Chapter M

℞ Saponi viridis }
Ol. Cadini } ā ā ℥ i
Alcohol. }

M. (Kelsey).

℞ Liq. Carbon. Detergentis (Wright’s).
Glycerinæ ā ā ℥ i
Zinci Oxidi }
Calamini Prep. } ā ā ℥ ss
Sulphuris Precip. }
Aquæ Puræ ℥ vi

M. (Allingham).

DIVULSION.

Forced dilitation as a means of relief and cure for certain forms of rectal trouble, although a much abused and somewhat barbarous practice, has positive and undoubted merits. It is only justified, however, in peculiar and isolated cases.

The wholesale stretching of the sphincter ani muscles as a “cure all” is certainly to be deprecated as unscientific, illogical, and without the advantages or benefits claimed for it by rattling and noisy fanatics. Divulsion injudiciously employed may be followed by a long and tedious recovery, complicated with very undesirable sequelæ and thereby excites much adverse criticism.

The case of a lady recently came under my observation, who, although in average health, complained a little as many women do, and thought she was troubled with hemorrhoids. Through the advice of her physician, a college professor, she submitted to the operation of stretching on general principles. Irritability of the rectum followed, with soreness and continued pain. Finally two large sympathetic buboes developed, which suppurated, and were slow in healing. This happened a little over a year ago, I am reliably informed, and she has not yet fully recovered.

A number of cases have come to my notice where stretching was practiced for the cure of piles, imaginary spasmodic stricture, etc., without the least benefit, except, possibly, that accruing to the physician.

A young married man, foreman of a printing-office, complained at times of slight pain in the region of the liver. His physician, an editor of a medical journal, made an examination of the rectum with a speculum, and informed him that it would be necessary, to preserve his health, to undergo the operation of stretching the sphincters.

The day was appointed and hour set for the operation, which, fortunately for the young man, was “nipped in the bud” by the physicians arriving a little late; and through the advice of a friend he seized the opportunity and “skipped out,” came to my office, and was examined. His bowels were regular, there was no history of rectal disease, and not the least sign of any; nor was there a shadow of an excuse for an operation.

The cases in which divulsion seems to be of greatest benefit are found mostly among women of a peculiar high nervous tension or organization, where the muscles become hypertrophied from repeated spasm, and constipation resulting from ineffectual efforts to expel the feces. In such cases forced dilitation is followed by the most satisfactory results.

It should be accomplished with patient lying on the side, and under the most profound anæsthesia. Rectal dilators, which distribute the force evenly all around, may first be used, then the thumbs, or the thumb of right hand and index finger of the left, or two fingers of each hand, to completely paralyze the muscles. The process should be slow and gentle, and caution exercised lest the tissue give way from the application of undue force.

Local causes should always be sought, and excluded if practical, before heroic measures are adopted for the relief of spasmodic sphincter. There are instances where tightness of the sphincters exist, superinducing constipation, etc., not traceable to any appreciable cause. These cases may be relieved without the aid of general anæsthesia, by graduated dilators or rectal bougies, accomplishing little at a time, daily or tri-weekly.

When constipation depends upon inertia, or a lack of expulsive power of the rectum, I think moderate dilitation advisable and decidedly beneficial.

POLYPUS.

These innocent growths can be successfully removed, when within reach and most of them are, without the loss of blood or the infliction of pain, by carbolic acid injection to act as a styptic and deaden the sensibility, while the scissors is used to sever their connection with the bowel.

Allusion is made, in speaking of the diagnosis of hemorrhoids, to the different forms and varieties of polypi, consequently no further description of them will be given here. Polypi, being more dense and fibrous than hemorrhoids, are not readily permeated by the injection compound. Neither can the hemorrhoidal needle be used with any advantage unless they be large and soft in structure. Therefore a small hypodermic needle is selected and 95 per cent. carbolic acid. This strength of carbolic acid is not only a powerful styptic and cauterant, but its fluidity permits it to be forced throughout the fibrous structure with ease.

The action of the acid should extend fully to the base of the polypus, which is then clipped off a little outside of the line. The stump goes through similar changes to that of hemorrhoids after injection. In long or pediculated polypi, it will only be necessary to apply the acid at the base sufficiently to intercept the circulation before excision.

A little cocaine may be used first, if the parts are very sensitive, and the same precaution should be taken with regard to the protection of the adjacent and surrounding parts from the excoriating effects of the carbolic acid, as recommended when operating on hemorrhoids.

PROCTITIS.

Inflammation of the rectum, like any other phlegmasia, may arise traumatically or idiopathically; by contiguity of structure or continuity of surface. The acute symptoms are very much like acute dysentery, which disease, in my opinion, nearly always extends to the rectum, causing the characteristic symptoms of weight, tenesmus and straining at stool.

Irritable rectum in the absence of diarrhœa is diagnostic of the complaint. The bladder and prostate may be affected through sympathy, and colicky pain reflected to the small intestines or stomach. In the more chronic forms, constipation, tenderness and the cul-de-sac partially filled with mucous are distinguishing features.

Carbolized hot water irrigation, prepared hot corn starch, slippery elm water, bismuth, etc, together with a suppository of iodoform, bismuth and opium, or bismuth, opium, belladonna and calomel, will be found serviceable in the acute stage. About a half tumbler full of a saturated solution of chlorate of potash, injected slowly and retained for ten or fifteen minutes, is said to effect a cure by one or two injections.

Chronic proctitis, also called irritable rectum, and sometimes rectal catarrh, with symptoms that might be expected to emanate from a disease of the mucous membrane, rarely amounting to a diffuse thickening of the rectal walls, is treated similarly, except less palliative. Combinations of eucalyptol, iodoform and bismuth; or eucalyptol ½ dr., oxide of zinc 1 dr., vaseline 1 oz., are highly recommended after the rectal douche.

Some physicians hold that chronic inflammation of the rectum is a disease of more frequent occurrence than all other rectal diseases combined. And equally as pernicious, causing many functional and even organic troubles through reflex action.

FLUSHING THE COLON.

I have always been loath to admit the value of a thing which did not come from an authoritative source. A little retrospective medicine, however, is sufficient to teach any of us that many important discoveries have been made without the free-will and full consent of “acknowledged authorities;” and that it is not positively necessary for progressive physicians to first obtain their permission before being allowed to think and act for themselves.

Flushing the colon is a discovery of intrinsic worth, brought to notice in an irregular way, and has its place as a remedial agent with which every physician should become familiar. If you doubt its efficacy, and want a free evacuation of the bowels without taking physic, lie on the back and inject into the rectum slowly with a bulb-syringe one-half gallon or more of hot water, and you will get it inside of fifteen minutes.

I do not see that Dr. A. W. Hall, who claims in his health pamphlet to be the father of the process, and whose name bears the titles of Ph.D. and LL.D., and consequently deserving of the respect of an educated man, makes out a clear case in defense of his “New Hygienic Treatment” as a life-giving principle, _either_ in health or disease.

His argument is certainly unphysiological, and we are left to infer that nature has been derelict in the construction of man, which he has been instrumental in supplementing. If he were to confine himself to disease alone, his reasoning would appear more plausible; but he claims that people enjoying good health, with no physical ailment whatever, should wash out the colon.

No doubt Dr. Hall has been greatly benefited by flushings of the colon, as also have many others, which offers some apology for the enthusiasm and interest he manifests in the “new revelation;” but we shall be compelled to look to others for the pathological conditions in which it will be found of greatest service.

Respecting the colon itself, there are two very diverse conditions, with their concomitant symptoms, in which flushing will be found of great benefit. The one a diseased condition of the mucous membrane, of a chronic dysenteric or an ulcerative character. The other, a sluggishness or torpidity of the bowel belonging to a constipated habit.

The most easy, simple and efficient manner of practicing the flushings, according to my experience, is by assuming the position shown in the cut. A piece of oil-cloth, rubber-cloth, or a newspaper may be used to protect the carpet. One or both feet are allowed to rest on the floor, and the hips can be raised by the slightest exertion for a few moments, any time it is desirable to hold and hasten the water down the incline.

Beginners should use a common bulb syringe, with water rather hot, varying in quantity as they become accustomed to the process, from a quart to a gallon or more, and a bulb-full squeezed out slowly, with intervals between, giving it time to pass out of the rectum into the colon. On regaining the erect posture, if the rectum be loaded with feces or distended with water, the desire to expel its contents may be irresistible, especially if air has passed through the syringe; although a little practice will enable any one to exert great control over his or herself in this respect.

Dr. F. H. Etheridge (_Trans. Chicago Med. Soc._) gives a number of cases of impacted colon, where daily flushings, extending over a period of from one to three months in each case, were followed by the most grateful results. This, too, after the persistent use of drugs had almost hopelessly failed to even afford temporary relief.

Without segregating the cases, some of the diseased conditions mentioned in connection with his patients were dyspepsia, characterized by anorexia, acid and bitter eructations, bad taste in the mouth, gaseous distention, gastric weight and pain. Also cephalalgia, chills, vertigo, chloasmic spots, _muddy sclerotics_ and _complexion_, insomnia, ennui, eczema, psoriasis, dysuria, etc.

He says: “Daily movements of the bowels are no sort of a sign that the colon is not impacted; in fact, the worst cases of costiveness that we ever see are those in which daily movements of the bowels occur. The diagnosis of fecal accumulations is facilitated by inquiring as to the color of the daily discharges. A black or a very dark green color almost always indicates that the feces are ancient. Prompt discharge of food refuse is indicated by more or less yellow color. It would be interesting to inquire why fresh feces are yellow and ancient feces are dark.

“Absorption of the feces from the colon leads to a great many different symptoms; amongst others, anæmia, with its results, sallow or yellow complexion, with its chloasmic spots, furred tongue, foul breath, and muddy sclerotics. Such patients have digestive fermentations to torment them, resulting in flatulent distention, which encroaches on the cavity of the chest, which in excessive cases may cause short and rapid breathing, irregular heart action, disturbed circulation in the brain, with vertigo and headache. An over-distended cæcum, or sigmoid flexure, from pressure, may produce dropsy, numbness or cramps in the right or left lower extremity.

“I have often questioned whether chloasmic spots were not due to fecal absorption. These spots are pigmentary matter deposited under the skin. It is a physiological fact that all pigments originate in the liver. In a condition of health their abnormal deposit we never see. It is only when the patient is not well, in some way, that these spots are noticed. They are infinitely more common in women than in men. It is easy to see that their sedentary life is more apt to lead in them to the filling of the colon. Absorption from the colon produces a poisoned blood, which in turn deranges every organ of the body, among others the liver. It is possible that the action of light, as in photographs, contributes in some way to precipitate the deposits of these chloasmic spots, because we see them chiefly upon the parts of the body exposed to light....

“The use of a long rectal tube is unnecessary. The patient should be placed in a genu-pectoral position, the shoulders thus being lower than the hips. The water will be made to descend while anatomically ascending the intestines. Patients can be made to receive from one to six pints of water in this position without the slightest trouble. One of the effects of the water is to distend the colon, and in that way pressing away the walls of the loculi from the accumulations that fall into the current of water and are passed out while the water is leaving the intestine. The patient will oftentimes complain of severe tormina, checking the current of water for a few seconds, and will be followed by complete relief. The presence of such a strange foreign body in the intestine as hot water in many cases excites prodigious peristaltic activity, thus producing the tormina. Plain hot water is all that is necessary to use; the water should be hot; cold water, or tepid water, will not do. It will produce great suffering. One patient took the flushings for a fortnight, returning vowed she would never use any more because they produced such terrific cramps. Upon inquiry it was found that she was using tepid water. The subsequent use of hot water by her was never followed by a cramp. Upon many patients this large amount of water acts as a vigorous diuretic. Where patients suffer as well from renal insufficiency, I am in the habit of telling them to use a pint or a pint and a half of hot water after the flushing has passed away, and to lie upon the back with hips elevated for half an hour. Thus retaining the water, it will act as a powerful diuretic. Some patients can administer this flushing with greatest ease, while others will develop a most phenomenal awkwardness. I am in the habit of telling patients to kneel in the bath-tub, who are at all awkward about using these flushings.”

REFLEXES.

The lower end of the rectum is richly supplied with both sensory and sympathetic nerves. The sensory greatly predominating at the verge, making it one of the most acutely sensitive surfaces of the body. In ascending upwards the sensory gradually give place to the sympathetic, until little sensibility is imparted by the touch three inches from the entrance in a normal condition.

This accounts for the hidden cause of so many reflexes, having their seat of origin from lesions an inch or more above the anus, where the sensibility is not always sufficiently great to attract attention.

It has been claimed that obscure rectal disorders may so undermine the nervous system by reflex irritation, allowing the inroad of general systemic disease, that many die yearly from this as the primary cause, without ever knowing the source and origin of the fatal malady.

That migratory pain, headaches, dyspepsia, sleeplessness, palpitations, sexual weakness, nervousness, despondency, irritability, and a general breaking down of the system, may all be caused by a small ulcer or other irritation of the rectum, which has passed unnoticed by either physician or patient.

Nearly every physician is familiar with the white ring around the mouth extending up the sides of the nose, produced by the presence of pin worms in the rectum, or a fatal lock-jaw caused by a broken off needle or rusty nail in the foot. Such illustrations alone, are sufficient to demonstrate conclusively the power of this dynamical disturbance called reflex action.

While there is doubtless unwarrantable exaggeration concerning rectal reflexes by some, there are many unpardonable oversights by others. A case was reported in the _Medical Record_ where all preparations were made to operate for organic stricture of the urethra, which, perchance, proved to be a reflex from a small rectal fissure. When the fissure was cured the spasm ceased. A case of roaring in the right ear was relieved by the cure of a fistula, says Dr. Rorick, who also speaks of two other similar cases.

A very remarkable case occurred in my own practice, where the right testicle had been enlarged to the ordinary size of a well developed case of orchitis for some years, and had resisted all manner of treatment, completely disappeared after the removal of hemorrhoids. The case of hemorrhoids, which was one of the worst I ever saw, is represented in Fig. 2.

Another case was that of a merchant, who suffered frequently from a sensation of drawing and weight in the back of the head and neck. When these attacks came on, his memory became so badly impaired that he was rendered unfit for the transaction of business. He noticed during the attacks that there was a feeling of heaviness in the rectum, swelling and tightness of the sphincters, and a lack of expulsive power at stool.

Examination revealed several pockets and papillæ of the variety shown in Fig. 23, which was taken from this case. Have not been apprised of any return of the trouble since an operation for the removal of these abnormalities.

As evidence that physicians should be a little more vigilant in the observation and study of rectal reflexes, the case of a very talented and influential lady of this State might be appropriately instanced. Her general health had been greatly impaired for a long time, with unexplained and repeated outbursts of sickness. Several prominent physicians were consulted, to whom she called attention to a little uneasiness, at times, in the rectum with an irritable bladder. They all examined the rectum, in their way, and ridiculed the idea of local disease, but went on treating the reflex symptoms, with nothing more than temporary relief.

The successes of a local specialist in the treatment of hemorrhoids by the Brinkerhoff system, whose ignorance of anatomy was such that he denominated the sphincters “dispenser” muscles, induced her to pay him a visit. He found a well defined superficial rectal ulcer, and exhibited it to one of the previously named doubting physicians. The ulcer was quickly healed and the lady restored to health.

She became so enthused over the result, that she took up the study of rectal diseases for the benefit of others, as a missionary, so to speak; and it is needless to say that the physicians who failed to detect the cause of her trouble did not reap any of the emoluments of her labors, but there were several irregular practitioners who were ready listeners, took in some handsome fees as a reward. Her motto, true to a grateful nature, was to “praise the bridge that carries you over.”

CONDYLOMATA.

Condyloma, from _kondulos_ _Gr._, a “knot,” or “tubercle,” may be applied to any small, hard tumor, flaps, tabs of flesh or wart-like excrescence about the anus, whether of syphilitic or non-syphilitic origin.

They may take the form of one of the radiating folds, or flattened transversly by the pressure of the buttocks, and consist of a hypertrophy of the skin from localized inflammation or irritation, and sometimes continue to grow after the cause has been removed.

A cutaneous tag as a relic of an external hemorrhoid, after it has lost its identity and become dense in structure, is properly a condyloma; also a warty vegetation developed from the papillary layer of the derma. Certain forms of condylomata are pathognomonic of ulceration and other serious changes going on above. The discharge at the anus producing these fleshy tags.

Some writers prefer to limit the meaning of the word to certain varieties of growths about the anus. But it appears less liable to confuse, to use it in a literal and a generic sense; making the varieties associated with their causes, qualifying terms: as syphilitic, non-syphilitic, warty, cancerous, innocent, etc.

The objection to cocainizing condylomatous growths of any size, and excising them, is the annoyance from the bleeding that sometimes follows, which will often break through a heavy crust of Monsels’ salt. The prettiest way to remove them is by galvano-cautery. When electricity is not at hand, carbolic acid injection is equally as effective. It may be necessary where the skin is thick and horny in texture, to afterwards trim off the remaining ragged edges with the scissors.

NEURALGIA.

Neuralgia of the rectum as a clinical entity is rare indeed. Mention is made here simply in acknowledgment of the affection, having met with but one case, and that in a very nervous and delicate lady, who maintained that she was cursed with a rectal ulcer.

In obedience to this idea her physician had examined the rectum, under anæsthesia, and found what he called a rectal ulcer at a point where the uterine cervix rests on the rectum. His diagnosis was, no doubt, founded upon her belief, and as an apology for the examination and treatment resorted to, which put her to bed for six weeks.

There were no symptoms of rectal ulcer, other than pain, and no lesion found by a digital examination or seen through a speculum. She insisted on taking chloroform and a more thorough examination made. This was done without revealing anything more than what had already been ascertained, and the diagnosis of neuralgia confirmed.

Pain continued, periodical or irregular, in the absence of mechanical pressure (uterine) or structural lesion, in the region of the sphincters, or higher up, is diagnostic. If in the sphincters alone, dilitation may be sufficient. When higher up, constitutional treatment with galvanism is advised.