theory, though it may excite your disapproval, and perhaps your ridicule,
yet it can be easily verified by directing your management towards the
destruction of the parasite, when all symptoms will disappear. Mercury is
quoted as nearly a specific for the annihilation of these marauders, and
the very best method of administration is by using Lotio Niger.
“Thrice daily the patient should relax, the respiration of the cutaneous
surface by the free application of hot water, just as hot as it can be
comfortably endured. Then immediately afterwards _while the skin is made
absorbent_ by the action of the liquid heat, it should be saturated
with this medicine in the most thorough manner. Within three days time
the itching will be reduced fifty per cent., but the complete result is
attained only after a continued use of from four to eight weeks.
“In many cases there will remain points or patches where the agent does
not seem to act, and to these I usually apply the regular unguentum
hydrargyri. Avoid all soaps and ointments except as above stated, thereby
preventing the obstruction to absorption of the remedy as it has to enter
the pores of the skin in order to act upon these energetic enemies that
hold their victims under such a terrible bondage.”
It is characteristic of pruritis for the paroxysms of itching to come on
mostly after the patient gets warm in bed, at which time the annoyance
may be further increased by a moisture or exudation about the anus.
In longstanding cases the skin becomes thickened, horny in texture, and
loses its pigment and elasticity. Sometimes portions of the radiating
folds will become so hypertrophied and elongated, from the effects of
gouging and scratching, that they look like and are sometimes called
external piles, which in reality are nothing of the sort, but properly
speaking would come within the range and meaning of non-syphilitic
condylomata.
I have successfully removed these formations by the same process adopted
for the cure of piles. They go through similar changes after injection
and open up a cavity surrounded by a ragged, thick, calloused skin,
which, after first being cocainized, can be trimmed off with a pair of
scissors. If there are several large tabs I do not operate on all at one
sitting.
[Illustration: FIG. 29.—Thickened condition of the skin in pruritis
(Esmarch).]
In the treatment of pruritis ani, a thorough search for a local cause and
its removal will find a lasting reward in the results obtained.
Of the obscure local causes, perhaps animal and vegetable parasites are
the most difficult to find. The injection of a decoction of quassia bark
or lime water and carbolic acid, will be efficacious in dislodging the
oxyuris vermicularis, which may or may not be seen, like small pieces of
white thread lodged between the anal folds.
For the vegetable parasites, tricophyton, etc., (microscopical)
sulphurous acid ranging from 50 per cent. up is an old tried remedy.
Immoderate eating, drinking coffee, and smoking excites the itching with
some. Whenever it be decided that no local or constitutional disease
can be found as an assignable cause, and that it is purely neurotic
in character, we commence to grope in the darkness for remedies. What
relieves one will not another; and what relieves for a time will lose its
effects altogether.
Hot water compresses, a little short of scalding, are good for relief and
a good intercurrent remedy. Among the remedies highly recommended are
linseed oil, thuja occidentalis, carbolic acid, _citrine ointment_, oil
of cade, oxide of zinc, compound tincture of green soap, black wash, and
_galvanism_. The anode is placed over the perineum and base of scrotum
and the cathode against the anus or within the grasp of the sphincters.
Claimed to be a specific. Nerve stretching by divulsion of sphincter
muscles is also recommended.
Formulæ:
℞ Ung. Citrini ʒ ii
Balsam. Peru ʒ iss
Acid. Carbol. gr. xx
Sulphuris ʒ iii
Cerat. Simp. vel Lanolini ℥ i
M.
℞ Hyd. Chlor. Mit. ℈ iv
Adipis ℥ i
M. Said to be specific for pruritis ani or vulvæ.
℞ Hyd. Chlor. Mit. ʒ i
Balsam. Peru ʒ iss
Acid. Carbol. gr. xx
Lanolini ℥ i
M. et sig. Apply after hot sponging.
℞ Ol. Cadini ʒ i
Acid. Salicyl. gr. xv
Ung. Zinci Oxidi q. s. ft. ℥ i
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.
[Illustration: FIG. 30.—Graduated Rectal Dilators. (Pratt’s).]
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.
[Illustration: FIG. 31.—Flushing 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.