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HE
DISEASES, INJURIES, AND MALFORMATIONS
RECTUM AND ANUS,
HABITUAL CONSTIPATION.
T. J. ASHTON,
SECOND EDITION.
LONDON:
JOHN CHURCHILL, NEW BURLINGTON STREET.
• -• • •••
•• I • • •
• • • • • * •
• • • • *• •
• • •
• • • •
PRINTBB BT 9, £. AOLASD,
tAxnoLomM ctoift.
B2.
S57
PREFACE
TO THE KIKST EDITION.
The frequency and severity of the Diseases of tlie
Rccttim and Anus, impressed me, at an early period
of ruy professional life, with the im])ortance of study-
ing their pathology and treatment, and the very gene-
ral existence of these maladies in till classes of society
necessarily afforded a wide field for observation.
When the treatment of these affections first occu-
pied my attention, I greatly felt the want of a book
to which I coidd refer for information on some of the
more obscure and difficult cases. In tlie systematic
works on Surgery I foimd the subject but superficially
treated ; and though several excellent qiouogruphs
have been published, the authors have confined their
observations to certain of the affections only ; among
these stand pre-eminently the writings of Mr. Pott,
Mr. Copeland, and Mr, Syme. The treatise of Dr.
Bushe of New York, wiio unfortunately died si
after its publication, is the only one with which I
acquainted that embraces the whole subject, and
it I have gained much valuable information. To
Syme, of Edinburgh, belongs especially the mer
enforcing upon the attention of the Profession, Ir
wTitrngs and practice, a simple, rational and effica
mode of treating several of these affections, ag
endeavouring to unmask the empiricism into \
their treatment has chiefly fallen.
The Lectures of Sir Astley Cooper and of Sir
jamin Brodie. contain much useful infonuatiou, am
replete with practical observations.
In the foUowing pages, I have endeavoured to<
a simple narrative of the natiu^, causes, symj^
and the result of my experience in the treatmei
the several diseases of this region. 1 have also (ji
the opinions of viuious authors who had prevj
written on the subject, eitlier in support of the
ciptes I have adopted, or to illustrate in what re
I differ from them. And I am not without a
that this work may be of service to those men
of the profession who liave not had many opportia
of becoming practically acquainted with these disf
and be the means of enabling them more effidi
to relieve the sufferings of those committed to ■
chai'go; lastly, if I have not accoiuphshed the o
PREFACE. VU
of my desire, I trust the failure will be found to be-
long rather to the form and composition than to the
matter, which is derived &om a close study of the
literature of the subject, and a considerable share of
practical experience.
31, Cayendisu Square ;
January, 1854.
PREFACE
TO THE SECOND EDITION.
The favorable reception of this work by the pro-
fession, the opinions expressed by the medical press, and
the necessity for a new edition, have confirmed the
impression I entertained at the commencement of my
labours, that a work on this important subject was
needed. Whilst finding no reason to alter the arrange-
ment of the contents, nor, as a result of more extended
experience, to deviate from the principles of treating
the various diseases propounded in the first edition;
the present volume has been carefully revised, addi-
tional cases have been introduced in further illustra-
tion of the subject, and several of the chapters have
been extended.
31, Catbkdibii SqCillE,
1857.
CONTENTS.
PAGB
Introduction ...... 1
CHAPTER I.
IRRITATION AND ITCHING OF THE ANUS.
Causes ....... 9
Treatment . . . .12
Cases ...... 11 — 14
CHAPTER II.
INFLAMMATION AND EXCORIATION OF THE ANUS.
Causes . . . .16
Symptoms . . . . .16
Treatment . . . .17
CHAPTER III.
EXCRESCENCES OF THE ANAL REGION.
Nature and causes . .19
Treatment ...... 22
L Xii roNTKNTS. ■
1
^H
^^^^H a. Large tumour of a fibrous nature excised from
^^^^H . the anus of a man ....
^^^^^1 fering for BOTeral years
2^^
^^^^^1 c. Large wart; growth BurrouDding the anus
24
^^^^^1 d. Condylomata from tcucorrhcca occasiooed by
^^^^^1 ulceration of the os uteri
25
^^^^^1 IT. Condylomata from vaginal leucorrhcca
25
^^^^^ /. Condylomata from irritation, by contact of op-
^^^^^1 posed cutaneouB aarfaces
21
^^^^H g. Condylomata resulting from the folds of integu-
^^^^1 ment left by the collapsing of external hccmor-
^^H
2?
^^^^^H CHAPTER
f
^^^^^ CONTEACTION OF THZ
1 Causes .......
29
1 Symptoms ......
32
1 l^eatment .......
34
t Cases : —
^^H^ a. Congenital contraction of the anus of a child
34
^^^^^B b. Contraction of the anus following remoTal of
^^^^^1 external htemorrhoids ....
35
^^^H e. Remo?al of external hemorrhoida, followed by
^^^H contntctioQ of the anus, complicated vith fis-
^^^^^ aare ......
35
^^^^1 d. Contraction of the anus from syphilis
36
^^^^^1 t. Contraction of the anus from infiltration of
^^^^^B ......
'{
OK THE AND8 AND LOWEtt PAHT OF THE RECTm.
< from coQBtipBtiou , cured
i intense enffering for four
Characters of fiaaure of the anuf
CaUBea
Treatment .
Cases: —
a. Fiaaure of the anue
without operation
b. Fissure of the anus
months j cured by incision
c. Fissure of the anus cored by local applicatious .
d. Fissure and Losmorrboids inducing the idea of
stncture of the rectum
e. Fissure of the posterior part of the rectum, with
an external bsmorrhoid
f. Fissure leading to the formation of an nicer i
sympathetic afTectiou of the urinary organs
jr. Fissure degenerating iuto »n ulcer ; treated by
; implication of the urinary organs
CHAPTER VI.
IF TUB ANUS AND EXTREMITY OF THE RECTCH.
Character of pain ......
Causes ........
Treatment .......
Cases : —
^ a. Neuralgia of the rectum caused by mercurializa-
■ tion . .....
^L h. Neuralgia of the rectum relieved by pressure
CHAPTER VII.
INFLAMMATION or THE RECTUM.
CauKS ....--■
CompticatioDB ...-■'
Trefttment ..-■■'
CHAPTER VIII.
ULCERATION OF THE RECTUM.
CauBes ...-■••
Symptoms ...■■■
Treatment ...-.■
Cases ; —
a. Syphilitic ulcerntion of the rectum
b, Superlicial ulceration of the rectum treated with
nitrate of silver ....
e. Saperficial ulceration of the rectum treated with
nitric acid lotion ....
d. Ulceration of the mucoua membrane of the
rectum ; incision of the sphincter
e. Phagedenic ulceration of the rectum arrested
by the application of nitnc acid ; Bobscqiient
division of the sphincter
CHAPTER JX.
IL AFFECTIONS.
ClBBsification of hsemorrhoidal complai
External bRmorrboida
Internal bFcmorrlioida
Complications of htemorrhoids
65
86
88
90 I
93
Hp^^^^^^H
^^H
Causes .......
1U5 ^^1
Syrap'onis
^^1
DiagnoaiB .......
119 ^^H
Treatment .......
^^H
C43B8 :—
^^1
a. Internal htemorrhoids, pain in the foot the pro-
^^1
minent effect .....
^H
4. Horne Tooke'a case; Btrangnlation of internal
^^1
hfcmorrhoids .....
^^1
c. Eaternsl hemorrhoid, conatitutional treatment .
^^1
157 ^H
e. External hfemorrhoid, tumour incised
158 ^^1
160 ^^1
g. External heemorrhoids after hihouB fever .
^^1
^^H
faces, and fisaure of the uniiB .
^H
^^1
k. Congestionof the miicouB membrane of the rectum
^^H
attended by great pain .
IC7 j
/. Internal hBemorrhoids relieved by medical treat-
J
ment ......
ins ^^m
m. External and internal hsemorrhoids ; conBiderable
bleeding, palpitation of the heart, relieved by
^H
^H
constitutional treatment
^H
^^1
exee.<Bive hieraorrhage ....
^^1
0. Internal heemonhoids ; much lose of blood; gid-
^^1
diness and drowsiness ; axaluria; constitutioDal
^^1
treatment .....
^^1
^^1
of the eatameni% health restored without ope-
^H
ration ......
^^1
q. Hiemorrhoids induced by stricture of the urethra
^^1
Casbs : —
r. Internal bRmorrhoids treated «ith nitric ncid
<, Internal hteoiorrlioida ; patient iipwArda of eighty
years of age ; treated with nitric acid .
t. Internal hEemoirhoidB, exceasive pain ; treated witb
nitric acid ....
v. Internal hEcmorrhoids : stricture of the nrethra,
htemorrhoidi treated with nitric acid
V. Internal hsemorrhoids, medical treatment nol
ceeding, the tumours removed by ligature.
w. Internal hsmorrhoids, great loaa of blood, removal
of tumours by ligature .
X. Internal bsemorrhaids ; catameuial and ban
boidal flux alternating; tnmoura removed hj
ligature ....
y. Internal hEemorrhaida ; operation by ligature
r. Internal haamorrbotd, constant descent of tumour
removal by ligature
aa. Internal biemorrhaid ; great pain ; bleeding
descent of tumour ; ligature applied
bb. Internal biemorrboida, great constitutional effects
nicer of rectum ; operation
CauacB
Sjmptoma .
Treatment .
CHAPTER X.
OP H«MOBKHOIDAL VEINS.
Can«e«
Synptoma .
CHAPTER XI.
FHOLAPSUa OF THE RECTDM.
206
i
H^^^^^^p
^^H
Treatment
^H
Cases:
^^M
a. ProlapsuB in a child from deficient nourishment .
^^M
b. FralapBus of six iucbcs of the intestine from atone
^^H
in the bladder
^^M
c. Prolapsus caused by disease of the liver and
^^M
dysentery, induced by a long residence in India
214 ^^M
d. Prolapsus preceded hy morbid irritability of the
^^M
atomaeh and bowels ; cured by operation
215 ^^M
e. Prolapsus relieved witbout operation
^^M
^^H
billty of the bladder ; cured by operation
218 ^^M
^^^U CHAPTER
^1
^^^^^ ABSCES9 n'eah the rectum.
^^1
Causes .......
219 ^^H
Symptoms ......
226 ^H
Treatment ......
237 ^^M
Cases i
^H
|< a. Large abscess, unattended by local aymptoms
222 ^^M
b. Abscees near the rectum ; iutolcralilc fcetor when
^^H
opened ; no connection with the bowel
^^1
c. Tranmatic abscess, from wbich a piece of bone
^^1
and portion of the dresa were extracted
224 ^^B
il. Two pieces of clolh removed froiu an dbBceas
^^1
caused by a gun-shot wound several months
^^1
previously .....
^H
e. Abscess caused by a piece of hone perforating the
^^H
coats of the rectum ....
224 ^H
' /. A needle extracted which had caused great pain
^H
for some months ....
^H
jr. Great pain from a bone lodged in an abscess
225 ^H
h. Extensive gsngreiious abscess from the lodgment
^^1
of a chicken bone ....
^H
1. Abscess containing shot and feculent mutter
6
225 ^H
k. A fish-bone (lischiLrged horn hd abacoHs twelve
months af^er it vhs swallowed
/. Abscess trom which [he core of an apple was
moTed ....
ffi. Abscess from the lodgment of a fisb-bone
N. AbsccM from which the peWis of a snipe was
moved ....
o. Abscess produced by perforation of the rectum by
a fish-bone ....
CHAPTER XIII.
riSTDLA IN AND.
Causes ......
Symptoms .....
Treatment .....
Cases :
n. Fistula from absreRs following an nicer of the
rectum ....
b. Fistula in ano, communicating also with an ope:
ing in the groin
c. Louis XtV, trial of Tarious plans of treatment
• d. Fistula closed spontaneously
e. Hotraorrbage from dividing the sinus high up tl
bowel ....
/. Fistula from disease of iiver i hEcmorrhnge after
J. Fistula connected
A, Fistula connected <
r. Fistula connected
i. Fistula dependent
/. Fistula in auo following a kick
tN. Fistula, with two external openings
n. Fistula resulting from an abscess caused b;
sure lo cold and wet
ith disease of ischium
til disease of arch of pubis
■ith caries of sacrum .
n disease of the ischium
CONTENTS.
XIX
o. Fistula in ano, and urinary fistula consecutive on
gonorrhoea ....
p. Fistula from an abscess being allowed to pursue
its own course ....
q. Fistula in ano; several external openings and
extensive sinuses . . . •
CHAPTER XIV.
POLYPI OF THE RECTUM.
Nature of polypi
Symptoms
Treatment .
CHAPTER XV.
STRICTURE OF THE RECTUM.
Causes
Seat of stricture
•Symptoms
Diagnosis .
Treatment
Cases :
a. Stricture from growth of fat exterior to the
bowel . . . . .
b. Stricture from fibrous deposit external to the walls
of the rectum ....
0. Supposed stricture, continued use of the bougie ;
no contraction discovered after death .
CHAPTER XVI.
MALIGNANT DISEASES OF THE RECTUM.
Varieties of malignant disease ....
Symptoms ......
Diagnosis ......
Treatment ......
Cases :
a. Medullary sarcoma occurring in a boy ; death
from peritonitis ....
TAOB
274
275
276
279
280
282
285
289
291
294
298
286
286
295
303
306
308
308
305
XX CONTENTS,
m
^^^L b. Fungoid Jisense of the rectum i general liealth
'"'
^^^1 uanfTected for some time
308
^^^^ c. Carcinoma of tlie rectum ; large dosea of opiates
^^^H required to procure case from pain
310
^^H d. Cancer of the rectum ; secondary deposita in tlie
^^H liver and lumbar glsnds
311
^^^H e. Cancer of the rectum implicating the Tagina ;
^^^^ coDSIant diarrbiEa ...
314
^^^^L f. Cancer implicating posterior and lateral portions
^^^^H the rectum ....
315
^^V CHAPTea XVII.
a
^H I>-JI>R1ES OF THE RECTUM.
■
^^^ Cauwfl of injury .....
316"
318
Laceration during parturition ....
321
Treatment ,....,.
323
Cases:
a. Rectum of a cLild wounded in the operation of
lithotomy .....
317
£. Laceration of the rectum from constipation
318
c. Longitudinal laceration of the rectum and margin
of the anuB
320
d. Tranarerse laceration of the mucous memhrane
of the rectum ....
321
*. Laceration of the recto-vaginal septum and pas-
sage of the child per anum
322
/ Laceration of rectum and part of the periueeum
during parturition ....
322
ff. Laceration of rectum from the kick of a cow
324
A. Perforation of rectum hj the end of an umbrella .
325
i. Perforation of rectum and bladder hy leg of a
cliajr .....
325
ft. Perforation of rectum and peritoneum by an
enema pipe .....
325
M
^^^^^^^H
^^M
/. Pcrforalion of rectum and vagiiiH by a clyster
H
P'pe
^H
m. A cBiheler thrust through ibe urethra into the
^^M
rectum .....
336 ^H
CHAPTER XVIII.
H
FOREION BODIES IN THE RECTUM.
^1
Symptoms ......
^H
DiagnoBis
329 ^H
^H
Removal of alrine coneretions ....
^H
Cases :
^H
330 ^H
b. Portion of bone that hud been swallowed arrested
^^1
Ht the BDIIS
330 ^H
e. A fish-boiie that had been swallowed arrested at
^^1
the rectum j removal ....
^H
d. A concretion of iron and magnesia fifteen inches
^H
in diameter, removed from the rectum of a lady.
^1
^^^1 e. Three large concretions, each containing a plum-
^H
^^^H atone for a nucleus ....
333 ^H
^^H^ /. A bottle of Hungary wine thrust into the rectum,
^H
^^^H ff. Flask of crystal removed from the rectum
^1
^^H A. Porcelain jelly-pot in the rectum
334 ^H
^H
^^^B k. Pipe of a syringe in the rectum
^1
^H
^^^B obviate coBliveness , . . ,
335 ^H
^^1
1 the stomach, and ultimately lodged in the rectum
^H
I^^H N. A mutton-bone removed from the rectum which
^^1
^^^H had been swallowed eight days previously
^H
^^^H 0. Jaw-bone of a turbot in the rectum
336 ^H
^^H p. Jaw-bone of a Ssh lodged in the rectum
^H
^^^m q. A forked stick thrust into the rectum to overcome
^H
^^M
-. A I hree-p rouged stick introduccii into ihe rectum i
removed two montbs afterwards from sbscessea
over the gluteus muscle 338
; Pig's tul thrast into tlie rectum of h female 338
. A blacking-pot forced into the reclum by a fall ;
extraction; death fVom subsequent iaflnmnia-
tton 339
E. A CRDe, nine inches in length, thrust inio the
bowel ..... 339
':. Stick penelrating the sigmoid flexure of ibe
colon ; not discovered till after death . 342
'. A large plug of wood introduced into the bowel
for the purpose of atopping a (iinrrha;a 342
:, A quantity of gray peas lilliiig the rectum and
producing death . ... 342
!. Half n jaw-bone of a rabbit removed from the
rectum by Mr. Lislon . 343
. The neck of a wine-bottle cs:tracted from the
rectum ..... 343
'. A bougie, nine inches in length and an inch in dia-
meter, removed from the rectum 343
CHAPTER XIX.
UAL?0BMAT10NB OF THE KEGTUM.
Contraction ftnd occlusion of the anus
Imperforate rectum
Absence of rectum
Rectum terminating in the bladder and urethra
Rectum terminating in the vagina
Rectum opening into the sacral region
Cases :
a. Imperforate anus i Eucceasful operatiou
b. Imperforate anus i operation successful
c. A case reported by Mr. Copland Hutchin
tl. Imperforate rectum, by two partitions
349
349
350
■
^^1 (.'ONTENTS,
^
e
Imperforate rectum ; operntioii repealed three
H
times , . , . .
^^1
/. Imperforate rectam ; operatioD not performed till
^H
the eleventh day ... .
351 ^^1
9
Imperforate rectum ; discovered second day after
^^1
birth ; operation ; death
352 ^H
h
iDteatinal cnnal openiug under scapula .
Absence of the rectum ; and Ibe intestinal csnal
^^H
opening on the face ....
^^1
k
Imperfomte rectum and anus: the rectum reaching
^^H
to half an inch of the external aurfsce
^^1
I
Partial ah sen cc, imperforation, and malposition of
^^1
the rectum .....
^^1
m
Imperforation and partial Rheence of rectum ;
^^1
operation performed three times
^H
n.
Imperforate rectum; an incision more than two
inches in depth necessary before the intestine
H
was opened .....
^H
0,
Imperforate rectum ; deatli of the child on the
^^1
ninth day, the bowel not haviug been opened .
301 ^^1
P
^^H
the child was eight months old
^H
1
Imperforate rectum ; Dr. Baillie
Two caaea operated on by Mr. C. Hutchinson,
362 ^H
the intestine not opened in eitlier
^H
».
Occlusion of rectum and yngina
3G3 ^H
f.
Rectum terminating at tlie middle of the sacrum .
364 ^H
u
Imperforate anus and absence of a portion of the
^H
rectum .....
3G4 ^H
X.
Two caaea recorded by Mr. Smith
365 ^H
V
Imperforate rectum, the intestine reached by inci-
^H
sion two inches deep ....
^H
z.
Child with imperforate bowel, no opening made ;
^H
lived five weeks . . , ,
^H
aa
Imperforate anus and partial absence of rectum ,
^H
1 hb.
Ten cases recorded by Dr. Parker, of New York .
^^1
1 XXiv CONTENTS. ^^M
I
I^^B
^^
^^^^^B ec. The feeceB voided per urethram in a womnu
369
^^^^^V dil. The rectum opening in the urctlirn aulerior to
^^^^1 tlie prostate ; the child lived eight months
369
^^^^^P ee. A boy, four years and a half old, with the rectum
^^^^^1 opening into the urethra
3?0
^^^^^1 J^. Imperforate rectum ; a communication with the
^^^^^H urethra by a valvular opening .
370
^^^^^P ffff. Imperforate rectum ; Mr. FergUBson's case
:i/0
^^^^^V hh. Ascites in a fcetua, with malformation of rectum
^^^^^B and other ....
3/1
^^^^H It. Imperforate rectum and anus ; bond opcuiug
^^^^B bladder , . - . .
371
^^^^^V ik. Mr. Lizar'a case of imperforate rectum and nmia
372
^^^^^B 11, Rectnm communicating with bladder bv a narrow
^^^^^H canal, a quarter of ati inch in length
372
^^^1 «m. Dr. case ....
372
^^^^^B ttn. A child passing its fceces perurethrnm ; lived in
^^^^m that condition for Dearly nine months
373
^^^^^B 00. Dr. CbcTcr'a case of rectum opening into the
^^^^^B nrcthra or neck of bladder
37.3
^^^H .....
^^^^^m qq. Rectum communicating with vagina; operation
^^^^^1 performed three times
3-6
^^^^m rr. Mr. Coplaod Hutchinson's case of rectum com-
^^^^H municating with vagina
.i;8
^^^^H n. Contracted anus ; a communication between tlie
^^^H^ rectum and vagina ...
■MH
^^^^^B tl. Uectnm opening through the sacrum
379
^^^r CHAPTER XX.
W lUUlTL'AL CONaTIPATlON.
1 Sympathetic effects .....
380
1 CfinseB .......
381
B FemioiQas effects of too frequent recourse to purgatives
38-1
^ Treatment ......
383
1
INTaODTJCTION.
In the whole range of surgical pathology no class of
diseases among civilised communities is so prevalent,
causes more suffering, or induces so many varied and
distressing sympathetic affections as those of the rectum;
happily for the sufferers none succmnb more readily to
judicious, and, in the majority of cases, to simple treat-
ment, when it is put in force at an early period of the
malady ; but unfortunately it often happens, from a
mistaken delicacy on the part of the patients, or from
some other cause, proper advice is not sought till
the constitution has become seriously deranged, or the
local affection no longer endurable; or it may be
that, under preconceived and erroneous notions as to
the nature of the affection, or from the prominence and
severity of some one of the sympathetic effects, the
sufferers are induced to adopt a variety of empirical
1
8 INTROHrCTION.
remediea which fail to afford the desired relief and
restoration of health, and which are often productive
of the most pernicious residts.
From the important functions of the rectum, from the
constant or recurrent pain attendmg diseases affecting it,
induced each time the bowels evacuate their contents,
and the serious constitutional distm-bance these diseases
excite, they require the carefiU attention and deep con-
Bideration of the surgeon. Tn past ages and in the pre-
sent time a popular idea has prevailed that a deeper
knowledge of, and a more intimate acquaintance with,
the diseases of any certain organ is obtained by an exclu-
sive consideration of that particidar part ; but no greater
faUacy can be conceived, it being only by a comprehen-
sive view, and after due consideration of all the symptoms
produced, and the various phases presented by dis-
ordered function and organic change in the various parts
of the animal economy, that a just conclusion as to the
fans et origo viali can be arrived at. Perhaps few classes
of disease exemphfy (he necessity of a wide and mature
consideration more than those implicating the rectum,
either primarily or secondarily ; for the same symptoms
will often be found existing under the opposite conditions
of cause and effect. Thus, in the female, many instances
have occurred of stricture of the rectiun being supposed
to exist, and a long and useless treatment had recourse
INTRODUCTION.
to, when ultimately all the patient's sufferings were found
to depend on a displaced uterus, or on some morbid
enlargement or growth of that organ ; and the converse
is not unfrequently the case, of a patient being treated
for leucorrhcea or uterine disease, whilst the real source
of the symptoms has been in some affection of the rcctmn.
In the male also, will be observed stricture of the urethra,
diseases of the prostate gland and bladder simulating
those of the rectum ; or, on the other hand, diseases of
this portion of the ahmcntary canal producing irritability
and other disturbance of the genito-urinary organs. Nor
is it in contiguous parts alone that the reaction of one
organ on the other is met with, it is necessary therefore to
bear in mind the more remote sympathies induced in the
cephahc, thoracic, and abdommal viscera, as evinced by
headache, vertigo, impaired vision, palpitation of the
heart, gastric distension, pain, and sickness ; and de-
ranged secretion from the kidneys, as exhibited by the
various urinary deposits.
Formerly some of the affections of the rectum, which
in reahty are very simple in themselves and easily re-
lieved, rendered the subjects of them the victims of the
most painful and in many cases dangerous operations.
But by the advance of surgical science generally, and the
study and observation of these particular diseases, even
the most painful of them may generally be remedied by
4 INTRODTiCTTOS.
medical treatment ; antl when an operation is necessary
for the removal of morbid structure or for the purpose
of inducing a healthy reparative process, it is simple in
character, quickly performed, occiiaioning but a slight
amouut of pain, and confining the patient for only a
vejy limited period. Thus tistula in ano, which, at a
comparatively recent period, was considered among the
heaviest afflictions tliat flesh is heir to, from the bar-
barous treatment that was then practised and considered
necessary, as a consequence of the false notions and
erroneous pathological principles that prevailed, and
which led to the scooping out of the parts in the track
of the fistula, or to the extensive destruction of the srur-
rounding tissues by corrosive unguents, is now remedied
by a slight incision, performed in a few seconds, and not
occasioning the loss of more than a few drops of blood.
It was only a few years since it was deemed essential
for the cure of fissure of the anus to entirely divide the
sphincter muscle, but it is now proved that when an
incision is required it is not necessary to make it more
than a few lines in length, and to extend it no deeper
than through the mucous and submucous tissues. In
all operations about the anus the general rule in sur-
gery, that of not removing more of the integument than
is necessary, cannot be too forcibly insisted on; for if
this is not observed the patient will be doomed to
I
INTaODUCTlON.
much inconvenience and misery by the contraction that
ensues.
The constitutional origin of these local affections and
their reaction on the general system, when their cause
has been extrinsic, must always be borne in mind, for if
this be over-looked, our hopes of success in the treat-
ment will often not be realised.
Besides prescribing proper remedies and giving strict
injunctions with regard to diet and exercise, it is
advisable that the surgeon should apply the dressings
with his own hands, for though there is no difBculty in
the matter, and little skUl required, yet it is essential
to the comfort and recovery of the patient that they
should be accurately and properly adjusted ; nurses and
attendants, from not thoroughly apprehending the object
to be attained, are too apt either to cram and distend
the parts with the dressings, or not to approximate them
with sutficient nicety : the surgeon should also exhibit
the enemata, unless he has some inteUigent and trust-
worthy person on whom he can rely. These matters
may appear comparatively trifling, but if they pass un-
attended to we shall often be disappointed in the result
of our treatment, let it in other respects be ever so skil-
fully and well directed.
In some morbid conditions of the rectum great advan-
tage is derived by the use of the speculimi for the purpose
INTRODDCTION.
of examination, and also in performing some operations.
In most cases one of the form of the annexed tigure will
answer the purpose ; It is an old-fashioned instrmnen^
and may be made of polished metal, or of glass silvered,
and covered with caoutchouc. Several specula differing
but slightly have been contrived ; some are made with
metaUic or wooden plugs to fill up the side opening while
the instrument is introduced, but the finger will be
found a far better substitute ; others are furnished with
handles fixed or moveable, which are worse than useless,
being only m the way. Mr. Blaise, of the firm of
Philp, Whicker, and Blaise, surgical-instrument makers,
of St. James's Street, has invented a thrce-bladed spe-
culum, which in some instances will be found exceed-
ingly useful, as by it a surgeon has the power of dila-
ting the bowel and moi-e fully exposing to view the
diseased part when extensive. The instrument which I
use is a slight modification of his, being somewhat coni-
cal, trumpet-shaped at the mouth, and admitting the
introduction of the finger, so as to prevent the mucous
INTRODDCTION.
membrane being pinched between the blades when they
are closed previous to withdrawing it. The following
engravings accurately represent the speculum as seen
when closed and when partly open.
All instruments used for the purpose of injecting ene-
mata should be provided with elastic gum jets instead
of those made of metal or ivoi^, which cannot be passed
sufficiently high up the bowel, and are objectionable by
reason of the probabihty of injury being infficted with
them. The most convenient and efficient instrument for
patients to use themselves, is an eight or ten ounce India
rubber bottle, furnished with a stopcock, and having an
elastic jet about eight inches in length,fitted to plug instead
of to screw on. When it is intended by enemata to
imload the colon of accumulated fzecal matter impacted
in its sacculi and distending that intestine, a long elastic
8 INTEODUCTION.
tube, known as "O'Beinie's tube," should be passed
up the bowel, and the fluid injected by means of a well-
made double-action pump. Before using the injecting
apparatus it should be filled with fluid, otherwise the
air contained will be forced into the patient's bowels
and cause much pain and annoyance ; this precaution is
highly necessary, for it is astonishing how much sufl'ering
will be induced if it is disregarded.
It is stated by all English writers on the subject,
that diseases of the rectum prevail almost entu-ely in
the better classes of society ; from opportunities I have
had I can vouch that this statement is erroneous, and
that they exist among the working classes to an incre-
dible extent, but from certain prejudices and popular
opmions they entertain, as well as for other reasons, they
seldom seek relief at our hospitals.
I
IRRITATION AND ITCHIMO OP THE ANUS.
Itching at the anus is a very common affection ; it
is more generally a symptom of disorder or irritation in
some portion of the alimentary canal than a Rubstantive
disease ; but so distressing ia it in many cases that
it forms the most prominent feature of the patient's
ailments. It occurs more frequently at or after the
meridian of life than at an earlier period, though it ia
occasionally met with at all ages. It is most commonly
caused by the presence of ascarides in the rectum or of
other entozoa infesting some portion of the intestinal -
tube ; by the accumulation of faeces in the rectum and
colon ; by the improper use of mercurial and other pur-
gatives ; by irritation about the neck of the bladder and
prostate gland ; by derangement of the digestive organs,
and a depraved condition of the excretions and secre-
tions, particularly of the Uver and kidneys. It may
follow the recovery from dysentery, and very generally
precedes and accompanies hsemorrhoidal and other affec-
tions of the rectum. Females sometimes suffer much
10
IRRITATION AND ITCHING OF THE ANUS.
from pruritus ani during the period of gestation ; and it
not unfrequentiy depends on derangement, or occurs at
the cessation, of the menatroal function. Errors of diet,
particularly the indulgence in highly seasoned dishes and
too great a quantity of wine, viW produce it ; unwhole-
some food wUl also have the same effect ; this was illus-
trated in the case of a professional friend who suffered
severely from this affection, induced by indulging his
taste for game that had been kept till it had become
completely putrid ; the disease left him shortly after the
shooting season was over; and the following year, being
dissuaded from gratifying his appetite for the unsavory
food, he was fi'ee from the affection, save on one or two
occasions when he could not refrain from partaking of
some birds that were particularly high.
Itching of the anus commonly occurs in feeble and
debilitated constitutions ; and is sometimes accompanied
by an eruption of papulee or tubercles, which may also
coexist in other parts of the body, but in the greater
number of cases no eruption will be perceptible- The
itchmg is often most distressing on getting warm in bed,
and frequently prevents the patient sleeping till he is
completely worn out.
When the disease is of long standing, and the patient
has yielded to the strong incentive to scratch and irritate
the part, the skin around the anus will become thick-
ened and furrowed, the furrows assuming a radiated
i
IRRITATION AND ITCHING OF THE ANrS. 11
direction diverging from the centre of the anus. They
vary in number and length, and though often deep are
generally free from ulceration, if due attention to clean-
liness is observed ; but should this have been neglected,
and irritating secretions have accumulated, inflammation
will be induced, followed by excoriation and ulceration.
In the spring of 1854, 1 attended a married woman,
a patient at the Blenheim Street Dispensary, who
suffered most severely from a pruriginoua condition of
the anus and vulvae. She was the mother of several
children ; and when she applied to me, was in the fifth
month of pregnancy. From the commencement of
gestation she had experienced intolerable itching around
the anus and posterior part of the vulvffi, rendering her
life perfectly miserable. The skin, by scratching and
irritation, had become rough and indurated, and deeply
fissured, but was free Irom ulceration. In consequence
of not being able to sleep at night, and her torments
being but little mitigated during the day, her general
health was much impaired. The treatment consisted of
aperients, tonics, with acids, and various local applica-
tions ; a solution of the nitrate of silver affording most
relief. But although, by the treatment adopted, her
sufferings were much diminished, they did not entirely
subside till after her confinement, which occurred at the
proper period.
Some authors think that a pruriguious state of the
12 IRRITATION AND ITCHING OF THE ANUS.
aniis ought not to be interfered with, as it wards off more
serious diseases, and they instance cases in which, after
the itcliing has been relieved by treatment, or subsided
spontaneously, death has followed ; but they fail to
support their views by the evidence of accurate and
minute post-mortem examinations ; moreover, their want
of knowledge of those obscure and frequent diseases of
the heart and minute vessels of the brain capable of
causing sudden death, with which we have recently be-
come acquainted through the observations and patho-
logical researches of Dr. Quain,* Mr. Paget.f and
others, into changes of structure, must make us hesitate
to receive such inferences as correct ; even were it
not, as has already been stated, that pruritus ani is
more frequently a symptom or an effect of disease of
Btructure or function in some one or other of the viscera
than a purely local affection.
In the treatment of this very obstinate and trouble-
some disease, great patience and perseverance will often
be requisite both on the part of the patient and medical
attendant. By the latter it must be borne in mind, that
the affection is ratlier a symptom of constitutional de-
rangement than a disease atii generis, therefore the first
• ' On Patty Diseiwes of the Heart,' by E. Quaiu, M.D.,
Medico-Chirurgical Transactions, vol. xixiii.
+ ' On Fatty Degeneration of the Vessels of the Brain,' Medical
Gazette, New Scries, vol. i, p. 229.
IRRITATION AND ITCHING OP THK ANCB. la
endeavour must be to ascertain the cauac producing it.
Id females, when the menstrual function has ceased, or
is about to do so, it will be most important to keep the
bowels free, to attend to the secretion of the liver,
kidneys, and skin, and to direct exercise in the open air
to be taken daily. If ascarides in the rectum give rise
to the affcctiMi, they must be dislodged by such means
as are recommended in treating of the subject under the
head of foreign bodies in the rectum.* If haemorrhoidal
tumours or condylomata exist, they must be removed
by excision, unless the hjemorrhoids are internal, in
which case the hgature or concentrated nitric acid most
be employed. Should the patient Ije delicate, and his
habits sedentary, plain and nutritious food wdl be neces-
sary, conjoined with proper exercise, and the administra-
tion of alterative, tonic, and chalybeate medicines ; but
if the contrary be the case, and he has been accustomed
to indulge in highly seasoned dishes, and to partake
freely of wine and spirituous liquors, he must be re-
stricted to a vegetable diet, and the quantity of stimuli
considerably reduced, if not altogether disaUowed :
various remedies have been recommended in this disease,
and will be found more or less efficacious according to
the circumstances of the case ; among them may be men-
tioned the decoction and infusion of cinchona with nitric
or nitro-hydrochloric acid, and the various preparations
• Chap. XVIII.
14 IRRITATION AND ITCHING OF THE ANU8.
of iron ; the bowels must be acted on by the occasional
use of purgatives. When an eruption exists on other
parts of the body, five grains of the compound pill of
chloride of mercury should be taken at bed-time, or the
same quantity of mercury and chalk with hyoscyamus,
conium, or extract of poppy ; and the compound decoc-
tion of sarsapariUft, two or three times a day : when the
gums become tender the quantity of mercury must be
reduced or even left off for a short time, as ptyaUsm to
any extent must be avoided. It will be advisable to con-
tinue the remedies for a few weeks after the disease has
subsided, in order to guard against a ^elapse.
The due attention to the functions of the skiu haa
been insisted on, and much advantage as well as comfort
will be derived from the use of the warm-bath every
second or third day.
The local remedies that will be found most useful are
lotions containing acetate of lead with wine of opium,
lime-water and calomel, or the bichloride of mercury, the
bicyanide of mercury in bitter almond mixture, or
a saturated solution of biborate of soda, ointments of
lead, zinc, nitrate of merciu-y, &c. ; but that which will
frequently be found most serviceable, is brushing the
part over with a solution of nitrate of sOver so as to
produce a sUght exfohation of the skin. I attended a
gentleman, connected with a city bank, who suffered
most severely &om this affection; he had received
i
IRRITATION AND ITCHING OF THE ANT78. 15
advice on various occasions, but had not found benefit
from the medicines ordered. On making an exami-
nation, the thin skin of the anus was observed to be
dry and inelastic, and intersected by sUght cracks.
His general health was deranged by too close application
to business. I prescribed a combination of aperient
and tonic medicines^ and used a solution of nitrate of
silver to the part on three occasions, entire rehef fol-
lowed, and his general health improved. He now takes
more exercise, and is quite well.
INFLAMMATIUN AND KXCORIATION OP THE ANOS.
Simple inflaimuatioii and excoriation of the anus is
not of infrequent occurrence in warm weather, particu-
larly in individuals disposed to obesity. Long-con-
tinued walking, horse-exercise, long journeys in car-
riages with soft and warm seats, often produce it. It
may also be a consequence of errors in diet, or indul-
gence in high living ; the too frequent use of large
doses of calomel and cathartic medicines, will often
excite inflammatory action in this region ; a vitiated con-
dition of the excretions from the alimentary canal, the
irritation of worms, of diarrhoea, and of dysentery, may
be the exciting cause, and among the poorer classes they
arise from a neglect of cleanliness.
The symptoms will be similar to those of superficial
i nflamm ation in other parts ; at first, slight itching will
be experienced, succeeded by a feeling of heat and
smarting, which will be accompanied by redness and
tumefaction ; walking and sitting, by the friction and
heat which they cause, will increase the pain.
i
INFLAMMATION AND KXCORIATIOX OF THE ANUS. 17
In directing the remedial meaus, the exciting cause
must be first considered. If the inflammation and
excoriation are the result of obesity and excessive exer-
cise, either on foot, horseback, or riding many hours in a
carriage, it will be only necessary to wash the parts two
or three times a day, to apply powdered oxide of zinc, or
hair powder, and to keep a fold of lint or linen between
the buttocks ; it may sometimes be advisable to enforce
the observance of the horizontal position. Enemata
will be the best means of keeping the bowels open.
Should the cause depend on a depraved state of the ex-
cretions, this condition must be remedied by the exhibi-
tion of appropriate medicines, small doses of mercury
and chalk, with extract of taraxacum, or blue pill with
hyoscyamus and extract of colocynth, to be taken at
night and the following morning ; Rochelle salts, with
infusion of senna, or a bitter tonic infusion: the sul-
phate of magnesia, dilute sulphm-ic acid, and the com-
pound uifusion of gentian, or infusion of cascarilla,
make a good purgative ; otiier similar combinations may
be prescribed ; the remedies are to be continued until
the alviue discharges become healthy. The same local
treatment as that previously recommended must be
adopted. If dysentery or diarrhoea be the cause, the
effect will cease with the subsidence of these diseases.
If the abuse of cathartic medicines has set up the dis-
ease, it will be only necessary to discontinue them, and
18 INFLAMMATION AND EXCORIATION OF THK AJIDS.
to apply some slightly astringent lotion locally, and the
effect will be removed. When inflammation and exco-
riation have been produced by a neglect of cleanliuess,
the observance of ditterent habits is the first step to-
wards a cure ; soap and water must be used several
times daily ; if the hair around the anus has become
matt«d together by the discharge and filth, forming an
incrustation over the excoriated sui-face, it must be soft-
ened by the appUcatiou of linseed-meal poultices, and
the free use of the hip-bath and soap ; on no account
must it be removed by cutting the hairs, otherwise the
stumps left wall cause much irritation and distress, until
they have again attained a certain length. Some time
since I witnessed the misery thus induced in a labouring
man, and the excoriation prevented healing for a con-
siderable time by this thoughtless procedure. When
the parts are sufficiently cleansed, poultices, impregnated
with opium and a solution of acetate of lead, or lint
saturated with lotions of nitrate of silver, sulphate of
zinc, or acetate of lead, may be kept to the parts ; or
ointments of the nitrate of mercmy, bichloride of mer-
cury, oxide of zinc, &c., may be applied, The recum-
bent position must be maintained, and the bowels acted
on by cooling laxatives and emollient enemata.
CHAPTER m.
EXCRKSCI!NCi;S OF THE ANAL RtGlON.
The fine skin aurromidiiig the anal orifice and the
mucous membrane at the verge of the anus are subject
to various morbid growths, designated by authors of
past ages by the fanciful appeUations of scycoma, fici,
mariacae, cristce, porriis, condylomata, verrucse, &c. These
growths differ much in appearance, consistency, aud
sensibility, some being acutely painful, whilst others
occasion but little suffering.
In one form they will be observed as distinct and
separate tumours, nith a snifioth surface, sometimes
slightly lobulated, having a constricted base, and usually
flattened in form, owing to their compression between
the nates ; they vary in size from a pea to that of a
chestnut or larger; and commence as small folds of skin,
soft and pliable at lirst, like the healthy tissue, but, as
they increase in size, become of firmer consistence by
the development in their interior of a fibro-eellular
tissue. Others will be met with partaking of the cha-
racter of warts, and consisting of clusters of enlarged
20 EXCRESCENCES OF THE ANAL REfilON.
arborescent papUlre, rising to one or two inches above the
surface of the skin, and in some coses entirely surround-
ing the anus, the aperture of which is liidden in
morbid grow1;h.
The most common cause of exen^scencea of the i
region is some local irritation ; thus we frequently meet
with them as a coniplicHtion of several diseases of the
rectum attended with discharge; in some individuals
the secretion of the perspiratory glands is so copious,
that the parts are constantly bedewed with moisture, and
irritation ensues ; those (>er8on8 in whom tlie glutei
muscles arc largely developed are liable to these morbid
productions, as a consequence of the irritation produced
by the close apposition of the integumental siu-faces.
The smooth and lobulated fonn of excrescence not unfre-
quently has its origin in the prolongations of integument
remaining after the collapsing of external piles, which,
taking on a new and increased action, and by a species of
abnormal nutrition, become transfonned into tumours
that may attain a considerable size.
Exoresc<?ucC8 of the anal region are more frequent in
women than in men, probably owing to the circumstance
that, in addition to the exciting causes the latter are
subject to, in the female the parts are liable to be irri-
tated by the contact of discharges — simple and specific —
from the uterus and vagina. They occur more often in
the adolescent of either sex than in the adult, except
i
EXCRESCF-NCKS OF THE ANAL REGION.
21
that form of tumour which has its origin in an external
haemorrhoid.
Besides those growths to which the terra excrescence
is applicable, tumours of various kinds occur in this
locality ; they are more prevalent among the inhabitants
of hot countries than in Europe, and in them also attain
a large size, but this may be owing to their not coining
under surgical observation till an advanced period of
their existence. Of the several forms of tumoui'S, the
fibrous is the most frequent. Mr. Cui'hng* mentions
having had a tumour of ttiis kind sent to him by
Mr. HoweU, of Clapton, which had reached unusual
dimensions ; it had been excised from a gardener, forty-
one years of age ; it weighed upwards of half a pound,
and was composed of fibrous tissue, an*anged in several
lobes ; it had been pendulous, and attached to the margin
of the anus by a narrow neck. There was an ulcer on
its surface, produced, no doubt, by pressiu'e in sittmg
and friction against the dress. This timiour had been
seven years in forming.
In addition to the pain experienced in the morbid
growths themselves, their presence increases the irritation
in which they had their oiigin, and the skni around be-
comes excoriated and fissured, producing great smarting ;
or, if the integument remains intact, the patient mil be
• ' ObsiTTations on Diseases of the ilei-tum,' liy J, B. Curling,
p. 122.
EXCRESCENCES OF THE ANAL REGION.
tormented with intolerable itching, generally worse at
night, and interfering seriously with his rest ; neither are
the effects always confined to the part, pains in the hips,
thighs, and sacral regions being experienced, and also
derangement of the bowels. Mr. Mayo* mentions the
followhig case, and similar instances have come under my
own observation :
A woman, set. forty-eight, was tmder Dr. Watson's ci
in Middlesex Hospital, She had been suffering for seve:
years with pain and uneaaineaa, extending from tlie anus to
the loins, and round the lower part of the belly, aggravated
when the bowels acted, which were generally in a disturbed
state, being either relaxed or constipated. All these symp-
toms depended upon two large tliick condylomata, one on
each side of the anus> I removed these tumours with a
scalpel ; the surface healed very quickly, and the patient was
fifee from all the distreBs she had preyiously experienced.
When the anus is surrounded by warty growtlis, in
addition to the symptoms already described, the patient
will be subject to haemorrhage, and an exceedingly fetid
and copious secretion.
In the treatment of these atfections at their commence-
ment no operation is necessary, as the excrescences, if
Bmall and not much indurated, will generally disappear
by the application of a lotion of the bichloride of mer-
• ' OliservatioiiB on Injuries and Diseases of the Rectum,' by
Herbert M»yo, p
eral
i
EXCRESCENCES OF THE ANAI, REorON.
cury, in proportion of a grain of the salt to an ounce of
water ; should they be attended with itching, a solution
of the nitrate of silver, or a lotion of the bicyanide of
mercury in bitter-almond mixture, will usually succeed
in allaying it. But when the growths are large and
dense, excision is the only effective and proper plan of
treatment ; a probe-pointed bistoury or scalpel is much
the more surgical instrument than the scissors, which are
commonly recommended to be used ; with the knife the
incisions can be made more rapidly and with greater pre-
cision, and, what is of more consequence, with much less
pain to the patient. The operation may be |}erformed
either with the patient Ijing on his side, or kneeling and
leaning over the back of a chair. Each tumour is to be
seized with a pair of di-essing forceps, and removed close
to its base, but none of the siu-rounding integmuent is to
be taken away. In whatever position the patient is, the
surgeon should remove the lower growths first, so that
the bleeding may not interfere with his view of the others.
If the anus is siu-rounded by warty excrescences, a com-
position-bougie may be introduced into the intestine, and
then, with a circular sweep of the knife, the whole growth
is at once removed. It is seldom that any vessels will re-
quire ligature; however, should any present, they are easily
secured ; a considerable oozing of blood ^vill sometimes
take place from the incised surface, which can always be
readily suppressed by a well-arrduged pad, pressed firmly
24
EXCHESCENCES OF THE ANAL REGION.. I
to the part by a T bandage. Provided there ia evidence
in the individual of a strong predisposition to the forma-
tion of these growths, nitrate of silver may be appl
after their removal, in order to modify the vitality of
part, and clieck any tendency to reproduction : dui
cicatrization, a lotion containing sulpliate of zinc, acetate
of lead, or alum, should be used ; and the patient should
be directed to observe great cleanUness. The ligature and
escharotics have been recommended in the treatment of
these affections, but recourse should not be had to them,
as they occasion great pain, and do not effect the desired
object. While house-surgeon at University College
Hospital, a patient, aged eighteen, was under my chai'ge
with a warty growth surrounding the anus, between two
and three inches in diameter, and rising more than an
inch above the integument. As he would not at
submit to an operation, astringent and escharotic ap]
cations were made use of, but without much effect,
aiiterwarda attempted its destruction by Hgatm-e, bul
owiug to its density, only partially succeeded. In si
cases I have since removed the disease with the knife.
The several kinds of tumours occurring iu this region
are to be removed by excision.
The following cases will be sufficient, in illustration
the subject.
KXCRESCENCES OP THE ANAL REGION.
Condylomata from leucorrhcea.
Mrs. , let, thirty-five, the mother of several children,
had suffered from Icucorrhcea for more than two years, the
discharge being so profuse as ta render her constantly wet
and uncomfortable ; lumps formed on the labia, and about
the anus, gradnally increasing in size ; the adjacent parts
became excoriated and painful. Before coming under my
care she had taken various medicines, and used lotions and
ointments without benefit. It being evident that the morbid
growths on the external parts arose from irritation, produced
by the discharge irora the vagina, an examination was made
with a spcculiun, and ulceration of the os uteri discovered,
which was also congested and enlarged ; there was profuse
muco-purulent secretion from the uterus and vagina.
The treatment adopted was leeches and the application of
nitrate of silver, and afterwards alum injections ; cicatriza-
tion of the ulcerated surface took place, and a healthy condi-
tion of the uterus and vagina restored. When the vaginal
discharge had diminished the condylomata were removed by
excision, and a fold of lint, saturated with lead lotion,
applied ; the wounds healed in a few days.
Condylomata from leucorrhma.
M. A, P., eet. twenty-sis, single, applied at the Blenheim
Dispensary, May SJth, 1853. She had been for some time
subject to vaginal leucorrhoea, the discharge being very pro-
fiiae. Tumours formed about the anus ; they were not painful
at first, but latterly she ha<l experienced much smarting and
26 EXCRKSCENCES OF TUB ANAL REGION..!
diBComfort. She waa cMorotic; her eyes were dull; skin,
^ms, tips, and tongue, pale ; arms flabby ; menstruation
irregular and almost devoid of colour. Mild purg;atives,
chalybeatea, and vaginal iujections were prescribed ; the
condylomata were excised, and a slightly astringent lotion
applied ; ablutions with soap and water were used night a
morning ; the local disease was cured, and in a few weeks h
general health had greatly improved.
Condylomata from irritaiion, by contact of opposed\
cutaneous surfaces-
W. G.," let, thirty-one, very stout, occupation sedentai
being engaged in a merchant's office in the City. Perspirea
freely ; haa always suffered from excoriation between the
buttocks in warm weather; some excrescences bad formed
around tbe anus ; he had been told they were esternal piles,
and directed to use gall ointment, and to take sulphur and
treacle; he experienced no relief, and the tumours increased
in size, attended with great smarting and pain. His bowels
were regular, and, in other respects, he enjoyed good health.
On examination, three condylomata on the verge of the anus
presented; they were dense and about the size of beans;
the surrounding skin was excoriated, and bedewed with a
copious secretion. I excised tbe tumours, and ordered a fold
of lint, saturated in lead lotion, to be kept applied till the
parts had healed. I also advised ablution, with soap and
water, night and morning, and keeping the buttocks sepa-
rated by a single fold of lint between them. The treatment
adopted had the effect, in a few days, of removing all the
discomfort he bad previously suffered.
EXCRESCENCES OF THE ANAL REGION.
Comli/lomata remlting from the folds of integument, left
by the collapsing of external hemorrhoids.
Dr. Ashwell brought to my house the husband of a patient
of his, the Rev. Mr. , who wished to eonault me respect-
ing an affection from which he had suffered for some years.
This gentleman was stout, with the muscular system laj^ly
developed. He informed me he had for a long time expe-
rienced the most intolerable itching about the anus, and was
also annoyed by a constant watery discharge ; he had consulted
several surgeons ; various lotions had been prescribed, and
the solid nitrate of silver applied twice, which caused him
most severe pain, without any beneficial effect. Many years
previously he had been the subject of haimorrhoids, and had
had several large piles form at the verge of the anus ; when
these subsided, loose folds of skin remained, which occasioued
him uo inconvenience for some time, but at length he began
to experience the symptoms which now caused him such severe
annoyance. On making an examination, I observed the skin
around the anus, and for about three inches posteriorly,
inflamed and cracked, and bedewed with a serous secretion;
three dense condylomata, the size of the shell of an almond,
were connected with the anal margin, the whole of which
was indurated, but not contracted. He was informed that
excision of the tumours was the only means of freeing him of
the disease, and he readily consented to the operation.
Being somewhat affected with flatulence, and the bowels not
acting freely, he was directed to take three grains of blue
pill and a grain of ipecacuanha every night, and a draught.
2S
EXCRESCENCES OF THE ANAL REGION.
twice a day, composed of infusion of cinchona, infusion of
senna, tartrate of potash, with some aromatic tinctures ; by
these means the bowels were freely acted on, and on the
fourth day 1 reuioved the growths, cutting them off with a
probe-pointed bistoury ; Dr. Ashwell was present, and very
kindly assisted me. No ligatures were required, a comprese,
retained firmly by a T bandage, restraining the little hemor-
rhage that ensued. Ou the following day the wounds were
dressed with oxide of zinc and spermaceti ointment, and in
a week were quite healed, as well as the cracks in the sur-
rounding integument ; a lotion of the bichloride of mercury
in bitter-almond mixture wa* directed to be applied, and in
a short time all induration of the anus had disappeared. I
learn from Dr. Ashwell that this gentleman continues
perfectly free from all the symptoms which he had
experienced.
It ia evident these growths had their origin in the folds of
skin left by the collapsing of the external piles ; and had the
treatment, hereLnafter advocated, been adopted of incising
external hiemorrhoidal tumours when large, this gentleman
would have escaped the sufferings he subsequently ex-
perienced.
CoNTKACTioN of tlie anus is productive of serious
meonvenience and distress to the patient; it is not a
common affection at the present day, but when it was
the custom to treat 6stula in ano by extensive incisions,
to scoop out the sinus and siuronnding indurated parts,
or to destroy the tissues extensively with escharotics, it
must have been a very general result of such surgical
interference. Mr. Pott, deprecating De la Faye's treat-
ment of fistula, as causing contraction of the anus, says,*
" If M. De la Fayc had ever, in his own person, had
the misfortune to experience the inconvenience arising
from the loss of skin near to the fundament, or had he
attended to that which it produces to those who, either
from choice or necessity, ride or walk much, I aru inclined
to believe he would have been more sparing of it,"
M. De la Faye himself was not insensible of the evil
• ' The Chirurgical Works of Percival Pott,' e^tcd by James
Earle, 1790, vol. iii. p. 133.
30
CONTRACTION OF THK ANUS.
resulting from his plan of treatment, and to guard
against it, advised the introduction of tents ; the follow-
ing are his words : "Lorsqu'on a coupe dans I'operation
une portion considerable du bord de I'anus, et que les
chair commencement a remphi- le vuidc, il faut mettre
• dans rouverturc de cette partie une tente, un peu courte,
qui en empechant le retrecissement lui conserve son dia-
metre," but which it will often do, in spite of all the
tents in the world.
The causes producing contraction of the anus are, loss
of substance by ulceration, or by wounds, cither acci-
dental or caused by siu-gical operations. In the Chapter
on Piles their excision is alluded to as a cause of this
condition of the anus ; and I may here repeat, that the
surgeon, in removing external piles, cannot be too careful
not to take away more of the skin than is absolutely
necessary, and he should also avoid an error I have
several times seen committed, that of excising the cede-
matous ring of integimient and cellular tissue around the
anus, caused by irritation in the rectmn, and very gene-
rally accompanying inflamed internal haimorrhoids. Dr.
Colics * mentions a case where, for the purpose of extir-
pating warts, a ring of the skin at the verge of the anus
had been cut away along nith these excrescences, the
condition of the patient was rendered truly miserable :
• ■ Dublin Hospital Reports,' vol. v, p. 15i,
CONTRACTION OF THE ANUS.
31
Mr. M'Coy * adda another illustration of the evil effects
of improperly removing the integument of the anus ; he
says : " I saw a gentleman who had been operated on
four years before by an eminent surgeon, and bo small
and rigid had the opening of the anus become, that no
sohd larger tliun a pea could be passed fi'om the bowels,
and with the miserable prospect of its gradually becoming
still smaller." Contraction also results from inflammatory
action, inducing infiltration of lymph in the areolar tissue
of the anus, or effusion of the same material on the sur-
face of the mucous membrane, which, becoming orga-
nized, forms false membranes and filamentous bands,
reducing the capacity of the opening, and interfering
with its power of dilatation.
The matter of syphilis and gonorrhcea coming in con-
tact with the anus, m those who are regardless of clean-
Uness, produces a form of contraction first described by
Mr. White,t as follows : " Not unirequently a contracted
state of the rectiun occurs as a consequence of the vene-
real disease. When the disorder proceeds from this
cause, it generally commences with an appearance either
of ulceration or excrescence about the verge of the anus.
The sphincter ani becomes gradually contracted, and.
• ' Lectiu«8 on the Theory and Practice of Surgury,' by
Abraham CoHcb, M.D., see note, vol. ii, p, 115.
t ' ObservationB on Strictures of the Eectum and other Affec-
tions,' by W. White, Bath, 1820, p. 18.
CONTRACTION OP THE ANUS.
the disease extcBding upwards within the rectum, a con-
siderable thickening and induration of the coats of the
intestine takes place, which produce great irregularity
aud coutraction of the passage. Sometimes there is a
continued Une of coutraction from the anus, as far as the
finger can reach, then termmating in a kind of cartila-
ginous border, the inner membrane havuig a thickened
and condensed feel. There is a discharge indicating a
diseased, if not ulceratedj state of the inner membrane,
above the contracted portion of the intestine. All the
cases which I have hitherto met with of this nature have
occmred in females, and they have uniformly proved
incurable when attended with the stnictural derange-
ment just described."
Since the publication of the first edition of this book,
I have met with two cases of induration and contraction
of the anus arisuig from venereal disease ; both patients
were females. The affection differed from that described
by Mr. White, iu not implicatijig tlie rectum ; the disease
yielded in both cases to a steady perseverance in the use
of the iodide of mercury and the iodide of potassium.
Contraction of the auus is sometimes congenital ; if
the opening is not very small it may not attract attention
in the early period of infancy, from the evacuations being
fluid, and passing without much difficulty.
The symptoms in this affection are very similar to
those of contraction of some portion of the canal above
I
CONTRACTION OP THE ASC
33
the anus ; the pain will not be so severe as in stricture
of the rectum, neither will there be the constaut puru-
lent discharge which attends the latter disease. The
feces will be passed mth difficulty and pnin ; they will
be compressed and figured, and, if they are solid, a
sense of bulging out of the anus and perineum will be
experienced during tlicir passage. By the sufferings
occasioned the patient is often induced to postpone the
calls of nature, but generally has reason to repent doing
so, for the faeces, accumulating and becoming hard, con-
siderably increase the pain and difficulty in defecating.
In such a case it is no infrequent occurrence for the
mucous membrane to be lacerated longitudinally by the
passage of the stool, constituting fissiu^ of the anus ;
spasmodic contraction of the sphincter will be super-
added, attended with violent aching, for a longer or
shorter inter\'al, whenever the bowels act.
Those who suffer from this condition of the anus gene-
rally conceive they have stricture of tlie rectiun ; how-
ever, we have the satisfaction of being able to assure the
patient that the disease is of a much less serious nature,
and we shall further be able to promise not only a speedy
but effectual cure.
Digital examination causes considerable pain, which
will be greater if fissure coexists, but by it we can
ascertain the nature and extent of the disease ; if the
patient is very nervous, or very sensitive to pain.
34 CONTRACTION OF THE ANUS.
clilorofomi may be inhaled previously to the examination
being made.
The treatment must be both medical and siu-gical.
If inflammatory action be present it must be sulidued
by topical bloodletting, hot fomentations, and cataplasms.
The bowels must in all cases be kept loose by laxatives,
as castor oil, confection of senna, Sic. ; great case will be
afforded by emollient enemata. The diet must be very
moderate in quantity, and unstinmlating in quality.
The anus must be dilated by the introduction of bougies,
and must be effected with mucli gentleness, for more
pain will be experienced in this disease than in stric-
ture of the rectum, in consequence of the greater sensi-
bihty of the integument than of the mucous membrane.
When the instrument is used the patient should rest on
a couch or bed, with his knees di-awn up. The better
time for passing the bougie will be shortly before the
usual period of the bowels acting. Ablutions with soap
and water, twice or thrice a day, Avill add to the patient's
comfort, and lessen the local irritation. If much pain
and nervous excitement be occasioned, anodynes may be
required, which may be administered either by the mouth,
or as suppositories, or enemata.
Conffcnilal contraction of the anus, cured by dilatation.
Some yeara gince I saw, in conjunction with the late Mr.
Morton, a child, about two years old, with congenital con-
CONTRACTION OP THE ANUS.
35
traction of the anus, which would not admit a larger inBtru-
ment than a number eleven bougie ; the belly waa tumidj and
the general health impaired ; dilatation waa had recourse to,
in a short time the bowels could be entirely relieved, and,
with the aid of tonics, the patient progressed favorably.
Conlraclion of the anus fo/loioinff the removal of
external piles.
W. \y., set. thirty-nine, a clerk in a merchant's office, had
suffered for some years from internal and external piles;
two years previously to my seeing him he had had the ex-
ternal ones removed; he described the wounds caused by
the operation as being large, and that they were some time
healing ; after this he felt free from all his previous discom-
fort, but, at length, found a gradually increasing difficulty
in passing his motions, and great straining was necessary to
effect their expulsion ; he also observed the stools were
small and contracted when they were solid; to lessen the
pain he suffered he had frequent recourse to castor oil.
On examination the anus presented several cicatricesj
the radiating folds of the integument were effaced, and the
anus would only admit the tip of the little finger. The
general bealth had suffered by the pain and the anxiety
the affection occasioned; the plan of treatment was that
which has been described, and a rapid recovery ensued.
Contraction of the anus following an improperly perj
operation, complicated with fissure,
J. T., a tailor, had suffered from piles and had beei
30
CONTRACTION OP THR ANUS.
operated on ; he now complained of difficulty in defecating,
attended with severe smarting, followed by a^^hing; the
history and the condition of the patient were similar to those
described in the preceding case, except that there was fisHure
in conjunction with the contracted state of the anus.
Bougies were used smeared with an ointment of grey powder
and spermaceti, and extract of belladonna, applied on lint,
to relieve the painful contraction of the sphincter. The
fisenre healed without the necessity of making any incision.
I have not met with a case of contraction of the
anus and rectum as described by Mr. White. Dr.
Bushe* relates the following case, which he considers
syphilitic.
An officer, who had been engaged in many a well-con-
tested field, and had endured great fatigue, and many
privations while campaigning, became the subject, in suc-
cession, of hepatitis, dysentery, ague, and dyspepsia. By
proper medical treatment, and great attention on his own
part, he imjiroved much, but never regained his former state
of health. In 1824 he contracted an ulcer on his penis,
wliich healed with great difficulty, and was soon followed
by secondary symptoms, uuder which his health rapidly
deteriorated, and when I saw him, in the summer of 1826,
he was greatly emaciated, with nodes on his bones, an
eruption on his akin, chronic iritis, and induration, thicken-
• 'Treatise on the Malformations, Injuries, and Diaeases of
the Rectum and Amu,' by George Bushe, M.D., New York, 1837,
pp. 260, 261.
CONTRACTION OF THE ANUS.
37
ing and partial ulceration of the marginal integument and
mucous membrane of the anufl. He had suffered most
annoyance from this last affection, having much purulent
discharge, constant tenesmus, and escruciating torture both
at and after stool. Leeches, fomentations, saturnine and
opiate poultices, the introductioji of meshca of lint besmeared
with lard and extract of hcUadonna, as well as emollient and
anodyne lavements, were tried in vain, at the same time
that sarsaparilla and osjmuriate of mercury were ad-
ministered.
This poor fellow sunk in a few mouths, and on dissection,
about an inch and a quarter of the extremity of the gut
was found diseased.
Two cases have come under my observation of con-
traction of the anus by infiltration of lymph, both had
been preceded by dysenteric symptoms ; and after their
subsidence mild mercurials and iodide of potassium were
prescribed, and dilatation had recom-se to with the hap-
piest effect.
This disease, of frequent occurrence, and giving rise
to more uneasiness and suffering, in proportion to the
pathological condition of the structures involved, than
perhaps any other disease to which tlic human frame is
liable, has met with very little consideration from the
majority of surgical writers, and ia even unnoticed in
most systematic works on siu-gery ; although the dis-
tinguished surgeon, M. Boyer, in tlie tenth volume of
his ' Traito des Maladies Chirurgicales,' pubhshed in
1825, well described this malady, in this country it has
not received that attention which the subject demands,
and there is strong reason to believe the diagnosis and
treatment are not so familiarly kno^vn as might be de-
sired, a fact to be regretted the more, a.s little difficidty
presents itself in either.
Fissure of the anus, usually occurs during the middle
period of life. Dr. Bushe* has not observed this affec-
• 0|i. cit., |i. 100.
FISSURU OF THE ANUS. 89
tion before the age of eighteen, or later than sixty-nine
years of age. Professor Miller* says, "they" — fissures
— " have been observed in children at the breast ;" but
this must be of rare occurrence, the predisposing and
exciting causes seldom existing till after puberty. One
of the latest"writers on diseases of the rectum, objects to
the term fissure, and speaks of the affection as " irritable
ulcer of the rectimi :" although, in many instances,
when the surgeon ia first consulted, it may present the
form of an oblong ulcer, yet I have no hesitation in say-
ing the primary condition was essentially a fissure or
craclc of the nmcous membrane.
In tlie majority of cases, tlie lesion is confined to tlie
mucous membrane only, but occasionally extends to the
submucous cellular tissue, or even to the muscular fibres
of the sphincter : the inferior extremity of the fissure is
usually immediately within the margin of the external
sphincter, or implicates the skin at the margin to a slight
extent, but is not unfrequently situated higher up. A
fissure may exist on either side, or perhaps on both sides
of the bowel : it less frequently occurs posteriorly, and
still more rarely anteriorly. If an examination is made
early in the disease, the fissure has the same appearance
as the crack that occurs in the lip during the decline of
catarrh, but it soon degenerates into an ulcer, in the
• 'Practice of Siir^rv,' by .Tarnes Miller, F.R.S.E., Edinhurgli.
1662, p, 380.
40 FISSURE OF THE ANUS AND
Bfune manner aa wounds of other parts that do not heal
readily, aud will be moat commonly observed to be
about an eighth of an inch in width, and from a quarter
to an inch in length ; at first the edges are sharp, and
the surface florid, but after tlie disease has existed for
aome time, the former become indurated anri raised, and
the surface pulpy and ash coloured ; the surrounding
membrane may be inflamed, and its surface rendered
friable, or the ulcerative process may exU;nd, and an
ulcer be formed, varying in size from a four-penny piece
to that of a shilling.
The symptoms in the early stage of this disease are
not generally severe, aud are only experienced while at
stool, when, at some point or other, there will be smart-
ing of greater or less severity, or perhaps only a slight
stinging or pricking sensation may be felt ; if the dis-
ease is allowed to progress, the smarting dmdng the act
of defecation will be greatly increased, or the paiu may
be burning or lancinating, followed by excruciating
aching and throbbing, with violent spasmodic contrac-
tion of the sphincter muscle, continuing from half an
hour to several hours.
The stools, when solid, will be streaked with purulent
discbarge and slightly with blood, and when more soft
will be tigim^d and of small size, leading the inex[>eri-
enced to imagine stricture of the rectum to be tlie cause
of the sufferings endured ; charlatans also have availed
LOWKR PAllT OF THE RECTUM.
themselves of the latter symptoms to delude their victims
into the belief of the existence of a more serious malady.
The disease being fully established, the paiii will be in-
duced by sneezing, coughing, forced respiration, and by
micturition, and so violent docs the agony become, that
individuals thus afflicted, even avoid taking sufficiency
of nourishment, in order to lessen tlie (piantity of fasces ;
they also in their dread ])08tpone the calls of nature, but
only with the effect of aggravating their torments.
Sitting is painful, and in order to protect the anus from
pressure, the patient rests on one hip or on a comer
of a chair, or he may be compelled to remain recumbent.
Partaking of highly seasoned dishes and fermented
liquoi-s will always mvolve tlie penalty of increase of
pain ; in females, the pain w*ill also be increased during
the menstrual period. From nervous irritation, pains
are often felt in other parts, simulating sciatica or rheu-
matism ; the urinary organs are also liable to be sympa-
thetically deranged, and thus the attention may be
diverted from the real seat of disease.
It is stated women are more subject to this affection
than men. I have observed it frequently in both sexes ;
and am unable to say that the one is more obnoxious
to it than the other ; want of proper exercise certainly
predisposes to it ; women are sedentary both from habit
and the usages of society; in them also, constipation,
one of the exciting causes, is frequent, partly arising
42 PISaCRK OF THE ANLS AND
from their habitually neglecting to obey the calls of
nature, which for a time they do with less inconvenience,
in consequence of the greater capacity of the jielvic
cavity than in the male, but thereby laying the foun-
dation of protracted or permanent ailment ; men are
sedentary from the various occupations in the affairs of
life ; and among the working classes, many are com-
pelled by the nature of their business to maintain the
sitting posture for a number of hoiirs consecutively,
and in these all diseases of the rectum and anus are
extremely prevalent.
The predisposing causes are constriction of the anal
orifice, either from spasmodic action of the sphincter,
occurring from intestinal irritation produced by the in.
gcsta, or a vitiated and acrid condition of the secretions,
or from the cicatrization of wounds after surgical opera-
tions, accidental or specific nlccrs, or injuries to the part.
Haemorrhoids are frequently the predisposing cause and
a complication of this affection ; they narrow the outlet,
and by the repeated attacks of inflammation to which
they are subject, the surrounding tissue loses its elas-
ticity, and is rendered friable and easily torn or broken.
The exciting causes are constipation, induration of the
fiecal matter, and the violent action of the expulsive
muscles requisite for its evacuation.
The examination necessary for ascertaining the nature
and extent of llie disease is almost always attended with
A
LOWER PART OF THB RECTrM.
much pain, aiul for this reason it will be often advisable
to administer chloroform previoiisly ; as before stated,
the fibres of the superficial sphincter are strongly and
spasmodically contracted, and the fundantent, instead of
presenting a hollow cone, has rather the appearance of a
flat surface with a minute perforation in the centre,
marking the anal orifice. If by the forcible separation
of the buttocks, the fissure cannot be brought into view,
the specaluni ani must be used, or by the careful intro-
duction of the finger, it may be detected as an elevated
ridge, palpable to the tonch, in proj)ortion to the exist-
ing mduration. If the fissure be situated deeply in the
columnar folds of the bowel, and the examination be
made at an early period of the disease, the siu-geon may
not be able readily to detect it by his finger, but he will
become acquainted with its locality by the patient com-
plaining of pain at some one particulni' point. Should
the fissure have taken on the ulcerative process, the limit
to which it has extended may also be detected by the
finger, but it will be necessary to make an examination
with the speculum ani, that the exact condition as well
as the dimensions may be ascertained pi-cviously to
determining the plan of treatment.
My experience fully justifies me in stating that iu
the majority of recent cases it is not necessary to have
recourse to an operation, although some of high authority
in the profession assert that incision is the only effectual
44
riSSURK OF THK ANtS AND
remedy, and that all sorts of applications, soothing and
irritating, are unavailing.
If the fissure exists at the verge of the anna, and is
of recent origin, the patient must be directed to have
recourse to ablution with soap and water, night and
morning; after evacuating the contents of the bowels,
half a pint of cold or tepid water should be tlux)wn up ;
and when this has been ejected, a small piece of lint,
saturated with the following lotion, or one of similar
properties, nmat be kept applied to the part.
it Plumbli Acetatia, gr. x ; Liquoris OpiL Seilativi, 1T|.x3
Sambuci, iiv. Misce.
Where there is much spasm of the sphincter, the
extract of belladonna, in the proportion of a drachm of
the extract to an ounce of s|}ermaceti ointment, or oint-
ment of acetate of lead, is commonly successful in re-
lieving this distressing symptom. Belladonna has been
employed in combating [)ain and spasm in diseases of
the rectum by many eminent siu-geons for a nmnber of
years. Dr. Copland, in his valuable work, the ' Dictionary
of Practical Medicine," appends a note, stating that
Dr. Graham, of Stirling, was the first to employ tliis
medicine in diseases of the rectum and anus; on re-
ferring to the first volume of the ' Edinburgh Medical
Commentaries' (a.d. 1774), p. 419, I find he apphed it
to the iieriurum, for a solid tumour situate in the recto-
U
LOWKB PART OP THE RKCTl'M.
vaginal septum, and states he has observed great ad-
vantage to accrue in using it in diseases of the rectum
and anus. Sir Benjamin Brodie formerly prescribed it
in the form of a suppository, hut from the serious symp-
toms sometimes produced by its influence on the brain,
he is not now in tlie habit of employing it.
At the same time that local treatment is being prac-
tised, it wUl be necessary to attend to the state of the
secretions and exn-etions, and to correct any error in the
patient's habits and manner of living.
If after a fair trial of the simple means that have been
recommended, the fissure does not heal, but on tlie con-
trary, the edges become indurated, and the surface pulpy
and indolent, the free application of the nitrate of silver,
at intervals of a few days, for two or three times, will
generally induce a healthy reparative action in the part,
though often at the cost of nuich pain to the patient.
The use of belladonna ointment and enemata after stool
must be continued.
But cases will occur in which both these plans fail,
and it will be necessary to have recourse to a modifica-
tion of the operation recommended by M. Boyer, namely,
incision through the idcer ; but it need not be carried
through the sphincter, as he advised, though since his
time, and even at present, the greater number of sur-
geons divide the parts to the extent he recommended.
That this improvement in the surgical treatment of
fissure of the rectum should remain so little known is
somewhat surprising, as both Sir B. Brodie, in his
'Lectures,' pubUshed in 1836, and Mr. Syme, in his
work 'on the Rectum,' directed the attention of the pro-
fession to the fact, of a very Umited incision only being
necessary to its cure.* The operation maybe perfonned
in two ways, either by cutting from within outwards, or
from without inwards. lu either mode the patient must
rest on his side, with his knees drawn up, and the but-
tocks projecting over the edge of a sofa or
bed, or he may lean over a table or back of a
chair. For the purpose of cutting from with-
in outwards — the plan hitherto generally
adopted — a straight probe-pointed knife, of
the shape and size of the figure here given, will
be most useful ; it is made thicker at the back
than nn ordinary bistoury, by which a ridge or
button on the end is rendered unnecessary.
The forefinger, previously oiled, being intro-
duced into the rectum, the knife must be
passed flat upon it till the point reaches
the upper margin of the fissure or ulcer,
when its edge must be turned, and an incision
made through the mucous membrane, with-
• Sir B. Brodio recently informed the author, that this modifi-
cation of M. Boyer's operatioii was inlnidueL'il by the late Mr.
Copeland.
' OV TIIK ItlXTl'M.
47
out exteuding it through tliu other structures. The
other mode of making the incision is that advocated
by Mr. Syme, and is ])erfomied by transfixing the ulcer
beiieatli its base with a small, shaii^-poiuted curved
bistoury, and cutting inwards through its centre ; the
opposite side of the bowel must be protected by the
introduction of the finger, as previously directed.
Having on several occasions wounded myself, I find that
in dividing the ulcer inwards from without, the better
plan is to introduce the speculum, and to cut into the
open aide. In operating in this affection, as well as in
many others, the surgeon will experience great advan-
tage if he is able to use the knife with either hand.
When the disease is situated in the anterior or poste-
rior portions of the rectimi, no incision should be ex-
tended beyond the mucous membrane iu cither direc-
tion, for the reason that wounds towards the coccyx split
and separate the fibres of the external sphmcter only,
and are difficult to heal, while anatomical considerations
will deter ua from using tlie knife anteriorly ; iu the
male, from tlie bulb of the urethra being in close prox-
imity, and in the female the shortness of the perineiun,
and the knowledge that division of the anterior fibres of
the sphincter in them is so frequently followed by incon-
tinence of fiBces.
The following cases illustrate the several phases of
this affection.
FISSDRB OF TIIK. ANCS ANO
Fissure of the anus from constipation.
G. C, Bet. thirty-one, a saddler, became an out-patient
under my care at University College Hospital, 1845, From the
natnre of his business he sat the whole day, and felt too tired
on leaving work to take any exercise ; he suffered from dyspep-
sia and constipation, the bowels not acting oftencr than every
second or tliird day ; he was frequently attacked with giddi-
ness and singing in the head ; liis tongue was coated and
large ; defecation was always attended with violent straining.
Eight days previously to his applying at the hospital, while
at stool, and making violent expulsive efibrts, he felt some-
thing give way, and a smarting as the fseees passed; he also
observed some blood ; afterwards, each time the bowels were
moved, he experienced pain and aching, the latter being very
severe. On examination of the anus a slight fissure was
observed, florid, and verj' painfud when touched. Ordered to
apply a poultice at bed-time, and to take an ounce and a half
of castor oil in the morning.
The next day the bowels were freely moved, attended with
piun; the fissure was less inflamed; he was ordered to repeat
the oil, in less quantity, every morning, and to keep a small
piece of lint, smeared with the following ointment, closely
applied within the margin of the auua :
fl Uiiguenti Zinci, jj ; Extraeti Belladonnte, Jy. Ft. Unguentum,
By continuing this plan, and using ablutions night and
, morning, in ten days he was quite well.
1
LOWER PART OF TOE RECTCM.
I Ji*«ttre, intense suffering for four months cured by
incision.
Mrs. K , delicate, the mother of several children, had
suffered from estemal hfemorrhoids during her pregnancies,
and had always had great difficulty in keeping the howels
open. Soon after her last confinement she experienced
smarting at the anus when at the closetj followed in a short
time by intense agony; various purgative medicines had been
prescribed but without affording the slightest relief. Occa-
sionally her linen would be slightly stained with blood and
pus, particularly after passing a hard stool. When I saw her
— Nov. 18-15 — she had for sonic weeks been unable to leave
the sofa, as the pain came on if she walked altout or even
stood for a short time ; sneezing, or any slight exertion also
produced it ; her health was very much impaired and she
was in a state of great nervousness and despondency. Making
an examination, a small oval ulcer was perceived, extending
half an inch upwards from the anal margin rather posteriorly
on the left side; the sphincter was thrown into violent
contraction by the examination-, the colon could be felt
through the abdominal parietes distended with fteees. To
free the bowels of their accumulated contents, enemata were
injected by O'Beime's tube, and moderate doses of castor
oil were prescribed.
My friend, Mr. Morton, saw this patient with me, and we
agreed that an incision should he made through the ulcer,
which I performed by passing a probe-pointed knife on the
forefinger introduced into the bowel ; a few meshes of lint
:■ i: ':'.■■•/
50 FISSL'RE OP THE ASUS AND
spread with tlie followiug ointment were inserted into the
wound :
Jl Unguenti Cctacei, j^vij ; Eitracti BelladoniiB;, 5j- M. ft.
Unguentum.
The dresBinga were continued, the bowels kept easy, and the
local affection was speedily cured. She afterwards took a
combination of tonics and aperients, by which a regular state
of the bowels was induced, and her health became perfectly
restored.
Fissure of the anus cared by local appUcaiioTia.
Mr. , ffit. thirty-four, of nervous temperament, has
suffered for some years from indigestion and irregularity of
the bowels, being sometimes costive and at other times
affected with diarrhcea. Has consulted several medical men,
but never pursued any plan of treatment si^gested. He
applied to me early in 1851, sufiering from indigestion at-
tended with pain at the epigastrium, flatulence, excessive
nervousness, and inability to rest at night. On microscopic
examination of the urine it was found to contain numerous
crystals of oxalate of lime ; he took mild aperients and bitter
iufiisions with nitric and nitro- hydrochloric acids. He per-
sevcTcd in the remedies, and his health greatly improved.
In the beginning of June of the same year he was slightly
troubled with an external pile; under ordinary treatment
all inconvenience subsided in a few days, a small pendulous
flap of skin on the anterior margin of the anus remaining.
On the 24th of the same month I was sent for in great
haste, and found him suffering intense pain at the anus
A
LOWER PART OF THE EECTOM. Bl
extending up tlie hollow of the sacrum ; pulse quick and
irritable, tongue slightly furred, bIuu somewhat hotter and
drier than natural, countenance anxious; he had experienced
slight pain for two or three days, and was in a state of great
alarm about himself, imagining he had cancer of the rectum
commencing, having a short time previously lost a sister by
that disease. Examination revealed a fissure of the posterior
part of the amis, about an eighth of an inch broad, and half
an inch in length. An enema of four ounces of decoction of
barley and sisty minims of laudanum, was administered at
once, with the effect of relieving the pain : three grains of
grey powder, and five grains of Dover's powder were taken
at bed-tirac, and an aperient draught in the morning. The
following day, the bowels acted several times, the smarting
and aching were less ; the latter was relieved by an enema
containing thirty minims of the tincture of opium.
A small strip of lint, impregnated with the following
lotion, was applied within the margin of the anus, and re-
newed three times a day :
pi Zinci Sulpliatis, gr. vj ; Tincturro Opii, 5^3 ; Aqiias Sambuci,
Jiij. M. ft. Lotio.
The bowels were kept open by laxatives, and he took a
mild tonic with alkalies. In nine days he had completely
recovered.
Fissure and k/Bmorrhoids inducing the idea of the existence
of stricture of the rectum.
Mrs. M , set. thirty-seven, married, the mother of
four children, has sufifered from haemorrhoids for some
52
FISSURE OF THE \NC8 AND
years, particularly dtiring pregnancy ; she consulted me in
consequence of fearing she had stricture of the rectum. She
had for some time previously experienced considerable pain
at the time of defecation, which she described as of a cut-
ting character, resohing itaclf into severe aching, frequently
80 agonizing as to compel her to go to bed. She tried the
local application of cold and hot \i ater, experiencing alight
relief from the latter. The symptoms which added greatly
to her alarm, and which she had been told indicated stric-
ture of the rectum, was a reduction in size, and contortion
of the evacuations when they were at all solid. On making
an examination 1 found two external piles, and the buttocks
being divaricated, a (issure was also perceived passing up-
wards between the pdcsj the sphincter ani was strongly
contracted. The bowels having been freely acted on by
castor oil and an enema, the piles were removed and the
fissure touched with nitrate of silver; the operation was
performed while she was under the influence of chloroform.
After the third day the fissure was dressed with the follow-
ing: — spermaceti ointment one ounce, acetate of lead six
grains, extract of belladonna a drarhm; the bowels were
kept easy by taking a teaspoonfnl of the following electuary
every night.
^ Confeetionis Sennae, PotasKe Bitartratis, Extracti Taraitaci,
ana partes cquales. M.
When the spasmodic action of the sphincter had subsided
the ointment was discontinued, and four ounces of water
containing eight grains of sulphate of zinc, and a drachm of
tincture of lavender, were injected into the bowel night
A
LOWBR PART OF TIIK RKCTIIM. 53
and niorning. She recovered in less than a month, and
all symptoma of stricture of the rectum entirely disappeared.
Fissure of the posterior ^jart of the rectum, and external
pile,
Mrs. H- , set. twenty-nine, married, a patient at the
Blenheim Dispensary, in the autumn of 1851, suffering from
ulceration of the lips, fissures of the ton^e, aud general
ailment; in the early part of February, 1852, she was pre-
maturely confined of a dead cliild. On the 2nd of March she
again placed herself under my care, complaining of smarting
of the anus on defecation, followed by extreme aching,
which continued for one or two hours. Examination re-
vealed an externa! pile, the sphincter was strongly con-
tracted, and within the margin of the anus, at the posterior
part, a fissure existed. The pile was excised, and an oint-
ment containing opium directed to be appUcd to the fissure ;
a laxative confection was also prescribed. The confection
not acting on the bowels sutEciently, she took, on alternate
nights, for a few times, five grains of blue pill and one drop
of croton oil, which unloaded the ImwcIs thoroughly. She
then resumed the electuary, and injected into the bowel
twice daily six ounces of infusion of linseed. Before the end
of the month she had quite recovered.
Fissure leading to the formation of an ulcer ; st/mpatketic
affection of the urinary organs.
In 1851, I was considtcd by Mr. , let. forty-five. He
had suffered for about eight weeks previously severe pain
54 FISSfRE OF THE ANUS AND
at the anus, extending up the sacrum to the loius, each time
his bowela were moved; it first commenced after a voty
costive motion. He was much troubled by a frequent desire
to micturate ; and had noticed his linen slightly stained with
blood and matter. Leading a sedentary life, and being of
costive habit, he had for several years taken large quantities
of Morrison's pills.
On examination, finding the sphincter ani strongly con-
tracted, and taking into consideration the other symptoms,
I suspected the existence of an ulcer, the result of fissure.
An attempt to introduce the speculum inducing intolerable
p^n, chloroform was administered, and the instrument then
used ; an ulcer was exposed on the left side, of oval form
and nearly an inch in its vertical diameter; the edges were
sharp and indurated, and the surface an ash colour. Mer-
cury with chalk and Dover's powder were prescribed to be
taken at bed-time, and a teaspuonful of confection of senna
and sulphur in the morning, to be followed by an emolhent
enema. He was directed to observe the recumbent position.
From the appearance of the ulcer I deemed incision neces-
sary, Ijut it was objected to, and a. wish expressed that other
means should first be tried ; nitrate of silver was applied on
three separate occasions, and other applications were had re-
course to during a period of six weeks, but without ad-
vantage. 1 then insisted on the necessity of the operation,
to which the patient gave his consent. Having administered
chloroform, 1 introduced into the rectum the forefinger of
the right hand, and passed upon it a probc-poijited straight
bistoury, and made an incision through the ulcer, dividing
the mucous membrane, submucous cellular tissue, and pos-
^
LOWER PART OP THE RECTUM.
55
aibly a few muscular fibres. Prom the time of the operation
the ulcer rapidly improved, and in less than three weeks he
waa restored to health and eomfort.
Fissure degeneraimg into an ulcer ,- sympathetic affection
of the urinary organs ; incision.
Mr. S , set. thirty-nine, a gentleman residing in the
country, had suffered for some time pain in the rectum, and
frequent desire to micturate. His usual medical attendant,
considering the symptoms depended on irritation of the
urinary organs, prescribed appropriate medicines to allay
that condition, and catheters were also introduced into the
urethra, but without benefit. On his arrival in town he
applied to me. In stating his case he complained of great
pain at the anus during the act of defecation, increasing to
intense agony, and contuiuing for about two hours after-
wards. The Ijowels were constipated, and from the pain he
suffered he put off the calls of nature as much as possible ;
his bladder was very irritable, having frequent desire to pass
his urine. By digital esamiuation of the bowel, au ulcer,
with indurated edges, was felt on the left side. Having
ordered means by which the bowels were fully relieved, the
following day I incised the ulcer, by transfixing its base
with a small curved knife, and cutting into the open side of
a speculum, previously passed into the bowel. The ulcer
presented a foul, indolent surface, with defined raised
margin. The after treatment was the same as haa been
advised, aud a rapid recovery ensued.
NEORALGIA OF THE AND8 AND EXTREMITY OF THE
RECTDM.
That the rectum and anus are occasionally affected
by a morbid exaltation of sensibility, independently of
inflammatory action in a recognisable form, or tlie exist-
ence of any appreciable lesion to account for the pain
experienced, cannot be doubted ; nor is there any reason
why these parts should be exempt from this affection,
when we find it attacking not only the face, Umbs, and
other parts of the body, supplied by the cerebro-apinal
nerves ; modem investigations into the pathology of the
nervous system supply abundant evidence why also
organs supplied by the ganglionic neiTcs should be
affected by neuralgia, as well as other parts of the
animal economy.
This disease, in its substantive form, will be most
frequently met with in aniEUiic individuals, in wliom
the nervous sensibility is generally excessive and often
deranged. Females, whose systems have been depressed
by menorrbagia, or frequent child-bearing, particularly
1
NttUBALGIA OF THE ANUS.
57
if the labours have beeu attended with violent f
are liable to become the subjects of this disease, as well
as other forms of neuralgia. Those individuals who
have been dcbihtated by accidental losses of blood, by
diseases of a depressing character, or by excesses and
irregular habits, are also prone to the affection.
The pain varies much in character and in intensity in
different cases, and will be observed to do so sometimes
even in the same patient ; it will be described as aching,
lancijiating, throbbing, burning, &c. ; it may be pre-
txded or accompanied by neuralgic pains in other parts,
or be the only one affected. The paiu in some cases
is constant, but is more often remittent, in other cases
it will be observed to be periodic, returning at certain
intervals and contiuuing for a definite time; atmos-
pheric changes also exert a powerful influence on the
disease.
Neuralgia of the rectum more often arises from irrita-
tion in some portion of the alimentary canal than from
other causes ; the stomach, small intestines, or colon,
being the primary source of the Section ; or it is
induced or accompanied by irritation of the uterus and
vagina in the female, of the testicle in the male, or of
the urinary organs in either sex ; exposure to cold and
damp, sitting on cold and wet stones, will occasion it;
it is also induced by the influence of malaria. In the
autumn of 1852 I had a man under my cai'c who was
58
NEURALGIA OF THE ANDS AND
said to have piles, but upon inquiring into the history
of the case no doubt remained in my mind tliat he was
suffering from neuralgia induced by malaria ; he com-
plained of great pain at the fundament, occurring daily,
and continuing for some hours ; it was not induced at
stool, neither was it aggi-avated by the evacuation of the
contents of the iutcstine ; he had no bleeding from the
anus, nor was there any tumour or lesion of any kind
discoverable. He had been engaged diu-ing the harvest
time in Essex, and exposed to the influence of night an-.
The skui, dming the time the pain was present, was
slightly hotter thau natural, and the pulse a few beats
quicker ; the tongue was coated, and the bowels were
tolerably regular. To improve his general health pur-
gatives and tonics were prescribed, and continued for a
few days ; to mitigate the pain he was directed to a])piy
an ointment of one part of the extract of belladorma and
seven parts of lard, but it failed to have the desired
effect. His bowels having beeti freely acted on, and
his tongue becoming cleaner, quinine was administered,
wider the use of which the pain dechned, and he very
shortly entirely recovered.
The treatment of neuralgia iu any form is often diffi-
cult, from the obscurity of the cause giving rise to it,
and this, if possible, must be ascertained. If it can be
traced to irritation, resulting from fa;cal accumulations
or a depraved condition of the secretions and excretions
^
EXTREMITI OF THE EECTUM.
of the alimentary canal, such purgatives as are deemed
most appropriate to the case must be prescribed, con-
joined with a strict observance of regimen, both in regard
to quantity and quality. In anaemic patients it will be
advisable to prescribe the various preparations of iron ;
the ammonio-citrate of iron in infusion of caluraba will
be tolerated when other salts of this metal disagree;
should in-itability of the stomach exist, hydrocyanic acid
may be added witli advantage. But some of the other
preparations will at times be more desirable, such as
the carbonate, the saccharated carbonate of iron of the
Edinburgh Pharmacopceia ; the sulphate of iron in com-
bination with the sulphate of quinine, to which, if neces-
saiy, a purgative effect may be given, by the addition
of the sulphate of magnesia; these and other remedies
will be required, according to the peculiarity of the
constitution and complications of the affection under
consideration. I have found small doses of cttract of
belladonna of marked benefit in neuralgia of the head,
the face, and of the arm, the same residting in one case
of neuralgia of the rectum, in which it was prescribed.
Anodyne encmata may be used at the same time tliat
we are administering medicines by the mouth ; and
lotions containuig aconite, belladonna, opium, and other
narcotics and sedatives, applied locally. Steaming the
part with infusions of narcotic plants will at times afford
rehef, when other means have failed. In some persons
60
OF TllL ANL8 AND
pressure has mitigated the pain, whilst the slightest touch
caunot be tolerated by othei's.
The following curious case of this disease is related by
Mr. Mayo I*
I attended a patient with Mr. Stephenson, of Edgeware
Road, who suffered from pain in the rectum. Something
less than two years before this he had a syphilitic ulcer
upon the penis, for which he had taken an unusually large
quantity of mercury, owing to the difficulty of producing
aeuBiblc mercurial action in the system. The ulcer, how-
ever, healed; but while he was recovering, and his system
was yet charged with mercury, he began to experience
aching pains in the incisor teeth, and in the rectum. The
sense of aehiiig in the teeth and in the rectum was not con-
stant, but would come on frequently during the day, without
any assignable cause. It had lastetl a year and a half,
during which he had remained free from symptoms of luea.
This patient, who was otherwise in good health, suffered his
mind to be greatly distressed by the continuance of the
neuralgia. He was anxious to try every plan which held
out the least promise of btucfitting him. But of all the
remedies which he tried he appeared to experience relief
from one only, which was a course of sarsaporilla.
Dr. Bushc f relates three cases of what he considered
• ' ObservatioDB on lujuries and Diseases of the Eectum,' by
Herbert Mayo, Loodon, 1S83, pp. 56, 57.
t Op. cit., pp. 113-110.
J
KXTREMITV OF THF, RRCTLM.
61
neuralgia, but, Ftoiii the history of the first two and the
result of the treatmeut adopted m the second, 1 am
induced to think the symptoms arose from the existence
of some lesion, which was most probably superBcial
ulceration oi- fissure, perhaps not to a greater extent
than the removal of the epithelium, and which, though
it could not be discovered by digital examination, might
be inferred from the pain caused by pressure on the
pai'ticular spot. In the third case the patient had suf-
fered from tic douloureux in the face, for some time
previously to the rectum being affected. She expe-
rienced relief by firm pressure, which she cfiected by
folding a uapkm into as small a compass as possible,
placing it between her buttocks, and sittmg on a wooden
chair.
Inplammation of the rectum is either sthenic or
asthenic, acute, sub-acute, or chronic ; it may be the
primary disease, or secondary, residting from disease
existing in the neighbouring parts, and will be either
simple or specific in its nature.
The predisposmg causes of proctitis are a sanguine
and u-ritable temperament, sedentary occupation, par-
ticularly if conjoined with the indulgences of the table,
a full habit of body, hsemorrhoidal affections, venereal
excesses, and voluntary and involuntary pollutions ; dis-
ease of the bladder, prostate gland, and urethra in the
male, and of the womb and vagina in the female. The
exciting causes act either through the medium of the
intestinal canal, or from without.
Of those which act from within, the most frequent
and important arc the ingcsta — dietetic or medicinal-
substances swallowed with the food, either intentionally
or accidentally, which lodge and irritate the intestine or
penetrate its coats, such a3 fish bones, spiculse of other
J
INFLAMMATION OF THE RECTCM. 1)3
boiies, the stones and seeds of fruits, &c. ; the prolonged
aud improper use of aloetie and resinous purgatives,
frequent and large doaes of calomel and other merciuial
preparations, the long-contiinied or excessive use of
arsenic, emmcnagogues similarly prescribed ; the presence
of entozoa, accumulation of fieces, morbid secretions
and excretions, concretions formed in the bowels, and
haemorrhoidal affections. To these Bushe * adds rheu-
matism and gout, and relates two cases that came
under his observation. The external agents in inducing
inflammation of the rectum are accidental injuries, sur-
gical operations, and wounds involving the anus and
rectum; foreign bodies introduced from without, and
the operation for their extraction ; acrid enemata and
suppositories, injuries inflicted by clumsy attempts to
administer enemata ; the contact of syphiUtic and gonor-
rhceal virus and other infecting agents ; the exhalation
from foul privies — where the accumulation of night-soO
is great— rising against the anus during the act of defe-
cation; from this cause soldiers, when encamped, arc
often affected with inflammation of the rectom, par-
ticularly if dysenteric diseases prevail, with which proc-
titis may be confounded ; the abstraction of animal heat
by sitting on the wet and cold ground or stones, or on
a wet seat while driving in an open vehicle ; the latter
cause, besides inflammation, often inducing abscess and
• Op. oit., p. 87.
U4 INFLAMMATION OP THE REUTCM.
fistula in ano in coachmen and others : inflammation
may occur in the parturient female from protracted
labour, from injury from the use of obstetric instru-
ments, rendered necessary by the emergency of the case,
or by the improper and nnskiJful application of them ;
and other contingences of the puerperal state. ^
The sjnnptoras will be modified by various circiun-
stances, depending upon the constitutional powers of the
patient and the nature of the exciting cause. The acute
sthenic proctitis is manifested by a feeling of fulness,
weight, throbbing, and heat at the anns, extending up
the sacrum ; frequent desire to go to stool, attended
with great straining, but by scanty evacuations, and
with mucous, membranous, or muco-sanguineons dis-
charge, the pain and suffering at the time being greatly
increased. The sphincter ani will be contracted, the
mucous membrane of the bowel will be red and highly
sensitive, its temperature exalted, which will be evident
to the finger if introduce<i into the bowel, but great tor-
ture to the patient will thereby be occasioned.
The sympathetic constitutional disturbance varies with
the attack and nafiu« of the cause. If it arises from
cold, rigors and chills may precede the local symptoms ;
the concomitants of pyrexia will be present, namely,
loss of appetite, heat and dryness of skin, and thirst ;
the tongue is white, loaded, and enlarged, with tlie
impressions of the teeth indented into its margins ; the
J
INFLAMMATION OP THE RKCTCM.
functions of secretion and excretion are impaired and
disordered, the urine is scanty and high coloured, and is
passed frequently and with difficulty if the urinary
organs are implicated by the extension of inflammation
to them ; should the disease have been neglected, and
large fiecal accumulations have taken place, vomiting
may occur, but this is not often the case.
The complications of inflammation of the rectum are
often of a serious character, and require careful consider-
ation and treatment. The urinary organs in the male
are frequently affected, the prostate gland, the neck of
the bladder and lu^thra becoming involved in the iuflam-
matory action, causing dysuria, strangury, or even reten-
tion of urine, the latter depending upon spasm of the
muscular structure acting on the urethra. In the female
the inflammation is more prone to extend to neighbour-
ing parts, the vagina, the os and cervix uteri becoming
implicated, accompanied by distressing bearing-down
pains. Occasionally, cases will be met with where the
inflammation has extended to the peritoneum, rendering
the patient's sufferings much greater, and seriously in-
creasing the danger ; to the other symptoms we shall
then have superadded abdoiniual tenderness, more or
less extensive and severe, in proportion to the activity
of the inflammatory action ; tympanitis will abo be
present.
Like inflammation attacking other parts, proctitis may
5
(16 INFLAMMATION OF THE RECTUM.
tenninate in resolution or subside by haemorrhage taking
place from the mucous surface of the intestine ; relief of
all the symptoms immediately foUowing. Should the
patient have previously suffered from internal haemor-
rhoids, the same termination may occur by the accession
of the ha:morrhoidat flux. But if neither of these fa-
vorable results be arrived at, the iuflammation may lead
to ulceration of the inner coats of the bowel, au ulcer of
greater or less extent being formed, or the ulcerative
process may attack the follicles, and produce a number
of distinct ulcers. Suppuration, external to the intes-
tine, is liable to ensue from extension of the inflamma-
tion or by perforation of an ulcer or ulcers, causing
abscess between the rectum and vagina in the female, or
between the bowel and neck of the bladder in the male,
-or in either sex in the loose cellulai tissue around the
bowel, and, as a residt, the formation of fistula in ano.
The hemorrhoidal veins and peritoneum may be in-
volved in the inflammation, and in cither case the com-
plication is of a very serious character, and is fraught
with much peril to the patient. Lastly, acute proctitis
may subside into the chronic form, and induce various
changes in the tissues of the rectum and colon, and
parts adjoming, such as ulceration, simple or fistulous,
thickenmg, indui-ation, and contraction of the coats of
the intestine, stricture, spasmodic stricture, spasmodic
contraction of the sphincter ani, fissure, &c.
INFLAMMATION OF THB RELTIIM. tt7
Chronic proctitis may occur primarily as well as
e the result of the acute or subacute form of the
Asthenic acute proctitis occurs chiefly in cachectic
and exhausted constitutions, or may be caused by the
poisonous and depressing properties of the exciting
cause, as when occurring from exposure to the emana-
tions of foul privies.
In the treatment, the first thing to be considered
is the nature of the predisposing and exciting causes
and the activity and character of the inflammatory
action. If the inflammation has been produced by
the lodgment of foreign bodies, by the accumulation
and induration of faecal excretions, or alvine concretions,
they must be dislodged by mechanical means, all possible
gentleness being observed in the operation. If the
presence of ascarides is the cause, they must be expelled
from their habitation by the administration of vermifuge
medicines, and the use of oleaginous and terebinthinate
cnemata. Having attained these objects, the bowels
should be kept free from irritation by the use of emol-
lient cnemata, and attention to the quality of the ingesta.
In the s'thenic form of the disease, and in plethoric in-
dividuals, it will be necessary to take blood locally by
cupping over the sacrum and on the perineum, or by
the application of leeches around the anus ; the bleeding
bemg promoted by the patient sitting over warm water
INFLAMMATION OF THE RKCTUM.
after the leeches have fallen off, or by the use of hot
linseed-meal poultices. The wann-bath, senii-cupium,
or hip-bath, will afterw'arda be serviceable.
The state of the excretions and secretions must be
attended to. Hydrargyrum cum creta and the pulvis
ipecacuanbae compositus will be beuefieial ; if pain and
tenesmus be complained of after depletion, the com-
pound ipecacuanha powder or simple ipecacuanha powder
with henbane, extract of hop, or extract of poppy, may
be administered ; great relief will also be experienced by
the administration of enemata, of four or six ounces of
infusion of linseed, containing from thirty to sixty
minims of laudanum. After the irritabihty of the
rectum by these means has been somewhat allayed, the
bowels should be moved by fresh castor oil or olive oil,
or by the confection of senna and sulphur, with or with-
out the addition of copaiba, according to circumstances.
Diluents should be taken freely, and all stimulating
ingesta avoided.
The subacute and chronic forms will require the same
treatment slightly modified. The abstraction of blood
will be less necessary than in the acute form, but the
warm-bath or hip-bath and soothing and emollient ene-
mata will he equally beneficial and necessary in the
former states of the affection as in the latter. If exco-
riation, heat, and irritation, are experienced, great reUef
will be afibrded by the use of a cooling and anodyne
J
INFLAMMATION OF TUK RECTUM. OV
lotion, such as a solution of the diacetate of lead, with
acetic acid and wine of opium ; pledgets of lint, satu-
rated with it, being kept constantly applied to the
parts.
The asthenic form of inflammation of the rectum
rarely admits of depletion, either general or topical. It
has a greater tendency than the other varieties of inflam-
mation to spread up the intestinal canal, therefore our
endeavours must be directed to prevent and limit the
extension of the diseased action and to support the vital
powers of the constitution. The first object is to be
obtained by the use of the warm-bath or hip-bath, fol-
lowed by stimulating embrocations apphed over the
sacrum and to the hypogastrium ; warm terebinthinate
epithems, applied on flannel, will be of great service ;
demulcent and anodyne enemata should be employed
early in the treatment, and are always beneficial. The
constitutional treatment will consist of the administra-
tion of small doses of quinine with camphor, ipecacuanha,
and the sedative extracts ; castor oil either alone or with
turpentine should be prescribed to move the bowels, or
the confection of senna with the extract of taraxacum
and bitartrate of potash.
Should lUceration or sphacelation occur, the treat-
ment recommended in Chapter VIII. * must be
adopted.
• Page 72,
70 INFLAMMATION OP THE RECTL'M.
In this, as in all other diseases of the rectum, great
care is necessary in administering an enema not to in-
jure the bowel with the pipe of the instrument, and
there will be less probability of mischief occurring if
the jet be made of clastic gum tube instead of metal or
ivory.
The specific form of proctitis, arising from goiior-
rhceal or syphilitic infection uuist be treated in conformity
with the principles of treatment for the diseases occurring
in other parts. Eneraata should not be used in these
cases, lest they should favoiir their extension, but strict
cleanliness must be enjoined : the use of cooling and
anodyne lotions, and such other means aa are usually
employed to allay local inflammation, must be put into
requisition.
The occurrence of peritonitis will be a most serious
complication, and demand active and prompt measures
in the treatment. In plethoric individuals blood should
be taken freely from the arm, and a large number of
leeches applied to the abdomen, followed by hot anodyne
fomentations, or by, what is much better, a flannel wrung
out of hot water, and freely sprinkled with warm tur-
pentine; calomel and opium must be administered
more or less frequently, according to the urgency of the
symptoms, and counter-irritation estabhshed on the
lower extremities by stimulating pediluvia and sina-
pisms.
■TION OF THE RECTUM.
71
The hip-bath and anodjTie enemata and a strict ob-
servance of the horizontal position will be most effica-
cious in reheving the bearing-down pains experienced by
females suffering from proctitis.
When the urinary organs are affected, and dysuria
and strangury induced, the warm hip-bath will be re-
quired, which if insufficient to afibrd relief, we shall be
called upon to direct other measures, particularly if re-
tention of urine should take place ; then it would be
advisable to prescribe a fiill dose of morjihine in addition
to the bath ; tartar emetic, ui frequent and nauseating
doses, will generally relax the spasmodic condition of
the muscles preventing micturition ; but if these means
fail, and the bladder is much distended, it must be relieved
by the gentle introduction of the catheter.
DLCEHATION OP THE RECTUM.
It is intended in this chapter to treat of ulcers re-
sxilting from einiple or specific inflammation, or occur-
ring as a complication or effect of other dist^asea and
lesions. Those originating in fissure have already been
considered.
Perhaps the most frequent cause of simple ulceration
of the mucous membrane of the rectum arises either
from bruising and aubse(|ucnt inflammation, or from the
surface being abraded, and a slight laceration produced
by the passage of indurated faeces : it occurs in persons
of constipated habit, in whom the nmcous membrane of
the rectal pouch is often relaxed, and in the act of de-
fecation a small portion slipping down below the upper
margin of the sphincter, becomes jammed between it
and the faical mass, producing one of the lesions men-
tioned, and leading to ulceration.
It occurs not unfrequently as a consequence of
dysentery, either acute or clu'onic, and of colliquative
diarrhoea. It may be either the cause or consequence
ULCERATION OP THE RECTUM.
73
of abscess of the rectum and anus, or be the result of
one of the forms of proctitis described in the previous
chapter.* Ulceration is often occasioned by the entangle-
ment and lodgment of the fEDces in the mucous follicles
of the rectum, in which case several ulcei-s will generally
exist.
Ulceration of the rectum is frequently found as a
complication of disease existing in other organs, rather
than as a primary and simple lesion. We meet with it
associated with tubercular diseases of the lungs and liver,
and tubercular deposits in other parts of the body. In
children it is often a complication of tlnnsli, of disease
of the mesenteric glands, and a consequence of chronic
diarrhcea. Diseases of the urethra and prostate gland
in the male, and of the uterus in the female, also give
rise to ulceration of this bowel.
Ulcers in this region will assume different forms and
phases, in like manner as when they occur in other and
exposed parts of the body, being similarly influenced by
the causes producing them, and the state of the consti-
tution of the individual. They vary in size as well as
number, and are cither superficial or involve the vphole
thickness of the coats of the intestine. If produced by
the lodgment of fseccB in the lacunae, they will be mode-
rate in size, deep, and if they have existed any length
of time, the edges will be indurated and prominent.
• Page 6(5.
74
rUERATlON OF THE RECTUM.
The symptoms of ulceration of the rectum are a dis-
charge of saDJous, purulent, or muco-punilent matter
oozing from the anus, soiling the patient's linen, and
producing great discomfort, and perhaps excoriation of
the external parts ; pain in the gut extending up the
sacrum to the loins, or sense of weight in tlie bowel,
aching down the uiside of the thighs, smarting at stool,
and, if the ulcer be situated near the verge of the anus,
there will also be spasm of the sphincter, as in fissure of
that part ; the faeces will be besmeared with blood and
pus, and the patient will be troubled with teneanms, and
irritation of the urinary organs. Mr. Colics,* speaking
of the pain and dlscbai^e in tliis disease, says, " At
times the quantity of discharge is much lessened, and
then the sufferings of the patient are aggravated ; but
on the flowing off of a large quantity he experiences
great relief;" this I presume must have been due to
the acute and excessive inflammatory action, and not
depending alone upon the quantity of matter secreted by
the ulcer.
When the ulcer is situated just within the external
sphincter, and spasm of that rauacle does not exist, it
may be brought into view by divarication of the but-
tocks, and pressing aside the edges of the anus with the
fingers ; but if it exist higher up the intestine and in
the most usual position in which it is found, namely,
" ' Dublin Journal/ vol. t, p. 156.
I
J
ULCERATION OF THE EECTrM. 75
immediately above the upper margin of the internal
sphincter, the speculum must be used to dilate the anus,
when we shall with ease be able to judge of the situa-
tion, form, extent, and character of the ulcer. Mr. Colles*
rcconmiends " a blunt polished gorget, with its con-
cavity looking towards the seat of the disease, to be
passed upon the finger into the rectum ; then, by evert-
ing the anus as much as we can, we shall obtain a full
view of the ulcer by the hglit reflected from the gorget."
By the introduction of the finger, and making a careful
and gentle exploration, we may arrive at a verj' correct
biowledge of the extent, form, and situation of the ulcer,
by the pulpy feel of its surface, and by its edges being
raised above the surrounding tissue ; but, aa the intro-
duction of the speculum is not attended with more pain
than digital examination, it is preferable and more satis-
factory to have recourse to it, as we shall thereby acquire
a better notion of the precise character of the sore.
Ulcers of the rectum assume every variety of fonn
save that of the healthy ulcer, with small florid acu-
minated granulations rising to the level of the surround-
ing surface, and the process of cicatrization advancing
from the margins. Ulcers in this region, in unhealthy
and broken-down constitutions, are sometimes attacked
with phagedsena.
Many circiunstances conciu- to interfere with a healthy
• Ctp. cit.
76 ULCERATION OF THE RECTUM.
reparative process in ulceration of the rectum. The con-
stant contusion, and stretching of the ulcerated surface
by the passage of the fjeces, the irntation produced by
contact of the excretions^ the congestion that occurs in
the capillary vessels by the whole weight of the column
of blood reacting upon them, from the absence of valves
in the portal venous system, and the depending situation
of the hsemorrhoidal veins, from which the retimi of
blood may be still farther impeded by accumulation of
fffices, or the presence of pelvic tmnoiu^ pressing upon
them. Other impediments exist to the healing process,
such as the puckering and undue and unequal pressure
the ulcerated surface is subject to, if situated within and
embraced by the internal sphincter ; and, lastly, the ira-
possibihty of keeping dressings accurately applied to the
ulcer, and making that equal and constant pressure,
which proves so efficient in ulcers occurring in other
parts, accompanied by retarded venous circulation.
From the liability of ulcers of the rectum to become
congested whUc the patient is allowed to be about, it will
be necessary to confine him to the bed or sofa while
under treatment ; and during that time a strict regimen
must be enforced, all stimulating food being prohibited,
and only that allowed which will form the least amount
of excrementitious matter.
In tliis disease we shall seldom be called upon to prac-
tise genei-al bloodletting, but, if there be much throbbing
ULCERATION OP THE RECTUM-
77
and fulness about the part, the local abstraction of blood
by cupping or leeches to the sacral region and perineum
may be necessary ; emollient enemata will always be
beneficial. Attention must be directed to the state of
, the general health, which we must endeavour to restore
by appropriate means, if it has been impaired by disease
or irregularity of habits. Constipation must be remedied,
the bowels are to be freed of faecal accumulations by
enemata, thrown up by O'Beime's tube ; the functions
of the liver and pancreas are to be promoted by mild
doses of mercurials, taraxacum, or nitro-hydrochloric
acid, and irritability allayed by sedative and sudorific
remedies.
Provided the ulceration is recent and not of great
extent, it may generally be made to heal by the adoption of
the constitutional treatment just mentioned and by topical
applications. The ulcer is to be brought into view, as in
making an examination, and the solid nitrate of silver
appUcd more or less freely, according to its condition, or
either of the following lotions may be used by means of
a camel-hair pencil or swab of charpie.
:, ad ]d ; Aqus DiBtill^tEc, ^j. Miace
^ Argenti Nitratis, gr. :
fiftt Bolutio.
9> Addi Nitrici Diluti, itviij ;
fiat lotio.
Aquge Distillatte, ^. Miece
It will be necessary, in some cases, to have recourse to
these applications several times. Four or six ounces of
ULCERATION OF THE RErTlM.
water, with zinc, or lead, and two or three grains of ex-
tract of opium or belladonna rubbed up in it, and injected
into the bowel once or twice in the twenty-four hours,
will sometimes be found useful.
Under the foregoing plan of treatment the ulceration,
if not extensive, will generally take on the reparative pro-
cess and cicatrization rapidly follow. But it frequently
happens the surgeon is not consulted till the disease has
persisted some time or is extensive, attended with great
pain and violent spasmodic contraction of the anus ; local
apphcations will then be of no avail, and incision must
be had recourse to ; it is to be performed in the same
manner as described in Chapter V,* on fissure, only that
the sphincter muscle must be entirely divided. The
incision is to be made through the centre of the ulcer,
except when it is situated on the posterior or anterior
aspect of the rectum, in which case it will be advisable to
make an incision on either side of the median line, for the
reasons elsewhere urged ; light dressings must be applied
to the wound, and a rapid cure usually ensues, llie
principle on which this is effected I conceive to be the
following : the ulcer is freed from all undue pressure, the
spasm of the muscle ceases, the blood-vessels are relieved
from engorgement, the faeces pass without difficulty, and
medicaments may be more easUy applied to the part.
Previous to the operation the bowels should be un-
• Page 38,
J
ULCERATION OF THE RECTUM, 79
loaded by a dose of castor oil or laxative electuarj', fol-
lowed by an enema of thin gruel ; and after it has been
performed, a dose of opium should be given for the
double object of tranquillisiiig the patient and producing
temporary constipation.
Should idc«ration attack many points of the intestine,
and extend high up, there will probably be a fatal ter-
mination of the case, in spite of the most judicious mea-
sures we can employ.
Venereal idceration may attack the rectum by the
du-ect application of the poison from the genitals, or it
may coexist witli some form of secondary syjihilis. In
the first volume of the 'Pathological Transactions'* is an
account of the extensive ulceration of the rectum from
syphilis ; the specimen, exhibited by Mr. Avery, was
taken from the body of a girl who died in Charing Cross
Hospital; the ulceration extended three inches up the
intestine, and occupied the whole internal surface to
that extent.
Venereal ulcers of the rectum are seldom met with,
except in those of the most depraved morals ; and when
they occur they often take on a phagedenic action, from
the constitution being worn out by vice and debauchery,
death speedily terminating the sufferings of the unhappy
victims ; in this country this form of disease is rarely
seen except in those prostitutes residing in the neighbour-
• Pagea 67. 68.
ULCERATION OP THE RECTUM.
hood of the docks or other low localities, and who, during
their brief period of existence, are constantly under the
influence of spirituous liquors.
Syphilitic ulceration uot unfret|uently leads to per-
foration of the recto-vaginal septum in the female, and
recto-vesical walls when occurring in the male ; records
of such cases are more mmicrous in the writings of
foreign authors than iu those of this country.
The treatment must be varied according to circum-
stances. In phagedaena we must try to arrest the morbid
action by the application of the concentrated nitric acid,
taking care not to induce perforation of the bowel. The
constitutional powers must be maintauied by nutritious
food, stimidants, quinine, &c.
Ulcemtion occurs in cases of stricture of the rectum
above the constricted part, as a consequence of pressxu^
of accumulated freces ; the whole thickness of the intes-
tine may be perforated, giving rise to abscess, which
may open externally by the side of the anus, or per-
forate the serous cavity of the abdomen, producing fatal
peritonitis.
In the treatment of this last form of ulceration our
attention must be directed to the cause, and if that
camiot be remedied we shall be able to do but little to
mitigate the efiect.
J
ULCERATION OP THK RECTl'M. oi
Siiperfcial ulceration treated mth nitrate of silver.
Mrs. T , of middle age, delicate conBtitution, had been
subject to mucous diarrhoea. Three weeks previous to con-
sulting me she experienced great pain at stool and afterwards,
of a smarting tiurning character ; slie had purulent discliarge,
and complained of a sense of weight in the rectum, paiu up
the sacrum and in the loins, and bearing-down of the womb.
By examination I discovered extensive superficial ulceration
near the upper margin of the sphincter, I injected an enema
of decoction of linseed, and afterwards passed the solid nitrate
of silver over the ulcerated surface. I directed she should
confine herself to the couch, and that her diet should consist
of broths and farinaceous food, and desired her to liave a hot
hip-bath each night before retiring to bed. Her bowels were
kept easy, and cnemata of four ounces of mucilage with
liquor plumbi diacetatis and tinctura opii, were injected
into the bowels twice a day. Twelve days sufficed to effect a
cure.
Superficial ulceration treated mth nitric acid lotion.
Mr. H sought my advice on account of purulent dis-
charge from the anus, great pain in defecating, continuing
for some hours afterwards; he also had irritability of the
bladder. He was aecuatomed to high living, and attributed
his indisposition to having swallowed a spicula of a bone of a
partridge, which injured the bowel in its passage outwards.
By examination I detected a superficial ulcer, somewhat less
than a shilling in size, the edges were iufiamed and ttie siir-
83 ULCERATION OF THE RECTUM.
face covered with a tenacious nmco-punilcnt matter. I
applied the nitric acid lotinn on the occasion, put him on
spare diet, enjoined tlic reciimbent position, and directed
the administration of an enema every day. He made a rapid
recovery.
Ulceration of the mucous membrane; incision of the
sphincter.
Mrs. L for several months had suffered pain in the
rectum at and after defecating, accompanied by purulent dis-
charge, which she attributed to intenial piles; she took
various empirical remedies recommended by friends, being
unwilling to seek medical assistanec ; but, her sufferings in-
creasing, she ultimately placed herself under my care. Her
bowels had always been constipated, seldom acting without
medicine. Some years previously she had lisemorrhoids,
which were removed by operation. I examined the bowel,
and discovered above the sphincter an ulcer on the right side
of the intestine of the size of a shilling; the edges were
indurated, the surface pulpy. Being unwilling to submit to
an operation, a variety of applications were used, the nitrate
of silver, nitric acid, and others of a less active character ;
the recumbent position was adhered to, and a light diet
observed ; the bowels were kept easy by laxatives and emol-
lient enemata, but the ulcer did not heal. Finding no benefit
from the treatment, she consented to the operation proposed.
I divided the sphincter, carrying the incision tlirough the
centre of the ulcer; an opiate was given after the operation.
The wound was dressed in the usual manner ; it granulated
ULCERATION OF THE HKCTDM. So
firom the bottom, healed kindly, aud in less than a month she
had quite recovered.
laceration, its extension arrested by nitric acid, and
division of the ^hinder afterwards.
Mr. William Bennett requested me to see F. M— — ■, set.
forty-one, of broken-down constitution. Somewhat less than a
fortnight previously he began to csperience pain in the rectum
and anus ; it increased in severity each day, and was excruci-
ating when the bowels were moved ; his linen was stained with
pus and blood. When I saw . him, febrile sj-mptoms were
strongly marked, the skin being hot, his face flushed, tongue
dry and brown in the centre, and the margins and point preter-
naturally red ; the pulse feeble and quick ; he was much pros-
trated. By the finger introduced into the bowel, at its posterior
part, a large ulcerated surface was felt, commencing a quarter
of an inch from the anus. On dilating the anus the edges of
the ulcer were perceived to be irregular, abrupt, aud highly
inflamed ; and the surface was covered with an ash-coloured
slough ; &om the recent accession of the symptoms it must
have extended rapidly. A large enema was at once ad-
ministered, which unloaded the bowel. I then applied nitric
acid to the surface and edges of the ulcer ; a dose of opium
was given immediately afterwards. On the following day,
perceiving the ulcerative process to be arrested, I divided the
sphincter on each side, cutting &om within outward in the
usual manner; lint was placed between the edges of the
wounds, and three fourths of a grain of morphine in solution
was directed to be taken immediately, and six grains of
b4 ULCEaATION OF THE RECTUM.
Dover's powder and two of gray powder at bedtime ; a poul-
tice to be applied to the part, and renewed at night. The
powder was repeated twice a day for a short time; he
remained in bed, and his diet was restricted to broth and
arrowroot. The constitutional symptoms subsided; the
third day he had some castor oil^ and the dressings came
away, when the bowels acted ; after which a lotion of nitrate
of silver was used to the ulcer, and simple lint to the
incisions. The plan was continued till the parts were quite
healed, which occupied little more than a month.
HEMORRHOIDS is a term applied generally to certain
tumoiiTs occurring at the verge of the anua, or within
the rectum. The term, like many others, is not the
most appropriate that could be chosen, as it conveys no
adequate idea of the nature of the disease ; yet by use
it has become familiar both to the profession and the
public, and its import generally understood; piles is the
popular name under which these affections arc known,
indeed, by many, and by the working and poorer classes
especially, almost every other disease about the rectum
and anus receives the same designation.
It is not sm^rising that the ancients, from a deficiency of
knowledge of anatomy and pathology, were unacquainted
with the true nature of tJie disease, that they should
have had very erroneous opinions of the structure of
the tumours forming hiemorrhoida, and have enter-
tained the notion that they performed the function of
evacuating black bile and melancholic humours from the
system. After the discovei-y of the circulation of the
86 U.EMORRHOIDAL AFFECTIONS.
blood by the illustrious Harvey, a new but equally
erroneous theory was generally received, it being con-
ceived that bleeding from external ])iles depleted the
system generally,, and that hsemorrhage from internal
piles depleted the portal system only,
Monttgrc* gives the following classification of hBemor-
rhoidal complaints : —
1
Blind or dry Hjemoirhoids (Cteca)).
2
with dischEiTge
White discharge (Alba
the intestjjies
SunguiueouEi discharge
(Sanguinoknbc)
) with catarrh of
By Exhalation
(FliientcB)
By Rupture
3
Hiemorrlioida
Varicose
Dry
Bleoding
with tumours
(y™„)
(Tumentes)
MariscouH
Drr
(Marii«B)
Bleeding from
dilated porea
4
Painful Hsemor-
rboids
(DoIentcB)
Nervous
Fissured
5
Hffimorrhoidfl
Indolent
From induration
with constriction
of the tisBues
oftheanuH
(Cum constric-
Painful
Spasmodic
tione ani)
Scirrhous
• ' Dea H^morrhoides ou Traite Analytiquc de toutea les Affec-
tions Hemorrhoidales,' par A. J. de MoiiU'gre, Deuxiemc Edition,
Paris, 1880, p. 71
H^MOKRHOIDAI. AFFKCTIONB.
6. Hmnorrhoids fSuperfinial
with ulceration (
(Ulcerate) [ Fistulous
7. Hemorrhoids Prom elongati
with proIapBua
(Cum proci-
deatia ani
8. HcemorrhoidB
with irritation of I
the bladder , Strangury
(Cum irritatione
of the
I internal memhrano
From invBginatioa of
I the intestiueH
[ With dysuria
i) iHxmaturia
Athough this classification, complete and comprehensive
as it is, and very clearly showing the various characters and
phases of liaemorrhoidal tumours, the most practical and
important to bear in mind, as influencing the treatment, is
the division adopted by most EngUsh authors into internal
and external haemorrhoids ; the fonuer being those which
occur within the margin of the anus, and involve the
mucous membrane of the intestine, and the latter those
which are situated external to the sphincter ani, and are
covered by the thin integument of the anus.
The nature and structure of haemorrhoidal tumours
have not been clearly understood till within recent times.
By the older writers they were considered to be dOata-
tious of veins, the same views being adopted by many
modern authors, and at the present time a very general
opinion prevails that they are simple varices, and analo-
HJiMORRllOlUAL AFFECnoNS.
gous to that morbid condition observed in the spermatiC'
veins constituting varicocele, or to the dilatation of the
8ui>erficial veins of the legs, which causes so much dis-
tress, and so often gives rise to a very troublesome form
of ulceration.
External hemorrhoids — lliese tumours occm- at the
verge of the anus, and are covered by the thin integu-
ment of that region, but occasionally they will be ob-
served to extend a short distance within the anal orifice,
and will theu be partly covered by the integument, and
partly by the nnicous membrane of the intestine. In
form they are mostly globate, and have a broad extended
base ; they are of a livid colour at first, but lose that as
their active state subsides. They are tense and elastic
to the touch, and exquisitely painful when inflamed, the
anguish tlicn being so great that the patient is unable to
walk or take any exercise — ^in some cases even sitting is
impossible. They consist of the integument and cellular
tissue into which blood has been extravasated, as a
result of a congested state of the hsemorrlioidal vessels
and determination of blood to them, produced by causes
to be hereafter mentioned ; generally, the blood is en-
cysted in a central cavity, with a smooth glistening sur-
face J in some cases there are several of these cavitieB
filled with blood.
After the acute stage att<'nding the development of
these iLiuioiirs has subsided, the blood that has been
HEMORRHOID A I. AI'FECTIONS.
89
efFuaed into their interior becomes absorbed, and if they
hnve not been distended to any great extent the skin
contracts, and the parts resume their natural condition ;
but if the tumours have attained the size of a cherry,
or larger, the elasticity of the integument will have been
destroyed by over distension, and upon absorption of
their fluid contents pendulous flaps remain, prone to
take on increased action, and form excrescences which
may attain a considerable size
When several attacks of external piles have occurred,
the cellular tissue of these tumours, by inflammatory
action, become infiltrated with lymph, and condensed,
and they do not then collapse on the subsidence of the
inflammatory stage, but remain permanent, and give
rise to other lesions, which occasion as much or more
sufiering than the primary disease.
Mr. Howship* describes another form of externa]
pUe, which he terms the serous hsemorrhoid ; he thinks
the difference in structure depends on the strength of
the constitution ; the sanguineous haemorrhoidal tumour
occurring in the strong, and the serous in those of low
vital powers. He very justly dwells on the necessity of
drawing a distinction between the two kinds, as our
treatment will thereby be influenced. This serous
' ' Practicat Observations on the SymptomB, DiscnmitiationB,
and Treatment of Bome of the most important Diseaseg of the
Lower Int«Btine and Anus,' by John Howship, 1824^ p. 208.
90 H.f;M0RRH01DAL AFFECTIONS.
bicmorrhoidal trnnour is pale, clastic, shining, semi-trans-
parent, and more frequently forming a ring round the
verge of the anus than appearing as a distinct tumour.
I have many times observed these swellings, but cannot
agree in considering them as a separate variety of
hsemorrhoidal tumour, but as an cedematous distension
of the loose cellular tissue and thin skin of the parts,
depending on irritation in the immediate vicinity. This
state is more frequently seen as an effect of inflamed
internal hsRmorrhoids than from any other cause, though
I have witnessed it occnrring from fissure of the anus,
acrid intestinal secretions, and similar conditions.
Internal hmnorrhoids. — The tumoiu-s constituting
internal piles, consist of a morbid alteration in some
portions of the mucous membrane of the rectmn, and
submucous areolar tissue, with an augmented and
abnormal development of the capillary vessels. Like
the external variety, they were formerly considered to
be a dilatation of the veins. It appears somewhat sur-
prising that this opinion should have been retained by
many of the later writers, for when speaking of the
character of the hEemorrhage, they describe it as florid
and bright, and more nearly resembling arterial than
venous blood, which it would not if it were poured out
from veins, particularly when they are m a dilated and
debilitated condition ; in them the circulation must ne-
ceesorily be slow, and, consequently, the blood would
hj:morrhoidal affectionb. 91
acqiiire a deeper colour. But examinations on the living
subject, and dissections on the dead, clearly demonstrate
a different condition. A varicose state of the hsemorrhoidal
veins ia not unfrequently met with ; however, tbcy fonn
tumours very different in character, and in the symptoms
they occasion, from those now under consideration.
By dissection, internal hjiemorrhoidal tumours will
be found to consist of both arteries and veins, the latter
capacious, not in a diseased condition, but merely of
abnormal development ; the areolar tissue of the mucous
membrane is hypertrophied, and if the tumours have
existed long, and been subject to repeated inflammatory
attacks, it will also be condensed. The surface of these
tumours is villous, presenting to the unassisted eye a
granular appearance ; they generally bleed freely if rudely
touched, or accidentally scratched by the nail during an
examination, the blood being of a bright red colour.
Dr. Bushe states, he has been able to rub off an ex-
ceedingly vascular and fragile adventitious membrane
from their surface, and is of opinion, they may thus
acquire an increase in magnitude. To the touch they
have a spongy elastic feel, and by some authors are con-
sidered to resemble erectile tissue in structure ; had they
compai'ed them to those abnormal developments of the
vascular system termed aneiuism by anastomosis, the
analogy woidd liave been more correct.
Internal hemorrhoids vary much in size and number,
92
HEMORRHOIDAL AFFECTIONS.
but the accessory phenomena attending tliem, such as
pain, LaDmorrhage, &c., are not increased in proportion
to either, and cases are met with in which a greater loss
of blood occurs, or a greater amount of pain aud suffer-
ing is induced, from ouc or two small piles than when
there are several large ones.
When one of these tumours is situated near the
anus, tliough it may not have attained any great size, it
is very liable to be prolapsed during defecation, particu-
larly if the bowels are costive, giving rise to paui, spasm
of the sphiucter, and other distressmg symptoms. Those
that are situated higher in the bowel are not prolapsed
so early in the disease ; but, by repeated irritation and
the dragging down they experience during the time the
ffiRces are evacuated, they Ijccome elongated, and at
length protrude externally ; at first they return vrithin
the anus, by the action of the museles of the part, but
after a time the patient finds he is obhged to replace
them with his fingers ; in some cases this is done ^ith
facility, but others present where greater difficulty is
experienced, owing cither to the size of the tiunours, or
to their being constricted by the sphincter muscle ;
under these circumstances the suffering is very great,
and the individual is induced to postpone the calls of
nature, or defer them till the night, finding it easier to
return the tumours whilst he is in the horizontal position, in
which he also experiences more speedy relief from pain.
HEMORRHOIDAL AFFECTIONS.
93
III many cases, when the tumouTB are large aud nume-
rous, aiid have been subject to prolapse for a length of
tuue, the sphincter and tissues of the aims lose their tone,
are much relaxed, and the patient is subject to constant
annoyance by their protrusion whenever he attempts to
walk, and even by riding in a carriage ; nor is the pro-
lapsus in this stage confined to the tumour alone, for the
bowel, having lost its support, the pouch of the rectum
is easily dragged down by the morbid growths, and by
the expulsive efforts at stool.
As a consequence or complication, some of the fol-
lowing phenomena always attend hsemorrhoidal tumom^ ;
inflammation, pain, hemorrhage, mucous discharge,
ulceratiou, abscess, fistidte, fissure, prolapsus, and inita-
tion propagated to other organs, as the urethra, bladder,
prostate gland, and testicles in the male, and to the
vagina aud womb in the female.
Inflammation, of greater or less severity, always attends
the formation of piles ; it may not be severe at first,
nor occasion much inconvenience, bemg marked only by
itching of the anus, and a sense of fuluess and slight
aching j in other cases the inflammatory symptoms will
be much more prominent. When it has recurred several
times, and the tumours have become permanent, the
pain will be very great. Inflammation, if not checked
by treatment, or terminated by resolution or by the
supervention of the hsemoiThoidal flux, may induce
94
n.^MORRHOIDAI, AFFECTIONS.
various morbid actions in the tumours, as ulceration,
suppuration, &c. ; it is, also, liable to extend to the con-
tiguous organs in either sex.
The pain attending hEemorrhoids will vary much in
character and intensity in different cases, and \vill bear
no proportion to the size or number of tumours which
exist, being frequently most severe when only one small
haemorrhoid is present ; the complications attending this
affection will also have great influence with regard to it.
In the quiescent state of the tumours there will merely
be a sense of weight and fulness in the rectum ; if in*
flammation be present there will be throbbing, heat, and
aching, aggravated by defecation ; should the compli-
cation of fissure exist, there wiD be smarting at stool,
followed by spasm of the sphincter, and aching of an
agonizing character coutiiming from half an hour to
several hours.
In some cases the pain will extend to the urinary and
genital organs in either sex, up the sacrum to the loins,
to the hips, and down the thighs. I have seen a case
where the pain was chiefly located in the heel and under
part of the foot, and have observed the same in several
patients who had stricture of the lU'ethra ; in them it
was, at first, increased by passing the catheter, but sub-
sided as the strictiu-es yielded to treatment. Su: Benjamin
Brodie mentions an instance where paui in the foot was
the prominent feature of the bsemorrhoidal affection. He
H^MORRnOIDAL APFECTIONB. 95
says, " A lady consulted me concerning a pain to which
she had been for some time subject, beginning in the left
ankle, and extending along the instep towards the httle
toe, and also in the sole of the foot. The pain was
described as being very severe. It was unattended by
swelling or redness of the skin, hut the foot was tender.
She laboured also under internal piles, which protruded
at the water-closet, at the same time that she lost from
them sometimes a larger and sometimes a smaller quan-
tity of blood. On a more particular inquuy, I learned
she was free from pain in the foot in the morning ; that
the pain attacked her as soon as the first evacuation of
the bowels had occasioned a protrusion of the piles ; that
it was especially induced by an evacuation of hard faeces ;
and that if she passed a day mthout an evacuation at all,
the pain in the foot never troubled her. Having taken
all these facts into consideration, I prescribed for her the
daily use of a lavement of cold water ; that she should
take Ward's paste {confectio piperis coraposita) tlu^e
times daily, and some laxative electuary at bed-time.
After having persevered in this plan for the space of six
weeks, she called on me again. The piles had now
ceased to bleed, and in other respects gave her scarcely
any inconvenience. The pain in the foot had entirely
left her. She observed, that in proportion aa the symp-
toms produced by the piles had abated the pain in the
foot had abated also."
96
H.EMORRHOIDAL AFFECTIONS.
HBemorrhagc is one of tht; most frequent of the acces-
sory phenomena of internal piles, and at times the moat
prominent symptom, and, when excessive, is also the J
most alarming from the serious effects thereby occasioned;
it usually takes place during the evacuation of the con-J
tents of the bowel, occurring after the passage of t
faeces, but sometimes precedhig them. It is mostly of an
active character, but may become passive by the vessels
being debiUtated, and the blood attenuated, as a conse-
quence of the profuseness of the hfemorrhagic discliarge.
The colour of the blood evacuated is bright vermilion, ■
and is exuded by the capillary vessels of the mucous I
membrane of the tumours or excrescences constituting 1
the piles ; this will be very evident on examinatiou when \
they are prolapsed. In other cases the blood will be I
projected in fine streams, as if from minute vessels or
dilated pores ; but we are not able to detect these after
the haemorrhage ceases.
The severity of the concomitant symptoms denoting i
loaded state of the hacmorrhoidal vessels is not always an
index of the amount of hjemorrhage that may occur,
sometimes the discharge of blood being trifling though
the preceding premonitory signs have been strongly
marked ; whilst, in other cases, the loss of blood will be
very great, notwithstanding that Uttle discomfort or
inconvenience has previously been experienced.
In the commencement of the ha?morrhoidal affection
I
HjeHORRHOIDAL AFFECTIONS,
the bleeding will xisually cease after a few days, and the
several attendant symptoms then subside ; yet not unfre-
quently the bleeding will continue for a much longer
period. Some individuals experience but a single attack
during life ; while in others, the hsemorrhage may return
at uncertain intervals of weeks, months, or years ; or again,
it may assume a i)eriodic character, and return at longer
or shorter, but regular intervals. As a general rule, the
bleeding increases both in frequency and amount with
the duration of the disease. In females it is not unusual
to observe the hemorrhoidal discharge interfering with or
becoming vicarious with the catamenial functions, and in
some instances these discharges will alternate.
There can be no doubt that the quantity of blood lost
in many of the cases recorded must have been greatly exag-
gerated, and patients are always prone to imagine it
larger than it really is from the alarm created by the
sight of blood, by the show it makes on their hnen and
clothes, as well as from the liability of its admixture
with other fluids imposmg on their inexperience.
Mr. Du Pasquier informed me a patient of his lost
one night, while in bed, eight or nine pounds of blood.
Mr. Calvert* adduces the two following cases, which
came under his own observation. " A middle-aged
woman, a patient of the Manchester Infirmary, in whom
* ' A Praotical Treatiee on Diseases of tlie Rectum aud Anu^,'
by G. Calvert, pp. lG-17, London, 1824.
98
n^MOBRHOIDAI, AFFECTIONS.
the haemorrlioidal discharge had been long suppressed, I
was seized with coUc pains, with a sensation of weight |
about the loins and sacrum; an enema was exhibitedj I
which brought away some liquid feces, and soon after a I
discharge of bloody fluids, aiuountuig to more than three I
chamber-pots full in less than two hours. She was I
dreadfully reduced in consequence, but the paius sub- I
sided, and after some time she regained her former 1
strength." " A young woman, an out-district patient of I
the same hospital, was affected with pain in the head and j
loins, symptoms of general fever, with tenesmus and I
sympathetic irritation of the bladder. In this state she |
continued for some days, when the haemorrlioidal dis- I
charge to which she had been subject returned, and more 1
than a pint of blood was voided for near a fortnight. I
The pains in the head and loins, with the other symp- I
toms, disappeared with the recurrence of the discharge, I
and were succeeded by a small feeble pulse, cedema of j
the face and extremities, oppression at the region of j
the stomach, and great prostration of strength. The I
discharge was eventually stopped by the vigorous use I
of spirituous and astringent injections, with such other '
means as are generally employed when affections of this
nature are continued from debility."
The following are some of the cases quotedby Montegre,*
• Op. cit., pp. 27— 3(
J
HiEMOERHOIDAL AFFECTIONS.
09
to which, however, credence cannot be given without
hesitation. " Montanus,* according to the report of
Sehwevcher, saw a patient who had passed two pounds of
blood for forty-five successive days, and fiaaUy rtx;overed.
Coniariusf mentions the case of a gentleman, who, after
drinking freely of Hungarian wine, lost two pounds of
blood from the nose, and six pounds on each of the four
following days from the anus. Nevertheless he got well
without any remedy, PommeJ gives the case of a man,
thirty-six years of age, of an atrabilious temperament, who
for a long time had been subject to an excessive liBemor-
rhoidal flux, for which he tried many remedies without
obtaining reUef. At length, having adopted the idea
that it had a venereal origin, be underwent an antisyphi-
Utic course of treatment, in consequence of which the flux
disappeared. However, he was soon attacked with dis-
tressing symptoms of cholera, when the haemorrhage re-
appeared. During a month he tost nearly a pound of
blood daily, which was followed by cohc, pains of the
face and extremities. By a generous diet, nutrient in-
jections, and cold baths, the heemorrhage was arrested,
and exercise on horseback rendered him convalescent.
Lanzoni§ cites the case of a priest who daily passed a
• ' Apend. ConBilior Montani,' p. 59, Basil, 1
t 'Observ. Med.; 26.
I ' TTtdtie des Maladies Vaporeuses.'
§ ' Consult. Med.,' 97 ; ' Oper.,' t, ii, p. 203.
100
H.-EMORRHOIDAL AFFECTIONS.
pint of blood jkt aniim. Ferdinand* says that a girl,
twenty years of nge, of a sanguineous temperament,
sedentary habits, and endowed with much vivacity, in
consequence of a violent chagrin, arising from jealousy,
became affected with hiEmorrhoids, and for many mouths
daily evacuated about half a pint of blood while at stool.
The menstrual discharge ceased, her face became pallid
and cedematous ; under proper treatment she perfectly
recovered."
The amount of hsemorrhage in different cases varies
much ; in some it is but trifling, perhaps not more than
a few drops, or at most a teaspoonful, whilst in others
it may be from one to several ounces, or even as much
as a pint, depending on the general condition of the
patient, and the presence or absence of irritation or
vasciUar excitement in the pelvic viscera. At first, the
discharge of blood may be salutary in effect, by relieving
the congested condition of the vessels or hver giving
rise to the local affection. Frequently the patient will
experience a relief of the feeling of weight and fulness
in the perinacum and rectum, and the other unpleasant
symptoms that existed, by the loss of a small quantity of
blood. The occurrence of the hsemorrhagic flux may
serve for a tunc to ward off fatal effects by preventing
vascular determination to organs important to life when
they are affected by disease. But when the bleeding is
• ' Hist, Med.,' 10, p. 40,
J
HEMORRHOIDAL AFFECTIONS.
101
great, or becomes habitual, the constitation suffers and
a txain of unpleasant symptoms arise ; the patient be-
comes pale, the florid colour of the lips in health fades,
the gums and tongue are blanched, the compleition is
sallow and dingy, and has a peculiar waxy appearance ;
deficiency of physical and mental energy supervenes, he
is listless, his sleep is disturbed, the temper becomes
irritable and peevish, frequent headache occurs, which is
increased by the upright position, and relieved by the
horizontal posture ; the heart's action is easily excited, and
the organ will palpitate violently on slight bodily exertion or
mental agitation ; there is difficulty of breathing, parti-
cularly in going up stairs, or ascending an incline, and,
finally, as a consequence of the ansemic conthtion of the
patient thus induced, cedematous sweUing of the feet
and legs occur.
Mucous discharge from the anus is a very frequent
and annoying accompaniment of ha;morrhoidal affec-
tions. It varies much both as to quantity and appear-
ance ; in a female patient I attended at the commencement
of 1853, it was most profuse, it ran down her legs
while walking, and constituted the chief source of an-
noyance to her. When active irritation of the mucous
membrane exists, the discharge is watery, resembling a
thin solution of gum, and frequently acrid, producing
excoriation of the surrounding parts. When the secre-
tion is the effect of clironic irritation, it is gelatinous in
IQi
HEMORRHOIDAL AFFECTIONS.
appearance, and resembles frogs' spawn, or the white c
an unboiled egg. If the secretion is watery it exudes
fironi the anus, and soils the patient's linen, and render* 1
him otherwise uncomfortable ; when tenacious and mo- I
derate in quantity, it is discharged at stool only, but ifl
profuse, any exertion, such as ruuniug, walking, riding,
either on horseback or in a carriage, and even laughinyi
and sneezing, will cause its ejection.
Ulceration of the surface of the mucous membrane of I
piles, is the result of severe inflammatory action, or isJ
produced by friction and iiTitation of the patient's clothea^a
when the tumours are subject to prolapsus; if arisiuf
from the former cause, it attacks the foUiclcs, and pen6*l
trates deeply ; wliilst from the latter, the ulcerated sur-l
face will be more extensive but superficial. Extemall
piles are more often affected by ulceration than intemall
ones, especially when they have become permanent and!
indurated, in consequence of repeated inflammatoiyi'l
attacks. We not imfrequently meet with small ab.
scesses and sinuses in this last class of tumours. Oofl
casionally abscess wUl occur in the ceUiilar tissue of thsa
rectum, by its implication in the inflammatory action, orl
by perforation of the mucous tissue by ulceration, and I
thus lead to the formation of fistula in ano. Should!
abscess form in the male auferior to the anus, and preaBl
upon the urethra or neck of the bladder, retention of
urine may be superadded to the patient's other syrap-
H.KMORIIHOIDAL AFFECTIONS.
103
toms. In females, the abscess will extend to one of the
labia, or open into the vagina, forming recto-vaginal
fistula, or, by bursting externally by the side of the
bowel, establish fistula in auo.
Fissures of the anus, as a complication more fre-
queatly takes place when the piles are external, and
have existed for some time, and the tissues, by chronic
inflammation, are indurated ajid rendered less yielding
to distension. They commence as slight cracks or tears,
resnlting from the passage of bulky and hardened faeces,
and increase by the ulcerative process, from the constant
irritation they are afterwards subject to by the action of
the bowels and the lodgment of faecal and acrid matters.
The pain accruing from this compUcation is verj' dis-
tressing ; it is induced each time the bowels act, and
will continue for several hours afterwards attended with
spasmodic contraction of the sphincter ani.
The sufferings and inconvenience to a patient affected
with mternal piles, is often greatly increased by their
protruding external to the anus. When the tumours
are situated immediately withm the rectum, they are
subject to prolapsus ui an earlier stage of the disease,
owing to the eversion of the lower part of the mucous
membrane, which occiu^ at the time of emptying the
bowels, and to the faeces thrusting the tumoiu^ before
them ; when situated higher up in the intestine, they do
not descend at so early a period, but, by the pressure
104
HEMORRHOIDAL AFFECTIONS,
and elongation they arc subject to from the passage c
the feces, they at length protrade externally. At I
the piles are retracted within the anus by muscul
action alone after the bowels have been relieved, but, i
proccsg of time, this no longer occurs, and it becomet
necessary to rctm-n them. Another source of distre
from the prolapsus of piles, is their hability to strangi
lation, either by the spasmodic contraction of
sphincter, or by sanguineous engorgement ; under th«
circumstances the assistance of a surgeon will be i
quired to effect the replacement of the extruded parts |
if the patient delays seeking the necessary aid, mort
cation takes place, endangering his life should the constiJ
tution be impaired by any cause, or tlie vital powers 1
naturally feeble ; if the contrary condition exists,
the general health be good, the tmuours will slough o^
and a cure will thus be eflfected, but at the expense t
much suffering.
The converse condition of the anus to the precedi
will cause serious distress to some, as a consequence c
the sphincter having lost its tone, and becoming greatJ
dilated by the frequent protrusion of the piles, by thei
size, and by the long persistence of the disease, thi
patient will not only he subject to the annoyance i
prolapsus of the bowel with its attendant miseries, bul
will be unable to retain his feeces.
In addition to the complications and consecutive e
H.EMORHHOIDAI. AFFBCTI0N8.
105
which have ah^ady been considered, others will arise ;
thus, in the female, by the contiguity of parts, the
vagina and uterus are liable to be affected ; whence
arises leucorrhoeal discharge more or less profuse in
quantity, accompanied by pain and distressing bearing-
down sensations ; in the male, from the same canse, and
the free anastomosis which exists between the prostatic
plexus of vessels and those of the rectum, the prostate
gland may be affected, inflammatory action excited, in-
ducing enlargement and other evils ; the neck of the
bladder will not unfrequently be sympathetically in-
volved, and strangury or retention of urine, result. By
the long continuance of chronic inflammation from hse-
morrhoidal disease, stricture of the rectum sometimes
occurs.
Numerous causes tend to excite hiemorrhoidal dis-
ease. In some cases we shall be able to trace it to he-
reditary predisposition, age has its influence, sex, climate,
and period of the year, also have effect. Plethora, par-
ticularly when combined with sedentary occupations and
indulgence in the pleasures of the table, strongly pre-
disposes to the disease ; mechanical and pathological
obstruction to the venous circulation of the intestine, is
another cause ; irritation within the bowels as from
ascarides ; dianhcea, dysentery, irritating enemata, the
injudicious use of mercury, certain stimulating purga-
tives, highly seasoned dishes, and certain alimentary
106
H-f;MORRHOIDAL AFFECTIONS.
substances ; diseases existing in contiguous parte, i
the prostate gland, stricture of the oretlira, stone in t
bladder, &c., will give rise to hsemorrlioids, and, lastlw
may be mentioned, excessive venery and masturbation. J
It will be desirable to trace how far, and in whi
manner, the several causes that have been mentiom
operate in inducing the disease.
Hereditary predisposition sometimes promotes the (
tablishment of the disease, not so much by any l<x
tendency to the formation of piles, as by a similarity c
constitution and general organization. Thus we shi
find both parents and children to be of a bilious tempi
ment, of lax muscular fibre, the venous system of i
augmented state of development, and the nervous sea
bihty exalted, whereby the depressing passions have i
greater influence. This hereditary aptitude to hsem
rhoidal affections has been traced by many authoraa
Bushe* has observed it in several families in connexioi
with similarity of organization, and also where that i
not exist. A French authorf mentions an instance of I
family of nine people who were thus afflicted.
From several circumstances we do not often met
with hsemorrlioids till after the age of puberty ; disease
from sanguineous engorgement more frequently in early li
attacking the head and chest than the abdominal orgaiK
■ Op. cit., p. 170.
t M. J, B. Je Larrcn|ue sur ' Les Hsemorrhoides,' Puns, 1819.
H^MOKRHOIDAL APFKCTIONS. 107
however, some months since I had a child of two years
of age under my care at the Blenheim Dispensary, suf-
fering from external piles. One author mentions two
cases occurring in his practice, in which one patient was
between six and seven years of age, and the other five,
the latter also had stone in the bladder. Other prac-
titioners have met with the disease at an early period,
but this is very far from being commonly the case. In
the middle period of life we find all diseases of the
abdominal organs more frequent, owing to the peculiar
susceptibility then existing to vascular repletion and
engorgement of this region ; the circulation is less rapid
in the adult, and that portion of the vascular system
retm-ning the blood to the heart is more fully developed
in mature life. It is aft^r the age of puberty that the
various affairs and occupations of hfe engage the atten-
tion J then the habits become sedentary ; depressing
passions and the infiuence of temperament appertain also
to the middle period of existence. Females who have
enjoyed immunity from hsemorrhoidal affections during
that portion of their lives when the menstrual functions
were regularly performed, not unfrequently become the
subjects of them at the chmacteric period, especially
those who are plethoric, and, in such cases, the ha^mor-
rhoidal flux may be regarded as salutary, by diverting those
congestive affections from the sevei-al important organs,
that so often succeed the cessation of the catamenia.
108
II.'EMORIIHOIDAL AFFECTIONS.
Great diversity of opinion prevails as to the ]
frequency of hsinon-hoidal affections in males and
females. Much will dcpeud on the cireiimstances in
which both are placed. Montegre thinks them more
common in females in an occasional or accidental form ;
and to occur in males in a more regular and constitu-
tional form. The experience of Mr. Syme and Dr.
Bushe tends to confirm their greater frequency among
men ; the latter writer supposes the menstrual function
should sufficiently relieve the system of sanguineous
repletion ; certainly, iii the majority of cases of haemor-
rhoids occurring in females that have come under my
observation, the catamenia have either been suppressed,
or the function more or less deranged, but in some
cases this will be rather an efiect than a cause. Females
who are plethoric aro very liable to be the subjects of
hsBmorrhoids at the turn of life, when the menstrud
flow ceases ; and, in some instances, these discharges
alternate with each other for some time before the
uterine functions entirely subside.
Warm, moist, and miasmatous climates dispose to
haemorrhoidal affections, by inducing general relaxation,
and of the venous system in particular ; they also favour
congestion of the abdominal viscera, and develope the
bilious, sanguineo-bilious, and melanchoUc temperaments.
Those who have resided for some time in the East or
West Indies are very prone to suffer from haemorrhoids.
HXH0RRH01DA.I. AFFECTIONS.
109
In the southern states of America, in South America,
in Egypt and Turkey these affections are very common.
In the two latter countries the morals and manners of
life of the people exert a great influence in producing
these diseases. In dry climates, whether cold or tem-
perate, these aS'ections are less frequent, as is also the
case with regard to many other diseases. In our
climate the variableness of the temperature often pro-
duces congestion of the internal organs, giving rise to
various inflammatory and morbid actions ; these are
more liable to occur if the functions of the skin have
been excited from any cause, and then checked by its
being suddenly cooled down by a rapid fall in the
atmospheric temperatiu-e.
The periods of the year in which the vicissitudes
of t«mperatiui3 are greatest predispose more to the
development of these aflections than when the weather
is either warm or cold, but equable. Some writers
think these diseases occur more frequently in spring,
from the phenomena of life being more active at that
season, the blood being more readily formed, and in
greater quantity, also that the increased temperature
expands the volume of the circulating fluid. It is also
asserted, that northerly and north-easterly winds bring
on the hscmoiThoidal discharge, but I presume they
hai*e no specific influence further than by checking the cuta-
neous exhalatiou,andthuB determining the blood internally.
110
HEMORRHOIDAL AFFECTI0S8.
Plethoric individuals are more liable than others to be
affected with hiemorrhoids. In them the state of reple-
tion of the vascular systi'iu is often induced by partaking
of a larger amount of almieut than nature requires, com-
bined with a deficiency of exercise, which also excites
several of the other causes co-operating in producing dis-
ease of the rectum.
Any impediment offered to the return of the blood
from the lower bowel will cause hBemorrhoids. It will
arise from two causes, the one being mechanical in its
immediate effect, the other pathological, and depending
on disease and alteration of structure ui acme of the
internal organs. Those causes which act mechanically
are the pregnant uterus, ovarian and other tumours de-
veloped in the pelvis or abdomen, which, by pressure
on the large venous trunks, impede the ascent
of the blood ; tight lacing and cinctures also have the
same effect. The pathological causes are congestion and
structural diseases of the liver, pancreas, and spleen ;
diseases of the lungs, heart, and large blood-vessels,
interfering with the free circulation of the blood.
Hiemorrhoids are frequently a concomitant of preg-
nancy, and in this state are of the accidental or occa-
sional form, being induced by the gravid uterus pressing
on the venous trunks, and by the general plethora which
exists diuing this period. •
Constipation is one of the most frequent and common
A
HEMORRHOIDAL AFFECTIO.NS. Ill
causes of lisemorrlioidB which we meet with ; it tends to
induce the disease id several ways ; thus, when the feces
are retained, they become iudiu'atcd and impacted, and
produce irritation of the mucous membrane, and con-
sequent afflux of blood to the rectum ; by accumulation
they distend the intestine, and, pressing on the veins,
interfere more or leas with the return of the blood. In
this habit of body the bEcmorrhoidal vessels become
greatly engorged during the act of defecation from the
violent efforts of the expulsatory muscles, and the con-
gestion, arising durbig the temporary suspended respira-
tion, that always attends violent muscular action.
Those persons whose habits of life are sedentary are
very generally the subjects of piles, more especially if
they indulge freely at table. By inactivity of body, the
functions of the several eraunctory organs are diminished,
and, not the least important, that of the skin, which,
when properly performed, frees the system of the pro-
ducts of the effete tissues, which, if retained, have a
most pernicious effect on the animal economy generally.
From deficiency of exercise the function of the liver is
lessened, and congestion is very Uable to occur. Con-
stipation, and its effects, as a result of this mode of
life, is nearly always present. The sitting position main-
tained by persons of the habits under consideration de-
termines the blood to the hsemorrhoidal vessels. From
these cii-cumatances, it is very common to meet with
U2
Hi^MORRHOIDAL AFFECTIONS.
hEemorrhoidal diseases among clergymen, barristers,
lawyers, those confined to the counting-house, and among
the working-classes, the natiu^ of whose occupations
compels them to sit many hoiu^, as dressmakers, tailors,
shoemakers, and others. It is very common for indi-
viduals thus circumstanced to have the haemorrhoidal
discharge occurring in a regular manner, and, when mo-
derate in quantity, having rather a beneficial effect than
otherwise, and possibly saving them from some more
serious maladj'.
Sometimes the haemorrhoidal flux will appear as a
translation of hasmorrhagic discharge from some other
oi^an ; thus arresting and keeping in abeyance morbid
action that has given rise to haemoptysis, haematemesis,
epistaxis, &c. Bushe mentions having observed several
instances in which this occmred, and i-ecords t\vo cases :
the one of a gentleman from Ireland, who had hiemop-
tysis, which ceased on his being attacked vrith hasmorr-
hoids, and he enjoyed good health ; resorting to Paris,
and being annoyed by the piles, he had them i-emoved
by Baron Dupuytren ; after that he rctimied to America,
and laboured under a determination of blood to the
head, of this he was relieved by leeches to the anus and
by the administration of aloes and blue pill. The other
case is that of a gentleman subject to epistaxis, and who
suffered from a aeries of cerebral symptoms, consequent
on its suppression. Dr. Bushe being consulted, pre-
J
llyEMORRHOIOAL AFFECTIONS,
113
scribed stimulatiag pediluvia and brisk purgatives. On
tlie patient feeling a desire to defecate, he discharged
about a pint of blood per anum, to the immediate relief
of the head symptoms ; a regular haemorrhoidal flux
coiitinmng, he had no return of the epistaxis, or any
of the unpleasant circumstances attending its suppres-
Mental emotions and passions, both exciting and
depressing, are causes of hEemorrhoids ; thus anger,
fear, sorrow, ennui, &e., excite a remarkable and vital
action of the ganglionic nerves of the abdomen, mani-
fested by a sense of sinking, weight, constriction, and
pain at the epigastrium. The result of this impression
is extended to the surface of the body ; the cutaneous
vessels contract, inducing pallor, and the blood, driven
from the surface, accumulates in the internal organs,
producing various functional disorders of the stomach,
derangement of the liver, jaundice, diarrhoea, or haemor-
rliagic discharge from the rectum.
Internal irritation from a variety of sources will
produce these affections. Ascarides, which infest the
lower portion of the ahmentary canal, are not an in-
frequent cause ; irritation arising from diarrhcEa and
dysentery will excite the hscmorrhoidal disehai-ge, and
we shall observe it not unfrequently as a crisis in other
diseases ; thus it occurs in fevers, particularly bilious
and gastric fevers ; also when inflammation has attacked
114
HEMORRHOIDAL AFFECTIONS.
the brain or aiiy of the organs lodged in the thoTadC
and abdominal cavities ; and in other conditions of the
system, as hypochondriasis, &c.
Diseases of contiguous organs, by inducing an afflux
of blood to the pelvic viscera, and by extension of in-
flammation and irritation, are common causes of haemor-
rhoids; we observe tlieni accompanying disease of the
prostate gland ; occmring as a consequence of stone in
the bladder ; the effect of stricture of the urethra con-
sequent on the vascular turgescence and violent straining
in micturition, attendant on the aggravated forms of the
latter affection.
Excessive venery and masturbation, by producing
relaxation of the system, and by determining the blood
to the organs in the pelvis, produce ha?morrhoidal
disease.
Certain purgatives and drastic medicines, as aloes,
scammony, gamboge, black hellebore, rhubarb, the
neutral salts, &c., particularly if prescribed in too fre-
quent and too large doses, induce hfemorrlioids ; they
act directly by irritating the mucous memijranc of the
rectum, and by inordinately exciting that portion of the
intestine, and the lower part of the colon. Of all me-
dicines calomel and the other preparations of mercury
have been productive of most mischief in the affections
we arc now considering, as well as inducing other dis-
9 of the digestive organs. It is not from the use of
■
II EMORRIIOIDA
tlie mineral, but its general abuse, that the evil arises ;
the practice is justly reprobated by Drs. Copland,
Elliotson, and other writers on the practice of medicine.
It may, however, be questioned whether all the medicines
first mentioned, when pro])crly administered, exert much
influence in inducing the disease, and whether it is not
rather to the state of the constitution rendering these
medicines necessary, that we should ascribe the local
aSectious. They will severally readily reproduce the
hsBmorrhoidal flux when once it has taken place, but it
is not to be inferred from this, that they will cause the
disease, as morbid action having once occurred in a part
is much more easily re-established even by slighter
causes ; therefore, before attributing the malady tn
medicines, it is essential to ascertain if there may not
be other causes to which it may owe its origin.
As well as to living above par, conjoined with a defi-
ciency of exercise, we shall be able to trace the diseastr
in some people to eating various alimentarj' substances,
particularly highly seasoned dishes, spices, onions,
shallots, &c. ; to partaking of very hot or cold beverages,
or too great a quantity of stinudating drinks : certain
wines, such as claret, champagne, also cyder and beer,
will, in some individuals, readily induce the affection.
The local application of cold or heat, as sitting on stone
seats, on the cold and damp ground, on damp cushions,
the habit of standing with the l)ack to the fire, riding
116
HiEMORRIlOIDAL AFFECTIOKS.
rough horses, prolonged walks in hot weather, travelliDg
a number of consecutive hours in a carriage, sitting on
pierced seats whereby the blood gravitates to the anus,
consequent upon its being unsupported, and on the ob-
struction to the circulation from the pressure on the sur-
roiuiding parts ; stimulating pediluvia, irritating and
large enemata, are other causes of hBemorrhoidal affec-
tions.
The sjinptoms attending hsemorrhoidal diseases vary
much and are greatly influenced by the state of the
general health of the patient, the exciting cause whether
accidental or constitutional, and the complications with
which they are associated, and also by the piles being
internal or external.
In the first attack, the patient will probably experi-
ence but slight inconvenience. If the disease is only of
the congestive form there will be itching and a sense of
weight and fulness in the rectum, with uneasiness in the
perinEEum ; in a few days bleeding may occur, but does
not always take place in the early attacks, and when it
does it is usually critical, all the symptoms and dis-
comfort disappearing for the time. If the disease does
not thus subside, but is permitted to increase, or when
several attacks have been experienced, the symptoms
will be augmented in number and severity, and, in
addition to the weight and fulness at first felt, there will
be heat and throbbing, the pain at stool will be greater
I
H-CMORRnOIDAL AFFECTIONS. 117
and will continue for some time afterwards ; pain will
also be felt up the sacrum, in the loins, and down the
thighs ; after a short time a flow of bright blood will be
observed either preceding or after defecation ; usually
increasing in quantity with the duration of the disease,
and often becoming the moat prominent symptom, and
causing great derangement of the general health. As
the disease progresses a feeling of the presence of a
foreign body in the rectum will be experienced, and at
stool one or more tumours will be protruded ; at first
they are retracted spontaneously after the action of the
bowels, but, in process of time, from increase in size and
loss of tone in the parts, it becomes necessary for the
patient to replace them with his hand. Should the piles
become constricted by the sphincter many of the symp-
toms of intussusception or strangulated hernia may be
induced. lu weak and debilitated persons the sphincter
loses its tone, the anal orifice becomes dilated, and the
hiemorriioidal tumours will then descend upon the
slightest exertion, or even when he is in the erect posi-
tion, causing great annoyance and discomfort; in this
condition they will be liable to idceration from the
friction to which they are exposed by contact of the
clothes. A mucous discharge soiling the linen is a fre-
quent symptom ; it is some times so profuse as to run
down the patient's legs whilst standing ; it may also be
very acrid and produce excoriation of the external parts,
adding greatly to his other sufferings.
118
HjeMOKftllOIDAL AFFECTIONS.
By sympfltliy and contiguity, the initability and sensi-
bility of the bladder and urethra will be increJised,
micturition will be more frequent, and, in the aggravated
form, we ahall observe the opposite effect, strangury, or
even retention of urine.
All patients who are the subjects of ha^nioi'rhoids
suffer more or less from constipation, with its concomi-
tant symptoms, flatulence, pain, and constriction at the
epigastrium, vomiting, &c. Where the disease is fully
established, particularly if much blood has been lost,
there will be pidlor, and a jwculiar dingy waxy appear-
ance of the countenance, the respu-ation will be hurried
and irregular, the heart's action readily increased by the
slightest bodily exertion or mental emotion ; this is often
no distressing as to lead the patient to think he has dis-
ease of that oi^an, for which he may seek advice, and,
hy dwelling too exclusively on this one effect, may mis-
lead his medical attendant from the real disease.
Giddiness, drowsmess, weiglit and pain in the liead,
are very common symptouis in these affections, and occa-
sionally, spasm and rigidity of the extremities will be
complained of. The attacks are not unfrequently
ushered in by rigors ; the tongue will be furred, large,
and deeply notched by the impressions of the teeth ;
the skin will he harsh and dry ; the functions of the
kidneys deranged ; the pulse, increased in velocity, will
be hard, and contracted, or rendered weak, irri-
I
H.«MORRHOIDAL AFFECTIONS. 119
table, and quick, from debility, suffering, and loss of
blood.
Hsemorrhoidal affectioiia are liable to be overlooked
from two causes, the one being a delicacy on the part
of the patients, leading them to conceal the origin of
their sufferings, the other the severity of some of the
symptoms, or derangement of other organs consequent
upon tliem, diverting the attention away from the real
seat of disease ; however, a careful investigation into the
origin and history of the case will not fail to elucidate
its true natm^,
The diagnosis of haemorrhoids will not be attended
with much difficulty, there being few diseases with which
it is possible to confound them, and the error can occur
liy taking only into consideration some one or other of
the prominent features of the affection.
Hemorrhoidal tumom-s may be mistaken for polypi
of the rectum, but the converse is more usually the case,
particularly by patients themselves. Polj-pi are more
gradual in their growth, they arc not preceded or accom-
panied by the constitutional or local inflammatoiy symp-
toms that attend piles ; in the benign variety of polypi
hEemonliagc does not occur, except to a very slight
extent, and that only on tbe passage of a bulky and
costive stool ; their surface is smooth and somewhat
glistening, and not villous or granular, hke biemorrhoidal
excrescences.
HiMoaHHOlDAL AFFKCTIONS.
A very cursory examination will enable us to dis-
tinguish hsemorrhoidal tumours firom prolapsus of the
rectmn ; in fact, the only form with which they can be
confounded is, when a fold of mucous membrane on
either side descends, and, in the course of time, becomes
thickened and rugous ; in this state, however, there is an
absence of the ordinary symptoms of piles ; the pro-
lapsed portion of the intestine is free from hsemorrhagic
discharge, is not subject to alternations of turgesccnce,
and flaccidity ; and, besides the extent of the base of
attachment, we can roll the two sm-faces of the mem-
brane upon each other.
External haemorrhoids, when their surfaces are ulce-
rated, may be mistaken for venereal excrescences, but
by tracing the origin of the tumours, by the subse-
quent history of the case, and the absence of other symp-
toms of the latter affection, a correct diagnosis may be
formed.
The most important distinction we have to consider,
both in the prognosis, and with regard to treatment,
is the source of haemorrhage, wliich may be intesti-
nal, and not the result of piles. But here a little con-
sideration will prevent error : intestinal haemorrliage
is generally a result of acute and dangerous visceral
disease, and the constitutional disturbance attending it
will be severe, and of marked character; it moTO
frequently accompanies the advanced stages of nialig-
d
HJIMORRHOIDAL AFFECTIONS. 121
nant fevers and general cachexia. The state of the
blood discharged will enable us to form a tolerably
correct opinion whether it be from piles or not; when
it occurs from any portion of the intestinal canal above
that which is the seat of hemorrhoids it will be clotted,
very dark, and mixed with the fseces and excretions, and
will be passed at stool without any of the distress at-
tending piles ; nor shall we be able to detect by digital
examination per anum any form of tiunours or varicose
state of vessels. But, on the contrary, if the htemorrhage
be from piles, the blood will either precede or follow
defecation, will he florid in colour, and fluid, with all the
characters of being recently extravasated. There will
also be the local symptoms attending these affections,
as weight and fulness in the rectiuu, pain, and othera
which have been previously mentioned ; these will be
aggravated at stool ; besides, examination will reveal
the presence of one or more tiunours, or other lesions.
Before commencing the treatment it is most important
that a careful and minute exammation of the rectum and
anus should be made when a patient complains of any
of the symptoms of haemorrhoidal disease ; firstly, that
we may arrive at a correct knowledge of the peculiar
kind of tumour, and the condition of the parts, also as
to the existence or not of any comphcatiou ; and, se-
condly, because the accounts given by patients them-
selves are frequently inaccurate, and they are too apt to
1-22
H.EMOBBHOIIUL APFF.CTIONS.
dwell on any one or more of the symptoms that may be
most distressing to them.
In making an examination in the male, the patient
should be directed either to lean over the back of a chair,
or to lie upon a sofa on his side with the nates projecting
over the edge, and tbe knees drawn up ; the latter position
is preferable, and should always be adopted with female
patients. The parts, when inflamed being acutely pain-
ful, all possible gentleness must be observed, particularly
if fissure of the anus exist as a complication, as slight
irritation nill often induce excruciating agony. Previous
to making a digital examination of the interior of the
bowel, the cavity of the nail should be filied with soap,
which will prevent its scrat-ching the intestine, and the
finger must be dipped in oil to facilitate its introduction ;
lard and unguents do not answer so well, as they inter-
fere slightly with the delicacy of the sense of the touch.
Having become acquainted with the abnormal con-
dition of the parts, the next consideration is, whether the
liEemorrhoidal affections are of a constitutional or acci-
dental origin ; it is on arriving at a just conclusion on
this point "that the principles of treatment must be based,
and on it our success must depend. When pdes have
existed for a long period, have continued from youth, or
the conmiencement of pidierty, when they supervene
upon or replace some serious organic or habitual af-
fection, if they are preceded by constitutional disturb-
A
QjEMORHhoidal affections.
aiice, find succeeded by au improvement in the state of
the health, if well-marked indications of plethora exist,
which is relieved by the accession of the hsemotThoidal
flux, aud if indications of congestion, or disease in any
of tlie organs accompany or follow its suppression or in-
ttirruptiuu, or an hereditary predisposition exists, a con-
stitutional nature may be inferred, and local treatment
must be a sccondar)" consideration, and not adopted till
the constitutional cause has been removed or palliated ;
this is especially necessary if there is a predisposition,
hereditary or otherwise, to apoplexy, gout, phthisis, hae-
moptysis, epistaxis, or other kinds of hemorrhage.
Various authors mention instances in which a neglect
of the consideration of the constitutional origin, and the
adoption of a local treatment of piles, has been followed
by serious or fatal consenuenecs. Dr. Copland mentions
three cases having come under his observation, in one of
which fever was induced, in another apoplexy, and in a
third melanchoha, by the improper arrest of luemor-
rhoidal discharge. Mr. Howship states the case of a
gentleman subject to gout, who, m opposition to proper
medical advice, was induced by a charlatan to have
iccom'se to a strong vitriolic lotion with the effect of
arresting the haemorrhagic discharge, but the patient
soon after died of gout in the stomach.
The general treatment of liEcmorrhoidal affections must
consist in enforcing a strict observance of moderation in
124 H.EMOHRHOIDAL AFFECTIONa,
diet, due attention being paid both to the quality and
nature of the aliment, as weU as quantity ; all stimu.J
lating food and beverages must be forbidden, and only
that allowed which is uuirritating and easy of digestion p
this is a matter so important, not only in the diseaf
herein treated of, but in all others, that it would be \
to give a patient written instructions on this jioint in thai
same manner as when medicines are directed to be taken.;a
The bowels must be regulated, aud constipation coniJ
bated, by deobstruent laxatives and stomachic aperients
If fiscal accumulations in the colon exist, these must I
removed by emollient enemata ; iu many cases the use c
O'Beime's tube will be highly serviceable in dislodginj
the excrementitious matter. When the secretions and']
excretions of the chylopoetic viscera are depraved
deficient, means must be adopted to restore them to i
healthy state ; for this purpose a few grains of the bloo]
pill with one of powdered ipecacuanha should be directc
to be taken at bed-tune, or mercury with chalk andfl
extract of taraxacmu may be substituted; and in thi
morning one of the following draughts should
taken : —
]jt Infijsi Senna) comp., 5VJ ; Infusi Gentian» comp., 57 ; Tinp*]
tuTEB Cardamomi comp., ^. Fiat haustua.
Pi Decocti Cmclionse, Infusi Sennie comp., aa ^vj. Fiat baustuflJ
If these are not sufficiently active, sulphate of magj
H.CM0RR1I0IDAL AFFECTIONS. 125
iicsia, potassio-tartrate of soda or sulphate of potash may
be added; castor oil is a most useful laxative in these
diseases ; a tcaspoonful of the following electuary, taken
either at bed-time or early in the morning, answers very
well in movmg the bowels once or twice.
9' Confectionis SenntP, Sulphuria Loti, aa jj ; Pulveriii Jalapcc,
^ ; Pulveris Zmgiberis, ^ss ; Sodie PotaBsio-tartratiB, Jiv ;
Syrupi Zingiberis, q. 3. : ut fiat eleutuarium.
The addition of two or three drachms of copaiba to
the above will be very beneficial in many cases, but it
renders the electuary so nauseous that some patients
cannot take it; if, however, it is made into boluses and
wrapped in wafer-paper, it may be swallowed without
being tasted. The functions of the skin and kidneys
must receive most earnest attention, various diuretic and
diaphoretic medicines must be prescribed, as the citrate
of potash and nitrate of potash in camphor mixture ; a
solution of the acetate or citrate of ammonia, camphor
mixture, sweet spirits of nitre, and the inspissated juice
of the elder ; other formidEO will readily suggest them-
selves to the practitioner.
The importance of regular and moderate exercise
must be enforced on the attention of the patient ; by it
the whole of the vital functions are stimulated to a
heahhy action ; thus the circulation is increased, parti-
cularlv in the extremities, nutrition is more rapid, and
126
H.BMOKRllOIDAl
the depurating and excretory organs arc excited Ib
elimiuating matters that have served their purpose hi the
economy, which, if retained, are productive of much of
the apparent derangement of the system.
The vicissitudes of temperature must be guarded
against by proper clothing, and benefit will follow tho
occasional use of the warm-bath, particularly whou the
action of the liver or skin is torpid. Both in external
and internal haemorrhoids ablution with soap and water
night and morning will be attended with great benefit
and comfort. It is not merely by washing away irri-
tating secretions and cxcrementitious matter that this
results, but by a direct and specific efiect of the soap
on the parts themselves. In internal lisemorrhoids, or in
congestion of the vessels of the rectiun, tlie injection of
half a pint of cold water after each dejection will be of
essential service ; the advantage resiUting therefrom
arises from a twofold efiect, the one by removing any
feculent and irritating matter, the other by the imme-
diate impression of the cold upon the nerves and vessels
of the intestine.
The several complications and phenomena attending
hjemorrhoids require special consideration with regard
to treatment, bearing in mind, at the same time, the
cause and origin of the disease. When symptoms de-
noting congestion and repletion of the ha^morrhoidal
vessels are present, the bowels must be moved by castor
A
H.EMORRHOIDAL AFFECTIONS. 12?
oil, or the electuary before mentioned, or some other gentle
purgiitive. It may be necessary to have recourse to the
local abstraction of blood ; cupping over the sacrum or
on the perineum is preferable to the application of leeches
around the anus ; it occupies less time, is less annoying
to tlic patient, and docs not produce the local determina-
tion of blood that leeches do. When the patient has
previously suffered from hemorrhage, leeches applied to
the anal region \vill frequently reproduce it, or it may
appear for the first time by the determination of blood
induced by their application. After the bowels have
been moved and blood abstracted, the warm hip-bath
will afford ease, or flannels ivrung out of hot water ap-
pUed to the perineum and sacrum may be substituted.
Whou the tumours are iuflamed, local depiction will
generally be necessary ; for the reason just urged, cup-
ping will be more advisable than the application of
leeches. If the piles are internal, and are prolapsed,
they must be returned within the sphincter by gentle
pressure, made by a fold of lint smeared with olive oil
or spermaceti ointment ; this must not be neglected, or,
from vascular engorgement or constriction by the sur-
rounding muscular fibres, mortification will probably
residt, occasioning severe constitutional disturbance and
much suffering. Several instances of the disease being
thus removed have come under my observation. In
this manner the celebrated Home Tooke vras cured of
k
H^MORHHOIDAL AFFECTIONS.
a disease he had loDg suffered from. Sir fienjaujin
Brodie,* in liis lectures, narrates the circumstance : —
" Many years ago I was dining Avith Dr. Pearson, and
after dinner he gave an account of Home Tooke's illness.
He said that he had long laboured mider piles ; that at
last mortification had taken place ; that there was no
chance of his recovery ; and he added, that he had that
morning seen him for the 'last time. I remember that
in the middle of this history there came a knock at the
door, on which Dr. Pearson said, ' Here is a messenger
■with an account of my poor friend's death.' However
it was some other message ; but by-and-bye a messenger
did arrive, saying that Home Tooke was much the same
or a little better. It turned out, as I have been in-
formed, tliat the piles sloughed off, and from this time
he never had any bad symptom. In fact, he was, if I
have been rightly informed, cured of a disease which
had been the miseiy of his life for many years preceding,
and he Uved for some years after^vards."
After the tumours have been replaced, hot poppy-
head fomentations should be applied, to be succeeded by
hot Unseed-meal poultices. Some sui-geons have advised
punctures and scarifications of the inSamed and pro-
truded piles ; it is a practice that should not be adopted,
hemg founded on erroneous principles, and will only
cause the patient much annoyance vrithout affording the
• ' Meilical Gazette,' vol. iv, p. 74C.
J
n*;MORRHOIDAT. AFFECTIONS. 129
desired relief. Mr. Calvert says he saw a case of fatal
liBeniorrhage foUow the practice. Montegre and Buahe
alike condemn the proceeding. After the inflammation
lias somewhat abated, cooluig and anodyne lotions will
aSbrd great relief ; an aqueous solution of opium with
acetate of lead and elder-flower water or rose water will
answer the purpose. Enemata of cold water are bene-
ficial in the latter stage of inflammation ; the instrument
used should be provided with an elastic gimi jet, as one
of ivory or metal will be likely to injure the tender parts.
The bowels must be kept gently open by means of an
aperient electiiary, castor oil, or other laxative.
If the tumours have fallen into a state of mortification
from excess of inflammatory action, or from constriction
by the sphincter muscle, meal poultices must be applied
till they have sloughed off aud the parts have become
clean, afterwards the mjection of slightly astringent
lotions will promote the heaUng of the ulcers left by the
separation of the sloughs. If the system is much
depressed, stimidants, and bark with the mineral acids,
will be necessary, but the general treatment must be
regulated according to the character and severity of the
constitutional distiu-bance.
As previously stated, the pain accompanying these
affections varies much in character and intensity, and is
often greatest when there is little apparent change of
structure in the part ; it is generally aggravated by the
9
180 H^MOKRIIOIDAL AFFECTIONS.
several complications met with, being most severe wlien
fissure of the anus and spHsm of tlie sphincter are pre-
sent. If pain is the result of the acute stage of the
attack, the treatment advised in the congestive and
inflammatory conditions will relieve it ; but it is some-
timea intense when only slight stmctural alteration of
the tissues exists unatteuded with active inflammation ;
under these circumstances, the bowels being first regu-
lated, and any depraved condition of the escretions
corrected, anodyne and opiate enemata must be usedi
or a bougie introduced a short distance up the rec-
tum, previously smeared with one of the following
unguents : —
^ Opii PulveriB, gr. x; Un^enti Ceta«ei, ^. Misce.
EL Extracti Hyoacyarai, vel Eitracti Coaii, Jj i Ungneati
Cetacei, Svij. Misce.
(it Hydrargyri c. CretA, Eitmcti Hjoscyami, aa ^ ; Unguenti
Cetacei, ^. Misce.
When there is fissure of the onus, the last ointment,
applied on strips of lint, will reUeve the pain, and often
induce the healing process ; but if spasmodic contraction
of the sphincter coexist, the extract of belladonna must
be substituted for the hyoscyamus.
So long as haemorrhage appears beneficial in reheving
any organ threatened with disease, it must not be
arrested, but any error in the constitution or habits
of the patient that tends to maintain or increase
]its I
J
ILEMORRHOIDAL AFFECTIONS.
131
should be corrected. When the losa of blood is frequent
or large in quantity, and the patient thereby rendered
weak and pale, and the irritability of the system in-
creased, measures must be taken to moderate the flow,
or to stop it entirely. In the first place, the bowels
must be regulated so as to act gently every day ; for
this purpose the lenitive electuary with sulphur ; or
sulphate of magnesia, and dilute sulphuric acid in a
bitter infusion, or in the infusion of roses, may be taken
tarly in the morning, and a teaspoonful of the confection
of black pepper or Ward's paste, should be taken two
or three times a day. The injection into the rectimi,
morning and evening, of four or six ounces of cold
water, will be highly beneficial from its sedative and
astringent effects. If the patient leads a sedentary life,
he must take exercise daily in the open air, by which
the secretions will be increased, and the circulation
equalized. The food must be moderate in quantity
iinatinuilating in qutdity, and taken at regular and
stated intervals.
Should feebleness and exhaustion be produced by the
constant recurrence, or by the sudden profuseness of the
liEemorrhage, active measiures must be taken to arrest it,
and afterwards means adopted to restore the powers of
the patient. The recumbent position is directed to be
observed, and, if necessary, the pelvis must be elevated ;
then, according to the lu^ncy of the case, we must
132
h*;mokrhoidal affections.
avail ourselves of the several remedies we have at com-
mand; the injection of iced water or of metallic and
vegetable astringents, as a solution of iron, copper, lead,
or alum, or a decoction of logwood, oak-bark, pomegra-
nate, bistort, or tonnentil. I find a solution of tannic
acid, in proportion of a acniplc to a drachm in six ounces
of water, better than any other local astringent. Ice
finely powdered and put into a bladder, may be applied
to the sacral and anal regions. The dilute sulplmric
acid in infusion of roses, or acetate of lead with opium,
and the balsams and terebinthinates may be prescribed
to be taken internally-
Some authors have suggested the application of cup-
ping-glasses to the upper parts of the body, and sina-
pisms and hgatures to the upper extremities ; others
have recommended bleeding from the arm, but I think
few surg<;on8 will be inclined to adopt the latter recom-
mendation, in a patient already reduced by the hcemor-
rhoidal flux. Plugging the rectum, and in extreme
cases the actual cautery, have been advised, but neither of
these means is often practicable, unless the jjoint from
whence the blood flows can be brought into view, and
then, by ligature or other means, we may be able to
succeed in stopping the bleeding. "When the hsemor-
rhage is of a passive character, occurring continuously,
and weakenu]g the patient by slow degrees, the adminis-
tration of the preparations of cinchona, in combination
J
ILKMOHRHOllUL APFECTIONB.
133
with the mineral acids, will be of service ; sulphate of
quinine and sulphuric acid, and the various chalybeate
preparations, may also be administered.
The discharge of mucus from the bowel, which so
generally accompanies internal haemorrhoids, and ia a
cause of extreme annoyance to the patieut, is to be ar-
rested by the injection of cold water into the rectum
morning and evening. But if the disease has existed
long, and the secretion is profuse, a few grains of sul-
phate of zinc, acetate of lead, or tannic acid, may be
added to the water.
Tumours occurring at the verge of the anus, forming
external haemorrhoids, require different treatment from
those which are internal to the sphincter. lu the acute
stage of external piles, when they are small, hot fomen-
tations, poultices, and the medical treatment already
advised, will generally succeed in relieving the symptoms,
but if they be large and tense, much time and pain will
be saved to the patient by making n free incision
through them, and evacuating the contained blood. Tiie
incision should be made with a small cxirved bistoury
in the direction from the circumference towards the
centre of the anus ; inunediate relief will follow, and the
very slight bleeding that takes place, which is rather
beneficial than otherwise, is never sufficient to cause
either the patient or surgeon any anxiety ; the wound
wiU heat by granulation, the skin contracts, and the
134
n.EMOBRHOIDAI. AFFECTIONS.
parts are restored to their normal condition in a few
days. But if this proceeding be neglected, permanent
tumours will be formed in the manner previously described.
Wlien tlieae exist, tliey should be excised, and it is
the only advisable plan of treatment ; if the error be
committed of applying ligatures to these as to inter-
nal piles, intense suffering will result, a striking example
of which I witnessed in a case some time since. Care
should be taken not to remove more of the integument
than covers the tumour, or, upon cicatrization of the
wounds, contraction of the anus will ensue, the serious
consequences of which have been referred to in Chapter
IV. The usual mode of excision is by means of a pair
of curved scissors; the pUe, being seized with a vul-
sellum or pair of forceps, is to be cut off with the
scissors, the incisions radiating from tlie circumference
towards the centre of the anus. A less painful mode of
removing these tumours is by a probe-pointed straight
bistoury ; when the tumours are large and much in-
durated, they shp before the edge of the scissors, render-
ing a second or third cut necessary ; besides, a certain
amount of bruising of the tissues occure in this manner
of operating, and occasions great pain imless the patient
is under the influence of chloroform. In using the
knife, the incisions can he made with a greater degree
of exactness ; each tumour is to he held with the forceps
and incised at its base, tlic lower half of the incision
J
H-EMORRHOIDAL AFFECTIONS.
being made first, that the blood may not interfere with
our view. If the hseniorrhoid be small it can ]ye cut off
with one stroke of the knife, but if large the preceding plan
is tlie better, as the removal of more of the integuraent
than is neceasaiy can be thus avoided. Should fissure
of the anus coexist, it will generally heal after the excision
of the tumours ; slightly stimulating lotions and ointments
will sometimes be advisable till the cure is complete.
In the majority of cases it will not be necessary to
mterfere siu-gically with internal piles, if the treatment
already described be steadily pursued, and the patient
strictly attends to the injunctions of his medical adviser
with respect to diet and exercise. Even when the
tumoiu^ are lai^e, and have existed for some time, the
use of soap and water externally, night and morning, the
injection of cold water or lime water after each dejection,
and keeping the bowels easy, will enable the subjects of
them to pass their lives in tolerable comfort. But when,
notwithstanding the adoption of these means, the tu-
mours continue affected with pain, wearing out the
strength of the patient, or bleeding occurs to such an
extent as to affect the constitution, producing the various
symptoms that have been described, or that the tiuuours
are constantly protruded, and a profuse mucous dis-
charge kept up, it will be advisable to remove them by
surgical operation. I may be permitted to repeat that
it is onlv when the constitution suffers from the IochI
liyEMOBRHOIDAL AFFECTIONS.
disease we are to remove it ; and we must be careful
not to do so when tlmt disease appears beneficial in ward-
mg ofl' thoae of the more important organs of the chest,
head, and abdomen, which, if aggravated, might termi-
nate fatally. J
If after a minute and careful inquiry as to the exist-
ence of any hereditary predisposition in the patient to
other disease, and as to his previous state of liealth,
also his freedom from disease of the head, of the thoracic '
and abdominal viscera, and after a mature consideration
of the whole cuxiumstances of the case, the propriety of an
operation shall be determined on, the next question that I
will engage the attention, is the beat mode of proceed- I
ing. It is premised, that before having recourse to any
surgical interference, the general health of the patient
has been attended to, and the bowels thoroughly un-
loaded, measures that are highly important to a success-
ful issue of the case, the neglect of which has often
seriously aggravated a patient's sufierings, and led to a
tardy recovery. Formerly great difference of opinion
existed regarding the plan to be adopted, many eminent
BUi^cons advocating excision, while others used the J
ligature ; one reason for this want of agreement among I
those who have written on the subject, depends much
upon their not having drawn a tlistinction between in-
ternal and external piles, but applied a general rule to
the treatment of Iwth kinds. It is now, however,
fe J
t.EMORHHOlDAL Afl'ECTlONS,
generally admitted that excision ia applicable only to
external tmiiotirs, while the ligature, and, in some cases,
the use of nitric acid, are preferable in the removal of
internal h£eiiiorrhoids. That the operation of exciBion
itself is more rapidly performed than the application of a
Ugaturc cannot be denied, but when we take into ac-
count the fretjuency of liEemorrhage, and the necessity of
applying hgatures to the bleeding vessels, of making
pressure, or of searing the wounded surfaces with red
hot irons, as practised by Dupuytrcn, there cannot be
a question that the patient escapes on more easy terms,
and even more quickly, when the ligature is used. The
opponents of the Hgature have imagined various evil
consequences as following its application, such as phle-
bitis, diffuse inflammation of the cellular tissue of the
pelvis, peritonitis, and tetanus ; and have adtied instances
where the apphcation of Ugaturea was followed by fatal re-
sults; but theyneither verified their surmises as to thecsuse
of death by post-mortem examination, nor have they shown
that the cases were such as justified surgical intCTference.
Several surgeons of eminence at one time had recoorse
to excision, but were led to abandon the plan by fatal
effects following it. Sir Astley Cooper* says, " For
excision, in the early part of my surgical career, I was
• ' LecturcB of Sir Astley Cooper, Bart., on the Principles and
Practice of Sui^ery, with additioiia) Notts and OaaeB,' by Frederick
Tyrrel, lH25, p. 342.
1S8 HEMORRHOIDAL AVPECTIONS.
a strong advocate ; for I found it a leas painful operation
than ligature, and it appeared to me not dangerous ;
but as my experience increased, I was induced to
change my opinion, and to consider excision as not
divested of danger." Sir Astley then records three fatal
cases, the first the wife of a surgeon, the second a gentle-
man from Guenisey, and the third the Earl of S — .
Sir Benjamin Brodie* remarks, " With respect to inter-*
nai piles, then, there is no objection to the ligature,
while there is the greatest objection to their simple ex-
cision. This is the doctrine which I was taught by
Sir Everard Home in this hospital when I was a student.
But I met \*ith a copy of Mr. Chne'a ' Lectures on
Surgery,' in which he stated he removed infernal piles
by excision ; and this observation was added, ' A timid
BUi^eon removes them by ligature.' Knowing Mr.
Cline to be a very cautious practitioner, I thought in
what he recommended there coidd be no kind of danger,
and for some time, therefore, I was led to follow hia
suggestion. In the first one or two eases I found no
inconvenience to arise from my altered practice ; but
then a case occurred in which the patient lost a great
deal of blood ; in another case, the hiemorrhage was so
great that the patient nearly died ; and then a tliird cJise
occun-ed, in which also tlie patient lost an enormous
* ' Lecturea on Diaea«es of the liectam.' liv Sir U. C. BroJic,
' Miilical Oawjttc,' vol, iv, ]). BW.
J
II.F.MOBRH0IDAL AFFECTIONS. 139
quantity of blood, so much, that I now only wonder that
he did not actually die. Since thou I have never re-
moved large iiitenial piles except by ligature." Mr.
Sjmc,* after referring to Sir Astlcy Cooper's cases, adds,
" If other practitioners had been equally candid, we
should doubtless have had more testimony as to the
danger of this operation ; and every surgeon who has
practised it must have experienced more or less alarm.
Before my own \iews were settled as to the best means
of treating the disease, I, on one occasion, cut away an
internal hemorrhoid, which was partiaDy protruded, and
1 found it necessary to employ manual pressure for
several hours to restrain the bleeding that followed. In
another case I succeeded in securing the vessels by
ligatiUB." Dr. Bnshef also enters his protest against
the excision of internal piles, in the following words : —
" I have perfonued the operation several times, and,
after it, have had to tie up arteries, plug the rectmn,
and in one instance to apply the actual cautery. In-
deed, I so nearly lost two patients, that when left to my
own choice I no longer have recourse to this operation."
But if, for any reason, this plan of operation should
he preferred, it is to be performed in the following
• 'On Diseases of the Rectum,' by James Syme, F.B.S.E.,
I'rofesaor of Clinical Surgery at the Univenity of Edinburgh,
third Edition, 1854, pp. 77-78.
t Op. cit., p. 183.
140
H^MORRHOIDAI. AFFECTIONS,
manner: — The bowels having been unloaded by the
administration of mild pnrgativee, an enema of thin
gruel should be administered some little time pre-
vious to the operation, in order to make the tumours
protrude at the onus, or the patient may be desired
to sit over hot water in a close stool, and strain till
th^ are prolapsed. He should then lean across a
table opposite a good light, or he may lie on a couch or
bed, with the nates projecting over the edge, and his
thighs flexed on the abdomen ; the buttocks are to be
separated by an assistant, and the surgeon, grasping the
pile in the blades of a vulaellum or pair of forceps with
the one hand, excises it with a pair of ciurcd scissors
held in the other ; each tumour is thus to be cut off.
taking care not to remove any of the mucous membrane
that is uninvolvcd in the affection. Should profuse
bleedmg result, pressure by means of the linger must
be made ; if after a short time this does not succeed iu
arresting the hscmorrhage, it will be necessary to dilate
the rectum with a speculum ani, and secure the bleeding
vessels by ligatures, or if this cannot be aftcomphshed,
Dopuytren's method of applying the actual cautery to
the part may be necessary. So frecpiently did this
surgeon find it requisite to have recourse to such means
of arresting bleeding, that he had irons of various shapes
and sizes for the purpose. Elevating the pilvis, and
applying bladders, containing pounded ice and salt, to the
J
H.EMnBRHOIDAL Al'FECTIONS.
sacnira and anus, will assist the other means employed.
Plugging the rectuni in the ordinary maimer is very ob-
jeetionable, as bleeding may continue internally, imob-
served by the attendants, till the patient is exhamted.
If it be deemed advisable to have recourse to compres-
sion, it is best made by an oval-shaped bladder of India-
rubber, which can be inflated by means of an elastic
tiibe connected therewith. Bushe invented an instru-
ment for arresting bleeding from tlie wound made in
lithotomy, and recommends it in cases of hBemorrhage
from the rectum following the excision of piles ; it con-
sists of a tube closed at one end, the other being open
and furnished with a stop cock : the sides of the tube
are perforated with holes, and a portion of intestine
surromids it, which is secured at each end by waxed
tlu^ad. The instrument being introduced into the
bowel, the intestine is inflated through the tube, and the
air retained by turning the stop-cock. After the opera-
tion a dose of opium should be administered, vnth the
object of tranquillising the system, and of preventing
the action of the bowels for two or three days. At the
expiration of that time a dose of castor oil must be
given, and the bowels afterwards kept open by repeating
it as often as occasion requires, or the lenitive electuary
or other aperient may be substituted. Emollient ene-
mata during the treatment are very essential, and will be
productive of much benefit and comfort.
U2
H.tMOKttHOlDAl, AFFECTIONS.
From what has been stated, it is quite evident that
exciaion of internal haemorrhoids is neither safe nor ad-
visable, and that other means must be had recourse to.
When the tumoiu^ are large no plan for their removal is
so effectual as the Ugaturc, which, if properly applied,
occasions but little pahi, and the operation does not oc-
cupy more than a few minutes. So far as my own ex-
perience goes, I can amply testify that this method is
entirely free from the evil consequences mentioned by
some writers, provided the necessary precautions pre-
viously pointed out have been attended to. In this
belief, I am supported by the evidence of gentlemen
whose eminent (wsition in the profession has afforded
them a wide field for observation and practice, and
whose opinions command the highest respect. In a
recent consultation with Sir Benjamin Brodie, respect-
ing a patient who was suffering from piles, compli-
cated with prolapsus, he remarked, " the ligature is a
perfectly safe proceeding." He adiled he had lost three
patients after the operation, but two of them had albu-
minuria, and occurred before he had become acquainted
with the pathology and important alterations in structure
of the kidneys inducing that state of the urine, which
tfie valuable researches of Dr. Bright and subsequent
investigators have, since then, so ably and clearly demon-
strated. In the third case. Sir Benjamin at first refused
to interfere, on account of the patient's broken-down
A
H.4;M0KRU0inAL AKFliCTIONa.
143
constitution, and it was only at his most urgent request,
and after all the unfavorable circimistanccs had been
dearly pointed out to him, that he consented to perform
the operation. That other fatal results have ensued upon
the application of the ligature is admitted, but in these
cases it will also be found the general health of the
patient, or the presence of serious disease of the kidneys,
or other important organs, rendered the operation imad-
visable. It is such cases that are adduced as militating
against the practice of applying the ligature, by those
who put forth some peculiar but generally not very
original plan of treatmeut.
Some surgeons mclude the pile iin a single noose,
but the method is unadvisable, for, unless the hsemor-
rhoidal tumour is connected by a very narrow peduncle
the ligature cannot be drawn sufficiently tight to cut oif
effectually all vascular and nervous connexion, whereby
the parts are longer in separating, and a greater degree
of inflammation is induced. Mr. Mayo* mentions a case
in which he operated, and included some large tumours
in single hgaturea which had not the effect of completely
strangulating tlie parts, and he was obhged to apply
others after a few days, a proceeding that must of neces-
sity have been very painful from the inflamed condition
of the piles at that time. But another important ob-
jection is the liability of the ligatm^ to slip off; this oc-
• Op. cit., p. 70.
144 n.«MOHRHUIDAI. AFFKCTIONS.
curred in several cases recorded by Mr. Howship,* and,
although the disease was ultimately removed by the
excessive inflammation set up, it was at the cost of much
suffering to the patient. Another illustration of the
evil arising from this mode of applying the ligature, was
mentioned to me by a professional friend, who had the
opportunity of observing the case. A gentleman was
recently operated on by a hospital surgeon who in-
cluded a large hBemorrlioid in a single noose, the result
of which was that the hgature slipped off, rendering a
second operation necessary ; the same thing again oc-
ciuTcd, and a third ligature was applied ; by tlicse re-
peated operations the patient suffered severely, and was
confined to liis bed for several weeks. To obviate these
objections, it is better always to pass a double ligature
through the base of the tumour, and to tie it in two por-
tions. For this purpose an ordinary curved suture needle
will suffice, but a needle like those used in operating on
h
• ' PMctical Observations on the Symptoma, Diucrimination,
and Treatment of some of the moat important Diseases of the
Lower Intestines and Anus.' By John Howehip, third Edit. 1824.
U
If.EMOKRHOIDAL APPFXT10NS.
145
na3vi, and having the curve here represented, wiU be more
convenient. Dr. Bushe* invented an instrument which is
very useful in some cases, particularly when the surgeon
has not efficient assistance. The an-
nexed woodcut aceui-ately represents
the form of the instnunent, the needles
fitting into the needle-receiver vary
from half an inch to an inch iu
length. The following is the manner of
using it ; — The needle being armed
with a double ligature is made to
transfix the tmnoiu- through its centre :
which is then to be grasped t)y a pair
of forceps, and withdrawn from the
socket of the holder. All this can
be accomplished without entangling
the needle in the surrounding parts;
because, the convex portion of the
needle-carrier being alone opposed to
the prolapsed parts, it pushes them
out of the way without injury, and
thus makes room for the ascent of the
needle, so that it can be seen pre-
cisely where to enter its point.
The ligature should be strong dentist's silk, or, what
is preferable, an even and fine hempen cord ; whichever
t Op. oit., pp, 188, 189.
UG
n.EMORRUOIDAI. AFFECTIONS.
is used must be well waxed, that it may not be acted oiS'1
by
moisture, andthnttlie knot may not slip. The length!
should be about twenty inches ; it is also a good plan
to have one half stained, whereby we can distinguish the
ligatures after their division. j
The patient is to be placed ]
in the saiuf! position as tbat
described for excision, and the
tumours made to protrude
by the means previously di-
rected.* The buttocta are .
then to be held apart, and th^J
surgeon grasping the tumour |
to be operated on with a vul-
selliun, or by that which is the
preferable instrument, a pair of
forceps of the form represented -
in the annexed figure, commits J
them to the hands of an as- 1
sistant. who is to make suffi-
cient traction to bring the base
of the hfemorrlioid into view,
and enable the operator to
pass the needle armed with a i
double hgature through its centre : this having been ac- J
complished, the ligatiu^ is then to be divided, and the ■
• Page 140,
d
llyEMORRBOlDAL AFFECTIONS.
147
ncetUe withdrawn. He next proceeds to tie them. Sir
Astlcy Cooper recommends that they should not be dmwn
tight, thinking thereby to lessen the pain and irritation,
but he erred in his supposition, and produced that whicii
he was desirous of avoiding. When parts have their
nervous and vascular connexion completely interrupted,
their vitality at once ceases, and nature throws them
off as speedily as possible ; this being the object of the
operation, it is desirable to draw the ligatures perfectly
close. The upper one is to be tied first, and then the
lower one ; the extent of the tissue to be included, is to
be regulated by fixing the limits with a tenacidum, or by
the use of a pair of forceps. With the same object, it
has been proposed to transfix the piles with various kinds
of pins, which are withdrawn after the ligatures are
tied ; the proceeding has no merit m it, and is never ne-
cessary. Care should be taken not to include in the
ligature any of the mucous tissue that is unaffected, it
is still more essential to exclude the skin at the margin of
the anus, or great suffering will be induced. It is seldom
there are more than three or four tumours, and these
must be operated on at the same time, otherwise the
irritation produced by the ligature of one of the hasmor-
rhoids, will cause inflammation to attack the tissue of
the others, which, from being in a morbid condition, is
rendered more liable to it than the healthy structures.
After the knots have been made fast, the ends of the
148 HEMORRHOIDAL AFFECTIONS.
ligatures must be cut off half an inch from them ; and
the parts returned within the anus. Some have advised
that the piles should be clipped off near the ligatures,
but there is no necessity for it, they soon become flaccid
and shrink ; besides to do so would endanger the ligatures
retaining their hold.
The ligatm-cs generally separate from the sixth to the
tenth day, no advantage is to be gained by pulling at
them or mterfering with them in any way, they arc sure
to be thrown off in proper time. I have known in-
stances of their being pulled off prematurely to the mani-
fest disadvantage of the patient ; it must be recollected,
they are placed imder different circumstances to ligatures
attached at the bottom of deep wounds, as in amputations
of Umbs and in other great operations ; in such cases
gently twisting them occasionally is advisable, if they have
not become loose at the usual time for their separation.
At different periods, various escharotics have been
extolled, and become a fashion in the treatment of
hiemorrhoids ; but, as in many instances they did not
realise the advantages that the advocates of them would
induce others to believe, they fell into disuse. In cer-
tain cases the application of the strong nitric acid, or the
dcuto-nitratc of mercury, will prove highly beneficial
in removing the morbid growths, and may be advan-
tageously substituted for the use of the ligature. Other
escharotics, either from theu' deliquescence and impos-
i™- J
HEMORRHOIDAL AFFECTIONS. 149
siljility of limiting their action, or other rensons, are
inappheable. I have seen coses recently, in which the
nitrate of silver and the sulphate of copper have been
applied, but these salts are not of the slightest service
in removmg the morbid tissues, though they may
palliate the symptoms when not severe. Dr. Houston *
was the first to advocate the use of pure nitric acid for
the cure of certain forms of hemorrhoidal disease. I
have found it very effective, and when the tumours arc
sessile, with florid granular surfaces, looking like half a
strawberry, the appUcation of it is the preferable plan of
treatment ; but if the piles are large and pendulous, the
ligature ought to be used. Several mstances have come
under my observation where mischief has arisen by
attempting to destroy large growths with the acid ; in
three cases, a communication hnving been formed between
the rectxmi and vagma, by its too free appUcation.
When the part of the mucous membrane morbidly
afiected is of hmited extent, and does not rise much
above the surrounding healthy siuface, the acid may be
apphed with safety and advantage. The disease is to be
brought into view, either by dilatation of the anus, or by
being made to protrude externally, and the acid apphed j
the eflcct must be judged of, by the change in appear-
ance of the tissue, which will lose its natural colour and
lH;coinc of a grayish-white. An alkah in solution is to
• ■ Dublin Joumul,' vol. »xiii, ji. 94.
150
n,EM01lHII0IDAL AFFECTIONS.
be used to neutralize the excess of acid, and prevent its
action on adjoining structures ; the parts then being
smeared with oil, the operation is finished. A small
piece of lint wound round the end of an cye-prolie, is a
convenient mode of applying the acid. Dr. Houston
directs a piece of wood shaped like a spatula to be used,
but a probe and lint are always at hand, and answer best.
The pain occasioned by the operation is not great, but
care must be taken that the acid is not permitted to
come in contact with the skin at the margin of tbe
anus, or the converse will occur. 'J'he eschar produced
by the acid will separate between the third and sixth
day, leaving a healthy ulwr ; at tliis time the patient
will expt'riencc some smarting when the bowels act.
The aft«r treatment is to be the same as when the liga-
ture has been applied.
M. Araussat advocates what he terms tlie cir-
cular cauterization of the base of hsenion'hoidal
timiours, which he effects by means of variously con-
structed forceps, the blades of which arc charged with
Fulcho's caustic. The advantages of the plan nre not
very apparent, and when we are told it is necessary to
irrigate the parts with cold water for several consecutive
hours, and that one patient, to relieve the pain, sat in
a cold bath for a week, it is one not likely to be generally
adopted. A full account of the mode of operating,
with illustrative cases and drawings of the instruments
1
EMOitUIIOlDAL AKPECTJ0N8.
151
employed, is to be found in tlie New York Journal of
Medicine.*
When external piles exist with internal ones, tliey
must be excised at the same time that the others are
operated ou, or they will become inflamed by the irrita-
tion which necessarily follows, and occasion extreme pain
and annoyance. But it is liighly essential that a correct
diagnosis be made between external piles and the cede-
matous swelling of the margin of the anus, induced by
the condition of tlie internal piles ; for if an error is
made, and tlie cedematous integument removed, the
serious evil of contraction of the aims will ensue on the
cicatrization of the woimds.
Whether excision, Ugature, or the application of nitric
acid be had recourse to. a dose of opimu should be
administered after the operation, and in tins there is a
double intention to be answered, tlie one to tranquilhsc
the system and allay pain ; the other, and the chief one,
is to lock up tlie bowels for a day or two, to prevent the
irritation that would be produced by their action, On
the thinl day, if the bowels are not moved of their own
accord, an emollient lavement must be administered, this
should be repeated on the fourth or fifth day ; after-
wards the bowels must be kept open by castor oil,
lenitive electuary, infusion of senna witli decoction of
cinchona, or similar remedies.
" Vol XV, n.. Ill— 282— 4il.
152
IlfMOUKHOIDAL AFFECTIONS.
For the first two daya the patient must be confined
to his bed ; on the third day, according to circum-
Btances, he may be allowed to leave his room, and lie on
a sofa ; about the fifth day he may begin to move about,
and, if the weather penuit, he may take a gentle walk or
a drive in a carriage.
'ITie diet for tlu^e or four days must consist of sago,
arrowroot, barley-water, beef-tea, mutton, veal, or chicken
broth ; when the patient begins to walk about, some
solid food may be allowed, but great moderation must
be observed.
When the ligatures have come away, or the eschar
produced by the action of the acid separates, leaving
an ulcerated surface, the injection of four or six oimces
of water, with two grains of sulphate of zinc to the
ounce, will expedite its healing.
Occasionally it happens on the second or third day
following the operation, that the patient experiences
some difficulty in micturating ; a dose of hyoscyamns,
with nitric ether, in camphor mixture, and a hot hip-
bath, will genei'ally remove these symptoms ; should
these means, however, not succeed, and retention of
urine supervene, it will be necessary to introduce the
catheter ; but we shall seldom be called upon to do so ;
nevertheless the bladder must not be allowed at any
tunc to become over distended.
In the treatment of idccvatioii of piles, it will generally
A
HEMORRHOIDAL AFFECTIONS. 153
be advisable to remove them ; if thuy are external, they
miist be excised ; if internal, the ligature or nitric acid
must be employed.
When fissure of the anus exists as a complication, it
will usually be found accompanying the external form of
hemorrhoids. The tumours must be excised, and a
mild astringent ointment, with or without the extract of
belladonna, apphed, according as there is spasm of the
sphincter mmcle or not. If this be insuificient to heal
them, it will be necessary to have recourse to the ope-
ration described in Chapter V.
If abscess take place in connexion with piles, an early
and free incision must be made, otherwise fistula in ano
may result.
The protrusion of large internal piles from the anus
causes the patient great annoyance, and at times is alone
sufficient to induce liim to seek surgical aid. At first
the protrusion only takes places at stool, but in the pro-
gress of the disease, the sphincter becomes relaxed and
the anus dilated, so that they fall down when the patient
makes the slightest exertion, or even on his assuming
the erect posture. If no contraindication exists, the re-
moval of the tumour or tumours is the best treatment,
but if this is not admissible, six or eight ounces of cold
water must be thrown up the bowel twice or thrice a day ;
various astringents may be added to the fluid, such as
sulphate of zinc, idum, acetate of lead, tannic acid, &c.
154
H.EM0RHH0IDA1. AFFECTIONS,
Surgical mechanicians have invented various instru-
ments for the prevention or cure of piles, but they
succeed in accomphshing neither ; however, their con-
trivauceB are useful in assisting to prevent the protrusion,
and the discomfort arising thereftx)ni, when it is un-
advisable to remove them by operation. The instrument
made by Mr. Eagland is perliaps the best of the kind ;
but when a truss cannot be obtained, a pad of lint, and
a T bandage, will answer the pui'pose.
It has been recommended to make temporary pressure
on internal piles, by tim iutroductioii of a bougie into
the rectum, and retaining it tliore for an hour or longer
eveiy day ; but whenever suca-ss has appeared to follow
the proceeding, it has been due to the constitutional
treatment that has been adopted at the same time, and
not to the use of the instrument. Those who advocate
this plan, entertain the idea tliat internal piles are dilated
veins, and that as pressim; is beneficial in dilatation of
the veins of the leg, it nmst also be beneficial in these
cases ; forgetting that the rectum is surrounded by
yielding parts, and therefore tlie impossibihty of making
finu and equable pressure ; they also overlook the fact
that in the varicose condition of the veins of the leg
pressure is only useful so long as it is continuously
applied, and that in many cases the bandages have to
be put on with great nicety to afford the dcsii-ed reUcf,
and, even after this has been piu-sued for years, tlie
J
HEMORRHOIDAL AFFECTIONS. 156
veins remain in the same dilated condition, and all the
miseries attending tliem return if the bandages are left
ofi" only for a few hours.
When the patient begins to regain health and
strength, he must avoid all the causes that induce the
disease from wMch lie suffered. He must live sparingly,
and be careful to keep the bowels regular; he must
take as much exercise, short of fatigue, as he can, so
that the skin and other excretory oi^ans may fully per-
form their functions and prevent plethora. If these
means are insufficient, or, if by neglect of the advice
given him, and returning to former habits of indulgence,
he is threatened with congestion of any of the organs
in the head, chest, or abdomen, the feet should be im-
mersed every night in hot water and mustard, and the
bowels should be freely acted on ; a dose of calomel
and jahip will be the best to commence with, after-
wards a few grains of blue pill, or gray powder, with
a grain of ipecacuanha, may be taken at bedtime, and
a purgative draught in the morning, as the compound
infusion of senna, with decoction of cinchona, or potassio-
tiirtrate of soda in infusion of calimiba. Blood may be
tiiken by cupping from the region of the organ threat-
ened, or from the sacrum and perinseum.
With regard to the use of chloroform in operations
Oil hiemorrhoidal tumours, much must depend on the
piitient's own wishes on the subjecl ; 1 should never
Ion H45MOHRHOIDAL AFFECTIONS.
recommend it except in removing external piles thai
have become permanent, the pain attending their excision
being very sharp for the time. Applying the hgature
or tlie nitric acid to internal haemorrhoids does not
usually cause more pain than the patient can very
readily bear, unless the nervous system be very excitable,
or he is peculiarly obnoxious to pain. Besides the
surgeon requires Ins co-operation to prolapse the tu-
mours, and to prevent their retraction while he is per-
forming the operation. However, if the wish to inhale
it is expressed, I should never think of offering any
strenuous opposition, iniless there were reasons rendering
it improper and dangerous.
The following cases will illustrate the different phases
of hiemorrhoidal affections, and the treatment.
External hamorrhoid, treated without operation.
Mr. , tall and stout, generally takes moderate exer-
ciBC, and lives temperately. Some years siuce suffered from
fistula in ano, and was operated on by Mr. Copeland; au
external pile waa removed at the same time. He consulted
me on the &th of May, 1853, fearing Us former malady was
retanung ; for several weeks he had not taken bis usual
exercise, and had lived ratlier more highly ; the last few days
of April he had experieiiccd itching and fulness of the
rectum, and ultimately a lump formed ; he then sought my
advice. On making an examination I perceived an external
pile on the left side ; it was tense, of purple Colour, and
HjEmorrhoidal affections. 157
liut very slightly painful j no internal hEemorrhoids existed.
His tongue waa fllightly furred and large, face somewhat
dashed, conjunctivte congested, pulse full.
^ Hydrargyri cum CretA, gr. iij j Eitracti Taraiaoi, gr. vij.
Fiant pil. ij, oniiii nocte BomendEe.
^ Infusi Qentianas comp., 5iv : Infusi Semiro comp., Jj ; Po-
tftsax Salphatis, 3iBs. Piat baust. Bccunda quoqae mane
The anus to be washed with water and yellow soap night
and morning.
All inconvenience subsided on the second day after I first
saw him, the tumour was flaccid and was contracting. The
pills and draught were continued for a few days longer j he
still uses ablutions twice a day, and has had not the sHghtest
symptom of any affection of the rectum since.
External hemorrhoid, incision of the tumour, rapid
recovery.
W. C , (et. thirty-seven, a saddler ; an out-patient at
University College Hospital, in the summer, 1845 ; of ordi-
nary stature and conformation, bilious temperament, works
hard at his business, sitting ten hours a day ; lives well, and
is in the habit of drinking freely of heer and spirits, hut is
seldom tipsy. Several days before applying at the hospital
he experienced slight itching and fulness at the anus ; on
the evening previously the symptoms increased ; he then had
throbbing and acute pain, became thirsty and feverish, and
had not been able to sleep during the night. In the morn-
ing he was sensible of a tumour having formed at the margin
158
n.cMoniiHOinAi: affections.
of the amis. When he applied for advice hia tongue WM
fiirred, skin hot, and his countenance indicated pain and
■want of rest. His bowels had been irregular, sometimes not
acting for two or three daya. On examination, an external
pile presented ; it was purjile, tense, and very painflil.
Ordered to take four grains of blue pill, and one gndn of
ipecacuanha immediately, and the following draught two
hours afterwards : —
{t PiJveriB Bhci, gr. xv ; Pulveriu Jalaps, gr. viij ; Potasete
Sulphatis, Sss; Tinctune Cardamomi comp., 5i; Aquie
Cionamomi, 5ij' Misce fiat hauatus.
To foment the parts with hot water and to go to bed.
The medicine having acted freely, on the following morn-
ing I divided the pile with a bistoury and evacuated the con-
tained blood ; the fomentations to be continued. On the
second day he resumed his business, the incision healed, and
the skin contracted to its normal condition. He aiterwardfi
took for two or three weeks a tonic and aperient mixture,
and by my advice abstained from spirits, and drank but a
moderate quantity of beer daily.
The brother of this patient had previously been under my
care for fissure of the anus.
External htEmorrhoid, tumour incised.
Mr. , ffit. thirty ; tall j of great muscular develop-
ment, plethoric habit, not accustomed to take much exercise
except occasionally during the sporting season, and is ca-
pable of great exertion and endurance without fatigue, He
Uvea freely, his general health is good ; occasionally feels a
H.EMOKRHOIDAI, APPECTIONS.
fiilnras of the head and drowsinCBs ; lie then has
a brisk purgative, which relieves him.
He sent for rae in May, 1852 ; he was in bed complaimng
of great pain at the anus ; his countenance was flushed, skin
hot, tongue furred, pidsc accelerated, and he had headache.
He informed me he had been to a succession of dinner
parties, and had eaten and drunk frceiy, and had not felt
quite well for several days ; the morning before my seeing
him he experienced an itching at the anus and a fiilness
about that region ; towards evening his discomfort increased,
aud he began to experience throbbing and acute pain; he
went to bed somewhat earlier, hoping a night's rest would
relieve Mm. On making an examination I perceived an
external pile, half an inch in diameter, spheroidal, tense, of
a deep purple colour, and very painful when touched. To
use hot fomentations and to continue in bed; five grains
of calomel and five grains of Dover's powder to be taken
immediately, and the following draught two hours after-
wards : —
S- Infusi SennsB comp., xj ; Pulveris Jalapa;, gr. -viij ; Sodjp
Potassio-Tart., 3j ; Spiritua Myristicie, ^". Misce fiat
haustas.
The medicines acted on the bowels freely several times.
On visiting him in the evening, finding the pile still tense,
I divided it by transfixing the base with a small curved
bistoury and cutting outward. The next day he was able
to be about ; the wound healed without any trouble in a
day or two after, I advised him to obsene moderation in
living, and preacribcd the following draught to be taken
every morning for two or three weeks.
& Infuai Qentianae comp., 5^ i MagacsuE Sulph., 5j ; Acidi
Bulphurici dil., lUiij ; Tincturaj Auxantii, ^. Misce fiat
haiutus.
External hcemorrhoid and fissure of the anus.
Mr. , set. twenty-eight, residing in Wcstboumo
Terrace, Hyde Park, was advised to eonsult mc, by my ftiend.
Dr. Quaiu. He is of ordinary stature and conformation,
living moderately, not taking much exercise, has always
been dyspeptic and of costive habits ; the last few years he
has suffered more or leas irom smarting during defecation,
attended with slight haemorrhage, followed by aching pain.
The attack for which I was consulted commenced the day
previously with severe throbbing pain, and great tendemeaa
at the anus ; on making an examination, an external pile, the
size of a filbert, on the margin of the anus of the left side,
presented : it was tense, exquisitely paiufiil to the touch,
and of a deep purple colour. At the posterior part, and im-
mediately within the margin of the anus, was a fissure about
half an inch in length, appearing of recent origin, the
margins being sharp and florid j the sphincter ani was
slightly affected with spasm ; general constitutional disturb-
ance was indicated by thirst, loss of appetite, furred tongue,
acceleration of the pulse, and by the preternatural heat and
dryness of the skin. He was directed to observe the recum-
bent position, to foment the anus with a hot decoction of
poppy-heads, to apply a piece of lint smeared with extract of
H.EMOKItHOIDAL AFFlsrTlONS, 101
conium and spermaceti ointment to the fissure, and to take
at bedtime a teaepoonfiil of an electuary consisting of con-
fection of senna, sulphur, jalap, bitartrate of potash, copaiba,
aud syrup of tolu.
On the following morning the bowels were freely moved,
attended with smarting at the time. The tumour was still
teuBc and painfid, I therefore dirided it, and turned out a clot
of blood; bleeding to the amount of one or two drachms
followed. Directed to use a sponge and water when visiting
the closet instead of paper.
The electuary and ointment were continued for a short
time, and in ten days all disease had subsided ; the loose
skin resulting from the distended hemorrhoid contracted en-
tirely, the part resimied its natural condition, and the fissure
of the anus had quite healed.
Dr. Quain informs me he has seen this patient recently
{Dec. 1853), and that he has continued free from all symp-
toms of fissure or piles.
External piles after bilious fever, prolonged suffering
from not permiiting incision of the tumour.
Mr. C. C - -■ ■ , set. twenty-three, convalescent, after se-
veral weeks' severe illness from bilious fever. On one of my
visits he complained of great pain and throbbing at the
anus, and fulness of the perinaium. An examination revealed
a large external pile of the size of a cherry, on the left
margin of the anus ; it was of a deep purple hue, tense, and
very painful. Under the idea of regaining his strength more
rapidly, he had for several days eaten very heartily, and
n
162 H£UORRHOIDAI. AFFECTIONS.
taken several glasses of wine, notwith standing he had 1
admonished to observe moderation in living, Ordered to
confine himself to the recumbent position ; to have no solid
food ; to use hot fomentations of deeoction of poppy-heads
to the anal region, and to take a teaspoonfol of the following
electuary at bedtime :
Jt Confectionia Serniie, Svdphuris Loti, Extracts Taraiaci, aa Xj ;
PotaSBffi Bitart., 3iv ; Syrupi Zingiberia, q. s. Misce Gat
eleetuarium.
The next day he was no better ; he had not been able to
take the electuary, as his stomach turned against it ; he was
desired to form it into boluses of convenient size with wafer-
paper. I proposed dividing the pile with a bistoury, but he
would not listen to anj-thing like an operation.
By the means suggested he managed to take the elec-
tuary, and it acted freely the following morning; the pile
was still tense, but not so pauiful; three others, of small
size, had formed on the opposite side. He waa directed to
continue the electuary and fomentations, and to live sparingly.
Under the treatment he continued to improve, but a fort-
night elapsed before he was free from pain, the pile had then
collapsed, leaving a large fold of loose skin. At this time
he became very nervous about himself, was restless at night,
and perspired profusely. Ordered to take twice a day the
following :
51 InfiiBi CinchoiUB, Jibb ; Acidi Nitrici diluti, mi ; Syrupi
Aurantii, '^. Fiat haustus.
In another week he was much better, and gaining
HEMORRHOIDAL APPECTION8.
163
strength ; he left town for Brighton, where he remftined for
Bome time.
I have seen this gentleman lately ; he is now atout and in
good health ; the loose fold of skin around the anus still
exists, and may probably become the scat of disease on the
occurrence of a slight exciting cause. Had he consented to
the small incision requisite, 1 have no hesitation in saying
his sufferings would have been materially less, and of shorter
duration.
Emtemal piles, with ulcerationof their surfacea and
fissure of the anus -. operation .- cure.
T. R , (el. twenty-eight, by occupation a copying-
clerk, in a law-stationer's office, of ordinary stature and
conformation, bilious temperament. Previous to fourteen
years of age he suffered from hiematuria ; since then he has
enjoyed good health till the early part of 1852, when he ex-
perienced itching and fulness at the anus, and after a few
weeks, smarting at stool was superadded. His bowels have
been habitually constipated, and, from the nature of his oc-
cupation, he maintains the sitting position many hours during
the day, and takes very little exercise. In June, he became
a patient in a metropolitan hospital : he described his symp-
toms, and was told he had piles ; no examination was made
during the two months he was there : medicines were pre-
scribed, and he left somewhat better.
On the 11th of November, 1852, he applied at the Blen-
heim Dispensary, complaining of smarting at stool, foUowed
by severe aching, which continued for some time; his suffer-
ings were bo great that he was rendered incapable of follow-
164
n^MORBTIOlDAL AFFErTIONS.
ing his employment. HU countenance was ansiooK, hia
pulse ([uick and irritable, and lie was exceedingly nervous
and apprehensive ; Lis tongue was furred and large, with the
imprcsaions of the teeth deeply notched in the margin : he
had tenderness at the epigastrium, and flatulence. On
making an examination several external piles were seen,
varying in size from a large pea to that of a bean : their
surfaces were ulcerated, they were hard and tense, and fi»-
Burcs existed between them. On attempting to ascertain
the extent of the latter internally, the introdnction of the
finger into the rectum brought on violent spasm of the
sphincter, and induced intense pain. It was proposed lie
should have the tumours around the anus removed, to which
he assented, but postponed the operation for a short time on
account of some private affairs demanding his atteution.
He was directed to wash the anus with soap and water morn-
ing and evening, and to use a sponge and water at the clo&et
after evacuating the contents of the bowels. A teaspoonful
of an aperient electuary was ordered to be taken at bed-
time, and two tablespoonfuls of compound infusion of gentian
with ammonia and bicarbonate of potash twice a day.
AW. 28. — Had seen my patient several times since he first
applied tome: liis general health was now much improved,
and he has cxperiencHd rehef by following the treatment
suggested. This day I removed six external piles, making
the incisions converge from the circumference towards the
centre of the anus, Mr. H. Thompson kindly rendered mc
assistance, and administered cldoroform to the patient.
About two ounces of blood were lost during the operation ;
no vessels required ligature, and the sUght oozing that fol-
HEMORRHOIDAL AFFECTIONS, 165
lowed was easily restrained by a pad of lint aad a j bandage.
Before leaving he had recovered from the effects of the
chloroform, and became aware of the operation having been
performed by feeling slight smarting. To remain in bed.
Nov. 29, — Visited him in the afternoon. Half an hotir
after I had left him he had lost all pain, and he has been
qaite comfortable since ; his bowels not having been moved,
he was directed to take a dose of the confection wliich bad
' been previously prescribed, and to apply a piece of lint
spread with zinc ointment to the wounded parts.
In ten days the wounds had quite healed, also the fissures
that existed between the piles ; for a short time he took an
aperient and tonic mixture. He regained bis health, his
bowels act regularly, and lie bas continued perfectly well
since.
The severe suftcrings this patient endured might have
been spared bim had an examination been made when he
applied at the hospital, as a less routine plun of practice
would probably have been adopted, and the diseaae cured in
the first instance.
Internal heEmorrkoidal tumours in an farly stage;
medical treatment.
J. S , at. nineteen ; ashoemaker; came under my^ care
at the Blenheim Dispeusary, 1853, affected with syphilitic
lepra, for which a solution of bichloride of mercury and arsenic
was ordered, and he progressed favorably.
On tbc 8tb of March, 1853, be complained of having expe-
rienced, for three or four days, pain, weight, and throbbing,
166
HEMORRHOIDAL AFFKCTI0N8.
in the rectum, increased at stool, and attended with the dis-
charge of a small quantity of blood. For several weeks his
bowels have been conatipated, and lie has sat at work &om
an early hour in the morning till late at night. His eyes
are dtill, the sclerotic conjunctivaj slightly tinged yellow,
tongue furred, and the teeth indented into the edges, pnlse
quicker than natural, skin hot and dry. Examining the
rectum, the mucous membrane was observed to be congested,
and several small purple lumps were seen immediately within
the margin of the anna. I prescribed five grains of gray
powder and a drop of croton oil, to be made into a pill, to
be taken at bedtime. To use ablutions of soap and water
after each stool.
March 10. — The pill acted freely. Has less uneaAiness
this morning. To take three grains of blue pill and two of
extract of conium every second night, and the following
draught every morning — Compound infusion of gentian, half
an ounce ; compound infusion of senna, one ounce ; potaesio-
tartrate of soda, a drachm and a half. To continue the ene-
mata and ablutions.
March 22.— lie has continued the remedies ; all the symp-
toms have subsided, and his general health has greatly im-
proved. To omit the pill ; to take a draught twice a week,
and to continue the use of soap and water.
April 5. — Has had no return of the hsemorrhoidal affec-
tion, the mucous membrane of the bowel perfectly healthy in
appearance.
H^MOIUUIOIUAL AFFECTIONS.
Congestion of the mucous membrane of the rectum,
attended with great pain.
A. S , set. thirty-two ; a carver, of ordinary stature and
conformation, bilious temperament. Some years aince he
suffered from irregularity of the bowels, and latterly has
been very costive. In the early part of Nov. 1852, he expe-
rienced great pain at stool, also aching, and extreme discom-
fort at the fiindameut while at work ; this was sometimes so
severe as to compel him to go home. Slight bleeding from
time to time has taken place.
He applied at the Blenheim Dispensary, Dee. 7, 1852,
complaining of great pain at the fundament. On examina-
tion and separating the margins of the anus^ the mucous
membrane was observed to be congested, and the htemor-
rhoidal veins turgid. Digital examination revealed uo dis-
tinct tumours. The speculum ani showed the whole mucous
membrane within the limits of the internal sphincter in the
same condition as at the margin of the anuB. His tongue
was coated and notched, the countenance hea\y and anxious,
pulse more frequent than natural, his bowels had not been
moved the last two days. Five grains of gray powder and
one drop of croton oil, to be taken every night. To wash
the anus night and monung with yellow soap aud water,
and to use half a pint of cold water as an enema after each
dejection.
He took the pill prescribed on the three following nights,
the bowels were freely acted on, and he felt much less full-
ness and aching in the rectum. Ordered to omit the pill.
and to take a teaapoonfiil of a laxative confectiou every ,
oight; to continue tlic ablutions; and to use the caemata I
of cold water-
In three weeks he was free from all disease, and by having
recourse to the electuary occasionally, if the bowels are at all
confined, he has since continued perfectly well.
Internal hcemoTrhoids, constilulional treatment.
The Rev. , set. Bixty-five, residing in Surrey, of mode-
rate stature and healthy appearance, for some years has had
at times htemorrhage from the rectum when the bowels were
evacuated, preceded by a sense of fulness and discomfort in
the part. The symptoms have always been aggravated on
his visits to town, when he is induced to enter into society,
and live rather more freely than he is generally accustomed
to. By examination, I detected a small internal biemor-
rhoidal tumour, the mucous membrane was congested, and
two loose folds of integument esisted on the right margin of
the anus, the remains of external piles. He was ordered to
take following electuary :
ft Confectionis Senna;, y ; Sulphuris Loti, ^s ; Kxtracti Ta-
raxaci, ;^iv ; Syrupi Tolutani, <\. s. Fiat Elcntuarimn. A
tcaspooiiful to bo taken at bedtime.
Eiglit ounces of cold water to be injected into the rectum
after each dejection.
By taking the electuary occasionally, continuing the ene-
mata of eold water, and avoiding living too highly, lie has
been free from tia^iuorrbagc and pain.
ILEMORRHOIDAL AFFECTIONS.
External and internal piles ; considerable bleeding,
palpitation of the heart, ^c.
A. A , aet. fifty-Bix ; married, of moderate stature, very
stout. Applied at the Blenheim Dispensary, Oct. 2, 1852,
in consequence of considerable losses of blood per anum
when at stool. She appears exsanguinated, lier lips, gums,
and tongue are colourless ; the countenance is anxious and
sallow, pulse quick, weak, and irritable, and she complains of
violent palpitation of the heart, induced by alight exertion ;
she has long been of constipated habit of body, and has not
taken much exercise for several years.
The present attack commenced by itching of the anus,
followed by a feeling of fullness, throbbing, and acute pain,
the latter extending up the sacrum and down the inside
of the thighs. Hemorrhage took place, and after it had
occurred a few times the feeling of fullness and pain became
much less. On making an examination, the margin of the
anus was observed surrounded by external piles in a state of
semi-distension ; digital examination of the bowel demon-
strated ao internal pile on the right side, the size of a
cherry, and having a broad base. I directed her to return
home, and to confine herself to the recumbent position. To
have an enema of a pint of thin gruel, thrown up the bowel
at once, and to take, at bed-time, a tcaspoouful of an elec-
tuary containing copaiba.
Oct. 3. — The enema brought away a quantity of indu-
rated fteces. The bowels had acted twice this morning at-
tended with hicmorrhagc. To continue the electuary at bed-
170
H-«MOERHOinAI. AFFECTIONS.
time, and to use half a pint of cold water, coniauung a
scruple of tannic acid as an enema after each stool.
Oct. 6. — She loses much less blood at stool ; the confec-
tion moves the bowels twice a day. To inject cold water
only after defecating, and to use soap and water cxtemaUy
night and morning.
Oct. 16. — But slight bleeding now occurs. She is much
troubled with flatulence. To continue the enemata of cold
water and ablutions. To take every night seven grains of
compound rhubarb pill, two grains of blue pill, and two
grains of extract of henbane ; and, twice a day, one ounce
of compound infusion of gentian, 6ve grains of carbonate
of ammonia, and a drachm of compound tincture of carda-
moms.
Oct. 20. — Since I last saw her no bleeding has occurred ;
her countenance is brighter, her tongue clean, and the
bowels act regularly. The external piles are collapsed,
leaving an irregular fold of integument half an inch in
length around the anal margin.
April 7, 1853. — This patient continues free from all pain
and inconvenience, she takes the pills occasionally, and has
not omitted to observe ablutions with soap and water night
and morning.
Strangulated internal piles, preceded by excessive
heeviorrhage-
D, B , xX. thirty-four, a jeweller, applied at the Blen-
heim Dispensary, Sept. 27, 1852; he is above the average
height, of ordinary conformation, bilious temperament, com-
plexion unhealthy, habitual state of mind melancholy, habits
HjEMORRHOIDAL AFFECTroNB- 171
of life irregular. He has suffered for fourteen years from
esternal piles ; during the last four years has lost a con-
siderable quantity of blood from the rectum, and has experi-
enced great pain within the gut.
The present attack commenced on Sept, 25, with exeru-
ciating pain in the rectum, aggravated at stool, and attended
with copious hsemorrhage. His countenance and lipa are
pallid, pulse feeble and quick, akin dry and hot, tongue
furred. On making an examination, I perceived four large
internal piles prolapsed and tightly embraced by the
sphincter; the thin integument around the anus raised in
folds. Ordered him to go home and to bed. I visited him
at his house, and returned the prolapsed piles ; in doing this
it was necessary to make very firm and continued pressure.
To be cupped over the sacrum and on the perinaeum. An
ounce of castor oil to be taken inamediately, and hot fomen-
tations to be applied to the anus.
Sept. 30, — He is in less pain, the bowels have acted twice,
the piles are prolapsed ; they were returned with greater
facility than yesterday, and were less congested. Three
grains of gray powder and fotir of Dover's powder to be
taken at bedtime, and a teaspoonful of a purgative electuary
in the morning. To continue the fomentations, and to
return the piles should they be prolapsed at stool.
By observing the treatment directed, the acute symptoms
soon subsided. I proposed removing the tumours by liga-
ture, but, being free from pain, he preferred waiting the
cliance of another attack. Ordered him to use soap and
water externally night and morning, and to inject half a pint
of cold water after each dejection.
172 BAIMORRHOIDAL AFFECTIONS.
Dec. — By following the injunctioiis given him he haa been
free from pain, but the tiunours are occasionally protruded,
and he has lost, from time to time. a. small quantity of
blood.
Nov. 1853. — At the present time 1 have a patient under
my care with a very close atrictnre of the urethra, who
was acquainted with D. B — ; he informs me that he died
a few months since of some acute disease of the chest,
following a drunken bout and exposure for several lughts.
He was very clever at his business, but seldom worked more
than three days in the week ; the remainder he spent in
debauchery.
Internal hesnwrrhoida, much loss of blood, attended toitk
ffiddiness and drowsiness ; oxalvria ; relief by medical
treatment.
R, R , aet. thirty-eight, was advised to consult me by
my friend, Mr. William Bennett, surgeon to the Bloomsbury
lufirmary. About fourteen years since he first suffered from
external piles, which have continued to trouble him more
or less up to the present time ; eight years ago he experi-
enced pain within the anus, and a sensation of the presence
of a foreign body ; defecation was difficult, attended with
increase of pain and htemorrhage, and from that period he
has continued to lose a considerable quantity of blood at
intervals; he has also been annoyed by a constant discharge
of mucus from the bowel. H has always been subject
to constipation, and suffered from ilatulcnce, pain in the
abdomen, giddiness of the head, and dcpi-ession of spirits.
His habits of bfc arc temperate.
lI.EMORBHOlDAL AFFECTIONS.
173
. the lOth of Nov., 1852, hia coim-
Hc came t(
tcnaocG was sallow, eyes dull, tips and gams pale, tongue
furred, pidse frequent and irritable, bowels acting scaiitily
and irregularly; has little power of retainiug his fieccs
during any violent exertion ; the bladder is irritable, aud
he has some diffieulty in micturating. Tbe anal orifice is
surrounde^l by a margin of loose skin, evidently collapsed
external piles; the sphincter ani is relaxed. Introducing
the finger within the intestine, two large internal htemor-
rhoida were felt; these were extruded by a very slight
effort at straining, and the mucous membrane was then seen
in a gramdar state. He informed me that the liaemor-
rhoidal timiours descended by walking or riding in any
vehicle that shook him much. To take six grains of ex-
tract of taraxacum, and three grains of blue pill every
night, and in the morning a teaspoonful of an electuary
compounded of confection of senna, sulphur, bitartrate of
potash, jalap, copaiba, ginger, and a aufiicient quantity
of syrup. To use ablutions of soap and water night and
morning.
Nov. 14, — He has taken the medicines ordered, and the
bowels have acted every day, but not freely; he passed some
clots of blood yesterday, and this morning a table-spoonful
of bright blood. To continue tbe remedies.
Nov. 17,— He has had very little pain, and passed but a
small quantity of blood ; still complains of drowsiness and
giddiness. Examination of the urine demoustratcd an ex-
cess of urea, and under the microscope numerous crystals of
oxalate of lime were seen.
njKMORRHOIDAL AFFECTT0N8.
^ laluai Oontiiuiffi comp., Jx : Magnesite Sulphatis, |} ; Aridi
Sulphurici dOuti, Bias. M. fiat mist. ; eumat cocbL ij
magna bia in die.
To inject half a pint of water, containing sixteen grains of
sulphate of zinc, after each evacuation of the bowels.
Dec. 1. — He has taken the medicines regularly, and used
the enemata as directed ; feeling so much better, he did not
think it necesBary to see rae at an earlier period ; he has
had no sanguineous discharge the last twelve days; a slight
mucous discharge continues. He can now retaiu his &ecca
during exertion ; he was drowsy on one occasion since hiK
previous visit to me, but is not so now ; his eyes are bright,
countenance clear, pulse 76 ; the irritability of the urinary
organs has ceased.
Dec. 15. — Has continued the medicines, and expresses
himself as feeling better than he has for many years ; his
countenance is clear and healthy, pulse regular, appetite
good; he does not suffer from flatulence, haa gained strength,
and does not feel fatigac after an ordinary amount of exer-
cise. To inject cold water only after each atool.
This patient visited me in May, 1853; he had continued
to take the medicines occasionally, aud had not omitted the
injection of the cold water ; the only annoyance he experi-
ences is a mucous discharge &om the anus. I examined the
IkjwcI : the internal piles are still large, but not turgid ; the
mucous membrane is in a much healthier condition. Re-
moval of the piles was adrised in the first instance, but his
occupations prevented him laying up for a few days, and as
he now suffers but little comparative inconvenience, he ia
content to remain as he is.
HEMORRHOIDAL AFFECTIONS,
Internal htsmorrkoida ; loss of blood, cessation of the
catamenia; health restored without operation.
Miss , ffit. twenty-two, of ordinary stature and con-
formation ; her health had declined three years previously to
her coming nnder my care. The menses appeared when ehe
was sixteen, and continued regularly till she was nineteen ;
they then became scanty, and twelve months afterwards
ceased altogether ; she became pale, lost flesh, suffered from
dyspepsia, had frequent headaches, and was extremely ner-
vous. Change of air had been tried, and she bad been
under medical treatment at various places.
On qiiestioning her as to her aymptoms and the state of
the bowels, I learned she had always been costive, and, at
the commencement of her iu disposition, she had pain and a
feeling of fullness in the lower howcl, which increased in
severity ; after a time she lost blood per anum when the
bowels were moved, the quantity increasing with the persist-
ence of the disease, aud the last two years she never visited
the closet without losing more or less. She had not men-
tioned the circumstance to her mother or to any of the
medical men under whose care she had been; the reason she
assigned for not having done so was that she had never been
questioned on the subject. She was perfectly antemic, her
pulse was feeble and irritable, she had frequent headache,
which was increased by walking, or even by sitting upright,
her extremities were eold, the eyes dull, tongue furred, the
countenance had a waxy unhealthy appearance; the ab-
domen was hard, and the bowel slightly descended at stool. I
ire
H,«MORRIIOIDAL AFFKCTIUNS.
made an examination, and found two li^moirhoidal tutnouTB.
Medicines and encmata were prescribed to unload the bowels,
afterwards an astringent iojection was used after each CTacu-
ation, for which cold water was substituted in about a fort-
night. ChalybeatcB and laxatives were then orderedj and
under this plan of treatment she perfectly regained her health
and strengtli, and was able to resume the equestrian exercise
she had previously been accustomed to,
Internal and external {Hemorrhoids induced by stricture of
the urethra ; excision o/ external piles ; subsidence of
internal piles by cure of stricture.
G. B , *Et. forty-three, married, of robust constitu-
tion ; for a long period had obscn'ed the stream of urine de-
creased in size, and, for some months before applying to me,
it had not been larger than a small crowquill, and if the
weather was wet or cold he passed it in drops only ; he had
frequent desire to urinate, and was obliged to get out of bed
aeveral times each night; during micturition be strained
violently. For nine months he had suffered from internal
and external piles attended with frequent paroxysms of pain
and bleeding. Although suffering much, he had neglected
the stricture of the uretlira ; he sought my advice for the
affection of the rectum. Tracing the progress of his mala-
dies, I conceived the hsemorrlioids to have been induced by
irritation and determination of blood, escited by the disease
of the urethra, and the straining that attended micturition ;
therefore it was necessary to relieve that affection before
benefit could accrue from treatment of the piles ; with some
difficulty a No. 2 catheter was passed through the stricture ;
H^MORRnOIDAL AFFECTIONS.
177
by the introduction of others, gradually increasing the size,
the canal was ultimately restored to its proper calibre ; during
tliis treatment the bowels were kept open by laxatives ; ab-
lutions of soap and water were used night and morning.
When the urethra was aiifficiently dilated to permit the urine
to pass without any straining, and the irritability of the blad-
der had subsided, half a pint of cold water was injected into
the rectum night and morning, after defecation, with the
effect of arresting the hsemorrhage. The two external piles
that existed were hard, and occasionally painiul, and if he
walked much were liable to get slightly excoriated, they were
therefore excised; the wounds healed readily; by attending
to keep the bowels easy, and continuing the injection of the
cold water, the symptoms of the internal hemorrhoids sub-
sided. There being a disposition in the stricture of the
urethra to contract, a bougie is passed once or twice, at in-
tervals of a few weeks.
Internal hemorrhoid ; loss of blood inducing suppression
of the menses ,- lemorrhma ; nitric acid applied to the
pile : health restored.
M. J , set. twenty-seven, married four years, has no
family. Tall and of ordinary conformation. Her habits are
sedentary ; previous to her marriage she followed the occu-
pation of a dressmaker; she had suffered much from dys-
pepsia and constipation. About the end of 1819, she began
to experience discomfort in the rectum, having a sense of
fullness and aching in the part ; these disagreeable sensa-
tions increased, and, in a few months, resolved themselves
into acute pain, which was aggravated after a motion ; the
12
178 H/EMORRHOIDAl. AFFECTIONS.
bowels acted very irregularlyj sometimes not for several days,
at other times diarrhoea supenened. In a short period after
the accession of acute pain, she began to lose blood per
amim ; the quantity increased, and varied from a table-spoon-
ful to half a pint ; at times it was florid, at otbers dark and
clotted. The menses became irregular, and at length ceased,
and she was troubled with leucorrlicea. Slie had liad advice,
and taken various medicines, such aa confection of senna,
blue pill, saline purgatives, but without benefit.
When 1 saw ber — autumn, 1850 — she was pale, weak, and
nervous, suiFering from frequent headache, which was in-
creased in intensity in the upright position ; her feet were
always cold, and she complained of flatulent distension of
the stomach and abdomen, and great pain in the rectum,
attended with mucous discharge and bsemorrhagc at stooL
Ordered a dose of castor oil to be taken in the morning, and
a pint of thin gruel as an enema, two hours al'terwards. Tlie
bowels acted several times, and when I visited her the intes-
tine was slightly prolapsed, rendering visible the margin of
a florid, granular excrescence of the mucous membrane ; by
pressing the intestine down, the whole diseased surface was
brought into view; it was about five eighths of an inch in
^ameter, and of an oval form ; the rest of the intestine was
healthy. Laxatives and tonics were prescribed to regulate
the bowels, and restore her general health ; and to restrain
the Weeding, cold water, containing lead, zinc, and other
astringents, was injected twice a day ; she was also confined
to the sofa. The treatmcut was persevered in for a month,
with the effect of improving her health, but not relieving the
pain in the bowel, or diminishing, in any sensible degree,
H.EMOHRHOIDAL APFECTIOSS. 170
the hsemorrhage. It was, therefore, determined to apply
nitric acid to the morbid tissue. Tlie bowels having been
thoroughly freed, and the mucous membrane made to descend
by the administration of an enema, concentrated nitric acid
was applied to the diseased part, which was afterwards
smeared with oil, and the intestine replaced. An opiate was
administered, the patient experienced but slight pain after
the operation, and slept well at night. On the third day she
had some castor oil ; when the howels acted she felt some
smarting, but no hfemorrhage occurred. She was directed
to inject four ounces of cold water, containing eight grains
of sulphate of zinc, night and morning. In rather more than
a fortnight all local disease had disappeared ; by the use of
tonics, attention to the bowels, and taking exercise, she re-
gained hcj health, the leucorrhcea ceased, and the catamenia
re-appeared at proper intervals.
Internal hmmorrhoids ; the patient upwards of eighty
years of age; successful treatment by nitric acid ; irri-
tability of the bladder ; phosphaiic urine.
A gentleman, upwards of eighty years of age, applied to
me, three years since, complaining of a sense of fiUlness in
the rectum, and a constant desire to defecate; he stated that
whenever he visited the closet he lost a small quantity of
blood, and that a protrusion of the bowel took place [ he ex-
perienced no difficulty in returning it, but it often descended
when he walked. He had tried several forms of mechanical
appliances to retain the bowel in its position, but they failed
in the intention, and oiUy occasioned him uneasiness and
180 HjEMORRnOlCAI. AFFECTIONS.
aimo^ance. Making an examination, 1 found two h^moirhoidal
tumonra prolapsed, their Burfaees were florid and granular,
and one tumour was slightly ulcerated ; the lower part of
the intestinal canal was loaded with scybala, the pouch of the
rectum was much dilated, and appeared to have little power
of contracting. The prostate gland was indurated and
slightly enlargedj his urine was alkaline and thick. I first
directed attention to unloading the howels, which was effected
by aperients and encmata ; and afterwards restoring tone to it,
by the administration of small doses of strychnia, and the use
of astringent injections ; these objects were accomplished; but
the bowel continuing to descend and my patient being much
troubled by the sense of fullness in the rectiun, I applied the
concentrated nitric acid to the htemorrhoidal excrescencea ;
the pain it occasioned was ao slight that no confinement waa
necessary. On the third day after the operation, the bowels
were moved by medicines, and their action was attended with
considerable smarting; each succeeding day this was less,
and in ten days all inconvenience from the haemorrhoidal
disease was removed, and he has had no return of it since.
On several occasions the irritability of the bladder has tor-
mented him much, the urine at these times depositing a large
quantity of phosphate of ammonia, forming a tenacious mass
adhering to the Imttom of the chamber utensil. This condi-
tion was relieved by the administration of small doses of
morphia and nitric acid, and washing out the bladder with
water slightly acidulated with the same acid. This gentle-
man continues under my care, and by washing out the bladder
more or less frequently as the condition of tlie urine necessi-
tates, by the use of aperients and tonics as occasion may re-
HEMORRHOIDAL APPECTIONB. 181
quire, he is able to pass the time very comfortably, aad to
take exercise when the weather permits.
Internal hemorrhoids, excessive pain ; treated with
nitric add.
Mrs. , let, thirty-three, married; the mother of four
children, the youngest three years old, of delicate consti-
tution, has always suffered during her pregnancies from
enlargement of the veins and oedema of the legs ; the bowels
at those perioda were particularly obstinate ; she baa always
been of costive habit, and has had constant recourse to pur-
gatives, chiefly saliuea ; during the period of gestation she
has also suffered &ora external piles. In 1848 she began
to experience aching, weight, and fullness in the rectum ;
htemorrhage occurred at intervals, increasing in quantity
as time rolled on. Pain in the bowel became very dis-
tressing.
When I was consulted (1850) she had not been able to
leave the house for some weeks, and had been confined to
the couch, feeling easier in the prone position. She was
pale, nervous, and debilitated ; the menstrual secretion had
been scanty and occurred at lengthened intervals ; she com-
plained of acute pain in the rectum, increased to a violent
degree at stool, followed by hffimorrhage of an arterial cha-
racter. Her skin was dry, tongue flabby and furred, pulse
small, urine scanty and high coloured ; appetite bad, it had
previously been capricious, sometimes voracious ; she had
pain at the epigastrium, and flatulence; the abdomen was
hard, and dulness on percussion in the course of the colon
182
HyEMORRIIOIDAL AFFECTIONS.
existed. Examining the rectum, it waa found loaded with
indurated feces ; on the right side, about three quarters of
an inch &om the margin of the anue, were two excrescences,
each about the size of a fourpenny-piece, their aurfaccs were
florid and granular in appcarajice, and bled freely on the
slightest touch. I proposed applying the concentrated nitric
acid to the morbid tissues ; but, it being necessary to unload
the bowels and get the constitution into a better state, the
following remedies were prescribed, and the patient ordered
to remain in bed.
IL Piliiluj Hydrargyri, gr. iij ; Pulveris IpecacQanhs comp.,
gr. V ; Extract! Glycyrrhizs, q, b. ; at fiant pil. i^. hora
somni eumends.
5t Pulveria Rhoi, gr. xviij ; Soda Potasaio-Tart,, Jiss ; Confec-
tionb Aromatici, gr. i ; Eesentue Cinnamomi, n[yj ;
Aquffl Cinnamomi, ^i^s, M. fiat haustus, primo mane
BumenduB.
y, Decoct. Hordei, Ixis ; Olei Bicini, Jj. M. fiat enema.
The remedies acted freely in the momiug, attended with
pain in the rectum and a considerable discharge of florid
blood.
Qi PotasGffi Citratis, ^ ; Potassie Nitratis, gr, sxx ; Tinctnna
Serpentariffi, 517 ; Aqux, Jv^e. H. fiat mist. ; sumat
cochl. ij, ampla tcr die.
The pills, draught, and enema were administered four
times, the abdomen became soft and the general health
somewhat better, but the pain in the bowel continued, and
hemorrhage occurred at each action of the bowels, which the
injection of cold water failed to check.
ILEMORRHOIDAL AFFECTIONS. 1S3
On the seventh day after I first saw her I introduced a
speculum ani, and touched the raised and granulated mucous
memhrane with the strong nitric acid, using a piece of lint
on the end of a probe; smarting was experienced at the
time, but this soon subsided, an enema of four ounces of
starch and thirty miuims of litjuor opii scdativus having
been injected into the bowel. Ten grains of Dover's powder
were administered at bedtime. She passed a tranquil night ;
on the third day the boweU were moved by a dose of castor
oil, smarting was experienced at the time ; she was directed
to inject twice a day four ounces of water and eight grains
of sulphate of zinc. In ten days the sloughs had separated
and the ulcerated surfaces nearly Iiealcd. The bowels were
kept open by castor oil. In a few days more she was quite
free from the local malady, hut was still pale and weak.
The foUowiug draught was prescribed :
^ Fern Ammonio Citratis, gr. v ; Potasss Bicarb., gr. sij ;
Magnesix Sulph., 3j ; Aquie, ^xj ; Synipi, ^ M. fiat
haustuB in actu efiervGacentiie cum ducci Uinonis cochl.
ample bis in die sumendus.
This medicine was continued for several weeks, and she
went out every day for a walk, or in her carriage if the wea-
ther was unfavorable. Her health became better than it
had ever been, the menstrual function was performed regu-
larly and was natural in (quantity.
H^MOHRHOIUAL AFFECTIONS.
Interval hantoTrhoids, preceded by dysentery ; great loss
of hload; stricture of urethra. Hemorrhoids treated
with nitric acid.
Major J , a tall, fine man, of a naturally good consti-
tution, but impaired by a long residence in India and active
military service ; had suffered several times from dysentery ;
for seven years had liad piles, frequently lost considerable
quantities of blood, the bleeding at times continuing for balf
an hour; defecation was always attended with pain and
much straining, the pain being aggravated when the fiecea
were bidky and indurated ; the bowel slightly descended at
stool, but returned by muscular contraction. He had had
various remedies prescribed, as lenitive electuary and sul-
phur, copaiba, Ward's paste, &e., but without benefit. No
examination of the bowel bad been made by the several
sui^eona he bad consulted. His countenance and conjunc-
tivie were slightly yellow; tongue covered with a creamy
fur; skin dry; appetite moderate; had flatulence, and fre-
quently felt fullness and pain at the epigastrium after eating ;
urine high coloured, and voided in a small stream, with some
straining; slight tenderness over the liver on pressure; no
enlargement of it indicated by percussion ; pulse feeble and
irritable. By examination after the action of the bowels,
the mucous membrane being prolapsed, a florid granular
surface, from which blood freely oozed, was observed; it
was about the size of a sliilliug, and slightly raised from the
surrounding tissue ; it was very painful when touched ; the
finger introduced into the rectum did not detect any tumour.
d
U^MORRIIOIDAL AFFECTIONS.
185
The treatment adopted was at first small doses of mercury
with chalk, and extract of taraxacum, aperients every second
morning, subsequently tonics, with nitric acid, and various
preparations of iron; enemata of cold water were used,
afterwards astringent fluids. Examination of the urethra
detected a stricture, through whicli a No. 3 catheter was
passed with some difficidty ; the introduction of instruments
twice a week was had recourse to, the size being gradually
increased, till the natural calibre of the urethra was restored.
By perseverance in the remedies, his general health was
much improved, the countenance became clear, the pain in
the region of the liver subsided ; but though feeling much
better, the bleeding from the rectum continued. Having
given medical treatment a fair trial without much benefit to
the local disease, I deemed the application of nitric acid
advisable. The bowels having been freely moved by extract
of colocynth and blue pill taken at night, and an enema
administered the following morning, the florid granular
surface of the pile was exposed by a speculum, and freely
touched with strong nitric acid, chalk-and- water being sub-
sequently used to neutralize the excess of acid, and prevent
injury to the surrounding tissue. After the operation, a
dose of laudanum was administered. On the third day, the
bowels were moved by castor oil; for some days subse-
quently he experienced smarting when at stool, but the pain
gradually lessened. He was directed always to use ene-
mata of cold water after defecating. It is now four years
since I attended this patient, and he has not had the
slightest return of any of the symptoms from which he pre-
viously su fie red.
H^MOBRHOIDAI. AFFKCTION9.
Internal hfEmorrhoida, viedical treatvicnt not arresthiff t
symptoms, the tumours removed hy ligature.
The Rev. , ret. forty-Beven, of ordinary stature, \
studious and sedentary habits, lived more freely than ■
compatible with the little exercise he was accustomed i
take; had long suffered ft^m constipation, flatulence, and
^ddiuess. For several years previous to my seeing him
he had been subject to haemorrhoids, attended with great
loss of blood at times. WTien he consulted me in the
spring of 1846, bleeding had occurred daily for three weeks,
which had greatly reduced him. On examining the intes-
tine three internal piles were discovered, two being much
larger than the other. His pulse was quick and weak, his
tongue furred, and skin dry. Ordered five grains of gray
powder, and six grains of Dover's powder to be taken at
bedtime, and one ounce of castor oil in the morning; an
hour after taking the oil a pint of thin gruel was thrown up
the bowel. The medicine and enema acted freely, bringing
away a large quantity of indurated fiecca, attended with pain
and a considerable loss of blood. The bowels were kept easy
by an aperient electuary, and eight ounces of cold water,
containiag a scruple of acetate of lead and twenty minims of
tincture of opium, injected twice a day ; the hemorrhage
continuing, turpentine and other remedies were tried, but with-
out any beneficial result. I proposed ligature of the tumours,
to which he was unwilling to submit. Mr. Liston then saw
him in consultation, and agreed upon the necessity of the
operation. On the following day, double ligatures were
i
HEMORRHOIDAL AFFECTIONS. 187
applied to the tumours, in the manner directed in the text,
and firmly tied ; a dose of castor oil and an enema had been
administered and had acted freely before the operation was
performed ; thirty minima of the liquor opii sedativus, in
camphor mixture, were given immediately afterwardB, Pain
was experienced during the afternoon of the first day. On
the third day after the operation, the bowels were moved by
castor oil; the ligatures separated on the fifth and sixth
days. The bowels were kept easy by emollient enemata,
and half a pint of cold water, containing sixteen grains of
sulphute of zinc, was injected twice a day. He was quite
well in ieas than four weeks ; be had taken the following
mixture for some days, and was ordered to continue it till
the bowels got into a regular state ;
Decocti CinchoniB, 5vsh; Tinctuara Cinohonse comp., jiv;
Magnegice SulphatJB, 5vj ; Acidi Sulphurioi diluti, ^.
Misce fiat mist, sumat cochl. ij, m^aa bis in die.
He was enjoined to take exercise every day, and to attend
to the condition of the digestive functions. I have not
heard of this gentleman since the sununcr of 1852, but up
to that time he had been quite free from any bfemorrhoidal
affection.
Internal lnEviorrlioids, great ioss of blood, removal of
the tumours hy ligature.
K, M , aet. thirty-seven, single, a cook in the service
of my friend and colleague, Mr. Hulmc, who requested me
to see her, as be was then suffering from severe indisposi-
tion. She stated she was first attacked with piles ten years
1S8 HJIMORRHOIDAL AFFECTIONS.
ago, and has never been well since ; for the last five yean
she has lost a considerable quantity of blood at intervals.
Hajmorrhage had been going on for three weeks previously
to my seeing her (Feb, 1853) ; she had not informed Mr.
Hulme of her indisposition till she was no longer able to
keep about ; he ordered her to bed, and directed cold and
astringent appHcations. When I saw her she was perfectly
blanched and hardly able to turn in bed ; her pulse was feeble
and quick ; on making an examination, the anus was observed
surrounded by a fold of integument greatly distended, and
having a pale semi-transparent appearance. Three internal
hsemorrhoidal tumours existed ; they were pendulous, and
about an inch in length and three eighths of an inch in
diameter; the mucous membrane was granular, and bled
freely on being slightly touched.
Taking into consideration the duration of the disease, the
state of the patient, and the condition of the tumours, I
deemed removal of them by ligature the most appropriate
plan of treatment. Early in the morning she had taken a
dose of castor oil which had acted freely, it was therefore
determined to perform the operation at once ; an enema of
worm water was administered, and on being ejected the
tumours were prolapsed ; double ligatures were then passed
through each of them, and tied tightly so as entirely to
interrupt all vascular and nervous connection. The ends of
the ligatures being cut oflT, the piles were returned within
the sphincter ; thirty minims of tincture of opium were given
for the purpose of producing temporary constipation and of
tranquillizing the system.
On the second day after the operation she had pain in the
HEMORRHOIDAL AFFECTIONS. 189
bowel, and sbght difficulty in micturating. Directed to have
a hip-bath ; to take a dose of castor oil the following morn-
ing, and to have an emollient enema injected twice in the
twenty-four hours.
The whole of the ligatures had separated by the eighth
day, no bleeding had occurred since their application. Slight
inflammation of the rectum supervened, which was due to
the patient not attending strictly to the directions given her
with regard to diet and medicines ; it speedily yielded to
simple treatment, and she made a favorable recovery. The
external fold of oedematous integument coUapsed, and the
anal orifice resumed its natural size. She has had no pain,
hsemorrhage, or other symptoms of the disease, and continues
perfectly well.
Internal piles; catamenial and litBrnorrhoidal fiux
alternating; tumours removed by ligature.
M. C , let, thirty-nine, married twelve years ; has had
five children; for several years has suflfercd from internal
piles, which first appeared wliile ahc waa pregnant with her
second child ; prior to that time she enjoyed good health.
She placed herself under my care in 1845 ; she was then
pale, nervous, and weak. During the preceding twelve
months the hsemorrhoidal affection had troubled her greatly ;
her bowels were torpid, never acting without being excited
by medicines ; she experienced great pain in the bowel, up
the sacrum, in the loins, and down the thighs. Sometimes
at the catamenial period profttse haemorrhage occurred from
the rectum and superseded the uterine function ; on other
occaeiouB the menstrual fiow appeared in due course, and
100 HEMORRHOIDAL AFFECTIONS.
then there was little or no bleeding irom the piles. In the
intermediate time she lost blood whenever the bowels acted,
and was much troubled with mucous discharge. Her pulse
was quick and weak, her skin pale, dingy, and clammy ;
she complained of violent palpitation of the heart from the
slightest exertion; her feet were always cold, and swelled
much during the after part of the day. I examined the
bowel, the amis was somewhat relaxed, and two large inter-
nal hsemorrhoids were partly prolapsed, they were highly
congested and very painful. The first object was to improve
her health generally ; for this purpose she took small doses
of gray powder and Dover's powder at bedtime, and castor
oil in the morning ; also, for a few days, a misture of citrate
of potash and nitrate of potash in camphor julep ; afterwards
the ammonio-eitrate of iron in infusion of calumba ; several
enemata were exhibited. In ten days her health was im-
proved ; the bleeding from the piles, though not so profuse,
still eontinued ; she had considerable pain at times, and ex-
perienced great annoyance from the mucous dischai^e and
prolapsus of the tumours.
It being determined, after due consideration, to apply a
ligature to the hsemorrhoids, a large enema was thrown up
the bowel by an elastic tube, and after it had come away a
double ligature was passed through the base of each tumour
and tiedj the ends were then cut olf and the parts returned
within the anus. My late and lamented friend, Mr. Morton,
attended the case with me, and kindly lent me his assistance
on the occasion. Some pain was experienced during the
night, and in the morning she felt slight difficulty in passing
her water; these symptoms were relieved by a hip-bath.
HEMORRHOIDAL AFFECTIONS.
191
and warm poulticcB to the anus ; a draught of hyoacyamuB
and nitric eether in camphor mixture was prescribed. On
the third day after the operation the bowels were moved by
a dose of castor oil, which was repeated every second day
for a fortnight. The first ligature separated on the sixth,
and the last on the ninth day ; six ounces of water, contain-
ing twelve grains of sulphate of zinc, were then injected up
the bowel night and morning. In three weeks the local affec-
tion was quite cured ; but as the bowels did not act freely, and
she had not thoroughly regained her strength, the following
medicines were prescribed :
^1 InfuBi Sennce comp., Infiisi Ciuchonae, iiu jvj ; Potassae Sul-
phatiti, gr. XXX ; Liquoria Taraiaoi, Jj. M. fiat haustus
primo mane sucneudus.
^ Infiiai Galumbfe, JvsB ; Ferri Amraonio-citTatis, jkb; Spiritas
Ammonice Aromatici, 5) ; Syrupi ZiogiberiB, 5iij> Miaco
fiat Mist ; capiat eochl. ij, magna bis in die.
She continued the remedies for a few weeks, in which
time her health was restoredj and the catameuia become
regular.
Internal hemorrhoids; eadsteitce for several years ;
operation by ligature.
Mr, S , set. forty-three, tall, muscular system of ordi-
nary development ; is of very rcgidar habits, and moderate
in reganl to both eating and drinking. Being engaged in
business, he is not able to take much exercise. He has
always been of costive habit, the bowels not generally acting
oftener than once in two or three days. For many years he
193 H/EMORRHOIDAL AFFECTIONS.
has suffered from the several aimoying and diBtressing symp-
tomB usuully attending internal hsemorrlioids. About eight
years previous to applying to rac, the piles descended at
stool ; for a time they were retracted after defecation, but
for several years he has been obliged to replace them : for
two years they have protruded from the anus on his assum-
ing the upright position. The discomfort and annoyance
caused by their constant protrusion became ao great as
seriously to interfere with all the pleasures and enjojinents
of life. He had not had advice for several years, liut had
treated himself, and possessed most of the hooks that had
been published on the subject for a long time past. His
countenance was clear ; tongue but slightly fiirred, and not
notched by the impressions of the teeth ; his skin was eool,
and the urine free from deposit. The sphineter ani was
relaxed, and two hscmorrhoidal tumours, the size of hazel-
nuts, dense, and hut slightly compressible, were prolapsed.
By passing the finger into the rectum they were found to
be connected to the upper margin of the internal sphincter.
It being evident that removal of the tumours was the only
treatment that could relieve him, and the state of the con-
stitution admitting the immediate performance of the opera-
tion, it was decided that Hgatures should be applied.
The following medicines were prescribed ;
pj Eitracti Colocynthidia comp., gr. yjj Pilulie Hydrargyri,
gr. iv. Mistw fiant pilulie ij, bora somni sumcndte.
B> Infusi SeuniB comp., Jij; Iniiui Cinchonte, ^vj; Pulveria
Rhei, gr. viij ; Potassag Tartratis, ^ ; TinctuKB Carda-
momi comp., ^. Fiat haustus, primo mane aumendus.
ft Decocti Hordci, Jxi. Fiat enema.
H HEMORRHOIDAL AFFErTIONS.
The 1)owela by these remedies having been very freely
acted on, in the afternoon I passed a double ligature through
the base of each tumour. They were seized separately by a pair
of forceps, and drawn down by Mr. Henry Thompson, who
kindly assisted me, while I transfixed them with a needle.
The ligatures having been drawn thoroughly tight, the ends
were cut off within half an inch of the piles, which were then
returned within the rectum. Half a drachm of tincture of
opium in camphor mixture was administered immediately.
On the second day after the operation, my patient, feeling
no pain, had left his bedroom. His skin was cool, tongue
moist, and pulse quiet. A laxative was prcseribcd to be
taken if the bowels did not act the next day. In ten days
this gentleman called on me ; the ligatures had come away,
and the parts had quite healed. I advised him to take an
aperient and tonic mixture to get the bowels into a regular
state, and to inject half a pint of cold water after defeeating.
This plan of treatment had the desired effect, and he has
not since experienced the slightest in<
Internal hcemorrhoid ; constant descent of tumour ;
removal hy ligatare.
Mr. , ffit. thirty-seven, residing in Porehcster Terrace,
of ordinary stature and conformation ; nervous, anxious dis-
position, has always experienced difficulty in regulating hia
bowels, which have been habitually constipated ; not accus-
tomed to active exercise. For several years he has lost blood
at stool, and at times had severe pain in the rectum, which
rendered him incapable of bodily or mental exertion. Two
18
H^MORRHOIDAI. AFFECTIONS.
years previously to his coining under my obBcrvation, a tu-
mour dcacende<l from the bowel when at the closet, and
since its first descent, it has always been necessary to re-
place it by the finger. He mentioned tliese facts to Dr.
Quain, his physician, who desired him to eousidt me. His
pulse was weak; countenance pale; eyes dull; tongue
fiured; abdomen hard; ekin dry; urine cloudy, which,
under the microscope, presented numerous octahedral and
dumbbell crystals of oxalate of lime. The sphincter ani was
contracted ; the mucous membrane of the rectum was ob-
8er\'ed to be congested. By digital examination, a tumour,
the size of a cherry, was detected, attached to the upjicr
and anterior margin of the internal sphincter by a fold of
mucous membrane ; it was firm, and but slightly elastic.
From the nature of the tumour it was decided to remove it
by ligature. He remained under the care of Dr. Quain for
three weeks, during which time his general health was
greatly improved. The bowels having been thoroughly freed
by the administration of four grains of blue pill, and six
grains of compound coloeynth pill at bedtime the previous
night, and castor oil and an enema in the morning, with the
assistance of Mr. H. Thompson, I applied a double ligature
to the tumour, transfixing its base with a needle fixed in a
handle. He remained in bed three days, and experienced but
little pain. On the fourth morning he took a dose of castor
oU ; the bowels acted freely, attended with some uneasiness
in the part. He was directed to get up, but desired not to
stand or sit too much. The following draught was prescribed,
to be taken every morning: Compound infusion of gentian,
one ounce and a half; sulphate of magnesia, one drachm;
H.CMORRHOIDAL AFFECTIONS.
195
carbonate of magnesia, ten grains. One ligature came away
on the fifth day, and the other on the ninth ; for some days
afterwards he had smarting at stool, but it gradually sub-
sided. He took the medicine for throe weeks, after which
the bowela acted freely each day without it ; he had greatly
improved in appearance, was quite cheerful, and depressed
himself as being better than he had been for many years.
Jnternal hemorrhoid, attended with great pain, bleeding,
and constant descent of the tumour ,- ligature applied.
The following case was also sent to me by Dr. Quain :
Mr. , a publican, tall and stout, his eyes dull, and
sclerotic conjunctiva yellow, his tongue large and flabby,
covered with a thick fur, and the edges deeply notched by
the impressions of the teeth. He informed me that he took
httle or no exercise, sometimes not leaving the house for
upwards of a week ; he lives freely, but is not often intoxi-
cated; has always suffered from constipation, and Lad long
been annoyed by dyspeptic symptoms, as well as various un-
comfortable sensations in the rectum. Four years previous
to applying to me, he discovered that " a lump" descended
at stool, attended with bleeding and severe pain; it bad
L always been nccesHary to replace it with his fingers. Digital
I examination detected on the right side an indurated pile,
■ attached to the bowel, about two inches above the anus.
I An enema being administered, a pile the size of a large
B cherrj' was extruded. Considering the density of the tu-
I mour, its constant descent, and the strong desire of the
H patient to be relieved of his sufferings, it was decided an
HyfiMonnilOIDAL AFPKrrlONS.
operation should be performed. Under the judicioiiR treat-
ment of the physician who referred him to me, in ten days
the constitntional defects were remedied. At the expiration
of this time, with the assistance of my friend and colleague
Mr. Holme, I carried a needle, armed with a donblc liga-
ture, through the base of the tumour, and tied it firmly iii
two portions. The bowels had been freely relieved prcvioua
to the operation; after it had been performed, a dose of
opium was administered. Por four days, there was slight
feverish cxeiteraent and redcraa around the anus. Tliese
yielded to salines, low diet, and linaccd-mcal poultices. On
the third morning, he took some castor oil, and repeated it
every second morning for a few times. Enemata of ftaxseed-
tea were daily used. By the eleventh day, the ligatures had
come away, and the ulcers resulting had quite healed. The
necessity of taking escrcise was strongly impressed on Mm,
and he was directed to inject half a pint of cold water after
defecating, to use soap-and -water externally morning and
evening, to live moderately, and to keep the bowels regular
by the following mixture ;
^ Infusi Senoie oomp., jiv ; Infuai OentianK comp., jiij ;
Putassm TartratiB, ^iv; Tinct. Aurantii wmp., Synqu
Aurant., aa "^ir. Fiat miBtiira; capiat cochl. iij, ampla
Internal hcemorrhoida, great loss of blood indiidng de-
bility and palpitation of the heart; an ulcer at the
posterior part of the rectum, with considerable indu-
ration of the »urroundin(/ tissues.
The Rev. C. C — , let. fifty-three, residing in the North of
H.EM0IIRHOIDAL AFFECTIONS.
197
Ireland, came to London, to consult me for an affection of
the rectum which commenced ten years previously. At that
period, he experienced itching and a fulness ahout the
fuudament, and occasionally lost a small quantity of blood;
the accession of these symptoma was soon attended with
protmsion of tumours from the bowel each time he visited
the closet, and lie was seldom &ce from pain in the rectum
and sacral region. He gradually grew worse, and for the
last four years, he daily lost a considerable quantity of
blood, and any slight exertion was attended with violent
palpitation of the heart, and a feeling of faintuess; he also
suifercd from cramps in the legs, and great irritability of the
bladder, inducing a frequent desire to micturate. He had
tried various medicines that had been prescribed, and had
been for twelve months in Germany, drinking mineral
waters, but experienced no benefit.
When I first saw him, hia countenance was pale, hia lipa
and gums colourless, and the tongue much furred ; the eyes
were dull ; his pulse was weak and irritable. By straining
slightly, an indurated hiemorrhoidnl tumour the size of a
chestnut was made to protrude ; the finger being introduced
into the bowel, it was found to be connected with the npper
margin of the internal sphincter. At the posterior part of
the rectum, an ulcer three eighths of an inch in diameter
was felt ; the tissues annexed were so dense as to raise a
suspicion of cancer in the mind of a medical friend who
examined him also, but in this opinion 1 did not coincide.
Blue pill and i|)ccacuanha were directed to be taken at
bedtime, and a tonic and aperient draught every morning.
After using these remedies for six days, his general health
198 HAMORRHOIDAL AFPECTI0N8.
being mucli improved, with the aasiBtasce of Mr. H.
Thompson, I passed a double ligature through the base of |
the hemorrhoidal tumour, and tied it in two portions. I
afterwards, with a probe-pointed knife, carried up on the
index finger of the left baud, incised the ulcer on each side i
of the median line. On the third day, the bowels were j
moved by castor oil ; on the sixth day, the ligatures came j
away ; he suffered so little after the operation, that he was j
now able to leave the house. He was directed to take the ]
following draught twice a day for three or four weeks :
$t Syrupi Ferri lodidi, Jj i Tinctunc Fern SeaquicUor., mxi ;
Aqua:, 5xj. Ft. haustus.
And he very shortly returned to Ireland. Three montha
afterwards, passing through London, on his way to Brussels,
he called on me ; his countenance was florid, and he informed
me, he had been perfectly free from all symptoms of his
former complaint; that he could walk many miles withoat |
fatigue, had been free from palpitation, and had gained a I
stone and a half in weight. I examined the rectum, all i
induration had diaappeared, and no evidence of former dis-
ease remained. I saw this gentleman again, a few months
since, and he remains quite well.
ENLARGEMENT OF THE HiEMORRBOlDAL VEINS,
The hEemorrhoidal veins arc liable to dilatation quite
distinct from, and not to be confounded with the morbid
condition of the several tissues constituting piles. They
assume precisely an analogous condition to the veins of
the testicle forming varicocele, and to the branches of
the saphena vein constituting the troublesome affection
generally known as varicose veins of the leg.
There are certain physiological causes that predispose
to the enlargement of the htemon-hoidal veins, and others
that arc pathological. It will be remembered that the
portal system, which commences in the veins of the
rectum, is destitute of valves, consequently the radical
branches are subject to the pressure of the entire column
of blood. Impediments to the venous circulation are
very liable to occur from congestion of the Hver, from
pressure on the venous trunks by overloaded and dis-
tended intestine, by the pregnant womb, and abnormal
abdominal tumours.
Generally there appears to exist a predisposition to
200 ENLARGEMENT OP TUE
venous dilatation in those who have the baemorrhoidal
veins enlarged, it being not unusual to observe it asso-
ciated with varicocele and a varicose condition of the
branches of the saphena veins.
The symptoms are a sensation of weight and disten-
sion about the rectum, uneasiness in the loins, a fa'Iing
of sinking and general lassitude, and the same mental
depression which is observed to attend dilatation of the
veins of the leg and testicle. The dilated veins may be
felt on cither side of the rectum like a bundle of earth-
worms, the same as in varicocele. They sometimes form
tumours, projecting internally or exteniuUy to the
sphincter, but their appearance is very different from
those caused by haemorrhoids.
Since the publication of the first edition of this work,
through the kindness of my colleague Mr. Hulme, I had
an opportunity of examining a very aggravated case of
this disease occurring in a female, a patient of his, at the
Blenheim Dispensary. The veins formed large tumours
around the anus, aud as far as the finger could reach were
felt extending up the rectum ; the veins of both labia were
also greatly dilated, and conveyed to the touch the feeling
that has been described. In other cases which have
come under ray notice, the veins have not formed tumours
external to the sphincter ani umscle, but could be dis-
tinctly felt within its margin, and were attended by the
symptoms above mentioned.
HEMORRHOIDAL VKTNS.
Surgery will be of no avail either in the cure, or in
the relief of this affection; but by judicious medical
treatment the symptoms and distress arising therefrom
may be much mitigated. It is most essential that at-
tention be paid to the proper performance of the chylo-
poietic organs, that constipation be not permitted to exist,
and that the skin and kidneys shoidd duly perform their
functions. Moderate exercise will be beneficial, aa the
venous circulation is thereby facilitated; the patient
should avoid standing for any long period, as the erect
posture favours gravitation of the blood. The subjects
of venous dilatation being generally of lax fibre, they
will be much benefited by the use of tonics, more espe-
cially the mineral acids. Six or eight ounces of cold
water may be injected into the rectum twice or
thrice a day with advantage, the cold-bath and ab-
lution in cold water, night and morning, will afford
great reUef, as also will a jet of cold water directed
agtuQst the anus.
PR0LAPSD8 OF THK RECTUM.
Independently of the eversion of the mucous mem-
brane that frequently attends internal haemorrhoids, and
which has been considered in the Chapter on Hffiuior-
rhoidal Affections, the rectum is subject to protrusion
from other causes.
Prolapsus or procidentia ani, are the terms by which
this form of disease is familiarly known ; an error in no-
menclature very evident from the fact that the anus is
merely the terminal a])ertare of the alimentary canal,
and cannot therefore itself be protruded. Prolapsus
recti is now very properly used by several recent writers,
and conveys a correct idea of the affection.
Two forms of prolapsus recti occur : in the one the
whole of the tunics of the rectum descend, in the
other the mucous membrane alone is prolapsed. By
many former writers it was maintained that the mus-
cular coat of the intestine was never extruded, but
preparations which are to be seen in King's College
and other museums, incontestably show the opinion to
PEOLAP8U8 OP THB RBCTUM.
203
be erroneous ; in the large majority of instauces, parti-
cularly where the eversion does not take place to a great
extent, it is the mucous and submucous areolar tissue
only that descends ; the firmer attachment of the mus-
cular coat to the surrounding parts and its function
render it less liable to be prolapsed than the mucous
membrane, which is more voluminous and but very
loosely connected. Mr. Copeland,* doubted the pro-
trusion of the muscular coat ; he says, " In almost every
case of prolapsus ani, it is the internal membrane only
of the intestine which descends through the sphincter
muscle. The connection of the external sm-face of the
rectum is so firm with the surrounding parts, that it is
almost impossible the whole should be protruded toge-
ther ; a separation or elongation of the union between
the coats of the intestine must therefore precede the
disease, and form its essential character ; whether it be
produced by the efiusion of blood between them, or by
the continued tenesmus, or efforts to pass the fseces, or
pecuharity of structure, or any other cause."
From anatomical causes, children are more subject to
protrusion of the bowel than adults ; thus in them the
sacrum is less curved, the coccyx is not ossified and
remains moveable on the sacrum, the intestine itself is
straigbter, and its connections are less extensive from the
* 'Observations on the Principal Dist^aseB of the Bectum and
Anus,' by Thomu Copeland, third edition, 1824, p- 73.
204
PROLAPSUS OF THE RECTUM,
imperfect development of the prostate, urethra, and
vesieulsD seminalcs.
The causes of prolapsus are constitutional, and de- i
pend upon some pecuharity of the general health or of ]
the habits or occupation of the mdividual ; or they are
local, either from disease or irritation existing in the
rectum or m contiguous organs.
Of this affection, as well as of several others to which 1
the rectum is liable, costiveness is one of the most general
causes. When the bowels are not relieved every day
the feeces accumulate and become hard, the watery
portions being taken up by the absorbent vessels, the
bowel becomes distended, local and general irritation is
induced, and violent expulsatory efforts are necessary to
dislodge the indurated mass ; which, pressing on the ,
bowel in descending, may not only drag down the
mucous membrane, but cause the rectum itself to I
protrude.
Chronic diarrhcea and dysentery arc likewise causes
of this disease ; they are accompanied by straining,
irritation, and determination of blood to the lower ,
part of the intestinal cantil ; and inSammatoiy action
and various morbid alterations of structure are in-
duced.
Disease of the liver is not unfrequcntly associated, aa j
a cause, with prolapsus of the rectiun ; those who iiave I
resided in hot and miasmatous countries and baveJ
PROLAPSUS OF THE RECTUM. 205
suffered from hepatic affections, are very liable to ex-
perience the miseries of prolapsus, and we thus find it
prevailing greatly in individuals returned from ludia.
Prolapsus may result from indigestion : the primar)'
seat of the e\Tl being in the stomach or duodenum, or
some defects in the functions of the pancreas and liver,
whereby the fjecal matter is rendered irritating and
diarrhcea induced ; or, on the contrary, the rectum and
colon may not be sufficiently stimulated and ficcal accu-
mulations are consequently promoted.
Sedentary occupations act rather as a predisposing
than as a direct cause of prolapsus. By insufficiency of
exercise a torpid state of the alimentary canal is induced,
the biliary secretion becomes diminished, and the skin
does not properly perfonu its excretory ftmctions.
Prolapsus may be attendant upon the violent straining
and forcible muscular efforts during difficult partiuition,
or from the relaxation occurring by frequent child-bear-
ing. It may also be produced by violent and immoderate
horse-exercise.
Constitutional weakness, hereditary or induced, is
another cause. The children of the poor are the sub-
jects of prolapsus, from being ba<Uy nourished, and living
in close and unhealthy habitations, or by being suckled
too long. In a pubfic infirmary, a short time since, I
had an infant under my care, which illustrated, in a
marked degree, the effect of neglect and deficiency of
206 moLAPscs of the rectum.
proper noumhnient ; several inches of the bowel were
prolapsed ; it was with great difficulty it could be re-
duced, and it was still more difficult to prevent its
descent ; but no treatment could be of any avail, the
debility being so great and the assimilative functions so
impaired, that death very shortly put an end to the little
patient's sufferings.
'ITie local causes in adults are hEemorrhoidal disease,
polypi, enlarged prostate, stricture of the urethra, stone
in the bladder, inflammation of the bladder, inflamma-
tion of the rectum, loss of tone in the sphincter ani
from some lesion of the spinal cord, or other circum-
stance; from debihty of the intestine itself, produced by
excessive faecal uccimiulations, or the habitual use of
large enemata, and the extraction of large foreign bodies
from the rectum. In children, the most frequent causes
are urinary calculi, intestinal irritation produced by
acrid secretions, or the presence of entozoa, and the
irritation that often exists during the period of dentition.
The symptoms produced by prolapsus recti are various,
according to the duration of the disease, and the extent
to which the bowel is protruded. The tumour in children
is red, p}Tamidal, and coiled in form ; in adults it is
either globular, cylindrical, or appears as lateral folds on
each side of the anus. The amount of intestine pro-
truded varies from a mere fold of the mucous membrane
to several inches of the whole of the tissues. In the
PROLAPSUS OF TBE RECTUM. 207
case of a ctiOd who had stone in the bladder, which Mr.
Liston removed, the intestLne was prolapsed to the
extent of six inches. At the commencement of the
affection, the intestine is retracted spontaneously after
the passage of the motion, but ultimately it becomes
necessary to replace it with the hand. Sometimes the
protrusion increases very rapidly, especially in children ;
but if the patient is an adult, and not advanced in life,
or labouring under constitutional debility or weakness of
the muscular apparatus of the anus, it takes place more
gradually. A copious secretion of red glairy mucus is
poured out from the lining membrane of the rectum ;
pain is felt m the hips, down the thighs, and even ex-
tending to the legs and feet, and may be attributed to
rheumatism or sciatica.
After prolapsus has existed some time the mucous
membrane becomes indiu-ated and loses its villous
appearance. When the sphincter is relaxed and the
anus dilated from the repeated protrusion of the bowel,
the latter descends on the slightest exertion, even
assuming the upright position is sometimes sufficient to
cause it to fall down ; it is then very liable to become
ulcerated from the friction to which it is exposed ; in
these cases the pain and distress are almost insup-
portable ; defecation produces acute agony, and the
patient is compelled to lie down for an hour or two
208
PROLAPSl'S OF THE RECTUM.
In the treatment we have to consider the removal of
the cause, the rephicenient of the protruded intestine,
and the retention of it in its natural position ; if
we fail in the latter, it will then be necessary to have
recourse to operative surgery.
Our first efforts must be directed to the replacement
of the protruded bowel ; provided the prolapsed portion
is free from engorgement, this may be effected at once,
but if, on the contrary, inflammation and vascular tnr-
geacence exist, leeches must be applied to the surroimd-
ing parts, and subsequently hot fomentations of decoc-
tion of poppy-heads. SoDie have reconuuended scari-
fications and leeches to the bowel itself, but their use
has been justly censured by most practical surgeons.
If the engorgement is not suificient to reqiure the
abstraction of blood, the application of cold lotions will
prove beneficial. In order to replace the intestine, the
patient must be placed on his side in the recumbent
position, or be directed to knetil on the bed and rest on
his elbows ; the buttocks being separated by an assistant,
the sui^eon grasps the tuiuoiu- in a piece of oiled linen,
makes finn compression, and, having reduced its volume,
pushes it within the sphincter. During this proceeding
the patient must be desired not to strain, otherwise
our endeavours will be opposed. Should contraction of
the spliiiicter prevent the return of the bowel, the patient
may be put under the infiuence of chloroform, when the
PROLAPSUS OF THE RECTUM. 209
obstacle to the replacement will probably be removed;
but muscular relaxation is not the constant effect of this
anaesthetic agent, the converse being sometimes the case,
and spasmodic contraction induced. Should the con-
striction of the sphincter persist, the rauscle must be
divided by inserting under its margin the nail of the
forefinger on which the knife used in operating in fissure
is to be carefully guided, and the necessary incision
made. In children, especially if the prolapsus be large,
great difficidty will be experienced in returning it; to
facilitate the operation, some recommend the introduc-
tion of the finger into the bowel, which is to be carried
up with it ; while the finger is being withdrawn, the
intestine is to be supported with the left hand. Sir
Charles Bell recommends the finger being covered with
oiled paper, which will allow its withdrawal without
bringing down the bowel.
Having returned the prolapsus, a pad of lint must be
applied and retained with a T bandage. The attention
must then be turned to the constitutional treatment and
to the removal of the cause. The digestive organs
shoidd be attended to, and auy errors of diet corrected ;
the aliment allowed must be easy of digestion, nutritious,
and such as will not cause bulky evacuations ; highly
seasoned dishes and large quantities of vegetables and
fruit are to be prohibited ; the tone of the stomach,
if impaired, is to be restored by bitter infusions
14
210 PROLAPSUS OF THK RECTUM.
and aromatics, with the addition of soda, potash, of
ammonia ; in some cases, the mineral acids will be
found to agree better than alkalies.
Too great attention cannot be paid to prevent costive-
ness, which so generally accompanies this disease either
as a cause or effect, but we must avoid having recourse
to drastic purgatives. Emollient enemata, castor oil,
lenitive electuary. Rochelle salts, and other similar reme-
dies, will be the most desirable. It is very essential not
to overlook the state of the liver, congestion of this
organ will often be indicated by the lividity of the
prolapsed bowel ; alterative doses of mercury with ipeca-
cuanha, taraxacum, and nitric acid, will be serviceable in
hepatic derangement. After every evacuation the anus
should be washed with soap and cold water, and four
or six ounces of an astringent injection thrown up the
rectum : the decoction of oak bark with alum, or a
solution of tannic acid, arc better than solutions of the
mineral salts.
In children, the treatment of prolapsus of the rectum
is very troublesome and often tedious ; the nurse must
be directed not to allow the child to sit straining on its
chair as is too commonly the practice, and she should
be instructed to replace the gut immediately after the
motion is passed, previously washing it with a httle
alum and water, or a solution of tannic acid. The
bowels must be kept easy, for which purpose castor
PROLAPSUS OP THE RECTUM.
211
oil is the best agent ; some advise calomel and jalap,
but it is likely to produce tenesmus. Sir BeDJamin
Brodie* recommends the following treatment : " Purge
him with calomel and ihubarb occasionally ; be very
eareful about his diet, that he does not eat a great
quantity of vegetable substance, which tends to fill up
the cavity of the bowel, while it afibrds but little
nourishment; tmd every morning let some astringent
injection be thrown up. The injection which I have
generally used is a drachm of tinct. ferri muriatia in a
pint of water ; and two or three ounces or more of this,
according to the age of the patient, may be injected
into the ^ect^ml every morning, the child being made to
retam it as long as possible."
When calculus vesicae is the cause of the prolapsus,
the stone must of course be exti'acted, and the effect will
then probably subside without any special treatment;
if the presence of ascarides cause the bowel to descend,
they must be removed by the means recommended in
the eighteenth chapter.
Prolapsus recti in the adult, if of long standing, will
rarely admit of being remedied by medical treatment,
and we must have recourse to surgical operation for the
rehef of the patient. Of the various operations that have
been suggested, none are so simple, attended with so
little pain, and so effectual as that proposed by the late
" ' Medical Gazette,' vol. xv, pp. 845-6.
212
PROLAPSUS OP THE RKCTUM.
Mr. Copeland.* The patient, previously prepared by the
bowels having been thoroughly unloaded by mild pur-
gatives and enemata, is directed to lean over the back of
a chair, or to rest on a bed with his legs drawn up ;
according to the extent of the disease, one, two, or more
folds of the raucous membrane arc to be pinched up with
the forceps, figured at page 141, or, with a pair of
common dressing forceps, and included in a firm, round,
and smooth ligature ; the knots must be drawn tight,
that perfect strangulation may be effected. In order
that the ligatures may not slip, and that they may come
away sooner, I prefer transfixing the base of each fold
with a needle carrying a double hgature, and tying it in
two portions ; the pain is by no means increased, and
the cure is expedited, as the threads have a smaller
amount of tissue to cut through. After the operation,
the prolapsus and the ligatures, the ends of the latter
having been cut off, are to be returned within the
sphincter. The patient must be confined to bed, and
a dose of opium or morphia administered. On the
second or third day the bowels should be moved by an
enema of Qaxseed-tea, or thin gruel and oil, and this
must be repeated every day. or every second day, as may
be necessary. For some days the bowel will descend
more or less, but as the ulcers caused by the hgatures
• ' Obsen-atioiis on the Principal Diseases of the Rectum and
Anns,' Third Edition, 1824, pp. 79 to 88.
PROLAPSUS OF THE EECTUM. 213
cicatrize, this will diminish, and a perfect cure will be
I
Since the publication of the previous edition, at the
suggestion of Sir Benjamin Brodic, I have applied the
concentrated nitric acid to the mucous membrane of
the prolapsed bowel with the happiest result, and think
it is the better plan of treatment, except in those
cases in which the mucona membrane is very lax and
voluminous.
When the descent of the bowel is caused by piles, the
treatment recommended in the ninth chapter must be
followed. If the protrusion is a result of relaxation of
the anus, a marginal fold of the integument and mucous
membrane must be excised from either side; but the
smgeon must be careful that while seeking to remove
one source of annoyance he does not produce another
which will give much more trouble than the primary
affection, namely, contraction of the anus, which is cer-
tain to take place if he removes the integument too
freely ; the patient is placed in the same position as for
lithotomy, or in that just described (page 212) ; a pair of
forceps, a scalpel, or a pair of curved scissors, are the
instruments required.
In some cases, on account of age, debihty, or other
circiunstances, an operation cannot be performed ; an
endeavoiu- must then be made to support the intestine
by pads and a T bandage, or by a truss similar to that
su
PROLAPSUS OF THE RECTUM.
recommended by Gooch.* The best instrumenta of the
kind that I have seen, are those made by Mr. Egg and
Mr. Eagland.
The following cases illustrate this affection :
Proli^sua, earned b^ disease of the liver and dysentery,
induced by a long residence in India,
Mr. A , set. thirty-nine, had becai nearly twenty years
in India ; the latter part of the time his health had failed, and
his liver became affected; he had also had several dysenteric
attacks. Shortly hcfore leaving for England the rectum
began to descend, and during the voyage occasioned bim
much suffering and inconvenience ; mercury was adminis-
tered freely hy the surgeon of the ship, but with no benefit
to his health. He consulted me after he had been in Eng-
land two years; he was sallow and somewhat emaciated, his
pulse was weak, quick, and irregular, he had frequent pal-
pitation of the heart, and he waa much troubled with
flatulence ; the bowels were irregular, and when they acted
he suffered great pain, which continued some hours after-
wards ; he also complained of being annoyed by a discharge
of mucus, and bleeding from the part. The scvcraJ regions
of the body were carefully examined ; no organic disease of
the heart could be discovered ; the liver could be felt extend-
ing an inch below the margin of the ribs, and pressure over
it produced a dull pain. A fold of the bowel on each aide of
the anus waa protnided, and could not be kept up except
• ' Cases and Practical Remarks i
Goooh, Norwich, 1767, vol. ii, p. 168.
Surgery,' by Benjamin
PROLAPSUS OP THE RECTUM.
215
when he was in the horizontal positioDj the Burfaces were
slightly ulcerated and somewhat altered from their natural
appearance. The urine was examined on several occasions,
and was observed cither loaded with crystals of uric acid, or
with those of oxalate of lime. This patient was seen also by
the late Mr. Morton, of University College Hospital, who
concurred in the plan of treatment adopted, which was mild
purgatives, gray powder with extract of taraxacum, and tonics
with the nitro- hydrochloric acid, and the use externally of
abluhiona and astringent lotions. When his health had im-
proved, ligatures were applied to both sides of the prolapsed
bowel, and portions of the mucous membrane completely
fltrangulatcd ; the prolapsus was then returned, and a dose of
opium administered. The operation produced a slight
amount of pain, but it subsided in an hour or two ; he slept
soundly during the night. On the morning of the third day
he took a dose of castor oil, which moved the bowels several
times, and caused a return of the prolapsus ; the ligatures
came away on the fifth day, after which the bowel protruded
but very little, and before cicatrization was complete it had
ceased to come down at all. During the time he was under
treatment, his diet consisted of broths, arrowroot, and light
puddings. When the ulcers produced by the ligatures were
nearly healed, he used enemata of cold water night and
morning, and in less than a month he had quite recovered.
Prolapsus, preceded by morbid irritability of the stomach
and bowels ; cured by operation.
A gentleman, set. fifty-three, stout and of relaxed mus-
cular fibre, had for many years suffered from morbid irrita-
216 PROLAPSUS OF THE KliCTCM.
bility of the stomach, being much troubled with flatulence
and frequent vomiting of a watery fluid ; his bowels were
generally constipated, and defecation was attended Jwith
violent straining ; at times lie had attacks of diarrhtca. He
had uo appetite for pMn food, but partook freely of highly
seasoned dishes. At length protrusion of the bowel at atool
was superadded to his other ailments ; for a time it was re-
tracted after the evacuations had passed, but ultimately it
became necessary to replace it with the hand. He expe-
rienced much pain and misery from the disease, and his linen
was constantly soiled with mucus and fseccs. Being very
nenouB and timid, and thinking some operative proceeding
would be necessary, he endured the disease without making
it known to his medical attendants ; he had tried a variety
of remedies without any decided benefit. When he came
under my care 1 prescribed laxatives, tonics, and astringent
lotions, with the effect of improving his health ; however, the
bowel continuing to be prolapsed, he consented to the opera-
tion I proposed, and accordingly a fold of the protruded
membrane on each side was included in ligatures, which
were tied as tightly as possible ; the parts were then returned
within the anus, and an opiate administered. For the first
two or three days he complained of pain ; this was mitigated
by the use of morphine and the application of hot poultices
to the anus. The ligatures separated in less than a week ;
at this time the operation did not appear to have been suc-
cessful, as the bowel still came down at stool, but as cicatri-
zation progressed it protruded less, and shortly did not de-
scend at all. The disordered condition of the stomach was
relieved by tonics and the mineral acids, and the administra-
PBOLAPSrs OF THE RBCItfM.
tion of the oxide of silver in combination witb a mild aperient
piU every night for some weeks.
Prolapsus relieved mtJtout operation.
W. C , Bet. Bixty-Heven, of feeble conBtitution, had
been for many years Btibject to falling down of the bowel,
which he attributed to straining violently at stool, being of n
constipated habit ; he had long been necessitated to replace
the bowel with hia hand after defecation. I first saw him, in
conjunction with my friend, Mr. Bennett, in consequence of
his not being able to return the prolapsus, and its becoming
excessively painful and occasioning great constitutional dis-
turbance. The prolapsed intestine formed a tumour the size
of a large orange ; its surface was inflamed and very painful ;
some difficulty waa at lirst experienced in returning the ex-
truded bowel, but by firm and constant pressure it was at
length accompbshcd ; he was confined to his bed, hot fomen-
tations used, and medicines prescribed to allay the constitu-
tional symptoms. On the following morning a dose of castor
oil was prescribed, and when it acted the bowel again de-
scended, but was reduced witb less diflSculty than on the
previous occasion. The state of his constitution rendered an
operation unadviaable, but, by attending to keep the bowels
open by^ gentle laxatives, and after their action using soap
and water to the protruded part, by replacing it immediately,
and retaining it by mechanical means, he was restored to a
state of comparative comfort.
218 PROLAPSUS OF THE RECTDM,
Prolapsua of the rectum, leucoTrluEa and irritabilify of
the bladder.
Mrs. , tel. forty-three, of very delicate constitution,
the mother of one child, but has had many miscarriagcB;
from the state of her health she has taken very little exer-
cise, and has always had great dif&ciilty in keeping the bowels
open. In the spring of 1849 she began to be troubled by a
protmfiion of the bowel when she strained at stool, which
gradually increased ; under medical advice she went to
Brighton in the autumn, and tried sea-bathing, but with little
benefit. The disease increased, and at last the bowel fell
down even when she walked, profuse leucorrhceal discharge
and irritability of the bladder were also induced. I first saw
her in 1851, a circular fold of the bowel, between one and
two inches in length, was prolapsed ; after being returned it
fell down again immediately on her walking about. Pallia-
tive means were tried for some time, but with no decided
beneficial result further than improving the general health.
It being evident that nothing but an operation would keep
the intestine in its proper place, and the bowels having been
thoroughly acted on, ligatures were applied on each side of
the protrusion, in the manner described in the text ; she
progressed very favorably, the ligatures separated in the
usual time, and she was no longer troubled by the descent
of the bowel ; by the use of alum-baths the leucorrhocal dis-
chai^ ceased, and by taking tonics and laxatives she was
restored to a better state of health than she had enjoyed for
many years.
Abscess or abscesses fonning iii tht; vicinity of the
rectum detuaDd especial attention, and more prompt
treatment than when occurriTig in most external parts
of the body, in consequence of the evils immediately
depending upon them, and the sequelee arising from
implication of the bowel.
Purulent formations in the neighbourhood of the
rectum are not of infrequent occurrence, from the nature
of the tissue surrounding the terminal portion of the
intestinal canal, which is especially prone to suppurative
action, and in this locaUty the predisposition is increased
by the looseness of the tissue itself, by its being imsup-
ported by surrounding parts, by the numerous blood-
vessels that exist there, and their liabihty to congestion
from position and other causes.
Abscesses near the rectum occur under various cir-
cumstances; they may be idiopathic, and either acute,
subacute, or gangrenous ; they occur after fevers and
diseases of a debilitating character, and in these cases
220 ABSCESS NEAR THE RGCTCM.
appear critical; they may be produced by cold and
damp, as sitting on stone benches, on the wet ground,
or B wet seat while driving ; they also arise from various
causes in connection with diseases of the rectum, as in
Btrictore of that part ; with the existence of internal
and external piles ; with ulceration of the lacuna; and
pcribration of the coats of the intestine, the result of
inflammatory action arising from the entanglement of
the faeces in the folUcIes, or other causes mentioned in
the Chapter on Inflammation of the Rectum. Consti-
pation and accmuulation of faecal matter in the rectum
and colon will induce the formation of abscess by causing
congestion of the vessels, which is increased during
defecation by the violent straining to expel the hardened
excrement. Foreign bodies penetrating through the
tissues of the intestine and sphincter muscle into the
cellular membrane, such as fragments of bones and
other substances that have been swallowed ; injuries
from without, as blows or wounds, lead also to suppura-
tive action.
Abscesses sometimes present near the rectum con-
nected with disease in other parts, as with caries of the
spine, ilium, or sacrum, with disease of the hip-joint,
and with affections of the uterus, prostate gland, &c.
They are also met with in patients labouring under
various organic diseases, either of the hver, heart,
or lungs ; phthisical patients are often suflerers from
ABSCESS NEAR THE RECTUM. 221
abscesses near the rectum, wbich generally lead to the
formatiou of fistula in ano.
The acute idiopathic abscess is generally preceded
by thirst, dryness, and heat of skin, scanty and high-
coloured urinej and, in fact, by the usual symptoms of
pyrexia. In the part itself there will be heat, pain,
throbbing, tumefaction, and more or less redness of the
integument. These symptoms continue for a few days,
when at length pus is formed, rigors frequently marking
its advent. When suppuration has been fairly and fully
accomplished the feverish symptoms subside, and the
patient generally becomes cool and comparatively easy.
Although the swelling may now be considerable, and the
part exquisitely painful to the touch, the acute throbbing
previously experienced diminishes, and is superseded by
a dull heavy sensation. If no surgical means be adopted
to evacuate the matter, nature will form an opening for
its discharge either externally through the integument
or internally through the intestine.
The subacute abscesses generally form far from the
surface, and frequently contain a considerable quantity
of ill-conditioned pus: at first they do not occasion
much pain or inconvenience ; a sensation of bearing
down of the rectum is experienced by the matter press-
ing upon it, but as it increases in quantity it gives rise
to severe and distressing symptoms ; there will be vio-
lent spasm attended with great pain ; there will also be
2S3 ABSCESS NEAR THE RBCTUH.
a constant desire to go to stool, although the bowels are
fi^ from faecal accumulation. In other cases there will
be no local symptoms of the existing mischief, and the
constitutional ones may be obscure and perplexing. Sir
Benjamin Brodie* mentions the case of a gentleman he
attended, in whom an abscess formed by the side of the
rectum, and who was not conscious of any local syiup-
toms. He had been for some time subject to headache
and languor, and was obliged to go home and he down
during the day. The first notion he had of the exist-
ence of the purulent collection was its bursting one day
while he was walking.
Ab mentioned, the pus in these abscesses is not of a
healthy character; it is, for the most part, of a dark
colour, and frequently excessively fetid ; the latter cir-
cumstance may be owing to its contamination with
faeces entering by a small apertiu-e in the intestine,
though I suspect it more frequently depends on the
transudation of gases or fluids ; indeed the stench is
often much more fetid and offensive than any unlimited
quantity of feculent matter. In a case 1 operated on in
1863, the fcetor waa mtolerablc, and a free use of the
chloride of lime was necessary in the ward of the infir-
mary where the patient was ; and I remember a similar
case, some years since, at University College Hospital :
in neither could any connection with the bowel be
* ' Medical Gazette,' vol, ivi, p. 26.
ABSCESS NEAR THE RECTCM.
detected, and they both healed without forming fistula,
or requiring anything more than keeping the incision from
closing till the cavity had filled from the bottom.
Gangrenous abscess usually occurs in those whose
constitutions have been impaired by luxurious living, or
by debauchery and excesses. The symptoms commence
with rigors attended with fever; the pulse at first is
full and hard, the tongue is coated, the akin dry and
hot, there is gi'eat thirst, loss of appetite, and general
restlessness ; but the character of the symptoms soon
changes, the fever becomes of the adynamic type, the
pulse is then weak, quick, and irregular, the counte-
nance flushed, the tongue becomes brown and dry in the
centre, and the edges red and glazy, and, in the worst
forms, the lips and teeth are covered with sordes. The
secretions and excretions are disordered, extreme debility
and prostration arc present, accompanied with more or less
stupor. With the early constitutional symptoms a deep-
seated pain near the rectum is complained of; if the
part be examined, hardness will be found, which rapidly
extends, and the integument assumes a livid colour,
while the pain becomes of a burning character. Tenes-
mus and dysiuia are more likely to be present and
severer in this than in other forms of abscess which we
meet vrith near the neck of the bladder, except those
occurring between the prostate and rectum.
Traumatic abscesses occur from violence from without,
224 AB3CESS NEAR TlfK RECTUM.
as from gun-shot wounds, punctures, and contusions;
and from witliin by the entanglement by the sphincter
of various foreign bodies which either pierce the intes-
tine or produce perforating ulceration. Abscess from
the first cause is seldom seen except in the practice of
miUtary surgery.
M. Ribes* mentions the case of an officer who received
a musket-ball in the right buttock, which passed into the
rectum, fracturing the tuber ischii in its course; the
external wound healed in about six weeks, when an
abscess formed in the riglit side of the perinaeum ; thia
was opened, and a fragment of bone and some pieces of
cloth were extracted. Bushe f had a soldier under his
care who was wounded in India, the ball passing into
the rectum ; the opcmng into the intestine healed, but
the external one remained fistulous till two pieces of cloth
were removed, several months after receipt of the injury.
Numerous interesting cases of traumatic abscess oc-
corring from the entanglement of foreign substancea
within the rectum, are on record, among them the fol-
lowing. Le Dran relates a case, which occurred to
M. Destendau, of a man who for nine months laboured
under fistula caused by the lodgment of a piece of bone.t
* * M^moiros do U Soct^t^ Medicals d'Emulation,' tomo \x.
t Op. cit., p. 235.
{ ' Obserratdons de Chirurgie,' tome ii, observation Ixxxvi, p. 222,
Paria, 17S1.
ABSCESS NEAR THE RECTUM.
225
Petit* extracted a needle, which for six months had occa-
sioned excmciating paiu during defecation. In another
case he removed a small triangular bone which had been
the cause of great pain for several montlia. In a third
case there was extensive mortification around the anus,
from the lodgment, of ten days' duration, of a chicken-
bone. In a fourth case he opened an abscess which
contained shot and feculent matter. Shearmanf re-
lates a case of a fish-bone being swallowed and dis-
charged twelve months afterwards from an abscess by
the side of the auus. HarrisonJ describes a case of an
abscess resulting from an apple-core, swallowed eight
months previously. Sir B. Brodie^ relates the following :
" I was sent for to a gentleman with a very large abscess
formed by the side of the gut. He suffered a great deal
of local paui ; had a very frequent pulse, brown dry
tongue, very hot skin, and typhoid symptoms. I opened
the abscess, and let out a quantity of putrid offensive
matter, which suificiently explained the typhoid symptoms
under which the patient laboured. And after I had
opened the abscess, I introduced my finger into the cavity,
and sticking across it I found a long fish-bone, which I
extracted. The fish bone had evidently penetrated
• "Trait^s des Maladies Ciiirui-gieales,' Ouvrage posthume de
J. L. Petit, tome ii. + ' Philos. Trans.' 1763,
J ' Memoirs of the Medical Society of London,' vol. v, 1796,
§ ' Medical Gazette,' vol. xvii, p. 27,
15
226 ABSCESS NEAR TUB RECTUM.
through the mucous membrane of the bowel, and in all
probability some small portion of feculent matter had
passed by the side of the fish-bone, thus accounting for
the remarkable putridity of the matter." Mr. Green
tells of a case in which the pelvis of a snipe was re-
moved from a large abscess. A case was mentioned at
a meeting of the Pathological Society of London, in
December, 1856, of a lady who had an abscess in the
ischio-rectal fossa, which was opened ; and Mr. South, on
making an examination, found that it had been produced
by a fish-bone having perforated the coats of the rectum ;
the bone was nearly two inches in length, and about half
of it was projecting into the cavity of the abscess.
The symptoms and consecutive consequences of ab-
scess in tliis region are greatly increased in severity by the
implication of the integrity of the intestine; much, how-
ever, will depend upon the habits and constitution of the
patient. The precise situation of the abscess will exer-
cise considerable influence ; if it exist on either side of
the anus the symptoms ivill be less severe than when it
is situated anteriorly, as other important and very sen-
sitive parts are then involved and their functions inter-
fered with ; thus, in the male, the neck of the bladder,
the prostate gland, and the urethra will be affected, and
the flow of the urine interrupted. In the female, ab-
scess in the anterior walls of the rectum, if allowed to
pursue its course, may open in front into the vagina,
ABSCESS NEAR THE RECTUM. 227
nnd posteriorly into the rectiim, and induce the very
distressing condition of recto-vagina! fistula.
It is not always easy by touch to satisfy ourselves of
the existence of pus in this region; readily to detect
fluctuation, it is necessary to possess in an eminent de-
gree the " tactus emditus," " a gift of rare value, per-
haps partly innate, yet doubtless capable of being
acquired by the education of the finger and the judg-
ment."* The difiiculty arises from the elasticity of the
cellular tissue, somewhat simulating fluctuation, and
also from the depth from the surface at which the matter
is often formed. In the latter case, we may not be able
to gain any information by the appearance or by the
touch of the external parts ; but by introducing the
finger into the rectum, we shall be able to detect it
bulging into and diminishing its capacity ; if fluctuation
is not distinct, and there be any doubt about it, two
fingers of the one hand should be introduced, and made
to press the suspected abscess outward, whilst, with the
fingers of the other band, counter-pressure is made, and
we shall thus be able to ascertain with greater certainty
the presence of fluid.
When symptoms of the formation of acute phleg-
monous abscess exist, the patient should confine himself
to the horizontal position, leeches should be applied to
* 'PtinclpleB of Surgery,' by James Miller, F.R.S.E., Second
Edition, 1850, p. 208.
228 ABSCESS NEAR THK RKCTUM.
the part, followed by hot fomentations and emollient
cataplasms. If the patient be robust and plethoric,
general bloodletting may be necessary, particularly if
much fever exist ; the bowels must be opened by mild
laxatives, drastic purgatives being avoided, as they woiild
be productive of more harm than good, by determining
blood to the rectum, and inducing violent straining and
disturbance of the surrounding structures : the diet
must be low and unstimidating in quality ; diluents,
which may be freely allowed, will be beneficial in reducing
the feverislmess. Shoidd there be any difficulty of
micturition, the warm hip-bath must be had recourse to,
and if retention of urine occur, warm anodjTie enemata
must be administered, shoidd the warm-bath not be
sufficient to overcome it ; if these fail to afford relief, the
catheter must be used before the bladder becomes over-
distended.
We must not be too sanguine in adopting these means
to prevent the fonnation of ])us, though we shall occa-
sionally succeed in doing so ; yet, if wc do not, we shall
have lessened the force of the luorbid action. When it
is evident that the formation of matter cannot be pre-
vented, comfort and benefit will be derived from the ap-
plication of hot fomentations and warm cataplasms, by
their soothing and relaxing effects on surrounding parts.
As soon as there is sufficient reason to suspect the pre-
sCTjce of pus by the accession of rigors, by detecting
ABSCESS NEAR TH K KKCTVM,
fluctuation, or by a feeling of boggioess in the centre of
the hnrdeued part, a free incisiou must at once be made ;
waiting till the superimposed tissues are thinned, and
pointing of the abscess takes place, is a practice to be
avoided, as the cavity of the abscess will increase, and
there will be a greater probability of the bowel being
denuded, or a communication being established by the
formation of an opening for the exit of the matter tlu'ough
it, in which case fistula in ano is certain to be the
result.
Opening an abscess is a very simple o|«ration, and
easily accomplished ; but having frequently witnessed
the in8iction of unnecessary pain by the incision being
made improperly, I may be pardoned here saying a few
words on the manner iu which it ought to be done. A
variety of instruments, of different forms, are sold in the
shops, under the title of abscess-lancets ; but not one of
which is half so good as a simple straight bistoury, with
a fine point and smooth sharp edge ; it should be held
lightly between the thumb and first two fingers of either
hand, if the operator be ambidextrous, so that in the case
of any unsteadiuess or sudden movement on the part of
the patient, the hold may at the moment be released.
The blade of the bistoury, held perpendicularly to the
surface, should be gently pushed into the soft parts till
the point has entered the suppiu'ating cavity ; this will
be ascertained by the cessation of resistance to its on-
280 ABSCESS NEAR THE RECTDH.
ward progress, and by the freedom of motion admitted,
also by the matter welling up by the side of the instru-
ment ; after the point has been made to penetrate a suili-
cient depth, the handle should be inclined somewhat,
and, by a shghtly sawing motion, the incision carried to
the requisite extent, By observing this method, the
pain of the operation is much lessened. Abscesses are
frequently opened with an ordinary lancet, which is in-
serted and made to cut its way out by elevating the point ;
this occasions much pain, in consequence of the skin, the
most sensitive part of the body, hauging and dragging on
the edge of the instrument. In many books the expres-
sion, a plunge of the lancet or bistoury, is made use of;
a surgeon's knii'c should never be plunged anywhere, no
saving of time or pain is effected by such a procedure ;
the limits of the puncture must thereby be uncertain ;
and the walls of an abscess are Uable to be transfixed,
or parts wounded that it would be most desirable to
avoid.
When an abscess is deep-seated by the side of the
rectum, and a considerable thickness of tissues exists
between it and the external surface, advantage will he
gained by endeavouring to make it bulge, by introducing
the fingers into the bowel in the same manner as when
making an examination ; the kniife is then to be steadily
carried down to it and, the point having entered the
cavity, the incision of the extent requisite is to be
ABSCESS NEAR THE RECTUM, 231
made at once. Some surgeons, after puncturing the
cavity of the abscess with a sharp-pointed knife,
prefer enlarging the wound with a probe-pointed
bistoury.
In the subacute abscess, Dr. Buahe advised several
small punctures instead of one free one. I think most
surgeons will be inclined to practise the latter. I have
seen buboes treated in a hospital by a series of small
incisions or pimctures, under the idea of preventing any
scars after cicatrization, but the plan was always unsuc-
cessful, the matter not finding a free outlet ; sinuses
were formed, and the vitality of the integument impaired,
rendering it necessar)' to lay the several openings into
one, or to destroy the tissues by potassa fusa ; and the
same results would follow opening an abscess elsewhere,
if the like plan were adopted.
In gangrenous abscess free incision is absolutely
requisite, that the sloughs may readily be discharged; this
form so far resembling carbuncle in character, in there
being a considerable destruction of the cellular tissue.
After the evacuation of the contents of an abscess, a
warm poultice must be applied ; the horizontal position
must still be preserved, and the bowels kept easy by
laxatives. The diet allowed may be better than when
resolution was being attempted, but it must not be stimu-
lating or heating ; beer, wiiie, and spiiits should be pro-
hibited, except in the gangrenous form of abscess, when
232
ARSCUSS NEAR THE RECl'UM
they will probably be requisite, from the debilitated con-
dition of the patient.
As there is greater disposition in the uitegiiment to
heal than in the cellular tissue, care nmst be taken to
prevent the closure of the external opening before the
cavity has healed from the bottom ; this is to be done
by inserting a slip of hnt between the hpa of the woimd,
but the whole cavity is not to be crammed, as was oiice
the custom, and is still frequently practised on the Con-
tinent.
After opening a traumatic abscess, if the presence of
ball, sphnter of bone, portion of the dress, or any other
foreign substance, can be detected, it must of course be
CHAPTER XIIl
FISTULA IN ANO,
Ak abscess formed in the ischio-rectal fossa, although
opened early by free incision, and before the cavity be-
comes greatly distended with pns, frequently will not
heal ; it may fill up and contract to a certain extent, but
it does not become entirely obliterated, a naiTow tract
remaining indisposed, from various causes, to yield
further to reparative action without surgical interference.
It is this sinus which constitutes the affeetion designated
fistula in ano.
The distui-bance to which tie part is subject whenever
the bowels are moved, and the action of the sphincter, are
assigned by most surgeons as the reason why the heal-
ing process is arrested; but may it not be attributed,
with more reason, to the nature of and the several dis-
advantageous circumstances attending on an abscess in
this locahty, such as tlie depending position, the nume-
rous veins that exist there, and their liability to con-
gestion, all of which tend to retard the process of
granulation and cicatrization ? Moreover, when these
284 FISTULA IN ANO.
phenomena are alow in their progress, the surface of
the internal cavity assumes a peculiar organization,
which, save that it is destitute of villi, somewhat re-
sembles mucous membrane in structure, function, and
in the inaptitude of the oppcraed surfaces to unite. It is
not alone in the neighbourhood of the rectum, but in
other situations also, that wc find sinuses form, when
the healing process is tardy. In complete fistula in aiio,
the passage of particles of the less sohd feculent matter,
and the gases generated in the intestinal canal, also
prevent the healing process. Those who maintain the
opinion that the action of the sphincter is the chief
cause in preventmg reparation, argue, a posteriori,
that division of the muscle, whereby it is set at rest
for a time, effects a cure; may not the successful
result rather depend upon laj-ing the sinus freely open,
as when we have recourse to the same plan of proceed-
ing in the treatment of sinuses occuiring in other
situations ?
Fistulie in ano arc described by most writers as per-
fect — fistula; ani completje, — and imperfect — fistulae ani
iacomplcttc ; the fonner are those which have both an
opening into the intestine and one externally ; the latter
have but one opening, which may cither be internally in
the mucous membrane of the intestine, or externally in
the integument. When a fistula has no communication
with the cavity of the bowel, it is called a blind external
FISTULA \{i ANO. 235
fistula, and when the opening exists only within the
anus, and there is no exteraal coiumunication, it is
known as a blind internal listiila. Bhnd external fistula
is very rare, an internal ojjening almost always existing
if tlie abscess has degencraft:d into that state to which
the term fistulous may properly be appUed. The open-
ing into the intestine may be very small, or, from the
sinuosity of the fistula, we may be unable to detect it on
a first examination, yet on a second or third exploration,
conducted with care and a due consideration of the posi-
tion it is most likely to occupy, and the employment of a
suitable probe, it will probably be discovered.
A difference of opinion exists between several eminent
surgeons as to the formation of the internal opening in
complete fistula. Sir Benjamin Brodie says, " I believe
that tliis is the way in which fistuliE in ano are always
formed, namely, the disease is originally an ulcer of the
murcus membrane of the bowel, extending through the
muscular tunic into the cellular membrane external to
the intestine ; and I will state my reasons for entertain-
ing that opinion. The matter is of great importance as
a question of pathology, but it is one of great import-
ance, as I sliall show by-and-by, in connection with
surgical practice. It is admitted by every one, that in
the greater number of cases of fistulte in ano, there is an
inner opening to the gut as well as the outer opening ;
and I am satisfied the inner opening always exists,
236 FISTULA IN ANU.
because I scarcely ever fail to find it, now that I look for
it in the proper place, and seek it carefully. I have, in
a dead body, examined the parts where fistulae liad
existed several tunes, and in every instance I have found
an inner opening to it. This affords a very reasonable
explanation of the formation of these abscesses ; it is
almost impossible to understand, on any other groiuid,
why suppimitiou should tnke^lace in the vicinity of the
rectum more than iu any other part of the body, and
why the cellular membrane there should suppurate more
than cellular membrane elsewhere. Moreover, the pus
contained in an abscess near the rectmn scarcely ever
presents the appearance of laudable pus, it is always
dirty coloured and offensive to the smell; sometimes
highly offensive, and occasionally you find feculent
matter in it quite distinct. There is no reason why an
abscess, simply formed in the cellular membrane, should
smell of sidphuretted hydrogen ; but there is a good
reason why it should do so if it be connected with the
rectum.
" This being the case, it is easy to understand why
these abscesses do not heal. The least quantity of
mucus, even from the gut, or of fecult-nt matter issuing
into the ca\ity of the abscess, is sufficient to cause
irritation, and to prevent it heahng ; and I have, more
than once, in the living person, been able to trace the
progress of the formation of one of these abscesses.
FISTULA IN ANO.
337
For example, I was sent for to see a lady who com-
plained of some irritation about the rectum, and on
examining it, I found an ulcer on the posterior part.
1 ordered her to take "Ward's paste, confcct. piperi8
nigri, or cubeb pepper — I forget which. A month after-
wards she again sent for me, and I found there was an
abscess. I opened it, and from the outer opening a
probe passed into the gut through the ulcer, which had
been the original cause of the disease. The original
opening of an abscess is generally very small indeed,
but occasionally it is large, and when the ulceration has
proceeded to some extent, large enough to admit the
end of the little finger. The inner orifice is, I believe,
always situated immediately above the sphincter muscle,
jnst tlie part where the faeces are liable to be stopped,
and where an ulcer is most likely to extend through
both tunics." Mr, SjToe* remarks, "I do not hesitate
to affirm, that when a fistvila in ano is formed, the
mucous membrane always remains entire in the first
instance, and is never perforated until after suppimition
has taken place. M. Ribes-j- presumed that inflam-
mation and ulceration of piles was the common origin of
fistiUje in ano ; he says, " In one hundi-ed cases of
fistula of this part, ninety-nine are formed by this pro-
• ' Diseases of the Rectum,' Third EiUtion, p. 25.
+ ' Quarterly Joumnl of Foreign Medicine and Surgery,' toI. ii.
338
FISTULA IN ANO,
cedure, and have their origin from this cause." From
cases that have been under my own observation, I
differ in opinion from the authors just quoted, as to the
internal opening being always formed either in the one
way or the other, and am convinced that perforation
of the intestine takes place both from within and with-
out; but, however interesting the question may be,
pathologically considered, it does not affect the plan of
treatment to be adopted. Practically, the more im-
portant subject is the situation of the internal opening,
as it is essentially necessary to the success of the ojw-
ration that the whole of the parts intervening between
the two openings should be thvided; and unless the
internal opening is searched for in the right direction
it will most probably escape detection ; and fi-om this
cause many complete fistula have been considered to
be incomplete, or blind external fistula;. But the
greater evil arising from the inaccurate knowledge of
its usiuil locahty was, that surgeons were induced
to divide the intestine much higher than necessary ;
and frequently, from the internal opening not being
included in the incision, the disease returned, or the
wound would not heal. To M. Ribca attaches the
merit of investigating the question, and showing that
the interna! opening is never at a greater distance than
an inch and a quarter from the anus. Sabatier first
called his attention to the fact. Ribea examined the
rjSTULA FN ANO. 239
liodies of seventy-five people who had fistula at the
period of their death ; iii the majority the internal
opening was jnst above the point of junction of the
mucous membrane of the intestine and integument of
the anus; and not in a single instance did he find it
situated at a greater distance from the anal margin
than five or six lines. Since the pubUcation of the
results of his observations, they have been verified by
several eminent surgeons, yet the practical deductions
therefrom are not always at the present day properly
considered or acted upon by all practismg the surgical
art.
The symptoms of fistula in ano are not always very
acute, occasionally there is great pain, but more fre-
quently a feeling of uneasiness only about the anus is
complained of, with more or less tenesunis at stool and
difficxilty in the evacuation, particularly if the bowels
are costive, or the function of the digestive organs de-
ranged ; in complete fistida in ano, and in the blind
internal form of the complaint, the evacuations are
smeared mth pus and mucus, perhaps also slightly with
blood. One, and sometimes the chief, source of annoy-
ance to a patient with fistula is, the discharge, in a
greater or less quantity, of purulent or muco-purulent
matter, soiling his finen, making it wet and uncomfort-
able, and producing excoriation of the nates. In com-
plete fistula he is further annoyed by the escape of
240
FISTTILA IN ANO.
flatus and mucuB from the intestine, and should the
fistulous channel be very free, feculent matter will also
be expelled. Besides these symptoms, the minds of
many people are aff'ected with an impression of physical
imperfection and weakness in their organization, render-
ing them miserable and unhappy. As in other diseases
affecting the rectum, various sympathetic pains are ex-
perienced ; they are referred to the back, the loins, and
the bottom of the abdomen, pain extends down the
leg and to the foot, which is not imlikely to be attri-
buted to sciatica, unless the Iiistory of tlie case is care-
fully inquired into.
The external and internal openuigs differ m cha-
racter according to the duration of the disease, and
the cause that has given rise to it. In some cases,
especially in phthisical patients, the opening will be
prominent, and the edges hard and round. In others
the apertiu'e will be indicated by a crop of pale and
flabby granulations, prone to bleed from shght violence
done to them. If the abscess which originated the
fistula was of a gangrenous character, the opening will
most likely be irregular, and the surroimding skin livid
and imdemiined, and its vitality reduced by the de-
struction of the subjacent cellular tissue with the blood-
vessels that ramified therein. In many instances both
the internal and external />pcnings will be very small,
and liable to escape notice in a superficial examination ;
FISTULA IN ANO. »41
when such is the case, their position will most readily
he detected by making pressm^ on the surrounding
parts, and causing the matter to exude, or the fistu-
lous track may be felt as a cord under the integument.
Generally there exists but one internal opening, and
that is within five or six lines of the margin of tho
anus, as before stated, but now and then a second will
be found ; though some writers maintain such is never
the case, yet others of undoubted abOity and veracity
have stated they have met with instances where a
second, and in one instance a third, was present, and
specimens in the Museiun of the Royal College of
Surgeons, and other pathological collections, establish
the fact. We meet not infrequently with scvenU ex-
ternal openings which arise from the abscess having
been allowed to pursue its own coiu^e and burst ; if it
has been of the gangrenous form, it is more than
probable there will be more than one external opening,
or the several openings may depend on the formation
of distinct abscesses at separate times, which may or
may not communicate with each other.
Tlie track of a fistula is not always direct, but in
many cases is tortuous, sometimes it will be found
coursing just beneath the integument to the margin of
the anus, then passing upwards immediately imder the
mucous membrane, and oijeniiig into the rectum, or it
may pass through the fibres of the sphincter muscle.
242
PISTOLA IN ANO.
in which case the passage of the probe may be imp
by its fibres, should the exploration produce spasmodic
action. Sir Astley Cooper* mentions having exaiuined
the body of a man, who died of a discharge from a sinus
in the groin, and who also liad a fistula in ano ; he
traced the sinus to the groin, under Poiipart's ligament ;
it then took the course of the vas deferens, and descended
uito the fistula in ano.
The cavity of an abscess may extend considerably
above the internal openuig of a complete fistula, even for
three or four inches. After gangrenous abscess, the
bowel is sometimes extensively detached from its con-
nections vrith the adjacent tissues, and what is termed
a horse-shoe fistula will be formed, that is, a communi-
cation will exist around the posterior part of the rectum.
A pathological preparation in the museum of St. ITiomas's
Hospital shows this condition of the parts, and there
are others in several of oiir museums.
Wlien a patient complauis of symptoms of fistula, a
careful examination must be made j if the patient be a
mate, he should be desired to lean over the back of a
chair, or rest with his elbows on a table, but if he be
nervous, or the patient a female, it is better to place Iiim
or her on a couch or bed, with the buttocks projecting,
and the knees drawn up towards the chin. The nates
• Lectures of Sir Astley Cooper, Bart., on the ' Piinciplea and
Practice of Surgery, with Notes by Tyrrell,' vol. ii, p. 32C.
FISTULA IN ANO. 243
being separated, the external opening of the fistula
must be sought for; if it be not evident to the eye,
pressure must he made with the finger by the side of
the anus, especially wliere any hardness can be felt,
when most likely matter will be made to ooze out, and
thereby indicate its situation. According to the side on
wiiich the fistula exists, the forefinger of the one hand,
being previously oiled, must be introduced into the
rectum, a probe sHghtly curved is then to be inserted
into the external opening, and carried gently on ; in the
female it must be directed almost transversely, as in
them the anal concavity is less than in men. Varying
the position of the point of the probe, according to the
resistance it meets with, \vc shall soon be able to dis-
cover the internal orifice, or feel the end of the probe
tlirough the intestine, where it is denuded, and where
the interna! opening would be, were the fistula complete.
It is necessary to bear in mind the usual situation of the
internal opening, or the pomt of the probe may be too
much elevated, and carried above it, and the surgeon
commit the error of 8U])posing he is unable to detect it
in consequence of the height at which it is situated, or
that the fistula is of the blind external form.
In making the exploration, no force should be applied
to the probe, or it may be thrust through the waUs of
the sinus into the loose cellular tissue siurouncUng the
gut, and a very erroneous impression of the course
FISTULA IN ANO.
of the fistula obttuned. It must be recollected, thai
a probe is an instrument not to lie directed
with an absolute control, but one from which
we are to gather information : it is to guide
and instruct us. The probes I am in the habit
of using are fashioned like the annexed wood-
cut, with a flat handle, whirli, however, is not
designed that the instnuucnt may be grasped
with greater firmness, but for the purpose of
affording a clear idea of the relative direction
of the point when hidden from view in the
cavity of the sinus. Tlie internal oj^ning
may often be detected by those whose sense of
touch is acute, either as a sliglit tul)erclc, if the
sinus be callous, or by feeling a slight depres-
sion at the point where it exists.
It is no wonder that our ancestors enter-
tained the greatest dread of tistida in ano, and
considered it one of the most formidable of
diseases, when we think of the barbarous pro-
ceedings wliicli were liad recourse to in its
treatment. With tlie term fistulous was always
connected an idea of callosity or diseased condensation
and alteration of the structure of parts which could only
be removed either by cutting instruments or caustic, and
severe were the tortures the unhappy suflnrers were sub-
jected to. Some surgeons, fearing hjeniorrhage by ex-
\
FISTULA IN A\0. 246
cising the fistula, made use of the moat active escha-
rotics, whereby they laid the cavities of the rectxun and
fistula into one, wldle at the same time they supposed
the callosity to be wasted and consumed,
Dionis* tells of one Le Moyne, at Paris, who acquired
great reputation for the cure of fistula : " His method
consisted in the use of caustics, that is to say, with a
corrosive luiguent, with which he covered a small tent,
which he thrust into tlie ulcer ; by which he daily, Httle
by little, consumed the circumference, taking care to en-
large the tent daily ; so that by the widening of the
fistula, he discovered its bottom. If he found there any
callosity, he corroded it with his ointment, which also
served to destroy the coney burrows ; and at last with
patience he cured many. This man died old and rich,
by reason he made Ids patients pay very well for their
cure, in which he was in the riglit ; for the public value
things no otherwise than in proportion to the sum which
they cost. Those who wcii; a&ighted at the thoughts of
the scissors, threw themselves into his hands, and though
the number of rascally pretenders is very great, they
never yet want practice."
Others who had less dread on the subject made use
of various formidable instniments for cutting out the
fistula. A Dr. 'l\mier, wlio practised somewhat more
* ' A Course of Chirurgical Operations and DomonBtratdcuu in
tUu Itoyat UarduD al Paris,' imbliohed a.u. 1733, p. 224.
246 FISTULA IN ANO.
than half a century since, used an iron scoop, which he
describes as made " tike a cliecaemonger's taster, to be
thrust up the rectum, and assist in the division of it."
Mr. Pott remarks, " What ideas this gentleman had of
the disease, or of human sensation, I cannot imagme."
In all ages up to the present, there have not been
wanting impudent pretenders, with some never-failing
nostnmi for the cure of fistidse, or some mysterious man-
ner [jeculiarly their own, with which to delude the un-
wary suflerer. Louis XIV had fistula in ano, and being
unwnUing to submit to the oiwration, various methods
were proposed to liini for curing tlie disease without in-
cision, but being unwilling to have them tried on his
own person, he caused a number of his subjects suffer-
ing from fistula, to be treated by the different plans
which were suggested. Dionis* thus relates the history :
" In the year 1686 there arose near the kiii§;'8 anus a
email tumour, inclining towards the perimeum; it was
neither inflamed ; it grew slowly, and, after ripening, broke
of itself, by reason that the king would not suffer Monsieur
Felix, Ms principal chinirgeon, to open it as he proposed.
This small abscess wa* attended with the ordinary conse-
quences of those not Bufliciently opened to »dmit the appli-
cation of remedies to the bottom of the cavity ; there waa
only a small orifice through which the matter run ; it con-
tinued to suppurate, and at la«t became fistulous.
' Op, <
.. p, 221^.
FISTULA IN ANO.
347
"The Bolc way left of curing it waa manual operation;
but the great cannot always be brought to yield to it. A
thousand persons proposed remedies which they pretended
to be infallible, and some of them, which were concluded to
be the best, were tried, but none of them succeeded.
" His majesty was told that the waters of Barege were
excellent in these cases, and it was also reported that he
would go to those waters ; but before taking the journeyj
he thought fit to try them on several patients ; four persons
were found who were afflicted with the same distemper, and
sent to Barege at tlie king's expense, under the direction
of Monsieur Gervais, chirurgeon in ordinary to his majesty ;
he made the necessary injections of this water into their
fistulas for a considerable time, and used the proper
means for their cure, and at last brought them all back,
as far advanced towards that end as when they first went
thither.
" A woman reported at Court that, going to the waters
of Bourbon, in order to be cured of a particular distemper,
she was by the use of them cured of a fistula, which she
had before she went thither. One of the king's chirurgeons
waa sent to Bourbon with four other patients, who returned
in the same condition they went.
" A Jacohine friar applying to Monsieur Louvoy, told
him that he had a water with whieb he cured all fistulas ;
another boasted of a never-failing ointment ; and yet others
proposed different remedies, alleging the cures which they
pretended to have done. The minister, determining to
neglect no means in order to the procuring a restoration of
a health so important as that of the king, caused several
348
cbamben to be furnished, in wliicli he placed persons
afilicted with fietulas, and caused them to be treated pur-
suant to the several methods of the boasting pretenders to
cure them in the presence of Monsieur Felix.
" A year was spent in these various essays, and not one
patient cured,
" Monsieur Bessiere, who examined the indisposition,
being asked his thoughts by the king, freely answered bis
majesty, that all the remedies in the world would prove
vain without manual operation.
" At last the king, to whom Monsieur Louvoy and Mon-
sieur Felix gave an account of what had passed, seeing
no hopes of being cured otherwise than by operation, on
which Monsieur Felix continually insisted, determined for
it i but would not acquaint any person with his resolution ;
he delayed it till his return horn Pontainbleau, and one
morning had it performed when nothing of the natiu^ was
suspected by the courtiers, who, going to attend the king's
levee, were informed that he had undei^one the o|)cration,
and resolutely suffered all the incisions which Monsieur
Felix thought proper to be performed.
"This happened on the 2lBt of November, 1687. Mon-
sieur Fcl«, to whom the king had left the liberty of
appointing what chirurgeon he pleased to assist him, chose
Monsieur Bessiere, who was accordingly present at this
operation, where besides were only Monsieur de Louvoy,
and the two physicians, Dr. Daquin and Dr. Fagon. The
cicatrizing was very well managed, and the king perfectly
cured. His majesty also royally recompensed all those
who had rendered him Bcrviee whilst under this indis-
FISTDLA IK ASO.
249
position ; he gave to Monsieur Felix fifty thousand crowna ;
Monsieur Daquin one hundred thousand livres ; Monsieur
Fagon twenty-four thousand livrea j Monsieur Bessierc forty
thousand livres, and to each of his apothecaries, in number
four, twelve thousand livres j and to one Cage, Monsieur
Felix's apprentice, four hundred pistoles."
The sum total of these fees equalled SI l',700.
If the health of the ifldivitlua! i8 good, and all circum-
stances are favorable, a fistula may sometimes be made
to heal without an operation. Sir Astley Cooper* men-
tions, in his lectures, two cases which were cured by
injections. I have succeeded in several instances in
healing them without oj)erat!on, though the cure has
been somewhat tedious. When a patient objects to
the necessary operative proceeduigs, we may try other
means ; constant pressure must be niade upon the track
of a sinus, wliich sliould be injected with a solution of
sulphate of zinc, or copper, or nitrate of silver. When
the cavity of the fistula has been hard and callous, I
have cauterised it tlu'oughout its course with nitrate of
silver. The following ia tlie maimer of doing it ; having
ascertained the pi-cc;ise direction and sinuositiea of the
fistula, a probe is to be bent into the form that will most
readily [lass ; it should then be coated by dipping it into
the cjutstic melted in a watch-glass over a spirit-lamp ;
thus armed, it must Im; rapidly piissed into the fistula,
• Op. cit,, vol. 11, i>. 334.
850 FISTULA IN ANO.
and allowed to remain a few seconds, and then with-
drawn ; a simple poultice or water-dressing sliould be
applied for the first twenty-four hours, and after that
pressure must be made along its coiu«e. During the
treatment the bowels must be kept open, and soup and
water used to the anus night and mommg. By these
means we shall sometimes succeed in healing the fistula ;
but it is a plan not to be relied on. An isolated ease
will occur now and then, in wliich a fistula will close
without any surgical interference. Four years ago a
patient applied to me with complete fistula of the right
side ; the external opening was about an iuch and a
quarter from the ani^, and the internal one between two
and three lines from the anal orifice. At the time he
was under the trentiiient of Dr, Quain, at the hospital
for Diacases of the Chest at Bmmpton, his Imigs being
seriously afiected by tubercular deposit. On consulting
with this gentleman, we agreed that it would not be ad-
visable to do anything for the fistiila, fearing to aggravate
the pulmonary affection. He was directed to wash the
anus with soap and water night and nioming, and also
after defecating, and not to allow the bowels to become
constipated. The fistula healed about six months after
I first saw him. He continued under the judicious
medical treatment of Dr. Qunin, and his health greatly
improved : but in the early part of the autunm of 1S55
he caught a severe cold, wliich inci'cased the activity of
FISTCLA IN ANO.
251
tlip tuliercular disease of tlie lungs and tcnninatcd liis
life.
We must not delude ourselves or our patients with
the idea that fistula can often be cured without an
operation ; however we now have the satisfaction of
knowing that the formidable proceedings of former days
are not requisite, and that an incision of limited extent
is all that is necessary; the operation occupies only a
few -seconds, and causes comparatively Httle pain. But
there are some persons whose nervous susceptibihties
are so exalted, and the dread of cutting instruments so
great, that no reasoning or persuasion will induce them
to consent to the best and easiest plan of treatment.
Under these circumstances recourse may be had to tlie
ligature. In past time it was frequently employed, but
the tediousncss of the process, when the ligature had
to ulcerate through any thickness of parts, and the
irritation that frequently attended its use, led to its
being discarded. Mr. Pott* thus expresses his opinion.
" The terror wliich a cutting instrument necessarily car-
ries with it, the fear of a &ax of blood from some con-
siderable vessels, together with a strange, nonsensical
opinion, that a gratlual division of the parts was followed
by a more sound cure, than an immediate one by cut-
ting, produced the coarse, unhandy method by ligature.
. . . But as the whole operation is. on every priu-
• 0]). eit.vol. i
K 125, 12C.
252 FISTCLA IN ANO.
ciple of ease, expeilition, safety, or certainty, unfit for
praetice, it would be an abuse of the reader's patience to
dwell any longer upon it." Sir Astley Ckwper says,
"Tiniid persons prefer this mode of treatment to the
biife, idtliougli in the one case tlie irritation is long
continued, and in the other, tlie pain is only of a few
minutes' continuance.
"That it succeeds in some instances I have known,
for some of my patients, having submitted to this remedy,
returned to mo well.
" My oljjection to it is, that the irritation it produces
is liable to occasion other abscesses, whilst healing that
for which it is employed."
Mr. Luke revived the use of the ligature, and invented
several mstruments for passing and tightening it ; in the
first volume of the "Lancet" for 1845, are drawings
and descriptions of these ; he also recites nine cases
treated by this method, but 1 believe he now regards
incision preferable to it. I have on one occasion had
if'course to the ligature, as the patieut would not consent
to any other oiwration, and a eiu^ was effected. The
ligature was kept tense by attaching an india-rubber
ring, such as is now generally used to secure pa()ers toge-
ther, which being put on tlie stretch, was fastened to the
buttock by a strip of plaster.
Since Mr. Pott proiiounded Ins principles of treatment
of tiatula by sini[ile lUvision, and pi-ovcd the soundness
FISTULA IN ANO. 253
of those principles in a very extended field of public nnd
privnte practice, the objectionable operations formerly in
voguEj have in this country been almost entirely set
aside. Yet some surgeons may still prefer the prin-
ciples and practice of our forefathers. Mr. Syme*
remarks, " As was to be expected, however, many prac-
titioners clung to the methods in which they had been
educated ; and even in the present day there are some
who, whether from imbibing the bad example thus trans-
mitted to them, or from an uidiappy pecidiarity of judg-
ment, still prefer the old and unjustifiable process of
excision. I have seen an eminent professor of surgeiy
in Paris cut out the fistula, and imdcrstand that he
continues to piu^ue this practice. Some years ago a
middle-aged woman came under my c-arc in the Surgical
Hospital, on account of a recto-vaginal fistula, and stated
that the complaint commenced with a fistula in ano, for
which she had had an operation performed by the sur-
geon of a provincial hospital, who cut something out and
laid it on the table, since which there had been a com-
munication between the rectimi and vagina. More
lately, a gentleman from the north of England, applied
to me on account of some unpleasant consequences re-
sulting from an operation, or rather, series of operations,
to which he had been subjected on accoimt of fistula in
ano. His principal complaint was inability to retain the
• Op. cit, Third Edition, pii. 36, 36.
254 FISTULA IN ANO.
contents of hb rectum, wliicli, notwithstanding the re-
sistauce of a carefully constructed bandage, were wout to
be suddenly and involuntarily discharged, so as to cause
great discomfort, and constant apprehension. Though
prepared to find something far wrong, 1 was not less
surprised than shocked, upon inspecting the seat of the
disease, to see no appearance of an aims, but instead of
it, a deep excavation, at the bottom of which the mucous
coat of the bowel presented itself to view, completely
divested of the sphincter. From these and other facts
of the same kind that might be mentioned, I fear it
must be concluded that tlie plan of excision is still not
entirely abandoned ; but, feeling assured that those «'ho
persist in adhering to it, notwithstanding all that has
been said aud wTitten on the subject, would not have
their views altered by any argument in my power to use,
I shall leave them to follow the progress of improvement
at their own leisure."
When it was the custom to divide the rectum through-
out the entire extent of the fistula, a simple knife was
not by many deemed sufBcient, and " ingenious, mecha-
nical, and whimsical people have busied themselves in
inventing instruments for tliis purpose : the syringotomy,
the culteDus fulcatus, the probe razor, &c., have at all
times been in use ; scissors also of various kinds, both
straight and crooked, have been employed in this ope-
ration i the first three may be made to serve the purpose
FISTULA IN ANO. 3o5
very well ; but to the last (the scissors) there is in this,
as well as in almost every operation in which they are
frequently used, a palpable objection, viz,, that by
pinching at the same time they cut, they occasion a
great deal of unnecessary pain. They are, I know, in
great use with many, who if they were deprived of
their probe scissors, would think tbeioselves incapaci-
tated from doing business ; but they are, upon all occa-
sions where mere division is required, a very bad in-
strument ; they may assist an awkward or an unsteady
hand, but they are more fit for a farrier than for a
surgeon."
" In all chirurgic operations, the instruments made
use of cannot be too simple, nor too keen.""
The importance and advantages of the observations
of M, Ribcs regartUng the situation of the internal open-
ing of a fistula, and the principles deduced therefrom,
namely, that it is not necessary for effecting a cure of
the disease, to carry the incision to a greater height
than where it exists, or where the mucous membrane is
denuded and thinned, if there is no internal opening,
is now fully estabhshed. Mr. Syrae, the eminent pro-
fessor of clinical sm-gery, of Edinburgh, has for years
inculcated and acted upon these principles in his prac-
tice, and testifies to their perfect success : I have never
carried my incisions higher, and have never been dis-
• Pott, op. eit., pp. Ill, 112.
266 FISTULA IN ANO,
appointed in the result. But some surgeons of great
ability aud eminence in the profession, and ^vriters of
high authority, have pursued the practice of Mr. Pott.
Sir Astley Cooper* advisos, " If auy portion of the sinus
remaui above the opening into the rectum, it shoiUd be
divided with the probc-point«d scissors." Mr. Copeland
carried his incisions to the bottom of the sinus, and
expresses surprise that Mr. Pott, in his treatise on tistuhk
in ano, should have passed unobserved the hBemorrhage
that sometimes takes place from the incision and the
difficulty of arresting it ; and he further aays, " I will
venture to say that it has occurred to ahuost eveiy
surgeon who is in the habit of performing this ope-
ration."t
The same author gives the following cases in illus-
tration.
"A carpenter, about thirty years of age, had the
operation for tistula in ano performed on him in the
year 1803. There were two extensive sinuses in the
nates divided, but the principal one extended above
three inches up the side of the gut, and then ]3erforated
it ; this also was laid open. There was considerable
haemorrhage at the time of the operation ; but the
patient fainted, and the bleeduig stopped; aud when
• Op. cit., p. 330.
t ' ObstrvationB on the Principiil Diseases of the Rectum aud
Anus,* by Thomaa CopelanO, 1824, p. 86.
FISTULA IN ANO.
the wound was dressed, he went to bed. After he
had been in bed about an hour, the haemorrhage re-
tiu-ned, and the bleeding artery was so high up the
sinus, as to be entirely out of the reach of the needle
and ligature; the gut, therefore, and the wound were
filled up with compresses of hnt, wet with spirit of
turpentine ; and for some time, it was thought that this
mode of compression had succeeded in stopping the
heemorrhage ; but, diuing oiu- fencied security, his pulse
became hardly perceptible, his lips pale, and the whole
body was in a cold sweat. He was now supported by
wine and other cordials ; and in a short time the hjemor-
rhage burst out again, with as much violence as ever,
and continued for more than an hour. All the com-
presses were now removed, the rectum cleared as much
as possible of coagulated blood, and the wound left
without dressings. The haemorrhage stopped, and did
not return again, but very large quantities of coagulated
blood were evacuated with the faeces for three days
afterwards. He was, as may be supposed, extremely
debilitated by this loss of blood, but finally recovered
his strength, and his fistula was dressed and cured in
the usual way."
" A gentleman, about fifty-six years of age, who had
been subject to complaints of the hver, and frequent
hremorrhage from the nose, Iiad the operation for fistula
in ano performed. A sinus leading into the rectiun,
■258 FISTULA IN AND.
about an inch from the aniis, was first divided, and then
another passing towards the os coccygis ; the opening
of this last discovered another sinus penetrating the gut
about an inch or rather more above the former one
which had been divided. This was also laid open, and
the wound bled very freely ; but the orifice of the bleed-
ing vessel could not be discovered. In a short time the
haemorrhage diminished, and the wound was dressed in
the usual way, by introducing a piece of hnt from the
gut into the divided sinus. There was some degree of
haemorrhage nearly the whole night, and in the morning
a. small artery was discovered, and a ligature passed
round it : but tlie bleetling continued and increased very
considerably, when he had an evacuation in tlie middle
of the day. The wound was cleared of all the dress-
ings, together with the coagulated blood, and the hsmor-
rhage ceased."
" During the succeeding night there was no bleeding,
but in tlie morning it returned when he had a stool,
and he lost about four ounces of florid fluid blood. The
wound was now filled with lint, wet with Ruspini's
styptic, which happened to be at hand ; tliere was a httle
haemorrhage diuing the day, and in the following night,
which, however, he passed tolerably well, and the wound
began to suppurate plentifully. But when he had an
evacuation of the faeces, the bleeding again returned,
thougli in a less degree, and for many days he lost some
FISTULA IN ANO.
269
ounces of fluid blood every time he passed bis stool.
At last it ceased altogether, the wound went on well,
and in about six weeks was quite healed."*
Mr. Liston.t was in the habit of dividing the sinus to
the bottom, and on several occasions, when T have as-
sisted him, I have been obliged to make pressure for
some time to arrest the kemorrhage. Mr. FergussonJ
does not appear to appreciate the advantages of a
limited incision in fistula in ano, as, after' speaking of
the position the surgeon should place himself in, he
says, " He should then introduce the end of a probe-
pointed bistoury through the external opening, and
push it slowly along the sinus until it reaches the
upper extremity." Again :^ "I beHeve it is best to
open a sinus throughout." Dr. Bushe, whose practice
was very extensive, divided the textures as high only
as the internal opening into the rectum, and always
found it sufficient for the ciu-c.
When a patient with fistida seeks surgical assistance,
and an operation is deemed advisable, the general health
must be first attended to, if at aD impaired, due atten-
• Op. cit., pp. 159—163.
t 'ElemeQts of Surgery,' by Eobert ListoD, Second Edition,
p. 564r. ' Practical Surgery,' by Robert Listen, Fourth Edition,
p. 138.
J 'Practical Surgery,' by "William Fergusaon, Third Edition,
p. 747.
§ Page 748.
860 FISTULA IN ANO.
tion being paid to the functions of the liver, kidneys,
and skin. On the morning previously to the operation,
the bowels should be acted upon by a mild cathartic,
and an enema of warm water or thin gruel adminis-
tered ; the operation is then to bo performed in the
following manner. The patient kneeling on a chair.
and resting on the back of it, or leaning with his elbows
on a table, or lying on a bed or couch, with his knees
drawn np, and the nates projecting, an assistant sepa^
rates the buttocks, and the surgeon, introducing the
forefinger of the right or left hand into the rectum, ac-
cording to the side on which the fistiJa exists, makes
himself familiar with its track and position by using
the probe aa previously directed ; having accomplished
this, he passes the blade of a probe-pointed curved
knife into the external orifice along the course of the
fistida, making it emerge through the internal opening,
the point being hitched by the finger in the rectuni ;
both hands are then depressed, and with a slight sawing
motion the intervening tissues are divided, and the
knife and finger brought out together. If the surgeon
be timid, or unaccustomed to operate, or the fistula so
tortuous that the knife cannot readily pass along its
track, a grooved silver director, or strong probe, may be
used ; it must be bent as required, and, having been
introduced tlunugh the opening in the integmnent and
that in the bowel, the end is pulled down, and made to
PISTDLA IN ANO. ZOl
protrude at the anus ; the parts are then to be divided
by passing a eliarp-pointed curved histoury along the
grooved channel, and the operation is finished. This
plan occupies a few more seconds in performing it, and
occasions somewhat more pam than the other.
When more than one external opening exists, or
sinuses extend towards the Iiip, the whole of them must
be laid open at the same time, or a second operation
will be necessary, which the patient may not be willing
to submit to, and the cure will be protracted. In the
writings of a late very distinguished surgeon, it is re-
commended to lay open and heal the sinuses in the
buttock before dividing the fistula ; but no possible ad-
vantage can be derived therefrom.
When the incisions are completed, a strip of lint
must be inserted between the divided surfaces, to prevent
their uniting again before granulation takes place from
the bottom ; but the wound must not be crammed, as
is sometimes done, or irritation will be produced. If it
is thought desirable, an opiate may be administered
after the operation, rather to prevent the action of
the bowels for two or three days than with any other
intention.
The first dressings are not to be removed by the
surgeon, but allowed to remain till the bowels act, and
they will then come away with the feces ; if they are
not moved of tlicir own accord by the third day, a dose
262 FISTULA IN ANO.
of castor oD must be administered, and, mIctim^S*
ration, the wound must be cleansed, and another piece
of lint inserted. Till the wound has nearly healecl, the
surgeon should, each succeeding day, inject a little thin
gruel so that the bowels may be kept easy ; and after
their action, the dressings ore to be renewed. If there
be not sufficient reparative action in the part, the lint
must be dipped in a weak solution of zmc or nitrate of
silver, in order to excite the required degree of stimu-
lation.
At first the patient must be confined to the recum-
bent position, and hia diet must be spare, if he be ple-
thoric i but if, on the contrary, liis vital powers be low,
we must be more hbcral in the quantity of food allowed,
and we may also find it necessary to order a certain
amount of wine or beer, and to prescribe bark and other
tonics.
Bleeding is of very rare occurrence when the operation
is performed in the manner just described, though it is
by no means uncommon when the incision is carried un-
necessarily high ; should it occur, the finger is to be
introduced into the rectum, and lint passed along it so
as to fill the wound ; gentle but firm pressure is then to
be maintained for a time, and it will be very rarely that
anything else is required ; however, should the bleeding
continue, the bowel must be dilated with a speculum,
and any vessel that is seen secured with a ligature.
I^ISTI'LA IN ANO.
203
Elevating the pelvis, and applying a bladder containing
powdered ice to the sacrum and anus, will assist in
suppressing the haemorrhage.
When the fistula is of the blind internal form our
method of proceeding must be different. The internal
opening is then to be found ; it will be indicated by the
escape of matter when pressure is made externally, or
acute pain will be felt at one spot, and will inform us of
its position ; a probe, more or less curved, or bent at an
angle if the openiag is not close to the anus, mnst be
passed into the sinus, and the end made to project
against the integument; with the point of a knife an
incision is then made down on it, and a complete fistula
will thus be formed ; the operation is then to be finished
with a ctirved knife as just directed.
External bUnd fistula, extending to the coats of the
intestine, must be made into a complete one by perfora-
tion of the bowel with a knife ; the point at which this
must be done is where the internal opening is usually
found ; when the fore-finger is introduced into the
rectum, and a probe directed along the course of the
fistula, the point will be plainly felt at a particular spot
where the mucous membrane ia denuded and thinned.
A knife similar to that used in operating on complete
fistula is made to follow the same channel as the probe,
and the point being felt by the finger placed within the
aims, is pressed onward against tlie edge of the nail, and
264 FISTULA IN ANO.
by a slight motion made to cut through the intestine ;
the point is then depressed, and the intervening tissues
divided. As the surgeon's finger is very Uable to be
wounded in cutting through the gut, it has been pro-
posed to paaa a wooden gorget into the rectum, and to
cut on that, but if the end of the nail be presented to
the point of the knife instead of the pulp of the finger,
the operator will escape injury.
Savigny invented a bistoury especially for this opera-
tion, it had two blades side by side, the one having a
round point, the other a sharp one, the latter beuig
made to project beyond the former when required. The
blades were passed hi the usual way, and the probe
point being felt pressing against the intestine, tlie sharp
pointed blade was projected, and the bowel perforated ;
the pointed blade was immediately retracted, the con-
joined blades being theu carried through the pimcture,
the incision was finished as with a common bistoury.
The instrument is ingenious, but not necessary to a
surgeon capable of performing the operation ; besides, the
conjoined blades make the instrument thick and clumsy.
The ordinary curved probe-pointed bistoury, recom-
mended by Percival Pott, and known as his knife, an-
swers every purpose, but is larger than is required; one
of the size and form of the annexed figure will be found
most convenient. I have the blade made somewhat
thicker in the back than the common bistoury, which
FISTULA IN ANO.
265
renders tlie button at the end super-
fluous, and the edge at the point cau
be kept in better order. In usiug the
ordinary bistoury, an accident is liable
to occur by the instrument breakin g
this may result from the unsteadiness
of the patient, or from the density and
cartilaginous induration that tates place
in the tissue, when the disease has been
allowed to continue for years, but
chiefly depends upon the fashion the
instrument-makers have of grinding
the blade thinner and notching it at the
termination of the cutting part. I
have witnessed this accident happen to
Mr. Listen ; on the occasion he passed
a second knife along the broken blade
which fell from the wound on the
completion of the incision. To guard
against any inconvenience arising from such an accident,
he recommended the operator always to be provided
with a second knife.
By lar the larger proportion of fistulae in ano admit
of remedy by the slight incision which has been shown
to be all that is requisite ; but, before performing it, or
giving the patient an opinion on the probabihty of its
aEFording rehef, we must asccHaiu if any constitutional
266 FISTULA IN ANO.
or local cause exists that may be likely to render the
operation imsuccessful or disappoint the hopes of the
patient.
It has already been observed that affections of the
thoracic and abdominal organs predispose to this dis-
ease, which then stands only in relation of effect to the
primary malady, and therefore success is not likely to
attend our efforts whilst the cause remains in active
force. The most common cause that will rt^nder a prog-
nosis unfavorable regarding the result of an operation,
is the patient being the subject of phthisis, in which
case, if the operation be performed, the wound will not
heal ; or shoidd it do so, the probable result will be,
either the formation of a fresh abscess, or the aggravation
of the pulmonary disease. However, it is not every case
that must deter us ; we have now ample proof that
phthisis is not the hopeless disease that it was formerly
considered, and that after symptoms of piUraonary tu-
bercle have existed, patients recover, and live free from
any complaint for many years ; therefore, when applied
to under these circumstances, if the issue of the thoracic
disease be uncertain, or there is a prospect of recovery,
we are not justified in withholding our attempts to cure
the lesser affection, but which in the imagination of the
patient is the greater evil, and occasions much discom-
fort and annoyance ; besides, declining to operate, is apt
to induce a state of hopeless mental depression and
FISTULA IN ANO.
despondency. On the other hand, though the operation
may bo performed at tlic particular desire of the patient,
it would not be prudent to propose or urge it in ad-
vanced phthisical cases, or the surgeon may bring great
discredit on himself.
Among the causes of abscess in the anal region, was
mentioned perforatiou of the coats of the iutestine by
fish bones, spicidse of bones, and other substances which
had been swallowed. An abscess thus formed, as a
matter of course, will not heal so long as the foreign
body is allowed to remain. 'ITie patient seldom recol-
lects, or is even aware of having swallowed any hurtfid
substances ; therefore it is only by examination with the
finger or probe that the substance, whatever it may be,
can be detected. The fistula is to be operated on in
the ordinary manner, and if the foreign body cannot be
removed without lacerating the parts, the incisions must
be enlarged.
As a consequence of abscess in the perinteum, fistulous
communications may be established with the rectum
and urethra ; this complicated form of disease is usually
the result of the abscess spontaneously discharging itself
into those passages, — the fascia of the perinieum re-
tardmg its outward course — instead of its contents
having been evacuated by early incisions ; external open-
ings sooner or later take place, and are situated near
the root of the scrotum or verge of the anus. The
SOS FISTULA. IN AND.
patient now is in a pitiable condition ; a fetid discharge
from the external orifices is a source of great misery ;
uiine escapes from the rectum, and thin feculent matter
and flatus from the urethra, not unfrequently stricture
of the urethra exists with this form of disease, in which
case it is necessary to dilate it before proceeding to
remedy the fistulas. The internal opening in these cases
is generally higher in the bowel than in ordinary fistulse.
In operating, the same principles must be acted on as
in the simple form of fistulse ; the intervening tissues be-
tween the internal opening and that nearest the anus
are to be divided, theu the siuus between that and the
urethra is to be exposed ; some dry lint is to be in-
serted into the wounds, and the after treatment con-
ducted on ordinary principles. Sometimes a small
fistulous communication wUl remain between the rectum
and urethra after the wounds hove healed externally,
permitting a few drops of mine to escape by the bowel
occasionally, proving a source of annoyance to the
patient, and causing a fear of a return of his former
condition. The rectal orifice must be brouglit into view
by the spccidum ani, and the closure of the fistiUous
track will be effected by passing along it a probe coated
with nitrate of silver, or a wire heated in a spirit*lamp
or by the galvanic current.
Fwtula in ano will sometimes coexist with stricture of
the rectum, in which case the internal opening wiU be
FISTt'LA IN ANO. 269
above the conBtricted portion of the intestine, if xdcc-
ration and abscess have ensued, as a result of the pres-
sure and irritation induced by the resistance offered
to the evacuation of the faeces ; but, although associated
with stricture, the internal opening may still occupy
its usual situation, and the fistida may have been caused
either by the irritation excited by the stricture, or inde-
pendent of it.
When the opening is above the preternatural contrac-
tion of the intestuie, the latter must be dilated before
any incisions are practised for the ciu^ of fistula ; and
when the fistula is below the stricture we shall effect but
Uttle benefit till the rectum is restored to its natural
cahbre.
Fistula connected with diseases of the sacrum, Uium,
or pubis, cannot be benefited by incisions so long as the
osseous parts remain diseased ; if any portion of the
bone be necrosed, it must be extracted, or be thrown off
by nature, before a recovery can be looked for, Mr.
Syme* mentions two cases connected mt\i disease of
bone ; the one a man who had been repeatedly operated
on for fistula iu ano, without obtaining rehef ; a careful
examination discovered an exfoliation from the tuberosity
of the ischium lying in a capsule formed by the origins
of the flexor muscles of the leg. The second case — that
of a young woman, who suffered from fistula in ano ; a
* • On Diaeaaes of the Rectum,' Third Edition, pp. 54, 55.
S70
PlSrOLA IN ANO.
1
probe being felt to grate against a hard substance it
was extracted, and found to be a thin scale of bone,
probably detached from the arch of the pubis.
In (he ' Lancet'* there is an account of a man, aged
forty-seven, who was in St. Thomas's Hospital, having
6stula in ano, for the cm^ of wliich the usual operation
was performed, but without benefit, and tlie patient con-
tinued to experience excruciating pain ; subsequent ex-
amination discovered the rectum to be considerably
ulcerated, and partaking somewhat of the characters of
cancer ; this condition was ultimately discovered to de-
pend on caries of the sacrum. Latclyt there was a man
at the Marylebone Infirmary with fistula in ano, con-
nected with necrosis of the tuberosity of the ischium ;
the dead bone was removed by operation.
Abscess, from disease of the hip-joint in its advanced
stage, usually opens posteriorly, and below the articula-
tioHj but sometimes matter will burrow and effect an
opening near the anus ; it is scarcely necessary to say,
in such a case, the operation with the hope of curing the
fistula would be entirely useless.
The subjoined cases are examples of some of the more
ordinary forms of fistula in ano.
Fistula in ano the effect of a kiek. I
A young gentleman, Eet. seventeen, at one of the public
I
• Vol. ii, 1835, p. 461. + Oct., 1856.
VISTULA IN ANO. 271
Bchools, received a kick from a companion, which was fol-
lowed by the formation of an abscess; it was allowed to
burst, and, beyond keeping some lint to the part, to prevent
his linen being stained, nothing had been done ; during the
vacation, he came under my care. I found an external
opening Iretween one and two inches from the anus ; a probe
passed into this could be felt by the finger in ano, in contact
with the walla of the intestine which were very much
thinned; no internal communication could be discovered.
Constitutional treatment was had recourse to for a few days,
and after the bowels had been thoroughly unloaded, an in-
cision was made through the sinus and bowel from the point
at which it was denuded. It was deemed advisable to keep
liim in bed for a week ; the bowels were kept easy by lax-
atives, and an enema of eight ounces of thin gruel injected
every morning; the woimd was lightly dressed, and in about
three weeks had quite healed.
Fiatala in ano ; (teo external openings ; operation ;
cure.
Mrs. , let, twenty-seven ; when I was consulted she
had been married six years, and had had no family. TSto
years previously to her marriage she experienced heat,
itching, and fullness in the rectum; these symptoms in-
creased, and after a time she occaaionally lost a small quan-
tity of blood at stool. A few months after marriage an
abscess formed near the anus, preceded by heat and severe
throbbing pain ; she used poultices and it broke, the skin
giving way in two places. Previously to the abscess bursting,
she had observed by her linen, that there was a alight pnru-
878 FISTULA IN ANO.
lent discharge from the anus. After the matter had obtained
vent she had less pain ; but continued to have great uneasi-
ness, and was annoyed by a constant discharge of pus.
On making an examination, two small fistulous openings
presented, one being about an inch from the aims, and the
other an inch and a qiiarter from the first, its direction being
outward and backward ; a fistulous track, extending between
the two openings, could be felt like a cord beneath the finger ;
at an angle with this sinus, another could be felt extending
towards the bowel ; a probe readily passed from the one ex-
ternal opening to the other, but, from the acute angle formed
by the two sinuses, it could not be made to enter the bowel.
At a quarter of an inch above the anal orifice, a small hard
tubercle coidd be felt ; and pressure produced some pain at
this point. She had always been of a costive habit, and had
not been accustomed to take much exercise. Her pulse was
not quick but rather sharp, her tongue was fiured and
notched, and she was much troubled with flatulence; the
renal accretion was disordered, there being an excess of \iric
acid. Mcdicmcs were prescribed to unload the bowels and
improve her general health. After persevering in these for
ten days the operation was performed. She had taken a dose
of castor oil early in the raoming, and an enema had been
administered an hour before I arrived at her house, by which
means her bowels had been thoroughly relieved. I first di-
vided the siuuB between the two external openings, and was
then able to pasa a probe through the fistula into the bowel
without the slightest difficulty, the end being brought in
contact with the finger of the left hand, introduced into the
rectum ; a small curved bistoury was made to follow the
FISTDLA IS ANO.
273
probe, and the intervening tissues divided ; only a few drops
of blood were lost. A piece of lint was gently inserted be-
tween the hps of the wonnds ; and she took half a draclim
of wine of opium in camphor mixture.
On the third day, the bowels not having been moved, she
took a dose of castor oil ; the dressings came away when it
acted. After this the wound wa.s lightly dressed each day,
and in little more than a week she was quite well.
Fistula in ano following an abscess caused by wet and
cold.
F. M , ffit. thirty-five, a coachman in a nobleman's
family, of moderate stature, and robust constitution. After
driving the greater part of a cold wet day, he felt towards
the evening a burning heat in the integument near the anus,
and during the night severe throbbing pain commenced ; this
continued three days, when he had a slight shivering fit,
after which the acuteness of the piun subsided, and resolved
itself into a dull aehing sensation; on the fifth day from the
commencement of the attack, he applied to me. There was
then very little constitutional disturbance, the tongue was
somewhat furred and his skin dry. On making an examina-
tion, the skin between the anus and the tuberosity of the
ischium was observed to have a dusky red appearance, and
fluctuation was perceptible to the touch, I made a free
opening with a bistoury, and evacuated about an oimce and
a half of unhealthy pus ; he was desired to keep a poultice
to the part, and to see me in a few days.
In a week after the abscess was opened I made a careful
m
274 FISTULA IN AtJO.
examination with a probe, and could not detect any com-
munication with the bowelj there appearing to be a thick-
ness of tiBSucB of at least half an inch between the walls
of the abaccBs and the bowel. He appeared to be pro-
greasing favorably; and he was directed to keep the
bowels regular, to live moderately, and to sec me again
in a short time.
He did not see me for several weeks, as he considered the
abscess would heal in time ; he had had pricking pain in
the part occasionally, but not at all severe. I made an ex-
ploration with a probe, and now discovered the coats of the
bowel denuded immediately above the margin of the anus.
On the following day, with the assistance of Mr. Thompson,
I divided the structures between the external opening and
the denuded bowel. The wound was lightly dressed, and he
was ordered to remain in bed. 'When 1 called on the follow-
ing day I was surprised to find he was out. I left word for
him to call at my house the next morning, which he did; I
dressed the wound, it was looking very healthy, and 1 de-
sired him not to neglect seeing me till he was quite well.
He came to me every morning for a few days, and he made a
very rapid recovery.
Fistula in ano, and urinary fisMa from abscess consecu-
tive on gonorrhgsa.
A young professional friend contracted a gonorrhosa, which
he treated himself by the use of strong injections; during
the time he rode much, and indulged too fireely in wine. The
result of these indiscreet proceedings was the formation of
FIBTCLA IM ANO.
27 B
an abscess between the urethra and bowel ; he allowed it to
take its own course, and the abscess burst into the rectum
and urethra, and ultimately an opening formed in the
perinsBum, through which some of the urine passed whilst
micturating. He now thought it time to give up the case,
and trust himself to other hands. He was confined to bed,
appropriate medicines prescribed, and a strict regimen en-
forced ; after some weeks his general health was improved,
the tissues intervening between the perinseal opening and the
one in the bowel were then divided, and the wound dressed
in the ordinary way. When it had nearly filled up
by granulation, a probe, coated with nitrate of silver,
was passed along the fistula to the urethra, and allowed
to remain a few seconds j on the following day, pressure
by means of a pad of lint and a bandage was made.
In about a month aftef the operation the parts had
healed.
Fistula in anofrom an abecess not being opened.
S. R , let. thirty-four, a groom, applied at the Blen-
heim Dispensary, suffering from a fistula in ano. He gave
the following statement of its formation : Twelve months
previously he had throbbing and heat near the fundament,
and the skin became very tender if pressed; he concluded
an abscess was forming, and had recourse to poultices, but
several weeks elapsed before it burst; passing a stool gave
him great pwn; shortly after this he observed the fsces
streaked with pus. He had continued the use of poultices,
hoping the part would heal ; he had also used varioua oint-
876 FISTULA IN ASO.
ments and lotions that had been recommended to him, but
without reaping any benefit from them.
On making an examination I perceived a small opening in
the integument aurrounded by fungous granulations, situated
an inch and a half from the anus ; a probe passed readily
from it into tlie bowel, and was felt about three quarters of
an inch above the margin of the anus by the finger, which
had previously been introduced. His general health was
good ; and the case appeared one that might be healed with-
out iacision, but as he was mast desirous to be cured as
quickly as possible, I determined to divide the parts, which
I did on the following day, having previously preseribed
medicines to unload the bowels. In lesa than a fortnight
the wound had quite healed.
Fistula !
ano ; several external openings and extensive
sinuses.
H. E , ffit, forty-one, a butler, came under my care
suffering from fistula. He attributed its origin to injury of
the bowel by a bone that he had swallowed, which he said
lacerated his inside on its passage outward, and gave rise
to an abscess by the side of the fundament ; he applied
poultices, and it burst in sis or eight days from the time
he first felt pain. He continued to poultice the part, and
he was in hopes it had healed, but matter again formed
and then discharged itself. This process recurred several
times, and other openings formed towards the buttock.
During this time he had taken various medicines, and used
lotions and ointments : one gentleman whom he consulted
FISTULA IN ANO.
277
proposed an operation, but hia occupation prevented him
lying up. At length, Ms general health filing, he was
compelled to submit himself to proper treatment. ^Vlien 1
first saw him liis countenance was sallow ; the sclerotic con-
junctivie yellow; hia tongue was much furred and deeply
notched tranaversely ; his pulse was soft and weak ; and he
had been of constipated habit for years. The integument on
the left side of the anus was of a purpliah-red colour, and
the aubeutaneous cellular tissue was infiltrated and inda-
rated; four fistulous openings existed, one was within an
inch of the anus, the furthest was five inches from it; a
probe directed through the nearest opening to the anus
passed a considerable distance up by the bowel ; by a careful
exploration an internal opening was found three quarters of
an inch above the external apliincter. He was confined to
his bed, and mild mercurials, taraxacum, and purgatives
were prescribed; when the bowels had been thoroughly
cleared out, and his countenance had assumed a brighter
aspect, he took the iodide of potassium and sarsaparilla.
Under this treatment the integument of the anal region
becanie more healthy and the induration considerably dimi-
nished, but its vitality was too low to offer a hope of the
healing process occurring without dividing the sinuses ; I
therefore laid them freely open, and also divided the tissues
between the opening in the bowel and the external one.
Two or three ounces of blood flowed, but no vessel required
ligature. The wounds were dressed in the manner that has
been directed ; and, after the third day, the bowels were
kept open by laxatives and enemata, and great attention to
cleanliness observed. He continued the iotlide of potassium
278 FISTULA IN ANO.
and sanaparilla for three or four weeks after the operation^
when the iodide of iron was substituted for it.
In consequence of the condition of the tissues^ and the
length of time the disease had existed^ it was nearly six weeks
before the wounds had entirely healed.
Like the mucoua cavities of the noae, utemg, and
vagina, the rectum is occasionally affected with growths
of the nature of polypi. Tht-y vary in structure and
form, and may partake of the character of the raucous
poly])U8, the sarcomatous species, or the malignant. Sir
Astley Cooper* describes those observed by liim as
resembhng a worm or leech in form, vascular, and of a
deep red colour, Dr, Bu8he+ thinks the mucoua species
the most common. Mr. SymeJ says the disease pre-
sents itself in three different forms ; the first being simi-
lar to those described by Sir Astley Cooper; in the
second the growth is soft, vascular, prone to bleed,
lobulated, or shreddy and malignant looking, but pos-
• ' The Lectures of Sir A. Cooper, Bart., oa tbe Principles and
Practice of Surgery,' edited by J. Tyrrell, vol. ii, p. 357.
t ' A Treatiae on the Malformations, Injuries, and Diseases of
the Kectum and Anus,' New York, 1837, p, 227.
J ' On DiseaBea of the Rectum,' by J. Syme, Third Edition,
Edinburgh, 1854, pp. 103-105.
280 I'OLYPI OP THE RECTUM.
sessing a peduncle or footstalk sometimes capable of
sound cicatrization after being divided; in the third
form which jiolypua of the rectum assumes, the tumour
is of a firmer consistency, smoother surface, and more
regularly spheroidal or of oval form. In the ' Rev.
Medico-Chirurgicale,'* M. Leclayse describes a fungous
tumour of the rectmu attended with bloody discharge
occiuriug in children. He records three cases, the ages
of the patients were respectively six months, five years,
and eight years. The growths appear to be of the cha-
racter of the second form of polypus described by Mr.
Syrae ; and their removal was effected by the application
of nitrate of silver.
The experience of Mr. Syme and Dr. Bushe, as well
as the inference to be drawn from the majority of cases
of this affection that have been recorded, lead to the
conclusion that these growths most frequently occur in
adults, though the greater number of cases observed by
Sir Astley Cooper were in young subjects ; only one case
of a child with polypus of the rectum has at present come
mider my observation.
The symptoms of polypus of the rectum will at first
be rather annoying than painful, the patient being trou-
bled by mucous discharge from the anus soiling liis
linen ; as tlie polypus increases, weight and fullness of
the rectum, tenesmus and the sensation of the presence
• Tooic vii, p. 346.
i
POLYPI OF THE RECTUM. 281
of a foreign body will be compUuned of. If it be
situated near the anus it will be protruded at stool,
and will require to be replaced by the hand ; if it lias
acquired any size, and is pyriform in shape, some diffi-
culty may be experienced in returning it within the
bowel ; or if long and narrow, as in one case in which
I operated, it will be always protruded. When the
attachment of a polypus is near the anus, the irritation
it produces will cause spasmodic contraction of the
terminal portion of the intestinal canal. Dr. Buslie*
had a patient in whom the bowel contracted with so
much force as to detach the tumour. The polypus was
of the mucous species. After the polypus has attained
a certain development, diarrhcea and dysenteric symp-
toms will be present, consequent on the irritation to
which the intestine is subject ; flatulent distension of
the stomach and bowels, and other sympathetic affec-
tions, will exist ; and if it be of the character of the
second species mentioned by Mr. Syme, the faeces will
be besmeared with blood or pus ; they will alSo be
contorted and figured, leading to the supposition that
stricture of the rectum exists.
In the benign polypi the health wUl not usually be
much afi'ected, but in the malignant variety there is a
sallow cachectic appearance of the countenance, the appe-
tite fails, the tongue is furred, and lancinating pains in
• Op. cit., p. 228.
S8& POLYPI OP THE RECTUM.
the rectum, extendiug up the sacrum and down the
thighs, and flatulent distension of the stomach and
bowels, will be experienced. As the disease advances
ulceration attacks the morbid growth and extends to the
coats of the intestine, a copious fetid purulent discharge,
and Iisemorrhage to a considerable extent occur, by
which the strength is greatly reduced ; defecation is per-
formed with difficulty and attended with great agony,
emaciation takes place, and the patient at last sinks, worn
out by pain, irritation, and hectic.
Polypi of the rectum are usually solitary, but occa-
sionally there may be more than one.
Mucous polypi are not very sensible, but they should
be removed as soon as discovered, there being a possi-
bility of their degenerating in structure and proving fatal.
Ligature presents the best means for their removal, and
is that which I have hitherto adopted. Bushe recom-
mends excision of polypi, and thinks there is no cause
for the apprehension of hemorrhage. Sir Astley Cooper
experienced considerable bleeding in one case, in which
he excised a polypus ; he usually removed them by
ligature. Mr, Symc has always had recourse to that
method. If the peduncle is near the anus, its connection
with the intestine may be brought into view by injecting
some warm water mto the bowel, and at its expulsion
the tumour will be prolapsed, when it must be seized
with a pair of forceps and pulled down, and its point of
POLVPI OP THE EECTUM.
283
attachment to the bowel will be Been ; a ligature should
then be applied around its origin, after which it may be
cut nfF by a pair of scissors, taking care not to cut it
so close that the hgature may be in danger of slipping
off. If the polypus be sessile, or its stalk broad, the
base should be transfixed by a needle carrying a double
hgature, and tied in two portions. When situated
higher up the gut, and the base not easily accessible to
the fingers, a canula, similar to those employed in liga-
turing polypi of the uterus, must be employed, ox the
ligature may be passed through a portion of gum elastic
catheter. Previously to performing the operation the
bowels should be freely acted on, that they may not
require to be reheved for several days afterwards. Sub-
sequent treatment is seldom necessary with respect to
the local affection, which is the only subject of conside-
ration now before us.
"When we consider the many points of analogy in
structxire and function of tlie rectum aud those of the
cesophagus and urethra, and of the numerous sources of
irritation to which the termiual iK>rtion of the intestinal
tube is exposed, it is not surprising that, like the last-
named two mucous cauals, it also should be liable to the
formation of stricture.
Contraction of the rectum is met with under two very
different forms. The one consists of a contraction and
induration of its coats and deposit of lymph in the con-
necting cellular tissue, which, when occurring within
certain limits of the anus, and coming under our ob-
servation before it has proceeded to too great an extent,
is very amenable to judicious surgical treatment. But
in the other form, unfortunately, we are able to do but
httle more than palliate the sufferings of the patient,
and perhaps retard the onward progress of the disease
to a fatal end. This second kind of contraction consists
of those heterologous growths aud degeneration of struc-
STRICTDRE OP THE RECTUM.
ture denominated malignaDt, appearing as carcinoma,
encephaloid, or colloid disease. It is obviously highly
essential we should consider the two forms separately,
and not confound them together ; for, as Mr. Syme* re-
marks, " Want of attention to this very obvious and ne-
cessary distinction has led to great misapprehension in
regard to tlie nature of the disease, and serious errors
of practice in its treatment." In this chapter it is
intended to consider only the simple or benign stric-
ture.
Stricture of the rectum results from iTiflammation and
prolonged irritation produced by a variety of causes,
and, as a consequence, the deposit of plastic matter
interstitially in the proper tunics and intercellular mem-
brane of the intestine, by which degeneration and alter-
ation of the tissues are induced ; the capacity of the
bowel is diminished, and is still further decreased by
the property of contraction inherent in the effused
material.
Constipation, however induced, is one of the most
frequent causes of irritation in the lower bowel, the fseces
lodge in the sacculi of the colon, become hard, accumulate
in tlie rectum, and set up a chronic state of low inflam-
mation. Prolonged indigestion, depending on functional
disorder of the stomach, duodenum, pancreas, or liver,
may have the same effect, in consequence of the acrid-
• Op. cit., third edit., p. 107.
28(J 3TRICTUHE OF THE RECTDM.
nesa and irritating properties of the escrementitioas
matter; and there are very few who have not them-
selves, when suffering from temporary derangement of
the digestive organs, experienced, during defecation, the
acute scaidmg and irritation so frequently attending that
condition. Another frequent soiu-ce of irritation ia the
very general habit, among many individuals, of having
recourse improperly and too frequently to powerful and
drastic purgatives. Dysentery and diarrhoea, particularly
when neglected or improperly treated, will lead to the
formation of stricture, and it may also result irom the
cicatrization of xdcers attending the former disease.
Stricture of the reetura is also caused by a deposit of
fat or fibrous tissue exterior to the bowel, but more fre-
quently the coats of the mtestine will be fonnd infil-
trated with the morbid growth. A case is recorded by
Mr. Travers* of an excessive growth of fat external to
the tunics of the rectum causing contraction. I have
in my possession a specimen of stricture of the rectum,
from a deposit of fibrous tissue external to its coats ;
it occurred in a woman,agcd fifty -four, who had been ailing
for twenty years, and for the last three years had been
subject to relaxed bowels, occasionally passing blood.
Ten days previous to death she was seized with severe
pain in the abdomen, which subsided in a few hours.
After this constipation followed, and on the eighth day
* ' Uedico-Cbtrar^cal TronsactionB,' vol. xrii, p. 361.
STRICTURE OF THE RECTUM.
she took some castor oil ; vomiting supervened, with
great distension of the abdomen and considerable pain ;
no evacuation of the bowels was obtained. On the fol-
lowing day she was admitted into a public infirmary.
She was much exhausted, and complained of great pain
ui the abdomen, which was large and tympanitic. The
previous history of the case indicating disease of the
rectum, an examination was made, and a contraction of
the bowel found to exist at three inches from the anus,
surrounded by a dense mass of morbid structure. She
died, the day after her admission, from exhaustion.
On post-mortom examiuatiou, the iutestines were
fomid gi'eatly distended. No peritoneal inflammation
existed. The rectum was contracted at the part already
mentioned, and was surrounded by a large mass, having
the appearance of fat, and very dense; but by the aid of
the microscope, as well as subjecting the specimen to the
action of ether, it was found to be composed of fibrous
tissue alone.* Injuries by foreign bodies, or from at-
tempts to extract them ; lacerations of the mucous mem-
brane, or of the whole thickness of the intestinal walla,
also produce stricture ; in the latt«r case it is usually
very intractable, as is urethral stricture, the result of
laceration by external violence ; operations for fistula in
ano and the extirpation of haemorrhoids, when improperly
performed, have given rise to this affection. Authors also
* See also ' Fatbological Transactions,' vol. vi, p. 201.
aOO STRICTDRE Or THE RECTUM,
mention syphilis, metastasis of cutaneous eruptions,
and suppression of discharges that have existed for
some time, and have become habitual, as causes of
stricture of the rectum. Others are of opinion that
there is frequently a predisposition to contraction of the
rectum ; and one recent author thinks this is not only
the case, but asserts he has " repeatedly noticed several
members of the same family afflicted with stricture."
It must not be supposed, as some writers would lead
us to do, that stricture of the rectum is a very frequent
disease ; those who have had the greatest opportunities
and the most extended fields for observation, whose
acumen in the diagnosis of disease, and whose integrity
is most to be reUed on, have not met with this affection
as a common occurrence. In the museums of our
hospitals the pathological specimens arc few, and those
who are in the habit of seeing large numbers of post-
mortem examinations meet with examples of it but
seldom. In a large parochial infirmary in which I have
had opportunities of examining many bodies, I have
seldom discovered stricture of the rectmn. In public
and private practice I have met with not a few cases of
dyspepsia in which the symptoms simulated those of
stricture, and, had I been induced to have used bougies
at the same time that internal remedies were prescribed, I
might have deluded myself with the belief that I had cured
a disease which, in reality, had never existed ; however.
STHICTUKE OK THE KECIUM.
289
I have the greater satisfaction in knowing I relieved all
the symptoms and discomfort of the patients by very
simple constitutional treatment. Dr. Bushe* remarks,
" Organic stricture is supposed by many to be of very
common occurrence, but I have not found it to be so ;
for the cases I have seen bore no proportion to the
munber I ought to have met with, were the statements
made in books correct."
The most usual seat of strictm-o of the rectum is
within two or three inches of the anus, and it can readily
be detected by the finger ; occasionally it is found higher
up, even in the sigmoid flexure of the colon, but these
cases are very few, and tlieir absolute existence has not
generally been known till after death ; ou the contrary,
the cases in which stricture was supposed to have ex-
isted, and absence of all contraction has been demon-
strated by post-mortem examinations, are by no means
rare. Some writers have expressed opinions that stric-
ture ia most common about the termination of the
colon ; Mr. Whitef says, " The situation in which we
meet with strictures in the aUmeiitary canal is most
commonly about the termination of the colon." Mr.
Salmon}: remarks, " In the majority of cases which have
• Op. cit,, pp. 264-5.
+ ' Observations on Strictures of the Kectum aud other AfTec-
tions,' by W. White, Third Edition, Bath, 1S20, p. 47.
J ' On Stricture of the Rectum,' by F. Salmon, Fourth Edition,
p. 23.
1»
290 STBTCTLBE OF THK HECTUM.
fallen under my observation, the stricture has been situ-
ated between five or six inches from the anus, about the
situation of the angle formed by the first portion of the
rectum. Next in frequency I have discovered the dis-
ease at the junction of the sigmoid flexure of the colon
with the rectum." Mr. South* observes, " These, how-
ever, must be very rare cases, for all the best authorities
declare the strictiue to be almost universally low down."
Finally, I may quote the opinion of Sir Benjamin
Brodie,t " Strictures of the rectum arc commonly situated
in the lower part of the gut, within the reach of the
finger. Are they ever situated higher up ? I saw one
case where stricture of the rectum was about six inches
above the anus ; and I saw another case, where there
was stricture in the sigmoid flexm^e af the colon, and
manifestly the consequence of a contracted cicatrix of an
ulcer, which had formerly existed at tliis part. Every
now and then also, I have heard from medical practi-
tioners of my acquaintance, of a stricture of the upper
part of the rectum, or of the sigmoid flexure of the
colon having been discovered after death. Such cases,
however, you may be assured, are of very rare occur-
rence."
Stricture varies considerably in extent ; it may aflect
• 'CheliuB' Syateni of Surgery,' translated from the German,
and accompaiiieil with additional notes and obsen-ations, by
J. F. South, vol. ii. p. 336.
t ' Medical Gazette,' vol. xvi, p. 30.
STRICTURE OF THE RECTUM.
291
only one side of the bowel, or be confined to one of the
folds of the mucous membrane wliich some anatomists
term valves, or the whole cii'cumference of the intestine
may be involved forming annular stricture: the same
difference also exists with regard to the extent to
which the bowel is affected longitudinally ; the Indu-
ration may be ouly a few lines in width or may extend
to several inches.
Stricture of the rectum attacks both sexes, and its
comparative frequency in each is neai'ly equal ; some
writers having seen a majority of cases in females, whilst
others have observed the reverse to obtain ; however,
they all agree that the difference in numbers is very
slight ; thus, out of fifteen cases of genuine stricture,
which were all Dr. Bushe had seen, eight were females.
The period of life in which this affection usually de-
velops itself is between twenty-five and sixty ; but it has
been observed as early as the ninth year, and &om
injury at five years of age. Dr. Bushe had a patient
die of it in his seventy-second year.
Stricture of the rectum is very uisidious in its pro-
gress, and the surgeon is seldom consulted till it has
made cousiderable advances, and the symptoms become
urgent. On mquiring into the history of such cases,
we shall find the patient has for some time previously
been . subject to constipation, the bowels acting only at
intervals of several days, the stools being scanty, passed
STKJCIURK UF THE RECrUM.
in small lumpa, or, attenuated and compressed ; at other
times diarrhoea supervenes, caused by the constant
irritation to which tlie mucous membrane is exposed,
the fluid faeces being ejected as if from a syringe. Itch-
ing and heat about the anus are early symptoms. The
stomach and upper part of the alimentary canal are
sympathetically afi'ectcd, digestion is impaired, flatuleut
distension and spasmodic pains in the abdomen are
complained of, and palpitation of the heart, and head-
ache, will be other sources of sufiering. After the dis-
ease lias progressed to a certain extent, there aiises a
sense of obstruction and weight in the bowel ; pain in
the loins, extending down the hips and thighs, irritability
of the urinary organs will be induced, and in the female,
there will be a sensation of bearing do^vn of the womb ;
nervous irritation and despondency will also accompany
this disease. The tongue will be loaded, the countenance
dull, and the functions of the liver and kidneys de-
ranged. After the disease has existed for some time,
the blood-vessels of the rectum and anus become en-
gorged, and tumours are formed, most commonly by the
extravasation of blood, which may become absorbed, and
leave elongated folds of thickened integument around
the anal orifice, Another consequence of vascular de-
termination and impediment to the circulation, resulting
from the condensation of the coats of the intestine and
the pressure exerted by the accumulated fseces, is the
STRtC'iURK OK TIIK RKCTUM.
■idn
formation of abscess in the cellular tissue external to the
bowel, which, bursting by one or several openings, de-
generate into iistulse. As the disease advances, the
patient will have sudden and frequent desire to evacuate
the contents of the bowels, violent straining ensues, he
])a3se8 chiefly mucus and a little blood, the ftecal matter,
if any, being small in quantity; as a consequence, a
sensation of fullness of the bowel remains, and is the
reason why the attempts to defecate follow at short
intervals. Sometimes temporary relief is experienced by
the supervention of diarrhcea; the mucous membrane,
from the irritation it is subject to, pours out a large
quantity of mucus, which, rendering the faecal mass fluid,
permits of its passage through the contracted channel,
and by this eflbrt of nature the whole or the greater
part of the accumulated matter is discharged, and
serious consequences for the time averted.
When the disease has progressed, and the passage
through the intestine becomes very narrow, the patient's
condition is one of great peril, and symptoms of strangu-
lated hernia or peritonitis may supervene at any moment :
the former may occur from the aperture through the in-
testme being too small to permit the ffcces to pass, or
from the lodgment of some body producing obstruction,
which may be a nodule of indurated faeces, or the stone
of a plum or cherry, the bone of a fish, or other sub-
stance that has been swallowed, becoming entangled
294 STRICTPRE OF 'I'llE RECTDM.
and occluding the opening. Obstinate constipation sets
in, followed by vomiting ; at first, the contents of the
stomach only are thrown up, but shortly the vomiting
becomes stercoraceous, and unless the natural passage
be restored, or an artificial one formed, a fatal termina-
tion will be the consequence. In other cases, the pa-
tient may be carried off by peritonitis, which is generally
induced by perforation of the coats of the intestine ;
ulceration taking place above the seat of stricture;
while this process is going on, diarrhcea is often pre-
sent.
Unless a stricture of the rectum is within reach of the
finger, and fortunately it usually is, the diagnosis must
be uncertain, and surrounded with doubt ; exploration
Ijy a bougie can never be satisfactory, nor can it aftbrd
us positive information, from the liability of its progress
being arrested by a fold of the mucons membrane, or
the promontory of the sacrum, or by a flexm-e of the
intestine, which in some individuals may be abrupt, and
also liable to alteration of position at different periods.
The instances are not few in which stricture has been
supposed to exist, and numerous fniitless attempts have
been made to pass a bougie, when, after death, no or-
ganic obstruction has been discovered. Mr. Syme* men-
tions the case of an elderly lady who had been supposed,
by two medical men of high respectabihty, luider whose
• Op. eit., pp. 110, 111.
STRIUTI'UK OF 'I'liK lll'.CTLllI.
care she was, to suffer from stricture of tlie rectum be-
tween five and six inches from the anus ; he goes on to
say, "Finding that the coats of the rectum, though
greatly dilated, were quite smooth, and apparently sound
in their texture, so far as my finger could reach, and
conceiving that the symptoms of the case denoted a want
of tone or proper action, rather than mechanical ob-
struction of the bowels, I expressed a decided opinion
that there was no stricture in existence. Not many
months afterwards, the patient died ; and when the
body was opened, not the slightest trace of contraction
could be discovered in tlie rectum, or any other part of
the intestinal canal. One gentleman who had been for-
merly in attendance, was present at this examination,
and wishing to know what had caused the deception,
which he said had led to more than three hundred hours
being spent by himself and colleague in endeavours to
dilate the stricture with bougies, he introduced one as he
was wont to do, and found that, upon arriving at the
depth it used to reach, its point rested on the promon-
tory of the sacrum." But even supposing the instru-
ment to enter a constricted portion of the gut, how are
we to tell whether it is a simple stricture or a carcino-
matous contraction ? a question of the utmost import-
ance, for the treatment that woidd be beneficial in the
former case, would only aggravate the latter.
When a patient complains of a difficulty in defecating,
21)6
STRICTURE OF 'IHK RECTUM.
and posses small and contorted stoob, it by no i
follows that stricture of the rectum exists ; a variety of
causes will produce these symptoms ; they are very com-
mon in dyspeptic patients, caused by spasmodic and
irregular contraction of some portion of the rectimi or of
the sphincter muscles ; the latter is a condition of parts
constantly attending ulceration of the lower part of the
rectuiu ; the pressure of a displaced and enlarged uterus,
ovarian, uterine, and other pelvic tumours, abscess of the
recto-vaginal septum, the impaction of alvine and biliary
concretions, and in the male, the enlargement of the
prostate gland, may all produce the like effects.
One peculiar feature in strictiu-e of the rectum is,
that sometimes the patient's general health remains
for a long period unaffected ; he may have suffered firom
constipation or irregularity of the bowels, which he
attributed only to functional disorder ; cases are on re-
cord, where the disease has advanced till fatal obstruc-
tion has taken place without the disease having been
previously suspected, either by the patient or his medi-
cal attendant. Usually the appetite fails, the patient
becomes pale, loses flesh, and ultimately hectic few
sets in. under which he sinks by the exhaustion of t]
vital powers. Previously, however, to the final teni
nation of the case, a copious muco-purulent secreticfl
takes place, and is sometimes so acrid as to pro
duce excoriation of the anus, and may be in sot
STRICTURE OP THE RECTUM.
297
quantity as to flow outward when the slightest exertion
is made, or even on the erect position being assumed.
Sometimes sufferers fi-om stricture die from the ac-
cumulation of fseces in the colon, before ulceration and
hectic commence; they become melancholy and paUid,
are greatly distressed by flatulent distension, the cir-
culation is disturbed, the pulse being weak and irre-
gular, respiration is embarrassed by the free action of
the diaphragm being impeded, pains in the legs and
cramps are complained of, the feet are cold, there is
determination of blood to the head, producing giddi-
ness and stupor, and, lastly, symptoms of internal
strangulation supervene, which terminate fatally, unless
reheved by operation.
The prognosis of stricture will be influenced by a
number of circumstances depending on the degree of
contraction, its condition, position, and the causes that
led to its formation. If within reach of the finger, and
the contraction and induration have not advanced far,
we may entertain hopes of very favorable results from
judicious treatment. But if the disease has progressed,
the hardening being great, and the passage of the bowel
much diminished, oin: opinions as to the prospect of a
cure vrill be less favorable. Should ulceration have
occurred, the patient is in a much worse condition,
and will require very cautious treatment, or the disease
may be aggravated instend of being benefited.
S98 STKICrURE OP THE BKCTCM.
The object to be obtained in the treatment of this
disease is, if possible, to restore the bowel to its natural
dimenaions, or, if that cannot be accomplished, to en-
large the constricted part sufficiently to permit the free
passage of the fjeces. Dilatation by the careful intro-
duction of bougies is the means by which this is to be
effected. In the majority of cases, it will not be pru-
dent to have recmu^e to the bougie immediately, either
in consequence of the irritability of the Wwel, or from
its being immensely distended above the point of con-
traction by the accumulation of feculent matter, which,
pressing against the stricture, is a source of constant
irritation, and tends to aggravate the disease ; therefore,
the importance of unloading the bowel before adopting
other means must be obvious. Thb is to be accom-
plished by the introduction of an elastic tube through
the atrictiu^ into the superincumbeut mass of faeces,
and injecting tepid water, tliin gruel, and olive oil, or
tepid water and soap ; this practice must be repeated
every day, or every other day, till the whole of the
fiecal accumulation is dissolved, and washed away ; the
size of the tube must be regulated by the tightness of
the contraction ; in some cases, we shall not be able to
iwe one larger than an lu'ethral catheter. If much local
or general irritability or restlessness be present an
opiate enema, or a suppository of the pilula sapouia
composita at bed-time, will be of the utmost service.
STRICTURE OP THE RECTUM. 299
followed in the morning by a mild unirritating aperient,
such a3 the coiifection of senna, tartrate of potash,
manna, castor oil, &c. Sir Benjamin Brodie recom-
mends the following draught to be taken two or three
times a day ; balsam of copaiba, half a drachm ; solu-
tion of potash, fifteen minims ; mucilage, three drachms ;
and nine drachms of caraway-water. If inflammatory
symptoms be present blood may be taken locally, and
a warm hip-bath used at night. It will be desirable
duruig the treatment that the patient should observe
the horizontal position as much as jiossible, and the
diet restricted to that which is light and nutritious, and
yields the smallest amount of escrementitious matter, such
as good broths, jellies, eggs, arrowroot, sago, and the like.
Having freed the bowel from the accumulated faeces,
and allayed the irritability of the part, we may endea-
vour to restore its caUbre by the introduction of bougies.
These are made of various substances, of metal, wood,
cloth covered with plaster, and elastic gum ; only those
formed of the last two materials should be used when
the stricture is not close to the anus ; I give the
preference to the elastic gum bougie, and have them
made more flexible than those usually sold in the
shops, which obviates the objection urged against them
by surgeons who advocate the use of those formed of
The surgeon, by previous examination having satisfied
300 STRrciTHK OF TIIK RKCTtM.
hiinself of the existence of stricture, and formed an idea
of the extent to whicli the narrowing of tlie intestine
has taken place, selects an instrument that wOl pass
into it without much difficulty. The patient is placed
on Ilia side, with his knees drawn up, and the bougie
lubricated with oil or lard, is passed upwards to the
obstruction, and steady but gentle pressure is made
against it ; no force must be used, and if the resistance
cannot be overcome without, a smaller instrument must
be tried, till one be permitted to pass : after it has
entered the coutraetion, it should be allowed to remain
a few minutes, and then withdrawn. Some authors re-
commend the bougie to be left in for several hours,
but such a mode of treatment is more likely to pro-
duce irritation than to effect the object we have in
view, namely that of stimidating the vessels to the ab-
sorption of the effused lymph forming the stricture.
If much irritation follows the operation, the patient
should have a hip-bath, and it may be necessary to
inject soothing and opiate enemata. At an interval
of three or fom' days, the operation is to be repeated ;
the same instniment that was introduced on the first
occasion should be used again ; if it passes with greater
ease, it may be withdrawn, and one a httlc larger
passed, and thus the treatment is to be pursued till a
full sized bougie can be introduced with ease, and the
patient treases to suffer iiiiy inconvenience.
STRICTUB.E OF THE RECTUM.
aoi
111 some cases of close stricture of long standing, we
shall gain time by incising its mai-gia previous to using
dilatation ; the best instrument for the purpose is a
narrow blunt-pointed bistoury passed into the stricture,
on the finger previously introduced ; several slight notches
are far preferable to one of greater extent, as there will
then be no fear of bseiuorrhage, or of matter forming in
tlie cellular tissue. Tt has been proposed to destroy
the indurated structure by various escharotics, but such
a proceeding must always be uncertain in its eflects,
from the difficulty of limiting the action of the caustic,
and therefore unadvisable.
Those cases of stricture that have come under ray
observation have been within reach of the finger, and
have been treated on the principles advocated in the
text.
Various instruments have been invented for dilatuig
strictures of the rectum, by Weiss, Buahe, Arnott, Sir
C. Bell, ChaiTiere, Bermond, Costallat, Coxeter, and
others ; but though all of them are ingenious, the bougie
will be found the most efficient.
When the stricture is in the sigmoid flexure of the
colon, we cannot expect to obtain much benefit by
bougies, from the imcertainty that attends their use in
such cases. Should the contraction become so great
that symptoms of permanent obstruction arise, the pro-
f establishin
priety (
liimg a
302 STBICTCRK OF THE BECTDM.
the patient's life, will be forced on our consideration.
The bowel may be opened through the anterior walls, as
su^ested by Littre, or from the lumbar region, as pro-
posed by Callisen, or by Amussat'a modification of the
latter. In the thirty -fourth volume of the ' Medico-
Chirurgical Transactions,' Mr, Luke has considered the
merits of the two operations, and in the thirty-fifth
volume there is a very valuable paper by Mr. CEesar
Hawkins, in which all the recorded cases are arranged in
a tabular form, and an elaborate analysis appended.
Details of several of the cases are also published in the
Society's Transactions.
CHAPTER XIV.
MALIGNANT DISEASES OF THE RECTUM.
The rectum is one of the parts of the humaa frame
in which is evidenced a disposition to those intractable
heterologous growths and transformations of tissue, com-
prehended under the titles carcinoma or scirrhus ;
medullary or encephaloid cancer, and colloid cancer.
Melanotic cancer of the rectum is not of rare occurrence
in the horse, but I am not aware of its having been
observed in the human subject, though I have seen in
the dissecting room, several instances of melanotic
deposits in the ischio-rectal fossa.
Unlike simple stricture, malignant disease occurs most
frequently in the upper part of the rectum, or in the
sigmoid flexure of the colon ; in a few cases the anus is
the part first affected, the disease then assuming the
form of epithelial cancer, and being of the like character
to that we observe occurring in the Up and other parts.
Carcinoma or hard cancer commences either as tuber-
culous growths, of cartilaginous consistency, projecting
from the svuface of the mucous membrane, or originates
304 MALIGNANT DJSJiASES OF THE RECTUM.
in the inter-muacular areolar tissue, and, extends inwards,
involving the other textures. In the progress of the
disease, the muscular fibres become pale, degenerate,
and lose their distinctive characters, in that of the
morbid growth ; the calibre of the bowel is diminished
by contraction, and by the projection of tubercles and
nodules mto it. Ulceration ensues, which may extend
till perforation of the bowel takes place. Abscess is
sometimes formed in the ischio-rectal fossa, leading to
the formation of fistula ; abscess may also occur in the
cellular tissue of the pelvis, and the matter discharge
itself by openings situated above the crest of tlie iUum,
over the sacrum, and about the buttocks and upper part
of the tliighs ; should an internal opening with the
intestine coexist, these channels will constitute sterco-
raceous fistula. The pelvic bones may also become
affected by caries, or otherwise involved iji the disease.
The rectum in some cases is involved in cancerous
disease, which has its origin in adjoining structures ; it
is frequently implicated when the disease has commenced
in the uterus, or in the upper part of the recto-vagiual
septum, and then, by the process of idceration, a com-
mnnicntion may be formed between the rectum and
vagina ; m the male the bladder is liable to be involved,
or the disease may originate in that viscus, and impbcate
the rectum secondarily. When the bladder is the
primary seat of the disease, it usually appears in the
MALIGNANT DISEASES OF TBE RECTUM.
305
form of medullary cancer. Mr. Busk* exhibited a
preparation at a meeting of the Pathological Society, in
1846, taken from a boy who died of acute peritonitis.
He had a tight stricture of the rectum, three or four
inches from the anus ; it was accompanied by ulceration
of the mucous membrane, and was produced by a lai^e
deposit of medullary sarcoma external to the muscular
coat of the intestine. In the greater number of cases,
unless they come under oiu- observation from the com-
mencement, we are unable to trace the disease to the
tissue or organ in which it originated, in consequence
of its extending, and so thoroughly pervading the whole
of the surrounding structures.
ITie extent to which the intestine is affected varies
with the character of the disease and its duration ; car-
cinoma may occupy the whole or greater part of the
circumference, and extend from one to six or eight inches
in a longitudinal direction. Medullary and colloid
cancer more generally implicate only a portion of the
circumference of the bowel, but its cavity will be greatly
reduced by the projection inwards of large masses of the
morbid structure.
We meet with malignant disease of the rectum occur-
ring concurrently with cancerous aifections of the mamma,
stomach, pylorus, and other organs, and it is very generally
" ' Puthologica] Transnctions,' vol. i, p. 67.
306
Malignant diseases of the rectum.
found as a secondary dqwsit in the lunibar and mei
teric glands, and in the liver.
Cruveilhier thinks cancer of the rectum, in wJi
form it may appear, is mostly a local disease ; but 1
majority of patliolt^sts consider that malignant
occurring in any part of the body, if ever local, is (
BO at a very early stage, that the constitution sp<
becomes tainted, and a cachectic and mahgnant diathi
established ; in practice, we find, when a cancerous ]
has been removed by operation, in the greater nui
of instances, it returns cither in the cicatrix or i
parts of the body.
Mahgnant disease of the rectum is more frequent i
females than in males, and in the former it is usually
developed at the period of the cessation of the menses.
Those about the meridian of life, or a little past it, are
mostly liable to these affections, but no age is exempt ;
cncephaloid disease is more hbely to attack the young
than carcinoma. Bushe* saw a case of the former in a
boy of twelve years, and Mr. Busk's patient, previously
referred to, was sixteen years of age.
Whatever may be the character of the disease, whether
carcinomatous, encephaloid, or colloid, it makes con-
wderable progress, in the majority of cases, before giving
rise to any severe or prominent sjTnptoms. Constipation
is one of the early effects, often attributed to functional
• Op. cit., p. 292.
MALIGNANT DISEASES OF THB RECTUM.
307
derangement only, but arises firora the morbid growth
projecting into and narrowing the capacity of the bowel,
and also annihilating the function and power of contrac-
tion. Haemorrhoidal excrescences, internal and external,
are frequent concomitants, resulting from obstruction to
tlic circvdation by the cancerous mass ; in some cases a
muco-sanguineous discharge, more or less profuse, may
be all that engages the patient's attention ; but sooner
or later a dull aching and fixed pain in the sacral region,
violent tenesmus, weight and bearing down, especially
after defecation, severe shooting and lancmating pains
extending to the louis, hips, and down the thighs, are
experienced. The stools are passed with difficulty
and pain, are scanty and frequent, and attended with
bleeding or a puriform sanies, which is often exces-
sively fcetid ; in fungoid disease considerable hfemor-
rhage occurs from time to time. In most instances the
stools are compressed and figui-ed, or passed m small
pellets, as in simple stricture, or diarrhoea may be
present. From contiguity or imphcation severe vesical
irritation is induced, and the patient is tormented by a
constant desire to micturate ; the whole of the digestive
organs are deranged, causing flatulent distensiou of the
stomach and intestines, and acute pains in the abdomen ;
as the disease advances, hiccough, eructations, nausea,
and vomiting are present ; the appetite fails, emaciation
and loss of strength ensue, the countenance assumes the
308
MALIGNANT DISEASES OF THE RECTCM:
peculiar leaden hue indicative of malignant disease,
anasarca and hectic supervene, and under continuous
suffering the vital powers succumb. Sometimes ob-
struction takes place, and the patient dies with the
symptoms of internal strangulation or acute peritonitis. 1
In the commencement, unless the disease is with;
reach of the finger, and occurs as hardened tubercles <
irregular fimgoid groivths, the diagnosis of the disease in
not easy, and requires a close and accurate consideratia
of all the sjmptoms, and a familiarity with the varioi
phases and phenomena of malignant disease, to arrive aifl
a just conception ; but in the advanced stage the exa
sively severe shooting paiuj the foetid puriform dischargi^ I
the rapid progress of the affection, and the peculiar un^ I
healthy aspect of the countenance, lead to a correct con^J
elusion. Yet the latter appearance is not invariably 1
present, as was illustrated in a man aged fifty, who ap' J
plied at the Blenheim Dispensary, in 1852, affected witlfl
fungoid disease, the masses of which nearly filled the I
pelvis ; his countenance remdned clear, and his general I
health was not much disturbed for a considerable time ; J
he lost blood at stool, and a copious haemorrhage fol* j
lowed any examination, even when conducted with ths^
greatest care and gentleness.
In the treatment of this disease all our efforts will be 1
unavailing in effectmg a cure, but by well directed means
we shall be able to mitigate the sufferings, and even to |
MALIGNANT DISEASES OF THE HECTUM. 309
prolong existence. Narcotics are the remedies chiefly to
be relied on to afford ease from pain ; they must be ad-
ministered by the mouth and by the rectum. It will be
desirable, in most instances, to confine the patient to a
couch, as walking, or even the upright position, will
aggravate all the symptoms, in consequence of the vessels
of the rectimi becoming congested by the gravitation of
blood. Great attention must be paid to diet, which
should be nutritious, light, and easy of digestion, all
stimulating and heating articles of food being strictly
forbidden. The bowels must be kept open by small
doses of castor or oMve oil, and, after each dejection,
emollient and anodyne enemata must be used. Sup-
positories of hyoscyamus and conium, separately or con-
joined, with or without the addition of camphor ; also
opium and its various preparations wiU be required to
allay the distressing pain. The warm hip-bath, by its
soothing effects, will be an useful adjunct in the treat-
ment, and, as it produces no fatigue to the patient, may
be used at all periods of the disease. Irritation is to be
allayed by injections of warm oil, lime water and oil, and
decoction of marsh-mallows with opium. If there is
acrid and foetid discbarge, emollient and mucUaginous
enemata, containing chloride of zinc, well diluted, Peru-
vian balsam, creosote, &c., must be used. According to
the patient's condition, we may prescribe the various
preparations of iron, or vegetable tonics with alkahes;
310 MALIGNANT DISEASES OF THE RECTUM.
arsenic is Bometimes prescribed for cancerous diseases of
other parts, but its usefulness in this or similar cases
may be questioned. Morphia and other preparations
of opium become indispensable, as the disease advances,
to assuage the pain and procure sleep. The tolerance
of this drug by the system, when affected with cancer,
is extraordinary ; doses will be required to procure ease,
which, under ottier circumstances, would prove fatal to
half a dozen individuals. A lady I attended with carci-
noma, which went on to ulceration, took eight grains of
morphia in twenty-four hom^, besides using narcotic sup-
positories and encraata, and, notwithstanding these large
doses, her sufferings were most acute ; her case was one
of the most distressing that could be witnessed ; she
ultimately sank exhausted by piiin and constitutional
irritation. In fungoid disease, the hemorrhage at times
is very profiise -. an endeavour to arrest it must be made
by the application to the sacrum of bladders containing
pounded ice, the injection of iced water, enemata con-
taining mineral and vegetable astringents, as the prepa-
rations of lead, zinc, copper, alum, tannic acid, infusion
of matico, &c.
Lisfranc proposed excision of the rectum, when affected
with carcinomatous disease, and he has performed the
operation several times ; other siu-geons have also had
recourse to the same proceeding, but the results are by
no means favorable. In the greater number of cases the
MALIGNANT DISEA8EB OP THE BECTUJI.
311
disease returned within a short period in an aggravated
form, and it is questionable whether those reported to
liave been cured were not instances of simple induration,
and not true cancer, I have never seen the rectum re-
moved, and should be very uuwiUing to undertake the
operation, from a conviction that I should not be render-
ing benefit to the patient in the shghtest degree ; and in
saying this, I believe I utter the sentiments of the ma-
jority of British siu-geons.
Cancer of the rectum; secondary deports in the liver
and lumbar glands.
Mr. C , set. forty-three, of moderate stature, and
slight conformation, had been the subject of habitual con-
stipation, and of hemorrhoidal affections, for some years.
In September, 1854, he experienced more pain, and lost a
larger quantity of blood than hitherto, and he then, for
the first time, mentioned the afi'ection to Dr. Quaiu, the
physician who usually attended him; under the judicious
treatment of this gentleman, the more prominent symptoms
subsided, but shortly recurred ; this circumstance, and the
persistence of a severe pain in the sacral region, induced him
to suspect disease of the bowel higher up; he recom-
mended the patient to see me, and he accordingly came in
December, 1854. In answer to my questions, he distinctly
stated that the stools were of natural bulk, hut that hia
bowels were very obstiaatc. On making an examination,
three prolapsed internal haemorrhoids preseuted, and the
312
MALIGNANT DISEASES OF THE RECTDM-
k
margin of the anus was surroimded by ncvcral looae folds
of integument, the remains of external piles. Distal
Bxamination did not detect any other disease; the bowel
above the upper margin of the internal sphincter, as far
as could be reached by the finger, being apparently in a
natural condition. His appearance, though not that of a
healthy man, did not excite any suspicion of the esistenoe
of malignant disease. Laxatives, with tonics and enemata
were prescribed. In Febmarj', 1855, he again came to
mc complaining of the pain in the sacral region, whidi
was of a lancinating character, and very severe; in other
respects, he had henetited much by the treatment suggested,
lie now stated the stools were small in size, and he had
to strain greatly to expel them. Passing the finger as high
up the bowel as possible, I detected a growth projecting
frora the posterior wail of the intestine ; it was formed of
several nodules, having to the touch a stony hardness ; his
countenance now had a sallow cachectic hue, I communi-
cated to Dr. Quain my opinion that the growth was
cancerous ; and on the 7th of February, he, and Mr. Hilton,
met mc in consultation ; they both coincided in the opinion
I had formed. Soon after this, the morbid growth came
more within reach, appearing to have been forced down by
the straining at stool, rather than to have increased hy
growth; it was now discovered that the whole calibre of
the bowel was afi^ected, and the passage narrowed to such
a degree as to admit only No. 3 rectum bougie. Up to
July, by the treatment adopted, he was kept tolerably free
of pain, his general health improved, and his symptoms
were in all respects less severe. From this time he began
MALIOrJANT DISEASES OF THE RECTUM.
313
to lose flesh and strength rapidly, and before his death,
which occurred on the 18th of September, 1855, emaciation
was excessive,
A post-mortem examination was made, and it was seen
that the disease implicated betweiin four and five inches of
the rectum, and commenced three inches from the anus ; on
cutting tlirough the diseased portion, it crunched under
the knife, the cut surfaces presenting a pearly wliite hue,
and yielded, on pressure, the characteristic cancer-juice ;
a thin section placed under the microscope, showed caudated
cells with nuclei, and others round, with nuclei and
nucleoli. The morbid growth formed a number of hard
nodules, projecting into the intestine, and diminishing its
cavity considerably. The descending colon was contracted ;
the ascending ajid transverse portions were natural, and
contained only a small quantity of feces ; the lumbar
glands were cancerous; and cancerous deposits, varying
in size from a haxel nut to a small orange, pervaded the
whole of the liver j the kidneys and stomach were healthy.
The thoracic and ceplialic viscera were not examined.
Remarks. — Although in such cases as the foregoing we
are precluded entertaining any hope of curing the disease,
yet, by judicious treatment, we may materially mitigate
the patient's miseries, and even prolong existence. Dr.
Quain frequently saw this gentleman with me; the plan
of treatment adopted, was the keeping the passage of the
bowel patent by the occasional use of the bougie; the
administration of laxatives and tonics, and a strict attention
to diet, with regard to that which afforded the largest
ainouat al nutriment and the smallest quantity of excre-
314 MALIGNANT DISEASES OF THE RECTDM.
nientitious matter. The pain in the aacral region, which
was very severe at times, was relieved by the internal and
external use of various narcotic and anaesthetic agents, as
Belladonna, Opium and its salts, ^ther, Cldoroform,
CIdoric ^ther. Enemata thrown high up the bowel, ty
O'Beime's tube, were frequently used. Flatulence which
was often a source of pain and great discomfort, was re-
lieved by the addition of /Ether, or Chloric ^ther, to the
thin gruel used for the enemata; Chloroform was also
tried, but was not beneficial.
Cancer of the rectum, implicating the vagina ;
diarrhoea.
1 was requested by I>r. Ridsdale, to see Miss
set. thirty, who for twelve months had experienced
pain in the rectum, and about the sacral region; she had
frequent desire to evacuate the contents of the bowel,
which were always fluid, and were ejected with force. For
several years, she had been subject to looseness of ibe
bowels, but had not paid much attention to the subject ; her
health had never been good, but she was now much weaker,
and had lost flesh considerably; her countenance was sal-
low, and expressive of much suffering ; her pulse was
feeble and quick. 1 made an examination of the rectum,
and found the whole circumference of the bowel occupied
by projecting nodules of cancer, thus confirming the opiaioo
Dr. Ridsdale liad given.
The disease had also implicated the posterior wall of
the vagina. The examination, which was made with &U
MALIGNANT DISEASES OF THE RECTUM. 315
possible care, produced considerable pain. Dr. Ridsdale and
myself agreed upon a plan of treatment, which afforded her
much rehef and comfort ; but her appetite failing, and the
looBeness of the bowels being uncontrollable, the vital powers
gradually became more feeble, and she died a few months
after I saw her.
Shortly after seeing the lady above referred to, I was
requested, by the same gentleman, to see another patient of
his, Mrs. -, the disease implicated the posterior and
lateral portions of the bowel only, and formed a crescentic
projection, narrowing the passage so much as barely to admit
the introduction of the finger ; the plan of treatment agreed
upon has atTorded considerable relief up to the present time.
The rectum is wounded intentionally in some i
gical operations, as in puncturing tlie bladder through
the trigone vesicate for the relief of retention of urine,
when an instnunent cannot be paased per urctliram ;
also in the treatment of some forms of stricture, a sub-
ject on which Mr. Cock has made some valuable obser-
vations in a paper published in the thirty-fifth volame
of the ' Medico - Chirurgical Transactions.'* It is
wounded in operating for fistula in ano, but not so
extensively as was formerly the custom ; and it may
be necessary to incise it for the extraction of foreign
bodies ; the surgeon sometimes accidentally wounds
the rectxim in performing the operation of hthotomy,
but this is seldom the case if the operator depresses the
intestine with the fore-finger of the left-hand whilst he
is making the deeper incisions ; he should also intro-
duce the finger into the rectum before he commences,
" See also Mr. Henry Tboinpson'B ' Easay on the Pathology
and Treatment of Strii-turc of the Urethra,' pp. 303—309.
IHJURIBS OF THE RECTUM.
317
as, by 80 doing, he will cause the bowel to contract, or
should it be loaded with fseces he will be made aware
of the fact, and will not proceed till lie has procured
their evacuation. Some years since I saw the rectum
of a child cut freely into by an hospital surgeon in
cousequence of the neglect of these precautionary mea-
sures ; the fseces were forcibly ejected through the
incision in the perinaeum, and greatly embarrassed the
operator.
The rectum is lacerated in various degrees and
directions by external injuries, and from causes acting
from within the body, as in parturition, or during tlie
expulsion of bulky and indurated fseces. The lacera-
tion may involve the whole of the structures or
the mucous membrane only, and thus two forms
of injury are met with — the complete and the in-
complete.
The incomplete form of laceration generally occurs
in those who are of constipated habit, and is more
frequently produced by the expulsion of a hardened
stool than from any other cause. If the rent is the
consequence of defecation it may be either vertical or
transverse ; when vertical it results from undue dis-
tension of the anus during the violent efforts of the ex-
pulsive muscles, while the sphincters are contracted, or
yield but slowly ; it usually terminates at the hue of
junction of the skin and mucous membrane ; when the
318 rNJURlES OF THE RECTUM.
laceration is transverse, its situation is above the margin
of the internal sphincter, and is the effect of a fold of
mucous membrane of the pouch of the rectum falling
under a mass of indurated faeces at the time of tlieir
forcible extrusion, and being dragged down with them
is torn from side to side. Those who are liaiile to this
accident are the subjects of constipation, and have the
upper part of the rectiua relaxed. Complete laceration
sometimes ensues from the same cause, though it must
be a very rare occurrence. Mr. Maj'o* relates a case
in which he was consulted, the patient, a lady of forty,
of constipated liabit, was on a journey, and the bowds
had not acted for many liours ; during a violent effort
to relieve them she felt something give way, and on
the following morning some faeces passed per vaginam.
An examination revealed a rent two inches from
the anus sufficiently large to admit the end of the
finger.
The symptoms of laceration, the consequence of dts
fecation, are a sense of tearing and giving way of the
part attended with pain, which is lessened after a time,
but does not entirely subside, and is renewed with
more or less severity whenever the patient goes to
stool; at the period of the occurrence the fseces ore
streaked with blood, and with pus as soon as suppu-
ration is established. After the accident the same
• Op. cit., p. 13.
INJURIES OF THE RKCTUM. 319
phenomena occur as in wouiida of other parts, inflam-
mation is set up, lymph is effused, the margins of the
rent become swollen, granulation and cicatrization fol-
low, or the woimd degenerates into an ulcer.
la the treatment of this injury it is essential to
keep the bowels easy ; emollient enemata will effect this
object better than any other means ; but mild aperients
may be exhibited if they be thought advisable ; active
cathartics must not be had recourse to, or they will be
productive of harm by exciting determination of blood
to the rectum, and rendering the evacuations acrid and
irritating. The wound must be cleansed after each
evacuation, or the lodgment of particles of fcccal mat-
ter will possibly give rise to agonising pain and spasm
of the sphincter. When the laceration does not readily
heal, but remains irritable and painful, nitrate of silver
in solution should be applied, or the solid pencil may
be passed lightly over the surface. In spite of these
means the wound sometimes will not heal, but passes
into the condition of an ulcer, in which case it will
be necessary to make an incision through it in the
manner directed in the Chapter on Fissure of the
Rectum.
In the greater number of cases the treatment de-
scribed, conjoined with the recumbent position and
moderate unstimulating diet, will be all that is neces-
sary. However, instances occur in which slight injuries
320
INJURIES Oy THE RECTUM.
are productive of excessive local inflammation or great
constitutional excitement; under tbesc circumstanoeB,
in plethoric individuals, it may be necessary to take
blood from the system generally, to apply leeches
around the anus, or to cup over the sacrum. When
the wound is inflamed and painfol, a cataplasm of
linseed, or bread impregnated with a solution of acetate
of lead and infusion of tobacco or laudanum must be
applied to the anus.
M. K consulted me under the following circum-
stances : the day previously, while passing an indurated
motion, she suddenly felt great pain and a sensation of
tearing of the anus ; she also noticed signs of blood ; the
pain decreased, and ahe remained tolerably easy till she
went to stool the following morning, when it returned with
great severity, which induced her to seek medical aesist-
ance. On examination, I perceived a slight fissure at the
margin of the anus, and found it involved the mucous
membrane for about an inch. 1 ordered her to have an
ounce of castor oil, and to wash out the rectum with an
enema of warm water ; there being tendemcas on pressure
around the external portion of the laceration, a poultice
was directed; these means afforded relief; however, the
laceration did not heal, it became irritable, and defecation
was followed by considerable pain; alter eight days I
applied the nitrate of silver, and repeated it two or three
times at intervals of two days, and a cure was shortly
effected.
INJURIES OF THE 1
321
T. M applied to me in consequence of experiencing
pain at stool witli pnnilent discharge from the anus. The
history of the case was, that some weeks previously, while
straining violently at the closet, he felt "something give
way at the end of the bowel," and blood flowed afterwards ;
be had previously been very costive; to lessen the pain subse-
quently produced by a hard stool, he took castor oil at frequent
intervals up to the time of bis seeing me. I introduced
my finger into the bowel, and felt at the upper margin of
the sphincter a fold of the mucous membrane that had
been torn from above, where a depression with a pulpy
surface then existed; the torn membrane was tumid and
indurated. He was ordered an ounce and a half of castor
oil to be taken early in the morning, and an enema of warm
gruel after the oil had acted; by these means the bowels
having been thoroughly unloaded, I then carried an in-
cision through the centre of the ulcer and lacerated mem-
brane. He was directed to observe the horizontal position,
and was restricted to a farinaceous diet. An emollient
enema was given on the third day, and ordered to be re-
peated every second day ; ablution with tepid water and
Boap to be used night and morning : by these means recovery
soon took place.
An accident commonly designated laceration of the
rectum occurs during parturition, but it is, in truth,
rupture of the sphincter only. However, it now and
then happens the intestine is also torn. The circum-
stances producing this injury appertain either to the child
21
tSUa INJVRItS OF THE HKCTirM.
or to the mother. Those which belong to the child,
are the large size and solidity of the head ; to its mal-
position, whereby is presented a longer diameter than
usual to the external outlet ; to malpresentations, as in
breech and footling cases, which do not receive the
proper direction so readily as the head; and face pre-
sentations, involving the passage of the head in its
longest diameter when passing over the pcrinaium.
The causes appertaining to the mother are her posi-
tion, as when the lumbar vertebrae are curved forward,
and the child's head thereby directed downwiu-d and
backward on the rectum and perineum ; the same occurs
if the promontory of the sacrum projects much ante-
riorly, or if the sacrum be but httie curved forward ;
and, lastly, the perinreum may be pretematurally broad,
and materially diminish the capacity of the lower outlet.
Sometimes the recto-vaginal septum is torn along with
the ])Osterior part of the perineum, and the child passes
per anum. The history of a case m which this accident
occurred, is given by Dr. Andrews, of Steubenville, Ohio,
in the 'Philadelphia Examiner,' for March, 1839; the
bowels were kept constipated during a nimiber of days,
and recovery took place. Another case is mentioned in
the'DabUn JoiuTial,' of a child bom peranum, with
laceration of the perinEeum for two thirds of its extent ;
the rent suppurated, gradually closed up, and the woman
made a complete recovery.
ITJJrniES OF TItE RECTUM.
323
The rectum may be lacerated by want of due caution
on the part of the medical attendant, either by not sup-
portbig the perineeiim, or by some awkwardness in cases
of preternatural presentations ; the improper and rniskil-
ful application of obstetric instruments may also induce
the lesion we are now considering.
In rupture of the recto-vagiual septum the condition
of the patient is truly pitiable j she is unable to retain
her fseccs, and is rendered miserable to herself and offen-
sive to those about her.
In laceration rcsuJtmg from parturition, no immediate
operative interference is advisable, as any attempt to
obtain union of the torn parts will be frustrated by their
condition, and the irritation produced by the lochial
discharge, but wc may very materially mitigate the
patient's discomfort by the cxliibition of emollient
enemata, by wasliing out the vagina with warm water,
and by drawing off the urine with a catheter, to pre-
vent its coming in contact with the wound and pro-
ducing irritation. The patient must be directed to lie
on lier side with the knees slightly flexed. The slighter
cases of laceration will sometimes heal imder this treat-
ment alone, but the more severe will not do so, and
after the lochia cease, and active inflammation in the
part subsides, we must endeavour to restore the con-
tinuity of the part. The jiatient's health having been
brought into as good a condition as possible by medical
S24 INJURIES OP THE RECTUM.
treatment, and the intestines being thoroughly freed from
fsecal accumulations, the edges of the tear must be made
law ; for this purpose, a small scalpel is the best iostru-
ment ; some xise the scissors ; a wooden gorget is to be
passed into the rectum, to support the parts while the
margins are being pared with the knife ; the edges are
then to be brought into apposition, and secured by
sutures, which are to be tied in the vagina ; the number
and kind of suture employed, must depend ou the na-
ture of the case and judgment of the surgeon ; the
twisted suture is better for securing the pcriuieal edges,
and the pin most appUcable is that used by Dr.
Bushe.
The rectum is torn by a number of accidents, with
or without injury to siurounding external parts ; I at-
tended, in conjunction with another surgeon, a woman
who received a kick from a cow she was milking at
the time, a lacerated wound was produced, extending
through the labium of the right side across the perinseum
and into the rectum ; an artery in the labium was pour-
ing out a jet of blood when we saw her. A ligature
was applied to the bleeding vessel and two points of in-
terrupted suture were inserted ; a fold of wet lint was
kept to the part, she was confined to the bed, great at-
tention paid to cleanliness, and the bowels were kept
easy by enemata : the diet was spare. The wound sup-
purated and completely healed by granulation. Dr.
INJTJRIB8 OF THE BECTDM.
325
Bushe* mentions having seen a case rf perforation of
the recto-vaginal septum by the end of an umbrella on
which the patient was in the act of sitting. In St.
George's Hospital Museum is a preparation from a man
who fell off a table, and the leg of a chair, that he upset
in falling, passed up the rectum, penetrated its walls,
and entered the bladder. There was very slight exter-
nal injury. He was in a state of collapse when admitted,
and he sunk in about twenty-one hours.
By awkward attempts, and the application of too
much force in endeavouring to pass a bougie up the
rectum, its tunics have been torn or perforated. By
ignorant and clumsy nurses, enema pipes have been
thrust through the rectum and peritoneum, and the
fluid injected into the abdominal cavity. In the museum
of St. Bartholomew's Hospital-j* is a preparation from the
body of a patient whose death was occasioned by the
perforation of the rectum by a metullic clyster-pipe and
the injection of a pint of gruel into the peritoneal
cavity. In the same museum are two other prepara-
tionsj of the rectum, uterus, and vagina, and the large in-
testine of a child. Ten months before her death, in an
endeavour to administer an enema, a clyster-pipe was
forced through the adjacent walls of the rectum and
• 0[). cit., p. 80.
t Sixteenth Series, No. 36.
X Ibid., Nob. 93, 94.
326 INJURIES 01' THE RllCTUH.
vagina. At the part tlius injured there is a small de-
pression in tlie wall of the vagina, and a long, pale, and
irregular cicatrix in that of the rectum. Near the cica-
trix, also, there are traces of small healed ulcers of the
mucous membrane of the rectum. Just l>eIow the cica-
trix, at the distance of about an inch from the margin
of the anus, the canal of the rectmu is reduced to an
eighth of an inch in diameter, and the adjacent tunics are
indurated. Above this structiirc the intesUne is greatly
dilated, and contained a large bucketfid of fluid ftecal
matter.
The rectum is sometimes perforated by unskilful at-
tempts to introduce a catheter into the bladder. In the
summer of 1852, I was siint for to see an Irishman
who had retention of urine ; the bladder was greatly
distended, and reached ncai-ly to the umbilicus ; forcible
attempts had been made to relieve it, and the catheter
had been made to enter the penis till the rings weoc
brought into contact with the glans, but no urine
flowed. 1 discovered the point of the instrument had
been thrust tlmmgh the urethra immediately anterior to
the prostate, and had passed into the rectum. By keep-
ing my finger in the bowel, I succeeded n'itliout much diffi-
culty in passing an instrument of moderate size into the
bladder, and, to prevent any mischief, I ordered it to be
retained for a day or two ; within ten days I was able
to pass a fiill-sizcd catheter, and the man did very well.
CHAPTER XVIII.
FOREIGN BODIKS IN 'mK RECTUM.
"We may be called upon to remove, by mechanical
means, various substances from the rectum, eitlier ui
consequence of their obstructing this outlet, producing
inflammation, or interfering with the integrity of the in-
testine.
These substances may be divided into two classes,
one being formed in the body, the other being intro-
duced from without. To the first class belong biliary,
intestinal, and fiEcal concretions, while the second \viU
include a long list of heterogeneous substances wldchhave
been swallowed, either accidentally or intentionally, or
introduced into the rectum through tlie anus by tlie in-
dividuals themselves with a view to obviate costiveness;
from a morbid state of the imagination, or by accident,
or they may liave been introduced by other persons from
feelings of miscliief or revenge. Those swallowed either
by accident or intentionally, in consequence of a per-
verted condition of the mind, include portions of bones,
the bones of fish and small birds, the stones of fruit,
FOREIGN BUUIES IN THE RECTUM.
coins, knives, pins, needles, nails, sealing-wax, brown
paper, cedar pencils, &c. ; and among the variety of sub-
stances that have been introduced through the anus,
according to the testimony of accredited authors, may
be mentioned, bottles, pots, cups, a knitting-sheath, a
shuttle with its roll of yam, a pig's tail, ferrules, rings,
pieces of wood, ivory, metal, horn, cork, bone, &c.
Foreign bodies that have been swallowed do not usually
occasion much inconvenience in their passage through
the intestinal canal, though it is soraetunes marked by
considerable irritation. Should the substance not be
discharged with the fjeces, but become entangled in the
rectum, it will give rise to inflammation accompanied by
tenesmus, violent straining, and perhaps prolapsus ; by
perforation of the tissues of the intestine it will lead to
the formation of abscess and fistula ; or partial or total
obstruction may be produced, followed by enteritis or
peritonitis ; these effects will be greatly influenced by
the size, form, shape, and nature of the substance. When
intestinal or fxcal concretions are the cause, the symp-
toms are gradual in their accession, and are preceded by
signs of derangement of the stomach, liver, and bowels ;
at first, the local disturba»ice is marked by a fcebng of
weight, distension, and pnin in the rectum, followed by
obstinate constipation, great straining to reUeve the
bowels, attended with more or less prolapsus of the
mucous membrane and congestion of its vessels ; and if
FOREIGN BODIES IN TIIF. RECTUM.
the patient be not relieved, enteritis, peritonitis, and death
will ensue. When the foreign substance has been intro-
duced through the anus, the symptoms are more rapid
in their development, and if the bowel has been at the
same time injured, they will be more or less serious in
their character in proportion to the extent and nature of
the lesion.
It is seldom that we can gain any information from
the patient when the substance has been swallowed, as
it often happens that he is unconscious of the circum-
stance, but if it has passed into the rectum from with-
out, the patient may then bu able to make us acquainted
with its nature and the manner of its introduction, unless
he be of unsound mind, or was insensible at the time
of the occurrence.
For extracting the various foreign substances it may
be our duty to remove, instruments of different sizes
and shapes, and effecting different objects, will be re-
quired, much depending on the form of the body to be
extracted and the material of which it is composed, and
on the ingenuity and tact of the surgeon. Should the
substance be a bottle, or jar of glass or earthenware, it
will be a good plan to insert slips of thin ivory, wood,
or gutta pcreha between it and the bowel, and thus
fonu a tube around it which would greatly facilitate its
extraction, and protect the intestine from injury, in case
the bottle or jar should be broken. The anus being
330
I'UltEir.N BOrilKS IN TIIK REnUM.
very dilatable, it will bi; rarely necessary to divide tlie
spMnctcrs, unless the foreigo body be sharp and angular,
and has penetrated the intestine, in which case an incision
on one or both sides may be required.
The position of the patient should be on the side,
with the knees drawn up towards the chin, and the
buttocks projecting over the edge of the bed or couch,
or, if deemed more convenient, he may be placed in the
same position as for the operation of lithotomy.
Some years since I removed an ivory tube from the
rectum of a woman, who was under my care, siiflering
from dyspepsia and torpor of the bowels, to which she
had been subject for a considtrable time. The rectum
being in a relaxed condition, besides prescribmg medi-
cines to be taken by the mouth, I had directed Iier to
inject a slightly astringent cneraa morning and evening ;
the apparatus she used for the purpose consisted of a
pig's bladder, into the neck of which was tied a smooth
ivoiy jet, and on this occasion, while using it, the tube
was forced from it into the rectum ; she immediately sent
for me, and I saw her wiUiin half an hour of the acci-
dent; on making an examination, the tube was felt
immediately above the margin of the internal sphincter ;
it was extracted mthout ditficulty, a pair of oesophagus
forceps being used for the purpose.
Three years since, a physician was suddenly seized,
while walking, with severe irritation and pain at the
TORKIGN BOniKS IS THE RKCTltM. 331
anus ; on his return home he bathed himself with hot
water, but it failed in affi)rdJiig any relief; the finger
being introduced within the anus, a portion of bone was
felt and removed ; it was a piece of mutton bone with
very sharp angular cornel's, and had it not been extracted
tluis early, doubtless it would have perforated the in-
testine.
In the early part of last year, I received an urgent
request from a professional friend to visit him imme-
cUately, he being suddenly seized with a severe and sharp
pain at the fundament. When I saw him, he was lying
on a sofa, and was afraid to move, as the least motion
produced the sensation or something running into him.
On making an examination, the sphincter was found
contracted ; the finger introduced into the bowel came in
contact with a fish-bone, one end of which had perforated
the intestine about a (juarter of an iiich above the anal
margin. With a pair of polypus-forceps, I grasped its
upper extremity, and pushing them upwards di-ew the
bone out of the tissues, then with the point of it resting
on tile index finger of the left hand, removed it without
difficulty or causing any pain. No evil consequences
followed.
We shall more often be called upon to remove from
the rectum intestinal and alvine concretions thai] any
other substances ; I have hatl on several occasions to free
the bowel of accumulated ami indurated feeces. These
332 FOREIGN BODIES IN THE RECTUM,
cases occur mostly in females, and depend on the
greater capacity of the pelvis permitting of accumulation,
combined with the very general habit of postponing the
calls of nature; when it occurs in men, they arc generally
advanced in years, or are the subjects of paralysis. A
lithotomy scoop is the best and most convenient instru-
ment for our purpose, but if that be not at hand, the
handle of a table-spoon is a very good substitute ; with
either of these and the forefinger of the other hand there
will be no difficulty in effecting the object. After we
have emptied the bowel as far as we can reach, eneraata
of warm soap and water, or olive oil, with decoction of
barley, should be injected into" the bowel by a long elastic
tube, as often as may be deemed necessary so as to
entu-ely free the intestines j after which cold water or
slightly astringent enemata must be used to restore the
tone of the bowel lost by the distension to which it had
been subjected.
Mr. Lacy,* of Poole, in May, 1858, removed piece-
meal from the rectum of a lady a concretion "at
least fifteen mches in circumference." The outer part
of it consisted of concentric layers of what looked like
red sandstone, and which proved, on examination, to
be a compound of udh and magnesia. The interior
was a softer mixture of the earthy and ferruginous
" * Pathological Transactions,' vol. vi, p. 203.
TOItBIGN BODIES IN THE HECTUU.
333
matters with many thousands of strawberry and other
seeds.
Mr. Jones,* of Llandyasul, removed three concretions
from the rectum of a farmer, two of them were as large
as a man's fist. " The concretions consisted of layers of
a substance of a brownish colour, much harder than
leather, each of them containing a plum-stone for a
nucleus,"
Somdiimes ascarides nestle in the rectum in such
numbers that they require to be removed manually,
which is to be effected in the same manner as fecal
collections, but we cannot thereby remove the whole,
and as they rapidly incrtiase if any remain, additional
means must be had recourse to ; our end may be effec-
tually accomphshed by injecting from two to eight
ounces, according to the age of the patient, of infusion
of quassia; or ohve oil, or turpentine in thin gruel,
may be used ; a dose of jalap, calomel, and aromatic
powder should be prescribed to be taken early in the
morning, and by these means the bowels will be
thoroughly cleared. An important point, and one fre-
quently overlooked in these cases, is to remove the
debihty of the intestines that always exists and favours
the development of these entozoa ; the bitter infusions
and mineral acids arc the best medicines for this pur-
pose; they will prevent the great secretion of mucus
• ' Lftucet,' Sept. 6, 1856, p. 278.
334 FORinr.s BODiiis is the rectum.
which forms the nidus of these parasitical crcatuw-s ;
the bowels must at the same time be kept regular by
purgatives.
The subjoined are some of the curious and interest-
ing cases of foreign bodies in the rectum which are on
record.
Nolet,* surgeon to the Marine Hospital at Brest,
relates the case of a monk, who, in order to cure him-
self of a violent colic, introtluced into the rectum a
bottle of Himgary wine, having previously made a hole
through the cork to permit the fluid to flow into the
intestine. In his desire to accomplish his object, he
pushed the bottle so far that it completely entered the
gut. Various means were tried to remove it mthout
Meeting the object ; at last a boy, between eight and
nine years of age, succeeded in introducing his hand
into the bowel, and withdrew the bottle.
Tuff'ell, in 1913, removed a flask of crystal from the
rectum ; but was obliged to break it, before he could
occomphsh its removal,
Dessault, in endeavouring to remove a porcelain
jelly pot, of conical form, and about three inches in
length, fractured it in several pieces ; however, he suc-
ceeded in removing them without injuring the intestine.
• ' ObBcrvations curieuses sur des Phenomenes ExtroordiniireB
qui regordent particulierement b M^decbe et la Cfairur^.' —
Oils, sniii, p. 103.
FOREIGN BODIES IN THE RK.CTUM. 335
Buzzaui,* in the year 1777, at Tiu-in, extracted from
the rectum of a man, a tea-cup, which the patient had
himself introduced, for the purpose of dilating the
bowel.
Morandf records the two following cases : A man,
about sixty years of age, presented himself at the
Hopital dc la Charitc, complainmg that the pipe of
a syringe had entered his rectum. Gerard introduced
his finger, and felt a foreign body, which he removed
with a pair of lithotomy forceps. It proved to be a
large knitting sheath of boxwood, six inches in length.
A weaver, who had long suffered from constipation,
having some vague notions of the efficacy of supposi-
tories, introduced into his rectum a shuttle with its
roU of yam. After five days he applied at the Hotel
Dieu. M. Bonliomme extracted it with a pair of Utho-
tomy forceps.
The two following cases are related by Hevin.J M.
Quesnay pilshed a bone, which was arrested in the
(esophagus, into the stomach. It was afterwards arrested
in the rectum, and induced great pam. The patient
again applied to M. Quesnay, who foimd the bone
sticking obliquely across the intestine, with the lower
end fixed in its walls. He removed it with a pair of
• ' Lancet,' 1855-0, p. 23.
t ' Mem. de I'Acad. Roy. de Chirur.,' Paris, 1700,
X Op. citi, tome iii.
33(!
Foreign bodies in tbe hbctuh.
forceps, first disengaging its inferior extremity by push-
ing it upward. Faget removed a mutton bouc from
the rectxun of a man he was called to see ; the bone
had been swallowed eight days previously.
Meeckren* mentions a case, in which the jawbone
of a turbot was arrested in the rectum. The patient
attributed the local and constitutional symptoms he
experienced to hiemorrhoids. The true cause was not
discovered tiU, in attempting to administer a lavement,
the pipe of the instrument came in contact with a foreign
body. Mecckreu made an examination, and detected
the bone with its ends fixed in the walls of the intestine ;
he removed it with his fingers. The patient recollected
having swallowed it eight days previously, and experi-
enced great pain in its passage through the intestine.
Meeckren also mentions a case which occurred to
Tholuix, in which the jawbone of a fish became arrested
in the rectum. It was cut across with a pair of
strong scissors, and the two portions extracted with
Thiandieref details the case of a man, aged twenty-
two, who, with the view to overcome costiveness, intro-
duced a forked stick into the rectum. This stick was
five inches long ; one prong was an inch and a half
longer than the other, and they were separated to the
• ' ObB. Med.-Chirui^.'
t ' Bullet. Qin ie Th^rapeut.,' Janvr., 1835.
FOREIGN BODIES IN TIIR RECTUM, 337
extent of two inches, each prong being about four lines
in diameter, and the stem formed by their union half
an iDch. He inserted the one stem first, and when the
short prong had entered the bowel, he endeavoured, by
dragging on the long one, to force out the indurated
faeces. In this ingenious essay it is unnecessary to say
he failed completely ; the pain being very severe, he
ceased his manipulations, and, finding it impossible to
withdraw the fork, he forced the long prong completely
within the anus, with the extraordinarj- idea that it
would be consumed with the food. Fearful to divulge
the nature of his case, he bore his sufferings in solitude
and despair, until the abdominal pain and difficulty in
urinating led him to seek the aid of Thiandiere, who, on
making an examination, soon discovered the foreign
body, but it was so high up that he could scarcely touch
it. He endeavoured, but in vain, to extract it with
a forceps passed through a speculum. The happy idea
then stnick him of using his hand, which, after having
washed out the rectum, he insinuated finger by finger.
Conducted by the long branch, he succeeded in reaching
the bifurcation of the stick, and disengaged it with
difficulty from a fold of the mucous membrane, in which
it had become entangled, then compressing the prongs
together, he safely removed it.
A similar case to the foregoing is recorded in the
338 FOREIGN BODIES 1> THE RECTVM.
Lancet.* A man, twenty-nine years of age, had suf-
fered from his cbildliood from prolapsus recti, and wa8
in the habit of reolacing the intestine without aid. On
one occasion, wlien the rectum was pi-olapsed, he cut a
branch of willow, which divided into two prongs ; hold-
mg these in his hand, with the otlier end of the stick
he pushed up the gut, but using too much force the
whole of the stick passed up also. The prongs ex-
panding rendered him unable to withdraw it. After
eight days, he was seized with acute pain in the breast,
which he ascribed to the presence of the foreign I
ui the rectum. An examination was made per s
but nothing detected ; two months afterwards, abscess
formed over the gluteus muscle, which were opened,
and the bifurcated ends of the stick protruded ; lliej
were seized, and broken at their angle of junction, and
the piea-s extracted. Each prong was nine inches j
length, and the conjoined stem two inches long
three quarters of an inch in diameter,
Marchettif mentions the following case. 8ome
students of Goettingen introduced into the rectum of
an unfortunate woman all, save the small exti
of a pig's tail, from which they had cut enough c
bristles to render it as rough as itossible. Vai
attempts were made to extract it, bnt in vain.
■ Vol. ii, 1835.6, p. 23.
t ' Obs. Sied. Rarior Syllog..' cap. vii.
FOREIGN BODIES IS THF. HECTCM.
339
chetti being consulted, adopted a very siiuple and
ingenious procedure, which consisted in securing its
inferior extremity with a etroDg waxed tliread, and
slipping over it into the rectum a canula prepared for
the purpose. He thus defended the bowel from the
effects of the bristles, and easily removed it.
Cuatance mentioos the case of a man who fell on an
inverted blacking-pot, and had the whole of it forced
up the rectum. Attempts were made for an hour and
a half to dilate the sphincter, and remove it with a
forceps, but in vain. The small end of an iron pestle
was then mtroduced, till it touched the bottom, and,
being held there firmly, was struck with a flat iron.
At the second blow the pot was broken into several
pieces, which were removed piece by piece by the
forceps, or the fingers. Next morning he laboured
under severe intestinal inflammation, with incessant
vomiting and excruciating pain over the wiiole belly;
he died at night. The pot was two inches and three
eighths in diameter at the brim, an inch and a half at
its base, and two inches and an eighth m depth.
In the first volume of the ' Medico-Chirurgical Trans-
actions,' Mr. Thomas relates the following case ; " A
gentleman, of an inactive and sedentary disposition, had
for many years, suffered from constipated bowels, which
increased to that degree that the most active cathartics
failed in producing the desired eflect. By the advice
FOREIUN BODIES IN THE 1
of B practitioner, whom he consulted in Paris, he dailr
introduced into the rectum a piece of flexible cane
(about h finger's thickness), where it was allowed to
remain until the desire to evacuate the fsces came on.
This plan succeeded so well that for more than a twelve-
month he never had occasion to resort to any other
means. One morning, being anxious to fulfil a parti-
cular engagement in good time, in his hurry he passed
the stick farther up, and with less caution than usual,
when it was suddenly sucked up into the body, beyond
the reach of his fingers. This accident did not inter-
rupt the free discharge of the f^eces, and the same
evacuation regularly took place every day, whilst the
stick remained in the gut. It was seven days after-
wards when I fii"st saw him ; he was in a very dis-
tressed state, with every symjjtom of fever, tension of
the abdomen, and a countenance expressive of the
greatest anxiety. His relatives and friends were totally
ignorant of the real nature of the case ; and nothing
less than the urgency of his sufferings could ever have
prevailed upon him to disclose it to me. Such were
his feeUngs on the occasion, that a violent hysteric fit
was brought on by the mere recital of what he termed
his folly.
" Upon examination no part of the caue could be dis-
covered ; but one end of it was readily felt projecting, as
it were, through the parietes of the abdomen, midway
FOHKION BODIES IN THK RRCTUM.
341
between the ilium and the umbilicus on the left side.
The slightest pressure upon this part gave him exquisite
pain. After repeated trials, I was at length enabled,
with a bougie, to feel one extremity of the stick lodged
high up in the rectum ; but without being able to lay
hold of it with the stoue forceps. To allay the irri-
tation for the present, an emoUient clyster, with Tinct.
Opii, jij, was given, which passed without the least im-
pediment, and did not return. On the next exami-
nation, two hoiu^ after, I found the sphincter ani con-
siderably dilated, and, by a continued perseverance to
increase it, the relaxation became so complete, that in
about twenty minutes I was enabled to introduce one
finger after the other, untd the whole hand was engaged
in the rectum. I found the bottom of the stick jammed
in the hollow of the sacrum, but, by bending the body
forward, it was readily disengaged and extracted. Its
length was nine inches and a half, with one extremity
very ragged and uneven.
" For several days after, the situation of the patient
was highly critical, the local injury, joined to the pertur-
bation of his mind, brought on symptoms truly alarm-
ing. At length I had the satisfaction of witnessing his
complete recovery ; and he has ever since, more than
two years, enjoyed good health, and the regular action
of the bowels, without the assistance of medicine, or any
other aid."
342
FOREIGN BODIES IN THE RECTUM.
A man, Eet. seventy-three, was admitted into the St.
Marylebone Infinnary. lie was delirious, and made liis
complaintit very incoherently. He said there was a stick
in his rectum, but no further iiifonnation could be
gained from him. He was seen by Mr. B. Phillips,
who suggested that the sensation of sotucthmg in the
rectum might be caused by the enlarged prostate, and
that in his delirious condition the sensation of a foreign
body was sufficient to impress upon his mind the idea
that it was a stick. He died the day after his admis-
sion ; and upon a post-mortem examination being made
a stick rounded at each end was found, its superior ex-
tremity had penetrated through the sigmoid flexure of
the colon into the peritonscal cavity.*
In the thirtieth volume of the 'Medical Gazette'! 's
an accoimt of a Greenwich pensioner, who was admitted
into the infirmary on the 20th of October, 1814, having
eight days previously introduced a large plug of wood
into the rectum for the piu-posc of stopping a diarrhoea.
It was with great difficulty extracted by Mr. M'LaughloD,
surgeon to Greenwich Hospital.
In June, 1S42, a man, set. sixty, was brought to
Kings College Hospital labouring under obstructiou of
the bowels, which he attributed to having eaten a large
• ■ Medical Gazette,' vol. ixii, p
t r'|>, 401, 462.
FOREIRN BODIKS IN THE RRCTl'M.
343
quantity of peas six days previously. He expired wiiile
being carried in a chair up to tlie ward.
On examining the body after death upwards of a
pint of gray peas was found in the rectum, they had
been swallowed without mastication, and had undergone
no alteration in passing through the alimentary canal,
except becoming swollen by warmth and the absorption
of moisture. The urethra was pressed upon, and he
had had retention of urme for four days. Tlie bladder
was enormously distended, its apex reaching the umbili-
cus, and its base nearly filling the brim of the pelvis.*
Mr. Liston+ removed from the rectum half a jaw-
bone of a rabliit, which had been swallowed in a plate
of curry.
Mr. Lawrence had a case in which a man had broken
the neck of a wine-bottle into liis rectum ; he gradually
dilated the sphincter, introduced his whole hand, and
removed it.
Mr. Fergussont removed a bougie from the rectum
of an old gentleman who was in the habit of using
such an instrument ; on one occasion he passed the
bougie within the sphincter, and could not withdraw it.
Several unsuccessful attempts had been made to remove
• ' Medical Gazette," to! m, pp. 6ft5, 606.
t ' Practical Surgery,' by Robert Liatou, Fourth Edition, 1846,
I ' Practical Surgerj',' Third Edition, p. 750,
344 FOREIGN BODIES IN THE RECTUM.
it, previous to Mr. Fergusson seeing the patient ; with
some difficulty he succeeded in seizing the end with
a pair of Uthotomy-forceps, and withdrawing it. The
bougie was nine inches in length, iuid an inch in
diameter.
CHAFfER XIX.
MALFOEMATIONS OF THE RECTUM AND ANUS.
Malformations and cougoiiital deficiencies of the
intestinal cnna! and its terminal aperture, occasioning
entire obstruction or adniittiug of but a very partial
evacuation of its contents, demand the especial attention
of the surgeon, trom the necessity of prompt inter-
ference, and the certainty of a fatal issue unless the
defect is remedied, by establishing a free outlet for the
meconium and excreraentitious matter of the alimentary
organs. The accomplishment of this object is thought
by many who have not had to treat such cases a very
easy and simple matter ; but to the practical surgeon
various difficulties present themselves. The diagnosis,
when the case is not one of occlusion of the
anus by merely a thin membrane, is attended with
doubt, as the symptoms and physical signs do not iu
the majority of eases afford a definite clue as to how
much of the intestine is deficient, or as to the relative
position of its termination to the external surface ; con-
sequently an attempt to reach it by cutting instruments
340 MALFORMATIONS OF THE
is attended with umch uncertainty. Moreover, suppos-
ing an operation to have been performed, and an opening
into the bowel made, this is only the beginning of the
surgeon's anxiety and trouble, for the proneness to con-
traction in the artificial aperture is so great, that it
is only by the most constant attention for weeks,
monthB, or even years, that it can be maintained. In
many of the recorded cases, an operation has been per-
fonned several times, in order to re-estabHsh the open-
ing ; a short time since. I was requested to operate on
a child fifteen weeks old, that had been operated on
twice previously ; the case will be again referred to
under the proper section of this cliapter. The result
of the majority of published cases is by no means en-
couraging, and if the history of others were known,
there is reason to l>elieve the view presented would be
still less so, and that littlt! hope exists of an iiif
thus bom ever attaining a mature age ; still, as it r
inevitably perish unless reheved by art, it behoves 1
surgeon to make an effort to preserve the life of t
child, if the nature of the ease can be so far made i
as to offer a jirobability of success.
CONTKACTION AND OCCLUSION OF THE AfFS.
The aual aperture is sometimes preternaturaliy sni
either in con-sequenct^ of a contraction in the extrcuj
RECTUM AND AN
347
of the rectum or irom the skin extending over the
border of the sphincter. The openbg may be only
suihciently large to allow the more fluid part of the
meconium to drain away, or the size of the orifice
may be such as to cause a difiiculty in passing, but
not entirely preventing, the escape of excrementitious
matters.
When the anus is merely contracted it nmst be
dilated by tents and bougies. If an extension of the
skin beyond the margin of the sphincter abridges the
anal opening, several slight notches may be made 'm
it with a blunt pointed knife, and afterwards it may
be dilated by the pressure of bougies.
Sometimes two anal apertures exist more or less
distant from each other ; the one may also be larger
than the other, and give exit to the greater part of the
contents of the bowels. If the two openings are close
together, and not large, it will be advisable to divide
the septum between them ; but if any great thickness
of tissue intervenes, it will be better to enlarge that
openuig which corresponds most nearly to the position
of the natural outlet, and to procure the closure of
the other ; to accomplish the one object, it will be
necessary to have recourse to dilatation by pressure
and incision, and when tliis has been effected, the other
may be brought about by the application of strong
nitric acid, nitrate of silver, or the actual cautery.
346 MALFURUATIOHS OF THE
In other cases total occlusion of the anus exists, an
anomalous condition much more common than eitlier
of the preceding forms of matfonnatiou. The structnre
closing the anns is not generally a continuation of the
integument, but a lamina of fibro-cellular tissue. It
is usually thui and transparent, permitting the mC'
conium to be seen through it, and forming a small
roundish prominence, which is most distinct when the
child cries or strains. This bulging membrane com-
municates to the finger a dougliy feel, and sense of
obscure fluctuation ; by pressure it is made to recede,
but it re-appeai-s immediately the finger is taken away.
In some rare cases the membrane is very thick and
dense, especially at the circumference ; the protrusion
will then be less prominent, and the meconium will not
be distinctly ft-lt or seen.
This form of malformation will probably be discovered
before any symptoms of obstniction arise, but if by
carelessness it is overlooked, some days may elapse ere
the child betrays any evidence of inconvenience or
sufiering ; but sooner or later it will be observed to
cry violently, to strain much, and although at first it
may have taken the breast readily, and retained the
uulk, sickness sets in, and if no relief be afforded, the
infant perishes with all the symptoms resemljling those
arising from strangulated hernia. When the membrane
is thin and the nature of the case evident, no delay
RECTUM AND ANUS. 349
in making an opening should take place; but if the
membrane be thick, and we should be in doubt as to
the continuation of the rectum, the operation may be
delayed for twenty -four or forty-eight hours, no mischief
being likely to occur in that time ; and during this
period the intestine will become distended, and the con-
dition of the parts be more clearly revealed.
The operation necessary to remedy this condition is
very simple, and consists of making a crucial incision
through the occluding membrane with a bistoury, and
removing the intervening flaps with a pair of scissors ;
dilatation will also most probably be required. I was
called to see a child of a poor woman, living in the
neighbourhood of University College Hospital, that had
the anus imperforate. It had been born about eighteen
hours ; tiie membrane closing the anus was thin, and
rendered prominent by the contents of the intestine ;
with a lancet two incisions were made crossing each
other, and the intervening angular flaps removed ; a tent
was introduced at first, but no contraction ensuing, its
use was veiy soon discontinued, and the infant pro-
gressed satisfactorily. Among the recorded cases are
the following : Dr. Thomas Cochrane,* in April,
1780, was sent for to see a child of a soldier of the
55th regiment; it had been bom eighteen hours pre-
viously, but no evacuation had taken place from the
* ' EdiabuTgb MudicaJ Commeataries,' vol. z, pp. 379-80.
850 MALFORMATIONS OF THE
bowels. The abdomen was much distended, and a
swelling the size of a lien's egg projected from the funda-
ment ; this being punctured, a lai'ge quantity of meco-
nium and gas escaped. Tlie child did well.
Mr. A. Copland Hutchinson* had a male cliild
brought to him, one day old, with imperforate anus.
When the chOd strained a bulging of the intestine was
very perceptible. An incision was made through the
occluding structiu-es, and the aperture maintained by
the introduction of dossils of lint dippt-d in oil. After
three weeks no further treatment was required.
I
IMPBKPoaATE EECTCM.
The anus in some cases is well ibrmedj
the bowel is continuous, but the meconium i
tained by a membranous partition, which may be
just within the anus, or an inch or more above
it ; as in imperforate anus, the membrane varies in
thickness, but is usually thin, the nature of the case is
made manifest by the retention of the meconium, and
by digital examination, or by using a probe or a small
elastic catheter or bougie. Dr. Bushcf mentions having
seen in the dissecting-room, a child in whom two par-
titions across the rectum existed, the one was half an
• ' Practical Observations in Surgery," Second Edition, 1826,
p. 2Gi.
t Op. cit,. p. 40.
RKCTLM AND ANl'S
351
inch from the anus, the other three quartei's of an inch
above that.
In imperforate rectum the obstructing membrane
must be incised by a narrow bistoury, carried up on
tlie finger, or by a phai-yngotamus, and bougies after-
wards employed. When the membrane is thick we
may not be able to tell whether the intestine is continu-
ous above till we have made the incision ; but if it be
thin it wiU bulge down upon the finger, and convey the
like sensation as when the anus is closed by a mem-
brane, Mr. Wayte* operated on a child bom 7th
March, 1814, in whom the rectum was occluded by a
septum, 'riie malformation was not discovered till the
child was two days old. In consequence of the closure
of the opening it was necessary to repeat the operation
on the 23d of April, and again on the 27th, after which
bougies were used daUy. The cliild died of hectic
when six montbs old ; caries of the sacrum was sup-
posed to exist.
A case occurred to Mr. Jenkinst of a male child
bom with imperforate rectum; the anus was perfect, and
a cul-de-sac extended upward for about three quarters
of an inch. No attempt to remedy the condition of
the parts was made till the eleventh day ; a trocar and
' Edinburgh Medina! and Surgical Journal,'
'Lanc't,' vol. ii. 1837-8. p. 271.
362
MALPOBMATIONR OF THE
canula were then thrust through the rectal septum, and
feces followed the withdrawal of the trocar. At the
time of the report, twenty-one days after the operation.
the child was progressiug favorably.
Mr. Mason* records the case of a male child bom
with imperforate rectum ; the malformation was not dis-
covered till it was two days old. The finger introduced
into the anus couid be passed upwards for about three
inches, at which point the canal was found to terminate.
The bladder was distiuctly felt anteriorly, and the sacrum
posteriorly. A trocar and canula were passed through
the occluding membrane ; on withdrawing the former,
a lai^e quantity of meconium escaped. The cliild died
twenty-four hours after the operation.
ABSENCE OP TBE RECTUM.
The rectum is sometimes entirely absent, or it may be
wanting in part only, the latter being the most frequent
occurrence of the two, In either case there may be a
well-formed anus, and above it a small pouch a few
lines in depth, or there may be no appearance of that
opening, the integument being continuous from side to
side.
When tlie last part of the intestinal tube is only par-
tially absent, the other portion usually terminates in a
cul-de-sac, at a greater or less distance from the surface
• ' Medical Times and Gazette,' New Series, vol, vi, p. 573.
RECTDM AND ANDS. 358
of the body, or it may be prolonged as a narrow tube
or imperforate cord, and blended with the adjacent
parts. When the whole of the rectum is absent, the
intestinal canal may open in some abnormal situation;
cases are recorded of the terminal opening being at the
umbUicus ; of the ilium opening externally above the
pelvis ; and two still more extraordinary cases, the one that
of an infant, in which the inferior portion of the abdomen
was badly developed, and the intestine turning upward
opened mider the scapula ; in the other, the intestine
mounted from the pelvis, tlirough the chest into the
neck, and opened on the face by a small orifice.
When a portion of the rectum is absent, it becomes
the surgeon's duty to do all in his power to estabhah an
outlet for the contents of the intestine, otherwise the
child must inevitably perish. If the anus be natural,
the prospects of success will he greater, the probability
being that there is no considerable interval between it
and the intestine ; and if the operator succeed in forming a
communication, no ultmiate inconvenience will be expe-
rienced. When the anus is present, the incisions must
be made through it, but if it be absent, they should be
commenced at the point it ought to have occupied. The
child is to be held in the lap of an assistant, who
should sit on a table before a good light; the knees
and thighs are to be flexed, and the perinaeum presented
precisely in the same manner as if the child were pre-
864
MALFORMATIONS OF THK
pared for lithotomy. The surgeon stttmg on a low
chair, then commences an incision about an inch lon^
which is to be carried more and more deeply in tl
natural direction of the anus, following the curve of tl
sacrum ; the surgeon's forefinger of the left hand in thfli
Wound must guide the course of the knife. If thsi
incisions be made directly upwards, or in the axis of the
pelvis, the bladder or other parts of importance may bq
wounded ; an opposite course, however, must be avoided,
or the surgeon will get behind the rectum. The disseo*
tion may be continued, if necessary, as far nearly as the
finger can reach. Shoidd the intestine be detected eithea
by the feel and sense of fluctuation, or by being seen at
the bottom of the vFound, an opening is to be made into
it, and the meconium evacuated; afterwards this opening
must be maintained by the constant use of tents of pre--
pared sponge, meshfs of lint spread with ointment, and
gum-elastic bougies. But should we not be so fortu*
nate as to discover the bowel, and as the child must
certainly perish unless an opening be made, we must
make a final effort to succeed ; a large-sized trocar and
canula are to be inserted in the direction in which it is
most likely to enter the intestine, and if successful, the
trocar is to be withdrawn, and the canula left in tl
wound, and secured there by tapes.
i
RECTUM AND ANUS. 355
Imperforate rectum and anus; the rectum descending to
half an inch of the surface of the integument-
I was requested by my friend Mr, Wm. Bennett, to see
a child eight days old, having an imperforate anus. The
mother had been attended in her confinement by a midwife ;
no advice had been sought on account of the malformation
that exiatcd in the child, and it only came imder obaervation
in consequence of the mother being seized with puerperal
peritonitis, which terminated fatally within twenty-four
hours of the supervention of the first symptoms.
On examination of the child, a slight depression was ob-
served at the ordinary situation of the anus, over which the
integimient was continuous. By pressure with the point
of the finger, a bulging and obscure sense of fluctuation was
perceptible, conveying the idea of the rectum terminating
in a cm/ tfe sac at a little distance from the surface ; the
abdomen [was slightly distended ; vomiting had occurred
once. The child was in articulo mortis, when I first saw it,
and it was evident the time had passed for an operation
to be of any avail, therefore no attempt was made to remedy
the condition of parts. The child expired in a few hours
afterwards.
On post-mortem examination, evidence of inflammatory
action was observed, the whole of the intestines being
agglutinated together by lymph. Tracing the large in-
testine, the rectum was found empty and collapsed, and
terminating about half an inch from the external surface,
the intervening space being occupied by dense cellular
SS3
MALFOEMATIONS OF THE
membrane ; the onward passage of the contents of the
bowels waa prevented by the colon being bent at an acuto
angle on the rectum, and dipping down into the pcMs.
This portion of the colon was distended with mecoiiium ;
it was conBiderfihly dilated on one aide, and adherent to the
small intestines. Trying to separate these adhesions, the
colon waa lacerated, the tissues at this point being of a
deep colour, and ranch softened in structure. It was this
portion of the intestine which was felt bulging against the
finger when pressure was made externally; and which
would have been opened, had an operation been performed.
The anal integument being reflected, a pale, thin, but
distinct external sphincter was observed, in which no
central aperture existed. The specimen was presented to
the Pathological Society.*
Pnrlial absence, im per/or at ion, and vialposil ion of the
rectum.
My opinion was sought in the following case, with tlxe
request, that I should perform any operation that might
be advisable. The child was five days old when it came
under my observation, and when bom had the appearance
of being strong and healthy. It took the breast readily
at first, but vomited after being suckled a few times. From
the third day, this recurred the moment uourisliment
entered the stomach. Urine had been excreted, but nothing
had passed from the bowels. The countenance indicated
suffering; the abdomen was much distended, and tym-
• See 'Transactions,' vol. *, p. 17G.
RECTUM AND ANUS. 3B7
panitic; slight pressure gave pain, and caused the child
to cry violently. The anus was perfect; on introdncing
the finger, it was arrested about three quarters of an inch
from the surface ; no bulging of the intestine above could
be felt, and by pressure the anal cut de sac could be pushed
up into the abdominal cavity.
No hardness or irregular fulness in any part of the ab-
domen existed, indicative of where the alimentary canal
terminated. Under these circumatancea, I deemed it im-
juatifiable to have recourse to any operative procedure.
The child died on the seventh day from its birth.
After death, I was permitted to make an examination.
The organs of the thoracic cavity were normal in structure
and position, as also were the stomach, liver, pancreas,
spleen, and kidneys; the small intestines, much distended
with flatus, were found occupying the left and anterior part
of the abdominal cavity; the ascending and transverse
portions of the colon were normal ; this intestine tlien
descended a short distance on the left side, and recroaaing
the abdomen, to the right side, terminated in a dilated
pouch, distended with meconium, reaching a little below
the crest of the ilium, from thence a membranous pro-
longation connected it with the anal oil de sac. On open-
ing the intestine, it was found perfectly impervious.
The correctneaa of the decision not to perform an opera-
tion was manifested by the relative position of the parts as
described. Yet this conclusion has been impugned by a
surgeon who, if he were to operate in such a case, would, I
fear, be more influenced by the imaginary cdal attending
the use of his knife, than actuated by a just and due con-
368
MALFORMATIONS OF TUE
Bideration of the prCBervation and well-being of his patient,
baaed upon a deliberate and sound judgment. It is evident
that had an incision, or a thrust with a trocar been made,
as is generally recommended, the peritoneal cavity and small
intestines would have been wounded, but the terminal portion
of the large intestine eoidd not have been opened. The spe-
cimen was brought before the Pathological Society in March,
1866.*
Imper/oration and partial absence of rcclum ; opera/ion
per/onacd -i/iree thiiea.
A lady and gentleman, residing in the neighbourhood of
WcBtboume Terrace, brought their infant daughter to me, in
October, 1856, requesting my advice. The child was fifteen
weeks old, and when bom was apparently well formed and
healthy. After a day or two it was obsen-cd that nothing
had passed from the bowels, and, on examination, it was dis-
covered that the anus was imperforate. An operation was
performed, and a canula introdnced into the bowel through
which meconium aud fascca passed ; proper means not being
taken to keep the opening patent, it soon contracted and
closed, and the operation had to be repeated, but due pre-
caution not being taken, the o])ening again closed. For two
days previously to the child being brought to me nothing had
escaped from the bowel ; vomiting occurred when it took
food ; it was thin and pale and the countenance indicated
long auffcring. The abdomen was much distended and tym-
panitic. No ana! depression existed, the integument being
" Sec ' TruiisftctioDB,' vol. vi, p. 200,
RECTUM AND ANUS.
3&9
extended from aide to side ; by carefiil examinationj a email
opening was discovered ; an ordinary probe could not be in-
troduced, but one of half the usual size was passed upwards
for its whole length. From the failure of the two operations
the parents were fearful the life of the cliild could not be
saved. I expressed an opinion that if an opening of snffi-
cient size were eatahlished and maintained, there appeared
no reason why the child should not live. Accordingly, I
was requested to do whatever I thought necessary ; and on
the 14th of October, with the assistance of Dr. Sanderson,
I performed the operation in the following manner : The
little patient being held in position as for lithotomy, I
passed with some difficulty a fiue probe into the bowel, and
having made an incision three quarters of an inch in length
through the integument, a director was introduced by the
side of the probe which was withdrawn ; four notches were
then made with a narrow bistoury run along the groove of
the director; the tissues were dilated with the fore-finger of
the left hand, and at about an inch and a quarter from the
surface the point of the nail could be got into a small aper-
ture, the margins of which were very dense and resisting.
A narrow probe-pointed bistoury being passed up on the
finger, seven or eight notches were made in its margin, the
tissues were dilated, and the finger passed into the bowel ;
on its withdrawal a large quantity of fasces passed. An
clastic tube, three eighths of an inch in diameter, was secured
in the wound ; the child was put to bed, and shortly fell
asleep.
On the following day, the child's appearance had much
improved ; fieces had passed freely through the tube, which
OOQ MALFORMATIONS OF THE
was removed and cleansed. I introduced my finger its whole
length, and broke down the adhesions, which liad commenced
forming at the points of incision. A dose of castor oil was
directed to be given.
After a week the tnbe was left out; and a number four
rectum-bougie directed to be passed up the bowel, and re-
tained five minutes once in the twenty-four hours ; after its
removal the bowel was to be washed out with three ounces
of warm thin gruel. For several weeks I saw this child
daily, and introduced my finger to prevent the part contract-
ing, the tendency to which was very great.
The child in a short time had perfect control over the dis-
charge of the fseces, and showed no symptoms of distress or
tmeaainess ; it gained fiesh and became lively and intelligent.
The size of the bougie was increased to number five and then
to six. With the exception of occasional indisposition firom
cold or other accidental circumstances, no child could progress
more favorably. I continued to \-isit it once or twice a week
and saw it alive on the Slst of January, 1857, when it ap-
peared^ remarkably well and Hvely. On the 5th of February,
I received a message to say the child had died suddenly
while in bed about half-past eleven o'clock. The mother
had seen it ten minutes previously, it was then breathing
easily and appeared quite well. The following day I made
a post-mortem examination. The thumbs were firmly con-
tracted into the palms of the hand. The stomach was much
distended and contained a large quantity of undigested food ;
the intestines contained a small quantity of feculent matter,
and the colon was empty. ' The rectum was normal in sise,
and terminated at an inch and a quarter from the surface.
RECTOM AND ANDS.
361
Most surgeons who have performed this operation have
been unsuccessful in saving the lives of their patients ;
however, a few cases have succeeded. An interesting
case of a child with imperforate rectum is recorded in
Langenbeck's new ' Sm-gical Bibliothcca ;' the malfor-
mation was not discovered till twelve days after the
child was bom, when it was seized with hiccough and
convulsions ; the abdomen was protuberant and hard,
pain was produced by pressure, and the cliild was much
depressed. An incision an inch in depth was made in
front of the coccyx, but it did not penetrate the intes-
tine; it was then extended another incli but with no
greater success. The operator then had recom-se to the
phaxyngotamus, with which he succeeded in piercing the
rectum. Clysters and tents were afterwards used, and
the child lived. I have in my possession a preparation
given me by my friend. Dr. Quaiu, namely, a case of
malformation of the rectum, in which the intestine termi-
nated in a closed sac. The preparation was presented
to the Pathological Society, and the particulars of the
case are published in the Society's Transactions.* The
anus was perfect, through whicli an incision was made
by the surgeon in attendance, but he was unsuccessful
in opening the bowel, and the chHd died on the ninth
Mr. Benjamin Bell met with two cases in which the
362 MALFORMATIONS OP TIIK
intestine was veiy distant from the integument. In
both he succeeded in forming an anus, but found it
very difficult to keep it pervious. A very eminent
author remarks, " Though keeping the opening dilated
may seem easy, to such men as have had no opportu-
nities of seeing cases of tliis description, it is far other-
wise in practice." In the ninety-eighth number of the
'Edinburgh Medical Journal,' is recorded a case in
which the tendency to closiu'e in the artificial anus was
so great that the operation had to be repeated ten times
before the child was eight months old.
In Dr. Baillie's ' Morbid Anatomy'* is a drawing of
a specimen of imperforate rectum terminating in a
cul de $ac ,- the anus was perfect, and a short and narrow
canal extended upward to within a short distance of the
intestine.
Mr. Copland Hutchinsont attempted, by means of a
scalpel and trocar, to open the intestine of a child to all
external appearances similarly malformed to the one
already alluded to, but was not sncccssfiJ in accomplish-
ing the object, probably owing to the absence of the
rectum. Some hicmorrhage took place, which was
restrained by application of lint saturated with turpen-
tme. In another instance of a male child with the anus
natural, but occluded half an inch from the surface,
* Fasciculus iv, plate S, fig. 4.
t Op. cit., pp. 2ftt— 274.
KKCTUM AND ANUS.
363
Mr. Copland HutcMnson endeavoured to establish an
opening in the bowel, by thrusting a trocar for more than
three inches in depth without Bu'ccess. The child died a
few hours after the operation ; and a post-mortem exa-
mination revealed the intestine separated from the anal
cul de sac by a quarter of an inch. The trocar had
passed behind the intestine and grazed its walls.
A female child, born the day previously, was brought
to Mr. Meymott,* there existed no opening into the
bowel. A depression existed just at the point of the
coccyx, but there was no opening in the skin ; the
vagina was also occluded ; a probe could be passed
into an aperture corresponding to the mcatiis uri-
narius, but no urine was observed to pass. An in-
cision was made into the perineum to the depth of two
inches and the bowel reached, which was made evident
by the free escape of meconium. Castor oil, calomel,
&c., were administered to the child, it died seventy-six
hours after birth. No examination was made.
Mr. J). 0. Edwardsf records the following: a male
child bom twenty hours previously, had had nothing
pass per anum, and refused the breast ; its abdomen was
distended and painful on pressure ; the lower limbs were
ligidly contracted on the pelvis; respiration was diffi-
cult, and the child constantly moaned. The anus was
'Lancet, vol. ii, 1829.3t
Ibid., vol. i, 1 829-30, p.
864 MALPOaSIATIONS OF THE
perfectly formed ; the introtluction of the finger de-
tected an obstruction an inch from the surface. Forty-
eight hours after birth this was incised with a bistouiy,
but the bowel was not penetrated ; the bladder and
blood-vessels were felt by the finger introduced into the
wound ; the child died the following day. An examina-
tion was made ; the rectum terminated in a cul de sac
at the middle of the sacrum, having a meso-rectum ia
its whole length, and a complete peritoneal covering.
The space of half an inch intervened between the termi-
nation of the rectimi and anal cul de sac.
Mr. Lindsay,* in December, 1829, had brought to
him a boy eight months old, bom with an imperforate
anus, and absence of a portion of the rectum. An
opening had been made, but at the time he saw him it
was nearly closed ; by bougies, &c. the aperture was en-
larged, and the child grew and became perfectly healthy,
but could not retain his faeces. When between five and
six years of age he lost flesh and became very ill ; it
was found the artificial opening had closed so much tliat
a quill could not be passed. Mr. Lindsay conceiving
the artificial anus was too near the coccyx, made another
more anteriorly; ultimately the posterior opening was
closed, and the child had perfect control over the bowel.
Mr. Smith, of Pljinouth,-|- had a female infant brought
• ' Lancet,' toI. i, 1835-6, p, 361.
t Ibid., vol. i, 1839-iO, p. 794.
RECTUM AND ANW8.
865
to him 17th January, 1840, thirty hours after its birth,
in consequence of there liaving been no evacuation per
anum. The anus was perfect, and admitted the finger
to be passed np half an inch. Vomiting of a brownish
feculent matter had taken place, and this recurred at in-
tervals till the child died. It lived nine ■ days. An
examinatiou after death revealed the colon, nine inches
in length, terminating in a closed extremity at its
transverse portion. A tortuous prolongation from the
anus, ten inches in length, and about the size of a swan-
quill, extended up the left side of the spine, it was
isolated from the otlier portion of the intestinal canal,
lie also mentions another case of a female infant with
imperforate rectum which came under his observation. A
dense cellular tissue, three quarters of an inch in thick-
ness, separated the bowel from the anus. An attempt
to reheve the child by operation was unsuccessful, and
it died on the fifth day £i-om its birth.
Mr. Gosse* operated on a child four days old, bom
with imperforate rectum. The incision was carried more
than two inches hi depth before the intestine was reached.
The child Uved till the twenty-fourth day, when it sank
without any particular symptom-
Mr. Georgef attended a lady who gave birth,
on the 10th May, 1849, to a child in whom, when two
• ' Medical Gazette,' vol. vi, 1
t Ibid., vol. «, 1849, p. 280.
t8, pp. lG-17.
366 MALFORMATIONS OF THE
days old, the rectum was discovered to be imperforate.
The finger could be iutroduced up the anus for aii inch.
Sir Benjamiu Brodie saw the case, and decided that an
operation would be unadvisable. The chOd lived five
weeks. After death, the terminal portion of the colon
was found covered by peritoneum.
Dr. N. Chevers* operated on a male child, five days
old, boru with imperforate anus, and partial absence of
the rectum ; the instrument used was a hydrocele trocar,
which was passed into tlie bowel, but the canula proved
too small to penult of the escape of the intcstina] con-
tents ; the child died, and the body was thrown into the
river by the parents.
Dr. Parker, of New York,+ records ten cases of im-
perforation and partial absence of the rectum. In three
cases there was no anal opening ; of these, the operation
was successful in saving the lives of two of the children.
In each of the remaming seven cases the anus was per-
fect, and a cul de sac extended upwards, to a greater or
less extent ; of these seven children the lives of two
were saved ; three died within twenty-foiu- hours after
the operation ; one died on the seventh day from neglect,
and the remaining one died in the seventh week from
contraction and closure of the artificial opening.
• ' Indian Annals of Medicine,' No. 1, p. 296.
t ' New York Journal of Medicine,' New Series, vol, liii,
p, 310.
RECTUM AND ANUS.
I imagine few English surgeons would propose to
adopt the operation of Littrc or Callisen for opening
tlie descending colon, much less putting into practice
that of Dubois, of opening the sigmoid flexiiie of the
colon, and passing a strong probe through it towards
the perinteura, by pressure rendering the end prominent,
if possible, and then cutting down upon it. So fonnid-
able an operation upon a new-boni infant could scarcely
be otherwise than fatal. But though the surgeon may
not be justified in propor^ng to open the colon from the
groin, he may be compelled to midcrtakc it at the
urgent entreaties of the relatives of the child. He
should distinctly state the uncertainty of a successfid
issue, and what will be the after condition of the
patient if it survives. The manner of performing the
operation is as follows : — ^The child behig placed on a
pillow, an incision about two inches in length is made
midway between the anterior superior spinous process
of the ilium and the pubis, a little above Poupart's liga-
ment, in a direction parallel with the course of the epi-
gastric artery : the integument, the several layers of
muscles, and the transversahs fascia, are to be divided ;
the peritoneum beuig exposed, is to be pinched up, and
an opening made by cutting horizontally through it ; a
director or the finger is then to be passed into its
cavity, and the incision enlarged to the extent of the
external one. If the intestine be now seen, it is to be
MALFORMATIONS OP THE
I
brought close to the wound, and two double ligatures,
near to each other, are to be passed through it, hy
which the intestine is to be secured to the margins
of the abdominal opening ; after which, by makmg a
longitudinal incision between the ligatures, the me<
niura will escape. If the child live, adhesive inflanuni
tion is set up between the peritoneal surfaces in app)
tion, and closes external communication with the cavity.'l
The evils to be afterwards contended with are, a ten"!
dency in the exttTiial opening to close, the protnisionl
of tlie mucous membrane of the bowel, and excoriation '
of the integiuncnt from the irritation of the excretory
matter, and the friction of the bandages, or apparatus _
used, to occlude the opening.
UNNATURAL TERMINATIONS OF THE RErTUM IN n
BLADDER AND URETHRA.
The rectum, instead of terminating at the anus is I
sometimes prolonged forwards in the form of a narrow I
tube, and opens into the posterior part of the urethra.
This malformation is more common in males than fe- I
males ; and in the former is more likely to be fatal
from the length and narrowness of the urethra. la j
most of these cases of malformation, some imperfection ]
of developiueut co-exiats, especially of the genito-urinary J
oi^ans. The opening of the intestine is usually veiy I
RECTUM AND ANUS.
aey
email, and permits only the more fluid portion of the
meconium to be evacuated.
In other instances, the intestine opeiiB into the bladder
somewhere between its neck and the part where the
ureters enter; in such cases the meconium and urine
will be mixed ; but when the opening is urethral, a
jet of meconium, or faecal matter, will generally precede
the urine.
In this species of malformation, the opening for the
dischai'ge of the contents of the bowel being so small,
the cliild rarely aurvivcs more than a week, but in-
stances are recorded of life being prolonged beyond
that, Fortunatus Licetus* mentions a woman who
voided her fsces through the urethra. Flaginif relates
the case of an infant in whom about three inches of
the rectum was wanting, the intestine termiiiatuig in
a canal four inches in lengtli, which passed under the
prostate gland, and opened into the membranous por-
tion of the urethra. The stereoraceous matter of course
was voided with great difficulty by the urethra, never-
theless, the miserable babe lived eight months, and then
only died in consequence of having swallowed a cherry-
stone which lodged in the recto-urethral canal. BravaisJ
• ' Do Monatorum CnuBis Natura et DiffercntiiB,' lib. ii, cap. 1
1616.
t ' Osservarione di Chirurgia,' tome iv, obs. 39.
t 'Actes de Ljon,' tome iv, p. 97.
24
870 MALFORMATIONS OF THE
records the case of a boy foiir years and a Iialf old,
in whom the rectum, after becoming very narrow,
opened into and appeared continuous with the urethra.
Paulleticr* also saw a similar case in a boy three years
and a half old.
Mr. Copland Hutchinsonf operated on a male child,
bora forty-eight hours. An incision was first made to
the depth of an inch and a half, then a trocar and
canula were inserted another inch and half, when the
intestine was reached ; the opening was maintained by
tents and bougies. After three months, the urine was
observed to be tinged with fieces ; it had not been ob-
served to pass per anum. The child died when about
ten months old from the irritation of dentition. An
examination revealed a valvular opening between tbe
rectum and commencement of the urethra.
Mr. FcrgUBsonf reports a very interesting case of a
male child, bom twelve hours previously to coming
under his observation. No anus existed, but the skin
where it should have been had a brownish appearance ;
above this, at a considerable distance from the siuface,
an indistinct tumour could be felt. An incision was
made to the depth of an inch and a half, but the bowel
• 'Diction, de Scienc. Mu'tl.,' tome iv, p. 157.
t Op. cit., p. 264.
X 'Edinbui^h MciUcal and Surreal Journal,' vol.
' Practical Sui^ry,' Thinl Edition, p. 740.
an^^
RECTUM AND ANL'S.
371
was not reached, nor could it be felt. The next day
meconium being observed to pass by the urethra, Mr.
Fergiisson determined to cut into the bladder, and he
opened this viseus immediately behind the prostate.
The boy died of disease of the lungs, when about six
years old.
Mr. Windsor,* of Manchester, relates a case of ascites
in a foetus bom at the full period ; there was malfor-
mation of the rectum, and other viscera, and absence
of the anus. The colon was nine and a half inches in
length : it passed in a straight line down the spine,
terminating in a constricted tube, which barely ad-
mitted the passage of a blowpipe ; this constricted part
opened into a pouch the size of a hen's egg, occupying
the portion of the rectum, and between which and the
bladder a communication existed by a canal half an
inch in length.
Mr. Randolph, of Hungerford, records in the
' Lancet,'t the particulars of a male child bom without
any opening in the anal region. Small quantities of
meconium were observed to pass per urethram. The
in&nt died on the ninth day. No operation was under-
taken for its relief, as the mother objected. By exami-
nation after death, the rectum was found to open into
the bladder immediately posterior to the prostate gland.
* ' Edinburgh Medical and Surgical Journal,' vol. ivii, p. 361,
t Vol. i, 1838-9, p. 162,
372 MALFORMATIONS OP THE
Mr. Lizars, — quoted by Mr. Fergusson,* — made an
opening into the rectum of a child bom with imper-
forate auus ; he had to cut deeply before the intestine
was reached. A communication between the rectum
and bladder existed. The child lived three weeks ;
from the time of its birth, a tumour existed over the
dorsum of the ilium, fluctuation was perceptible, and
the parts had a pecuhar appearance. After death, the
tumour was found to be an abscess, which extended
upwards and opened into the canal of the lumbar portion
of the spinal column.
Mr. Tatham,t of Huddersfield, operated 16th of
January, 1835, on a male child, two days old, for im-
perforate anus. The urine had been observed to be
mixed with the contents of the bowel. The bowel was
reached by an incision carried to the depth of one
inch fronj the surface. The child lived till the 20th of
March. An examination was made, and the bowel
found to communicate with the neck of the bladder
by a narrow canal, a quarter of an inch in length.
Dr. York, J of South Boston, punctured with a trocar,
the intestine of a male child bom with imperforate anus ;
the operation was performed when it was three days
old. The canula was left in the bowel for a week, after
• ' Edinburgh Medical aad Surgical Journal,' vol. xvii, p. 367.
t ' Lancet,' vol. i, 1835-6, p. 373.
X ' Boston Medical aud Surgical Journal,' vol. ilii, p. 273-1.
KECTDM AND ANUS.
which the Opening was dilated by a sponge tent, at
the end of six weeks the opening was still more in-
creased by incision, and a silver tube three eighths of
an inch in diameter was inserted, and retained for a
year. The tube becoming corroded, when the cliild
was about six months old, fseces were observed to pass
per urethram. The child died when eighteen months
old, from the effects of a fall ; for two months pre-
viously, the fjeces passed entirely by the urethra, the
artificial anus having closed in consequence of the tube
being left out.
Dr. Williamson,* of Aberdeen, saw a child, twenty-
four hours after birth, in whom there was no indication
of an anus, " its usual situation being covered by smooth
skin, of natural colour, continued from the perinjeum
over the buttocks." An attempt was made to open
the bowel by incision, which was carried more than two
inches in depth, without the object being accomphshed.
On the fourth day from the child's birth, faeces were
observed to pass by the urethra, and in a fortnight
afterwards they began to pass freely, in which condition
the child lived till it was eight months and twenty-two
days old.
Dr. N. Cheversf had a male child, five days old,
brought to him by its father, a Hindoo ryot. No indi-
* ' Medical GaJtette,' New Series, vol, ii, p. 767.
t ' Op. cit., p. 297.
374
MALFORMATIONS OF THE
cation of an anal aperture existed ; the abdomen n
much distended. An operation was performed, and
small canula introduced into the bowel. On the folloj
ing day feculent matter was observed to pass by ti
urethra. The case terminated fatally on the t
day after the operation. An examination of the
was made, and "a narrow duct passing from the I
part of the intestinal cul de sac into the neck of tl
bladder, or membraneous portion of the urethra," wi
foimd to exist.
When the rectum terminates in the urethra, tl
siugeon must endeavour to dissect down upon tl
extremity of the intestine, and establish a more i
venient and larger opening tlian that formed by nati
If the urethra opens in the under part of the pen!
as is not uncommonly the case, it may be possible 4
pass a probe into the intestine, which may be felt \
the finger in the womid, and then cut upon. But \
the intestine terminates in the bladder, the operatia
must be conducted in the same manner as if the rectal
were wanting. It has been recommended to cut inf
the neck of the bladder, but a successful issue wooll
be more thau doubtful. i
When the rectum terminates in the vagina, uj
opening is much larger than when it terminates in t|
RECTUM AND ANl'8.
urethra. This form of malformation will also admit more
easily of being remedied than tliat forming the suliject of
the previous section of this chapter, and may be situated
either in the posterior or lateral wall of the vagina.
Although there is a greater probability of an infant
living with this condition of parts, yet much suffering
and inconvenience must arise from it ; thus the mucous
membrane v/H\ be excoriated, ulceration induced, and
abscess may form in the adjacent cellular tissue.
Should the rectum terminate in a pouch, an opening
from the natural position of the anus may very readily
be made into it, by passing a blunt hook or bent probe
through the recto-vaginal aperture, and renderiug its
extremity saUent ui the perinxuui, which will then be a
guide for the knife. The artificial opening must be
kept patent by tents and bougies. But sometimes the
rectum tapers considerably before opening into the
vagina, in which case an incision must be carried back-
ward to a sufficient extent through the portion of the
vaginal partition that is below the opening ; a canula is
then to be passed into the bowel and retained by tapes.
The anterior part of the wound is to be brought together
by sutures ; great attention to cleanliness will be neces-
sary to promote the union of that which is to form the
recto-vaginal septum.
MALyOBHATIONS OF THE
Imperforate anm ; the rectum opening into tk*
Mtb. B , in consequence of fright, from the bouse in
which she lived taking fire, prematurely gave birth, when seven
months and a half advanced in pregnancy, to a female child.
It was diminutive and its vital powers were low. For the
iirat few days no malformation was suspected, as meconium
and small quantities of fieccs had passed ; but the child at
length appearing to suffer pain, and the abdomen becoming
distended, an examination was made, when it was diacovered
that the anus was imperforate, and that feculent mat ter
passed per vaginam. No means were taken to remedy i
condition of the parts.
When the child was about four weeks old, it came under
the observation of Dr. Gibb, who desired the mother to con-
sult me ; she accordingly brought her baby to my house. On
making an examination, there was no Indication of an anus
the integument being continuous from side to side ; at about
the junction of the sacrum and the coccyx a depression ex-
isted, but no sinus or canal led from it. Externally, no other
defect in its development was to be obser^'ed. Separating
the vulva;, at a quarter of an inch within the vagina, an open-
ing was seen large enough to admit a number ten catheter,
through this excremeutitious matter oozed ; a bent probe
passed through it, and its point prcsBcd downward could be
indistinctly felt externally. On considering the nature of the
case I proposed to establish an opening in the intestine,
more conveniently situated than that formed by nature. The
parents being very desirous to have anything done that
RECTPM AND ANUS,
377
offered a probability of remedying the defect and savuig the
child, gave a willing conaent that I should perform the neces-
sary operation.
Dr. Gibb fully concurring in my views, with his kind aa-
sietance I operated on the infant the day following that on
Thich I first saw it. The child being held with the perineeum
presenting, a strong probe bent was passed through the recto-
vaginal opening, the point being pressed firmly towards the
surface ; an incision three quarters of an inch long was
made through the integument midway between the commis-
sure of the vagina and the point of the coccyx, the point of
the probe was then cut on and brought through the wound.
I now discovered that the communication between the bowel
and the vagina was by a narrow tube, and that by firm pres-
sure at the bottom of the wound the pouch of the intestine
eould be indistinctly felt pressing downward wlien the child
strained. The incision was cautiously continued to a. depth
of an inch and three quarters, when the bowel was reached,
and a punctiire made with the point of the scalpel ; a probe-
pointed bistoury being then introduced, and the opening en-
larged so as freely to admit the finger, on the withdrawal
of which a considerable quantity of fieces were discharged.
About two ounces of blood were lost during the operation.
A fiill-sized lithotomy tube was secured in the wound and
retained for eight days, being removed only when it was ne-
cessary to clean it, and in examination of the parts. The arti-
ficial opening evinced a strong tendency to contraction, wliich
was counteracted by the daily introduction of the finger for the
first fortnight, and subsequently a number four rectum bougie
which has been introduced and retained for some minutes
378
MALFOBMATIOTIS OP THE
daily. The bonrl is also washed out with three
thin gmel. The child ie now five months dd, and }
greased most favorably, its health is good, it feeds wel^
the bowels act freely, and it has control over them.
mother was directed now to increase the eize of the iM
to number five.
pp4
Mr. Mantell" operated, iu September, 1788,
female child with imperforate anus; a small
existed between the rectum and vagina. In the sjri
of 178S, he had to repeat the operation in conseqia
of the closure of the artificial anus ; another sui^eonl
previously performed the operation for the secoud t
Mr. Copland Hutchinson+ was consulted resp*
a female child, four weeks old, in whom the anus \
occluded, and a communication existed between \
rectum and vagina, through which the faxes paaj
freely. The mother would not consent to any operaiai
Mr. Bathurst, of Strood, had a cliild under his caro
whom the faeces passed per vaginam ; there was d
an external opening at the i
, but not larger tli
would admit a probe; it was dilated by boogies.
. 1
[ies,«
the abnormal aperture between the rectum and va||
closed spontaneously.
• ' Memoirs of the MedicaJ Society of London,' vol. iu, p
ftEHTrM AND ANUB.
OPENINO IN ■
;al REQION.
La Faye, in page 358 of 'Piincipes de Chinirgie,'
records n case of deficiency of a portion of the
sacrum, the rectum opening at the lower part of the
back.
TERMINATING IN A COMMON OPENING WITH THE
GENITO-UKIXAHV OHGANS.
As Andral expresses himself, there sometimes appears
to be a tendency in the terminal orifices of the digestive,
urinary, and genital canals to be confounded together in
a cavity more or less analogous to the cIoaciE of birda.
Sometimes the urethra occupies its normal position, and
the i-ecto-vagmal septum may be partially or entirely
absent. All these malformations depending of course
on an arrest in the development in various degrees of
one or other of the stages through which the parts pass
in their formation.
OTHER ORGANS TBBUINATINI
IN THE RECTHU.
The lusus of the ureters opening into the rectum
has been seen, but it is an anomalous condition ex-
tremely rare.
CHAPTER XX.
HABITUAL CONSTIPATION.
Habitual constipation is one of tlie most preval
and troublesome functional disorders to which manli
is subject. Its sympathetic effects extend to eV
organ of the body, and oft«n occasion great dista
and anxiety to the sufferers, leading them to appreta
the existence of the most serious organic dise|
Neither can it be doubted that many of the pathologj
changes in structure of the viscera of the head, ch*
and abdomen, have their origin in functional dera
ment, induced either sympathetically by constip
and consequent derangement of the assimilative oi^
or by the retention of excrementitious matter. Of t
sympathetic effects on the brain and nervous systi
thereby induced we have evidence during infancy ad
youth in convulsive tits, chorea, and other nerva
affections, and in adults in the giddiuess, drowsina
headache, pains extending to various parts of the bod
and that distressing mental depression denomiiia||
HABITUAL CONSTIPATION.
hypochondriasis, wbicli not uiifrequently termiDates in
permanent perversion of intellect, or even in a more
distressing manner. The sympathetic effects on the
lungs and heart are indicated by cough and palpitation.
The reaction on the stomach is marked by disordered
appetite, vomiting, eructations, and a sense of gnawing
and sinking at the precordia. We have evidence of the
kidneys being affected in their morbid secretions as
marked by the various deposits we find in the urine.
The exhalant functions of the lungs and skin also be-
come deranged, as indicated by the fcetor of the breath
and perspiration ; and many of the distressing and un-
sightly diseases of the skin have their origin in consti-
pation and morbid accumulations in the bowels. Nor
do the genito-uriuary organs escape ; thus urethral,
vaginal, and uterine discharges and irritability of the
bladder are frequently induced. The countenance of
those who are the subjects of habitual constipation is
dull and heavy, the eyes lack their lustre, and the
tongue is observed to be deeply notched transversely.
It has been shown that many of the affections treated
of in the preceding chapters often have their origin in
this common cause.
To enter fully into the causes, symptoms, and remote
sympathetic diseases and effects of constipation would
far exceed the limits and objects of the present work,
but a few remarks on the most common causes of consti-
382
HABITUAL CONSTIPATION.
pation, depending on torpor of the colon, and the l
of obviating timt condition, will not be out of
Habitual constipation as a constitutional effect ooj
in those whose vital powers are naturally low, i
during the earlier periods of life we most frequeB
meet with it in delicate females ; but as age advanj
and the organic functions become enfeebled, we fin
prcvaiHng in either sex. The most frequent accidi
causes are sedentary habits, and the very cotni
practice of not attending to the first calls of natmi
evacuate the bowels. Fiecal accumulations are i
favoured, the bowel becomes distended, and in sqI
instances to an amazing extent ; its vital contractilitj
diminished, and it is rendered incapable of expelling;!
contents. Yet, notwithstanding this condition, frequeu
neither the patient nor medical attendant suspects t
real mischief that exists, from the fact that diarrhi
may at the same time be present, consequent on t
irritation induced by the overloaded state of the bow]
I have many times been consulted by patients, suffer^
from the effects of ftecal accumulations, who assidj
me their bowels invariably acted regularly each
and what they asserted was quite correct ; yet they
the subjects of torpor of the colon and fajcal acci
lations. On inquiring more particularly into such casfl
it will be discovered that though the bowels have bal
moved daily, the evacuations have been scanty, and tl^
nABITCAL CONSTIPATION. 383
a flense of fulness and discomfort in the bowel remain j
the fact being, that accumulations had been gradutJly
increasing, and the softer and more recent excrementi-
tious matter had passed over that which had been re-
tained and become hardened.
The habitual use of large and warm enemata relax
and distend the rectimi, and enervate its functions ; one
of the effects of which is to promote the occurrenre of a
form of intussusception and slight invagination of the
bowel, the upper portion descending into the lower,
occasioning many distressing symptoms ; a dull, heavy
pain and fulness is felt in the loins and sacral region,
defecation is difficult and painful, and the calls to stool
frequent ; the evacuations are small, or passed in lumps ;
or being rendered fiuid, from an increased secretion from
the mucous surface, the result of irritation, are ejected as
if from a syringe. These symptoms often induce a
suspicion of the existence of stricture of the rectum, and
the suspicion, although entirely groundless, may be
apparently confirmed, if an endeavour be made to pass
a bougie, and it be arrested in tte edge or fold of the
semi-prolapsed [mrtion of the intestine.
In the treatment of habitual constipation, tlie object
to be attained is the removal of the cause, to procure
fsecal evacuations by the mildest and least irritating means
adequate to the purpose, to restore the lost tone, and pre-
vent the recurrence of the torpid condition of the bowels.
384 HABITUAL CONSTIPATION.
It is too frequently the case, that most inappropmte
means are adopted to remedy this condition. Man)
people are in the habit of dosing themselves with
calomel or blue pill, and black dmuglit, or saline pur-
gatives, wliich besides teasing and tormenting the upper
part of the alimentary canal for no fault of its own, is
productive of very temporary relief and much permanent
harm. I could cite innumerable instances which have
come under my own cognizance, of the mischief that has
thus been induced, and many practical writers have
made the same observation. Dr. Graves,* in his very
valuable lectures on Clinical Medicbie, remarks, " Various
causes have combined to render blue pill and calomel
almost popular remedies, to which many have recourse
when tlieir bowels are irregidar, or the stomach out of
order. Indeed, it is quite incredible what a number of
persons are in the habit of taking these preparations,
either singly, or combined with other pnrgatives, when-
ever, to use the common expression, they feel themselves
bilious. This habit, sooner or later, induces a state of
extreme nervous irritabiUty, and the invalid finally he-
comes a confirmed and unhappy hypochondriac ; he is,
in fact, slowly poisoned, without the more obvious symp-
toms of mercurialization being at the time produced."
Should the rectum and colon be distended by faecal
* ' Clini(^a] Lectures on the Practice of Medicine,' by Robert
J. QravcB, M.D., Second Edition, vol. ii, p. 213.
UABtTUAL CONSTIPATION.
accumulations, they must be dislodged before we can
possibly effect any benefit ; for which purpose eiiemata
will be the most efficient means ; and the only effectual
mode of admimsteriDg them, is by a long eltistic tube..
In overcoming habitual constipation, much may be
done without medicine. In attaining tliis object, it is
essential that the patient should "solicit nature" at a
certain period of the day, immediately after breakfast
being the best time. By allowing the mind to be
occupied, and as it were directing the attention to the
subject shortly before visiting the closet, the desire will
very probably occur. The influence of the mind is
strongly marked in two gentlemen I am acquainted
with ; both are very regular in their habits, and arc
accustomed to evacuate their bowels shortly after
breakfast ; should circumstances occm-, obliging the one
to take his morning meal at an earlier hour than usual,
he is unable to relieve himself, unless the organic
functions are roused through the influence of the mind by
thinking on the subject while he is dressing, and
invoking as it were, the assistance of nature. The con-
verse is tlie case in the other gentleman ; if anything
imusual occupies his attention early in the morning, tem-
porary constipation ensues, which he is unable to overcome
by any etfort without the assistance of artificial means ;
headache, ftatuleuce, acid eructations, and pain at the epi-
gastrium ensue, which continue till the rectum is freed,
38(1 HABITUAL CONSTIPATION.
either by an enema or the return of hia accxistomcd time of
relieving the bowels, when the symptoms instantly subside.
Exerase is most important to the proper performance
of defecation, and no one has a right to expect the
enjoyment of health, unless he devote at least one or two
hours every day to walking or riding. A glass of cold
clear spring water taken early in the morning, and
friction of the abdomen with the hand while at the
closet, will materially assist in promoting the peristaltic
action of the intestines.
However, the simple means suggested wOl not always
be sufficient to accomplish our object, and it may be
necessary to have recourse to medicines. Saline aperients
afford temporary relief, but they afterwards increase the
tendency to constipation, and induce debility of the
stomach and small intestines. The combinations that i
have found most useful, are stomachic bitters and
aperients, as the decoction of cinchona or compound
infusion of gentian, with infusion of senna ; dilute
sulphuric acid and sulphate of magnesia in one of the
bitter infusions, or the infusion of roses ; seidlitz
powders, with tincture of calumba and compound
tincture of cardamoms. A teaspoonful of on electuary,
composed of confection of senna, bitartrate of potash,
carbonate of iron, and syrup of ginger, taken at bed-time,
will in many cases have the effect of jnxicuring a copious
evacuation in tlio morning.
HABITUAL CONSTIPATIOK.
Nitric acid with iniusion of bark without the ad-
dition of any aperient, will often give tone to the
intestines, and produce a regular action. The com-
pound extract of colocynth with quinine, to which,
if necessary, one or two grains of blue pill may be
added ; or equal parts of the compound galbanum
pill with the compound rhubarb pill will be found
useful ; to the foregoing I have, in some cases, added
with advantage the oxide of silver. The extract of
nux vomica iu combination with an aperient pill, has
a powerful influence in relaxation of the rectum ; or
the alkaloid strychnia, in the proportion from a thirtieth
to a fiftieth of a grain for a dose, may be prescribed with
either of the foregoing mixtures. But lavements are the
most important of all remedies in relaxation of the
rectum ; these should be the least irritating, so that the
bowel may not be habituated to this means of stuuida-
tion, and they should not exceed in quantity half a pmt.
1 have seen important benefit result from the injection of
six or eight ounces of cold water after each dejection,
and its retention for a few minutes ; when the relaxation
has existed for some time, it may be necessary to add
some vegetable or mineral astringent.
In concluding, T may recapitulate iu ii few words the
principles on which habitual constipation is to be treated.
In the first place it is highly essential that all who are
able should take daily exercise, short of fatigue; if.
388 HABITUAL C0N8TIVAT10N.
from bodily debility or other cause, the patient is anabk
to leave the house, frictions of the abdomen at the closet,
or whilst he is in bed, should be had recourse to ; a
regular period should be obsen'ed for evacuating the
bowels, and if the nisus does not occur, the mind should
be made to dwell on the subject a short time previously,
that the desire may be provoked ; a glass of cold water
taken early in the morning Avill often influence the action
of the bowels, Enemata of cold water, with or without
tiie addition of astringents, used after dejection, are im-
portant adjuncts in the treatment of habitual costivenesa.
When it becomes necessary to prescribe medicines to be
taken by the month, they must be so combined, that,
whilst they unload the bowels, they may strengthen and
impart tone to them, and drastic purgatives which pro-
duce debility of the intestinal canal should be avoided.
The diet of the patient must be regulated : breakfast
should consist of weak cocoa, which is preferable in most
cases to tea or coffee, with dry toast and fresh butter ;
with some people, brown bread is very useful in promot-
ing the action of the bowels, yet in others it will induce
pain at the epigastrium, Satulence, and heartburn. If
the patient dine late, he may take a plate of thin soup,
or n sandwich and a glass of water, for luncheon ; at
dinner he may partake of a moderate quantity of well-
cooked vegetables, with brown meats well done ; white
meats are to be avoided, being less digestible ; a veiy
HABITUAL CONSTIPATION.
389
general opinion prevails that chicken is more easy of di-
gestion than beef and mutton, but the converse is in fact
the case ; pastry must not be allowed, but there is no
objection to light farinaceous puddings, or the Italian
pastes, as macaroni, vermicelli, &c., which are highly
nutritious and easy of assimilation. According to cir-
cumstances, wine may or may not be taken ; though a
different opinion formerly prevailed, the French and
Rhenish wines are more wholesome than port and sherry.
Spain and Portugal grow many excellent light wines, but,
from the little encouragement given to commerce by the
governments of these countries, and the heavy import
duties, they seldom find their way to England. If any
reason exist that wine cannot be taken, weak cold brandy
and water may be substituted. In the evening, a cup of
coffee, tea, or cocoa, and a biscuit, may be permitted ;
but the habit of taking wine or spirits before going to
bed is to be entirely discountenanced. By the adoption
of the plan suggested, and implicit obedience on the
part of the patient to the rules laid down, we shall not
often be defeated in our attempts to restore him to
health and comfort.
1
i
,r
^1
^^^^^^^I N D E X. ^^^^^^^^B
Abicub qmt the aniu, S19
Anus, character of pain in neuralgia of ^^^H
chincter of pni in subacute,
the rei:lnm and. 57 ^^M
222
Mr. Maro't case of neuralgia of ^^^1
gangrenous, nsar the anus, 223
the rectum and, 60 ^^M
olisorvBlioiu on the manner of
treatment of neuralgia of the ei- ^^M
opening an, 229
tremily of the recluui and, 58 ^^^M
artificial, for Ihe relief of perma- ^^^M
not Blwayi easy of ileteclion
in, 227
of Ihe anni, 301 ^^H
near tbe rectum, a free open-
contraction of, 29 ^^H
ing preferable to leseral
■maU un«, 231
congenital contraction of. 32 ^^H
near the rectum, cauiei af,219
near the rectum, diignosia of,
contrictionofthe,33 ^^M
227
contraction of. mistaken for atric- ^^H
■ubacnte, near the rectum, 221
lure of tbe rectum, 33 ^^M
acute. 221
treatment of contraction of, 34 ^^^1
Dear ihc rectum, symptomi of,
symptom) of conlraction of the, ^^^M
226
^H
near Ibe rectum, traumatic,
223
contisction and occlusionof.treat. ^^H
near the rectum, Irialment of
mentof,3'l9 ^^H
acute, 227
IS ^^M
Abaenee of rectum, 352
fissure of the, 3B ^^H
of the reclom, Irealmcnt in, 353
belladnnna in fissure of the, 44 ^^H
Anal region, rscrescences of the, 19
causes of fisiure of the, 42 ^^H
greater frequency in women
incision in Giaure of the, 45 ^^H
of excrescences of tbe. 20
trealmeutof eicreBcencei of.
^^H
22
relative frequencv iu the sex of ^^^H
Anus, itching of Ihe, 7
fissure of (be, 41 ^^H
causes of itching and irritation of
symptoms of fissure of Die, 40 ^^^H
the, 9
tVeatment of fissure of ihe, 43 ^^H
empiions in itching of the, 10
itching of Ibe, a symploni of dis-
^^H
ease. 9
1 Irealmrnt of itching, 12
coriation of the, 16 ^^H
treatment of inflammation and u- ^^^H
1 neuralgia ofrectnm and, 56
coriatinnoflhc. 17 ^^H
1 causes of neuralgia of the eilre-
Aacnrldes in tbe rectum, ri^uioval of ^^M
1 mity of tbe KCtum and 57
^^M
H ^^H
H Bell's, Sir CharleB, method of reducing
stricture of the recluBi. 33
■ Bimdins from pilei, 96
and occlusion of Ihe anua.
■ Bono of Ihe pelvis, dHuist in Bno COa-
3-)e
■ Dccted with diieose ul. 269
and occlusion of the tnoa.
treatment. 349
■ liim, 300
■ 'nuiou. kinds or. !99
Destendiu, case of traumatic ahioM.
H Brodie, Sir II., case of abtceu from
224
■ Rhich » G>h.hoiic »M
Diarrhcea and dysentery cauwi of pro-
Upsui recti, 204
^^^^K oa the formiiioD of the
Diet in habitual constipation, 3R8
^^^^^^ opening in
Dionia' account at Louis XIV, 216
^^^^H fiBlula. 2ib
uu I.e Moyne'i method i>f treat-
^^^^H on remoTal of inlemiil
ing tistulE, 245
^^^F 13»
^ OD the litualion of slric-
^r tureof the rectum, 290
Eruptions in itching of the nnm, )0
^B Bushe, Dr„ CMa of abscess from a gTia-
Etchnrotics in itriclure of the rectum
^L >tiol wound. 224
not advisahle, 301
^^^^ on anure of llie aiiua, 38
in the treatment of hcnor-
^^^^^L on Ihe frequency of mrlcture
rhoidi, 148
^^^^H of the 289
Exeision'of extemat hiemorrhoida, 134
^^^^H OD remoiHl of inlemal pUes,
of the rectum, 310
^^^^M 139
Excoriation of the anus. 16
cau.es of. Ifi
^^^n 108
Excrescences of the anal region, 19
^B Cancer of the rectum, 303
of the anal region, greater
■ Carcinoma of Ihe rectum, 303
frequency in women, 20
■ Climate, influence of, in hemonholdal
of the anal region, treat-
■ afl-Gclions, lOH
ment of, 22
H Cooiier, Sir AtllCT, on the extent of the
■ incision in fistula,
Excision of polypi of the rcclnm, 282
^L on excision of inter-
Feci paid by Louis XIV, 219
^^^L 137
sion in fistula, 259
^^^^H remarka on the ligt-
Fisiureoflheanus, 38
^^^^H ture In (he treat-
oftheanus. eaUBMof. 41
^^^r menl of liilula
of the anus, a complication of
^^^^ auo. 252
^F on polypi of Ihe rcc-
of Ihe anus, relative frequency in
■ tuiii,279
the >e. of, 41
■ Copclind, Mr., on proUpiui recti, 203
of Ihe anus, symptoms of, 40
of the anw, treatment of. 13
H the operation for At-
nitoU in «no, 233
■ tula, 256
blind, external method of ope-
H Coniiipalion, habitual. 3B1
rating, 263
■ hahiluil,treBtmeDt or,3B3
blind, internal, method of ope-
rating in. 263
■ a CBUM of itricture of the
<D ano coexisting with Blricture
■ rectum, 285
otthe rectum, 268
in ano compUcated by nrethril
^^^^ Of the anut, cauKi of. 30
fiituli, 267
INDEX. 808
FiiluU in ano coniucted wltli iiuite at
IlKmorrhoidil WraourB. nature and atnic-
hip-joint, 270
ture of. 87
in aiiD, CDiinecled vith diteue of
veins, enlargement of,199
Iht ilium. Eicrum, or piil«i.
2G9
mem of, 199
<feins. ajinptomi of en-
259
in ano, the formation of llie in-
veins, treatment of en-
leraal opening in, 235
largement, 201
knirc, 26a
97.
2^2
bleeding from, 96
in ano, nitrate of .ilver and in-
a concomitant of preg-
jection in, 249
nancy, 110
in aao. operaiion for, 260
ia ano, reasons for not operating
by. 106
in, 26fi
constipation producing, 1
no 1
from, 267
in ano, lymptomi, 239
diagnosis. 119 '
mppreiaion of bleeding after
discharge of mucus from,
operating for. 262
101
inano, incliof, 241
disease in other organ*
causing, 113
261
excision of external, 134
liability of Icnife tireaklngin ope-
external, 88
rating on, 265
Fluctuation in abioesi near the reclum
curringwith, 103
not ilwnjs fasy of detection, 227
beat or cold causing, 115
Foreign bodiea in the rectum, 327
«ioa of, 140
hereditary predJspoailion.
106
incision of external, 133
internal, 90
Habitual conitipalion, 380
internal ligature of, 143 i
fecl>. 388
mental cuicilions earning,
113
Harriion'i CJie of absceai resulting from
an apple core. 225
temal, 136
internal, nature of, 90
affections, cases of, 156
number and tixe, 91 1
aflfectioni, causes of. 105
internal, operation of ex- 1
dsion, 137
of, 86
period of accession of.
affections, early opinion*
106
ofllie nature of. 85
pressure useless in treat-
affections, influence of cli-
ment of, 154
mate, 108
plethora a cause of, no
affections liable to be
relative frequency of, 108
overlooked. 119
scarifying inflamed, 128
sympathetic affection* of.
examination in, 121
118
affections, pain extending
treatment of complica-
to other pull in, 94
tions of, 126
394 ^^^
irKTnarrhnldB. g«nenl trcalnient of, 123
eiternsUreaLinent nf, 133
251
trtaled bj nitric acid. U8
Liilon. Mr., on divition of liiiuaea in ria-
IuUe. 259
or. 152
.ymptoral of, 116
ihB cure Of fistula. 2 IG
utoeration o( lurface of,
Luke, Mr., on the uae of ligature in tbe
102
treatment of fistula, 2S2
HeemorrhagG from piles. 96
Ilip-joinl, flilaU in »no connected nitli
Mnlformalions of the rectum and anui.
(liieue of. 270
345
Ilovihiu, Mr., on b form of external pile,
Msligoant disme of the reel am. 303
89
diaease of the recluni. diag-
nosis of. 308
irentmeot of, 3^1
"t^ of, 306 '""""' '^"""^
diieaie of the rectum, Ireat-
205
mcnt of, 3DS
iDdiUm of ettcnul banioTThoids, 133
itrictureofthe rectum, 301
the anat, 22
Mental emoiians cauaing hEemorrhoidt.
of the ani», cnutei of. 16
113
^H of the rectum, G2
Miller, Professor, on fis.ore of Ibe anut.
^^^^b of Ifae rectum, caugeaof, C2
39
^^^V es
^^" of the rectum, (jriuptomi
Mucous menibranc, alterations in «lroe-
of acute, 64
lurci from prolaptub, 207
Mucus, discharge of, from liKmorrttoid*,
of. e7
101
loiurieaofthe rectum, 316
Injury of the recluni during parturilion.
Neuralgia of anui, and extremitj' of r«o- 1
321
bj. US 1
for Bituli. 2A4
vessels ofthehrain. 12
luemorrboidi, nua>t>cr and aize
Petit, case of ahtceii, from whieb a
of, 92
needle was eitracted, 22b
Piles. Sb
»ion. 139
external, 88
IrriUlIon and itching of the anui, 9
internal. 90
Itdiing of Ihe anu!, 9
Poil'f fistula-knife. 261
of (he aniii, a symptom of dis-
Pott. Mr., remarks ou conlniclion of the
ease, 9
anui, 29
oftheBBUs, treanuent of. 12
remirks on the use of ligature
Laceration of the rectura,317
151
^^B of the rectum, CBusea of.
remarks on Dr. Turner'i me-
^^^^L 317
thod of seooping nut ■
fistula. 145
^^^^V traction of the uiu>.
Plelhor. a eause of bemorrhoid.. 110
^^^^H of rectum, (ymploma of, 316
Polypi ofthe rectum, 279
of the tectum, characters of, |
■^ 319
279
■ Ligature of internal bemorrhDidi, 142
of the rectum, removal of, 2H2
^b^^^ polypi of the rectnm, 282
niiitaken (or hKoiorrhoidi, 1 1 g j
^^^^B 1NDKX. 395
1 Polypi of the rectum most frequent in
Rectum, foreign boilles In the. 327
1 ■d<i1t).2a0
injuries of tl.o, 316 1
injury of the, during parturition,
321
impeifor«te, 350
ProcUtii, G2
enemala not la be used in ipe-
CB..1M of, 62
70 " 1
enemaU nol (o be uied ia
specific, 70
of the. 64
•jmplonii of acute, 64
the, 67
ProUpm arii, 202
laceration of ih*. 321
of the rectum, 202
reclL, causes of, 204
neuralgia of ettreinity of tbe, 56
recti, met of, 214
polypi of ihe, 279
of internil hsmorTfaoidl, 1D3
prolapsus of the, 202
recti, loMl c»u«., 206
stricture of the, 2B4
rcMi.ijrmplomiof. 206
Blriclure of the, nol frequent,
recti, trettment of, 20B
288
210
stricture of the, arlificial anus in
recri, iteatment by operation,
permanent obstruction from.
211
301
recti, alteration in niucoua
membrane from, 207
urethra, 368
Prurilui ani. 9
ulceration of, 72
venereal ulceration of the, 7i!
(liiain. Dr., on fiittj degeBemtion, 12
unnatural terminalions of the,
368
wounded accidentally in surgical
245
operations, 316
abieuce of the, 352
Rll>es. M., on the cause of fistula in ann. ,
BbKnee of, irealraent in, 353
237
■bicrsBnear tbe. 319
on the silimtion of the internal '
ciuaea of abaceaa near tbe, 319
opening in fistula in ano.
tubacute abicess near the, 321
238
ijmptomi of abscesa near tbe.
221
Sayigpy's fistula-histoury, 264
traumatic abscesa near to. 223
South, Mr., on (he sUualion of stricture
ireaiment of abaoeu near the
ofthe rectum, 2D0
22 r
Stricture of the rectum. 284 _
belUdoana in fissure of the
of rectum coexisting with fis-
lower part of the, 44
tula in ano, 268
cancer of the, 303
of the rectum not frequent. 288
carcinoma of the, 303
Syme. Mr, on the eitent ofthe incision
erroneous opinions of the pre-
in the operation for fislub).
valence of diaeaiea of tbe, 8
255
acision of the, 310
fissure of the loner part of the,
38
cases of fissure of the lower
temal opening in fistula
on the operation in fistula.
pan of the, 4a
253
incision in fissure of tbe lower
plan of making incision in
part of the, 46
fiasureofano, 47
treatment of fissure o[ the loner
on removal of internal piles.
part of the, 43
139
396
INDEX.
Syme, Mr., on the relative frequency of
haemorrhoidal affections,
108
on the varieties of polypi of
the rectum, 279
Sympathetic effects of habitual constipa-
tion, 381
Ulceration of the rectum, 72
of the rectum, frequently a
complication of other dis-
eases, 73
Ulceration of the rectum, venereal, 79
Veins, enlargement of haemorrhoidal,
199
Venereal ulceration of the rectum, 8
White, Mr., on contraction of the anus
from venereal disease, 31
on the situation of stricture
of the rectum, 289.
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