURE OF THE URETHRA, AFFECTIONS OF THE PROSTATE, AND STONE FN THE BLADDER. With. 103 wood-engravings. One volume, 8vo, 368 pages, muslin. Price, $3.75. "We are glad to ■welcome this able con- tribution to American surgical literature. It is not so exhaustive as the treatises of Sir Henry Thompson on Stricture and on Lithot- omy, nor does it pretend to be, but it is a very clearly-written and practical guide, and -will be found useful to c large class of readers. Its mechanical execution is very creditable, and it contains remarkably few typographical errors." — Philadelphia Medical Times. '" Having on different occasions during the last six years enjoyed the privilege of wit- nessing the performance by Professor Gouley of some of the most difficult and important operations on the genito-urinary organs, and having been profoundly impressed with his consummate skill and ability as a practical surgeon, we hailed with eagerness the promise of a monograph from his pen on a class of dis- eases tc which he had given special attention. . . . No practitioner who undertakes the treatment of the urinary organs can afford to be without it. It will, we are confident, give him a high position among the recognized au- thorities in the specialty with which his name has been for some years honorably associated" — Chicago Medical Xews. Fowler, E. P., M.D. SUPPRESSION OF URINE. Clinical Descriptions and Analysis of Symptoms. One volume, 86 pages, illustrated, muslin. Price, $1.50. Millard, H. B., A.M., M.D. A TREATISE ON BRIGHT'S DISEASE OF THE KIDNEYS ; Its Pathology. Di- agnosis, and Treatment, with Chapters on the Anatomy of the Kidney, Albu- minuria, and the Urinary Secretion. One volume, 8vo, 246 pages. Illustrated with numerous original illustrations. Muslin. Price, §2.50. "It is rare that we find a book so evidently the result of careful, original study, so fresh from the bedside, we may say, as the one be- fore us. Retaining, for reasons which he states, and which are sound, the general term ' Bright's Disease,' the author includes in his study the various forms of nephritis, which since the days of Dr. Bright have been recog- nized as simple, acute and chronic, interstitial, croupous, and suppurative." — The Medical and Surgical Reporter, Philadelphia, Pa. " This valuable work contains nearly all that is known in relation to this most fatal disease. This work is fully illustrated by wood-cuts, which are almost entirely original with the author and are very accurate. They, alone, give the reader a very fair idea of this disease." — Buffalo Physicians' and Surgeons' Invi stigator. "The perusal of this book will make the young physician familiar with the literature and therapeutics of the disease of which it treats without necessitating a laborious re- • search through the numerous volumes that have been written on the subject." — Mirror. "The only merit the author claims for this work is that it gives the result of nearly twenty-six years of hospital and private prac- tice, and of several years' study in the labora- tory. He is entitled to claim much more. It ' is decidedly one of the best books upon the subject ever published, and no one can read it without advantage." — The Medical Herald. " We have derived great pleasure from the perusal of this work, a pleasure enhanced by the readable type and excellent quality of the paper upon which it is printed. We heartily recommend it to the public. " — Canada Prac- titioner. "From stem to stern the book presents a practical and an original character that is truly refreshing to the practitioner." — Missis- sippi Valley Medical Monthly. ' ' Throughout the book he displays a remark- able lucidity which adds greatly to the pleas- ure and profit derived from a perusal of it." — Canada, Practitioru r. " Dr. Millard has gone into the considera- tion of this disease in a very thorough, practi- cal manner. It is a work which will amply repay perusal by any thoughtful student." — Canada Medical Record. "The author has written as one who not only ' has the courage of his opinions,' but also as one who possesses the faculty of ex- pressing them in clear language, and in a style well deserving of imitation by not a few of the fast book-makers of this continent." — Canada Lancet. 40 PUBLICATIONS OF WILLIAM WOOD & COMPANY. Diseases of the Kidneys, etc. Dickinson, "W. Howship, M.D., Cantab., Fellow of the Royal College of Physicians ; Physician to St. George's Hospital ; Senior Physician to the Hospital for Sick Children ; Corresponding Member of the Academy of Medicine of New York. ON RENAL AND URINARY AFFECTIONS. This volume has just been com- pleted, and concludes the work of which the volume on Albuminuria, published in Wood's Library for 1881, is the first part. Sold by subscription only. See page 51. Charcot, J. M., M.D., Professor in the Faculty of Medicine of Paris; Physician to the Salpetriere : Member of the Academy of Medicine, of the Clinical Society of London, of the Clinical Society of Buda-Pesth, of the Society of Natural Sciences, Brussels; President of the Anatomical Society ; former President of the Soci- ety of Biology, etc., etc. LECTURES ON BRIGHT'S DISEASE OF THE KIDNEYS, DELIVERED AT THE SCHOOL OF MEDICINE OF PARIS. Collected and published by Drs. Bourneville and Sevestre, editors of the Progres Medical, and translated, with the permission of the author, by Henry B. Millard, M.D., A.M. Illus- trated with two colored plates and with wood-engravings. One volume, 8vo, 100 pages, muslin. Price, $1.50. "The thanks of the profession are due to [ "Whatever may be thought of Professor the translator, Dr. Millard, for the way in \ Charcot's views of the various forms of renal which he has performed his portion of the i alteration, none can refuse to him the merit work, and to the publishers for the clear type i of a profound thinker and a most sagacious and elegant appearance of the book. It should observer, the philosophic character of his be read by every one who desires to be informed of the pathology of Bright' s disease." — Medical Hi cord. ' It presents as clear a view of ihe patholo- views being at once a record of the knowledge of the day and of the genius of their author." — Canada Lancet. The brochure is valuable enough to be well gy and histology of Bright's disease as can bo '■ worth the study of every busy practitioner who found, and clears away some of the obscuri- j has a new case of albuminuria to manage, and ties which have hitherto clouded the study of ' it will, of course, find a place upon the library the important subject." — Pacific Medical and j .-helves of every one." — American Journal of Sn rgical Journal. I the Medical Sciences. Stewart, L. Grainger, M.D., F.R.S.E., Fellow of the Royal College of Physicians ; Physician to the Royal Infirmary ; Lecturer on Clinical Med- I Lne; formerly Pathologist to the Royal Infirmary ; Lecturer in General Pathology at Surgeons' i [all, and Physician to the Royal Hospital for Sick Children ; Extraordinary Member and formerly President of the Royal .Medical Society of Edinburgh. A PRACTICAL TREATISE ON BRIGHT'S DISEASE OF THE KIDNEYS. One volume, 8vo. 334 pages, illustrated with seven lithographic plates, cloth. Price, |4.50. '' Tli is is a valuable contribution to the I distinct forms with which the name of Bright study of a lass of diseases which has enlisted is inseparably and honorably associated. . . . a great amount of laborious investigation dur- "The subject throughout is handled by a Lng the last twenty or thirty years. It is an master mind. To the general practitioner, original work, illustrated with plates, exhibit- I and especially to those interested in diseases . impressively the morbid ohanges of the kidneys, the work is invaluable."— which the kidneys undergo in the various and I Pacific Medical and Surgical Journal. Piffard, Henry G., A.M., M.D., Profei or of I lermatology, University of the City of New York ; Surgeon to the Charity Hospital, etc. a <;iim; to URINARY analysis for the use of physicians and STUDENTS. On.- volume, 8vo, 89 pages, illustrated. Price, $1.25. M \n;i:i \ MEDICA AND THERAPEUTICS OF THE SKIN. Sold only by sub- Bcription. Sec page 55. PUBLICATIONS OF WILLIAM WOOD & COMPANY. 41 Syphilis, Shin Diseases. Vidal, A. (De Cassis), Surgeon of the Venereal Hospital of Paris. A TKEATISE ON VENEREAL DISEASES. With colored plates. Translated, with annotations, hy George C. Blackman, M.D., Professor of Surgery in the Medical College of Ohio ; Surgeon to the Commercial Hospital ; Fellow of the Royal Medical and Chirurgical Society of London. One volume, 8vo, 499 pages, muslin. Price, $4.50. Taylor, R. W„ M.D., Surgeon to the New York Dispensary, Department of Venereal and Skin Diseases, Physician to Charity Hospital, New York. SYPHILITIC LESIONS OF THE OSSEOUS SYSTEM IN INFANTS AND YOUNG CHILDREN. One volume, 8vo, 179 pages, muslin. Price, $2.50. Keyes, E. L., A.M., M.D., Adjunct Professor of Surgery, and Professor of Dermatology in Bellevue Hospital Medical College ; Consulting Surgeon to the Charity Hospital ; Surgeon to Bellevue Hospital, etc. VENEREAL DISEASES. Sold only by subscription. See page 56. Diday, Paul. ON SYPHILIS IN INFANTS. Translated by Dr. G. Whitley. With Notes and Additions by F. R. Sturgis, M.D. With a colored plate. Sold only by sub- scription. See page 53. 5£^" In bringing out an American edition of Diday's exceptional work, Dr. Sturgis, in his preface, says : ' l He believes that this method of annotation will serve to bring out many points in the pathology and treatment of Infantile Syphilis better than it could have done in an independent work." Busey, Samuel C, M.D., Professor of the Theory and Practice of Medicine, Medical Department of the University of Georee- town ; Consulting Physician to St. Ann's Infant Asylum; Attending Physician to the Children's Hospital : Physician to the Louise Home ; Ex-President of the Medical Association, and of the Medical Society of the District of Columbia; Fellow of the American Gynecological Society ; Hon- orary Member of the Medical Society of the State of New York ; Member of the Philosophical Soci- ety of Washington, D. C , etc., etc. CONGENITAL OCCLUSION AND DILATATION OF LYMPH CHANNELS. Illus- trated with fiftv-six engravings. One volume, 8vo, 187 pages, muslin. Price, $2.00. Cazenave and Schedel. MANUAL OF DISEASES OF THE SKIN ; from the French of MM. Cazenave and Schedel, with notes and additions, translated by T. H. Burgess, M.D. Sec- ond American Edition, enlarged and corrected from the last French edition, with additional notes by H. D. Bllkley, M.D., Physician of the New York Hospital ; Fellow of the College of Physicians and Surgeons, New York ; Lecturer on Dis- eases of the Skin, etc., etc. One volume, 8vo, 348 pages, muslin. Price, $2.00. Liveing, Robert, A.M., and M.D., Cantab., F.R.C.P., Lond., Lecturer on Dermatology to the Middlesex Hospital Medical School ; Lately Physician to the Middlesex Hospital ; Author of "Notes on the Treatment of Skin Diseases," " Elephantiasi- Grascorum," etc. A HANDBOOK ON THE DIAGNOSIS OF SKIN DISEASES. One volume, 8vo, 260 pages, muslin. Price, $1.50. " The work is one which a careful perusal I in the field, we bespeak for it general favor would enable us to commend even though its with the profession. " — - Michigan Medical field was occupied by others, and as it is alone ' News. NOTES ON THE TREATMENT OF SKIN DISEASES. One volume, 16mo, 127 pages, muslin. Price, $1.00. Wilson, Erasmus, F.R.S. THE STUDENT'S BOOK OF CUTANEOUS MEDICINE AND DISEASES OF THE SKIN. One volume, 8vo, 445 pages, muslin. Price, $3.50. 42 PUBLICATIONS OF WILLIAM WOOD & COMPANY. Shin Diseases, U. S. Pharmacopoeia. Fox, Tilbury, M.D., London, Fellow of the Royal College of Physicians of London : Physician to the Department for Skin Diseases in University College Hospital : Fellow of the University College. SKIN DISEASES ; their Description, Pathology, Diagnosis, and Treatment. Sec- ond American from Third London Edition, re-written and enlarged. With a Cutaneous Pharmacopoeia, a Glossarial Index, and sixty-seven additional illus- trations. One volume, 8vo, 532 pages, muslin. Price, $5.00. "The spirit of industrious and accurate ob- ISmos — Am. Pub.), will now find its succes- servation which marks his writings, and, sor launched forth as an imposing octavo, lux- moreover, the excellence of his method, com- urious both as to paper and tj'pe. This is, in mand our hearty approval." — British and our opinion, a great improvement. We must "Fori ign Mt dico-Chirurgical Rt riew. confess to a virtuous horror of pocket manuals A safe guide to all who are engaged in the as recalling days when medical students were investigation of skin diseases." — The Dublin less sensible and industrious than, happily, Quarterly Journal of Medical Science. they now are. Not only is this volume much '• We can heartily recommend it to the stu- enlarged, but is also recast in parts and re- dent as a thoroughly sound and practical guide written. One of the most important new feat- to the study of diseases of the skin, in which ures is the addition of many new illustrations, he will find all the most recent investigations of which there are now nearly one hundred in into the etiology and pathology of these affec- the volume. The author has taken great pains tions ; while to the practitioner it will prove to include the latest researches in dermatology an eminently useful handy-book of reference." in this edition ; ahd we can, therefore, unhesi- — Edinburgh Medical Journal. tatingly recommend the book to our readers. "It is clear, concise, and practical. The Without question, it is now the most complete book is practical and richer in valuable con- and practical work on cutaneous medicine in tents than any other book on the subject of the English language. The ordinary student such small bulk" — Richmond and Louisville , will find in it all that he can desire, and will Medical Journal. only be led by its tone to wholesome methods '' We would advise all practitioners of med- and higher flights of research ; while the prae- icine to get this practical work and study it." titioner will fall back upon its resources with — Leav* nworth Medical Herald. satisfaction and with fresh resolves." — Notice '■Those who are familiar with the volume of the new edition in the London Lancet, Feb- as last issued, in the form of a pocket manual ruary 8, 1873. (the former English editions were small, thick The Pharmacopoeia of the United States. Sixth Decennial Revision. By authority of the National Convention for Revising the Pharmacopceia held at Washington. A.D. 1880. One volume, 8vo, about •inn pa_res, strongly bound in muslin. Price, $4.00; leather, $5.00; leather interleaved, $6.66. Unbound, printed on one side, $5.00. " Chief among the improvements which ap- adulterants." — Medical Counselor, Grand pear in the new Pharmacopceia is the substi- Rapids. tntion of parts for the old measurements of " The National Pharmacopceia is the stand- weighte." — American Pharmacist, New York arcl authority as to medical preparations. The City. present revised edition represents the best c-f- " The last edition of the Pharmacopceia forts of the best representative men in the shows abundant evidence that the Committee pharmaceutical profession of our country." — of Revision have performed their task in no Louisville Medical News. perfunctory manner, but with an industrious "The committee certainly have lived up to and conscientious devotion to the end in view their privileges. They have revised it. Com- — to make the book a closer approach to per- pared with 1870, it is almost a revolution, not Section than any of its predecessors." — New a simple revision." — T?U Medical Advance, York .\fiil,,;, I Journal. Ann Arbor. ■ In addition to the Pharmacopoeia proper, " The committee devoted a little more than it contain)i an historical introduction, notices two years to the work of revision, and the re- on percolation, temperature, weights and meas- suit of their labor is now before us. On ex- list of reagents, tables of elementary amining the work we are at once struck with substances, thermometric equivalents, specific the important differences that exist between gravity, solnbihty, saturation, etc., and sepa- it and its predecessors." — Medical Record, rate lists of articles added and dismissed from January 20, L8£ the Pharmacopoeia."— J/e<3ieaZ """' Surgical '• If once on the physician's table, this work Reportt r. will probably be more frequently consulted as " The ' get up* of the book is unexceptional an aid to prescribing than any other book in paper upon which it is printed is the his library, for it represents the results of the • printing clear and distinct, and the latest scientific researches. The committee choice of differenl types for expressing the who had this work in hand deserve great credit names of drugs, formula-, etc., very judicious." for bringing the work up to the present needs — New Remi of the profession." — Med. Rec, Jan. 20, 1883. " A valuable feature of the new edition con- "Every medical library should contain a suits of the various tests given to determine copy; also every pharmacist should own one." the purity of chemicals and the absence of — The Therapeutic Gazette. PUBLICATIONS OF WILLIAM WOOD & COMPANY. 43 Pharmacopoeia, etc. Edes, Robert T., A.B., M.D. (Harvard), Fellow of the Massachusetts Medical Society ; Fellow of the American Academy o£ Arts and Sciences; Late Passed Assistant Surgeon, U. S. Navy ;. Professor of Materia Medica in Harvard University ; President of the American Neurological Association ; Corresponding Member of the New York Therapeutical Society ; One of the Visiting Physicians at the Boston City Hospital. THERAPEUTIC HANDBOOK OF THE UNITED STATES PHARMACOPOEIA. Being a condensed statement of the Physiological and Toxic Action, Medicinal Value, Methods of Administration, and Doses of the Drugs and Preparations in the Latest Edition of the United States Pharmacopoeia (Apothecaries' and Metric System), with some remarks on Unofficinal Preparations. One volume, 8vo, 300 pages, muslin. Price, $3.50. ^y The " Handbook of the United States Pharmacopoeia " is intended to be a com- mentary, from a medical rather than from a pharmaceutic point of view, upon the latest edi- tion of that work, which is just completed, and which contains many more changes than have been made in any of the previous revisions. As the Pharmacopoeia now stands, it represents a very extensive pharmaceutic armamen- tarium, embracing all the important introductions to therapeutics of the last ten or perhaps twenty years. It is evident that a complete treatise on therapeutics is not to be looked for in a work of this size, even if the author felt himself confident to write one, but it has been his aim to show, as succinctly as is consistent with clearness, what each drug can do in the treatment of dis- ease, what it may do if not carefully used, and how far the various preparations are fitted to display its remedial powers. While theories erected upon slender foundations have been gen- erally neglected, the physiological action of drugs has been stated, in accordance with recent investigations, so far as it bears upon their practical uses and upon the symptoms and treat- ment of poisoning which may be occasioned by them. This knowledge, so far as obtainable, while it can never supplant the final test of careful and unprejudiced clinical observation, is of the utmost importance as a basis for the rational use of drugs, and, especially so, as a step- ping-stone for the advance of therapeutic science. Much attention has been paid to the very important subject of dosage, and while the endeavor has been to err, if at all, on the side of safety, the necessity of producing in some cases obvious effects, if it is desired to get therapeutic results, has not been overlooked. It is hoped that this book will be found by the physician a trustworthy guide in utilizing the agencies which the Pharmacopoeia places in his hands, and by the pharmacist a brief and intelligible statement of what may be expected from the substance he dispenses. Thomson, Anthony Todd, M.D., F.L.S., Fellow of the Royal College of Physicians ; Professor of Materia Medica and Therapeutics in University College, London, etc. A CONSPECTUS OF THE PHARMACOPOEIAS OF THE LONDON, EDINBURGH, AND DUBLIN COLLEGES OF PHYSICIANS AND SURGEONS, AND OF THE UNITED STATES PHARMACOPOEIA : BEING A PRACTICAL COM- PENDIUM OF MATERIA MEDICA AND PHARMACY. Edited by Charles A. Lee, M.D., Professor of General Pathology and Materia Medica in General Medical College. One volume, 18mo, 322 pages, muslin. Price, §1.00. Foote, John, F.R.C.S. (London). THE PRACTITIONER'S PHARMACOPOEIA, AND UNIVERSAL FORMULARY. Containing two thousand classified Prescriptions, selected from the practice of the most eminent British and Foreign medical authorities, etc., etc. With addi- tions by Benjamin W. McCready, M. D., Professor of Materia Medica and Pharmacy in the College of Pharmacy, New York, etc. In one 12mo volume, 390 pages, muslin. Price, $2.00. Johnson, Laurence, A.M., M.D., Fellow of the New York Academy of Medicine, etc. A MEDICAL FORMULARY. Sold only by subscription. See page 55. 44 PUBLICATIONS OF WILLIAM WOOD & COMPANY. Nharmacopceia, Nosological Table. Oldberg, Oscar, Ph.D., Member of the Committee of Revision of the Pharmacopoeia of the United States ; Author of the " Un- official Pharmacopoeia," " The Metric System in Medicine," etc. ; formerly Medical Purveyor of the United Stiitea Marine Hospital Service ; and Professor of Materia Medica in the National College of Pharmacy, Washington, D. C, etc. ; and Wall, Otto A., M.D., Ph.G., Professor of Materia Medica, The: apeutics, and Pharmacy in the Missouri Medical College, and of Materia Medica and Botany in the St. Louis College Pharmacy ; Member of the Committee cf Revision of the Pharmacopoeia of the United States, etc. A COMPANION TO THE UNITED STATES PHARMACOPOEIA. Peing a com- mentary on the Latest Edition of the Pharmacopoeia, and containing the Descrip- tions, Properties, Uses, and Doses of all Official and numerous Unofficial Drugs and Preparations in current use in the United States, together with Practical Hints, Working Formulas, etc., designed as a ready reference book for Pharma- cists, Physicians, and Students, with over 300 original Illustrations. Price, in cloth, $5.00; in leather, $6.00; in half morocco, $6.50. jgp The "Companion to the United States Pharmacopoeia " gives succinctly the name, synonyms (including all common or local English, together with the German, French, Spanish, and Swedish names), origin, habitat, description, varieties, substitutions, adultera- tions, common defects, marks of quality, properties, uses and doses of all the drugs and chem- icals of which it treats, and under each drug or chemical will be described its several prepara- tions, with formulas for making these. All formulas given are in definite quantities, solids by weight, and liquids generally by measure, the official formulas (in parts by weight) having been translated accurately according to the same plan. The book thus serves as a key and companion to the Pharmacopoeia. It gives only such information as pharmacists and physicians most frequently have occasion to put to practical use in their daily vocations, and hence botanical descriptions of plants, except of the parts seen in drugs, chemical processes, accounts of the physiological actions of medicines, etc., are omitted, and the articles treated of have been considered rather with reference to actual con- ditions and requirements of the trade and the practice of the professions concerned than from the standpoint of a text-book. It is hoped that the Companion will be found a reliable and complete pharmaceutical and medical formulary and dose-book, as well as a practical and reliable guide in the identification of crude drugs. Whenever practicable, the descriptions of drugs are accompanied by illustrations which, as a rule, represent actual specimens, even to the facsimile reproduction of the details of the venation of a leaf in many cases ; and characters best shown by the figures are not repeated in the text, such as, for instance, the form and size of leaves, etc. This work makes a large octavo volume of over twelve hundred pages, illustrated by more than six hundred and fifty original engravings drawn from nature, printed on fine calendered paper, and bouud to match the Pharmacopoeia. Rice, Chas., Ph.D., Chemist to the Department of Public Charities and Corrections. New York, etc. POSOLOGICAL TABLE, INCLUDING ALL THE OFFICINAL AND THE MOST Ml KOI ' KNTLY EMPLOYED UNOFFICINAL PREPARATIONS. One volume, L6mo, 96 pages, muslin. Price, $1.00. " This is something new in its line. By a J and by certain arbitrary signs which remedies of abbreviations and signs, all very in- are poisonous, which require caution, and telligible, the author bas boiled down the whole J some other points. The doses are given in pliarmu<:o|Hi'ia into a concentrated extract, fill j than 100 small pages, A very conven- md useful affair." — Pacific Medical and Surgical Journal. "This table gives the names of medicines, their doses, the formulas of the United States Pharmacopoeia and of other pharmacopoeias, apothecaries' weight, and a table for convert- ing them into the metric system is appended." — Medical and Surgical Reporter. " It is a book which has been prepared with much labor and care, and is admirably adapted to tiie purposes for which it is designed." — Maryland Medical Journal. PUBLICATIONS OF WILLIAM WOOD & COMPANY. 45 Effects of Drugs ; Chemistry, Pictures. Lewin, L., Dr., Assistant at the Pharmacological Institute of the University of Berlin. THE INCIDENTAL EFFECTS OF DRUGS, A PHARMACOLOGICAL AND CLIN- ICAL HANDBOOK. Translated by W. T. Alexander, M.D. One volume, 8vo, 239 pages, muslin. Price, $2.00. " That individuals vary in their susceptibil- ity to drugs, and that idiosyncrasies of the most unexpected character reveal themselves in practice, are observations of very ancient date. So startling are these accidental effects that sometimes their cause is apt to escape detection. Variations- in the phenomena of disease are not more common than variations in the action of drugs, depending largely, like the disease phenomena, on the acquired or in- herited peculiarities of the patient. Facts j belonging to this category abound in the med- ical periodicals and in the unwritten experi- ence of doctors, but Dr. Lewin is the first to make a book by collecting and classi ying these data, and adding to them his own obser- vations sharpened by special study. He de- serves credit for breaking new gi ound in the first place, and in the second for annotating, with admirable judgment, this somewhat neg- lected branch of knowledge." — Louisville Med- ical News. Witthaus, R. A., A.M., M.D., Professor of Medical Chemistry and Toxicology in the University of Vermont ; Member of the Chemical Societies of Paris and Berlin, etc. A TEXT-BOOK OF MEDICAL CHEMISTRY. Price, muslin, $3.50. "We do not hesitate to recommend this " The author has, we think, succeeded fairly work to the profession as a complete text-book in presenting what every practitioner should on the diseases of which it treats." — Medical , know of the science of chemistry." — Philadel- Tribune. \ phia Medical and Surgical Reporter. ESSENTIALS OF CHEMISTRY, Organic and Inorganic (Wood's Pocket Manuals) Price, $1.00. Draper, John C, M.D., LL.D., Professor of Chemistry in the Medical Department, University of New York, and of Physiology and Natural History in the College of the City of New York. A PRACTICAL LABORATORY COURSE IN MEDICAL CHEMISTRY. One volume, oblong 12mo, 71 pages interleaved, muslin. Price, $1.00. "The book contains, in a concise and scien- ! time is limited, and who desires practical re- tific form, all upon the above topics that is of ! suits with the least expenditure of time and practical value to the physician. We cordially labor and without the aid of an instructor." — recommend it to physicians and students." — Chicago Medical Times. Mississippi Valley Medical Monthly. "This little work comprises what a young " In printing the book every other page has doctor ought to know about chemistry for his been left blank in order that the student may patients' good." — Buffalo Med. and Surg. Jour. be enabled conveniently to record, in its proper i " It is bound so as to open from the top, so place, the results of the experiments he makes, ! as to easily lie open on the table, and, as it and of additional facts obtained from oral in- lies open, the lower page has been left blank struction." — Atlanta Medical Register. " Indeed, few books combine so much useful information in such a compact, correct, com- prehensive, and applicable manner." — Amer- ican Chemical Review. " This excellent manual is one of the best for any notes and additions which the student desires to make as he proceeds with his work." — Columbus Medical Journal. "The student is indeed to be congratulated in being able to secure a work of this nature prepared by a teacher of Dr. Draper's experi- extant for the student or practitioner whose j ence. " — The Mediccd Age, Detroit. Pictures for Physicians' Offices and Libraries. Edward Jenner, the First Inoculation of The Village Doctor. Vaccine, May 14th, 1790. Andrew Vesalius. the Anatomist. Spoonful Every Hour. The Sick Wife. Ambrose Pare Demonstrating the Use of Ligatures. The Young Mother. Size of each, 19x24 inches. Price, each $2.00 be sent upon application. The Rebellious Patient. • Study in Anatomy. William Harvey Demonstrating the Circu- lation of the Blood. The Anatomical Lecture. The Accident. Catalogues of these pictures will 46 PUBLICATIONS OF WILLIAM WOOD & COMPANY. Miscellaneous. Parkes, E., M.D. A MANUAL OF PRACTICAL HYGIENE. Edited by F. S. B. Francois de ChaumoNT, M.D. Sixth edition. With an Appendix. Giving the American practice in matters relating to hygiene. Prepared by and under the supervision of Frederick N. Owen, Civil and Sanitary Engineer. Two volumes in one, 8vo, 946 pages. Illustrated with nine full page plates, and fine wood-engrav- ings, muslin binding. Price, $5.00. Sternberg, G. M., M.D. BACTERIA. By Dr. Antoine Magnin, of Paris, and George M. Sternberg, M.D., F.R.M.S., Major and Surgeon, U. S. Army. One volume, 8vo, 494 pages. Illustrated with twelve full-page plates, including heliotype and lithographic reproductions of photo-micrographs. Muslin. Price, $4.00. Sternberg, G. M., M.D. MALARIA AND MALARIAL DISEASES. One volume, 8vo, 332 pages. Muslin binding. Sold by subscription only. See page 52. Sturgis, I. R., M.D. MEDICAL TOPICS, Containing : 1. Hints and Suggestions for Reform in Medical Education. 2. A Plea for the State Regulation of Medicine and Surgery. 3. Medical Education : Its Objects and Requirements. One volume, 8vo, 64 pages, paper cover. Price, 25 cents. Visiting List (Medical Record), or Physician's Diary. Containing all the valuable features of previous publications of this sort. Prices : For thirty patients a week, handsome red or black leather binding, wallet style, with or "without dates, $1.25; for sixty patients a week, same style, with or without dates, $1.50. Hun, H. A GUIDE TO AMERICAN MEDICAL STUDENTS IN EUROPE. Price, $1.25. Steel, J. H., M.D. OUTLINE OF EQUINE ANATOMY. A Manual for the use of Veterinary Students in the Dissecting Room. One volume, 12mo, 312 pages. Muslin. Price, $3.00. Buck, A. H., M.D. A TREATISE ON HYGIENE AND PUBLIC HEALTH. By various authors. Ed- it. .1 by AT.Tt F.-RT H. Buck, M.D., New York. In two volumes, royal 8vo, 702 and 657 pages. Illustrated by numerous wood-engravings. (Subscription.) I'ricc, per volume, in muslin binding, $5.00 ; in leather, $6.00; and in nio- rocco, $7.50. Hospital Plans. FIVE ESSAYS Relating to the Construction, Organization, and Management of Hos- pitals, contributed by their authors for the use of the Johns Hopkins Hospital oi Baltimore, one volume, 8vo, 553 pages. Illustrated by lithographic plans. .Muslin. Price, $0.00. Johnson and Martin. tiii; ixfli i.xci; of tropical climates on European constitu- tions. I'.y •! \mes Johnson, M.D.,and JAMES Ranald Martin, Esq. From tin- sixth Loudon edition, with notes by an American physician. One volume, Hvo, 624 pages. Muslin. I 'rice, $8.00. Kirby, F. 0., M.D. A TREAT I SK OX VETERINARY MEDICINE. As Applied to the Diseases and tnjuriei of the Eorse. Compiled from Standard and Modern Authorities. One vo'lunie. 332 pages. Illustrated by four ohromo-lithographic plates, containing numerous figures, and one hundred and sixty-eight fine wood-engravings. Sold by subscription only. See page 58. WOOD'S LIBEAET Standard Medical Authors. Iisr announcing the volumes in this now celebrated series, it may seem, to those discerning and appreciative gentlemen who, from the first have availed themselves of this project, unneces- sary to repeat what we have said at different times in former years respecting the general character and make-up of these books. And yet, as many thousands have entered the profes- sion since then, we consider it not amiss briefly to renew some of the more important features of this most successful scheme to supply standard medical literature at low prices. Until 1879 no attempt had ever been made by medical publishers to pro- duce books at less than the large prices, rendered necessary, in- deed, by the limited sale attained by most. It was a bold vent- ure to undertake to publish twelve volumes in one year, at but one-quarter to one-tenth the prices previously obtained — an un- dertaking which could only be successful from a sale vastly larger than before attained. That it was a success, and a grand one, is certain evidence of the wisdom of the plan, and of the sure support which the profession will always accord to enterprises conceived and car- ried out as this has been. In the seven years during which this library has been an- nually published, EIGHTY-FOUR VOLUMES of most valuable medical books have been issued, at a cost to the regular subscribers OF ONE HUNDRED AND FIVE DOLLARS ONLY ; but representing books (as published in other editions) to the VALUE OF NEARLY FIVE HUNDRED DOLLARS. 47 It would be impossible for any publisher to issue booKs of the high character proposed, at such a nominal price, un- less a sale could be guaranteed for the series very much larger than is ever attained by books as ordinarily published. We have contracted with well-known aulhors, eminent in their specialties, for new and original works upon subjects of pres- ent interest to practitioners, and especially conforming to the essentially practical character for which we desire this series to be known. If the expense of the production of such books as are con- templated were to be borne by the sale of an ordinary edition, the individual cost of such volumes would be from S5.00 to 87.00 each, and in several instances much more. By combining these volumes into sets or series of twelve volumes each — by the closest scrutiny of every item that enters into their cost of production and sale — by presenting them in a form so attrac- tive that they will enlist the interest of every lover of books, and by the adoption of a system of distribution by which every book-buying physician can have the opportunity of examina- tion and purchase, we are enabled to supply the series at the uniform price of $18.00 each, except as hereinafter named. Seven series have been published, and we shall soon enter upon the publication of the eighth. The very remarkable suc- cess that has attended this enterprise from its inception, the wide-spread support which it has continued to receive, has served as a constant stimulant to further effort in continuation of the libraries upon the same high standard of excellence. PRESS NOTICES. "The publishers are to be thanked for their untiring en- ergy and zeal, in thus furnishing the profession with such val- uable publications at so low a price — scarcely a nominal con- sideration." " We know of no better investment than a subscription to these series." ■■ Think of it ! twelve new books upon the various branches of medicine and surgery, by the best writers of to-day, for only $18.00;" (From the original announcement.) " For many years past Messrs. WM. WOOD & CO. have had under consideration the feasibility of producing medical books by foreign and American authors, in good style,, and yet at prices greatly less than heretofore attempted. The high cost of labor, and of all the materials used in the manufacture of books, has been an insuperable ob- stacle. Even now it would be impossible to carry out systematically any such idea if the ordinary methods of trade were depended upon. "It is believed that the Medical Profession will welcome and generously sustain any well-directed effort of such character, and consequently the following scheme has been prepared with much care, and is respectfully submitted for their approval and support. " The books selected for publication in this series will be characterized by the prac- tical nature of their contents — so far as possible — rather than theory. In general, the newest and' most recently written works only will be included ; occasionally some standard book, not readily obtainable or out of print, will be reproduced. Reference to the titles of books herein announced will clearly show the intent of the publishers, and the wide range of subjects included. "In the niairafacture of these books there is nothing omitted essential to first-class work ; they are as well made in every particular as the high-priced editions. " A broad-faced Long Primer type is used, cast especially for these volumes, and with this type, and size of page adopted, these volumes will contain as much matter as is frequently included in an ordinary book of 500 to 800 pages. The paper is fine cream-laid, manufactured expressly for the purpose. FINE COLORED PLATES AND SUPERIOR LITHOGRAPHS will be introduced, and wood-engravings will be freely used as required. The covers are of the best hard binders' board, covered with an extra quality and color of im- ported muslin, and embossed on the back and sides with new and original stamps. In every sense they will be honestly made books." The above expresses the-purpose of the publishers — as announced in their prospec- tus — at the opening of this enterprise. (H3P That the result has much more than met the expectation of its most sanguine friends and supporters is well knoicn to every book-buying member of the profession. The production in these series of such works as : Savage's — " Female I*elvic Organs." Ellis and Ford's-" Illustrations of Dissections." Munde's — " CJynecoIogy." Hart and Darh©ur's — " Diseases of Women." Carpenter's—"* Microscope and its Revelations." Park's — " Hygiene," with its " American Appendix." Kirfoy's— " Diseases and Injuries of the Horse." Holden's — " Human Osteology." •Johnson's—" Medical Botany." Hfoyes' — " Diseases ©f the Eye." Kirhcs' — ' v l*hysiol©gy," and very many others. — with all their wealth of illustrations in colored plates and fine wood-engravings — has been an ever- recurring matter of gratification to the subscribers, and an occasion of surprise even to bookmakers, at the facilities and possibilities of the bookmaking of to-day, as developed by the publishers of these remarkable volumes. JC^ 3 Detailed information regarding the volumes published in each series will be found upon the following pages, to which the most careful attention and scrutiny is invited upon the part of the careful book-buyer. 4:9 Woods Library of Standard Medical Authors. " This is certainly a bold undertaking, and can only be successful by a liberal sup- port from the profession. " ' ' One of the reasons why medical books are so expensive, as compared with books in general literature, is their comparatively limited sale. " " Of course the only way in which the enterprise can pay its originators is in an immense subscription list, and we earnestly ask for a general support along our line." " The publishers look for the support of the profession in this enterprise." " The scheme is one which the profession should endorse." " This will furnish progressive men with a rare opportunity to procure new books at exceedingly low figures." '■ Most of these volumes will be illustrated. Nothing yet offered will at all com- pare with this proposition. " " As this series is an experiment, we hope it will prove sufficiently remunerative to warrant a continuance during future years. The terms are so reasonable that a library of the best authors is now within the reach of all." '• We honestly believe that every medical man in the profession should enter his name us a subscriber." " Wm. Wood A: Co. make it possible for every practitioner, however poor his purse, to furnish his library with proper works, and they should receive the heartiest support from the profession!*' The above Press Notices show the welcome given to the enterprise at its inception. Bow fully the result met the expectation of the Press, the following notices among thousands will serve to show : — "They are handsome, inside and out; first el- paper, type, presswork and binding are all " In the mechanical execution of the books and the artistic work, especially, it is hut faint praise to say they arc far above the average of medical publications." • The character of the works and the amazing cheapness of the publication recom- mend this library to all practitioners. " " We are surprised that such books can be furnished for the money. The get-up of the books is in every respect equal with the high-priced editions now being sold." 50 Wood's Library of Standard Medical Authors. IFOIR, 1835. Seventh Series. Price, $ . . Volumes not sold separately. HUMAN OSTEOLOGY. Comprising a Description of the Bones, with Delineations of the Attachments of the Muscles, the General and Microscopic Structure of Bone and Its Development. By LUTHER HOLDEN, Ex- President and Member of the Court of Examiners of the Royal College of Surgeons of England ; Consulting Surgeon to Saint Bartholomew's and the Foundling Hospitals ; assisted by JAMES SHUTER, F.R.C.S., M.A., M.B. Cantab., Assistant Surgeon to the Royal Free-Hospital ; late Demonstrator of Physiology, and Assistant Demonstrator of Anatomy, at Saint Bartholomew's Hospi- tal. Sixth Edition. With 66 full-page lithographic plates and 89 wood-engravings. jpg~ This is another of these marvels of bookmaking for which Wood's Library has become celebrated. KIRKES' HANDBOOK OF PHYSIOLOGY. By W. MORRANT BAKER, F.R.C.S., Surgeon to Saint Bartholomew's Hospital and Consulting Surgeon to the Evelina Hospital for Sick Children ; Lecturer on Physiology at Saint Bartholomew's Hospital, and late Member of the Boated of Examiners of the Royal College of Surgeons of England ; and VINCENT DORMER HARRIS, M.D. Lond., Demon- strator of Physiology at Saint Bartholomew)' s Hospital. Eleventh Edition. Volume I. With a Colored Plate and 253 illustrations. SE3P = Kirkes' Physiology has long enjoyed a high reputation as one of the best and most practical works of its kind, and in this r.ew edition, just completed by Drs. Baker and Harris, is probably as ac- ceptable a book on the subject as could be presented to the practitioners of America. THE SAME. Volume II. With nearly 250 illustrations. ON THE WASTING DISEASES OF INFANTS AND CHILDREN. By EUSTACE SMITH, M.D., Lond., Fellow of the Royal College of Physicians ; Physician to his Majesty the King of the Bel- gians ; Physician to the East London Children's Hospital and to the City of London Hospital for Dis ease s of the Chest, Victoria Park. Fourth Edition. $^T~ This work, upon a phase of disease seldom treated of in ordinary medical text-books or the prac- tice of Medicine, is by the accomplished author of " Disease in Children," recently published by this house. A TREATISE ON CHOLERA. Edited and prepared by EDMUND C. WENDT, M.D., Curator of the Saint Francis Hospital ; Pathologist and Curator of the New York Infant Asylum, etc., etc.; in asso- ciation with JOHN C. PETERS, M.D., New York ; JOHN B. HAMILTON, M.D., Surgeon-General U. S. Marine Hospital Service, and ELY McCLELLAN, M.D., Surgeon U. S. Army. Illustrated with ma ps a nd engravings. H£ir° Availing themselves of the history and experience of Cholera Epidemics to the present day, to- gether with the new light thrown upon its mode of propagation, spread, and treatment the past year through the investigations of Professor Koch and others — the knowledge concerning preventive meas- ures, quarantine, etc., so recently acquired in France and Italy — the learned authors of this work aimed to produce a book which may at least serve to prepare the profession of America successfully to combat this dreaded scourge, should it unfortunately gain an entrance into our country. Being written spe- cially for Wood's Library, and wholly since the first of this year, it is the only treatise of any kind fully up to the most recent discoveries. POISONS : THEIR EFFECTS AND DETECTION. A Manual for the Use of Analytical Chemists and Experts, with an Introductory Essay on the Growth of Modern Toxicology. By ALEXANDER WYNTER BLYTH, M.R.C.S., F.C.S., etc., Public Analyst for the County of Devon, and Medical Of- ficer of Health and Public Analyst for Saint Marylebone. Volume I. With tables and illustrations. JU^T" This is the most recent treatise upon this important subject, and is full and complete — a perfect storehouse of valuable information. THE SAME. Volume II. With tables and illustrations. ON RENAL AND URINARY AFFECTIONS. Miscellaneous Affections of the Kidneys and Urine. By W. HOWSHIP DICKINSON, M.D. Cantab., Felloio of the Royal College of Physicians ; Phy- sician to Saint George's Hospital ; Senior Physician to the Hospital for Sick Children ; Correspond- ing Member of the Academy of Medicine of New York. Jt3F° This volume has just been completed, and concludes the work of which the volume on Albumi- nuria, published in this Library for 1881, is the first part. EPILEPSY AND OTHER CHRONIC CONVULSIVE DISEASES. Their Causes, Symptoms, and Treatment, By W. R. GOWERS, M.D., F.R.C.P., Assistant Professor of Clinical Medicine in Univer- sity College ; Senior Assistant Physician to University College Hospital ; Physician to the National Hospital for the Paralyzed and Epileptic. J5&™ Specially revised by the author for Wood's Library. CLIMATOLOGY OF THE UNITED STATES, AND ADJACENT COUNTRIES, and of such Foreign Ports and Places as have intimate Commercial Relations with the United States, with special reference to Health Resorts, and the Protection of Public Health. By A. N. BELL, A.M., M.D., Ed- itor of " The Sanitarian ; " Member of American Medical Association, American Public Health Asso- ciation, Medical Society of the State of New York ; Honorary Member of Connecticut Medical Society ; Corresponding Member of the Epidemiological Society of London, • formerly P. A. Surgeon U. S. Na vy, e ct. 855?" This work has been written specially for Wood's Library, by one whose training and study have been for many years in this line. DISEASES OF THE LUNGS, OF A SPECIFIC, NON-TUBERCULOUS NATURE. Acute Bronchitis, Infectious Pneumonia, Gangrene, Syphilis, Cancer, and Hydatids of the Lungs. By PROF. GERMAIN s£E, Member of the Faculty of Medicine ; Member of the Academy of Medicine ; Physician to the Hotel Dieu, etc., Paris. Translated by E. P. HURD, M.D., Member of the Massachusetts Med- ical Society ; Vice- President of the Essex North District Medical Society ; One of the Physicians of the Anna Jaques Hospital, Newburyport, Mass. With an Appendix by the Translator on the German Theory of Disease, and on the Tubercle Bacillus. 13^*" One of the most valuable works on the subject of recent times — fully up to date. DIAGNOSIS OF THE DISEASES OF THE BRAIN AND SPINAL CORD. By W. R. GOWERS, M.D., F.R.C.P., Assistant Professor of Clinical Medicine in University College ; Senior Assistant Phy- sician to University College Hospital ; Physician to the National Hospital for the Parahjzed and Epi- leptic. 51 Catalogue of the Titles of the Works published in Woods Library of Standard Medical Authors. 1884. Sixtli Scries. Price, $1§.00, Volumes not sold separately. LEGAL MEDICINE. By CHARLES MEYMOTT TIDY, M.D., F.C.S., Master of Surgery, Professor of Chemistry and of Forensic Medicine and Public Health at the London Hospital, Medical Qfflctr oj Health for Islington, Late Diputy Medical Officer of Health and Public Analyst for the City of London, etc. Volume III. Contents : Legitimacy and Paternity — Pregnancy, Abortion — Rape, Indect-nt Ex- posure — Sodomy, Bestiality — Live Birth, Infanticide — Asphyxia, Drowning — Hanging, Strangulation — Suffocation. PATHOLOGY AND TREATMENT OF GONORRHOEA. By J. L. MILTON, M.D., M.R.C.S., Lecturer on Diseases of the Skin, St. John's Hospital for Skin Diseases, etc. i&~ This work is fresh from the author's hands, and treats in a very practical way of this common disorder. DIAGNOSIS AND DISEASES OF THE HEART. By Db. CONSTANTINE PAUL, Professor Agrege in the Faculty of Medicine of Paris, etc. Illustrated by numerous fine wood engravings. A PRACTICAL MANUAL OF OBSTETRICS. By E. VERRIER, M.D. Translated from the French. Edited by E. L. PARTRIDGE, M.D. Profusely illustrated with fine wood engravings. HOOPER'S PHYSICIAN'S VADE MECUM : A Manual of the Principles and Practice of Physic ; with an Outline of General Pathology, Therapeutics and Hygiene. Tenth Edition. Revised by WILLIAM AUGUSTUS GUY, M.B., Cantab, F.R.S., JOHN HARLEY, M.D., Lond., F.L.S. Volume I. Illus- trated by wood engravings. HOOPER'S PHYSICIAN'S VADE MECUM : A Manual of the Principles and Practice of Physic ; with an Outline of General Pathology, Therapeutics and Hygifne. Tenth Edition. Revised by WILLIAM AUGUSTUS GUY, M.B., Cantab, F.R.S., JOHN HARLEY, M.D., Lond., F.L.S. Volume II. Illus- trated by wood engravings. MALARIA AND MALARIAL DISEASES. By GEORGE M, STERNBERG, M.D., F.R.M.S., Major and Surgeon United States Army ; Member of the Biological Society of Washington ; Late Member of the Havana Yelloio Fever Commission of the National Board of Health, etc. Illustrated. DISEASES OF THE OESOPHAGUS, NOSE AND NASO-PHARYNX. By MORRELL MACKENZIE, MO., London, Senior Physician of the Hopital for the. Diseases of the Chest and Throat, Lecturer on Diseases oj the Throat at Lond m Hospital Medical College, etc. Illustrated by wood engravings. 528'" The companion volume of this work, namely, "Diseases of the Pharynx, Larynx and Trachea," was published in the Library for 1880, and elicited the warmest commendation from the medical press of England and America. A TEXT-BOOK OF GENERAL PATHOLOGICAL ANATOMY AND PATHOGENESIS. By ERNST ZIEQXjER, Professor of Pathological Anatomy in the University of Tubingen. Translated and edited for English Students by DONA LD MACALISTER, A.M., M.B., Member of the Royal College if Pin, ■■ inn . ; I', Hi, hi iiinl Umlinil /.,:■/ n,->r of St. ■John's College, Cambridge. Part II — Special Pathological Anatomy. Sections I-VIII. Profusely illustrated. DISEASES OF THE URINARY AND MALE SEXUAL ORGANS. By WM. T. BELFIELD, M.D. BRONCHIAL AND PULMONARY DISEASES. By PR03SER JAMES, M.D., Lecturer on Materia IfeOica and Therapeutics at the London Hospital; Physician to the Hospital for Diseases of the Throat; Lute Physician to the North London Consumptive Hospital, etc. Illustrated by numerous wood engravlngf. MEDICAL BOTANY : A Treatise on Plants used in Medicine. By LAURENCE JOHNSON, A.M., M.D., Itrer on Medical Botany, Medical Department of the University of the City of New York ; Fellow of the New York Academy of Medicine, etc. Illustrated by nine beautifully colored plates and very DOmerona fine wood engravings. :>-± Wood's Library of Standard Medical Authors Fifth Series. Price, wis. 00. Volumes not sold separately. MANUAL OF GYNECOLOGY. By D. BENJ. HART, M,D., F.R.C.P.E., Lecturer on Midwifery and Diseases of Women, School of Medicine, Edinburgh, etc., etc.; and A. H. BARBOUR, M.A., B.Sc, M.B., Assistant to the Professor of Midwifery, University of Edinburgh. Volume 1. Illustrated with eight plates, two of which are in colors, and 192 fine wood engravings. MANUAL OF GYNECOLOGY. By D. BENJ. HART, M.D., F.R.C.P.E., Lecturer on Midwifery and Diseases of Women, School of Medicine, Edinburgh, etc., etc.; and A. H. BARBOUR, M.A., B. Sc, M.B., Assistant to the Professor of Midwifery, University of Edinburgh. Volume II. Illustrated with a lithographic plate and 209 fine wood engravings. THE DISEASES OF WOMEN. A Manual for Physicians and Students. By HEINRICH FRITSCH. M.D., Professor of Gynecology and Obstetrics at the University of Halle. Translated by ISIDORE FURST. Illustrated with 150 fine wood engravings. THE MICROSCOPE AND ITS REVELATIONS. By WM. B. CARPENTER, C.B., M.D., LL.D. Sixth Edition. Volume I. Illustrated by one colored and 26 plain plates, and 502 fine wood engravings. THE MICROSCOPE AND ITS REVELATIONS. By WM. B. CARPENTER, C.B., M.D., LL.D. Sixth Edition. Volume II. Illustrated with 26 plates and 502 fine wood engravings. HANDBOOK OF ELECTRO-THERAPEUTICS. By DR. WILHELM ERB, Professor in the Univer- sity of Leipzig. Illustrated by 39 wood engravings. A TEXT-BOOK OF GENERAL PATHOLOGICAL ANATOMY AND PATHOGENESIS. By ERNST ZIEGLER, Professor of Pathological Anatomy in the University of Tubingen. Translated and edited for English students by DONAL McALISTER, A.M., M.B., Member of the Royal College of Physicians ; Fellow and Medical Lecturer of St. Joh?i y s College, Cambridge. THE TREATMENT OF WOUNDS. Being a Treatise on the principles upon which the Treatment of Wounds should be founded, and on the best methods of carrying them into practice, including a con- sideration of the modifications which special injuries may demand. By LEWIS S. PILCHER, A.M., M.D., of Brooklyn, N. Y. Illustrated by wood engravings. A MANUAL OF PRACTICAL HYGIENE. By EDMUND A. PARKES, M.D., F.R.S., Late Pro- fessor of Military Hygiene in the Army Medical School ; Member of the General Council of Medical Education ; Fellow of the Senate of the University of London ; Emeritus Professor of Clinical Medi- cine in University College, London. Edited by F. S. FRANCOIS DeCHAUMONT, M.D., F.R.S., Fellow of the Royal College of Surgeons, Edinburgh ; Fellow and Chairman of the Sanitary Institute of Great Britain; Professor of Military Hygiene in the Army Medical School. Sixth Edition. Volume I. A MANUAL OF PRACTICAL HYGIENE, WITH AN APPENDIX. Giving the American practice in matters relating to Hygiene, prepared by and under the supervision of FREDERICK N. OWEN, Civil and Sanitary Engineer. Illustrated by chromo lithographic plates. Volume II. ON SYPHILIS IN INFANTS. B7 PAUL DIDAY. Translated by DR. G. WHITLEY. With Notes and Additions by F. R. STURGIS, M.D. With a Colored Plate. ISlf" In bringing out an American edition of Diday's exceptional work, Dr. Sturgis in his preface says: "He believes that this method of annotation will serve to bring out many points in the Pathology and Treatment of Infantile Syphilis better than it could have done in an independent work." A TREATISE ON VETERINARY MEDICINE, as Applied to the Diseases and Injuries of the Horse. Compiled from standard and modern authorities. By F. O. KIRBY. Illustrated by 4 chromo- lithographic plates, containing numerous figures and about 150 fine wood engravings. 53 f jp Library of Standard Medical Authors. Fourth Series. Price, £1§.©0. Volume* not sold separately. ILLUSTRATIONS OF DISSECTIONS. In a series of original colored plate?, representing the dissoc- •> tions of the human body, with descriptive letter-press. By GKORGE VINER ELLIS, Professor of Jjj Anatomy in University College, London, and G. H. FORD, Esq. The drawings are from nature by *o Mr. Ford, from directions by Prof. Ellis. Volume I. Containing 29 full page chromo-lithographic • plates. © ILLUSTRATIONS OF DISSECTIONS. In a series of original colored plates, representing the dissec- ~ lions of the human body, with descriptive letter-press. By GEORGE VINER ELLIS, Professor of Anatomy in University College, London, and G. H. FORD, Esq. Volume II. Containing 27 full- page &* chromo-lithographic plates. & |3|f" When, in the second series, we succeeded in presenting our subscribers with " Savage's Female £ Pelvic Organs,'' will its full-page lithographic plates, we supposed we had reached the extreme limit in •J reproducing expensive books at so low a price, but these two volumes of Ellis and Ford far exceed even - that. It is simply wonderful, and cannot fail to compel acknowledgment of the value of this series of 6 publications. It would have been impossible to accomplish such results, save in a library such as this, * in which all the volumes have a large and equal sale. LECTURES ON DISEASES OF CHILDREN. A Hand-book for Physicians and Students. By Dr. <£ EDWARD HENOCH, Director of the Clinic and Polyclinic for Diseases of Children in the Royal 2 Ch ante Hospital and Professor in the Berlin University. Translated from the German. B3F~ A new book, just ready, and of ereat practical value. g MATERIA MEDICA AND THERAPEUTICS. Inorganic Substances. Ey CHARLES D. F. .. | • The \\..rk treats the subject it relates to, from an American stand-point, the works heretofore in the market being of foreign origin. It will, therefore, be a very practical volume, for the Ube of physi- i km- throughout t his COlintry. p, LEGAL MEDICINE. By CHARLES MEYMOTT TIDY, M.B., F.C.S.. Master of Surgery. Professor 9 of Chemistry and of Forensic Medicine ami Public Health at the Condon Hospital, Medical Officer of p, Health for Tsltnaton, i.ut'- Deputy Medical Officer of Health and Public Analyst for the City of L<>i>- >, Oon, etc. Volume I. With two colored plates. Contents: Evidence— The Signs of Death— Identity— 'g The Cannes of Death - The p st .Mortem. » LEGAL MEDICINE. By CHARLES MEYMOTT TIDY. M.D.. F.C.S., Master of Surgery, Professor *> of Chemistry and of Forensic Medicine and Public Health at the London Hospital, Medical Officer oj * //• .I!'), for Islington, /.ai- Deputy tt< ileal Officer of Health and Public Analyst for the City of London, * Volume II. Contents: Expectation of Life— presumption of Death and Survivorship— Heat and V 1 -Ligaturing— Explosives— Starvation— Sex— Monstrosities— Hermaphrndi.-ni. £• for a thorough and exhanBfcive treatise upon this subject from some recognized S* authority has long been felt in English speaking countries. But the labor of preparing such a work is L Ions, requiring BUCh critical acumen anil familiarity with both medicine and law, together jgj with the mo-.t patient industry, thai even those more or less qualified to undertake the task have held 'hen fore, with no little satisfaction that the publishers have been able to secure this very valuable work for the Ubaoribers to Wood's Library of Standard Medical Authors. Each volume is Complete upon the topic, of which it treats. Upon completion, subscribers will possess, at a nominal cost, the fullest and mom thorough treatise on the subject of modern times. It will inter to know that the cost of the two volumes we now present, is, in the original English edition, over §13.00. 54 a Catalogue of the Titles of Works published in Wood's Library of Standard Medical Authors. 1 Tliird Series. Price, $18.00. Volumes not sold separately. l -,;MWW^M§: H ' DICKINS0N ' M - D - I11UStrated Wkh Plain and COl ° red ^hographic | treSuponltin the" language 8 ^ Standard ^^ ^ intereStin e sub J ect > and is the ™st complete | MATERIA MEDICA AND THERAPEUTICS OF THE SKIN. By HENRY G. PIPFABD, A M., s^Z r> ' Jje ;^ or ?J Dermatology, Medical Department of the University of ttie City of Neio York ■ w burgeon to Charity Hospital, etc. ?*."!*!■• m _ " Morbi epidermidem, epithelium, c?m'm, et cellnlosam membranum efficientes tarn multi sunt ut vix « L!L°f'- neia P atluntllr redigi; ex medicamentis autem quae maxime ad eorum morborum curationem /. sunt lm usu, hie proponernus."— De Goeter (1740). £ 83^= This original work is probably one of the most useful books for the general practitioner g ever published upon the subject, containing as it does a systematically classified mass of the most popu- •J lar and recent formulre. 2 A TREATISE ON DISEASES OF THE JOINTS. By RICHARD BARWELL, P.R.C.S. Surgeon m Uia>ing- Cross Hospital, etc. Illustrated by numerous engravings on wood. - j^r- This standard book, just re-written by its distinguished author, is, by special arrangement with - mm, published in this library in advance of its appearance in England. A TREATISE OH THE CONTINUED FEVERS. By JAMES C. WILSON, M.D., Attending Phy- sician to the Philadelphia Hospital and to the Hospital of the Jefferson Medical College, and Lecturer JL,' USi V D '?S>! 1 " S1S . at the Jefferson Medical College, Fellow of the College of Physicians, Phila- «»; r/n ri m ? an m , t, '°, du f^ n b y J - M. DA COSTA, M.D., Professor of the Practice of Medicine ',L r? ■ d ' Cine , at J he Jefferson Medical College, Physician to the Pennsylvania Hospital. Con- sulting Physician to the Children's Hospital, Fellow of the College of Physicians, Philadelphia, etc. f^P^! 6 W ° Uld hardly b ? P° SEib]e t0 Present to the profession a work of more universal interest than tn f'h ille ™ e ls „ s P ecl . all y Prepared for this series, and necessarily possesses great practical value to all practitioners of medicine. A MEDICAL FORMULARY. By LAURENCE JOHNSON, A.M., M.D., Fellow of the New York Academy of Medicine, etc. win^I Jt 'f a ! ?. nf? time sin ce the first publication of Ellis and of Griffiths; the present modern work will, therefore, be peculiarly acceptable. THE /3? E i SES OF OLD AGE. By J. M. CHARCOT, M.D., Professor in Faculty of Medicine of toJJiL Tl! C 'nr ■ t] \ e ^ al Petriere ; Member of the Academy of Medicine ; of the Clinical Society of London of the Clinical Society of Buda-Pesth ; of the Society of Natural Sciences, Brussels ■ President of the Anatomical Society etc., etc. Translated by L. HARRISON HUNT. M.D., with numerous additions by A L. LOOMIS, M.D., etc., Professor of Pathology and Practical Medicine in the Medical Department of the University of the City of New York; Consulting Physician in the Charity Hospital ■ to the Bureau of Out- Door Relief; to the Central Dispensary; Visiting Physician to the Bellevue Hospital; to the Mount Sinai Hospital, etc., etc. JS" This work is upon a subject little understood, and but little treated of by authors It will be almost the only book of its kind. COULSON ON THE DISEASES OF THE BLADDER AND PROSTRATE GLAND Sixth Edition. Revised by WALTER J. COULSON, F.R.C.S., Surgeon to St. Peter's Hospital for Stone etc and Surgeon to the Lock Hospital. Illustrated by wood engravings. ' VW This standard work has just been revised and is most highly commended by the leading medical journals of England. b GE uTrmuK E ?^ A un H ? M / STEY ; , A practical manual for the » se of Physicians'. By R. A. , « ■ ? A -^-' M -P' Professor of Medical Chemistry and Toxicology in the University of Ver- mont, Member of the Chemical Societies of I'aris and Berlin, New York Academy of Medicine, etc. f^T No medical chemistry especially intended for the use of practising physicians has appeared for a long time ; it is therefore believed this "-will fill a want long felt:' ARTIFICIAL ANESTHESIA AND ANESTHETICS. By HENRY M. LYMAN, AM MD Professor of Physiology and Nervous Diseases in Rush Medical College, and Professor of Theory arid Practice of Medicine m the Woman's Medical College, Chicago, III. EP~ The first comprehensive and complete treatise upon this comparatively modern and verv im- portant subject. J A T T? w A T.a S , E v °A F ? a D AND ^ETETICS. Physiologically and Therapeutically considered. By i". W. l'AV Y, M.D., F.S. Second Edition. A HANDBOOK OF UTERINE THERAPEUTICS AND DISEASES OF WOMEN Bv EDWARD JOHN TILT, M.D. Fourth Edition. wuivi^ju. Ly DISEASES OF THE EYE. By HENRY D. NO YES, M.D., Professor of Ophthalmology and Otology in Bellevue Hospital Medical College, Surgeon to the New York Eye and Ear Infirmary, etc Illus- trated by two chromo-lithographs and numerous wood engravings. 4.i. i ^r- T, I i ? treati8e is written with a special view to the needs of the general practitioner, and treats the subject in a very plain, practical way. 55 Catalogue of the Titles of the Works published iu Wood's Library of Standard Medical Authors. Second Series. Price, $1§.00. Volumes not sold separately. © ^ft ft *8 VENEREAL DISEASES. By E. L. KEYES, A.M., M.D., Adjunct Professor of Surgery, and Professor s of Dermatology in Jittlevue Hospital Medical College ; Consulting Surgeon to the Charity Hospital ; bt Surgeon to JJetlevue Hospital, etc. S |3^~ Ii makes a handsome volume of 361 pages, thoroughly covering the subject. It is written with 8 special reference to the needs of the physician in active practice, and is. well illustrated. *JJ A HANDBOOK OF PHYSICAL DIAGNOSIS: Comprising the Throat, Thorax, and Abdomen. By g DE. PAUL GUTTMAN, Privut-Docent in Medicine, University of Berlin. Translated from the Third v German Edition by ALEX. NAPIER, M.D., Fel. Fac. Physicians and Surgeons, Gta.-goiv. American *■ Edition, with a colored plate and numerous illustrations. • JiW" This standard work, the hiphest authority upon the subject, has passed through several editions J) in Germany, and has been translated into French, Italian, Russian, Spanish, Polish, and English. A volume of 3 14 pages. £ A TREATISE ON FOREIGN BODIES IN SURGICAL PRACTICE. By ALFRED POULET, M.D., £ Adjutant Surgeon- Major, Inspector of the School for Military Medicine at Val-de-Grace. Illustrated „ by original wood engravings. Translated from the French. Volume I. m {S?F" This new and practical work upon an entirely new subject is of unusual interest and value. It ** is translated by permission of ihe author, who has revised and corrected it, with additions, especially j? for this series. This volume is illustrated by many fine engravings. — A TREATISE ON FOREIGN BODIES IN SURGICAL PRACTICE, By ALFRED POULET, M.D.. « Adjutant Surgeon-Major, Inspector of the. School for Military Medicine at Val-dt-Orace. Illustrated _ by original wood engravings. Volume II. g A TREATISE ON COMMON FORMS OF FUNCTIONAL NERVOUS DISEASES. By L. *-d PUTZEL, M.D., Visiting Physician for Nervous Diseases, Iiand.tlVs Island Hospital; Physician to the Class for Nervous Diseases, Bellevue Hospital Out-Door Department; and Pathologist to the Lu- natic Asylum, IS. I. £3?~ This volume is especially prepared for use of general practitioners, and treats in a practical way ? g of the forms of nervous disorders commonly met with in practice. It makes a book of 262 pages. w * DISEASES OF THE PHARYNX. LARYNX AND TRACHEA. By MORRELL MACKENZIE, " S M. L> , London. Illustrated by 112 fine wood engravings. *© g3^"~ This work, by the best English authority is just completed, and will be welcomed by the profes- sion in America. It makes a large volume of 440 pages. S _ THE SURGERY. SURGICAL PATHOLOGY AND SURGICAL ANATOMY OF THE FE- .2 « MALE PELVIC ORGANS in a series of plates taken from nature with commentaries, notes, and £ i a es by HENRY SAVAGE, M.D., London, Fellow of the lioyal College of Surgeons of England, one S« of the Consulting Medical Oj/lcers of the Samaritan Hospital for Women. Third edition, revised and ft» greatly extended. 4> C^"32 full-page lithographic plates and 22 wood engravings, with special illustrations of the opera- jj fl lii QBOn Vesien- Vaginal Fistula, Ovariotomy, and Perineal Operation. This is the cheapest book ever _ published on any branch of medicine at any time, and is almost worth the entire cost of the twelve ii volumes. '2 THERAPEUTICS. Illustrated by D. F. LINCOLN, M.D., from the Materia Mcdica and Thera- J peutic ol \. TOS8EAU, M.D., Professor of Therapeutics of the Faculty of Medicine of Paris, Physician, to V Hotel l)i(u. etc., etc., 1J. P1DOUX. M.D., Member of ihe. Academy of Medicine, «■ Purr, etc., etc., and CONSTANTTNE PAUL, M.D., Adjunct Professor of the Faculty of Paris, Phy- pfi m to the St. Antoiin Hospital, etc. Ninth French Edition, Revised and Edited. Volume I. Any ** work by Trossean needs no introduction to the Medical Profession — his profound knowledge, his admir- ^ able facility Of imparting instruction, and his delightful styie commend whatever bears his name to their best considi ration. This work is said to be superior to any other upon the subject, and one which * will long continue to be a standard. The editon from which this translation is made has been thoroughly revised and edited by Dr. Paul, and brought down to Iho present year. THERAPEUTICS. Translated by D. I'. LINCOLN, M.D., from the Materia Medica and Therapeutics ft of !'. M. i>., Professor of Therapeutics of the Faculty of Medicine of Parts, Physicianto v / // . etc., ii. P] DOUX, M.D., M< mb< r of the Academy of Medicine. Pans, etc. etc, and ft mm; PAUL, .M.i >.. Adjunct Pi ofei-sor of the Faculty of Paris, Physician to the St. Antoine £ //■ tpital, etc. Ninth Edition, Revised and Edited. VolnmeH. © THERAPEUTICS. Translated by I). !■'. LINCOLN, M.D., from the Materia Medica and Therapeutics of " L TROS8EAU, M. D., Professor oj Therapeutics of the. Faculty of Medicine of Pdris, Physicianto *> i ii.r, i lu.ii. etc., etc., II. PIDOl '•■■ m D., Member of the Academy af Medicine, Paris, etc., etc.. and 7 -TWi IM. PAUL, M.I'.. Adjunct Professor of the Faculty of Paris, Physician to the St. Antoine $ Hospital, etc Ninth French Edition, Revised and Edited. VolumeJII. & DIAGNOSIS AND TREATMENT OF DISEASES OF THE EAR.— By ALBERT H. BUCK, M.P., H Instructor m Otology in the College of Physicians and Surgeons, New York; A ural Surgeon to the L x. v Eye ami Ear I 'uji 'ruio r >/: Editor of ZlemsserCs Cyclopedia of the Practice of Medicine, and Iffl \ i eatlse on Hygiene and Public Health. n MINOR SURGICAL GYNECOLOGY. By I'M I. P. MUNDE, M.D. A Manual of Uterine Diagnosis and thi rical Practice, for the Use of the Advanced student und il Practitioner, in one octavo volume of 802 Pages, With 800 illustrations. contain many hinis concerning the minor details of practice in the treatment of women, oommonly overlooked In general treatises. It is written especially for this library. 56 Catalogue of the Titles of Works published in Wood's Library of Standard Medical Authors. First Series. Price, $18.00. Volumes not sold separately. REST AND PAIN. A Course of Lectures on the Influence of Mechanical and Physiological Rest in the Treatment of Accidents and Surgical Diseases and the Diagnostic Value of Pain. By JOHN HILTON, F.R.S., F.R.C.S. Edited by W. H. A. JACOBSON, P.R.C.S. DISEASES OF THE INTESTINES AND PERITONEUM. Comprising Articles on— Enteralgia, by JOHN RICHARD WARDELL, M.D. ; Enteritis, Obstruction of the Bowels, Ulceration of the Bowels, Cancerous and other Growths of the Intestines, Diseases of the Caecum and Appendix Vermi- formis, by JOHN SYER BRISTOWE, M.D. ; Colic, Colitis and Dysentery, by J. WARBURTON BEG-BIE, M.D. ; Diseases of the Rectum and Anus, by THOMAS BLIZZARD CURLING, F.R.S. ; Intestinal Worms, by W. H. RANSOM, M.D. ; Peritonitis, by JOHN RICHARD WARDELL, M.D. ; Tubercle of the Peritoneum, Carcinoma ot the Peritoneum, Affections of the Abdominal Lymphatic Glands and Ascites, by JOHN SYER BRISTOWE, M.D. A CLINICAL TREATISE ON DISEASES OF THE LIVER. By DR. FRIED. THEOD. FRERICHS. Translated by CHARLES MURCHISON, M.D. In Three Volumes, Octavo. Volume I. Illustrated by a full-page Colored Plate and numerous fine Wood Engravings. A CLINICAL TREATISE ON DISEASES OF THE LIVER. By DR. FRIED. THEOD. FRERICHS. Translated by CHARLES MURCHISON, M.D. In Three Volumes Octavo. Volume II. Illustrated by a full pa?e Plate and numerous fine Wood Engravings. A CLINICAL TREATISE ON DISEASES OF THE LIVER. By DR. FRIED. THEOD. FRER- ICHS. Translated by CHARLES MURCHISON, M.D. In three volumes, octavo. Volume III. Illustrated by a full-page Plate and numerous fine Wood Engravings. MATERIA MEDICA AND THERAPEUTICS. (Vegetable Kingdom.) By CHARLES D. F. PHILLIPS, M.D. , F.R.C.S. E., Lecturer on Materia Medico, at Westminster Hospital, London. Re- vised and adapted to the U. S. Pharmacopoeia by HENRY G. PIFFARD, A.M., M.D., Professor of Der- matology, University of the City of New York, Surgeon to the Charity Hospital, etc., etc. This prac- tical book forms a volume in this series of 327 pages. A CLINICAL TREATISE ON THE DISEASES OF THE NERVOUS SYSTEM. By M. ROSEN- THAL, Professor of Diseases of the Nervous System at Vienna. With a preface by Professor CHARCOT. Translated from the Author's revised and enlarged edition by L. PUTZEL, M.D., Piiys- icijintoihe Class for Nervous Diseases, Bellevue Out-door Dept., and Pathologist to the Lunatic Asylum, BlackweWs Island. In two volumes. Volume I. Illustrated with fine Woodcuts. This new edition of Prof. Rosenthal's work is pronounced by the most eminent neurologists to be the best treatise extant upon the subject, clear in its pathology and full and practical in therapeutics. This is a volume of SSI pages. A CLINICAL TREATISE ON THE DISEASES OF THE NERVOUS SYSTEM. By M. ROSEN THAL, Professor of Diseases of the Nervous System at Vienna. With a Preface by Prof. CHARCOT. Translated from the Author's revised and enlarged edition by L. PUTZEL, M.D. Volume II. DISEASES OF WOMEN. By LAWSON TAIT, F.R.C.S. A new Edition, with considerable additions, prepared by the Author expressly -for this Library. This very compact, useful book makes a volume of 204 pages, with illustrations. INFANT FEEDING, AND ITS INFLUENCE ON LIFE ; Or, The Causes and Prevention of Infant Mortality. By 0. H. F. ROUTH, M.D. Third Edition. This unique work forms a volume of 280 pages in this Library. A PRACTICAL MANUAL OF THE DISEASES OF CHILDREN, WITH A FORMULARY. By EDWARD ELLIS, M. D. Third Edition. This standard book makes a volume in this series of 225 pages. A MANUAL OF SURGERY. By W. FAIRLIE CLARKE, M.A.and M.B. (Oxon.), F.R.C.S., Assistant Surgeon to Charing Cross Hospital. A new Edition, thoroughly revised, with important additions by an American surgeon. Nearly 200 illustrations. Over 300 pages. 57 NEARLY ONE HUNDRED DISTINGUISHED AUTHORS, HAVE CONTRIBUTED TO WOODS' LIBRARY OF Standard Medical Authors, INCLUDING Profs. A. L. LOOMIS— J. M. DA COSTA— HENRY D. NOYES— E. L. KEYES— A. H. BUCK- P. F. MUNDE— H. G. PLFFARD— R. A. WTTTHAUS— H. M. LYMAN— M. ROSENTHAL— F. T. FRERICHS— W. ERB— E. L. PARTRIDGE— A. TROUSSEAU— J. M. CHAR- COT— E. ZTEGLER— E. A. PARKES— W. GRIESLNGER— G. V. ELLIS, AND Drs. L. JOHNSON— PROSSER JAMES— J. C. WILSON— R. BARWELL— G. M. STERNBERG- MORRELL MACKENZIE— L. S. PLLCHER— C. M. TIDY— L. PUTZEL— H. SAVAGE— W. B. CARPENTER— BENJ. HART— C. PAUL— C. B. KELSEY— C. D. F. PHIL- UPS— J. HILTON— W. T. BELFIELD— W. J. COULSON— L. TAIT— F. W. PAVY— P. GUTTMANN— W. F. CLARKE— ETC., ETC., ETC. THERE HAS BEEN INCLUDED IN THE LIBEAEY, IN THE FIRST SIX SERIES, THIRTY-FOUR Beautifully Colored Full-page Lithographic Plates, ONE HUNDRED AND SEVENTY BLACK AND TINTED FULL-PAGE LITHOGRAPHIC PLATES, IN ALL OVER TWO HUNDRED PLATES, CONTAINING SEVERAL HUNDRED FIGURES, AND NEARLY FIVE THOUSAND OF THE FINEST, AND MOSTLY ORIGINAL, WOOD ENGRAVINGS, ALL OF WHICH HAS BEEN SUPPLIED AT THE MERELY NOMINAL COST OF FIFTEEN DOLLARS A YEAR TO THE REGULAR SUBSCRIBER. 58 NOW COMPLETE. Ziemssen's Cyclopaedia of the Practice of Medicine, In Twenty Royal 8vo Vols., including Buck's Hygiene (2 vols.), and the General Index. WITH WHICH SET IS PRESENTED A COPY OE ZIEMSSEN'S HANDBOOK OF DISEASES OF THE SKIN. This great work, the most full and complete treatise upon the practice of medicine in any language, is now complete. It is a standard which will long maintain its place as the great storehouse of medical knowledge. It seems proper upon the conclusion of this great work to ask attention to a few facts in connection with its translation and reprint. The attention of Wm. Wood & Co. was first directed to the advertisement of the German publisher, in the early part of 1873. After consultation with a number of prominent gentle- men of the profession, they concluded to venture upon the translation and pub- lication in English of the work to which it referred, the largest undertaking, by far, both as to the editorial labor and the amount cf money involved, of any medical publication in the English language. The estimates of the cost of the volumes, and the price at which the publish- ers could sell them, were based wholly upon the published plans of Mr. Vogel — thus, while the : ' copy " came from Germany with most satisfactory regularity, it was soon found that the volumes would much exceed the estimated number of pages ; and, after several years of publishing largely increased volumes, it was found that, even with such addition, it would be impossible to complete the work iu the fifteen volumes, as at first announced. The alternative then presented was, to increase the number of volumes, or abridge the matter ; the latter course would have been much preferred by the publishers, as enabling them to adhere strictly to their original estimates. So many influential subscribers objected, how- ever, that the}' felt compelled to announce that two volumes would be added to the set. It was hardly to be expected that there would be absolutely no adverse criticism of this course among so large a constituency as the subscribers to this work. It has been very gratifying, however, to find that this change, wholly be- yond their control, has been unsatisfactory to less than one per cent, of the sub- scribers. To show the difference between what they promised and what has ac- tually been given subscribers to Ziemssen's Cyclopaedia, the publishers give herewith the number of pages of each volume, in comparison with the average number as at first estimated, viz. : Promised, per volume, 500 to 700 pages. Average of 600. jes. Vol. 7 = 1,060 pages. Vol. 13= 987 pages, " 8= 949 " " 14= 911 " « 9= 936 " " 15= 808 " " 10= 584 " " 16 = 1,071 " " 11= 636 " " 17= 982 " " 12= 914 " Total number of pages already received by Subscriber, -''•--''..-- 14,596 " " " as promised .by Publishers, ------ 10,200 Given to Subscribers above their expectations, - - - 4,396 pages, or the equivalent of 7- 1 volumes of from 600 to 700 pages each. To the above is now to be added still another extra volume — Diseases of the Skin. It is, of course, well known that though this extra matter has cost the sub- scribers nothing, it entailed a very heavy and unlooked-for expense upon the publishers. They believe, however, this endeavor to do justly and generously by those who had supported this great undertaking has been appreciated by them. It is with no little satisfaction that the publishers can look back to the unex- ampled regularity, in book-publishing, Avith which the volumes appeared every three months for over three years, and it is with great pleasure that the publish- ers can now congratulate the subscribers and themselves upon the completion of the work. WM. WOOD & CO., Publishers. 59 Given, Vol. 1= 724 pa t'e 2= 763 ' a 3= 684 " a 4= 824 ' a 5= 726 ' ce 6=1,038 " ZIEMSSEN'S CYCLOPEDIA OF THE PRACTICE OF MEDICINE. This great work, the most full and complete treatise upon the practice of medicine in any language, is now completed. It is a standard which will long maintain its place as the great storehouse of medical knowledge. In now closing the record of the publication of this great work, the Publishers desire again to call attention to the great difference in the amount of matter promised by them to the subscribers and the amount that has actually been given to them. Promised, per volume, 500 to 700. Average of 600. f Volume 1= 724 pages. Volume 7=1.060 pages. Volume 13= 987 pages. 2= 763 " '• 8= 949 " " 14= 911 " /-;„,»„] " 3= 6S4 " ' ; 9= 936 " " 15= 808 " OC%A It it if>„ COO (f It lf)=1 071 il 17= '982 " 14 '• " Total number of pages already received by Subscriber, ------ 14,696 " li " '• as promised by Publishers, .------- 10,200 2= 763 1 3= 6S4 1 4= 824 1 5= 726 I 6 = 1,028 8= 949 9= 936 10 = 5S3 11 = 636 12= 914 G-iven to Subscriber.* above their expectations, - - 4.406 pages, or the equivalent ofi}i volumes of from 600 to 700 pages each. To the above is now to be added still another extra volume — viz.: Diseases of the Skin. COITTEUTS. 1. — Acute Infectious Diseases. Tart 1. j Vol.12. — Diseases of the Brain and its Membranes. 13. — Disea=es of the Spinal Cord and Medulla Oblongata. 14. — Disea-es of the Nervous System and Dis- turbances of Speech. 15. — Diseases of the Kidnt-y. 16. — Liseases of the Locomotive Apparatus and General Anomalies of Nutrition. 17. — General Anomalies of Nutrition and Poison. 18. — Hysiene and Public Health. Part 1. I -.— Hygiene and Public Health. Part 2. " 2. — Acute Infectious Diseases. Part 2. " 3. — Chronic Infectious Diseases. " 4. — Disea -es of the Respiratory Organs. Parti. " 5. — Diseases of the Respiratory Organs. Part 2. " 6. — Diseases of the Circulatory Organs. " 7. — Diseases of the Chylopoetic System. Parti. " 8. — Diseases of the Chylopoetic System. Part 2. " 9. — Diseases of the Liver and Portal Vein. " 10. — Diseases of the Female Sexual Organs. " 11. — Diseases of the Peripheral Cerebro-Spinal Nerves. " 20. — General Index to the Whole Cyclopaedia. ZIEMSSEN'S HANDBOOK OF THE DISEASES OF THE SKIN. PEABODY'S SUPPLEMENT TO ZIEMSSEN'S CYCLOP/EDIA. More than two hundred representative men have been engaged upon this enterprise. For Full list of Authors and Titles of Chapters please send to the Publishers for Catalogues. Price per Volume, Cloth, $5.00; Leather, $6.00; Half Morocco, $7.50. SPECIAL TIEIFLMS. Xow that tliis great work is completed, the set will be sent in full, to parties of approved credit, and liberal terms of paxjment as to time, allowed. WILLIAM WOOD & COMPANY, Publishers, correspondence invited. 56 & 58 Lafayette Place, New York. GENERAL INDEX TO ZIEMSSEN'S CYCLOPJDlI Miie Hundred and Ninety-Eight Columns of References to DISEASES— TIIKIR COMPLICATIONS AND REMEDIES. It has long been fell bert to this publication thai a full and complete Index in one volume fur the entire work i-s a neces&i .. ; in fact, it is alm<>-i impossible to avail one's self of the treasures of thin great store bouse "f medical knowledge without such assistance. The publishers, recognizing this, have, .f the several volumes. The result has astonished even those best acquainted with 7Jem*sen's -i. Ho— its richness 01 a great and standard work of reference has been brought out in the clearest S'i one possessing the work can at all afford to be without the General Index. It will arant that this Indexical volume furnishes, directly, the largest amount of suggestive informal ion in regard to Diseases, and their complication-, and indirectly to Remedies — their uses, their aotionh, an I their effects — obtainable from any one bout© — or any one volume ever published. in this respect it stands unique and alone, hpzriczes. The Index is bound to match the various bindings of Ziemsscn's Cyclopx-dia, and is sold at the same price, viz. ■ In Muslin Binding, $5 00 In Leather Binding, 00 In Half Morocco, 7 50 60 COMPACT. CONCISE. CONVENIENT. NO W REA DY. AN INDEX OF THE PRACTICE OF MEDICINE, BY WESLEY M. 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EDES, A.B., M.D. (Harvard). ^s?~ It has been his aim to show, as succinctly as is consistent with clearness, what each drug can do in the treatment of disease, what it mat do if not carefully used, and how far the various preparations are fitted to display its remedial powers. g&~ It is hoped that this book will be found by the physician a trustworthy guide in utilizing the agen- cies which the Pharmacopoeia places in his hands, and by the pharmacist a brief and intelligib.e statement of what may be expected from the substance he dispenses. " We cordially recommend the work to all Practitioners." BOCK'S ATLAS OF IIUMAM ANATOMY. ACCEPTED AS STANDARD BY French, Russian, English, and American Anthorities. INVALUABLE — to Student, Instructor, Demonstrator, Preceptor and the Surgeon who wishes quickly to refresh his memory befoie operating. A. SUPERIOR RESULT- at a minimum cost: 38 superbly Colored Plates. 362 Anatomical Figures. BOUND COPIES— Plates Hinged on Linen Guards, only §15.00. A TREATISE ON HYGIENE AND PUBLIC HEALTH, By various Authors. Edited by ALBERT H. BUCK, M.D., New York. In two Royal Octavo Volumes, Illustrated. Price, per volume, Muslin, $5.00 ; Leather, S6.0O; Halt Morocco, $7.50. tfg=- The study of Hygiene and Public Health has, more particularly of late years, become an absolute necessity to the medical pract tioner. The prevention of disease is not only recognizi d as more i port.inl than its cure, but with the light of recent study and research has become oftentimes even more easily pos sibie Intelligent people everywhere are alive to its importance. AUTHORS:-Juhn S. Billings, M.D.; Abraham Jacobi. M.D.; James Tyson, M D.: William Ripley Nichols: A. Brayt m Ball, M.D.; Arthur Van Harlingen, M.D.; D. F. Lincoln, M.D. : William H Ford.M.D.; Francs H Brown, M.D.: Roger S. Tracy. MD; Charles Smart, M.B . CM; Thomas J. Turin- . M.D; Henry C Sheafer; R i-witer W. Raymond, Ph.D.; Thus. B Cunis, M D.: Stephen P. Shnr it< !.. III. INJURIES AND DISEASES OF THE NERVES, BLOOD-VESSELS, AXD BONES. VOL. rF.— INJURIES AND DISI'.ASKS OF THE JOINTS. EXCISIONS AXD RESECTIONS. TREATS OF DEFORMITIES. [NJURIES AXD DISEASES OF VARIOUS REGIONS OF THE BODl <<>/.. /. REGIONAL SURGERY CONTINUED. VOL. II. REGIONAL BURGERY CONCLUDED. HISTORY OF SURGERY. APPENDIX. CEXE I v I > ) : ■: TO THE WHOLE SIX VOLUMES. VOLUMES I., II, III., IV., V, N<»\V UIOADV; V(H,UMli VI., IN DECEMBER-. PRICES. tra muslin binding, pel? volume, S6 In fine leather, raised bands, per volume, "i In h.-ilf morocco, marbled edges, per volume, SEND FOR ILLUSTRATED ANNOUNCEMENT (FREE). 62 INDEX. PAGE ALLEN, P. Lectures on Aural Catarrh 32 ANATOMICAL REMEMBRANCER 1 ASHB Y, H. Memoranda of Physiology 17 ASHHURST, J. The International Encyclo- paedia of Surgery 25 BARTHOLOW, R. Spermatorrhoea 38 BARWELL, R. A Treatise on Diseases of the Joints 4 BAUER, L. Lectures on Orthopaedic Surgery.. 23 BEARD, G-. M. Nervous Exhaustion, Neuras- thenia 35 BEDFORD, G. S. The Principles and Practice of Obstetrics 26 Clinical Lectures on tile Diseases of Women and Children. '..'A 26 BELFIELD, W. T. Diseases of. the Urinary and Hale Sexual Organs 38 BELL, A. N. Climatology 17 BENEDIKT, M. Anatomical Studies upon Brains of Criminals 37 BENNETT, J. H. Clinical Lectures on the Principles and Practice of Medicine. . . 8 BIGELOW, J. Nature in Disease 9 Brief Exposition of Rational Medicine 9 BINZ, G. The Elements of Therapeutics 15 BLYTH, A. W. The Analysis of Food and the Detection of Poisons 22 BOCK, C. E. Atlas of Human Anatomy with Explanatory Text 22 BODENHAMER, W. Practical Observations on Anal Fissure 13 Congenital Malformations of the Rectum and Anus 13 An Essay on Rectal Medication 13 On the Hemorrhoidal Disease 13 The Physical Exploration of the Rectum. . 13 BOSWORTH. F. H. Diseases of the Throat and Nose 33 BRAMWELL, B. The Diseases of the Spinal Cord 36 BR AUN, G. R. Unemic Convulsions 27 BRISTOWE, WARDELL, and OTHERS. Diseases of the Intestines and Perito- neum ... 8 BROCKLESBY J. The Amateur Microscopist. 21 BRODIE, B. Mind and Matter IS BROWN, H. E. Report on Quarantine on the Southern and Gulf Coasts of the United States 15 BROWN, W. S. A Clinical Handbook on the Diseases of Women 2S BUCK, A. H. A Treatise on Hygiene and Pub- lic Health 46 • Diagnosis and Treatment of Ear Diseases. 32 BURRALL, F. A. Asiatic Cholera 15 BUSEY, S. C. Congenital Occlusion and Dila- tion of Lymph Channels 41 BYFORD, W. H. A Treatise on the Theory and Practice of Obstetrics 27 CARNOCHAN, J. M. Congenital Dislocations of the Head of, Femur 23 CARPENTER, W. B. The Microscope and Its Revelations 21 CARPENTER, W. M. An Index of Medicine. 10 CASTLE, F. A. Wood's Household Practice of Medicine 10 CAZENAVE and SCHEDEL. Manual of Diseases of the Skin 41 CHAPMAN, E. N. Hysterology 27 CHARCOT, J. M. Clinical Lectures on the Diseases of Old Age 5 Lecture on Bright' s Disease 40 Lectures on Localization in Diseases of the Rrain 37 CLARK, W. F. A Manual of the Practice of Surgery 23 CODE OF MEDICAL ETHICS 9 PAGE COMSTOCK and COMINGS. Principles of Physiology 17 CORSON, J." W. On the Treatment of Pleurisy. 12 COULSON, W. J. Bladder and Prostate Gland. 38 CQRTIS, E. Manual of General Medicinal Technology 9 DELAFIELD, F. Studies in Pathological An- atomy, Vol. I. and II 3 DELAFIELD and PRUDDEN. Pathological Anatomy and Histoloay 3 DELAFIELD and STILLMaN. A Manual of Physical Diagnosis 15 DE WECKER", L. Ocular Therapeutics 32 DICKINSON, W. H. On Renal and Urinary Affections 40 DIDAY, P. A Treatise on Syphilis in New-born Children , 41 DRAPER, J. C. Laboratory Course in Medicai Chemistry 45 DUNCAN, J. M. Perimetritis and Parametritis 25 : On the Mortality of Child-bed and Mater- \ nity Hospitals 25 D WIGHT, T. Frozen Sections of a Child 30 EDES, R. T. Therapeutic Handbook of the United States Pharmacopoeia 43 ELLIS and FORD. lustrations of Dissections 2 ELLIS, E. Diseases of Children, with Formulary 29 EMMET, T. A. Vesico-Vaginal Fistula 28 ERB, W. Electro-Therapeutics 6 ERICHSEN, J. E. On Concussion of the Spine 36 FLINT, A. Compendium of Percussion and Auscultation 10 FOOTE, J. Ophthalmic Memoranda 30 Pharmacopoeia and Universal Formulary . 43 FOTHERGILL, J. M. The Physiological Fac- tor in Diagnosis 17 Indigestion, Biliousness, and Gout 14 FOWLER, E. P. Suppression of Urine 39 FOX, T. Skin Diseases 42 FRERICHS, F. T. Diseases of the Liver .... S FREY, H. The Microscope and Microscopical Technology 21 FRITSCH, H. Diseases of Women 28 GARRIGUES, H. J. Diagnosis of Ovarian Cysts 26 GARROD, A. B. Essentials of Materia Medica and Therapeutics 14 GODDARD, P. B. The Anatomy, Physiology, and Pathology of Human Teeth 24 GOULEY. J. W. S. Diseases of the Urinary Organs 39 GOWERS, W. R. Epilepsy, etc 36 ■ Diagnosis of Brain Disease 36 GRAHAM. D. A Practical Treatise on Massage 6 GREGORY, G. Lectures on the Eruptive Fevers 7 GRIE SINGER, W. Mental Pathology and Therapeutics 20 GUTTMAN, P. A Handbook of Physical Diag- nosis 16 HAMILTON, A. McL. Types of Insanity.... 37 HAMILTON, F. H. The Principles and Prac- tice of Surgery 22 HARRIS and POWER. Manual of the Physio- logical Laboratory 19 HARRISON, R. The Surgical Disorders of the Urinary Organs 38 HART ard BARBOUR. Manual of Gynecology 28 HELMHOLTZ, H. The Ossicles of the Ear and Membrana Tympani .... 32 HENOCH, E. Lectureson Diseases of Children 30 HILTON. J. On Rest and Pain 3 HOLDEN and SHUTER Human Osteology . 2 HOLMES. T. A System of Surgery by Various Writers 23 HOOPER'S PHYSICIAN'S VADE ME- CUM. A Manual of the Principles and Practice of Physic 9 HOSPITAL PLANS 46 G4 PUBLICATIONS OF WILLIAM ^YOOD & COMPANY. Index. PAGE HUN, H. A Guide to American Medical Stu- dents in Europe 46 INGALS, E. F. Diagnosis and Treatment of Diseases of the Chest, Throat, and Nasal Cavifes 12 JACOBI. A. A Treatise on Diphtheria 34 JAMES, P. Laryngoscopy and Rhinoscopy 34 JOHNSON, L. A Medical Formulary 43 A Medical Botany IT JOHNSON and MARTIN. The Influence of Tropical Climates on European Consti- tutions 46 KEETLEY, C. B. An Index of Surgery 22 KELSEY, C. B. Diseases of the Rectum and Anus 12 KEYES. E. L. Venereal Diseases 41 KIRBY, F. O. A Treatise on Veterinary Medicine 40 KIRKE'S HANDBOOK OF PHYSIOLOGY. IS KLOB, J. M. Pathological Anatomy of the Fe- male Sexual Organs 27 KNAFF, H. On Intraocular Tumors 31 LAMBERT, T. S. Primary Systematic Human Physiology, Anatomy, and Hygiene IS LEWIN, L. " The Incidental Effects of Drugs. . . 45 LID E LL. J. A. Apoplexy 36 LIVEING, R. On Treatment of Skin Diseases. 41 Diagnosis of Skin Diseases 41 LONGSTRETH, M. Rheumatism, Gout, and some of the Allied Diseases 4 LOOMIS, A. L. Lectures on Fevers 11 On Diseases of the Respiratory Organs, Heart, and Kidneys .... 11 A Text-book of Practical Medicine 11 Lesson in Physical Diagnosis 16 LYMAN, H. M. " Artificial Anaesthesia and a nsestbetics 4 MACKENZIE, M. Diseases of the Pharynx, Larynx, and Trachea 34 MILTON, J." L. Pathology and Treatment of Gonorrhoea 38 MILLARD, H. B. On Bright's Disease of the Kidneys 39 MORGAN, C. E. Electro-Physiology and Thera- peutics. 6 MUNDE, P. F. Minor Surgical Gynecology ... 25 MURCHISON, C. On Functional Derangements of the Liver S NEUBAUER AND VOGEL. A Guide to the Qualitative and Quantitative Analysis of the Urine 38 NOYES. H. D. On the Diseases of the Eye 30 OLDBERG, O. and WALL, O. A. A Companion to the United States Pharmacopoeia... 44 OWEN. R. The Skeleton and the Teeth 25 PARKES, E. A .Manual of Practical Hygiene .. 46 PARTRIDGE, E. L. A Manual of Obstetrics . . SB PAUL, C. Diseases of the Heart 10 PAVY, F. W. On Food and Dietetics 22 PEABODY, G. L. Supplement to Ziemssen's oredia 10 PHARMACOPOEIA OF THE UNITED STATES IS PHILLIPS, C. D. F. Materia Medica and Thera- e Kingdom) 11 Materia Medica and Therapeutics (Inor- '-■'" ... 14 PICTURES FOR PHYSICIANS' OFFICES AND LIBRARIES 46 PIFFARD, H. G. A Guide to Urinary Analysis 40 'in the Materia Medica and Therapeutics of the Skin -10 PILCHER, L. S. The Treatment of Wounds... y.| POULET, A. On Foreign Bodies in Surgical Practice 24 PRESCRIBER'S MEMORANDA 20 PUTZEL, L. mi Common Forms of Functional hoi . 86 QUAIN'S Elemeni ol Anatomy 1 RANNEY, A. L. Practical Medical Anatomy .. 2 A Practical Treatise on Surgical Diagno RICE, C. i | ible 44 PAGE RICHET, C. Physiology and Histology of the Cerebral Convolutions 36 RINGER, S. Hand-book of Therapeutics.. . 13 ROBINSON, B. On Nasal Catarrh and Allied Diseases 34 ROCKWELL, A. D. Lectures on Electricity (Dy- namic and Franklinic) 6 ROOSA, D. B. ST. J. On the Diseases of the Ear 33 Vest- Pocket Medical Lexicon 9 Ophthalmic and Otic Memoranda. ... 31 ROSENTHAL, M. On the Diseases of the Ner- vous System 35 ROSS, J. A Treatise on the Diseases of the Nor- vous System 34 ROUTH, C. H. F. Infant Feeding and its In- fluence on Life... . 30 SALTER, H. H. On Asthma: Its Pathology and Treatment 33 SALTER, J. A. Dental Pathology and Surgery. 24 SATTERTHWAITE, T. E. A Manual of His- tology 19 SAVAGE. H. " The Surgical Pathology 28 SEE,' G. Diseases of the Lungs 33 SEGUIN, E. Idiocy and its Treatment by the Physiological Method 37 ■ Medical Thermometry and Human Tem- perature 7 SEMELEDER, F. Rhinoscopy and Laryngo- scopy 34 SIMS, J. M. " On Uterine Surgery 26 SKENE, A. J. C. Diseases of the Bladder and Urethra in Women 26 SMITH, E. On Disease in Children 29 STEEL, J. H. Outlines of Equine Anatomy... 46 STELLWAG, C. On the Eye, including the Anatomy of the Organ 31 STERNBERG, G. M. and MAGNIN, A. Bac- teria 46 STERNBERG, G. M. Malaria and Malarial Diseases 46 STEWART, T. G. On Brighfs Disease of the Kidneys 40 STRICKER. S. A Manual of Histology 20 STURGIS, F. R. Medical Topics 46 TAIT, L. Diseases of Women 28 On Diseases of the Ovaries 28 TAYLOR. C. F. Mechanical Treatment of Dis- eases of the Hip- Joint C4 THUDICHUM, J. L W. A Manual of Chem- ical Physiology 19 THOMSON, A. T. A Conspectus of the Phar- macopoeias of the London, Edinburgh, and Dublin Colleges of Physicians and Sureeons 43 TIDY. C. M. Legal Medicine 10 TILT, E. J. A Handbook of Uterine Therapeu- tics 2S TROUSSEAU, A. Treatise on Therapeutics . . 14 VERRIER, E. Practical Manual of Obstetric- . 27 VIDAL. A. iin Venereal Diseases 41 VISITING LIST 46 VON TROELTSCHE, A. Diseases of the Ear in Children 33 WAGNER, E. A Manual of General Pathology 4 WEISSE, F. D. The Demonstrator 1 WENDT. E. C. A Treatise on Asiatic Cholera. 15 WEST, C. How to Nurse Sick Children 29 WILSON, E. The Students' Book of Cutaneous Medicine and Diseases of the Skin. . . . 41 WILSON, J. C. On the Continned Fevers 7 WITTHAUS, R. A. Essentials of Chemistry, Inorganic and Organic 15 The Medical .Students" Manual of Chemistry 45 INDEX RERUM 6 WYETH, J. A. A Handbook of Medical and Surgical Reference 23 Essays in Surgical Anatomy and Surgery. . 28 ZIEMSSEN, H. VON. Cyclopaedia of the Practice of Medicine 10 ZIEGLER, E. A Textbook of Pathological An- atomy and Pathogenesis 2 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 rules of the Library or by special arrange- ment with the Librarian in charge.