in children than in adults, making its appearance at every movement of
the bowels. The child thus affected should not be allowed to sit upon
the chamber-vessel and strain, but should lie upon the side or stand,
while the nurse should be instructed to draw to one side one of the
buttocks so as to tighten the anal orifice. After the motion the
protruded part should be well washed in cold water, and afterward with
some astringent solution of oak-bark, matico, or a weak solution of
carbolic acid applied with a soft sponge. The bowel should then be
gently returned and the child be allowed to lie at rest for a while. If
there exists intestinal irritation, small doses of mercury with chalk,
with rhubarb at night, with wine of iron three times daily, would be
indicated. {920} The application of an anal pad and a T-bandage will
give sufficient support. If this treatment be carried out a cure
usually results in a few weeks. Some cases do not yield to this mode,
and then the surgeon has to make trial of ergotin given hypodermically,
each injection representing a grain of ergot, which is to be thrown
into the submucous tissue of the rectum every second day for two weeks.
Should relief not follow its use, cauterization is to be tried. The
cauterants usually applied are nitrate of silver, acid nitrate of
mercury, and nitric acid. Of these, nitric acid is the best. After
anæsthesia is complete every portion of the extrusion should be touched
with the acid, care being taken not to bring it into contact with the
skin; afterward the bowel is to be freely oiled and returned. To
prevent its extrusion the bowel should be filled with soft cotton wool,
a compress placed over the anus, and the buttocks strapped tightly
together with adhesive plaster. For a general quieting effect the child
should be given paregoric. About the fourth day the adhesive plaster
may be removed and a dose of castor oil administered, which will bring
away the cotton plug with the dejection.
Prolapsus and procidentia in the adult are much less manageable;
indeed, these conditions are usually very obstinate. There may exist
causes extraneous to the bowel, such as urethral stricture or enlarged
prostate or an impacted renal calculus or a calculus of the prostate.
The bowel should be searched for polypi or hemorrhoids, and the
prolapse may be cured by the removal of the irritating cause. Failing
to find any such cause, the surgeon has at his command either
cauterization or a removal of redundancy. The former may be by nitrate
of silver or acid nitrate of mercury or the actual cautery. It is well
not to apply these strong acids to the aged or those who are broken
down in health, as very destructive sloughing has followed their use in
these cases. When these are used, the same plan as that mentioned in
case of prolapse in children should be pursued. Strong carbolic acid
may be used in these cases with much less risk of sloughing than when
the acid is employed, and it may be applied oftener--indeed, daily if
desirable. Van Buren has recommended linear cauterization with the hot
iron to the mucous membrane, the bowel contracting as a result of
cicatrization. In adults generally, and especially in the aged, all the
forms of cauterization are less satisfactory as a means of relief than
either of the various modifications of Copeland's operation, which
consists in removing by ligation elliptical portions of the mucous and
submucous tissues of the prolapsed bowel. The most satisfactory of
these is either to excise two or three oval portions of the mucous
membrane with flat-curved scissors and bring the edges together with
interrupted suture, or to pinch up in several places the redundancy in
a Smith's clamp and cut off the folds in advance of the instrument,
applying to the stumps the hot iron. Allingham prefers ligatures of
horsehair in these operations, and mentions the carbolized catgut in
preference to silk. He cautions the operator not to carry his knife
into the submucous tissue, as free hemorrhage would inevitably occur.
In old cases of prolapsus or of procidentia that are not amenable to
operative treatment much can be done to render them comfortable: the
air-dilated gum pessary will sometimes afford relief, or a pad and
T-bandage will prevent the parts becoming ulcerated by friction.
Neither gallic {921} nor tannic acid answers the purpose so well as
acorn flour. The frequent use of cold water to the part is always
attended with comfort, and sometimes with relief. In these old cases of
great relaxation Nélaton has used strychnia by the mouth, and Weber (of
New York) hypodermically, with fair result. Vidal has cured three cases
by the repeated use of ergotin locally, hypodermically. In order to
bring about a radical cure in these very chronic cases, very decided
means sometimes are justifiable. The late Mr. Hey of Leeds was the
first to propose a plan by which, through cicatricial contraction and
inflammatory gluing together of the various tissues composing the
bowel, the anus and sphincter muscle might be strengthened and improved
in tone; to which end he proposed to cut away the pendulous flaps of
skin around the anus. In cases where these flaps are very redundant a
cure is sometimes effected by this procedure alone. Other cases will be
benefited by the operation proposed by Dupuytren, which consists in the
removal of radiating folds of the skin and mucous membrane at the edge
of the anus. To quote from Holmes's _System of Surgery_: "This
operation is effected by laying hold of the fold of skin on each side
of the anus with forceps, then with a sharp curved pair of scissors
removing both skin and mucous membrane. In very severe cases four or
six applications of the scissors may be necessary."
POLYPUS OF THE RECTUM.--The polypi of the rectum are the gelatinoid and
the fibroid, but as a very rare occurrence a villous or warty polypus
has been found. Polypoid growths are very different bodies, but they
are too frequently confounded with true polypi. The only treatment is
their removal, and the safest method is by ligation of the pedicle, and
either cutting off the growth in advance of the knot or returning it
into the bowel. The patient should remain quiet until the sloughing is
complete, and his bowels must be confined, otherwise profuse and very
troublesome hemorrhage might ensue. Their removal by the clamp and
cautery is equally safe. Their removal by torsion or by the scissors is
unsafe.
The peculiar villous polypus causes great and exhausting hemorrhage. A
case was successfully treated by the application of fuming nitric acid.
FISTULA IN ANO.--In the palliative treatment of this very common malady
no great amount of relief can be afforded. Those who are aged and
feeble or those who are much broken down will find comfort to attend
the free local use of warm water, and the sinuses should be injected
with dilute solutions of one of the mineral astringents, the strength
of these not exceeding two grains to the fluidounce of water.
Cosmoline, simple cerate, ointment of the oxide of zinc, and even fresh
lard, make the patient easier, as they prevent friction of the
buttocks. One of the forms of the radical treatment consists in the
division of all the structures between the fistulous tract and the
surface. This may be accomplished either by the use of the knife or by
seton. Stimulating injections or cauterization has been known
occasionally to permanently close fistulæ in ano; but such plans of
treatment are unreliable, and usually unjustifiable. When the fistula
is not so high up in the bowel as to render the use of the knife
unsafe, this plan of treatment should be adopted. As an invariable
preliminary to all operations upon the rectum the bowels should be
thoroughly emptied and the patient should be placed under the influence
of {922} an anæsthetic. A flexible grooved director should then be
carried through the opening of the tract upon the surface and along the
tract to its opening in the bowel, should such exist. The forefinger
within the rectum will meet the point of the director as it emerges
from the internal opening, and the director should be pushed onward and
its extremity guided outward until it rests fairly upon the sound
integument outside, and all the included structures should be divided
along the groove of the director with a sharp-pointed curved bistoury.
Should the fore finger in the rectum not discover an internal opening,
one should be forced at the very bottom of the tract by rotating the
point of the director while making counter-pressure with the end of the
finger. Should several fistulæ be found, they should be treated in like
manner. Sometimes it will be found that the incision is overlapped by
the dusky-red flaps composing its margins, in which case they should be
trimmed off with scissors. When the tract extends deeper than its
internal opening, the latter should be ignored and the sinus laid open
to its very bottom. When no external opening exists, one should be
made, and the guide for this incision will be a point of induration
felt by the finger at some point not far from the surface. The director
entering at this point will find the tract, and should be pushed
forward as described above. These opened sinuses should be packed with
lint soaked in carbolized oil and confined by a pad and a T-bandage. It
is the practice at the Pennsylvania Hospital to apply after division a
stick of caustic potassa, allowing it to remain in contact with the cut
surfaces for several seconds, after which the wounds are to be packed.
This procedure ensures their healing from the bottom. The bowels should
be confined for a few days, after which a dose of oil may be given.
Besides attention to cleanliness and a daily renewing of the packing no
further treatment will be demanded. The hemorrhage attending these
operations is usually trifling. Should a vessel spring, a ligature may
be thrown around it. When an abundant general oozing occurs, the rectum
must be packed and a compress and bandage firmly applied. Should the
surgeon prefer the seton operation, he should carry several threads of
stout silk or a piece of rubber cord on an eyed probe into the fistula
and out of its internal opening, and by tying their ends firmly down
upon the enclosed tissues slowly effect the same result as in the
cutting operation. When the seton used is silk, the ends should be
carried through holes in a round leaden plate or through those of an
ordinary button, and tied. These setons are to be drawn tighter every
three or four days until the division of the enclosed tissues is
complete. The subsequent treatment is the same as in the other
operation.
A difference of opinion exists among surgeons as to the propriety of
operating for fistula in ano in persons afflicted with tubercular
disease of the lungs. The practice of the present day is decidedly in
favor of operating, without reference to the condition of the lungs,
provided the patient is not too much reduced in strength.
An operation for fistula in ano has been proposed and practised by
Reeves, which is a compromise between cutting and ligation. He says:
"It consisted in passing a strong and well-waxed silk ligature along
the track of the fistula into the bowel. An ordinary surgical probe
with an eye in its end carried this thread into the rectum. My bivalve
expanding speculum was previously introduced, and by its use there was
no difficulty {923} in seeing and seizing the ligature and bringing it
out through the anus. The probe was then withdrawn, and the ends of the
silk were wound round two strong pieces of wood which were held between
the fingers of each hand. An assistant passed a finger on either side
of the track of the fistula to steady the tissues and to resist the
traction which was put on the silk thread. The two pieces of wood were
then drawn toward me with a rapid sawing motion, and the fistula was
quickly divided, with the loss of scarcely any blood. Some oiled lint
and a pad and bandage were applied in the usual way; and the wound
healed well. No anæsthetic was administered, and although the patient
did not relish the operation, still it was quite bearable, and what she
felt most was a burning sensation, due, doubtless, to the friction of
the silk."
HEMORRHOIDS.--The treatment of this form of rectal and anal disease is
either medical or surgical according to the gravity of the case and
according to the obstinacy with which it resists local and general
therapeutic agents. An ordinary acute attack of external piles, such as
is often produced by neglect of the bowels, causing constipation, may
be treated in the following manner: The patient should rest and avoid
stimulating food and beverages. He should employ cold bathing to the
part frequently: indeed, great comfort and relief often follow this
treatment alone. An ointment of tannic acid, glycerin, and simple
cerate, or one containing calomel and extract of opium, will be found
useful. Fresh lard, cosmoline, vaseline, cold cream, ointment of the
oxide of zinc (benzoated) or an ointment containing extract of opium,
extract of galls, and extract of belladonna or stramonium, are some
among many agents that have been extolled for their relief. H. C.
Wood[46] recommends enemata of solution of chlorate of potassium and
laudanum. Enemata of lime-water and linseed oil are recommended by
Agnew: "One of the very best formulas for allaying the irritation
incident to hemorrhoidal affections consists of the following
combination: Acetate of lead and tannin, of each fifteen grains;
carbonate of lead and extract of stramonium, of each thirty grains;
creasote, five drops. With a sufficient quantity of cocoa-butter mould
this into fifty suppositories."[47] The internal exhibition of the
balsam of copaiba, twenty drops in capsules taken four or five times
daily, or the use of fifteen drops of liquor potassa rubbed up with
half a drachm of the balsam into emulsion, taken three times a day, has
been much extolled, as has also the confection of black pepper.
Sometimes these various means will cure a chronic or long-standing case
of piles, either internal or external. Wetherill has found that the
topical application of rectified oil of amber has cured long-standing
cases of piles. This oil should not be applied in cases where much
inflammation exists, and where the piles are internal the best mode of
bringing it in contact with them is to incorporate from three to five
minims of the oil with sufficient cocoa-butter to make a suppository.
One of these, pushed into the bowel night and morning for a week, will
not infrequently cause the piles to shrink up and finally to disappear.
The bowels should be kept open with the compound powder of licorice. It
should be remembered that magnesia irritates hemorrhoids. Success has
followed the internal use of ergotin, of the fluid extract of hamamelis
virginica, of the corn blast (ustilago maidis), and of small doses of
aloes combined with hyoscyamus. {924} D. Young has had good results
follow the internal use of glycerin. Chronic cases of piles have been
cured by the application of ointments containing carbonate of lead,
creasote, carbolic acid, or iodoform. Ergotin used hypodermically in
the vicinity of the anus or injected into the piles has frequently
resulted in a complete cure, and the same may be said of the injection
of carbolic acid directly into the tumors. In the application of cold
water to inflamed piles it should be borne in mind that its forcible
impingement upon them in a fine stream acts far more efficiently than
the mere bathing them. Some cases do better under the use of warm water
or warm sedative and astringent lotions. A warm flaxseed poultice mixed
with laudanum is a very comfortable application. In obstinate cases of
prolapse Agnew[48] recommends the use of a rectal obturator or the use
of a hemorrhoidal truss.
[Footnote 46: _Philada. Med. Times_, Dec. 6, 1879.]
[Footnote 47: _Surgery in the Pennsylvania Hospital_, p. 210.]
[Footnote 48: Agnew's _Surgery_, vol. i. p. 445.]
Those who suffer from prolapse of piles should avoid the habitual use
of cushioned seats. They should assume a semi-erect posture during
defecation, or, when this is attended with difficulty or inconvenience,
they should contrive a portable water-closet seat by boring a hole an
inch and a half in diameter through a piece of planed board, bevelling
it so as to fit the person. These means will often prevent the
extrusion of the tumors. After defecation the patient should rest for a
little while in the recumbent attitude.
The careful touching of external piles with strong nitric acid is a
mode of treatment that has been quite successful in the hands of some
surgeons. The intolerable itching of these bodies can be allayed by
touching them with tincture of aconite-root or with a concentrated
tincture of prickly-ash bark. Freezing them with the ether spray allays
the pain and itching for the time being, but these symptoms return with
redoubled energy after the effect has subsided.
Should an attack of the external variety of piles not result in
absorption, but leave an excrescence, painless but inconvenient, and
liable at any time to become inflamed, excision would be in order.
Divide the integument by an incision radiating from the anus, separate
the skin from the tumor down to its base, and after seizing it with
toothed forceps cut it off with scissors curved on the flat. Little
flaps or tabs of skin remaining after piles may be snipped off with
scissors. It is not well to operate upon external piles unless they
obstinately resist all milder treatment. There are frequently venous
enlargements containing blood-clot, and when this condition exists
proceed as follows: Pinch up the little tumor between the thumb and
finger of the left hand; transfix its base with a curved bistoury, and
cut out; at the same time, by pressure with the thumb and finger,
extrude the clot. Fill the bottom of the little sac with cotton wool,
and the operation is complete. It is not necessary in these cases to
wait until the inflammation subsides before operating.
The operative treatment of the internal variety may be by
strangulation, by the cautery, by the écraseur, and by the use of
caustics. The former of these is the safest and most convenient method,
and the one usually employed in the Pennsylvania Hospital, and should
be performed in the following manner: The lower bowel having been
thoroughly evacuated and the patient etherized, the operator should
gently but firmly stretch the sphincter. The patient should be placed
upon the side, with {925} the upper part of the body prone, the hips
elevated, and the thighs flexed upon the abdomen. Transfix the largest
tumor with a strong, long-handled tenaculum, cut through the skin at
the base with a knife or scissors around its external half, and hand
the hook to an assistant, instructing him to make gentle traction. Then
encircle the mass with a stout cord if the mass is not too large, or
pass a stout needle threaded with a double silk ligature, from without
inward, deeply through the base of the pile, drawing it through the
mucous membrane on the opposite side; cut loose the needle and tie
tightly, so as to completely strangulate the included tissues on either
side and leave the ends of the ligature long. Treat all the remaining
tumors in a similar manner seriatim, and then with scissors cut away
the strangulated bodies to within a safe distance of the ligatures, the
ends of which are now to be cut off close. Place an opium suppository
in the bowel, and the operation is complete.
When for any sufficiently good reason the patient will not bear the
ordinary anæsthetics, it will become necessary to modify the operation
as follows: The tumors having been well extruded by enema of warm water
or by the efforts of the patient, bend him forward over a chair and
direct an assistant to draw aside the buttocks. Then pass the double
ligatures as before indicated, but refrain from tying until all the
tumors are thus secured, as the operator will find it convenient to
draw upon the ligatures to keep the mass of piles within view and
working-distance. Then draw down each tumor, cut around its base, and
tie as before; cut off the ends of the ligatures and the greater
portion of each strangulated tumor, and return everything within the
bowel, and follow with an opium suppository. In many cases Morton has
used the nitrous oxide gas with the best results. The hook should then
be withdrawn, and each knot should be drawn more firmly down prior to
its reduplication. Following this procedure, if properly carried out,
the tumors will change color, becoming blue, thus indicating complete
strangulation.
The operation by the clamp and cautery is a good method when the
hemorrhoidal tumors are small. The operation is that of Mr. Cusack of
Dublin, and the clamp employed is that invented by Mr. H. Smith of
London. This instrument is so well known that a detailed description of
it would be unnecessary. In operating with it the tumor is to be drawn
well out and the clamp applied close up to its attachment with the
bowel. Strangulation is effected by means of the screw which runs
through the shafts of the handles. This accomplished, the strangulated
portion is cut off with scissors, which should leave a stump
three-eighths of an inch long. To this stump apply the actual cautery
at a dull red heat, touching its every portion, after which unscrew and
remove the clamp and look for hemorrhage. Should any occur, touch the
bleeding point with the hot iron. Confine the patient to bed for five
or six days and give sufficient opium to confine the bowels. After this
time has elapsed administer a dose of oil. Remember that but one pile
should be clamped at one time. "The taking two piles into the clamp at
once is sure to result in hemorrhage." Do not allow the cautery-iron to
touch the clamp. After the operation return the parts within the
sphincter and cut off any tabs of redundant integument with scissors.
The removal of internal piles by means of the écraseur was the favorite
operation of Chassaignac, but it is a mode of procedure which is now
{926} regarded with disfavor by the best surgeons on account of the
liability to hemorrhage, and from the fact that troublesome and
injurious contractions of the anus have not infrequently followed its
use. The employment of iron or copper wire instead of the usual chain
has been recommended by those who prefer this mode of operation. The
plan adopted by Chassaignac was to pedunculate the piles by tying a
ligature around the base and drawing them down. The chain being then
applied, the strangulation and crushing off was slowly accomplished by
means of the lever of the instrument. It should take from twenty to
twenty-five minutes' crushing to accomplish this object.
For the treatment of internal piles by caustics Houston of Dublin used
strong nitric acid. A fenestrated speculum should be employed, and the
acid should be applied with a piece of wood or with a glass brush, care
being taken to limit its action to the tumors, the redundant liquid
being mopped up with a swab of lint or prepared absorbent cotton. The
entire surface should afterward be bathed in oil. The acid is relied
upon to produce a granulating surface, by the healing of which and by
the subsequent contraction a cure is sometimes achieved. At best, this
plan of treatment has proved tedious and unsatisfactory.