LIBRARY OF CONGRESS, ©lap. :„_.__ ffl*pjri# 1 ** Shelf il.^.i-'b UNITED STATES OF AMERICA. A TREATISE ON DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE /by JOSEPH M. MATHEWS, M. D. PROFESSOR OF PRINCIPLES AND PRACTICE OF SURGERY, AND CLINICAL LECTURER ON DISEASES OF THE RECTUM, KENTUCKY SCHOOL OF MEDICINE VISITING SURGEON STS. MARY AND ELIZABETH HOSPITAL CONSULTING SURGEON LOUISVILLE CITY HOSPITAL CONSULTING SURGEON JENNIE CASSADAY FREE INFIRMARY FOR WOMEN LATE PRESIDENT MISSISSIPPI VALLEY MEDICAL ASSOCIATION PRESIDENT LOUISVILLE CLINICAL SOCIETY ; VICE-PRESIDENT LOUISVILLE SURGICAL SOCIETY MEMBER INTERNATIONAL MEDICAL CONGRESS, AMERICAN MEDICAL ASSOCIATION, SOUTHERN SURGICAL AND GYNAECOLOGICAL SOCIETY, KENTUCKY STATE MEDICAL SOCIETY, STATE BOARD OF HEALTH OF KENTUCKY ORATOR OF THE AMERICAN MEDICAL ASSOCIATION ON SURGERY, 1891, ETC. WITH SIX CHROMO-LITHO GRAPHS AND NUMEROUS ILLUSTRATIONS OCT 26 1892 NEW YORK D. APPLETON AND COMPANY 1892 c£>* 9> f Copyright, 1892, By D. APPLETON AND COMPANY. Electrotyped and Printed at the Appleton Press, U. S. A. TO MY COLLEAGUES OF THE MEDICAL PROFESSION WHO HAVE AIDED AND ENCOURAGED MY EFFORTS TO ADVANCE THE SCIENCE AND ELEVATE THE PRACTICE OF RECTAL SURGERY, THIS WORK IS INSCRIBED BY THE AUTHOR. PKEFACE. I have written this book because of a desire to record my individual experience of fifteen years as a rectal specialist, in answer to the demand of my students and friends. Dur- ing this time I have learned that many things that are taught are not true, and that many true things have not been taught. I have therefore not taken other men's opinions as my guide, but have accepted as truths only those things which could be substantiated by fact, and here recorded them. In differing from others on any special point I have tried first to state fairly and fully their views, and then my own. The verdict is left to the reader. I have introduced several chapters which are new to books on this subject. Among these will be found the following : Disease in the Sigmoid Flexure, The Hysterical or Nervous Rectum, Anatomy of the Rec- tum in Relation to the Reflexes, Antiseptics in Rectal Surgery, A New Operation for Fistula in Ano. I have styled the book A Treatise on Diseases of the Rectum, Anus, and Sigmoid Flexure. In embracing the sigmoid flexure in the caption, I do so because I have become con- vinced of its great importance as a seat of disease, and the utter lack of attention which it receives. From all time it has been recognized that serious pathological changes take place in it, but the works are singularly silent as to how to treat it when diseased. The chapter on The Hysterical or Nervous Rectum is embraced mainly to give my reasons for opposing some views of the learned and distinguished Prof. Groodell. The chapter on the Anatomy of the Rectum in Relation to the Reflexes is made to follow that of The Hys- Vi DISEASES OP THE RECTUM, ANUS, AND SIGMOID FLEXURE. terical Rectum in order to account for some vague affec- tions of the lower bowel. The subject of the " reflexes" is one of the most important before the profession to- day The chapter on Antiseptics in Rectal Surgery is inserted to demonstrate that such precautions can be practiced in this line of work. A New Operation for Fistula in Ano refers to my method of treating the disease by afistulotome. Al- though several have claimed the introduction of this little instrument, the dates, I am sure, will give me priority. I am greatly indebted to the following firms for cuts of instru- ments, which has enabled me to give so clear a demonstration of what a surgeon needs in doing rectal work, viz. : Messrs. John Reynders & Co., New York ; Messrs. Truax, Green & Co., Chicago ; Messrs. William Armstrong & Co., Indianapolis ; Messrs. Connable & Harper, Xenia, Ohio ; The Nedofik Manu- facturing Company, Wyeth City, Ala. To Dr. Paul Kempf, and to Dr. Henry Macdonald, artist for the publishers, I am especially indebted for the colored drawings which ap- pear in the book. To the publishers, Messrs. D. Appleton & Co., I wish to return my sincere thanks for the many cour- tesies that they have extended me, and for the elegant and artistic manner in which the book appears. Louisville, Ky. DIFFERENTIAL DIAGNOSIS OF DISEASES OF THE RECTUM, yii t3 H O Si CO CD CO c3 CD CO s H O W CO CO H 5 t-H „o fl 5^ CM O O .' CD OQ q jn M s^ £ .7; ►o CD «l ^ ,4 w QQ 5 I 1 8 O o 8 PLH QC *S O Tl /. CD o 8 c3 fc ,fi £ g fcO 8 =0 '3 ,£2 *. j> CO 8 S rt CO *. « CD O Uh ^ ^H CD lacl ^ p !- ^d cp CD -H G as co M A CD EH* o '5b .2-3 fccf- WJsq' 1! « wo ^Etiology. Pain. Dis- Constipation charge. or dlarrhcea. o,o s: *"|gog^^o§ £>rt, p,S cp - >3 CD'S • SCDT3 g.g3 co^ lis a s g ■ a, to ffi cpad £ o o3 a a^ ■^^ 10 or a 3 "3 u-S' ^ S V O -a C .i 3 D C W +° a bees .^ D i- K i. SPSS '"^lg .g«Mfto o_2 > o c6- a "S3 • M g s©ao;ao III •g ^ CD ■* a cu fl So CD

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TO o 5 CD goc cjoc |o£^ ST , ^g^°>©.-a cd ^ S 03 03 aj c3 a - CD CD "3 S» CDT5 co 6£< a cd : t.,3 _,^ bOX^H cS-S 3 S' <2° i-aa§vg g im's dilator. with hemorrhoidal trouble. In cases of fissure of the anus, or an irritable ulceration of the rectum, this is the ideal op- eration ; and the reason for its being so is easily understood. But to dilate a sphincter and break the fibers which keep up the irritation in the ulcer, to give the sphincter rest, and to cause the ulcer to heal, is a very differ- ent thing from dilat- ing a sphincter where well - formed tumors exist, with the expec- tation of dissipating them. There could be but one way in which they would disappear, and that would be by reabsorption. Dr. H. O. Walker, an eminent surgeon of Detroit, in a reprint published in 1887 on the treatment of anal fissures and haemorrhoids by gradual dilatation, reports some very beautiful cases that resulted favorably ; but in these, as in the other cases by different men who have written on the subject, I hold that there is no permanent cure where haemorrhoids exist, consequently the relief is but tem- porary. Eurand's dilator. 152 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXUHE. Whitehead's Operation. — Every few years the medical profes- sion is treated to some new operation in surgery, the pres- entation of some much-wanted instrument, or the modifi- cation of some operation or instrument. The custom has become so prevalent of late that the profession looks with suspicion on all such, until an honest demonstration is had. I do not wish to appear in the role of discouraging any honest attempt to improve upon old methods, yet I have seen so many instances when such an endeavor amounted to almost a burlesque, that I must be excused for doubting until I am convinced. Scarcely has there ever been such a consensus of opinion among noted surgeons in regard to the surgical treat- ment of any disease as internal haemorrhoids, Gross, Erichsen, Van Buren, Allingham, Sr. and Jr., Ball, Wyeth, Straus, Bull, Copeland, Bush, Cook, Sir Benjamin Brodie, Syme, Curling, Quain, Ashton, Gowlland, Cooper, Goodsall, Gerster, Boden- hamer, and a host of other authorities agreeing that the liga- ture is the simplest and most radical cure for internal haem- orrhoids. Their statements are proved true by comparison with other methods, by its simplicity, by its freedom from danger, and by its radical cures. Latterly there have been many methods proposed for the treatment of piles, and they have generally met with the same fate — namely, abandonment by the profession after a fair trial. Among these may be mentioned the injection plan, crushing, divulsing the sphinc- ter muscles, etc. Mr. Whitehead, of Manchester (England), has lately proposed a new operation for the cure of haemor- rhoids which consists in the radical excision not only of the pile tumors, but also of the entire hemorrhoidal plexus . It would require more time than I would have in this chapter to enter into a discussion of the many things that have been saidjpro and con about this operation ; therefore I shall con- tent myself with a review of the operation itself as coming from the lips of the author, and which is now known as Whitehead's operation. He thus describes it: "The anaesthetized patient, having been placed in the lithotomy position, and the sphincters INTERNAL HEMORRHOIDS. 153 paralyzed by stretching with the fingers, by the use of scis- sors and dissection-forceps, the mucous membrane is divided at its juncture with the skin around the entire circumference of the bowel, every irregularity of the skin being carefully followed. The external sphincters and the commencement of the internal sphincters are then exposed by a rapid dis- section, and the mucous membrane and attached haemor- rhoids, thus separated from the submucous bed on which they rested, are pulled bodily down, any indi- vidual points of resist- ance being snipped across, and the haemor- rhoids brought below the , . _, Curved pile scissors. skm. The mucous mem- brane above the hemorrhoids is now divided transversely in successive stages, and the free margin of the severed membrane above is attached as soon as divided to the free margin of the skin below by a suitable number of sutures. The complete ring of pile-bearing mucous membrane is thus removed." To this operation I shall prefer seven objections : 1. The operation can not be advised except in selected cases. No distinction is made between the character of piles. It is a notable fact that the most dangerous of all internal haemorrhoids is the small capillary bleeding variety. Haemor- rhage may be so great as to endanger the life of the patient. Upon examination, the tumor is found to be located much higher up the gut than the ordinary venous tumor, and not larger than a raspberry. Would any one recommend White- head's operation for a condition involving so little pathologi- cal change either in the vessels or tissues \ And yet this is an internal pile, with dangerous symptoms. A touch of nitric acid to the spot, or a silk thread thrown around the base of a small tumor, stops all bleeding and cures the pile. Again, the patient who has phthisis complains of a tumor protrud- ing from the anus at each stool. The vitality of this person is much below par ; nutrition is very bad ; confinement to 154 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. bed would be dangerous to his life. It would be folly to do the operation of excision in his case, which would mean non- union of cut surfaces, a flow of pus, weeks in bed, and a rapid advance of phthisis. By the use of the silk ligature the patient would not be confined to bed, and yet a radical cure of the pile would take place. 2. An anaesthetic is necessary in every case. Of course no one would attempt to do the operation without an anaes- thetic. It would be impossible to do it. There are many persons to whom, from physical causes, it would not be safe to administer an anaesthetic. If it be said in reply that on such you could do no one of the other operations, this alone admits the argument. For the other methods it can be said that they can be practiced without an anaesthetic, and it is admitted that the cure would be radical — as, for instance, by the ligature. 3. Full and complete paralysis of the sphincter muscles is necessary to do the operation. This is urgently advised by the author ; indeed, it would be impossible to accomplish the operation without this step. Those who have done much of this work recognize that it is a dangerous thing to prac- tice the divulsion of these muscles in all cases. Incontinence of faeces would often be witnessed if his advice was followed. The sphincter muscles in the female, as we have stated be- fore, yield much more readily than do those in the male, and are much longer in regaining their lost power. If inconti- nence of faeces resulted in consequence, as would often hap- pen, the result would be much more serious than the disease. Again, we witness in many patients who are enfeebled in health a lax condition of the sphincter muscles. This is es- pecially the case in tuberculosis. The operation would not be warranted in such cases. It can be said in favor of other methods that they can be practiced without divulsing the sphincter muscles ; hence in the cases cited they would take the place of Whitehead's operation. 4. The operation is "difficult, tedious, and bloody." I know that the author has replied to this charge that he is INTERNAL HEMORRHOIDS. 155 satisfied that it is an operation which can be easily performed by any surgeon possessing the average skill and intelligence, and to the charge that it is a bloody one he says that "it is never excessive haemorrhage ; such as I meet may very well take a subordinate position to other and more important considerations in the operation." To these two statements I wish to reply : (a) I am satisfied that all who attempt it will say that it is the most difficult of all the operations proposed for haemorrhoids ; (b) from the anatomical nature of the case, it is bound to be a bloody operation ; large vessels are necessarily divided and have to be secured ; (c) I quite agree with the author that haemor- rhage is a subordinate consideration to others in the opera- tion, for it is very difficult of execution and dangerous in many ways. 5. If union does not take place by first intention, pus ac- cumulates, and the result must be an ugly one if not dan- gerous. If the parts are not freely reopened, pus is confined, pent up in a recent wound, and the danger of sepsis enhanced. If they are opened, healing must be by granulation, over an extensive surface, together with the fact that flaps exist that must be cut away, or they will hinder a good result. By the use of other methods no such condition of affairs could exist. 6. The author recommends in doing the operation that the whole of the hemorrhoidal plexus be excised. This he makes absolute. To this I dissent. Just as well say that for a varicose condition of the veins of the leg the whole venous distribution of the limb should be excised. I can not agree that every dilatation here is a varicosity. No pathological change is evidenced in much of the plexus, and to remove these vessels that are simply distended with blood is bad sur- gery. It is a fact that they will return to their normal size and functions after the operation. This is witnessed after removing haemorrhoids by the ligature. Vessels that were engorged with blood resume their natural condition and ap- pearance. I once heard the elder Allingham say that after a satisfactory operation for internal haemorrhoids by the liga- 156 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. ture he had never operated a second time upon the same patient. This has been my experience. If the dilated veins that were left continued in a state of varices, the hemor- rhoidal tumor would have quickly reformed. 7. It can be maintained that secondary hemorrhage is likely to occur after this operation, and that the results given by the author do not justify his claim. Recognizing that secondary hemorrhage might result in these cases, and that it is a bloody operation, Dr. Henry O. Marcy has devised a plan of securing all the important vessels involved in the operation by continuous encircling animal sutures before di- vision. This, in my opinion, is an admirable suggestion, and should be followed by any one doing the operation. Dr. Marcy wisely says : u This plan certainly diminishes the loss of blood and insures against secondary haemorrhages." The two things most dreaded in this operation. To the statement that the results do not prove the claims of the author, I would say that if the statements of many of the leading authorities of the world are to be believed, the ligature has proved to be the simplest, most effectual, and the freest from danger of all methods of operating for internal hemorrhoids. The results as obtained by Whitehead could not be better than have been obtained with the ligature. The idea advanced that the danger in the use of the ligature lies in the fact that septic infection is likely to follow is chimerical. As the tissue of this well-formed tumor is passed through by the ligature, a healthy granulating surface is left, which resists all septic invasions. If this were not so, why is it that authors are able to report thousands of operations for hemor- rhoids by the ligature without the least semblance of sepsis ? I had the honor to report to the surgical section of the Amer- ican Medical Association a short time ago one thousand operations for hemorrhoids by the ligature without a single death or a case of septic infection. After an experience of fifteen years in operating for this trouble, I have never oper- ated upon the same patient the second time ; have never tied a vessel during the operation. That it is a simpler operation INTERNAL HEMORRHOIDS. 157 than Whitehead's can not be denied. That it is as free from danger is borne ont by facts. After a fair trial of his opera- tion I am forced to conclude : 1. That the operation meets the demand in but few cases. 2. When it is considered that a large proportion of subjects are unable to take an anaes- thetic, that some danger is always risked in giving an anaes- thetic, other methods, simpler in execution and freer from danger, can be practiced without the use of an anaesthetic and should be preferred. 3. As a full and complete paralysis of the sphincter muscles is necessary to the operation, great risk would be assumed in many cases. Other methods of cure would not necessitate this procedure. 4. From the fact that large blood-vessels have to be divided and that the rectum is a difficult place in which to secure arteries, the operation is in consequence "a bloody, difficult, and tedious one." 5. If union by first intention does not take place, as would likely be the case in strumous and other diatheses, the wound would be a large suppurating one, and sepsis would be invited. 6. The operation is not considered complete unless the whole of the haemorrhoidal plexus is removed. I submit that this involves an unnecessary amount of surgery and that the author's conclusions are based upon a wrong premise. 7. In view of the fact that the vessels are tied or twisted during the operation, and that the parts are in a diseased state, second- ary haemorrhage could be easily induced, and is a dangerous condition, especially so in the rectum. CHAPTER VII. THE LIGATURE IN THE TREATMENT OF INTERNAL HAEMOR- RHOIDS. I do not think it can be gainsaid but that the ligature is the easiest of execution, safest in its results, accompanied with less pain, and the convalescence quicker than any other method of treating internal haemorrhoids. Again, it can be asserted that most of the leading specialists and distin- guished surgeons of both this country and Europe prefer it to all other plans. It can be done under strict antiseptic pre- cautions, and statistics will show that fewer deaths have fol- lowed its use than any one of the other methods. Erich sen said that " all external piles should be cut off and all inter- nal piles tied. " I do not think to this day we can improve upon that injunction. The method has stood the test of time in the hands of the best surgeons, and the verdict to-day is as I have stated it. Allingham voices the sentiment of the pro- fession when he says : "Ido not think in the whole range of surgery there is any procedure worthy of the name of opera- tion which can show a greater amount of success or smaller death-rate than the ligature of internal haemorrhoids. " In this chapter I have given the names of some of the most eminent surgeons, both here and abroad, whose word must be taken with the greatest respect. Bushe never had a fatal case with the ligature. Sir Benjamin Brodie, who had a large experience, never lost a case. Mr. Syme never met with a fatal case. Ashton, Cooper, Van Buren, Bodenhamer, neither of whom ever met with a fatal accident. What lan- guage could be more to the point than that of Gross, our great surgeon, who said: "The operation by ligature is as THE LIGATURE IN INTERNAL HEMORRHOIDS. 159 simple of execution as it is free from danger and certain in its results." We must judge of a tree by the fruit thereof. And these results, gathered from such eminent authorities, speak for themselves. The operation by ligature being the favorite one in my practice, I shall take the liberty of repeating here some of the precautions and rules that I observe in the operation. I shall also differ from some noted authorities upon the man- ner in which the ligature should be used. The report that I made to the American Medical Association, and to which I have referred in this chapter, of Some Observations after One Thousand Operations for Haemorrhoids, included both exter- nal and internal piles ; patients taken indiscriminately from hospital, dispensary, and private practice ; those done in cab- ins, as well as those in well-regulated infirmaries. Up to that time I had never met with a fatal accident. A short time after making that report I lost a patient from tetanus after ligating internal haemorrhoids. To the principle involved in the use of the ligature all surgeons are agreed, but the method of application is, to a certain degree, disputed. The method of operating at St. Mark's Hospital, and practiced at that in- stitution for more than fifty years, is described by Allingham as follows: "The patient, having been previously prepared by purgatives, is placed on the right side on a hard couch in a good light, and is completely anaesthetized. Then I always gently but completely dilate the sphincter muscles. This completed, the rectum for three inches is within easy reach, and no contraction of the sphincter takes place, so that all is clear like a map before you. The haemorrhoids, one by one, are to be taken by the surgeon with a vol sella, or pronged hooked fork, and drawn down ; then with a pair of sharp scissors separate the pile from its connection with the mus- cular and submucous tissues, upon which it rests. The cut is to be made in the sulcus, or white mark, which is seen where the skin meets the mucous membrane, and this incision is to be carried up the bowel and parallel to it to such a distance that the pile is left connected by an isthmus of vessels and 160 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. mucous membrane only. There is no danger in making this incision, because all the larger vessels come from above, run- ning parallel with the bowel, just beneath the mucous mem- brane, and thus enter the upper part of the pile. A well- waxed, strong, thin-plaited ligature is now to be placed at the bottom of the deep groove you have made, and the assist- ant then drawing the pile well out, the ligature is tied high up at the neck of the tumor as tightly as possible. Be very careful to tie the ligature, and equally careful to tie the sec- ond knot, so that no slipping or giving way can take place. I myself always tie a third knot. The secret of the well- being of your patient depends greatly on this tying— a part of the operation by no means easy, as all practical men know, to effect. If this be done, all the large vessels in the pile must be included. The arteries in the cellular tissues around and outside the bowel are few and small, as they do not assist in the formation of the pile, being outside it. These vessels rarely require ligaturing. The silk should be so strong that you can not break it by fair pulling. If the pile be very large, a small portion may now be cut off, taking care to leave sufficient stump beyond the ligature to guard against its slip- ping. When all the haemorrhoids are thus tied, they should be returned within the sphincter. After this is done any superabundant skin which remains apparent may be cut off. But this should not be too freely excised for fear of contrac- tion when the wounds heal. I always place a pad of wool over the anus with a tight T-bandage, as it relieves pain most materially and prevents any tendency to straining." I have quoted this plan as detailed by Allingham, in his most excellent book on Diseas.es of the Rectum and Anus, because it is the most popular with all surgeons who use the ligature in operations upon internal piles, and that I expect to differ with the learned author on several important points in regard to the technique of the operation. Preparation of the Patient. — In these days, when modern sur- gery must obtain in all surgical operations, the rectal surgeon must give a very great deal of care to the preparation of his THE LIGATURE IX INTERNAL HEMORRHOIDS. 161 patient before operating. I shall therefore be excused for the reiteration of my suggestions on some points in antiseptics which will refer especially to this operation. Cripps advises that the patient should have a dose of castor oil the last thing in the evening two days preceding that fixed for the opera- tion, and regards it as an unfortunate oversight in the previous edition of his work that he recommended the medicine to be given the evening before the operation. He says it is a mistake to do so, because the patient is often much disturbed at night in consequence, and is therefore in a very unfit condition for any operation in the morning. But I should reverse the thing as he has it now definitely settled. If a purgative is given two days preceding that fixed for the operation, the purgative, in my opinion, will accomplish very little if any good looking to the operation. Twenty-four hours is quite sufficient for the rectum, if not the sigmoid flexure, to become loaded with faeces again. Cripps evidently expects the injection of a pint and a half of warm water that he has administered the morn- ing of the operation to clear out the rectum. This it will likely do, but it will not clear out the alimentary canal. Therefore a better plan, I think, if you have your patient under observation for two days, is to give him a brisk saline purge on the second day prior to the operation, and on the evening before the operation, to prevent a reaccumulation in the small or large intestine, give him a gentle purgative pill at bedtime, which will not disturb him through the night, as castor oil would do, and his bowels will be moved in quite sufficient time for the operation next day. Just before going to the operating room it is best to have the patient take a hot bath, and not the evening before, as suggested by Cripps. One night is quite sufficient to undo all that has been accom- plished by the bath, looking from a surgical standpoint. Pre- suming, then, that the patient is in clean linen after his bath, he is put on the table, and the parts to be involved in the operation are then thoroughly washed with a bichloride-of- mercury solution (1 to 3,000 or 1 to 5,000). The parts are shaved if necessary. I prefer the washing here with the mer- n 162 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. curie solution to ether, because the latter is accompanied with a burning sensation. Presuming that all the surround- ings are aseptic, the patient is put under the influence of the ansesthetic, after which he is placed in Sims' s position, with the legs drawn up toward the abdomen. I prefer this to the lithotomy position. In the latter it is necessary to secure the legs by Clover's or some other crutch, and those in the habit of operating with the patient in this position recognize the fact that the stoutest crutch sometimes gives way under the efforts of the patient while under the effect of an ansesthetic. An assistant, standing in front of the patient's knees, can easily hold them down. With a good light there is no diffi- culty in obtaining a perfect view of the rectum. I then intro- duce either a Cook or Mathews speculum and divulse the sphincter as widely as the instrument will distend it. This will be found to be an admirable help to the lingers, which are introduced after the speculum is withdrawn. Not much force is now required to distend the muscles ; but here I wish to emphasize that it is not my practice to break the muscles, and unless some such caution is given by the authors, the inex- perienced might think it necessary to do so. I distend until I feel a gentle relaxation. It will now be seen that the piles will present themselves, but not in their entirety. A mistake might be made here of ligating just what was in sight, think- ing this would complete the operation and effect a cure, but it is not so. It is best now to take hold of one of the large tumors with a four-pronged forceps, or clamp, and pull it forcibly down. It will then be seen that as much again as protruded is brought down. If this be repeated on the other side, granting that a hemorrhoid is found there, it will now be seen that the parts are everted and the other smaller tu- mors are brought into view. A pair of small retractors can be used in lieu of the forceps or clamps. These are given the assistant to hold while the operator secures the smaller piles, if any, and ligates them. It is important here to use two sizes of thread— a smaller size for the smaller tumors, and a larger. size for the large tumors. It has been my observation, THE LIGATURE IN INTERNAL HAEMORRHOIDS. 163 in tying small internal piles with, a large ligature, that it slips off more easily than if a smaller ligature is used. The character of thread is a consideration. I think a stout linen thread quite as good as silk, but it must be understood that it must be so stout that it will not break with the hardest pulling. Much confusion arises, especially after transfixing tumors, from having the thread break. It is best also to have it well waxed, for the reason that it adds somewhat to its strength, but mainly that it makes the knot more secure. The smaller tumors then are tightly tied without transfixing. As to the large tumors, my method is this*: Before putting the patient on the table, I carefully examine the parts to see whether there is any superabundant skin around the anus. To my mind this is of great importance. If it is a smooth anus, with no disposition to folds or superfluity of true skin, then I consider any cutting whatever unnecessary. However the parts may look after the mass is protruded, because great bulging takes place, not only of the tumors themselves but also the general anatomy of the parts, I refrain from the use of the knife, but proceed as follows : While the anus is being- held open by the assistant with the aid of the retractors, I have the nurse flush the rectum, as far as exposed, with the bichlo- ride solution, with an irrigator (1 to 5,000). The small tumors are picked up and ligated in the manner just mentioned. The large tumors are caught well at their base, drawn stoutly down by the forceps, held there by the assistant, and a curved needle, threaded with stout silk, is passed immediately through the base. The needle is now cut away and the ligatures tied stoutly, first on one side of the tumor and then on the other. The operator should be very careful to draw the thread each time to see that the corresponding half is pulled before tying, else he may tie the wrong thread, and if he does, no strangulation of the pile takes place. Having the tumor tightly tied on each side, the pile is now cut off with a pair of straight, not curved, scissors. By so doing, you have an even surface, whereas if you used curved scissors the cut dips more in the center than at the sides, and might embrace 164 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. more of the tumor than you proposed. It is a question how much of the pile should be cut away above the ligature. I think the advice usually given by authors is a little too care- ful — for this reason : If we only clip off a little portion of the tumor we leave the major portion or portions to be pushed back into the bowel ; consequently, that much more tissue is left to slough. If the tumors have been properly tied, I do not think the ligature is apt to slip, even if we cut tolerably close to it. The stump spreads out after the cut is made, and it is the rarest thing that it will slip off. Instead of cutting off one third of the tumor above the ligature, I am in the habit of cutting off two thirds, and I have never had haemorrhage result in consequence of this. The stumps, after being dusted with iodoform, are now reduced, the irrigation of the mercu- ric solution having been kept up more or less during the oper- ation. A piece of iodoform or bichloride gauze is now placed over the parts, one end of it being gently pushed into the anus and against the stumps. I am satisfied that by this ma- noeuvre the parts are kept from prolapsing. A large piece of absorbent cotton is now placed over the gauze and a T-band- age applied. The patient is then given a hypodermic injec- tion of one fourth of a grain of morphine and one one-hun- dredth of a grain of sulphate of atropine before he is taken to his room. This is repeated in one or two hours if necessary. If there has been no cutting done in this operation, the pain is very little, and frequently it is not necessary to give an opi- ate at all. I have found, after these operations, that sulphonal is a most excellent remedy to control the muscular spasm of the sphincter muscles, given in fifteen- or twenty-grain doses. If we have found that the patient has a superabundance of skin in the way of tags or folds, it will be necessary to do another operation. My plan is namely : The small piles are ligated in the usual way, and, presuming that they are everted or turned out, a four- pronged forceps, or a clamp, is made to catch them firmly at the base, encroaching more or less on the true skin, which is found coexistent with the parts. While the assistant holds it firmly out, a delicate knife is inserted on Plate II .4&Z$&& . . . ^IHMM&tfs* ML. ^ L Wk .# ~jjt* i ™**~' : ^?^*jy p ^jH^j8Btea^p rri ^Slir S^"""" K ~~»- |Bk. '' : '.' OPERATION FOR INTERNAL HAEMORRHOIDS BY LIGATURE. THE LIGATURE IN INTERNAL HEMORRHOIDS. 165 one side of the tumor at the junction of the true skin and mu- cous membrane and carried outward around the pile, includ- ing all the superfluous skin of that tumor, to the corresponding point at the other side. The hemorrhoid is then transfixed as in the manner suggested above, one thread being tied on the mucous side, tightly at the base of the pile, and the other thread is made to fall in the cut and is equally secured. The tumor is then cut off above the ligatures, leaving only enough to make the stump. Each large pile, which includes or is opposite any superfluous skin, must be treated in like man- ner. It will be seen that this operation differs materially from the one detailed by Allingham. In the first place, no cut is made in the so-called sulcus or white mark. My objec- tion to this advice is simply that it is nearly an impossibility, at least in the great majority of cases, to ever find the white mark, or to define exactly the sulcus. And as the superabun- dant skin is to be taken away in any event and by some manner, I think this is preferable to that suggested by Allingham. I think, too, that this manner of dealing with the superfluity of skin has its advantages over the other. It is easier for the student to comprehend what you mean, and you accomplish by one sweep of the knife what it takes two acts to do by the other. Then, too, you have a smoother surface left after the operation. According to Allingham's plan in cutting into the sup- posed sulcus, then ligating, the superabundant skin is after- ward cut off. In doing this it will be observed that often an irregular cut is made, and you have left a portion of skin or tissue next to the point of ligature, which, after cicatrization, leaves a ridge of scar tissue ; or if it be said that a clean cut is made, then you have done no more than has been suggested in the plan I mention. Another objection that I would prefer is the advice given that "this skin should not be too freely excised for fear of contraction when the wound heals." Now, I think this a very important point, but I beg to be on the other side of the question. One of the greatest annoyances after doing this operation is the swollen and ragged appear- 166 DISEASES OP THE RECTUM, ANUS, AND SIGMOID FLEXURE. ance of this skin that was left. If I had any one suggestion above another to give the operator, it wonld be to make a sweeping cut of these tags. So apropos to this subject is a case that I have now under treatment, and which is but a sample of many, that I beg to detail it here. Case. — Mr. V., a countryman, came to me ten days ago to operate on him for large protruding piles. I did the oper- ation after the manner suggested, at the time removing two large superfluous folds of skin, together with two haemor- rhoids, and noticed at the time that there were two other tags of uninflamed skin around the anus. Although it is my cus- tom to remove all such, in this case, for some reason, I left these two. The case progressed nicely until to-day, when I was summoned to the infirmary by my assistant, who said that the gentleman was in great distress from having two in- flamed piles protrude from the rectum. I went to see him, and found that during the night he had had an action, when the haemorrhoids that I had tied had sloughed off, and the two tags of skin that I had refused to remove during the operation had taken on an active inflammation and were very much swollen and oedematous. I gave him some palliative treatment, and expect to cut them off to-morrow, which will necessitate the administration of an anaesthetic. This has occurred to me a number of times in my practice, and will invariably occur if all superfluous skin around the anus is not removed during the operation. It will also occur if but a small portion of the tag is cut off, in that the stump will take on inflammatory action. I know it is said that if we remove too much skin around the anus in this operation contraction will result. I believe that this is chimerical. I have practiced this manner of operating for many years, and I have never yet had contraction result which was sufficient to call for any dilatation whatever. The patient should be put to bed, and a light diet, consist- ing mostly of fluids, should be given for several days. At noon of the third day I usually order that the bowels be opened, and I believe that an aperient will do this best. A THE LIGATURE IN INTERNAL HEMORRHOIDS. 167 Seidlitz powder, given on an empty stomach, will usually ac- complish the desired result. If it does not in a few hours it should be repeated. At the time that the patient feels that the bowels will move, all dressings should be removed, and an injection given of a pint or more of hot water. This insures a comparatively easy action. If they are disposed to act more than is thought necessary, they can easily be controled with a dose of paregoric, two to four drachms. If any pain should occur afterward in the abdomen indicative of an action, even up to the time that it is necessary to move the bowels again, paregoric should be administered. When the bandage is re- moved, and it is found that the cotton is sticking to the wound, it can be easily made to drop off by irrigating it with hot water. If some inflammatory action exists around the anus, the appli- cation of boiling hot water should be the method used to quiet it. Allingham says that if he finds any wool in the anus or sticking to the wound, a poultice is applied to soften the dry blood and assist in loosening the wool. I must take excep- tion to applying a poultice to fresh-made wounds. They are considered, and I think properly so, as a bed for germs, and I would not risk their application. Much more good can be accomplished by the use of the hot mercuric solution through an irrigator, often repeated. After the bowels have been moved on the second or third day, I have the parts irrigated one day with the mercuric solution, and the next day with the hot water carbolized, alternating with the two agents. After this irrigation I apply the iodoform gauze, without pushing it into the anus, over the gauze the surgeon's cotton, and then a T- bandage is applied. The parts should be dressed in this manner every day until the wound is healed. The liga- tures are apt to drop off from the sixth to the ninth day. A careful inspection of the parts should be made about this time if any ligature is left, for the reason that it is only held around a little piece of tissue. If this is so, a tenaculum should be slipped in the loop ; then, by pulling gently down, it can be clipped with a pair of scissors or with a sharp-point- ed knife. After all the tumors have sloughed off some sore- 168 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. ness will be felt, but I do not believe in the advice that an ointment should be applied. Grease is calculated to do a wound harm, certainly no good. Tell the patient to sponge the parts often with very hot water, and, if necessary, to use anything as a local application to induce the healing process if it is slow — blow either powdered iodoform or boric acid upon them ; then dress with dry cotton. The rectum should be syringed out once a day after the first dressings are re- moved until the patient is discharged. Retention of urine often takes place, in men especially, after this operation. To avoid any straining, it is best to use a soft-rubber Nelaton catheter until the patient is able to pass the urine. Patients will often say to you about the time the ligatures are separating that they notice some blood in their actions. This frequently alarms them, because they think "the disease is coming back again." We should anticipate this by inform- ing the patient that it may take place. While the patient is under your observation have him assume the recumbent po- sition. While feeling very comfortable on the third or fourth day, he will be very desirous of sitting up or walking around the room. Impress upon him the absolute necessity of re- maining in bed, for, if he should take any exercise, it will be noticed that the parts take on an inflammatory action. Some authors suggest that after the first week the finger should be anointed and passed into the bowel every day to make sure that no contraction results. I think that this habit would keep up an unnecessary amount of irritation and accomplish very little good. In my practice I have never found it necessary. It is an ugly one, to say the least of it, and I think it unnecessary. Complications. — Internal haemorrhoids are frequently com- plicated with other diseases of the rectum. Case. — A young lady, about eighteen years of age, was operated on for haemorrhoids by me, and the case progressed favorably until about the time I thought she was well enough to be discharged. A messenger came hurriedly to my hotel and said to me that my patient was in great pain and fright, THE LIGATURE IN INTERNAL HEMORRHOIDS. 169 for the reason that there was a large mass protruding from the rectum. On my way down to her house I conjured my brain as to what the matter could be. She was lying in a strained position, being afraid to move for fear some accident would happen ; and when I inspected the parts I saw protruding from the anus a tumor the size of a walnut, having very much the appearance of a large internal venous pile. By running my finger alongside of it into the rectum I felt a pedicle, and traced it for two inches up the bowel where it was attached. I recognized, of course, that it was a polyp that had escaped my observation at the time of doing the operation. I was not so much to blame when it is remembered that these growths are frequently held high up, perhaps in the sigmoid flexure, their pedicle allowing them to float. I ligated the pedicle without trouble and clipped the polyp off, and yet I felt some embarrassment for the reason that I thought my patient would think that it should have been attended to at the time I operated on her for piles. If she did so think, she certainly thought right, and my only excuse to her was that w T e could not do too much ligating at one time. I cite this, therefore, to show that internal piles may be complicated with polyps, with fissures or ulcers, with fistula, impaction of faeces, or with cancer. If these complications are met, it is best to relieve, if possible, each and all of them along with the operation for internal haemorrhoids, save, per- haps, cancer. It is not necessary to detail the operations necessary to each individual case, as they are taken up in a separate chapter. One of the most serious complications may result from the operation itself. I allude to the sphincter muscle when it is in a feeble condition either from age or disease. Therefore it should always be borne in mind that in such a subject dilata- tion should be very carefully practiced. A patient may not censure you for a failure to cure him of internal haemorrhoids, but he would always blame you if you left him in a condition the result of incontinence. The authors frequently mention that a contraction of the 170 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. parts may follow the operation for internal haemorrhoids, and therefore that this amounts to a complication ; but, in my experience as a rectal surgeon, I have never yet met with that complication, nor do I usually practice dilatation after the operation with either the finger or an instrument, nor do I understand how it can take place in many cases. The contrac- tion of tissue by a cicatrix is just as likely to draw the parts slightly outward as to form a contraction inward. At least I have never met with these cases as are detailed by some authors. Sepsis, including pyaemia, erysipelas, etc., is said to be a complication following this operation ; but if it is done under strict antiseptic precautions, it will not follow. Haemorrhage following Operations for Internal Haemorrhoids. — I do not believe that if the operation for internal haemorrhoids is done by the use of the ligature, properly applied, haem- orrhage would occur once in a thousand times. Haemor- rhage following this operation occurs from three sources : (1) Oozing from the cut surfaces in the tissues, which is prima- ry ; (2) slipping off of the ligature ; (3) cutting too quickly through. The first condition may arise from the fact that the gauze and the cotton have not been firmly packed and closely held to the parts. I believe that there is some art in applying the bandage to effect a close and tight compress. My method is this : Taking a four-inch bandage, eight feet long, I first tie it around the patient's body, just above the pelvis. The knot is made in front, leaving the short end six or eight inches long. The bandage is then passed between the legs and smoothly adapted over the cotton and then passed under the bandage around the waist at the back, then carried backward over the same line to the front again, and, passing over the front of the bandage, carried back the same way as before, being smoothly applied over the cotton each time and then tied to the short end that is left. No pins are used. It can be smoothly and tightly applied, thereby pre- venting any haemorrhage from the cut surfaces. Haemorrhage may result from the slipping of a ligature if THE LIGATURE IN INTERNAL HEMORRHOIDS. 171 it has not been securely placed, or if the pile has been cut off too close to the ligature. Case. — A young man came into my office complaining that he had just noticed the descent of a pile. I examined him and found a soft hemorrhoidal tumor presenting with a nar- row base. I slipped a thread around it and ligated the pile. With a pair of straight scissors I then cut it off, the little stump slipping back into the rectum. Being busy, I sent him into another room to lie down on the couch until I could see him again. I directed my assistant to remain in the room with him. In about one hour I was informed that he had grown restless, remarking that he felt all right and that he would go home. He took a street car and started home, which was a distance of at least thirty blocks. When he got into his door he was so weak that he fainted, and his wife, in pulling off his boots, discovered that they were full of blood. In a little while he was able to tell her what had taken place, when she immediately telephoned me that he was bleeding. Thinking that it did not amount to much, I delayed going until I received a second summons. Just then a doctor friend came in. I told him the circumstance, and he drove with me to the house. When we arrived there, we found the man in nearly a dying condition from haemorrhage. He had passed in two evacuations at least a gallon of blood. The extremi- ties were very cold, profuse sweat was over the body, his pulse could not be counted, and he was speechless, looking indeed like a dying man. It was after dark, and we had only a coal-oil lamp at our service as a light. While some one held the lamp I divulsed the sphincter, and could see the pumping of a vessel at the point where the ligature had slipped off. With a long artery forceps I secured it, and, by the aid of my doctor friend, put a ligature round it. This stopped all bleed- ing and the man made a good recovery. The case shows how a small operation may result disas- trously if not properly attended. In my experience of six- teen years in this special line of surgery, I have met with but one case of secondary hemorrhage. It occurred as 172 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. follows : A gentleman came to me from Frankfort, and was operated on for an ordinary case of internal haemorrhoids. Everything did well until the seventh day. The evening of the sixth I was at the infirmary, and he said to me that he had been nauseated all day, and he looked very pale. I did not, however, put much stress upon it. I was sent for at eleven o'clock the next day to see him. His remark to me as I went into the room was : " I feel just as I did when I took chloroform. I am very dizzy." I suspected the trouble, and just at this time he said tome: "Please allow me to stand up that I may get the fresh air." He suited the action to the word and was up before I could reply. Then he said quickly, "My bowels are moving," although there was a bandage on him. I had seen by this time, however, the blood trickling down his leg. I thought it best to allow him to sit on the commode, and as he did so over a quart of blood passed. We immediately lifted him into the bed, and I explained the situation to him, telling him that his condition would not warrant the administration of an anaesthetic, and that he must stand what I was going to do, for it was to save his life. I immediately divulsed the sphincter muscle and tamponed the rectum. All haemorrhage ceased. The tampon was al- lowed to remain Hve days and was then removed. Apropos to this subject, it is well to consider that haemor- rhage from the rectum may occur from a number of causes, and when met is a serious thing to deal with. It is not often that a bleeding vessel can be secured as was done in the case just reported. If any diseased condition exists or the haemor- rhage is secondary, it is a loss of time to look for the bleeding surface. Therefore I am not in the habit of following the directions of many who write on this subject — to stop haemor- rhage from the rectum by hunting for the bleeding vessel or local spot and making application of some caustic, such as nitric acid, carbolic acid, persulphate of iron, etc. Haemor- rhage in this locality is too dangerous a symptom to deal with in this manner. Causes of Hemorrhage. — The causes of haemorrhage from THE LIGATURE IN INTERNAL HEMORRHOIDS. 173 the rectum may be briefly named as follows : 1. Haemor- rhage following the ligation of internal piles. 2. From ul- ceration of the bowel. 3. From capillary haemorrhoids. 4. From a hemorrhagic diathesis. 5. From the tearing off of polyps. These, in my opinion, constitute the general causes of hemorrhage requiring surgical interference. Sir Astley Cooper lost a patient from haemorrhage after ligating a pile. The elder Gross reported a similar case. There are three causes for haemorrhage following this operation in addition to those already given : 1. The division of a vessel or vessels at the time of operating, which might sometimes follow the op- eration by clamp and cautery. 2. Puncture of a vessel in transfixing the tumor, the method so strongly advocated by Yan Buren. 3. In sloughing of the pile. But it is not the causes of haemorrhage that I desire to deal with especially in this chapter, but the method of ar resting it. In my opinion, in excessive haemorrhage from the rectum there are but two ways to be considered for its stoppage : One, ligation of the vessel, or the mass in which the vessel is included. Second, by the use of the tampon. There are a great many diseases of the rectum requiring surgical treatment ; hence it is no wonder that haemorrhage — both primary and secondary — occurs after these operations. It is recognized that in the division of a stricture of the rec- tum located as high as four inches, or a finger's length, above the external sphincter muscle, the main branch of the middle and inferior haemorrhoidal artery is frequently cut. Because of the distance within, the difficulty of reaching the severed end of the vessel is very great. Together with the fact that it is imbedded in a pathological structure, it is impossible to ligate it, and it becomes a necessity to tampon the rectum to stop the haemorrhage. In operations for fistula in ano the inferior or external haemorrhoidal artery is often severed, and although it is generally secured during the operation, sec- ondary haemorrhage sometimes follows. This has occurred in my practice several times in the past few years. It is not infrequent that polyps break off from their delicate attach- 174 DISEASES OF THP RECTUM, ANUS, AND SIGMOID FLEXURE. merit and, being fed with a good-sized artery, violent bleed- ing will sometimes take place. Except in one instance, I have never been able to secure the broken pedicle and ligate it. In these cases the tampon must be resorted to. The rectum being a favorite seat for cancer, it is not un- common that haemorrhage is so violent from the growth as to endanger life. These cases invariably require pressure to stop the bleeding. Several years ago I reported three cases of dangerous haemorrhage occurring in my practice from ar- tery rupture in the rectum. The tampon was used in two of these cases. Where the haemorrhage is not excessive, but constant, I am more and more persuaded that such cases are often treated for dysentery, the physician relying on the pa- tient's story, and putting but little stress on the loss of blood, or, as is more likely, looking upon the case as one of " bleed- ing piles " and leaving it alone, when in truth it is a dangerous condition. Surgeons who have divided fistulous tracts run- ning high up the rectum have been impressed with the great amount of blood that is sometimes lost. Gowlland, of St. Mark's Hospital, is so chary about dividing even the mucous membrane of the rectum that he has devised an operation to avoid this haemorrhage. He explained it to me as follows, to be used in dividing internal fistulae : It consists in the in- troduction of a long probe, threaded with a ligature to the very top of the sinus, pushing it through the mucous mem- brane, then bringing both ends of the thread out of the anus. Over these he pushes a piece of hard-rubber catheter, and, pushing it tightly up the threads until it comes in contact with the mucous membrane, it is secured by a small piece of wood stuck in the end of this temporized clamp. In case I cut the mucous membrane of the rectum to any extent, I am in the habit of using the tampon to prevent haemorrhage. Although I have used Mr. Gowlland's method several times with success, I have seen one case of proctitis result in such violent bleeding as to require the tampon to stop it. I preferred pressure here for the reason that it would do less damage to the already inflamed membrane THE LIGATURE IN INTERNAL HAEMORRHOIDS. 175 than a caustic. Foreign bodies in the rectum, by their pres- ence, or attempted removal, may result in the wounding of the blood-vessels, in which case either the ligature or the tampon would have to be resorted to. Allingham's method of plugging is, namely: " Having passed a strong silk liga- ture through your cone-shaped sponge near its apex, bring it back again so that the apex of the sponge is held in a loop of the thread. Then wet the sponge, squeeze it dry, and powder it well, filling up the lacunae with iron or other as- tringent. Pass the forefinger of your left hand into the bowel and, upon that as a guide, push up the sponge — ajDex first — by means of a metal rod, bougie, pen-holder, or a rounded piece of wood, if you can get nothing better. Now, this sponge should be carried up the bowel at least five inches, the double thread hanging outside the anus. When this is so placed, fill up the whole of the rectum below the sponge thoroughly and carefully with cotton-wool, well pow- dered with the alum or iron. When you have completely stuffed the bowel, take hold of the silk ligature attached to the sponge, and while with one hand you pull down the sponge, with the other hand push up the wool. This joint action will spread out the bell-shaped sponge like opening an umbrella and bring the wool compactly together. If this is carefully done, no bleeding can possibly take place either internally or externally. Half-measures in these cases are worse than useless, as valuable time is thereby lost. This plug should remain in at least a week, and it may remain in a fortnight or more." I tried this method of tamponing the rectum for several years, and found it a very awkward procedure. In the first place, with only the finger as a guide and your sponge filled with iron or other astringent, it is a most difficult matter to push the sponge into and then up the rectum. Then, after it is fully passed, it necessitates adding additional cotton below it. Again, the iron is very apt, in its effect upon the thread, to destroy it, and thereby you would lose the use of the thread when you desired to extract the sponge. A simpler 176 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. and better method than this is the one I now practice. The articles I use for the purpose, and always carry in my case, are : Absorbent cotton, a piece of hard-rubber tubing, a stout cord, and a bottle containing MonseVs solution. Begin- ning at about one inch from one end of the tubing, which should be eight inches long, I begin to wrap firmly with the absorbent cotton for fully five inches. The tampon is made to resemble a double cone in shape, or two cones placed to- gether with their widened ends in apposition. The circum- ference of the tampon in the middle should be fully six inches, gradually tapering toward each end. The whole tam- pon is then firmly wrapped with a stout cord which is tied at its lower end, and a double thread allowed to hang out of the anus. It might be said here that the same objection that I preferred to the other method that I described was that the iron would destroy the thread. That is all right if it should do it in this instance, for, if the tampon remains but a short time in the rectum, the cotton becomes so thoroughly soaked with the liquids that it hugs tightly the rubber tubing, and does not separate from it at any effort at pulling. The tam- pon is now soaked in MonseVs solution of iron diluted one third or one half with water. The rectum is quickly syringed out with a hot mercuric solution, the patient anaesthetized, unless too feeble to warrant it, the sphincters are freely di- vulsed with a dilator, and the tampon pushed up the rectum fully five inches. Pressure is then made on the tubing, and the speculum or dilator then removed. The whole of the live inches of the rectum is distended by the tampon, thereby re- ceiving its pressure and the astringent effect of the iron. The rubber tube answers two purposes : 1. It allows the escape of gases, and the injection of water through it, if necessary. 2. If haemorrhage takes place, it is at once indicated by the flow of blood through the tube. I prefer this method of making and using the tampon over Allingham's for several reasons besides those already given : 1. His, being made of sponge and pulled down to a balloon-shape, is apt to lose its own proper shape and assume that of a ball, therefore is less likely to exert equal THE LIGATURE IN INTERNAL HEMORRHOIDS. 177 pressure. By the other method a firm pressure is kept up all the time. 2. In removing the tampon of sponge, you have to rely solely upon the cord, which may pull through or break. In the other, a firm hold can be taken on the solid tubing of the tampon proper, and by a steady pull it comes easily out. Allingham says that this plug should remain in at least a week, and it may be retained a fortnight or more. I am in the habit of allowing the tampon to remain in the rec- tum but four days, even when it has been put in under anti- septic precautions and drainage allowed through the rubber tube. Sepsis is invited by allowing a tampon filled or satu- rated with nasty discharges to remain in the rectum, espe- cially so when there is a lesion. This method of plugging the rectum has been used by me for ten years, and I am satisfied that in a number of cases I have saved life by its use. Any one using the one method, and then the other, will see at once the value of the latter. Mr. Gowlland has designed some special tubes, made of vulcanite, shaped like a bougie, seven inches in length and about one inch in diameter. The base terminates in a rim which is perforated so that it can be sewn to a bandage. It is to be seen that a sponge or cotton would have to be wrapped around it, and wool packed into the rectum after it is intro- duced. I have never had the opportunity to use them, con- sequently can not decide as to their merit. If sudden haemor- rhage attacks the rectum, from whatever cause, the muscles should be dilated and a quick inspection made of the rectum. If a bleeding vessel can be seen and the parts are not diseased, it is the best plan, of course, to try and secure it by ligature, but I always feel safer, even in instances like this, after I have tamponed the gut. As a summary, I would desire to say that I have operated over one thousand times for haemorrhoids by the ligature. I have never had to operate the second time upon the same pa- tient for the affection, have never had an unnatural contrac- tion around the anus as the result of the operation, nor had ulceration or stricture to result. I have had in this time one 12 178 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. case of tetanus, superinduced by a debauch, which recovered, and one case of tetanus which terminated fatally. Have had one case of secondary haemorrhage occurring on the seventh day, which required the use of the tampon, and one case of primary haemorrhage, by the slipping of the ligature, which also required the introduction of the tampon. I do not be- lieve that had I used any other method as a constant thing I could report so favorably. CHAPTER VIII. FISTULA IN ANO. It is a question with surgeons which is the most common rectal disease that affects the adult. Allingham, with his vast experience, says fistula is. The records of my books will show that in my practice internal haemorrhoids are more common than fistula. I believe that if we take them indis- criminately the difference in favor of the one or the other would be very small. Patients are alarmed and look hor- rified when they are told that they have fistula ; when in- formed that they have piles, they usually regard it as a small affair. Fistula and piles are frequently combined ; indeed, one can produce the other. Operations are sometimes done for external piles, and a fistula is left which was not detected at the time. The surgeon should never be content with making a diagnosis of one rectal disease until he has thor- oughly searched for any other that might exist. I believe that men are more subject to fistula, and women more subject to piles. Fistula in ano is said to be a disease of middle life, but I have operated for it in the very aged and in an infant three weeks old. Case. — My friend, Dr. George W. Griffith, asked me to see with him an infant only three weeks old that had some rectal trouble. When we examined the little patient to- gether, we found a distinct external opening about half an inch from the anus, which communicated with the bowel. It appeared to me that it must have been congenital. The sinus was laid open and dressed as is usual in such cases. I be- lieve this to be the youngest case of fistula on record. Causes. — Fistula in ano is, in my opinion, invariably pre- 180 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. ceded by or is the result of an abscess. Now, it is very true that patients suffering from a scrofulous or tubercular diathe- sis may have the tissue around the rectum break down be- cause of this predisposition, and yet we find it assuming the nature of an abscess. Taking an abscess to mean strictly u a cavity filled with pus," we are to presume that this pus has been produced by one of the four pus-producing micro- organisms. To hold to this strict pathology, fistula originat- ing from the so-called "cold" abscess, or tubercular degenera- tion of tissue, could not be called an abscess at all, and yet for an understanding of the pathology or causes of fistula in ano I think it best to say that the disease originates with an ab- scess. Therefore the physician should always take the pre- caution in dealing with an abscess around the rectum to say to the patient or friends that the trouble in a large percentage of cases results in fistula. For, if an abscess is opened, al- though the patient is given instant relief from pain, if a fist- ula results he caD not understand why you refuse to tell him that such a disease would follow, and he would likely attrib- ute it to the ignorance of the physician and employ some one else to attend to the fistula. When an abscess is of the acute variety it is. very painful, and the hard tumor can be easily circumscribed. Such abscess is usually found in ro- bust and healthy people, and especially in those in adult life. The so-called " cold " abscess, or that resulting from a degen- eration of tissue, is not painful at all, and can not be circum- scribed. This is a dangerous form of abscess. In either form, be it acute or chronic, it should be opened and the con- tents freely evacuated. It is a difficult thing to say some- times what has caused the abscess around the rectum. It is true that traumatism might result in such inflammation as to give rise to suppuration, but in many cases patients tell us that no wound or blow or injury of any kind has been re- ceived. Anything acting as a long-continued irritant may produce inflammatory action in this neighborhood ; therefore it is to be supposed that dry faeces held in the rectum, re- maining there or passed with a straining effort, may give rise FISTULA IN ANO. 181 to an abscess. That a blow may cause such an effect the fol- lowing cases nicely illustrate : * Case I. — Some time ago a physician living in the west end of this city asked me to see a gentleman with him who was suffering the most intense agony in the neighborhood of the rectum. Upon arriving at the house, we found him rolling and tossing on the bed — physically a perfect man. He said that a few days previous he had stepped into a saloon to take a glass of beer. While standing in a bent position talking to the bar-tender, a friend came in and, slipping up behind him, dealt him a vigorous kick over the buttocks. He said it hurt him intensely at the time, and he told the man that he had seri- ously injured him, although it was done in a playful manner. The next day he began to suffer intense pain in the rectum. This continued for several days, and the physician saw noth- ing externally to indicate an abscess. I introduced my finger through an irritable sphincter muscle, and, about two inches above, detected a large abscess pointing into the rectum. I suggested that we put the man under an anaesthetic and pro- ceed to evacuate the pus. Thinking that it would be best to get an external opening, thereby preventing an internal fistula, I ran my knife alongside of the sphincter muscle, outside and in about one inch, struck the cavity, and let out a great quantity of pus. He was relieved at once of all pain, and the healing process went on and no fistula re- sulted. Case II. — I have now under treatment a gentleman with the following history: Mr. Gr., a farmer, aged forty-five, health robust, was standing on the street conversing when a friend approached him from behind and "bucked" him severely. The kick was received directly over the coccyx. He experienced violent pain at the time and expressed the opinion that he was seriously hurt. Upon his return home the pain was aggravated and he was incapacitated for work. A tumor appeared at the site of injury, with all the symp- toms of an acute abscess. He did not consult a physician, expecting every day that the abscess would open without 182 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. lancing. At the end of the fifth week he came to my office, and, after examining him, I advised that it be immediately opened. To this he reluctantly consented. In lancing it I discovered that the pus had burrowed deeply, seeking no egress externally. About four ounces of pus was evacuated. I advised him to go home and rest, warning him, however, that he might expect an extensive fistula to result. At this time he had a very bad color, an elevated temperature, and an accelerated pulse. After several days he returned to me in a very bad condition. A large fistulous opening, dis- charging pus freely, some fever, coated tongue, etc. I ad- vised an immediate operation, which was done. For several days he seemed to do well, but upon the fifth morning he had two severe rigors, which I considered septic. The wound looked badly, and altogether he was in an unpromising con- dition. At this time Dr. Ap Morgan Yance saw him with me. He continued for some days in this condition, but things took a favorable turn, and he is now out of danger. The wounds inflicted were necessarily large, but are now healing rapidly. The patient carries an accident policy for ten thousand dollars. It is often said that a constipated habit is one cause of this trouble, and yet we meet it in persons who have been perfectly regular, so far as the bowels are concerned, all their lives. One of the worst cases of fistula in ano that I have ever met was in a society woman of this city who seemed to be angered at herself or Nature for having the trouble. She said she could not understand why she should be so afflicted, because her mother had told her from infancy the importance of having a daily evacuation of the bowels, and she had re- membered the injunction all her life, and had strictly fol- lowed it. I am inclined to think that diarrhoea and dysen- tery are sometimes the cause of abscesses by their long-con- tinued irritation of the mucous membrane and the adjacent structures. Foreign bodies which have passed through the alimentary canal and lodged in the rectum, or such as have been pushed into the rectum, may, of course, excite to ab- FISTULA IN ANO. 183 scess. Therefore sometimes we can trace the cause of the abscess which we are called to treat, but in the majority of cases I do not believe that we can do so. Some authors speak of superficial and deep abscesses. I believe this to be a good division, especially looking to the treatment of them. An abscess may be small and, being in a location that does not affect the sphincter muscle, may not cause much pain, may break of its own accord, and yet this is the starting- point of a fistula. It must be understood that the great ma- jority of fistulse are progressive, and, whether they start with a very large abscess or with a very small one, may eventually be a serious affair. Cripps says: "I would advise any surgeon who may be still in doubt as to the starting point of rectal fistula to keep memoranda of all the cases of ischio-rectal abscess he is called upon to treat, and I will undertake to say more than one half of these end in the establishment of a fistula in ano ; and, further, if, when he is consulted by patients with fist- ula, he will take the trouble to question them carefully, he will find that their trouble almost invariably commenced with symptoms of rectal abscess." I do not wish to deny that more than one half of the ab- scesses which originate in the ischio-rectal fossae end in fist- ula, but as to its being the starting-point in more than half of the abscesses around the rectum I do not believe. Cer- tainly, if we take into consideration the superficial as well as the deep abscesses, the major portion of them do not be- gin in this fossa. As to the latter part of the quotation — namely, " that the patient will find that the trouble almost invariably commenced with rectal abscess " — I wish to exclude the adverb and say that the trouble invariably commences with an abscess. I have never seen a single case of fistula in ano that commenced in any other way. There are three varieties of abscesses found in this lo- cality : First, the marginal abscess, situated just at the ori- fice ; second, those which form in the loose connective tissue around the rectum, tolerably high up, in what Bichet called 184 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. " the superior pelvi-rectal space"; third, those found in the ischio-rectal fossae. I believe that the commonest seat of abscess around the rectum is in the loose connective tissue. Case. — A short time ago I was called in consultation with a physician of this city to see a patient who gave the following history : He was a plumber by trade, and said that the evening before he attempted to lift a boiler into position, and the weight was so great that it was with the utmost dif- ficulty that he could lift it at all, and during the attempt he felt something give way in the abdomen. He immediately let the boiler fall, and he himself fell to the ground in pain. He was carried to his home and put to bed, and shortly afterward began to refer the pain to the rectum. His physi- cian sent for me the first night, and we saw him together. The patient said that he was suffering a very agonizing pain inside the rectum, which had begun with the accident in lift- ing the boiler. I inserted my finger, but at no one point did he complain of great sensitiveness. We gave the man a hy- podermic of morphine, and, taking his history into considera- tion, we thought that very likely he might be suffering from intussusception of the bowel. Therefore, to anticipate it, we ordered a brisk purgative, more as a point in diagnosis than anything else. The purgative having no effect at the time ex- pected, I gave him six grains of calomel, to be followed shortly after by one ounce of C. O. salts. The next morning his bow- els had freely moved, which cleared up the diagnosis so far as the intussusception was concerned. But the pain in the rec- tum increased, and it required very large doses of morphine to control it. This man held an accident policy in one of the leading companies, and they, being informed of the accident, sent their own physician to investigate his case. Seeing him at the stage that I have mentioned, no one could tell exactly what nature of injury had been inflicted. After five more days I introduced my finger into the rectum again and felt a well-defined inflammatory tumor, which I at once took to be jan .abscess, though I could not at that time detect any FISTULA IN ANO. 185 fluctuation. We agreed to wait another day for further de- velopments, partly because I did not desire to evacuate the pus through the bowel, for fear of establishing an internal fistula, and yet the tumor was so high up, situated above the levator ani muscle in the "superior pelvi-rectal space," that I feared I would not be able to reach it by running the knife in from the outside of the bowel. So, after waiting two more days, I concluded to go down through the tissues on the outside of the sphincter muscles, and in making the cut I reached the cavity at the depth of about one inch and evacu- ated a quantity of pus. This case illustrates two points : First, that, although it was a very large rectal abscess, it was not located in the ischio-rectal fossa ; second, that these abscesses can be evacu- ated from the outside instead of the inside of the bowel, thereby securing good drainage and doing away with the risk of internal fistula. There was a very nice legal point involved here — namely, was this man's rectal abscess due to the attempt he made to lift the boiler, or, had he died of sepsis, would the accident company have contended the point ? I would have to affirm that I believed the accident caused the abscess. I have never seen an abscess around the rectum aborted. Sup- puration is the result, and the rule should be that just so soon as pus is detected it should be evacuated. I do not like the terms idiopathic and traumatic as applied to abscesses. In the first. place, in regard to abscesses arising in weak per- sons or in tubercular subjects, the term is really a misnomer, for the contents of such cavities, as I have intimated, are not, in the true sense of the term, pus at all. Sepsis is not to be feared from such, unless they are exposed to the air by an incision ; therefore I believe all abscesses proper are caused by inflammation, generally the result of traumatism. In cases of stricture of the rectum we frequently have secondary abscesses which result in fistula ; and physicians sometimes make the great mistake of operating for these fistulous si- nuses and leaving the stricture. The wounds made would never heal as long as the original cause of this condition ex- 186 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. isted, and therefore we inflict upon patients a worse condition than existed before the operation for fistula. I wish also to add that in cases of fistula in ano, complicated by stricture of the rectum, or vice versa, an operation upon the stricture will not benefit the fistulse, nor will an operation performed for the fistulse benefit the stricture. It is a bad condition of affairs and must be dealt with with a good deal of discretion. Case. — A railroad man, about thirty-five years of age, of small stature and feeble health, was referred to me for treat- ment. When I put him upon the examining table I saw all around the anus, in the perinseum, buttocks, etc., a great num- ber of small abscesses, together with a number of openings of fistulse. I introduced my finger and detected a very feeble external sphincter muscle— indeed, it did not respond to the touch at all — and above it a very close stricture. I was satis- fied, by the answers that were given to my questions, as well as by the physical evidences in the case, that the stricture was of a syphilitic origin. Now, this man was in a deplorable con- dition. It was with difficulty that he could have an action at all, and the discharge of pus from the numerous abscesses was very abundant. His general health had greatly failed him. I took the case under careful consideration and argued thus : If I dilate or break this stricture, he will have no con- trol over his actions at all ; if I lay open the fistulse, the wounds will not heal. So I could see nothing to do in this case but advise a colotomy. This he refused. I contented myself, therefore, in opening the small abscesses and in get- ting, as far as I could, a free drainage of pus, and suggested that he take a good tonic course of treatment. Conservative surgery should obtain just as well in dealing with diseases of the rectum as with disease anywhere else, and in cases where we are satisfied that we can do no good by an operation it should not be attempted. The method of dealing with abscesses around the rectum is very simple. If we are waiting for the formation of pus, large and very hot poul- tices of ground flaxseed should be applied often to the parts and covered with oil silk, to retain the heat. The pain should FISTULA IX ANO. 187 be quieted by hypodermic injections of morphine. When fluctuation is detected, the abscess should be opened. The method to be employed here is of some concern. Allingham suggests the following plan: " Place the patient on the side on which the swelling exists, pass the forefinger of the left hand well anointed gently into the bowel, then place the thumb of the same hand below the swelling on the skin. Now make outward pressure with your finger in the bowel, and you render the swelling quite tense and defined, it being, in fact, taken between your finger and thumb. A curved bis- toury can then be thrust well into the abscess and made to cut its way out toward the anus in the axis of the bowel." This is the plan used by him of laying open the smaller ab- scesses. To my mind, there are two objections to this method. First, the introduction of the finger into the rectum under these circumstances causes intense pain, against which the pa- tient vigorously protests. Second, he makes the cut toward the anus in the axis of the bowel. I think it a much better plan to make the cut parallel with the rectum in evacuating the pus, for the reason that it is very desirable that these external openings should not heal until all the pus has drained out and the discharge, which continues for several days, has been given free exit. When the cut has been made parallel across the folds, instead of toward the anus with the folds, the sinus is much more likely to remain open. My method of dealing with deep-seated abscesses is as follows : Getting the patient into a good light, I tell him what I am going to do. Then taking a knife with a good-sized blade— it is not necessary that it be curved— I plunge it into the cavity to its very depth, and as the knife is withdrawn I make an opening two or three sizes larger than that made in entering. My object in this is to get free drainage. I then introduce my finger or the end of the handle of the knife, and thoroughly break up all the loculi. I then syringe the cavity out freely with a solution of bichloride of mercury (1 to 5,000). Then a tent made of iodoform gauze is introduced into the cavity, just as much as it will hold. After the expiration of twelve 188 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. hours, I withdraw the iodoform gauze and allow any accumu- lation to pour out freely. I have used the bichloride solution here first, because I believe it to be a good antiseptic and at the same time a good stimulant to the cavity. However, afterward I substitute another agent— viz., peroxide of hydro- gen. Of course, our great object in dealing with cavities of this kind is twofold : First, to stop suppuration ; second, to heal the diseased structure. For preventing suppuration, we have chiefly relied upon solutions of bichloride of mercury and carbolic acid. Every surgeon is well aware of the fact that dangers attend the use of carbolic acid in the treatment of suppurating diseases, and the too free use of the bichloride of mercury in large suppurating cavities might not only cause too much inflammatory action, but also produce a general effect upon the system which would be shown in ptyalism. We have in a strong solution of peroxide of hydrogen a substitute for these two without any of their attending dangers. Un- doubtedly the best preparation of this agent is Marchand's peroxide of hydrogen. His fifteen-volume solution will re- tain active germicidal power for many months, if kept tightly corked in a cold place. The price, too, is within the reach of all, being about seventy cents per pound. It can be used, of course, in any strength that the surgeon desires. March and has devised a hand atomizer and ozonizer for the purpose of using the agent in an easy manner. The abscess cavity is injected once a day with this agent, either pure or diluted with water, from three to ten parts, and each time the tent of iodoform gauze is pushed gently into the external opening, but so as not to fill the cavity. As the healing process goes on, a less amount of the gauze is used. If large rectal abscesses are treated in this manner, the num- ber of cases of fistulse will be greatly reduced. Fistulas in ano have been divided into four varieties: 1. Complete fistulse. 2. Blind external fistulas. 3. Blind inter- nal fistulse. 4. Horseshoe fistulse. I can not say that I like this division. Too much stress is put upon the varieties by many physicians. I allude more FISTULA IN ANO. 189 especially to complete fistula? and the necessity of finding the internal opening. It is surprising to hear patients announce the fact that an operation has been refused them because the internal opening could not be found. It often occurs that patients say that the doctors have searched many times in vain for this internal opening, and at last have given it up and declined to operate. What this has to do with the opera- tion for fistula in ano I must confess I can not understand, and yet authors have taken great pains and teachers go to a great deal of trouble to explain how to find this opening. A very favorite plan is to inject the external opening with some colored substance, iodine or something else, and then have something on the inside of the bowel that it will discolor, and, when it is seen, they are able to say that an internal opening exists. Now, admitting that they are so desirous of finding this opening so that it may be included in the cut made for fistula, I would answer this argument by saying that if dur- ing the operation I introduce my grooved director and fail to find any internal opening, when one really exists, I push the instrument through the mucous membrane, then divide the tissues upon it, and search up the bowel from the cut, allow- ing the director to go as high as it will. Then, dividing again, we of course include any internal opening that might exist. Again, I would say to those who would introduce the director into a complete fistula, and allow it to pass through the in- ternal opening, then making a division of the tissues, that the operation for fistula is not complete unless they search higher up the mucous membrane from the bottom of the cut, because an additional little branch may run up in that direction. . Case.— Several weeks ago a gentleman came to me from a Northern city to be examined, he said, for fistula, remarking that several surgeons lately had him on the operating table under the effect of an ansesthetic, and, because they could not detect the internal opening, they did not operate upon him. I would not have believed this story except that I had had many patients to tell me, in substance, the same thing. I placed him on the table and discovered a very small exter> 190 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXUKE. nal opening up in the perineum, which ran toward the bowel about one inch in depth. It did not go into the bowel. I said to him : " I do not care to examine you any further, but propose to operate on you whether I can find any internal opening or not." He consented, and I did the operation the next day. The probe passed down, while he was under chlo- roform, to the mucous membrane, and I pushed it into the bowel, and then, substituting a grooved director, I incised the tissues and finished the operation according to rules laid down. He made a good recovery. Case. — A physician living in Kentucky brought an official of his county down to me for an "opinion" in a case of fistula in ano. In my consultation room the physician told me that he had had this patient in this city once before to see a surgeon, and that he searched for a long while by many different methods to find the internal opening, but failed to do so, and no operation was done. He then remarked that, after going home, he had tried upon many occasions to pass the probe into the bowel, but could not. I replied to this statement of the case that my consultation would amount to very little, for I paid no attention to finding an internal open- ing of a fistula, if an external opening existed ; that that could be done when the operation was performed. The pa- tient was taken back home, and I learned afterward that the country physician operated on him. Now, the point I wish to emphasize is, that too much stress is put upon the finding of this internal opening, and that it is not necessary to worry one's self about finding it, for it amounts to nothing, so far as the operation is concerned, whether it is found or not. My practice in operating for fistula in ano is to make a cut through the main sinus at first, and then hunt out every single sinus that may exist. Upon this point, too, I want to be very emphatic. Van Bu- ren was inclined to think, especially in the first edition of his work, that the inflammatory condition that was set up by the division of the main sinus would eradicate or heal any re- maining branches. I am positive that this is not true. If a FISTULA IN ANO. 191 fistula in ano has one main channel and six smaller branches, and if the main channel and five of the branches are divided in the operation, and the sixth branch is left, I am sure that in the majority of cases a good result would not obtain, from the fact that the sixth branch would not be closed. It must be remembered that these fistulous tracts are lined by hard cartilaginous material — the so-called " pyogenic" membrane. It has no vitality, is very tough, and will not heal unless freely divided at the bottom and the top or scraped out. Of course, the idea that this membrane was pyogenic was a mis- take, for pus is not a secretion, and this substance does not secrete at all. I recall a case that Allingham, Sr., detailed to me a number of years ago, which was about as follows : A lady of wealth, living on this side of the ocean, had her fistula operated on by a distinguished surgeon in this country, but noticed that after the wound had healed pus still dis- charged from the rectum. The surgeon did the second opera- tion on her, laying open the tissues in about the same place and manner ; and when the second healing took place she still noticed, months afterward, the same discharge of pus from the rectum. She then concluded to cross the ocean and con- sult Allingham. As is his most excellent custom, he carefully searched inside of the rectum for a cause of this condition of affairs, and he found, beginning at the end of what was the original cut for fistula, a small opening which ran up the gut about one inch. He introduced a small director into this channel and laid it open, after which the woman got well. Of course, it can be easily seen that the mistake the Amer- ican surgeon made was not to lay open the sinus that ran up the mucous membrane from the entrance of the internal fis- tula. I believe that it requires a more careful surgical opera- tion to cure a complicated fistula in ano than almost any other surgical disease. Even when we are the most careful and do the most cutting, tracing up every sinus and attend- ing to every detail and minutia of the operation, we find sometimes, when the healing process is complete, that the disease is not eradicated. It comes nearer to getting the 192 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. surgeon into disrepute than to lose a case after an abdominal section. Another thing that I wish to impress is, that, as far as possible, the surgeon doing the operation should have the patient under observation until the healing process is accom- plished. If he leaves his cases in the hands of others to treat after the operation is done, he will have many cases of fail- ure to report. To show how far the patient can be neglected after this operation, I mention the following case : Case. — I was called to a small town in an adjoining State to do an operation for a very deep and complicated fistula. I did the operation under as much antiseptic precaution as I could, considering the circumstances, but during the operation a great deal of haemorrhage took place, particularly from the bottom of a very deep cut through and into the left buttock. A great amount of tissue was trimmed away and a space was left nearly large enough to admit my hand. I had an aseptic sponge with me, which I placed at the bottom of the wound, and packed absorbent cotton over it. Then placing a bandage, I left for the city. I was requested to come back to see the patient in about ten days. I did so, and was told that the wound had been carefully cleansed at the end of the third day, all dressing removed, and the injections used as directed. The man being large, the parts naturally fell pretty closely together when the dressings were removed. I took out the cotton which had been inserted that morning, but there was more welling up of pus than I liked to see, w T hich could hardly be explained. I was about to redress the wound when my finger detected something at the bottom which did not feel like granulating tissue. I introduced a long pair of dressing forceps and, catching hold of it, I withdrew what proved to be the sponge which I had placed in the bottom of the wound on the day I did the operation. I quickly threw it out of the window, that the patient might not see it, and it was explained by the doctor telling me that he had neglected to remove it, consequently it had been in the wound for ten days. Of course, this greatly retarded the healing process. I more and more believe that the good results in this opera- FISTULA IN ANO. . 193 tion are due as much to the careful treatment of the wound as in the operation itself. Although I accept the divisions made herein of the varieties of fistula, I sometimes think that the term fistula in ano should be dropped. In the first place, fistula in this locality has very little to do, from an anatom- ical point of view, with the anus ; and, secondly, many fistulse that we meet in this neighborhood have no connection either with the rectum or the anus. There is a variety of this sort, although it is exceptional, which is sometimes met by the rectal surgeon. I allude to fistula that originates over the sacrum and extends either upward or downward, but, as far as the operation is concerned, it has nothing to do with the rectum, and yet falls within the domain of the rectal surgeon. Case. — Dr. K. sent for me a short time ago to see a Catho- lic priest who was suffering from fistulse. An examination revealed the fact that there were two external openings — one located over the sacrum, and one over the last lumbar vertebra. Introducing a probe into either one of these, it could be felt that the spine was crossed by the sinus or sinuses, but that they did not reach within several inches of the anus, and had no connection with it. An operation was done the next day, under chloroform, which consisted in laying open all the sinuses, trimming off all the edges, and scraping out thor- oughly the base of each tract. A very large and ugly wound was made. The case was taken charge of by his excellent physician, who was also a good surgeon, and a splendid recovery took place. I suppose my record book will show fifty such cases of fistulse located in this region, and yet under the general va- riety of fistulse in ano they are not classed at all. It must be understood that the same condition of affairs may exist in other locations around the rectum and yet not involve the rectum, as, for instance, in either buttock. It would be very bad surgery to push a director down into the rectum and ex- tend the cut through the same, under the idea that it was a fistula in ano, and that it had to be so operated upon ; and it may seem strange to say that this thing is ever done ; but I 13 194 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. know of a fact that it has occurred quite a number of times. To consider, then, the varieties : Complete fistula is said to be one where the sinus extends from an opening on the outside of the sphincter muscle through the mucous membrane into the rectum. The fistula is said to be a blind external one where there is an external opening without a corresponding internal opening. An internal fistula is where there is an internal opening and no corresponding external opening. The fourth variety has received the name of "horseshoe" from its resemblance to one, there being generally but a sin- gle opening into the bowel at the back part, while there may be two openings through the skin, one on either side. Fre- quently in this variety of fistula we have many branches run- ning off from the main branch, which makes a complicated condition of affairs, inasmuch as we have to consider the safety of the muscles in doing the operation. Complete Fistula. — It is said by most authors that this is the commonest form of fistula in ano, and yet if we would take the experience of physicians in locating the internal opening of a fistula, we would suppose that the external variety was the commonest. Of course we attribute this to the fact that it is very difficult to find the internal opening of a complete fistula. Some authors go so far as to say that all external fistulse have a corresponding internal opening, yet experience will teach that this is not the fact. As I have said, I do not believe in placing so much stress upon the finding of the internal opening, and I certainly would not abandon an operation for fistula because it could not be found. It is very well, how- ever, to study its situation. I take it that the formation of the original abscess is responsible for the establishment of both openings. As we have said, pus will burrow, and an abscess being a cavity filled with pus, it is very natural that in seeking an exit it should go toward the point that will offer the least resistance. Therefore the situation of the ab- scess has very much to do as to where this point of exit will occur. If the abscess is a marginal one, as the French say, it willbe very apt to open just within the verge of the anus FISTULA IN ANO. 195 through the mucous membrane or externally through the skin on the outside of the sphincter. If it is an abscess located in the "superior pelvi-rectal space" above the le- vator ani muscle, it will open through the mucous membrane into the bowel proper. If it is, however, located in the ischio- rectal fossa, the pus makes its way to the surface through the space of least resistance, which is usually both toward the surface of the skin over the fossa and inward to the space between the two sphincter muscles. A physician who is called on to attend a rectal abscess should keep in mind these points from the fact that it is for the well-being of his patient at least to prevent the sequel, which would be fistula in ano. If left to itself, an abscess originating in the fossa would likely break internally ; but the physician, recogniz- ing that this is the most serious form of fistula, will, as has been recommended here, open the abscess externally, thereby preventing the breaking of the abscess into the bowel. It is a matter of some concern as to where this internal opening is located, on the supposition that it exists. Physicians are in the habit of searching too high up the bowel to find it. Its usual location is between the two sphincter muscles, and the reason for it is that the least power of resistance is offered here to the abscess's forming in the ischio-rectal fossa. An- other error that we fall into is that we suppose fistula in ano to be a narrow and close channel communicating from the outside with the inside of the bowel. Such fistulse as these are seldom found, but upon close inspection it will be noticed that not only diverging from the main sinus along its route are additional branch sinuses, but also at the end of the origi- nal sinus, which ends at the internal opening into the rectum, they may be found. A probe could be swept around under the mucous membrane for perhaps an inch. This will explain why the operation usually advised for fistula, which is the simple laying open of the main sinus, will not effect a cure. In making the examination for either variety of fistula it is very well to use the finger in helping out an opinion. For instance, if we see an external opening in the neighborhood 196 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. of the anus, by placing the finger at this opening and run- ning along the route toward the bowel, if a fistulous sinus exists, it can be felt as a strong whip-cord or pipe-stem under the skin, or perhaps deeper in the tissues. If, however, this is not the route that is taken by the sinus, it can be detected in the same manner by tracing it out with the finger. When we have decided upon the line that the sinus takes, it is well now to introduce a probe into the external opening, and allow it to follow in the direction that the sinus takes. If it dips toward the bowel and stops at any particular point, by a gen- tle manipulation of the probe, or a dexterous move, it may pass farther on. After this is done, the forefinger of the right hand should be anointed with vaseline and inserted into the bowel. This will act as a guide and a firmer pressure can be made upon the probe, and it is very likely that the instrument would be felt just under the mucous membrane. If, after a little endeavor, it does not pass into the bowel, you should be content with your examination, being certain that, when the operation for fistula is performed, the internal opening will be found ; and, if not, the probe will be pushed through the mucous membrane and the operation made complete. I cer- tainly would prefer this method to that of injecting milk, iodine, etc., through the external opening, and then trying to observe by a speculum the point at which it flows into the bowel, for I consider this unnecessary. In cases where there are extensive fistulous tracts it is unnecessary to trace them at all, the only question being whether an operation is war- rantable, and this is to be determined by the existing com- plications or by the health of the patient ; as, for instance, where fistulous sinuses are the result of stricture of the rec- tum or perhaps cancer. Blind! External Fistula. — This I consider to be the least harm- ful of all varieties of fistula. It is supposed to be a tract that begins externally but has no internal communication. Therefore no portion of the contents of the bowel can enter it which would be possible in both internal fistula and the complete variety. It should be taken into consideration that FISTULA IN ANO. 19 7 there is a vast deal of difference in cases of fistula in ano. I have tried to impress the fact that some fistulae are pro- gressive and some are non-progressive. It may depend entire- ly npon circumstances which variety we meet. If an abscess has been the result of any special diathesis, we can look for much burrowing of tissue, even if the abscess has resulted from trauma, and in a feeble individual we can expect the same thing. Locality has much to do with it. In superficial abscesses we expect very little trouble. In deep-seated ab- scesses we expect more, but whether it be an acute or a chron- ic abscess it should be determined by the physician in charge whether it is a progressive one or not. In this connection I beg to report two cases which will be mentioned in the same line. Two brothers consulted me in regard to a fistula in ano in the person of each. It was a very singular coincidence that the fistulse were very much alike in both persons. An external opening could be seen dorsally situated, about an inch and a half from the anus. In one the abscess had oc- curred about six years previous ; in the other, about eight years. There was scarcely any weeping from either one of them. I made an examination with the probe and found that there was no internal opening. The sinus felt to the finger as a hard cord underneath the skin. No pain or inconvenience was noticed. They said to me that it was a busy season with them, and that if I thought the operation could be deferred it would meet their plans best. After making up my mind that it was simply an external fistula, lined by a hard carti- laginous membrane, I said to them that there was no danger of much progress of the fistula, and that as they had stood it for six and eight years without any apparent trouble, they could stand it for a while longer. That has been a number of years ago, and, although I have seen the gentlemen a num- ber of times since, they have never alluded to their fistnlae. Therefore I say that we will frequently meet fistulous sinuses that are not attended with any danger even if they are left, and yet this would be poor advice to give in a gen- eral way. 198 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. Case. — A young man consulted me for fistula, giving the history of an acute abscess several months before. He was advised to let it alone. But as he had noticed a rapid spread, as he expressed it, of the disease, he came to me for advice. Upon examination, I found a large, patulous, exter- nal opening, into which I could introduce my linger, and from which I could trace numerous sinuses. Although this young man was robust in appearance, I suspected that this fistula was tubercular in character and was rapidly extending. I advised him to have an operation done just as soon as pos- sible. He consented to this, and in doing it it was remarkable the amount of tissue that was involved. Sinuses were found running in different directions, which terminated in what ap- peared to be a cavity which drained itself through these chan- nels, located in the buttock. A very extensive operation had to be done for his relief. Another mistaken view that patients sometimes take, and are backed in it by the advice of the family physician, is to have this external opening healed. And here comes the ob- jection to the injection plan as applied to sinuses. I am sure that much more detriment is done to patients than good in following out any such advice. Charlatans are in the habit of applying some caustic to the external opening of fistulse and thereby causing them to heal over, and persuading the patient that he is cured of the disease. Now, in reality, he is made much worse by this procedure, for, if the external opening is closed, there being no internal opening to the fistu- la, the pus, serum, or what not, is confined in this channel, and it naturally seeks an exit ; consequently it burrows in different directions. If a case of this kind is watched while under any such treatment, at the end of several months it will be observed that there are a number of channels, whereas in the beginning there was only one. I have seen many of these cases that have come to me from the itinerants who have been under treatment, paid their money, and been discharged as cured ; and afterward, their trouble reappearing, they were referred to me for treatment. I always say to the patient FISTULA IN ANO. 199 who has an external fistula, and because of circumstances can not be operated on, that he should make it a point to keep the sinus freely open, and in the case of traveling men especially, I provide them with a little probe that they them- selves can each day insert, thereby evacuating the contents of the sinus and preventing any accumulation within the channel. Persons may suffer from this variety of fistula and scarcely know it. They will tell you of the original abscess and that it healed, and, to their mind, they had entirely re- covered. Perhaps they will add that occasionally they have noticed a slight weeping at a certain point, but when you come to investigate you can not find the point at all. I have known cases of fistulse operated on where the original sinus had escaped notice entirely. The orifice is often so very small that it will escape even a rigid examination. A fold of skin may embrace it, or it may be found hidden under an external tag. A favorite site is along the perinseum, perhaps covered by the scrotum ; but, to avoid mistakes, a careful search should be made in every instance until the opening is found. Another mistake sometimes made by surgeons is to operate upon the channels that are easily discovered, which are in reality but branches of the main sinus, and yet this original tract is never touched at all, or, in other words, is over- looked. Case. — A gentleman from Texas had been under the ad- vice and treatment of an advertising physician for eleven months. During this time he had performed eight or ten different operations upon him. Although the doctor (?) had advertised that he never used the ligature, each operation that was done on this man was by the application of a silk ligature, which was verified by my examination of him afterward. He was seen on the street one day in a crippled condition by a worthy physician of this city, who had been an old schoolmate of his. In the conversation it was revealed that this man had been away from his home under treatment here for nearly a year, had been broken up in business at his home, and had despaired of ever getting well. He was ad- 200 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. vised by the physician to leave the charlatan and seek my advice. When I examined him a very bad condition was observed. He had as many as five large and deep suppu- rating wounds around the rectum, caused by the cutting through of ligatures. Through two other sinuses the silk thread was still hanging. Upon a careful investigation of his case I detected, about two inches up the bowel, a large and angry-looking internal opening, which proved to be the origi- nal sinus in this case. I told him that I could not do any- thing looking to his relief unless he took an anaesthetic, and allowed me to do what I thought was proper. After consult- ing his physician friend he concluded to submit to my advice. After a little preparatory treatment he was put on the table for an operation. The first thing that was done was to lay open the main channel, which began in the rectum and ran out into the perinaeum, approaching the skin close to the scrotum. The wounds that had been made by the different ligatures were theu searched, and at the bottom of them sev- eral sinuses were found running in different directions. These were freely laid open. The edges of all the wounds were care- fully trimmed away, and the whole surface dressed according to antiseptic rules ; and at the end of three months this man was discharged cured, though a great deal of the scar tissue remained. Although the sphincter muscle was divided twice, he was afterward able to retain his faeces and to have his actions with comfort. He has paid me several visits since then, simply to show me in what excellent health he is. This case will go to show the necessity of seeking out every sinus that exists. It also goes to show that a very extensive cutting is sometimes necessary to effect a cure. Blind Internal Fistnlse. — These fistula? are of more importance than either of the other two kinds. If a fistula is complete, notwithstanding that it has an internal opening, it will drain itself to a certain degree at least of the faecal matter that passes into it from the bowel. If the fistula be an external one, it has no communication with the bowel, consequently nothing of this kind can pass into it. But if it be of the blind FISTULA IN ANO. 201 internal variety, these discharges find a lodgment in the chan- nel with no point of escape, consequently it is being contin- ually irritated. It is no wonder, then, that patients complain more of this variety than of either of the other two. Some- times they will come to you saying, they believe that they are suffering from an impending abscess. Upon examina- tion, you will find a small indurated tumor in the tissues or just under the skin, and yet if you allow these patients to remain away from you for a few days, they will tell you that the tumor has all disappeared, and that they are suffering no further inconvenience. This condition of affairs has been brought about by the passage of liquid faeces through the channel, causing a slight inflammatory action, which has afterward subsided by the tumor's evacuating itself into the rectum if it contains pus ; but if it is inflammatory, it may be reabsorbed. It is quite a good idea in all such cases for the surgeon to make an incision into this small tumor, even if he has no history of an abscess, or can not detect the internal opening of the fistula. It is much better to have drainage externally than internally in all fistulse. Another point to which I would call attention is, that if the blind internal fistula has existed for any length of time, it is very apt to be complicated by additional branch fistula? ; therefore, during an operation, it should be remembered that they should be sought for. It is very bad practice to say to any patient suffering from either variety of fistula that his disease is a simple one, for an operation may reveal a very complicated condition of affairs. Horseshoe Fistula. — In this form of fistula the internal open- ing is usually found on the posterior wall of the bowel, and from this a tract leads into the ischio-rectal fossa, not on one side only but upon both. Therefore we have one opening into the bowel, and one through the skin on either side. But I have seen this variety of fistula go completely around the bowel without any internal opening at all. This form of fistula requires the most delicate operation to effect a cure. If you follow the channel in its entirety, you have really cut 202 DISEASES OP THE RECTUM, ANUS, AND SIGMOID FLEXURE. the tissues away from their attachment to the rectum proper, and therefore the sphincter muscle loses its function ; or, if you divide the sphincter muscle twice in the operation, which is the usual procedure, at one sitting, you destroy its function. The plan of operating will be described further on. The Relation of Eistula in Ano to Phthisis. — The belief among people generally, and with many physicians, is that fistula in ano has some direct connection with the lungs ; not with the diseased lung only, but also with it when it is in a perfectly healthy condition. This impression is widespread with pa- tients suffering from rectal disease, and the questions pro- pounded by them are sometimes really ludicrous. I have often been asked if the cure of piles would not result in con- sumption, and I have often had the objection preferred to curing a fistula that, if the discharge was stopped, it would go to the lungs ; and this, too, from persons of splendid physique and in perfect health, suffering likely from only a local sinus caused by the passage of a fish-bone. I find, too, that patients have been prejudiced against the operation for the cure of fistula by some physician who has warned them against it, lest they have consumption as the consequence: Of course, to the learned physician this would be pure nonsense ; yet the prejudice exists, and we are forced to use a sensible argu- ment to refute it. Among the old authors the idea was preva- lent that the discharge from the fistula in phthisical patients had a modifying influence upon the disease. There are many to-day who believe in this doctrine. This is commensurate with the belief in issues, setons, etc. From this early teach- ing many vagaries have resulted. Even the old writers, who knew but little pathology, did not believe, nor did they at- tempt to teach, that the curing of a fistula in a healthy person would result in phthisis, and it is very strange that in this day of research and pathological study there are men who will, by an ill-advised word, consign a person to a life of disgust, if not of torture, by advising against an operation which could do no possible harm, but, on the contrary, relieve him of a life of suffering. FISTULA IN ANO. 203 Case. — Miss K. was brought to me by her family phy- sician suffering from an ugly condition of fistula in ano. He told me that he had had much trouble with the % abscess, not that it had caused much pain, but that it was so extensive and refused to break. He also stated that she was of a con- sumptive family, having just lost a sister with phthisis ; that other members of the family had died with it, and that this girl was suffering from an incipient tuberculosis of the lungs. She had lost considerable fiesh, had a bad cough and expec- torated freely, but her main complaint was about the fistula. The examination of the rectum revealed a characteristic, large, pouting opening of the sinus. The finger could be introduced into it and swept around in the tissues for a circumference of at least one inch. The skin covering this cavity was very flabby and of a bluish color. Under the circumstances I was a little chary about operating, and yet I realized the fact that this was a progressive condition of affairs, rapidly destructive to tissue, that the sinus would burrow in every conceivable way, and would not only undermine the sphincter muscles, but also break down the health of the patient. I therefore advised an operation. Incidentally I desire to say that in these cases the cough is a serious detriment. It is a well- known fact with surgeons who operate upon the rectum that the succussion from the cough is often so great as to prevent the healing of these wounds. Therefore, in operating upon the phthisical patient, the cough should be looked after. And another point that should be especially enjoined is, that this class of patients should not be confined to bed any longer than is absolutely necessary. I have frequently, upon the first week of confinement, advised them to get out of bed and take a walk, or in other ways gain some advantage from exer- cise and fresh air. This course will aid rather than deter the healing process. This young lady was etherized, taking it very kindly ; I divided the sinus running into the bowel, and then trimmed away all of the overlapping integument. The bottom of the sinus, or I should rather say the cavity, was freely scarified and dressed after the operation with bichlo- 204 DISEASES OF THE RECTUM, ANUS.. AND SIGMOID FLEXURE. ride gauze. A stimulating course of local treatment was pur- sued, the patient allowed to eat freely of good, nutritious food, and to partake of milk punches through the day ; and, after five days' confinement in bed, to get out a portion of each day and exercise in the open air. Although a little slow, this wound healed perfectly, and the general health of my patient was rapidly improved. Although it has been two years since the operation was done, there has been no reappearance of the trouble. It behooves us, then, as physicians, having the care of these cases, to look into the doctrine taught by the old mas- ters in regard to this disease, and see if there be truth in it or not. It can not be gainsaid that consumptives are frequently the subjects of fistula. These fistulse may be dependent upon the tubercular diathesis, or they may not. A person having diseased lungs may be just as liable to the other causes of fistula — i. e., foreign bodies in the rectum, bruising, trauma, effect of cold, etc. — as persons who are perfectly healthy. Is a fistula in ano in the consumptive patient a thing to be de- sired, for the reason advanced by the older writers, namely, that the discharge of the fistula modifies the disease of the lungs ? If answered in the affirmative, I would ask if it would not be good surgery to produce an anal fistula in phthisical patients, if they were so unfortunate as not to have one ? The question at issue is, Shall we operate for fistula in ano in pa- tients suffering from phthisis % Before attempting to answer let us consider what some of the older writers have said on the subject. In 1837, when Busch wrote his work on disease of the rectum, he said: "It is very apparent that a great many fistulse depend on disease of the lungs ; therefore we should not operate on them, else their healing will give rise to the increase of the pulmonary disorder and curtail life." A few years before this Brodie had said: "No operation should be undertaken for fistula when phthisis is present, for one of two things will happen ; either the sinus, although laid open, will not heal, or otherwise it will heal as usual and the visceral disease will make more rapid progress, and the FISTULA IN ANO. 205 patient will die sooner than he would have done had he not fallen into the surgeon's hands." Sir William Ferguson said that "the coincidence of fistula with disease of the lungs is often remarkable, and a surgeon would seldom be justified in interfering with a sinus under these circumstances." It seems that these really great men were given to theorizing in their day, as many are given to the same thing now. In these mat- ter-of-fact times we want to know if theory is borne out by clinical facts. When Busch tells us that it is very apparent that many fistulae depend on diseased lungs, and that we should not operate because the healing will give rise to in- creased pulmonary disorder, he should have established this saying by clinical facts, or his statement is good for nothing. When Brodie affirms that under the same circumstances the wounds will not heal, or if they should heal the patient would die sooner, he should have given us some statistics of opera- tions to prove it. The statement of Sir William Ferguson that we are not justified in interfering with the sinus, simply because the patient has a cavity in his lungs, is not substan- tiated by facts. Some of these writers say : " Don't operate, because the wound will not heal " ; others, that the wound will heal, and that this is the danger. Certain I am that if I oper- ate on any patient, under whatever circumstances, and the wound heals perfectly, I congratulate myself that I have done a good thing. The trouble in the consumptive patient is that the wounds are slow to heal, but not for the reasons usually given. But of this further on. Is there any degree of truth in the assertion made by these authorities that we should not operate on this class of patients ? Are their rea- sons predicated upon facts ? I imagine that this view has obtained credence principally because patients who have phthisis, complicated by fistula in ano, often die of the lung trouble ; and, if perchance an operation has been done for fistula, the blame has been laid at the surgeon's door, albeit that the life of the patient may have been prolonged and made comfortable rather than been shortened by the opera- tion. No good surgeon would risk his reputation by oper- 206 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. ating upon a patient who has rapid symptoms of advanced phthisis — as hectic, sweats, cough, emaciation, etc. — unless there was a strong demand for such operation. But that there are many cases of consumption made worse by an ex- isting fistula there can be no doubt. By curing the fistula the lung trouble will be benefited. There are several ques- tions that should be considered before operating upon the phthisical patient for fistula. 1. Will the wound heal ? 2. If the wound heals, will the patient be injured or benefited ? In answer to the first question, there are several reasons for supposing that the wound would refuse to heal : First, when the lung trouble has advanced to a degree of emacia- tion with cough, there is a bad nutrition of all the tissues of the body ; hence the tissues around the rectum are included. The blood-supply to the part is feeble, and the proper return of the same by the veins is impeded. Under these circum- stances the effort at repair would be poor. If cough exists, the succussion, as I have intimated, would materially prevent the healing process. A more serious reason than these, how- ever, is to be found in the condition of the parts operated on. The books are in the habit of giving three varieties of fistula — namely, external, internal, and complete — often for- getting to mention the different varieties of these three, and the operation is usually construed to be the introduction of a director and the division of the main tract. Any one who has operated many times for fistula in ano knows how er- roneous this is. As has been before stated, very often when one external opening presents itself, if a search is instituted, it will reveal many additional sinuses. Now, this is usually the case when fistula is found in the phthisical patient, not only many sinuses, but cavities of small caliber. If any of these escape notice, the wound does not heal because of the continual flow that is kept up. It would then become a ques- tion of importance whether the patient could bear that much cutting, especially if the sphincter muscle is involved. The surgeon alone is to decide. It has been an observation of mine that wounds upon the consumptive heal more readily FISTULA IN ANO. 207 than is supposed. I do not refer here especially to fistulous wounds. The character of fistulse may be very different from those described. I have seen many plain, uncomplicated cases of fistula in people who had phthisis ; although, as a rule, the sinus is after the manner described. Then the char- acter of fistula is very different, and it is upon this fact more especially that I beg to differ from the learned men that I have quoted. Without making any distinction, they assert that the fistula must not be touched if the patient has phthi- sis. Patients are to be left under this general rule to bear their pain and the annoyance of a continual discharge, when they have fistula, perhaps of insignificant proportions, which could be easily cured. But those taking this side of the question do not have to go to the older authorities upon the subject to have their ideas confirmed. Gross said: "All attempts at a radical cure of fistula are inadmissible when there are serious organic lesions in other parts of the body, especially the lungs. In such cases we can not be too cau- tious, lest in arresting too suddenly a discharge, which has perhaps become habitual, we throw the onus en the more important organ and induce death prematurely." Erichsen inclined to the idea that a fistula may act as a derivative in these cases, but says that in the early stages of phthisis an operation improves the patient's condition, then adds that an issue should be established in the arm or the chest for a time. These two opinions lead us to consider the second question : If the wound heals, will the patient be in- jured or benefited thereby? We are to suppose, then, that the patient has vitality sufficient for the wound to heal. Does the healing advance the phthisis ? Both from a theoret- ical view and a practical demonstration, I would answer in the negative. I have operated many times for fistula in phthisical patients, and I have never had cause to regret it. Just as often, for reasons other than those given by these au- thors, I refused to operate. Is a fistula in ano a derivative for the lungs, as Erichsen intimates ? If the principle of the doctrine of derivatives is correct — which I do not admit — this 208 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. appears to me to be most far-fetched of all. The fistula in the rectum can have no bearing on the lung in a derivative way. The distance is too great, and there is no anatomical connection— arterial, venous, capillary, or nervous — which could account for it. Hence I can not see what could be derived by it. The fistulous sinuses and cavities which exist as the result of the phthisical habit are simply the breaking down of tissue or the rapid degeneration of it. Therefore this is not only destructive, but is also a great waste. Then are we to suppose that, by keeping up the waste and allow- ing the degeneration of tissue to go on, we benefit an already enfeebled lung, or, by stopping this waste, we are, as Gross says, to hurry on the lung disease? We can not subscribe to this. If there was an overabundance of some destructive material in the body, whose presence was working harm, and by a derivative we could draw it away or waste it, then the proposition would appear reasonable ; but here we are draw- ing from an already impoverished body. Add to this the mental anxiety that exists, besides the loathsome disease, and I am constrained to say that in many selected cases the opera- tion should be done, and that I differ radically from the views herein quoted against the operation. 1. In incipient phthisis the operation is always justifiable, other things being equal. 2. In the rapid progressive fistula an operation should often be done to save tissue and prevent serious consequences. 3. If great cough exists, it militates against the operation. CHAPTER IX. TREATMENT OF FISTULA IN ANO. There can be no doubt that spontaneous cures take place of fistula in ano, sometimes without any interference at all, but usually as the result of a very simple examination with the probe. I am satisfied that I have seen at least a dozen such cases in my practice. Again, one will be surprised, in dealing with large rectal abscesses, where everything points to the fact that they will be followed by fistula in ano, when all symptoms disappear and the abscess heals without trouble, leaving no trace whatever. The first question that a patient with fistula in ano is likely to ask the surgeon is whether it can not be cured without an operation. To meet the whims of patients, more than any- thing else, I imagine that the injection plan for fistula or the local application of caustics was first introduced. Of course the objective point in this treatment is to destroy the so-called " pyogenic " membrane by means of the escharotics. Grant- ing that it could be done, the point must be conceded that it is not only slower than the knife operation, but it is equally as painful. Again, injecting into the sinuses an escharotic that will destroy the tissue which lines their internal surface, might incite sufficient inflammatory action to cause an ab- scess. This plan is a very old one, and the agents used were iodine, nitrate of silver, nitric acid, and in later years car- bolic acid. With modern surgeons the plan is nearly obso- lete. We find in the books, however, a reference to it, and in some few cases it might do very well to try it. Allingham thinks well of dilating the sphincters, the application of car- bolic acid, and the introduction of the bone stud to keep the 14 210 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. wound from healing. Agnew, in his book on the Treatment of Haemorrhoids and other Non-malignant Rectal Diseases, says: "The treatment by injection, sometimes classified as the 'non-operative method,' has been so successful in the hands of many that it is stoutly affirmed that any case cura- ble by the usual heroic methods is equally curable by this method. Different preparations have been used, chief of all being carbolic acid, ranging in strength from fifty per cent up. In adopting the carbolic-acid treatment, probably the better way, after preparing the sinus, will be to use an eighty- per-cent solution the first time, and subsequently a fifty -per- cent solution, protecting the parts from excoriation by any suitable unguent and absorbent cotton. Hot -water com- presses to relieve pain, eucalyptol, calendula, campho-phe- nique, etc., in the interim. Judgment will be required in not making too many irritant applications and granulation thus hindered for want of rest. ... As a preliminary step the ex- ternal orifice should be well dilated with a laminaria tent or other appropriate means, and a fistulous tract explored with a common probe and thoroughly cleansed with hot water in- troduced through a flexible silver cannula. The cannula is also used for the injection of a five- or ten-per-cent solution of cocaine to obtund the sensibility before the injection of the acid. After the fistula has been suitably prepared for the reception of the acid, the silver cannula, attached to a hypo- dermic syringe charged with the acid, is passed up into the tract, the finger inserted into the rectum, and the end held over the internal opening, if the fistula be complete, to prevent the acid escaping into the bowel. The cannula is then slowly withdrawn, and the acid gently forced out of the syringe at the same time. The residual acid is allowed to remain in the fistulous tract for a few moments. The tract is then pressed with the finger, and syringed out with a weak solution of acetic acid and injected with oil. Once in two or three weeks is sufficient to repeat the injection of the carbolic acid should more than one application be required. Often one application of a strong solution will be found sufficient to effect a cure." TREATMENT OF FISTULA IN ANO. 211 I have quoted Agnew in detail, first, for giving those of my readers who desire to try the plan an opportunity to do so ; and, second, to dissent from the opinion that this is even a good method in any variety of fistula when compared with the other accepted plans. As I have mentioned, no proper gauge can be pat upon the agent used. If too little, not suffi- cient inflammation is excited ; and, consequently, no good is accomplished. If too much inflammation is the result, great damage may be done. Therefore, concurring in the idea that if this tough lining could be destroyed without danger to the surrounding tissues, there might be a plan devised by which it could be done, in 1885 I read a paper before the Kentucky State Medical Society, suggesting what I was pleased to call "A New Operation for Fistula in Ano." It was described in the following words : " Taking the ordinary exploring probe, it is inserted into the external orifice of the fistula to deter- mine, if possible, that only one sinus exists. Being satisfied of this fact, I then take a long, slender laminaria tent, and push it gently into the fistulous sinus to the fullest extent it will go. This is allowed to remain for several hours, keeping the patient under observation during the interim, at the end of which time it is withdrawn. The procedure causes but lit- tle if any pain. The laminaria tent is preferable to a sponge, for the reasons that it is easier of introduction and furnishes its own moisture, which assists in its withdrawal. After this dilatation I take the smallest urethrotome, having a very small point ; closing the instrument tightly, it is pushed gently into the sinus as far as it will go, and then by the aid of the screw attachment I dilate the sinus. When this is done, the turning of the screw at the side of the instrument will cause the concealed knife to protrude at the distal end according to the measurement desired. The instrument is then carefully withdrawn, cutting through the wall of the sinus throughout its whole length. The cut, as will be perceived, has been made subcutaneously, and the pain is insignificant. What haemorrhage takes place is easily controlled by pressure. In several instances I have turned the instrument and reinserted 212 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. it, practicing the same procedure on the opposite side at one sitting. If this is not thought advisable, the patient is allowed to go for several days before repeating the operation, which is to include the other side. The advantages that I claim for the operation are, viz. : Over the injection plan it must take precedence for the reason, as above stated, that the injection of any agent that is commonly used for such purpose does not accomplish what is desired, and is attended with danger. With this instrument both the top and the bottom or each side, if necessary, can be cut through, thereby insuring a good granulating surface, and this too without pain. Over the ligature, either elastic or non elastic, it possesses the ad- vantage of cutting through both top and bottom or each side of this thick membranous sinus, while the ligature can not possibly go through any portion but the top of the sinus as it cuts its way out, leaving, of course, a callous bottom, which in many cases would refuse to heal, it being a positive rule in surgery, in the operation for fistula in ano, that the bottom of all these tracts must be divided to insure a cure. Salmon used to say, after he divided a fistulous tract, "Now I will make the back cut, which will divide the bottom of the sinus," recognizing, as he did, that unless this was done he would likely not get a good result. Again, in using the liga- ture, the sphincter muscle or muscles must, of necessity, be cut through by the ligature if the internal opening is above them. In the operation with the instrument I suggest, the muscle is not divided or interfered with. Over the ordinary operation with the knife it can be claimed — 1. That this oper- ation dissipates all horror in those patients who dread the knife. 2. That excessive haemorrhage is avoided. 3. The sphincter muscles are not cut. 4. The patient is not confined to bed or taken from business. 5. The tissues are not in- cluded in the operation. In the majority of cases that I have treated by this method I have done so without the patient's knowing that anything in the nature of an operation had been performed. Exhibiting the instrument to them — the knife being con- Plate III OPERATION FOR FISTULA IN ANO BY MATHEWS'S FISTULOTOME. TREATMENT OF FISTULA IN ANO. 213 1 cealed within it — they have never known other than that it was a probe. If I find, after waiting a few days, that a suffi- cient depth was not reached, the instrument is again inserted and the same procedure gone through with. The patient is kept under observation a sufficient length of time to be assured of a perfect cure. One point should be strictly watched, and that is that the external opening is not allowed to heal before the sinus does. Where pus cavities are found, or additional sinuses exist, of course this operation is not advised, but in the se- lected cases mentioned I am sure that the advan- tages claimed for it will be realized. A score of cases in my practice attest its value. I enocuntered many disadvantages in operating upon the fistulous tract with the urethrotome : 1. It was too large to enter the orifice of the sinus, so recourse was had to the laminaria tent. 2. It only cut upon one side, hence required a second introduction to effect a division of both the top and bottom of the mem- brane. To meet these difficulties, I had my instru- ment maker make for me a modest little instrument which, for lack of a better name, I call a fistulotome. By reference to the cut it will be seen that it is very small, being but little longer or larger than a good-sized probe. It has within it two concealed knives. It is probe-pointed and easy of introduc- tion. In the end is an eyelet, which I sometimes thread with a filiform bougie, the object being for it to search out and enter any small branch that may exist when the instrument is pushed to the very bot- tom by the screw arrangement at the distal end. Both knives are uncovered at the same time. They are of sufficient length to cut entirely through the indurated membrane as the instrument is withdrawn, the plan being to insert the fistulotome as far into the sinus as possible, then uncover the knives by the screw attachment at the end. In a few cases I have injected muriate of cocaine ; then done the 214 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. operation. However, I have never seen that it did nmch good. A better plan wonld be to inject the cocaine subcutaneously alongside the tract. There is so little pain accompanying the operation that I seldom nse this agent. Case I.— Mr. B., a mechanic, referred by Dr. Turner Anderson. After an extensive fistula, with a number of branches, had been laid open, with all the precautions as to trimming the edges, dividing the bottom of sinuses, etc., the wound healed perfectly. He came to my office a few weeks after he was discharged and stated that there was just a drop of something that caused a moisture about the wound. Upon examination, I found a small orifice, located just where the external cut was begun in the operation. Introducing a probe, I found that it entered, fully six inches, a superficial sinus that ran backward and not toward the rectum, and I had evidently overlooked it in the operation. While he was on the examining table in Sims's position I introduced my fistulotome, uncovered the knives at the end of the sinus, and the instrument was slowly and firmly withdrawn. As the knives approached the external orifice I quickly pulled it through the skin. A little bleeding occurred at the time and some soreness was complained of during the week, but at the end of ten days he came back and I could not discover the sinus at all. I watched the case until I was satisfied that there was no recurrence. Case II. — A woman reported at my clinic at the Ken- tucky School of Medicine with a fistula in ano, having an external opening about three inches to the left side of the anus. A probe revealed the fact that it communicated with the bowel, the depth of tissue being about half an inch. One of the surgical staff was allowed to do the operation. I did not notice him carefully, but I am satisfied that he simply made the division usually recommended, which was by intro- ducing a grooved director through the sinus into the bowel, and then dividing the tissues upon it, neglecting to make the back cut according to Salmon. The wound healed nicely. She reported back to the clinic, and, to all appearances, the TREATMENT OF FISTULA IN ANO. 215 parts were in good condition ; but while she was on the table I took a delicate probe and searched the route of the sinus, and found, at the very beginning of it, that the probe went into the bowel, evidently through the same old tract. My idea was that the tough lining, being left at the bottom, the wound simply closed over it, leaving the channel. This case illustrates the fact that, in using the elastic ligature, which only divides the top of the sinus, this same result might have been obtained. I took my fistulotome and pushed it through this tract until I could feel it upon my finger, which I had inserted into the rectum. I then uncovered the knives, pulled the instrument out, and, in cutting its way, it divided the bottom as well as the top of the sinus. The woman was well within one week's time, and no probe could be intro- duced. I could cite a number of other cases that have been cured by this little instrument, but will make these two suffice. I want to be explicit in saying that the cases in which the fistu- lotome will prove of service are limited, and yet I see for it as wide a field as that for the ligature, either elastic or non- elastic. I want to put myself on record, too, that the cutting operation, as usually practiced — which is to divide all the tissues upon the director, trim the edges, cut through the bottom, and lay open every additional sinus — is the one to be preferred in the majority of cases for fistula in ano. It is the means par excellence for the treatment of this disease, and I might add that from time immemorial the laity has fought against it. Recognizing this prejudice, the charlatan has been ever ready to play to it, and has, in his pretentious and deceitful way, increased this prejudice. I believe that every surgeon who is in the habit of operating for this trouble will agree to the statement that it is impossible to cure the larger proportion of fistula with on t the cutting operation. I can safely say that when any other method — such as caustics, ligatures, etc. — is brought into comparison with the knife as an agent of cure of any surgical affection, the preference must be given the knife. It has always been a mystery to the profession why 216 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. sensible people would consent to have tumors, etc., burned out by degrees with the caustic, hot iron, etc., in preference to their rapid extirpation with the knife. It is the story of the dog's tail being cut off piecemeal to avoid giving it pain. It might be said that we of the profession too often succumb to the w^hims and caprices of patients, thereby allowing them to dictate the means of cure. Therefore, in bringing before the profession this fistulotome, I simply ask a fair trial of it, not as a substitute for the operation by the knife, but as a means of curing a few selected cases that may be met with in the hands of any surgeon. Andrews, in his book on Rectal and Anal Surgery, kindly says: "An excellent regular surgeon, Dr. Mathews, of Louisville, has systematized this latter plan and made it more energetic. He dilates the external part of the fistula with a laminaria tent (and then with a fistulotome scarifies the interior), repeating the operation as often as is needful. It is demonstrated by Dr. Mathews on the one hand, and by the experiments of the quacks on the other, that by controlling these two conditions — viz. : (1) the un- favorable effect of the undrained septic fluid within the sac ; (2) the tightness of the external opening which prevents free drainage and keeps the sac distended with this putrid pus — many cases will heal spontaneously." Agnew says in his book, from which I have taken occasion to quote several times : ' ' The fistulotome, shown in Fig. 24, is a contrivance which is perhaps destined to take the lead in the treatment of fistula generally. It is constructed that the fine cutting blades close on themselves, while the instrument, which is flexible and probe-pointed, is being introduced, but immediately open on withdrawal, and thus catch up and cut through the fistulous membrane. Who the inventor of this clever device is I have been unable to ascertain, having seen the invention claimed by three different physicians, one of whom speaks of curing seventy-six per cent of all cases treated by one operation — that is, by drawing the fistulotome through the tract once. Cases of long standing require that the instrument should be turned at right angles and drawn through the second time, and pos- TREATMENT OF FISTULA IN ANO. 217 sibly repeated later on, and a tenotome employed to scarify any remaining indolent sinus." I have taken occasion herein to quote from the report that I made to the Kentucky State Medical Society in 1885, and I at least thought at that time that I was the originator of the plan. I have had no reason since to think that I was mistaken. It will be observed that at that time I was forced to use the small urethrotome, because I had never heard of any two- bladed instrument that had been devised especially for nse in fistula in ano. The gentleman that claims to cure seventy- six per cent of his cases of fistula with such an instrument certainly has a better instrument than the one that I have de- vised, or his successes have far overbalanced mine. But, for the reasons that I have already given, I am satisfied that with any instrument of the kind the cures would be very limited, outside of the character of sinus mentioned. Several years ago Dr. Frederick Lange suggested the ad- visability of treating fistula by excision of the entire fistulous tract, the raw sur- faces being brought together with sut- g ^ ures, with a view of securing healing by n , . , , • T _ Bush's needle-holder. first intention. I can not do better than quote his own report : "I described a cer- tain method, but my experience at that time was derived from a few operations, the results of which were only partly success- ful, though encouraging. The first operation was performed two years ago upon a lady who had a deep-seated fistula, the internal opening of which was situated two or three inches above the sphincter. She was perfectly cured in two weeks. Since then I have had about a dozen cases in which the extent of the lesion and the gravity of the operation varied, the re- sults being as follows : In four cases primary union occurred without suppuration. In three, a similar result was obtained with but slight suppuration. In four, the wound healed by granulation in a shorter time than it would have done after one 218 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXUBE. of the old operations. In one instance I did not sew up the wound at all on account of inflammatory infiltration of the edges. In another, that of a gentleman whom I had treated during the acute stage of a very extensive gangrenous peri- proctitis, there was so much cicatricial tissue that I did not venture to excise at all for fear of removing so much of the muscle that incontinence might result. This patient has still Needles in handle. an internal fistula which causes no inconvenience except a slight discharge. My technique has been essentially the same as that described by me before— viz. : excision of the entire fistulous tract, together with all the lateral sinuses, such as not infrequently exist in the cellulo-adipose tissue above the sphincters, and union of the deep tissues by means of buried sutures of iodoform catgut, as well as accurate adaptation of the edges of the mucous membrane. The field of operation is constantly irrigated with boro-salicylic solution. The edges of the integument I prefer to unite by only a few sutures in order to allow drainage of the first secretion. Opium is ad- ministered daring the first two days. After the second day the bowels are moved easily with injections, a sitz-bath being used after defecation. I performed this operation only once in a case of fistula of tubercular origin, the result being per- fect. There was a large shallow sinus which did not commu- nicate with the rectum, a condition which in my experience is not infrequent in tuberculous fistula. In the Medical Record of June, 1886, Dr. Stephen Smith published a paper on this subject, in which he stated that in 1879 he conceived the idea of treating fistula in this manner after reading in Dr. Emmet's book a description of that gentleman's plastic operation upon the perinseum. At that time Dr. Smith excised the granulat- ing surface of a fistula that had been operated on unsuccess- fully six months before. Consequently that operation was scarcely applied to a fistula proper. He does not state just when he adopted the method described by him, but if it was TREATMENT OF FISTULA IN ANO. 219 immediately after the operation above mentioned, he was probably the first surgeon to practice it. I take the liberty of claiming priority in my description of the details of the operation, and especially the use of antiseptic precautions, which differs in no essential feature from that given by him." I take this amount of space to devote to this operation simply that justice may be done Dr. Lange, as I have seen it stated several times that some surgeon in Berlin claims pri- ority in this operation. I have quoted from the proceedings of the New York Surgical Society, at its meetings of January 12 and 26, 1887, and it will be noticed from Dr. Lange's re- port that he says the first operation was performed two years before, which would be in 1885. In a paper read before the Mississippi Valley Medical Association, in 1889, I took occa- sion to call the attention of that body to Dr. Lange's opera- tion, and reported three successful operations done by my- self, according to his plan. Of course, there are many cases of fistula in ano which could not be successfully treated in this manner. It is so often the case that such an amount of diseased tissue has to be cut away to establish the healing process that it is impossible to bring the edges in apposition ; but where such a thing can be done, after the bottom of the sinus or sinuses is divided or scraped, and especially if strict antiseptic precautions are practiced, this operation is to be advised. We all know how long and tedious it is for the healing process to take place by granulation in these cases. Therefore I am inclined to think exceedingly well of the operation as suggested by Dr. Lange. The Operation for Fistula in Ano by the Knife. — There are but two other operations looking to the cure of fistula in ano that are worthy of consideration— viz., the elastic ligature and the knife. I have already stated that when these two methods are contrasted I much prefer the latter, but I wish first to call attention to the fact that the description given of the operation by the knife, by the majority of the general surgeons who have written about it, is not only incomplete but very misleading. Hamilton, in referring to the operation 220 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. in his most excellent book on the Principles and Practice of Surgery, says : "The probe, or somewhat flexible grooved director, being now thrust into the rectum and brought out at the anus, the operation is completed by dividing the interme- diate tissues. Having cut the sphincter, it only remains to lay a small piece of lint between the margins of the wound and place the patient in bed." To illustrate how erroneous this advice is, allow me to cite a case : If an abscess in the ischio-rectal fossa has left a sinus which runs directly into the bowel, and from this a branch fistula runs out into the perinseum, and another di- verges from the main channel into the buttock, no such operation as is described by Hamilton would effect a cure. It is the smallest part of the operation to lay open the tissues which lie over the main sinus. How often it is that the sur- geon is disappointed in the wound's refusing to heal after an operation for fistula, and an investigation reveals that it is due to a small sinus or pocket that has been overlooked ! I am sure, after a long experience in dealing with this opera- tion, that in the majority of cases operated upon, if a single sinus is left, a good result will not be obtained. In other words, the inflammation excited will not be sufficient to eradicate the branch fistula. The flaps or thin edges of the wound alone, if left, would prevent good union. Case. — Mr. L. F. S. had submitted himself for treatment to an advertiser who claimed not to use the knife, caustic, or ligature in the cure of fistula. He had been under constant treatment for several months when he discharged his sur- geon (?) and came to me. Upon examination, I found that a number of cuts had been made, if not with a knife, certainly with the ligature, and that they showed no disposition to heal. The edges of the wounds fell into the cut surfaces and were a source of great irritation. I discovered in the peri- neum an indurated sinus, which proved to be the oldest, or the original one, but had been overlooked by the gentleman who had him in charge. The patient was prepared for the operation, put under chloroform, this sinus divided, all the TREATMENT OF FISTULA IN ANO. 221 edges were trimmed thoroughly, and the wounds dressed antiseptically. He made an uninterrupted recovery and was discharged in a short time. This case clearly demonstrates two propositions : one, that if additional sinuses are left, a cure will not be effected ; two, that anything less than a free cutting operation would have failed to cure. Before doing an operation for fistula in ano by the knife, it is necessary to give the patient some special treatment. We will consider, first, that the trouble exists in the otherwise healthy individual. In this, as in all other surgical operations, the alimentary canal should be thoroughly cleansed by the administration of a free cathartic or aperient the day before the operation. The eveniug pre- ceding the operation he should be instructed to take a pur- gative pill, not an aperient. The preference is given to the pill for the reason that only one, or perhaps two, actions will result, whereas in the aperient a loose condition of the bow- els exists and they will, perhaps, move during the operation. If the patient be accustomed to drinking alcoholic or malt liquors, it is quite a good idea to administer, a day or two before operating, a calomel pill. The evening before, he should be directed to take a hot bath. On the morning of the operation he should do without his breakfast, except perhaps a glass of milk or coffee, and be directed to take another bath, after which he is to put on clean linen and he is ready for the operating room, after having his bowels cleared by an enema of hot water. The parts are then shaved and washed thoroughly with a bichloride-of-mercury solution (1 to 3,000). He is then anaesthetized, when the sphincter muscle is thoroughly distended with a speculum and the rec- tum is syringed out with the bichloride solution. Consider- ing now that the patient is ready to proceed with, he should be placed in proper position. After trying the different ones suggested by the authors, I have long since concluded that on the left side, with the knees well drawn up, the left arm being pulled behind the patient, is the best. The instruments necessary for the operation are one tenaculum forceps, two 222 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. rectal probes, one four-pronged forceps, one curved bistoury, three grooved directors varying in size, one pair of stout scissors, and one straight, heavy knife. Frequently we have not the number of assistants that we desire, and for this rea- son I devised a special forceps or clamp, which has already Rectal probes. been described under the head of the Treatment of Hemor- rhoids, which consists of four prongs instead of three, and is made to lock. By catching the tissues, they can be pushed aside, still in position, without the aid of an assistant hold- ing them. In a bowl on the table are the sponges in the bichloride solution (1 to -5, 000). I much prefer the sponge made of sur- geon's cotton, wrapped and sewed in antiseptic gauze, to the ordinary sponge. I am in the habit of throwing them away after the operation, thereby saving the necessity and trouble of disinfecting the sponge. The instruments are in the pan of carbolized hot water. The attendants as well as the opera- tor have been made aseptic. Method. — Supposing the case to be one of the external variety, the grooved director is inserted into the orifice pre- Grooved director. senting, and with gentle pressure allowed to seek its way as far as it will go. It will often be noticed that these tracts are tortuous and not straight. This should not confuse the operator, but after the director has gone as far as it will, with gentle pressure, the forefinger of the right hand should be anointed with pure vaseline, drawn from tubes, and inserted TREATMENT OF FISTULA IN ANO. 223 into the rectum. The end of the director will likely be felt encroaching upon the mucous membrane. It is very well to manipulate it and see if it can not be made to find the inter- nal opening if the finger has failed to do so. I have seen surgeons conf used by the fact that it could not be detected, Gowlland's director. and consequently the director would not go into the bowel. This confusion, however, is unnecessary, because in the event of its refusal to pass through, sufficient force should be used on the director to push through the mucous membrane. Then it is caught by the forefinger, and, while being pushed by the left hand, is guided by the finger out at the anus. It can be now held in position, a sharp bistoury is placed in the groove of the director on the outside, and all the tissues remaining upon it divided. The irrigator, containing a solu- tion of l-to-5,000 bichloride of mercury, being ready, a stream is now to be played over the wound, and a sponge is used to wipe away the blood. A probe should then be taken and run along the route of the cut, and it will, very likely, run into an additional sinus from the main tract. It should then be withdrawn, and a grooved director, of a smaller size than the one just used, should be inserted, when with the knife it is also laid open ; nor should we be content after find- ing this additional sinus, for a further search may reveal several more, and with their detection they should be laid open. Another point that requires some attention is the investigation of the beginning of the original sinus on the outside. It will frequently be observed that, for a line or two at least, the skin is undermined. The knife should be drawn across it. One of the most important steps in the operation is the trimming of the edges. If we neglect this, a bad result will frequently be met. I am in the habit of trimming the edges of the wound even if there are no flaps. It is well recognized that these wounds are to heal by granu- 224 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. lation, and this trimming aids it. The irregularity of the tissues, whether flaps or not, should be trimmed away. It will be often observed that a portion of the tissue is callous and our division of the sinuses has left ridges in it. This should be caught up with the pronged forceps and cut out with a pair of curved scissors. I frequently excise the whole bottom of the wound in this manner, and I am sure that it has aided much in the healing process. Some recommend the scraping out of these sinuses after the cut has been made. I have never been satisfied with that method of dealing with them. It will be found much better to treat them in the manner that I have suggested. The description of the operation that has been given deals with the external or complete variety of fistula. The opera- tion for an internal sinus, running toward the surface and having no external opening, is a more difficult thing to do. The difficulty lies in finding the internal opening and intro- ducing a director into it. One would think, from reading the descriptions in the books, that it was quite an easy matter to detect this opening. But the surgeon who has' operated often understands that it is a very difficult thing to do. If an ocu- lar inspection is made by means of a speculum, the mucous membrane is so put upon the stretch that it obliterates the internal opening, and if we use the finger as a guide there is nothing positive evidenced to the feel. Sometimes a lump on the outside can be seen and felt, which would indicate that it was the terminus of the internal fistula. If this is the case, an incision into it will reveal the fact, but in the majority of cases this is not shown. Indeed, I am of the opinion that fistula? of the internal variety usually run around or up the mucous membrane, and do not often extend out into the tis- sues unless the sinus or cavity is the result of a special di- athesis — as, for instance, tubercular. In this case the aperture is usually very large, and by inserting the finger into the rec- tum it will dip very readily into the opening. The operation consists in bending a flexible grooved director in the shape of a hook, and introducing it into the rectum upon the finger Plate IV. TREATMENT OF FISTULA IN ANO. 225 as a guide, and the two together to seek out the opening. When it is pushed into it and approaches the surface, the knife can be inserted over the point of the director and the fistula made complete. Then the operation is finished in the manner already described. A most serious condition of affairs is found in another form of internal fistula — viz., one which be- gins on the inside of the sphincter and runs around or up the mucous membrane. These cases go a long time without de- tection. The discharge from them is usually carried away with the fasces and escapes the notice of the patient, and it is only by the reflex symptoms that our attention is first drawn to it, such as an irritation of the bladder, the prostate, pain in the back and down the thighs, which can not be accounted for from an examination of the other parts. Then an exami- nation should be made of the rectum. In this instance the patient should not be instructed to take an enema before the examination, for, by so doing, the pus is washed away, but, having him on the table, an examination should be made in this manner : First, without the use of any oil or ointment, the anus should be gently opened with the two thumbs, and by a little manipulation a drop or two of pus will be seen. I wish to reiterate here that whenever pus is noticed escap- ing from the rectum, it indicates some serious trouble, gener- ally an internal fistula or an ulceration. After this examina- tion of the anus the finger should be anointed and inserted into the rectum and a search made for the opening of the fistula. We can be easily misled, however, in this examina- tion. We are told that a little elevated spot, or perhaps a depression, with elevated edges, is what we will find indica- tive of the opening. This may or may not be the case. We often find these little rough places in the mucous membrane of the lower rectum. A better plan is to distend the sphinc- ters with a speculum, and, by putting in the electric light, a perfect view can be had of the gut for several inches. We may then see a spot which has the appearance either of a little ulcer or an opening. By taking a long probe it can be then placed on this spot, and if a sinus exists it will enter 15 226 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. it and likely will take a direction up the mucous membrane. A plan that I frequently practice is to insert the speculum, and, even if nothing pathological is discovered, to wait for a while, and we will see the bubbling up of a drop or two of pus. Case. — A lady came to me complaining with the many reflexes that I have mentioned ; also stated that she had localized pain in the rectum. She had been through the hands of a gynaecologist and also a gen- eral physician ; had taken much medicine, but was not relieved or even benefited, |jp and her symptoms at this time were progressing rather than diminishing. I made an examination in the manner that I have suggested, first of the anus, but could detect no pus ; second, with my finger but could find no internal opening. I then examined her carefully-, with the assistance of another doctor, and, al- though a good light was thrown into the rectum, nothing could be seen to account for her trouble ; but I suggested that we keep the speculum in situ for a few minutes and watch for results. After a little while the doctor said, "There it is," and, in looking at the spot, we saw several drops of pus oozing out. The probe was then introduced and a sinus found, extending up the mucous membrane at least an inch and a half. A grooved director was inserted through it, and it was laid open with the knife. I was not content with this, but trimmed off the edges of the cut mu- cous membrane. It was a long time before all of her reflex symptoms disappeared, but they eventually did so. I have suggested that the operation for internal fistula? of Electric light and cautery in case. TREATMENT OF FISTULA IN ANO. 227 this kind is a very difficult and sometimes a very serious one. All operators in this line recognize that cutting the mucous membrane to any extent in the rectum results sometimes in profuse haemorrhage. I have described in another part of the book the manner in which Mr. Gowlland, of St. Mark' s, deals with this kind of fistulae. Allingham, Sr., has devised a pair of spring scissors with probe points to be used through a special grooved director. The scissors can only be removed from the groove by drawing them out toward the handle of the director. This prevents the scissors from slipping out. He says: "With this instrument you can divide fistulge high up the bowel, however dense they may be, with great facility and quickness." It has been my experience that this form of fistula is not often dense, and there is no difficulty experi- enced in cutting through it, the chief difficulty being the con- trolling of the hemorrhage. Thermo-cautery ready for use. Mr. Luke, in 1845, recommended cutting through the diseased structures in these cases, especially when compli- cated with stricture, by means of a fine piece of strong twine and a screw tourniquet. Of course, his idea was here to avoid the hemorrhage that I have spoken of as attending 228 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. such operations. Allingham substitutes the elastic ligature. I am not in the habit of using either plan in these cases. In the first place, if a stricture is complicated by fistula?, the latter are the result of the stricture, and we will generally find that there are a number of sinuses. It would be a rare case indeed if only one existed. It would accomplish no good, therefore, to lay open the tract of the fistula, but in such a case the stricture, being the primary cause, should be operated on first ; but my experience has been in dealing with cases of stricture complicated with fistula, beginning above the strict- ured surface, that an operation for fistula did more harm than good. My plan in dealing with internal fistula? running up the gut is to divide the channels by means of a grooved director and a knife, and either touching the bleeding points with a hot iron of the thermo-cautery, or plugging the rectum, after the manner already described. With all the ingenuity at our command, we will often find it a difficult thing to cure this form of fistula, especially if it is at all complicated — as, for instance, a tract or tracts running around the bowel, under the mucous membrane, and up the bowel. Case. — A lady was sent me from an adjoining State with the following symptoms : She had been a subject for more than a year of intense pain at a point parallel with the spine and about two inches from it in the left lumbar region. Along with this, she complained of a burning heat or pain inside the rectum. The bladder sympathized to such an extent that she suffered from painful micturition and a frequent desire to urinate. This woman was in a condition of nervous exhaus- tion, although physically she appeared to be a healthy woman. She fought against her trouble, but her mind was greatly disturbed by it. So prominent was this symptom that her husband said to me that frequently she had a confusion of ideas, together with a disturbed memory. Whether she thought herself in an incurable condition, or whether it was in some other manner that her mind was disturbed, she was, to say the least of it, a confirmed invalid. Upon the first examination I could not detect a sufficient amount of trouble TREATMENT OF FISTULA IN ANO. 229 iu the rectum to account for her symptoms, and yet she referred all her trouble to that part. Upon the second exam- ination I found, just over the sphincter muscle, a small sinus, which I divided. I kept her under observation for several weeks, and her general health improved, but she still com- plained of this sensitive condition of the lower rectum. A few days prior to the time that she had appointed to return home I made an examination with the nurse, and found a little external opening just at the verge of the anus. Putting my probe into it, it ran up and entered the lower border of the sinus that I had divided. For obvious reasons I did not desire to put her under chloroform to divide this, so I inserted a small director through it and laid it open. This gave her great pain and greatly disturbed her, and I regretted after- ward that I had inflicted it upon her. She then remained at the infirmary for a while until this little wound had entirely healed. She returned home, but her letters to me indicated that she was not relieved. Although, in a general way, some- what better, the local condition had not improved. She returned to this city in about as bad a condition as she went away. I confess that I was nonplussed. I determined to give her another rigid examination, but suggested to her that when I did so I would also operate at the same time for any trouble that I might find, thereby saving the necessity of taking the anaesthetic twice. She was a brave woman and willing to submit to anything that I said. She was prepared for the operation and put under the influence of chloroform and a search of the rectum made. I used a stout director instead of a probe for the exploration, and, to my surprise, it fell into a sinus which ran down into the tissues at least an inch, be- ginning dorsal] y with a little inclination to the right side, and then taking a course through the tissues toward the perinaeum, coming up in front to the mucous membrane. I pushed the director through the membrane, and with a stout knife divided the tissues on it. The cut caused a profuse haemor- rhage. I had the wound irrigated with very hot water, and then the bichloride solution (1 to 5,000), and packed the 230 DISEASES OP THE RECTUM, ANUS, AND SIGMOID FLEXURE. wound with iodoform gauze, and then plugged the rectum after the manner that I have described in a former chapter. On the fifth day I removed the plug and the dressing, and no haemorrhage followed. For weeks the rectum was irri- gated daily with the different antiseptic solutions. Pus was kept from flowing, but the wound was a long while in filling up, and for two months after the operation an immense deal of mucus would follow each irrigation. She improved con- tinually after the operation, both in a local and general way, and was, at the last time I saw her, able to walk many squares, had a good appetite, and suffered comparatively little pain. The pain in the lumbar region, however, would appear at intervals, but was not very severe. This case illustrates that unless a surgeon is very careful in his investigations of the rectum, a sinus or sinuses may escape his observation. From the very nature of things, the wounds on the inside of the gut will be a long time in heal- ing. The faeces irritate it daily, and the sphincter muscle prevents a rapid cure. It also illustrates what delicate sur- gery has to be practiced in this variety of fistula. Frequent examinations, after these operations, should be made, in order to see that an ulcer does not result. It can not be too strongly impressed upon the operator that the greatest care should be taken in doing any cutting operation around the rectum upon women. The anatomical relation of the sphincter muscle is entirely different from that of the male, and incontinence of faeces will frequently result in them from these operations. Even a thorough dilatation of the sphincter muscle for the purpose of curing a fissure or irritable ulcer might result in this condition, and, to them, the result is of a much more serious nature than the disease for which the operation is done. Treatment of Fistula by Ligature. — Very great prominence is given by some authors to the elastic ligature as the means of cure for fistula. I must confess that the more I use it the less I am pleased with it. I never have employed it but that I thought that I was temporizing instead of radically TREATMENT OF FISTULA IN ANO. 231 curing the patient. ~No surgeon wishes to do his work the second time, and this is sure to be the case if the elastic liga- ture is used indiscriminately. It can be very properly called Dittel's operation. Whereas he was not the discoverer of it, he has been the strongest advocate for its use. Mr. Allingham has employed it in more than one hundred and eighty varied cases, and says : "I can truly say I have over and over again been very glad that the utility of the elastic ligature had been brought forward by Prof. Dittel after it had quite fallen into oblivion." As I have said concerning some other operations, in the hands of an expert rectal surgeon and diagnostician it might be employed with some success ; but to say to the gen- eral profession, or to the student, that this is a good oper- ation for fistula in ano, would be the means of conveying a wrong impression, and one that was likely to do much harm. After operating for this class of disease for many years, I must confess my inability, in the majority of cases of fistula, to tell whether there is any more than one sinus existing or not. Now, the advocates of the ligature must admit the fact that, until a cut is made, no surgeon can tell the number of sinuses or their extent. They must also admit that the external opening is no guide to the amount of trouble that he may meet in the operation. In fleshy per- sons, branch sinuses of fistula? often do not begin at or near the surface, but radiate down through the tissues, and no evidence of a pipe-stem feeling is given to the finger. If these assertions can be verified, then it must be admitted that in all such cases the ligature would fail to cure. The laying open of a main sinus by the knife, ligature, or what not, will not eradicate additional branch sinuses. Again, there is a toughened and indurated condition of the walls of the fistu- lous tract. The ligature, of course, cuts only through the top of this, leaving the bottom untouched. I have only to revert to Mr. Salmon's teachings, "that if the bottom of a long-standing fistula is not divided, it will be impossible to establish the healing process." He was therefore in the habit of drawing his knife through the bottom of the sinus, and it 232 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. is known to-day as Salmon's back cut. I say, therefore, with all deference to the distinguished surgeons that have advo- cated its use, that I do not believe it comparable : with the knife under any circumstances. Even granting that there is but one sinus, the knife will accomplish in a few seconds what it will take weeks for the ligature to do. There are four con- ditions, either one of which, if existing, should prevent the use of the ligature : 1. Where more than one sinus is known to exist. 2. When the fistula is of long standing and the walls of the sinus are indurated. 3. When the general ap- pearance of the parts indicates a flabby condition of the skin or tissues which would cause the edges of the wound to be a source of irritation. 4. In cases of horseshoe fistula. Believ- ing that this statement is true, there are therefore but few cases of fistula left in which the ligature would prove of service. Indeed, the only condition that I call to mind would be a fistula of recent date, superficial in character and of but one sinus. Even then I should be temj)ted to throw some mu- riate of cocaine along the route of the sinus and slit it open. When the ligature has cut its way through, after several weeks' time, it has accomplished the identical thing that the knife does at last — that is, a division of the tissues. So it occurs to me that it is simply deferring to the whims and prejudice of the patient against the use of the knife, not to consider the other arguments that I have used. Again, in these days of antiseptic surgery, no surgeon desires to see pus escaping from wounds. It would be impossible to pre- vent this if the ligature is used in dividing a fistula. If, after the ligature has cut through the tissues, it is discovered that there are additional sinuses, the knife must be resorted to at last, for they may run in such directions or be so tortuous that the ligature could not be used for their eradication, and if this procedure had to be gone through with, the patient's reasoning powers will teach him that it would have been bet- ter to have used the knife at first. Or, if it is noticed, after the ligature has accomplished its purpose, that the edges of the wound are in a flabby condition, then these flaps must be cut Plate V. FOR FISTULA r IGATURE. TREATMENT OF FISTULA IN ANO. 233 away to insure the healing process, and to cut them away would be as severe as the knife would have been in the begin- ning. Or, if the operation has been done on an old-standing case of fistula, it will be observed, after the ligature has done its work, that the bottom of the sinus is in an indurated or callous condition, and, admitting that there is only one sinus, Mr. Salmon's back cut must be made through it to insure the granulating process. In horseshoe fistula no one would advo- cate its use. Advantages of the Ligature. — Allingham says: "What are the advantages of the ligature? Briefly these: That in sim- ple cases there is little or no pain inflicted by the operation ; the patient can walk about without danger. I have had many cases proving that nervous persons will often submit to the ligature when they will not to the knife. There is no bleeding — a manifest advantage in persons whose tissues bleed copiously on incision. I have found it useful in several such cases. In phthisical cases it is, in my opinion, the best means of dividing a sinus. In very deep, bad fistulse the elastic ligature is most valuable as an auxiliary to the knife. I now most frequently use it in this way— avoiding haemorrhage in sinuses running high up the bowel, where large vessels are inevitably met with." I will answer these statements briefly as follows : 1. " That in simple cases there is little or no pain inflicted by the operation." I have used the elastic ligature in quite a number of cases of fistula in ano, and I must say that I have yet to see the first patient that did not say that it was pain- ful. A ligature that is applied tightly enough to cut through tissue must be painful. Certainly the pain and distress are sufficient to prevent the ordinary application to business, and in each one of my cases the patients assumed a stooping in- stead of the erect position, and walked with some difficulty. Indeed, such was their condition that they did not desire to move about at all. 2. "The patient can walk about without danger." I once heard Prof. Richard O. Cowling, deceased, testify be- 234 DISEASES OP THE RECTUM, ANUS AN'D SIGMOID FLEXURE. fore a jury that no wound was so insignificant that it did not call for absolute rest. The expression was one of much meaning and made a great impression upon me at the time, which I have never forgotten. To say that a patient can walk about without danger one can hardly be certain, and to say that he is abte to walk about should be no argu- ment in favor of the operation. The wound would be con- stantly irritated by any such exercise, and the flow of pus insured. I can scarcely consider it good surgery to allow a patient to walk about with a wound that has to heal by granulation, especially when located in the region of the rec- tum. Surgeons to-day consider it of absolute necessity to dress wounds under aseptic and antiseptic precautions every day, and one objection to the use of the elastic ligature at all is that while they are making the wound, the cut surfaces can not be dressed at all, and if we add to this that the pa- tient is allowed to walk about and attend to his professional or other duties, surely this condition of affairs is increased. 3. "I have had many cases proving that nervous persons will often submit to the ligature when they will not to the knife." A distinguished specialist in the treatment of syphilis at Hot Springs, Ark., was in the habit of questioning his pa- tients as to their habits, such as the use of stimulants, tobacco, etc., and if he learned that they indulged in such, he would say to them positively that they must leave it off. If they answered that they would not or could not, he would say to them : "Then you go to some other doctor for treatment." I think that a good rule for a surgeon to adopt would be, if a patient said that he would not submit to the knife for an operation for fistula, when the surgeon was satisfied that the knife could be used and was the best, to tell him that he had better get another *surgeon. Surgeons often bring themselves into disrepute by succumbing to the dictation of patients, and I can see no better illustration of this than to use the ligature simply because a nervous person would not submit to the use of the knife for the treatment of a case of fistula in ano. TREATMENT OF FISTULA IN ANO. 235 4. " There is no bleeding — a manifest advantage in deal- ing with patients whose tissues bleed copiously on incision." In witnessing a number of operations done by my friend, Dr. John A. Wyeth, of New York, who has the reputation of doing ' ' bloodless " operations, I was impressed with the idea that haemorrhage is so easily controlled by the au fait surgeon that it is to be no longer dreaded. Therefore, in these operations about the rectum, " tissues which bleed co- piously on incision " can be easily controlled by the surgeon. 5. "In phthisical cases it is, in my opinion, the best means of dividing a sinus." To my mind, of all cases requiring the use of the knife for the eradication of fistulas, those occur- ring in the tubercular subject are the most important. In these subjects there is no well-defined sinus, but a degenera- tion of tissue, causing a cavity. When the cut is made, much flabby skin is found, and the skin itself, if not the tis- sues, is undermined. Add to this that different pockets are often found, which require scraping or trimming, and the ligature is certainly the worst of all methods for treating such cases. We all know, too, how indolent these wounds are, consequently how slow to heal. They require our con- stant attention, which should be begun from the very mo- ment that the operation is performed. If the ligature is used, we are compelled to wait until it has cut through be- .fore any attention can be given to the wound proper. I would also suggest that the effect upon the mind of a phthisi- cal patient wearing a ligature is anything but pleasant. 6. "In very deep, bad fistula^ the ligature is the most valuable as an auxiliary to the knife." To this I would pre- fer the same objection as that given in No. 4. In operating for deep fistula I have never yet seen a condition that I would not prefer to use my knife throughout the whole operation. If blood-vessels were divided that could not be tied, pressure has invariably stopped the hemorrhage. 7. "I now most frequently use it in this way— avoiding hemorrhage in sinuses running high up the bowel, where large vessels are inevitably met with." 236 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. I have never been partial to the elastic ligature in dividing fistulse that run up the bowel. For such purpose I much prefer the silk ligature, used after the manner of Mr. Gowl- land, or in the ordinary way. It does its work much quicker and with much less inconvenience. So it will be seen that I dissent from each and all of the so-called advantages of the elastic ligature over the knife, and I submit to the profession whether my objections are valid or not. I have sometimes thought that the silk ligature, used after the manner of the old physicians, had some advantages over the elastic ligature. One is that it can be more easily applied ; another, that it can be only moderately tightened. The only disadvantage it has contrasted with the elastic ligature is that it takes much longer to accomplish its work, and yet these patients, who have such horror of the knife, can easily afford to take a longer time if they are freed from pain and allowed to prosecute their busi- ness. The manner of applying the elastic ligature is very sim- ple. Numerous devices have been suggested for placing the ligature through the fistulous tract, but I am persuaded that the easiest and best is to thread a very stout probe with the ligature, and insert it through the sinus, pulling the distal Allingham's ligature carrier. end out of the anus and placing a bullet, through the center of which a round hole has been made, over the two ends, and pushing it up with a pair of tooth or other forceps, close against the tissues ; then, pulling firmly on the two ends of the ligature, the bullet is clasped tightly. This rubber cord should be of sufficient strength to bear a good deal of weight, and should be drawn so taut as to cut through without any further re tightening. But if it is noticed, after a sufficient length of time, that the ligature is loosened and hanging TREATMENT OF FISTULA IN ANO. 237 in the wound, then, by taking another bullet and cutting through its side, it is placed over the ligature, and, drawing it tightly again, the bullet is clinched. It wi]l then cut through the remaining tissue. Allingham, Sr., has devised an instrument for drawing the elastic ligature through a fistula from within outward that in the hands of an expe- rienced surgeon answers an admirable purpose. Treatment of Horseshoe Fistula. — This is the most serious form of fistula in ano with which the surgeon meets. I have never liked the term horseshoe fistula ; a better one would be com- plex fistula, because it gives a better idea of its pathology. In this form of fistula the idea that is meant to be con- veyed is that it encircles nearly completely the rectum. There may be only one external opening, but generally two internal openings. It will be seen at once that the objective point here is the sphincter muscle. The rule that should be always carefully observed is, not to cut through the exter- nal sphincter muscle twice at one sitting. Case. — A young man was brought to me, by his family physician, who gave the history of having had a large rectal abscess about a year before. It had left him with a fistula, the external opening being in the pernueum. He complained of the frequent formation of what were pus cavities in each buttock, which would break and discharge through this open- ing, and then, for an interim of perhaps several weeks, he would feel comparatively easy. Lately one of these cavities had broken through the rectum, discharging a good deal of pus. His general health had been impaired from the constant drain. I examined him as carefully as I could without an anaesthetic, and determined that there was a great undermining of tissue in both buttocks, and, extending across the coccyx, was a distinct feeling of a whipcord, which evidenced the con- nection between the two sides. I expressed to his physician the opinion that it would be a serious operation ; that the wound would be a long time in healing, and that perhaps the sphincter muscles would be impaired by the operation. We agreed to do the operation after a couple of weeks prepa- 238 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. ration, which consisted in building the boy up as well as we could by tonics, stimulants, and nutritious food. At the end of that time the operation was done as follows : The patient was put under ether and a long grooved director introduced into the external opening in the perinseum. It rapidly fol- lowed the large sinus which ran around on the left side and was forced to a point over the coccyx. A free division of the tissues was then made. We could then look down into this large, ugly wound, and, by placing my finger at its bottom, several smaller cavities were detected and the knife drawn through their bridges. I scraped it thoroughly of its debris, and had the wound irrigated with the bichloride solution. By the use of a probe a sinus was detected nearly midway of the cut, which ran into the bowel in a course toward the coc- cyx, but which included the sphincter muscle. I divided this sinus, and then proceeded to trim off the overlapping edges of skin all along the route. The whole wound was packed with surgeon's cotton, which had been dusted with boric acid. I refrained from operating upon the other side, although my examination showed that it was equally affected, because of the damage that would be done the sphincter muscle, not only by its division, but by cutting away so much tissue around it, leaving it without support. This wound was carefully watched, the general health of the patient looked after, and in six weeks after granulation had been established nearly to cicatrization, I operated on the other side, doing an oper- ation very similar to the first. It was four or five months before this patient could be discharged as cured, for during the time he was under treatment there was pocketing several times. After-treatment for Fistula. — It requires as much knowledge and care to carry the wound inflicted for a rectal fistula on to a perfect result as to do the operation. I am satisfied that just as many cases that result in a failure to cure are due to the want of a proper treatment after the operation as to the manner of doing the operation. Therefore I would advise the surgeon to keep these patients under his own observation and treatment TREATMENT OF FISTULA IX AXO. 239 until a cure is effected. One of the greatest dangers to be ap- prehended is the confinement of pus, and another abscess or pocketing of the tissues. If these are not dealt with just at the time of their occurrence, the fistula is very sure not to heal, and yet a little care on the part of the surgeon will pre- vent this. The two places that should be watched especially are the beginning and the end of the wound. This is espe- cially true if the external opening is located either in the perineum or dorsally over the coccyx. A pocket is very apt to form just under the skin at these two places, and if a kuife is drawn through them soon enough they cause but very little trouble. It must be remembered that these wounds must heal by granulation from the bottom. Time was when surgeons thought that pus was necessary to the healing of the wound ; but now, if we witness it in or on wounds, we know that something is radically wrong. Of all portions of the body, around the rectum is the most difficult to prevent wounds suppurating ; therefore, if we have a deep wound to deal with, it requires the most careful watching and treat- ment to prevent the pouring out of pus and its being held in the bottom of the wound, sometimes confined in a pocket. Each time that it is dressed, it should be seen that the sides of it do not lie in apposition. We will often think that we have the wound distended when we open the top of it and look down into it ; but if we will take a small instrument and insert at the bottom, we will find that the granulations have simply united from the sides. These should be broken up at once. My friend Dr. Leon Straus presented me with a little instrument that he brought with him from St. Mark's, de- vised, I think, by Mr. Herbert Allingham. It is a metal rod, eight or ten inches long, which he uses in pulling through the bottom of these wounds. It is quite a neat instrument and answers the purpose admirably. As a substitute, if one has not such an instrument, I would suggest the wrapping of an ordinary pen-holder with a thin layer of cotton and using it for the same purpose. The idea is that the bottom of the wound must be inspected every day to see that the granuia- 240 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. tions come up and no union takes place from the sides. It is a matter of some concern how to dress these wounds each day. For the first week my habit is to irrigate them with the bichloride-of -mercury solution (1 to 5,000). This, I am sure, is the best agent to prevent suppuration and does not interfere with the granulation. If the fistula has been a very complex one and many sinuses were divided, leaving a ragged wound, the very best dressing for a few days, at least, is Marchand's peroxide of hydrogen. This is a wonderful cleansing agent and has strong antiseptic properties. After the irrigation with the bichloride solution, I either dust the wound with powdered iodoform or lay a strip of iodoform gauze gently in the wound, pushing it down to the bottom with a pair of forceps. After the first dressing, the wound should never be stuffed or packed with anything, but simply a thin layer of the gauze placed between the sides. I then put a large piece of absorbent cotton over the wound and apply a T-bandage. The first dressing is usually removed on the second day. I believe that this is better than to allow it to remain three or four days, from the fact that a good deal of blood has oozed into the dressing, dried there, and acts as an irritant. The subsequent dressings are as I have detailed, with the exception that I frequently substitute, in the second week, a carbolized hot- water irrigation, or I make a solution of one part of campho-phenique with ten parts of hot water and wash the wound with it. Campho-phenique is a combination of refined camphor and pure chlorophenic acid. It prevents suppuration in fresh wounds and controls it in wounds at all stages. It has a local anaesthetic property which obtunds pain, and in this respect is preferable to the bichloride solution. I have carried a great number of large wounds to a perfect healing by the aid of these agents, which I again beg to repeat : Solution of bichloride of mercury (1 to 5,000), carbolic acid, campho-phenique, and iodoform. I have stated in a subsequent chapter that I did not believe that there was anything in the way of a surgical dressing that can equal the powdered iodoform. In these wounds made in opera t- TKEATMENT OF FISTULA IN ANO. 241 ing for fistula in ano it can not be dispensed with. It has but one objection, and that is its odor ; but patients have to learn to submit to it, just as they have to accept many things that they do not like. Proper care should also be given these patients for the maintenance of as good physical condition as possible during the treatment. It is not necessary to confine any case of the kind to bed for any great length of time. But this advice applies especially to operations upon phthisical patients. They should be allowed to exercise around the room or in warm halls. The debilitated patient should be properly fed, given stimulants when the physician thinks it is best, and tonics, constructives, etc., when demanded. A gentle laxative should be kept up during the entire treatment. I wish to reiterate that it requires as much knowledge and care to carry these patients through to a perfect result as any operation that is done in surgery. 16 CHAPTEE X. THE NERVOUS OR HYSTERICAL RECTUM. It has been said by some one that when the physician is confounded and can not make a diagnosis, he calls the affec- tion either hysteria or neuralgia. The general practitioner is often worried with his so-called hysterical cases. Since closer attention has been paid to nerve diseases, a clearer elucida- tion of their nature has been brought about. I have never been much of a believer in the term hysteria. From my observation of such cases, witnessing the symptoms, etc., I have always thought there was some cause for complaint out- side of mental impressions. The gynaecologist has found this out, and is to-day dealing with pathological conditions in the abdominal cavity which have been the main source of pro- ducing such disorders. Hysteria and melancholia go hand in hand, and by a reference to statistics we see that these pa- tients frequently drift into insanity. The point should be made out whether the cause be in the mind or in the body, and, having determined this, we are to go to work to locate the seat. Many a woman has been restored to health and to her family, that had been an invalid with this so-called hys- teria, by having a diseased ovary removed, or adhesions broken up in the abdominal cavity. It has become rather a fashionable thing to say that one suffers from nervous ex- haustion, and even physicians fall into error by classifying it among the simpler affections, when in truth it is one of the most serious diseases to which the human body is subject. To-day one of the most prominent subjects under discussion by the medical profession is nerve reflex, and I shall have occasion further on to deal with the subject in extenso. Not THE NERVOUS OR HYSTERICAL RECTUM. 243 only the general practitioner, but also all specialists, meet with hysteria or hysterical symptoms in some way or another, and the rectal surgeon is not exempt from this. In the past I have seen a great many obscure rectal affections resembling hysteria in their symptoms, and I do not know of any class of patients that suffer so horribly as these. I censure myself, even at this day, in my neglect of these people. In the past I took it for granted that they did not suffer as much as they intimated, and after a partial examination I frequently gave them a placebo only. These people invariably drifted into other hands, oftentimes into those of the quack, and perhaps would go through life without receiving any permanent bene- fit. I have headed this chapter The Nervous or Hysterical Rectum, in deference to the title used by Goodell, who read a paper before the American Medical Association (Obstetrical and Gynaecological Section) in May, 1888. The title used by Dr. Goodell was The Nervous Rectum, but the term most used in the article was "hysteria, or hysterical rectum." I believed then, and believe now, that the former caption was the more correct. In explanation of the position that he took he said : " The mind is sane, the organic body is sound, the individual as a whole is above reproach, and yet these muscles will be- have as if they were bereft of reason." Again he says : "The muscles most liable to become hysterical are perhaps the cir- cular ones, namely, the sphincters of outlets or inlets ; and while insanity, so to speak, is more localized, the sufferings are perhaps greater." The term employed here, "hysterical rectum," is, in my opinion, misleading ; and while the importance of these cases can not be overestimated, I am sure that the matter would be better understood if he had written of "some obscure affec- tions of the rectum," for the reason that it invites investiga- tion. Any surgeon who has had much to do in the way of examining the rectum has met with cases where the patient complained much when but little if any disease was found. Now, I will be permitted to say that I think the reason is that we frequently dismiss these patients without a thorough 244 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. examination. When one comes to .us complaining of a dis- turbance in the rectum, we naturally expect to find some of the ordinary diseases, such as haemorrhoids, fistula, ulcera- tion, or perhaps cancer ; but it requires a little longer time and a good deal more trouble to have the rectum washed out, the patient put in a proper position, and a search made for some small lesion, which, under the circumstances, is very apt to exist and to be the cause of all the symptoms that the patient may complain of. But if we come to the con- clusion, without this examination, that this patient is hysteri- cal, we are too apt to put her upon a nervine, or perhaps a tonic, and dismiss her. The result is that we never see her again as a patient. Webber defines hysteria to be "a dis- eased state of the nervous system evidenced by an almost in- numerable variety of symptoms." Recognizing to-day the power and manner of the reflexes, we had better say that we can have a diseased condition, simulating hysteria, caused by disease or an irritability of the periphery of a nerve. It is too common to class these patients as suffering from a functional nervous disease, when in reality it may be from a pathological condition at the terminal end, and not central, attended with nervous symptoms. Goodell further says, in speaking of the hysterical rectum : "In this form of hysteria there is usually present, in my experience, some one of the Protean symptoms of general nerve prostration, such as spine-aches, backaches, sore ovaries, weariness, wake- fulness, and nervousness ; but the chief suffering of the most exacting symptom is referred to some portion of the rectal tract, leading the physician to suppose that he is dealing with some coarse or traumatic lesion. The act of defecation then gives great suffering, followed by a painful throbbing, which may last for hours. Patients thus afflicted so dread the suf- fering that they school themselves into habits of costiveness, and often become victims of opium-eating.' ' This is a perfect description of this class of patients, many of whom would prefer death to such a life, and we would not be stating the case too strongly were we to say that this con- THE NERVOUS OR HYSTERICAL RECTUM. 245 dition will often end in actual insanity. In my experience as a specialist, I have had two cases to be confined in an insane asylum from just such a cause. But is Goodell correct when he says that such a case "may lead the physician to suppose that he is dealing with some traumatic lesion ' ' ? Would it not be stating it more definitely, correctly, and to the point, to say that in such a case the physician is dealing with a traumatic lesion ? Can any one doubt, after reading a descrip- tion like that given above of the hysterical rectum, that he has a diseased condition of the rectum to deal with % Where could you find a better description by any author of an ulcerated rectum than is given here: " Nerve prostration, spine-aches, backaches, sore ovaries, weariness, wakefulness, and nervousness " ? Now, in a general way, almost any spe- cialist, especially the gynaecologist, could account for these symptoms by referring the origin to the ovaries, tubes, or uterus. The general practitioner would find many conditions that would produce like symptoms, but in a further perusal of the case we are told that the chief suffering, or the most exacting symptom, is referred to the rectal tract. Now, we would naturally look to this tract for an explanation of the trouble. It either must be that there is some disease there, or by a reflex action the symptoms are made manifest in the rectum. Be that as it may, we are dealing with a pathologi- cal condition. Either the disease is located in the rectum, and by reflex is making the spine ache, ovaries tender, etc., or the disease is in some other part, and is reflected to the rectum by its nerve distribution. But a further study of the case aids us in making the diagnosis. " The act of defecation then gives great suffering, followed by a painful throbbing which may last for hours. Patients thus afflicted so dread the suffering that they school themselves into habits of cos- tiveness." I think rectal surgeons will bear me out in saying that in ninety-nine cases out of a hundred an examination of a patient suffering from these symptoms would reveal a lesion in the form of a fissure, irritable ulcer, ulceration proper, or it may be a peeling off of the epithelium, if not the mucous 246 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. membrane. I am certain, then, that in such cases, first, a lesion exists, and that the disease can not be cured until said lesion is eradicated. Secondly, if in these cases a lesion can not be found in the rectum after a long and diligent search, then they must be set down as a reflex condition, and by our knowledge of anatomy we shall either trace it out, or send it to a specialist who can do so. Since I have taken this view of the case I have given my patients a more careful examination, and have usually found a lesion, and by a treatment of the same I have usually cured them ; or if I was satisfied that the symptoms were those caused by reflex from some other dis- eased part of the body, I have referred them to the specialist to which they belonged. If it is a female, she is usually sent to the gynaecologist. If a male, he is sent to the genito-urinary surgeon. These cases are more common than they are be- lieved to be by the general practitioner, and they merit our closest scrutiny and care. Case I. — A young girl came to me who had been treated for three years for chronic diarrhoea. The least excitement would cause her bowels to move. She had on an average six to eight evacuations a day. If a stranger came into the room, she had to rush for the water-closet. She could not go into society for this reason. For three years she had taken no nourishment, by order of her physician, except stale bread, milk, and weak tea. She had "Protean" symptoms of nerve prostration, backache, wakefulness, nervousness, etc., to- gether with a burning sensation at defecation, and an aching pain hours afterward. I gave this girl a careful examination, and found a sensitive spot in her rectum. Under chloroform I divulsed the sphincter muscles and touched the spot with nitric acid. She made a rapid recovery. In a few days all looseness of the bowels had disappeared, and she ate a full meal three times a day. Case II.— Dr. J. G. Carpenter, of Stanford, Ky., thus re- lated to me a case in his own person : " I was the victim once of this spasmodic contraction of the sphincter ani muscles. Often, when riding on horseback and feeling perfectly well, I THE NERVOUS OR HYSTERICAL RECTUM. 347 would be seized with a sudden pain in the rectum, the sensa- tion passing all over me as if I were struck by lightning, causing me to drop the reins in agony of seemingly impend- ing death. A few weeks would elapse before another attack. On every sudden change of the weather I was affected. Forcible dilatation of the sphincter cured me." Case III. — William B., aged forty-eight, was sent to me suffering from the following symptoms : At the approach of defecation he felt a severe pain up in the rectum, thought by him to indicate the passage of the faecal mass over a sore place. During the act a lancinating pain was experienced, and after evacuation a dull, throbbing, aching sensation which lasted for hours. A nervous exhaustion supervened, which com- pletely unfitted the patient for any mental or physical labor. This condition lasted about two years. The symptoms seemed clearly to call for the divulsion of the sphincter. This was done under chloroform, and the patient was promised a cure. Several weeks after, he reported at my office, saying that he experienced no relief whatever, and expressed a desire and hope that he would die, so terrible was his distress. I then carefully examined him again, and could find no lesion what- ever. Recognizing the powerful effect of the reflexes in these cases, I advised that he go to a genito-urinary surgeon and be examined for a stricture of the urethra. This he did, and was told that he had both a meatic and deep urethral stricture. These were divided by the surgeon, and the man was relieved of all his distress. Case IY. — Dr. H., of Indiana, asked me at one of the medical societies to examine him after he had given me the following history : Several years ago, while pursuing his pro- fessional duties, he was attacked by a fearful pain in the rec- tum. It was as if a sharp knife had been thrust through him. It would come up as paroxysms, with a few moments only of intermission. He hastened to procure chloroform, and inhaled it at each approach of the paroxysm until it disappeared. He now carries a bottle of chloroform with him, and regards it as his best friend. Indeed, he says nothing would induce 248 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. him to part with it. He would go for weeks perhaps without an attack. Placing him in bed, I examined the rectum care- fully with the index linger. I had no instruments with me. I gave it as my opinion that a lesion existed, perhaps only the exposure of a sensitive nerve, and if a free divulsion of the muscle should not effect a cure, the lesion should be sought for and a local application made to it. He afterward consulted Dr. Cook, of Indianapolis, who gave him a careful examination with the speculum, and agreed to the diagnosis I had made. An operation was not done. We met him months afterward, and he reported that he had never had another attack, but he still carried the chloroform. Case V.— A professional gentleman, sitting in his office with his feet elevated, felt a quick, sharp pain dart through the rectum, near the verge of the anus. These pains came quick and often. He jumped to his feet and called for help. A friend, coming in at the time, caught him as he was in the act of fainting. The attack lasted about twenty minutes and was quieted by opium. I directed that he be taken home, and that suppositories of belladonna and opium be adminis- tered for their full effect. The patient had three other at- tacks in so many days, after which all intimation of rectal disease subsided, but I should add that his rectum had been treated during this time by free washings out with hot water and the use of suppositories. Case VI.— Dr. W., of the southern part of this State, came to me less than a year ago complaining that at the act of defecation he suffered a tormenting pain, which lasted from one to four hours, and then during the interim, between the acts of defecation, there was a dull, heavy feeling of weight experienced in the rectum, extending to the perinseum. It completely unfitted him for his country practice. An ex- amination revealed a congested condition of the vessels just at the verge of the anus, with one or two sensitive places around the gut. My assistant gave him chloroform, and I freely divulsed the sphincter muscles. He expressed himself as greatly relieved, and on the fifth day returned to his home. THE NERVOUS OR HYSTERICAL RECTUM. 249 In two or three months thereafter he began writing me that there had been an entire subsidence of his trouble, but that he was satisfied it was coming on him again. The symptoms increased rapidly, and after the expiration of several months he came back to me, suffering as much or more than he had previously. A friend of his said to me : " All of this man's trouble is in his mind" ; but the doctor said : "I believe that if you will practice a little cutting, with the free divulsion of the muscle, it will cure me." So the next day Dr. Dugan saw the case with me, when we agreed to administer an anaes- thetic and to do as the patient had suggested. I forcibly divulsed the sphincter, feeling it give way in its entirety. Then I inserted a speculum, and held it, while Dr. Dugan thoroughly scarified the gut. In less than three hours after the operation the patient said: "I feel now different from what I did after the other operation, and I am satisfied that I am cured." He went home on the sixth day, and I have heard nothing from him since. This case not only proves what I have said — that a lesion exists — but it also demonstrates that there are many cases in which the divulsion alone will not accomplish a cure. The nerve filaments that were ex- posed in this man's rectum had their sensibility destroyed by the use of the knife. Case VII. — A physician living near my office sent his servant after me with the message to come as quick as I could to see him. I did so, and found him in the most ago- nizing pain. He said that an hour before this, pain had begun in the rectum, seemingly without cause, and that it was unendurable. He had taken opiates freely, and had in- haled chloroform. He expressed the belief that it was caused by spasm of the sphincter muscle. I asked him to allow me to examine him digitally, and he reluctantly consented. I found the muscle spasmodically contracted, and it was with a good deal of difficulty and pain that I succeeded in getting the finger beyond it. This, however, I accomplished, and found just beneath the prostate gland an indurated and de- nuded spot. After the removal of my finger he said that he 250 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. felt that that small amount of dilatation had done him good. I suggested that he allow me to chloroform him and divulse the sphincter. As the majority of physicians would have done, he refused, but suggested that I send him a dilator in the form of a bougie, that he could introduce himself. This I did, substituting an oval speculum with a conical guide, and, by anointing it, he pushed it into the rectum and held it there quite a while. This procedure he kept up for some time, and, together with injections, suppositories, etc., he got over his attack in a few days. Unless that abrasion is cured, he is liable to have another attack at any time. Cases I, II, IV, and V were evidently traumatic lesions, causing the exposure of a nerve, and Case III was due to a traumatic stricture of the urethra, and the pain in the rec- tum was entirely reflex. All the rest of the cases were proved to have originated from disease in the rectum, though very difficult to find. Therefore I say if these diseases are relieved by local measures, it proves the affection to be local, or, more properly speaking, pathological, and not hysterical ; primary, and not secondary, in its nature. If they had been hysterical, the local treatment would not have given relief, but a constitutional course of treatment would have been necessary. Groodell says in his article : " Sometimes the site of the rectal pain lies higher up than the sphincter muscle, and is irrespective of the act of defecation. It is then liable to be periodical in its character, coming on at regular hours of the day, probably from the periodicity with which the accumulation of faeces in the lower bowel takes place." According to this statement, I can not believe in the idea of hysteria attacking a muscle, for the reason that the above is not a description of any unique condition found in the rec- tum, but is a very common one to the rectal surgeon. It is an every-day affair for the patient to say to us that the pain lies higher up than the sphincter muscle, and is not con- nected with the act of defecation. Investigation of these cases has demonstrated to me the fact that it requires a very little lesion to produce such symptoms. The books usually THE NERVOUS OR HYSTERICAL RECTUM. 251 refer to ulcers, or ulceration proper, as producing them, but in many instances I have found that the simple peeling off of the epithelium at certain spots is sufficient to bring about such a condition of affairs. In other words, I do not think it necessary that the gut should be ulcerated, and I know of no term to express exactly this condition, and yet through the speculum I have often seen it, and have called attention to the fact that it accounts for haemorrhage some- times from the rectum. In former years I was in the habit of searching for a well-defined ulcer, and paid very little at- tention to the condition of which I am now speaking, but by experience I was taught that it was of more importance than I deemed it, and yet I was more or less excusable, for the reason that I had never had my attention called to it by any of the text-books, and the truth of it goes to prove a fact which is pertinent to this question — that it requires a very small amount of change from the normal condition to produce the symptoms of which we have spoken. The very fact, as Groodell says, that the trouble is periodical in its character, coming on at regular hours of the day, probably on account of the periodicity with which the accumulation of faeces in the lower bowel takes place, will incline the rectal surgeon at least to suspect some abnormal condition in the bowel. I think that we can dissipate here all idea of " hys- teria" attacking the muscles. The muscle which would likely be affected — the external sphincter — is not in contiguity with the disease proper. Those that have observed these diseases with much precision have found that, when the lesion or abrasion is located in this part of the rectum, the sphincter is not made to respond to nerve irritation, but that we get the symptoms through other organs or by the reflexes. It is only pressure upon or disease of the nerves which supply the sphincter that produces the irritability and the so-called spasmodic action of the muscle itself. For in- stance, if we have what is called an irritable ulceration en- croaching upon the sphincter muscle, we will have the tor- menting and agonizing pain of fissure, and yet in my practice 252 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. I have known many instances of ulceration to exist in the bowel for a sufficient length of time to produce a strictured condition of it, and yet the patient had complained of but little pain. Indeed, such persons are more apt to come to you to be treated for constipation than for ulceration. I would therefore prefer to consider for the balance of the chapter what we could more properly term Obscure Diseases of the Rectum. — I believe with Webber that hysteria can be defined as "a disease of the nervous system having no recognized pathological condition. " I certainly be- lieve that it is impossible for a muscle to be attacked by such disease ; but whenever we have evidences such as have been described, they are, in my opinion, the result of disease at the seat of trouble, or by reflex from continuity of structure. Under the latter condition we will find disease as the cause of such symptoms located somewhere. If either one of these propositions be true, then the idea of such diseases being "hysterical" in their nature can not be sustained. The pro- fession has fallen into the habit of accepting the ordinary definition for hysteria, which is that it simply means an as- suming of symptoms when no disease exists. A better term for such manifestation in the rectum would be neuralgia, although, in the ordinary sense and application of the word, that is a misunderstood and a misapplied term. There are very many pathological conditions which exist in the rectum, any of which could, and do, present all the symptoms of the so called hysterical rectum. I can not, therefore, too strongly urge the necessity of a careful examination to detect these changes. For instance, the rectum because of its peculiar office, of its deficiency of valves in the venous supply of blood, of the dependent position, etc., is quite liable to a con- gested state, if not to an inflammatory one. Of course, the term congestion would signify that there was too much blood in this part, and that its return through the veins was im- peded ; hence we would have the so-called varicose condition existing here which is termed by some authors li&mor- rJioidal. Although I do not believe that a dilated vein or THE NERVOUS OR HYSTERICAL RECTUM. 253 a varicose vein, if you please, constitutes a hemorrhoid, yet I am satisfied that this is the incipient state which will lead to the hemorrhoidal condition, if not overcome. But, as I have mentioned, you may have this congested condition, at- tended with some inflammation ; and just as you could have varicose veins in the lower limbs, followed by ulceration, so you can have it here. Authors are in the habit of dealing with this state of ulceration as a consequence of the exist- ence of haemorrhoids. This is a very different state of affairs from the one of which I am speaking. In hemorrhoids we can only have ulceration as a condition resulting from fric- tion, brought about by frequent protrusion, etc., and I would mention that it takes a long time to produce such a condi- tion ; but where the blood-vessels are strutting from an over- distention of blood, it is very easy to understand that by the pressure of hardened feces as an irritant or of a dis- placed womb as an obstruction to the return of the flow, we could have a lesion in the vein wall which would terminate in an ulceration. Therefore I am inclined to the belief that although the theory usually given for the production of the hemorrhoidal condition is correct, I am satisfied that that which is initial of the hemorrhoids — namely, the congested blood-vessels — is also initial of the ulceration, etc., that is found in the rectum. As a cause of obscure disease of the rectum I mig-ht mention foreign bodies which frequently lodge in the pouch and produce distress, if not trauma. Case. — Several years ago a lady patient was sent me from Bowling Green, Ky., for examination. She said to me that she believed she had cancer, and a note from her physician implied that that was his opinion. This woman suffered with really an obscure condition of affairs. She did not have any acute pain, but said that she was always miserable — pain in the back and the thighs, and a general lassitude. She had lost much flesh, was constantly thinking of herself, and re- marked that she had no special desire to live. I attributed this more to her belief that she was suffering from malignant trouble than anything else. Placing her on the table, I intro- 254 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. duced my finger into the rectum, and immediately above the external sphincter, toward the perinaeum, I felt a hard, nodu- lar lump, which could be very well circumscribed. The rest of the gut seemed to be healthy. She gave no history of an abscess or of an acute inflammation of any kind. I told her, after the examination, that I thought an operation was necessary, which meant a free removal of the tumor. The next day she was attacked with pneumonia, and was attended by a physician friend in this city. After her recovery she was in such a debilitated condition that her physician ad- vised her to return to her country home and remain there until she was sufficiently recovered, in a general way, to undergo the operation. I did not hear from her for months, when one day I met a relative of hers in a hotel, who said to me: " Did you hear how that case turned out?" Not having heard from her at all, I said that I was ignorant of anything concerning it. He then told me that a few weeks before, while suffering from a diarrhoea, which was a common thing with her, she had gone to stool, and, in her effort to pass everything from the bowel, strained vigorously, but felt that there w T as something which would not pass. So she intro- duced her own finger into the rectum, and, feeling a hard sub- stance there, hooked the finger around it and pulled it out. And what do you suppose it was 3 " said the man. I had to confess my ignorance. " Why," said he, "it was a large jaw tooth with a perfect gold filling." I asked him if she gave any history of swallowing this tooth, and he replied that she did, saying that eighteen years prior to this, in the extraction of a number of teeth, she remembered to have swallowed one. It had become imbedded in the tissues of the rectum and remained there, and afterward ulcerated through. It is need- less to say that all her "obscure" symptoms disappeared. It is a very easy matter to wound the delicate mucous mem- brane at the verge of the anus, and if a lesion is once started, however small — even too small for detection — these obscure symptoms will result. In many instances one passage of hardened faeces is quite sufficient to accomplish the result. THE NERVOUS Oft, HYSTERICAL RECTUM. 255 The use of rough substances as a detergent, in which list I might include common printed paper, will accomplish this. The enema tube is known to be a frequent cause of such trouble, or the openings of internal fistulse too small for de- tection may cause all of these obscure symptoms. In a succeeding chapter, on the anatomy of the rectum in relation to the reflexes, I shall deal more explicitly with such disorders as proctitis, injuries to the uterus, or diseases of it, stricture of the urethra, cystitis, enlarged prostate, etc., which are common causes of these obscure symptoms. Until these abnormal conditions are cured it will be impossible to have the so-called hysterical symptoms disappear. Of one thing I am certain : that in not one single case, be it of a hysterical nature or one with obscure symptoms from what- ever cause, have they been benefited by constitutional treat ment in my hands. Besides these common diseases of the rectum, or, I may say, these obscure diseases of the rectum, there is another class that can not be described or accounted for by the symptoms or conditions which I have mentioned. Prof. Goodell gives a very excellent description of the con- dition to which I refer. He says: " There is yet another form of disease which I think may be classified under the general heading of nervous rectum, although its pathology is by no means yet fully understood. I refer to pellicular coli- tis, or pseudo-membranous enteritis, as it is usually termed, in which mucous casts of the lower bowel are discharged, with much tenesmus and abdominal pain, either by themselves or in the regular evacuation." In my opinion, these cases are not unique, but quite a number of them are to be seen by the rectal surgeon in the course of a year, and I can not agree that the disease, for disease it is, is a " sheer neurosis." I have seen the affection in patients not given at all to hypochondriasis, and relief has been obtained by remedies outside of those that affect the nervous system ; or, in other words, it has been treated as a local disease, and not as a nervous disease at all. I believe that in all of these cases a disease exists, the result of patho- 256 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. logical change, as the names colitis and enteritis imply, namely, by inflammatory action. I have never yet succeeded in curing such a case outside of direct or local medication. iEtiology. — The rational treatment of all disease necessarily depends upon a correct diagnosis. How difficult this some- times is, all practitioners of medicine, as well as specialists, are aware ; but I believe that specialism has done much toward elucidating the subject of diagnosis. It often occurs that a pa- tient suffering from some obscure malady has passed through the hands of many general practitioners and a few specialists, until at last some one has discovered the seat of disease and effected a cure. I can not believe that the medical profession, as a whole or in part, is so selfish as to detain a patient for treatment who rightfully belongs to another. My experience has been that whenever this point has been determined by either the general practitioner or the specialist, the patient is sent where he rightfully belongs, or is thought to belong. In deal- ing with this subject of the u nervous rectum," a term which of itself implies a doubt, it has been my object to demonstrate that an argument must be based upon clinical facts before a position is taken, and in regard to these affections I will state again that I believe that they have their local origin in the rec- tum, and that all nervous manifestations are secondary to it. If this premise be admitted, then the line of treatment is plain. Eelieve the cause (local), and the manifestations (general) will disappear. If the premise is wrong, and these troubles are "neurotic" — i.e., caused by a disordered condition of the nervous system— then the term " nervous or hysterical rectum " is the correct one, and the line of treatment would be to correct the general condition, and the local symptoms will take care of themselves. Now, I wish to say that I have seen some few cases where it was impossible for me to make out the pathological change, or to account for the symptoms by any of the reflexes, and that I was nearly forced to the conviction that they were the result of a "sheer neurosis," because sometimes the condition is very remarkable and diffi- cult to explain. But even granting that I was unable to find THE NERVOUS OR HYSTERICAL RECTUM. 257 the lesion or to locate the reflex, I would not be warranted in taking the position that the trouble was not caused by patho- logical change somewhere. Case. — A young lady was advised to come to me from a city in Pennsylvania, quite along distance. While sitting, nar- rating her case to me, she gave a sudden start and fell across the chair from the effect of a most terrific pain in the rec- tum. Although I gave her a hypodermic injection of a fourth of a grain of morphine, and another in the course of thirty minutes, it was more than an hour before she became quiet. She then told me that she had had these attacks at intervals of two to three weeks for several years, and that within the last year they occurred nearly daily and sometimes two or three times a day. She was afraid to go out on the street alone because of them, and had given up her gentlemen friends on this account. She was a very prepossessing girl, in good flesh, weighing about one hundred and forty pounds, and showed evidence of a good, generally healthy condition by the rosy color in her cheks, a good appetite, etc. She re- marked that if she could be relieved of this local disease she would be perfectly well, but rather than bear it another year she would prefer death. She described these attacks just as I had witnessed this one— namely, as a sharp, quick, lanci- nating, terrible pain, just within the rectum, lasting from a few minutes to several hours. It had no reference to the act of defecation at all, nor to the condition of the bowel, whether she was suffering from constipation or diarrhoea. The symp- toms were somewhat aggravated and the attacks more fre- quent during the time of her monthly sickness. I examined her rectum diligently and carefully a number of times, but could find no trouble. I had my assistant give her ether, and I forcibly divulsed the sphincter muscle, thinking that this would relieve her, and so told her. While under ether I care- fully examined the upper rectum, but still found no disease. This divulsion did her no good. Hearing her complain at one time of some pain at micturition, I had my friend Dr. W. H. Wathen to see her, and he thought it a good idea to divulse 17 258 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. the urethra, which he did. This accomplished no good. As I mentioned, she suffered more at the time of her menses, and Dr. Wathen advised that the cervix be divulsed. This he also did, both of us thinking that possibly we would trace the reflex to this origin. Like the others, this operation was per- fectly nil in its effects. The attacks went on. I should say that during all this time I was medicating the rectum locally. I applied a solution of nitrate of silver, injected large quan- tities of very hot water, used other injections, of the fluid hydrastis, hydrate of chloral, pinus canadensis, etc., all of no avail. I invited her upon one occasion to go before the Louisville Surgical Society, which met at my residence, said society being composed of twelve of the leading surgeons of the city. I had each and all of them to question her closely, and they could not advise anything more than had been done for her relief. She remained in my infirmary four months, and concluded at the end of this time to return to her home in Pennsylvania. The evening before her departure I called at the infirmary, found her in great distress in one of her attacks, and asked her if she had taken the hot water injec- tion that I had ordered. She said she had ; that it did her no good. I said : " Suppose you try a cold-water injection," and left her. The next morning I called and found this girl walk- ing through the hall in an erect position ; her natural position since she was first attacked was a stooped one. I said to her : " Why, what's the matter \ " She replied : " Why, don't you know that I haven't felt the least pain since taking that cold- water injection yesterday evening, and can walk with perfect ease % " This was such glad news that I told her to discard everything else and use the cold-water injections. She left that night for Cincinnati. Two days thereafter she wrote me that she had had no further pain ; that she had walked eleven squares that day and had done some shopping. I did not hear from her again for ten days or two weeks, when she wrote me that she had had only one slight intimation of pain and had called in her family physician, who wished to prescribe, or did prescribe, some of her old remedies, which she declined THE NERVOUS OR HYSTERICAL RECTUM. 259 to use. That was one week before she wrote me. She had not felt it since, and remarked that the night before writing me she had attended a ball, the first one in years, and had danced a number of times without any inconvenience at all. She continued to improve, and eventually ceased to write. Now, this case I am at a loss to understand. It comes nearer to being one of "a sheer neurosis" than anything that I have ever seen. Could it be that this trouble was neuralgic in character, having its origin probably in the exposure of a small filament of a nerve, and that the cold water so impressed it as to overcome its sensibility, according to the common aphorism in surgery, that if heat does not accomplish the de- sired purpose cold will % In tabulating the causes, therefore, of these " obscure af- fections of the rectum," I would have to restrict them to two heads : 1. The reflexes. 2. A lesion or pathological change at the seat of trouble. I must confess that of all vague terms used by a physician, this one, hysteria, is the vaguest. Having reference, as the derivation of the word implies, to the womb, the profession has been in the habit of characterizing many affections of the female which we could not understand as hysterics ; but so many symptoms analogous to these are presented in the male that we frequently see articles descriptive of them and the same term used, I do not deny that the nervous system is responsible for many strange freaks, but I do assert that much that is attributed to it has its origin in the periphery and not in the nerve-center. To-day is the era in medicine of the study of these nervous diseases, and I look for the time to come when many of them that are now classed as obscure may be made as plain to us as others which we do not doubt. I can not, therefore, believe in the " nervous rectum "per se, but would enforce again the necessity in all such cases of finding out the origin of the trouble by the closest scrutiny. As this chapter will be followed by one closely allied to it — namely, The Anal and Rectal Reflexes — I shall not deal with the treatment of these diseases just now. CHAPTER XL NEURALGIA OF THE RECTUM. Under the head of the hysterical or nervous rectum I have already discussed the cases which are commonly called neu- ralgic, but as in that chapter I did not deal with neuralgia as a term, I desire to say something more of it. E. P. Hurd, in his excellent book upon neuralgia, defines it as u a neurosis whose essential symptom consists in a lancinating pain, par- oxysmal in character, described as boring, burning, stabbing, localized in nerve trunks or their terminal branches ; apyretic, without redness or apparent swelling ; generally accompanied by secondary phenomena of a motor, vaso-motor, or secretory or trophic nature." He agrees with Anstie in considering that neuralgia occurs only in those subject to some impairment of general health. Allingham says: "I can see no reason why neuralgia should not sometimes attack the rectum as well as any other part of the body." This, to my mind, is a perfectly true statement, and yet I have seen so many cases in a general way that were called neuralgia, in which I doubted the correctness of the statement, that I am loath to name any affection of the rectum neuralgia without a thorough investigation. As will be observed, in referring to the chapter on The Nervous or Hysterical Rectum, I take the position that all cases of irrita- ble, nervous, or hysterical rectum are due to a well-defined lesion ; that the pathological condition is oftentimes difficult to detect, and in many instances can not be observed at all. In the cases that I shall now report I failed to find the lesion. Am I to believe that none such existed ? Are these cases due solely to a special diathesis, neuralgia, or to the reflexes, the NEURALGIA OF THE RECTUM. 201 disease originating in some adjacent organ or tissne ? I be- lieve firmly in the reflexes as accounting for pain, and yet in some instances they could be entirely ruled out. In such I believe that a pathological condition, such as congestion, in- flammation, or may be the simple exposure of a filament of a nerve, will account for the so-called neuralgia. I have been greatly interested in this subject, more especially for the reason that Hurd gives in his book, when he says that he is obliged to admit that, in spite of the imposing array of reme- dies, the neuralgic pain will refuse to surrender, and we are obliged in the end to capitulate ourselves and have recourse to the cowardly hypodermic syringe. This is a sad condition to contemplate, and if we can change the opinion that these cases in the rectum that simulate neuralgia are in reality due to a lesion, we stand a much better chance of curing this un- fortunate class of patients. In this connection I desire to report a few cases : Case I. — In the early part of 1891 I saw a patient who gave the following history : Aged fifty-three, small in stat- ure, nervous and melancholy in disposition, free from all evil habits. He complained of a local pain in the rectum, not ag- gravated by an action from the bowels. An examination of the rectum revealed no lesion, but his symptoms pointed so clearly to one, or at least to an exposed nerve, that I ventured the opinion that he could easily be cured by divulsing the sphincter muscle. This was done under an anaesthetic, and after a short time he reported at my office, saying that the operation had done him no good. He escaped my notice for several months, and during this time had consulted a number of physicians and taken many remedies without effect, and at last came back to me. I subjected him to a rigid examination but could find no particular trouble. I again divulsed the sphincter, this time doing it more thoroughly, and coated the whole of the lower surface of the rectum with a forty-per-cent solution of nitrate of silver. No better result was obtained from this operation than from the first. I sent him to a genito- urinary surgeon, who detected a stricture of large caliber and 262 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. divided it, thinking, perhaps, that this might relieve some reflex. The operation, however, had no appreciable effect. The man had taken all manner of tonics, etc., but he con- tinued in the same old way, and a greater melancholic I have never witnessed. There was not a moment in the day but that his mind was on his rectum. Case II. — A lady, about fifty years of age, in apparently good health, was referred to me with symptoms very like Case I. I made the same promise of relief if the sphincters were divulsed. This was done, but no relief followed. This case took a course very similar to the other one. Numerous physicians were consulted, and her family physician, who was an eminent man in the profession, did everything in his power to relieve her, but to no purpose. The symptoms are those of neuralgia — a dull, aching pain, always present in the rectum, but not aggravated by a movement from the bow- els. She is nearly a monomaniac upon the subject of her trouble. We have just agreed to send her to a gynaecologist. Case III. — A woman, about forty years of age, weighing about one hundred and eighty-live pounds, gave the follow- ing symptoms : She had a tormenting pain which she referred to the rectum, but, as she expressed it, the pain was located high up. She said there was no special pain during the act of defecation, but that generally before she went to stool she suffered abdominal pain, which frequently continued for an hour or two. I examined the rectum and could find no dis- eased condition. I advised her to take copious injections of hot water, and also put her upon Goodell's pill compound, viz. : 5 Ext. sumbul . . gr. j ; Asafcetida gr. ij ; Ferri sulph. exsic gr. j ; Acid, arseniosi g r - fV • M. Sig. : Four to be taken during the day. She took this prescription for some time, but without effect. It was not until several weeks had elapsed, while during a conversation she remarked that she had forgotten to tell me that she had suffered from what the doctor called a pelvic NEURALGIA OF THE RECTUM. 263 abscess, which had discharged through her rectum. This of course put a new phase on the matter, and I sent her to a gynaecologist, who afterward told me that her pain was evi- dently due to adhesions in the abdominal cavity, and that he had recommended a laparotomy. I never heard any more of the case. I might go on and recite a number of such cases, but these will be sufficient to convey my views. In the chapter on the hysterical rectum I have taken the position that all such cases are due to a lesion, exposure of the filament of a nerve, and in the chapter on the reflexes I contend that if the source of the reflex is ascertained and corrected, the so-called neural- gic pain will disappear, and therefore that these cases do not fall under the head of neuralgia at all. If a nerve filament is exposed, it is the exposure that causes the pain. If there be a lesion or trauma, the pain is due to the injury. I do not, therefore, consider that the neurosis which constitutes neu- ralgia exists. Anstie says that neuralgia occurs only in those subject to some impairment of general health. I am sure that the majority of such cases, as observed by me, have been in persons of robust health, and I must rule out cases of pain in the rectum caused by reflex from this class. It is a well-known fact that persons suffering from fissure, or from any disease of the rectum which causes pain, become nervous and hypochondriacal, and although Allingham says that these sensations continue after the ulcer has healed, it has been my experience that when they were relieved of the rectal irritation and pain these other symptoms disappeared. Dolbeau, of Paris, considers the essence of fissure to be neu- ralgic, and defines fissure of the anus as being a spasmodic neuralgia of the anus, with or without fissure. I certainly can not subscribe to any such view as this. The first portion of the sentence, that fissure of the anus is the cause of pain, which perhaps resembles the neuralgic pain, is correct, for this theory fully corroborates what I have said— that a lesion exists which accounts for the pain, and therefore neuralgia is ruled out ; but to the latter portion of the sentence, that a 264 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. " spasmodic neuralgia of the anus may exist with or witliout fissure," my position is that if there is no fissure and yet pain, it must be by reflex, and therefore not neuralgic. The pathological changes of inflammation, etc., which would go to make up a neuralgic condition of the nerve do not exist in these cases ; but when the point of reflex is ferreted out and stopped, no further disturbance of the nerve in the rectum is observed. It is very true, as Hurd says, that so far as the nerve trunk or terminal branches are concerned it may be ' ' apyret- ic, without redness or apparent swelling." We are very well aware of the fact that one or more of the symptoms of inflam- mation proper may be absent, and yet an inflammatory condi- tion exist. If a tooth aches and the dentist discovers that it is due to the exposure of the nerve, he would be inclined to prevent the exposure, yet in a case of facial neuralgia we would treat the nerve both locally and constitutionally. Some con- sider the spasm of the sphincter muscle as the cause of this neuralgic pain. I would argue that if the premise be true, it would not be a neuralgic pain, but simply one caused by spasm of the sphincter implicating a nerve. But I can not believe the premise true, from the fact that I believe the spasm of the sphincter to be caused by the lesion. This is very well illus- trated in cases where we have a mass of hardened faeces lying in the pouch of the rectum. A congestion and an abrasion exists in consequence of the foreign body, and excites the sphincter muscle to spasm. Allingham says: "I have been in the habit of calling pain in the rectum or sphincter muscles neuralgic when I have not been able to find out the slightest lesion, sign of inflammation, or discharge of any kind, and where the pain was not aggravated by action of the bowels. This I always consider an important point in diagnosis." This is very like the custom of some practitioners of pro- nouncing affections which have certain symptoms as mala- rial, when said symptoms may be brought about by constipa- tion or a faulty liver. Small doses of calomel in such cases have oftentimes done more good than many grains of quinine, and also by its administration the diagnosis was cleared up. NEURALGIA OF THE RECTUM. 265 They say that charity covers a multitude of sius. I am sure that when I was in general practice the terms malaria and neuralgia covered a multitude of my errors. So I am inclined to think about calling pain in the rectum neuralgic when we can not find a lesion. I quite agree with Allingham when he says " an important point of diagnosis is whether the pain is aggravated by the action of the bowels." But this neuralgic (?) condition of the rectum is frequently cleared up by dividing a stricture in the urethra or doing an abdominal section upon the woman. Allingham also says : "I have noticed the attack follow direct exposure to wet and cold by sitting upon damp grass." This is quite a different case, for here we have an exciting cause for the inflammatory condition of the nerve, together with the congestion of the blood-vessels. The ques- tion naturally resolves itself into this : Are these cases due solely to a special diathesis, and occur only in the debilitated and nervous person, or are they due to some reflex, the disease originating in some adjacent organ or tissue, or is the pain referable to the point where it is made manifest, say to a lesion, or exposure of a nerve in the rectum \ For my own part, I believe that these so-called cases of neuralgia are due, first, to a lesion in the mucous membrane of the rectum, and the con- sequent exposure of a nerve filament, or, second, the source of trouble is not in the rectum at all, but is reflected from some other organ or tissue. If the case falls under the first divis- ion, and the erosion, abrasion, or what not, is close to the sphincter muscle, the pain is aggravated during the act of defecation ; and if it is from the second condition, the pain is not aggravated during this act. Therefore I am inclined to believe that the term neuralgia as applied to these cases is a misnomer. Treatment.— A careful examination should be made of the anus and rectum. It is sometimes the case that a very minute sinus may exist in the folds just at the verge of the anus and be overlooked. It may be that over the sphincter muscle or higher up the rectum there is a peeling off of epi- thelium or an abrasion of the mucous membrane. Therefore 266 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. a good speculum should be employed, the room darkened, the patient put upon the table, and, when the instrument is opened in the rectum, the electric light after the manner de- scribed should be introduced and a careful search made for the abraded surface. If it is found, a probe with a thin film of absorbent cotton wrapped around its end should be dipped in pure nitric or carbolic acid, and the abraded sur- face touched with it. If the sphincter muscle is irritable and pain exists during the act of defecation or following it, the sphincter muscle should be divulsed. If no lesion can be found, and the sphincter is not irritable, we are to sup- pose that this pain in the rectum is reflected from some other source, and each and every organ, connected by nerve influ- ence with the rectum, should be carefully inspected and asked after, and then the patient referred to the specialist to whom he belongs. I have never found that any anti-neural- gic medication did these patients any good at all, and, as I have already said, they were not such subjects as called for quinine, iron, strychnine, or any other tonic. But one point I wish to thoroughly impress, and that is that these patients should not be allowed to take opium for their relief, for it is this very class of patients that become habituated to its use. It has been my observation that hot-water injections ag- gravate the trouble instead of lessening it, and in several 'instances I have seen marked benefit result from the use of cold water injected into the rectum, although, of course, I could not suggest this as a general rule. I wish to reiterate what I have said before— that, of all agents to prevent rectal troubles as a class, cold water will be found the most service- able. This especially applies to congestions, inflammations, atony, hsemorrhoids, both external and internal fistulse, etc. CHAPTER XII. IEEITABLE ULCER OE FISSTJEE. Theee is an anatomical as well as a pathological differ- ence between fissure and an irritable nicer of the rectum. Fissures are found at the verge of the anus, and should, therefore, be called anal fissures. Indeed, a fissure proper could not exist within the rectum. It is necessary to make this distinction because the treatment depends upon it. I think the setiology should be considered somewhat in mak- ing up our verdict. A consideration of the anatomy of the lower part of the rectum aids us very materially in the con- sideration of the subject. The predominant symptom devel- oped by a fissure of the anus, or of an anal ulcer, as you please, is pain, and this is made so from the implication of the external sphincter muscle in the trouble. I think in dealing with this special subject, or in rectal disease in gen- eral, we overlook the importance of the external sphincter muscle and overestimate the importance of the internal sphincter muscle. I am sure that I have seen cases where an ulcer was situated over the internal sphincter muscle, and was, to a remarkable degree, painless ; and yet, when the smallest number of fibers of the external sphincter muscle are implicated in the ulceration, pain is a very prominent symp- tom. Although the two muscles are in close apposition, it is the external sphincter which controls the outlet and responds in cases of danger. Hilton has pointed out the important fact that the nerves — principally branches of the pudic — which come down below the internal sphincter, pass out be- tween the muscles at the junction to become superficial in this situation. 268 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 'Now, it will be observed that an ulceration could exist above Hilton's white line and over the internal sphincter mus- cle, and yet not engage the nerve distribution. But whenever there is an encroachment made upon the external sphincter, the nerve-supply is made to respond. It is a well-recognized Nervous supply of anus (Hilton.) a, mucous membrane of rectum ; 5, skin near the anus; c, external sphincter muscle ; d, internal sphincter muscle ; He had probably heard that good wine needs no bush ; and as he has written a good book, with an excellent dedication and some sound aphorisms from the Greek on the first sheet, it mattered less about his motives. At any rate, after the table of contents and a list of charts and illustrations, we find ourselves plunging immediately into typhoid fever, which heads Section I (on 'Specific Infectious Diseases') of this royal octavo volume of 1,080 pages. No preliminaries are devoted to such' abstract subjects as nosology, symptomatology, etiology, inflammation, fever, etc. In this respect Osier's hook resembles Strumpell's. The style in which Dr. Osier's book is written is clear, concise, and at the same time animated. The type is very good. The finish of the paper is excellent, but the texture is not strong, and we doubt whether it stands well the strain of the eager student who will certainly want to use it often and much, or the inadvertence of the busy practitioner who will sometimes consult it hastily. The book has evidently been 'trained down' as much as possible to secure handiness without sacrificing even more important essentials. We should be glad to be able to think and speak as highly of every medical book presented for review as we can of this. In truth, had our enemy written it, we should be unable to find much consolation in his commitment."— Boston Medical and Surgical Journal. New York : D. APPLETON & CO., 1, 3, & 5 Bond Street. A TEEATISE ON THE DISEASES OF THE NERVOUS SYSTEM. By WILLIAM A. HAMMOND, M.D., Surgeon-General U. S. Army (retired list). With the Collaboration of GRAEME M. HAMMOND, M. D., Professor of Diseases of the Mind and Nervous System in the New York Post-Graduate Medical School and Hospital, etc. With 118 Illustrations. 8vo. 932 pages. Cloth, $5.00 ; sheep, $6.00. " Dr. Hammond's treatise on the diseases of the nervous system is a work which has been long familiar to the profession, and has attained a great reputation among the standard books for reference. In the preparation of the present edition the author has been aided by his son. A vast amount of clinical material is made use of, and the results of experimental investigation recorded. The book is written in a clear and pleasing style, and obscure conditions are dealt with in a manner which will prove of great assistance in the study of this most interesting class of diseases." — Canadian Practitioner. " Dr. Hammond published the first edition of his ' Treatise on Diseases of the Nervous System ' in 1871. It has therefore been before the profession for twenty years, and during these years it has continued to grow in public favor, this being the ninth edition that has been issued. Appreciation of this work has not only been shown in this country, but abroad, as it has been translated into the French, the Italian, and the Spanish languages. The present edition has been thoroughly revised, and several new chapters added. This is a book of such great value, and is referred to so frequently by the medical press and other medical works, that no library is complete without it." — Alabama Medical and Surgical Age. " There are few books, even upon those subjects which are constantly in the ordinary physician's mind, which succeed as has that of Dr. Hammond ; and when we recollect that when the first edition of this work appeared, neurology in America was in its very infancy, the rapid exhaustion of its editions is the more remarkable. 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