VOL. I. MARCH, 1907. º No. 1. The Proctologist EDITED BY ROLLIN H. BARNES, M.D. ST. LOUIS Those Who Have Contributed : DR. JOSEPH M. MATHEWS, Louisville, Ky. DR. R. D. MASON, - - - Omaha, Neb. DR. ARTHUR E. HERTZLER, Kansas City, Mo. DR. WILLIAM M. BEACH, - Pittsburgh, Pa. DR. H. A. BRAV, - - : Philadelphia, Pa. DR. ACHILLES ROSE, - New York City. $1.00 a Year. QUARTERLY. $1.50 a Year Postal Union. NEUROSINE Clinical Experience Has Proven that NEUROSINE is the most Efficient Neurotic, Anodyne and Hypnotic. A RELIABLE NERVE CALMATIve, ABATING severE PAIN, CAUSINC, NATURAL SLEEP. Contains no Opium, Morphine, Chloral or other Deleterious Drugs. TRY NEurosine IN RECTAL CASES, SOOTHING AND SAFE. Full size Bottle to Physicians, they Paying Express Charges. DIOS CHEMICAL CO., - St. Louis, Mo. y’reparations | TDAssoa vs Ar 98 °F OMPOSED OF-Benzoborate Soda, Concentrated Thymic Solution, Sulphocarbolate Zinc, Oil of Cassia, Alveloz, Boroglyceride Solution, Gelatine and Glycerine. 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Yours Respectfully, Is º in the treatment of Rheumatism, Gout, Bright’s , Ill. DR. GEO. R. H. º Disease, Diabetes, Etc. y Especially &Morning Sickness. M Send yor book of festimonials, and ask for a sample bottle. &MOUNTAIN OA L LEY WATER CO. 503–510 Calver Way, St. Louis, Mo. Antinaus Chem. Co. ST. LOUIS, MO. i } %e Kahama Chemical 0.9/wº (Ulp. Irurfulnuigi PUBLISHED QUARTERLY All communications relating to THE PROCTOLOGIST should be addressed to ROLLIN H. BARNES, M.D., Editor and Publisher, 412 N. Sarah St., St. Louis, Mo. CONTENTS. PAGE INTRODUCTORY, by Joseph M. Mathews, M.D., Louisville, Ky. e g 1. EDITORIAL, tº {} e * e & wº Q te 2 THE PRocroLoGIST, The Reason for His Existence, by R. D. Mason, M.D., Omaha, Neb. g tº tº tº ſº e o & 3 ExcISION AND IMMEDIATE SUTURE IN FISTULA AND ANO, (Illustrated), by Arthur E. Hertzler, A.M., M.D., Ph.D., Kansas City, Mo. * 9 CANCER of THE RECTUM, by William M. Beach, A.M., M.D., Pittsburg, Pa. e e § e • { & * 15 INFLATION OF THE RECTUM witH CARBONIC ACID GAS, by A. Rose, M.D., New York City, . © & º ſº º gº ſº 18 DISEASES OF THE RECTUM A SPECIALTY, by Herman A. Brav, M.D., Philadelphia, Pa., & & e gº * tº ſº 20 Abstracts from Current Literature Relating to Proctology. Treatment of Habitual Constipation, O. Kohnstamm, t te º 14 Dosage for Spinal Anesthesia, C. Hofmann, . tº • º * 19 Practical Points in the Operation of Colostomy, C. B. Kelsey, e © 24 Cancer of the Rectum, J. Petermann, . tº e e e . 25 Intestinal Bacteria, E. Palier, . g e e e e tº 26 Recent Writings that May Be of Interest to the Proctologist, iº § 27 Subscribe to The Proctologist. . .”.' *.*. to Rectal subjects. By so doing you will not only help yourself, but assist the most neglected department of medicine. Fill out the following form and mail at once. I subscribe for The Proctologist for one year, for which I agree to pay One Dollar. JW"a mºve Street Town, or City State THE PROCTOLOGIST is the only journal devoted to Rectal Diseases. ADVERTISEMENTS. LISTERINE The original antiseptic compound Awarded Gold Medal (Highest Award) Lewis & Clark Centennial Exposition, Portland, 1905: Awarded Gold Medal (Highest Award) Louisiana Purchase Exposition, St. Louis, 1904; Awarded Bronze Medal (Highest Award) Exposition Universelle de 1900, Paris. Listerine represents the maximum of antiseptic strength in the relation that it is the least harmful to the human organism in the quantity required to produce the desired result; as such, it is generally accepted as the standard antiseptic preparation for general use, especially for those purposes where a poisonous or corrosive disinfectant can not be used with safety. It has won the confidence of medical men by reason of the standard of excellence (both as regards antiseptic strength and pharmaceutical elegance), which has been so strictly observed in its manufacture during the many years it has been at their command. The success of Listerine is based upon merit The best advertisement of Listerine is—Listerine Lambert Pharmacal Company St. Louis, U. S. A. Ž . RS. (ſ 6) $ * A NEW IDEA The Golden Rule Series A system of Guide Books, designed to place within the reach of every physician and surgeon the salient points one must know and observe in order to get results. If you follow their teaching you WILL, GET RESULTS. This system is truly an innovation in Medical Literature. Vol. I. Golden Rules of Surgery. By A. C. Bernays, A.M., M.D., F.R.C.S., England, 232 pages. $2.50. Ready. Vol. II. Giolden Rules of Pediatrics. By John Zahorsky, A.M., M.D., Clini- cal Professor Diseases of Children, Washington University, St.Louis, Mo., 370 pages. Price, $3.00. Ready. Vol. III. Golden Rules in the Diagnosis and Treatment of Disease. By Hugo Summa, A.M., M.D., Professor Princi- ples and Practice of Medicine. Medi- cal Dept., St. Louis University, St. Louis, Mo. Price, $3.00. Nearly ready. Vol. IV. Golden Rules of Gynecologi- cal Practice. By Henry Schwarz, M.D., Professor of Obstetrics, Medical cal Department, Washington Univer- sity, St. Louis, Mo. About 350 pages. Price $3.00. Nearly ready. These volumes will be sold separately—or in sets. TERMs For SET : $2.50, and $1.00 per month until $11.50 have been paid. The C. V. MOSBY MEDICAL BOOK CO., publishers, 2315 Washington Avenue, St. Louis, Mo. N. - | W § iS. Ullr Irurtuluuist t VOL. I. MARCH, 1907 NO. 1 INTRODUCTORY. BY JOSEPH M. MATHEws, M.D. LOUISVILLE, KY. It cannot be gainsaid but that Proctology, to-day, is a distinct specialty; ranking alongside with ophthalmology, genito-urinary dis- eases, diseases of the chest, gynecology, etc., in importance. No medical work, be it Surgical or whatnot, is complete, to-day, that does not deal fully and explicitly with proctological diseases. The time has passed when a scant reference is made by medical authors to this important class of diseases. Then, too, there are published, both in this country and in Europe, large and comprehensive books on this subject, edited by as competent men as any that write in other special lines. These works on Proctology are sought after by the busy prac- titioner, with equal avidity, as are the books relating to other specialties. No medical journal of to-day that is up-to-date but contains a special department relating to Proctology, or gives space to lucid articles on the subject. Every medical college, claiming to be in the front ranks, must have this specialty well taught, for the student demands it. The medical examining boards of the country embrace in their list of ques- tions those relating to this special class of diseases, and the applicant may lose the rating necessary in obtaining his certificate to practice if he fails to answer these questions which go to make up the general average. Therefore it can be predicted that this journal which is to be devoted to Proctology will be successful, for it does indeed fill a much needed space, which deals with a very important subject. SUCCESS TO IT. 2 Editorial. EDITORIAL We do not offer any apology for starting a new medical journal. We think it sufficient to mention the fact that we are going to devote our efforts to the most neglected department of medicine—one that has as great opportunities as any specialty in medicine; one where more suffering ,and the most severe suffering is to be relieved, of any. We believe the greatest object of medicine should be to prevent and relieve suffering. Why, then, fellow workers, should we let this important department drift along as best it may, allowing many unfortunates to suffer who can be relieved. It is not our intention to emulate our own ideas at the expense of writings on Proctology. We want your contributions, and we will gladly print them as long as they are on Some rectal subject, no matter on which side of a disputed point they may be. Our object is to edu- cate, rather than to direct the line of treatment that should be followed loy the Proctologist. You will have the opportunity to present your arguments and prove your belief. The reader must draw his own conclusions; for we do not consider medical men children, and that the reading of some theory, that is not exactly regular to the current belief, is going to be injurious to the profession. Think of the number of ideas that have been expressed, but little discussed, that have laid dormant for years before becoming of general use. We ask and we need your support in this undertaking, and we want you to volunteer your experiences and investigations. We will print all that are presented, clearly describing your ideas, and, if necessary, enlarge and appear oftener in order to do so. We do not want to make too many promises, but we are going to put forth our best efforts; besides, we will gladly receive any sugges- tions and criticisms that will tend to aid us in bettering the welfare of Proctology. The Proctologist. 3 THE PROCTOLOGIST. THE REASON FOR HIS EXISTENCE. By R. D. MASON, M.D., OMAHA, NEB. Professor of Rectal and Pelvic Surgery in the John A. Creighton Medical College, Surgeon to St. Joseph’s Hospital, Consulting Surgeon to Mercy Hospital, etc. Being asked to contribute the first paper to this journal, which is being established to cover the field of proctology, or rectal diseases, I have thought it best to state some reasons why such a specialty should exist. The first, and probably most important reason is that the different diseased conditions found here are very common. Hardly anyone reaches adult life without having some rectal trouble which may vary in degree anywhere from a simple irritation to carcinoma. Oftentimes the actual lesion is so small and apparently insignificant that it is over- looked, and the symptoms which it produces are sought for in vain among other organs of the body. I could fill pages describing instan- ces, where, by curing some seemingly insignificant rectal trouble, diseased conditions that apparently existed in other parts of the body disappeared as if by magic. Another reason for the existence of the Proctologist is, that, until he appeared on the scene, the study of the diseases which he treats was sadly neglected. Twenty years ago there was scarcely anything taught in our medical schools along this line. The advice to “cut off external hemorrhoids and tie off internal ones” and to “introduce a grooved director through a fistulous channel and cut the intervening tissue” constituted about all there was to be said in the text books of that time. We know now that this was not enough, and that what little there was of it was bad. It was not enough because it left many things of importance out of consideration, and it was bad because the patient was worse off, many times, after the operation than before. If further reason why this specialty should exist were needed I would point ont that many of the diseases which come under this 4 - F. D. JMason. heading if “left untreated,” or if improperly treated, may develop into conditions that are cured with difficulty, or that may in some instances be incurable. This is seen in the damage done by the burrowing of pus in abscess and fistulas, the extensive destruction done by allowing extensive ulcerations to go untreated. Probably the most serious result due to neglected or bad treatment is that which I have previously pointed out in a paper read before the Nebraska State Medical Society, entitled “The importance of early diagnosis in cancer of the rectum and sigmoid flexure.” Here the claim is made that because of the irritation induced by the different rectal maladies that carcinoma may be developed, and that by properly treating these maladies in their incipiency this might, in some instances, have been avoided. I will not go into this in detail now, but will quote briefly from that paper. “My experience in treating rectal diseases leads me to believe that something may be done to forestal or prevent cancer long before it has actually made its appearance. I do not put much confidence in the theory that cancer is an inherited disease, neither do I believe that it is due to a germ, but I do believe that it is caused, at least in some instances, by prolonged traumatism, or irritation. This is especially noticeable in cancer of the cervix and pylorus, also in that due to irritation of the lower lip by the pipe, or the so-called smokers’ cancer. These localities are all subject to constant irritation, and should they become diseased from any cause, such as prolonged ulceration, or small growths, or from the irritation of an old cicatrix, malignant disease may develop. I realize the fact that I cannot prove absolutely that this theory is correct; neither can anyone else prove that it is not true, or demonstrate beyond doubt any other cause for the disease. If is not at all uncommon to find cancer following an old laceration of the cervix, in fact most of the cases found here are in the cicatricial tissue of an old, healed ulceration. In his “Operative Gynecology,” Kelley says, in speaking of these cases,' A potent reason for operating on these cases is the remarkable frequency with which they are associ- ated with cancer.’ It is well known that ulcer of the stomach, especially if located near the pylorus, where it is subject to the constant irritation induced by the contraction and dilatation of the muscular The Proctologist. * : * * * : * * * : * ~ * : * ~ * * * 5 fibres, may develop malignancy. As applied to rectal diseases, I wish to quote briefly from other authors as to the liability of irritation being the cause of carcinoma. Volkmann, Quenu, and Hartmann and Sterlin as quoted by Tuttle, claim that fifteen per cent of carcinomas are preceded by hemorrhoids. Gant says, “In this connection it is well to remember that the closest observers consider cicatrices, benign epithelial growths, ulcers (especially tubercular), epithelium displaced from whatever cause, and chronic inflammation as predisposing causes of cancer.’ Matthew says, “Chronic inflammatory products, cicatrices and benign epithelial tumors are favorable locations.' I might quote many other authorities along the same line to prove my position, but believe the above sufficient. Granting then that cancer may be caused by local irritation, especially in localities near openings of the body, it is important that these openings should be kept as free from disease as possible.’ “I feel so thoroughly convinced that the above position is correct, and that many difficult cases will clear up, and that many others will be prevented from developing into more serious or even fatal maladies by proper treatment, that I wish to quote from an article by Roswell Park, published in the Medical News, June 7th, 1902, and entitled ‘Surgery in Borderland Cases.’ - “So far as the colon and rectum are concerned, I would say that I never have treated a case of malignant or non-malignant stricture of this tube which has not already passed through the hands of others, being treated for dysentery, or piles, or something of that kind. In my own case I do not have to make a single exception to this statement. Too often they have long passed the period when even those formidable operations, to which Dr. Fitz takes exception, would be of any lasting benefit, and too often I have had to make a simple colostomy, feeling that the golden time had passed under medical auspices, and that the best vital interests of the patient would be conserved by less radical attack. Incidentally, also, I would call attention to the wisdom of early surgery in cases of minor importance, such as anal ulcer, fissure, etc., in which patients are encouraged under medical advice to fool away months or years of time with ointments or local applications, 6 Jº. D. JMason. when a good, thorough stretching of the sphincter or curetting of the ulcer would afford complete and final relief. I have known more than one instance of melancholia and mania relieved by attention of this lönd, the patients being thus redeemed from the grasp of the asylums.” In addition to the reasons already given for the existence of the Proctologist, it might be further mentioned that the study of any par- ticular portion of the body by a number of competent men, who are each striving to perfect themselves along a special line, is sure to pro- duce better results than could be had by the same men studying the whole field of medicine. It also broadens men's ideas of the field in which they are working and brings out new methods of treatment that might never have been discovered except by special work in restricted fields. An example of this is the work now done in rectal surgery, by means of local anaesthesia, either in the office or the patient's home. The author of this paper was a pioneer in this work, and was the first proctologist to advocate the use of very weak solution of cocaine or sterile water as a means of producing anaesthesia. This method was used and advocated by me ten years ago, and the first edition of my book published in 1901 contains the following words bearing on this point: “I have used cocaine in my rectal work for several years, and if properly managed think it perfectly safe, and that it will permit of a large amount of cutting with absolute freedom from pain. As a rule operations on the deeper tissues are not very painful even if done with no anaesthesia, and if the superficial tissues are attended to there will be no complaint on the part of the patient. I think most operators use too strong a solution. One writer says 16 per cent. I never use stronger than 4 per cent where it is injected into the tissues, and 10 per cent where it is used locally to the mucous membrane. I would prefer to inject 30 drops of 2 per cent solution than 15 drops of a 4 per cent solution. A large part of the benefit comes from the water used, and the pressure it exerts on the nerve endings. If anyone doubts this let him try using a large amount of plain sterile water by the infiltration method, filling the area to be cut as fully as possible; such tissue may be incised with but little discomfort.” These words were written nearly seven years ago when the treatment of these diseases by other than The Proctologist 7 Operative procedure under general anaesthesia was scarcely thought of. The efforts that have been put forth to place the specialty of rectal Surgery On a Scientific basis, and at the same time render it as simple as possible has been of great advantage to the public while kept in the hands of the specialist; but, on the other hand it has been a disad- vantage, and in many instances has worked an injury when attempted by those who are unfamiliar with the work. Many physicians who have failed in general practice have read the literature on the subject and thought that here was a chance to get into a specialty that was easy and that would at once put them on the road to prosperity. Others, who are really competent men having large practices in small towns, have attempted to do the work; both of these two classes have failed, as a rule. In the first instance, because of lack of ability to do it properly; in the second, because of lack of sufficient material to famil- iarize themselves with the work. No one can do good work along any line who only sees cases at long intervals. The country doctor, no matter how bright and competent he may be, would probably not see as many cases of rectal diseases in a year as the specialist in a large city would see in a week. There is another importnat point that comes in right here, and it is this: A host of incompetent men have arisen in the past few years who pose before the public as rectal specialists, whose sole ability con- sists in treating readily accessible hemorrhoids, cauterizing fissures, and doing a few other minor things. When a patient appears with a carci- noma, stricture, or other serious malady, they are unable to care for them properly. This is also true in case a patient comes with some complication affecting other organs, as the urethra, bladder, perineum, uterus, etc. A man whose field is limited to the first inch or two of the bowel is not one who should expect to pose as a proctologist. And finally, I wish to call attention to the worth of the competent proctologist when viewed from the standpoint of the patient. To the surgeon there is nothing more satisfactory than a successful Surgical operation. He thinks that the patient has been cured in the quickest, easiest, and most satisfactory way. In most instances he is correct. But the patient looks at it from another point of view. He dreads the 8 - JR. D. JMason. chloroform, and the thought of the knife, and the possibility of death causes him to shrink from assuming the risk. He prefers to suffer and remain uncured rather than to undergo what, to him, is a serious surgical operation. We know that the danger is small and that the cure will be perfect, and that there will be but a minimum of suffer- ing and a short time in bed, but even our large experience with others is not final proof to him that he will pass through it all right. Tell him that he can be cured just as thoroughly by some other method which eliminates chloroform or ether and an operation, but will re- quire more time and several visits to the office, and he will almost invariable choose the latter method. This question as to whether or not we shall allow the patient to choose the method that shall be adopted is an important one. If the doctor is not careful he may allow the patient's wishes to get the better of his own judgment. I have long since learned that where there are any important reasons why a patient should be treated in a certain way, rather than in some other way, that my decision should absolutely rule. Better lose the patient than pursue a line of treat- ment that you know is not for his best interest. The proctologist should be a broad-minded surgeon, capable of performing almost any operation, upon any part of the body; one who can diagnose and treat any complication that may arise in connection with his work, no matter whether it belong to the field of the proctologist, the gynecologist, the genito-urinary surgeon or any other special field. He should be careful as a diagnostician, skillful as an operator, firm in his decisions, and a patient, kind hearted gen- tleman who looks upon the sufferings of others with compassion, and their restitution to health as the one great object of his life—an object that is greater even than the fee he expects to receive. Such a man is sure to achieve success both professionally and financially. 500 Brown Block. Fistula in Ano. 9 EXCISION AND IMMEDIATE SUTURE IN FISTULA IN ANO. BY ARTHUR E. HERTZLER, A.M., M.D., PH.D. RANSAS CITY, MO. The method employed by most surgeons in the treatment of anal fistula is the simple incision operation. The main advantage of this procedure is its simplicity. Its chief disadvantage is the length of time required for healing to take place. The surgeon must either keep his patient in the hospital from two to eight weeks or dismiss him with a gauze pack. My results with excision and immediate suture has been so satisfactory that I venture a brief description of my technic. I would urge its employment not alone in the simpler cases but particularly in those extensive ones in which prolonged after-treatment is necessary when operated by incision and packing Cf the wound with gauze. No case in fact do I regard as too extensive for immediate suture. The method is of course contra-indicated when active suppuration is still going on. Specific cases too are unsuited for this method. As a preliminary preparation the patient is given a mild laxative the evening before operation. Some hours before he goes to the Operating room he gets a simple enema. A purge should not be given for it is undesirable to have the intestinal contents too fluid and the intestines in a state of unrest at the time of operation. The chief indication is to protect the wound from post-operative infection and this cannot be done when the bowels are in active peristalsis and the intestinal contents fluid. - The patient is shaved and scrubbed with soap and water after he is anesthetized. No antiseptics are used. The Sphincter is thor- oughly dilated after the scrubbing is completed. Time is required to do this completely without lacerating the mucous membrane. The rectum is now carefully irrigated with sterile water. A gauze tam- pon may now be placed in the rectum beyond the field of Operation. This pack need not be large, for if a purge has not been used there will be no trouble of flooding with fecal matter. I prefer to use no pack 10 Art/hºur E. Hertzler. at all. This avoids the danger of infecting the field of operation when the pack is dragged out after the operation is completed. Thus prepared an exact anatomic diagnosis of the fistulous tract is undertaken and the details of the operation planned. No attempt at a comprehensive diagnosis is attempted until the patient is anesthetized and prepared for operation. The existence of a fistula is accepted as an indication for operation. A complete diagnosis is impossible without an anesthetic and it is useless to subject the patient to the FIG. 1. FIG. 2. pain of making a partial one. When anesthetized, however, it is pos- sible with care to discover nearly all of the ramifications of the tracts so that there need be no surprises during the operation. This having been done a silver probe is passed from the skin opening to the open- ing into the intestine if the fistula be complete. If it is incomplete (if there really are such) the point of the probe is made to enter the rectum at the highest point of the sinus. The tip of the probe within the rectum is fixed with the tip of the index finger in order that it may be grasped with a forceps (Fig. 1) and drawn out of the anus. The flexibility of the probe permits the making of it in this way a sling. By making traction upon both ends of the probe the internal Fistula, in Ano. 11 Opening of the sinus may be brought to within working distance of the exterior, even in the deepest fistulas. This done a curved grooved director is passed behind the probe and the latter removed. (Fig. 2). if the internal opening is near the anus the director may be passed at Once without the preliminary traction with the probe. If, however, the opening in the gut is more than two inches from the anus the probe sling should be employed. The skin and mucous membrane are now incised from near one Opening to the other. Bleeding points are at Once caught up and tied. Usually numerous vessels will be found which require ligation. If these are attended to before the deeper parts are cut the subsequent steps will be more clearly defined. The underlying parts are now incised, care being taken to tie all bleeding points as soon as cut. When the incision approaches too near the director it diverges so as to include the wall of the fistulous tract (Fig. 3). Care must be taken that the director is not cut down upon for the opening of the fistulous tract permits the escape of infective material. Care in this part of the technic accomplishes more than an attempt at preliminary disinfection of the fistulous tract. The tract is now cut free, beginning at the skin end of the tract. When the rectal end of the tract is reached the edges of the gut are grasped with forceps (Fig. 3) near the director in order to prevent the upper end of the incision from retract- ing up the bowel out of reach of the operator after the director is cut loose. The remaining portion of the tract is now freed and removed together with the director upon which it is still threaded. When the internal opening is not over two inches within the gut the forceps are not needed for sutures can be passed without difficulty at this depth. Even in such cases the forceps are a convenience and may be used with advantage. The whole wound is now reviewed for bleeding points and all offending vessels ligated. Deep sutures are now passed into the pararectal tissue at the upper end of the wound (A, Fig. 4). In deep fistulas these may need to include the fibres of the levator ani. These sutures should be interrupted and of plain catgut. These deep sutures must not penetrate the intestinal wall. Separate sutures are now 12 ./7”//7/7' E. Herțz/e7". placed in the intestinal wall exclusive of the mucosa. Last of all the mucosa is united with a layer of sutures placed closely together. They should be not over five mm. apart. The knots are placed of course within the lumen of the bowel. The object is to make the wound inpervious to fluids at once, and it is the sutures in the mucosa that must be depended upon to protect the deeper layers of the wound from infection (B, Fig. 4). After a portion of the upper end of the wound has been so treated the forceps are placed at a point nearer FIG. 4. the anus and the sutured portion allowed to recede. It is convenient to place several pairs of forceps on the edge of the incised gut at the time of the removal of the fistulous tract. When this stage of the operation is reached it is then necessary only to remove the upper pair and continue the retraction with those nearer the anus. Successive portions of the wound are treated in like manner. Entire sections are completed before new sections are begun. This step-like com- pletion of the suturing makes a running suture unsuitable. In this way an incision within the rectum of five inches or more may be easily sutured. The same steps are repeated until the entire wound, includ- ing the wound in the skin, is closed (Fig. 5). When complicated fistulas exist several probes may be passed before the operation is begun as an aid to the determination of the Fistula, in Ano. 13 most advantageous incision. The various ramifications may be made plain, when they are very complicated, by the preliminary injection of methylin blue or iodin. With care the most complicated tracts can be dissected out and sutured at once. I have used applications of iodine and carbolic acid at points where there was some doubt as to whether or not the entire sinus wall had been removed. After the wound has been closed in its entirety the packing (when one has been used) must be removed. The wound must be protected T- -- FIG. 5. FIG. 6. from infection as well as possible with gauze and a retractor while this is being done. As a final dressing a gauze umbrella, either with or without a tube in its centre, to permit the escape of gas, is passed well up above the upper end of the wound within the gut. The sack thus made is packed comfortably full of gauze. (Fig. 6 shows this packing without the tube). This dressing serves the purpose of protecting the wound until the edges have united and it also served to keep the sphincter dilated. At the evening of the third day a mild laxative is given to be followed on the morning of the fourth day by the removal of the pack 14 .A7thwr E. Hertzler. and the giving of an enema as Soon as the patient feels a desire to go to stool. The strength of the laxative and the character of the enema must depend on the amount and character of the opiates the patient has received. By leaving the packing in position until it is desired to have the bowels move permits a passage without any danger of tearing open the partly healed wound. By the end of the fourth day the wound is impervious to fluids and the only danger comes from laceration at the time the bowels move. This danger is obviated by the plan outlined. Post operative tenesmus is easily controlled by small doses of opiates which at the same time binds up the bowels until movement is desired at the end of the fourth day. So long a retention of the packing does not cause discomfort provided time is taken to secure a complete dilatation of the sphincter at the time of Operation. Nor has disability of the sphincter resulted, though in a few cases com- plete control over gases was not regained for Several months. Patients are allowed to sit up on the seventh day and to leave the hospital at will. None remain beyond the tenth day and most of them elect to leave on the eighth day. I have repeatedly seen patients begin journeys on the train or to ride considerable distances in a buggy on the eighth day without discomfort or injury. The extent of the operation does not affect this rule in any way. TREATMENT OF HABITUAL CONSTIPATION.—C. Kohnstamm be- lieves that some substance among the intestinal digestion of meat has a direct inhibiting effect on peristalsis, or it may act indirectly by checking the secretion of the intestinal walls and render the contents drier, which renders them less susceptible to the peristaltic action Of the intestines. He advises the constipated to abstain from meat, eating abundantly of other things and especially of milk and butter. In from two to four days the bowels will be acting normally. He thinks that Nature intended man to eat like monkeys, and that man is not a carnivorous animal.—Therapie der Gegenwart, Berlin. Cancer of the Rectum. 15 CANCER OF THE RECTUM. BY WILLIAM M. BEACHI, A.M., M.D.,” PITTSBURG, PA. Surgeon to Presbyterian Hospital, Proctologist to South Side Hospital. The leading word in the caption of this short paper denotes a dis- ease that attacks the human family in nearly every stage of life, and is the common foe enlisting the energies of science to fathom the mystery and enable us to offer the poor victim some ray of hope. Cancer in the rectum is of all locations the most distressing, and it is the purpose of the author to teach conservatism in the treatment of Such cases. While my experience includes only twenty patients suffering from this disease, over a period of six years, I lay claim to the right of expressing the above conclusions as the best judgment. I realize the position taken by some of my learned colleagues in this Society, but the court will insist upon direct evidence as to results following operative procedures for the cure of well defined cancer of the rectum. Of my twenty cases, nine occurred in 1905, three to date during 1906, and eight occurring prior to 1905. The clinical diagnosis was verified in each instance by the pathologist, and the Series represented various stages of development. The types of cancer consisted of four; which were adeno-carcinoma; One Osteo-sarcoma, involving the coccyx and lower two segments of the sacrum; and the remainder epitheliomatous and scirrhus. Two died from shock following oper- ation; one being the Kraske, and the other excision by the vaginal route. These occurred in 1905 and 1906. A patient operated upon in 1899—perineal excision—lived two and one-half years. Of three cases in 1900, I performed excision in two; but the third was disposed of by establishing an inguinal anus, since the disease extended to the sigmoid flexure. The latter case was more extensive than the first two, but the tenure of life was as long, being two years, and apparently as much relieved as those treated by total extirpation. *Read before the American Proctologic Society, Boston, Mass., May, 1906. 16 William M. Beach. This observation modified my views since that time to such an extent that I with diffidence perform excision, feeling that colostomy, while only a palliative measure, offers as much relief with much less mutil- ation. And the past three years I have freely recommended to my patients and their physicians, colostomy as the most rational proced- ure in cases where indicated. The best guide for our judgment in the treatment of a case seems to me to be a consideration of, 1st. Location of the neoplasm. 2nd. Stage of the disease. - It is a common observation that most of these victims are quite advanced in the development of cancer or are unaware of the ravages when we are consulted. With the uninitiated consultant, the disease may be mistaken in the initial stages for simple ulceration, hemor- rhoids or tuberculosis. If any doubt as to diagnosis exists at the beginning, resort should be made to the microscopist. The opinion of most writers records the location of cancer of the gut in the fixed rectum, in the majority of instances. In my series, fourteen occurred in the ano-rectal portions of the bowel. When thus situated, and the adjacent organs are intact, extirpation should be performed and without preliminary colostomy; per contra, should the disease be found to involve neighboring parts by infiltration asso- ciated with pain due to defecation, I would not hesitate to recom- mend the establishment of a permanent inguinal anus. Diverting the fecal column to the inguinal site relieves much of the distress at the point of disease, inasmuch as comparatively little pain is evident even in advanced conditions of the disease. Hemorrhage is less likely to occur, and with the local use of detergent washes comparative com- fort can be maintained for a long time, for the reason that the intol- erable tenesmus is absent and the annoying discharges of muco- purulent material is lessened. - I herewith report two of my cases, one to illustrate the good result obtained by extirpation in selected cases, the other to show the adaptability of colostomy without any effort to remove the disease. Mrs. B., age 37, housekeeper, was referred by D. W., in 1902. Cancer of the Rectum. 17 Carcinoma was located in the anal rectum extending to the plane of the levator ani muscle. The neoplasm involved the sphincter muscles. Macroscopically the upper rectum was free from disease and extirpa- tion was decided upon, which was done by the vaginal route. I then referred the patient to an X-Ray therapeutist, whose treatment ex- tended over a period of six months. There was recurrence in eighteen months, and the patient died in January, 1905. - Mrs. B., age forty-One, Occupation housekeeper, was referred by Dr. H., of Pittsburg. Examination revealed carcinoma of the rectum, with infiltration extending to the labial and vaginal wall. Nodules were felt on the liver, showing the metastatic process and cachexia well marked. Her chief complaint consisted of colicky pains due to the rectal obstruction; the act of defecation also produced severe dis- comfort. To relieve these two conditions, I constructed a permanent inguinal anus, in February of this year, at the South Side Hospital. This treatment relieved her entirely, but, unfortunately, she now suffers from general sepsis and the end cannot be very remote. This patient had developed this disease well nigh two years previous to my first visit, and clearly belonged to the inoperable class. The author has no experience with serum in cancer, but hopes that present knowledge will soon be superseded by some measures that are more certain and enduring. The X-Ray is of little value. From the foregoing notations, the following propositions are tenable: - 1. That a radical operation for cancer of the rectum is indicated. (a) Where the disease is not far advanced; (b) Where the cancer is located in the anal rectum and does not involve neighboring structures. 2. Cancer of the movable rectum should be classed as inoperable as far as results are concerned. 3. In high up cancer, colostomy offers the best results. 4. Complications by metastasis and mechanical obstruction in- dicate colostomy. 18 94. Rose. INFLATION OF THE RECTUM WITH CARBONIC ACID GAS. BY A. ROSE, M.D., NEW YORK. The history of therapeutic use of carbonic acid is interesting but too little known. A few words will show how much we may be benefited by reviving what has been of service in the practice of our forefathers. - Physicians of the 18th century discovered the specific effect of carbonic acid gas on Sordid ulcers, they found it relieved pain, caused disappearance of purulent matter, stimulated granulation, especially was it considered as a precious palliative remedy in cancerous ulcers. The details of the observations published during the 18th century I have given in my book,” to which I beg to refer. In treating a case of cancer of the rectum, in which operation had been refused, by means of inflation with carbonic acid gas, I found the statements of physicians of a past century fully confirmed; the gas had indeed a most gratifying effect in alleviating pain. When carbonic acid is brought into contact with the nasal mucous membrane, it produces at first a prickling, but quite tolerable sensa- tion, followed by an agreeable, refreshing effect of warmth and dryness. The examination of the mucous membrane shows reduced sensibility. Then follows excitation of the nerve ends extending to the vasomotor nerve, which latter cause the dilatation of the capil- laries, which means accelerated circulation and increased glandular secretion. After this nervous activity becomes exhausted, the vessels become constricted, and again anaesthesia will be noted. When the gas is introduced into the rectum, it creates a pleasant sensation of warmth which is the manifestation of dilatation of blood- vessels and accelerated circulation. We see carbonic acid applied to mucous surfaces besides stimu- lating circulation, has an anaesthetizing influence, and this explains its beneficial effect on ulcers, especially irritable ones. In an old book I found that two physicians of a remote period, *Carbonic Acid in Medicine. Funk and Wagnalls Co., New York, 1905. Inflation of the Rectum. 19 Kuester and Perkins, the latter an American who lived from 1740– 1799, had treated ulcers of the rectum, especially in cases of dysentery, ly inflating the rectum with carbonic acid gas. Their reports of the excellent results with this method induced me to try it. In the De- cember number of the Annals of Anatomy and Surgery of 1883 I published my first case, which surpassed by its gratifying results my most sanguine expectations. During the last 24 years I have since in- flated the rectum with carbonic acid gas in all cases of dysentery which have come under my treatment, and invariably have I noticed the prompt effect on the tenesmus, speedy cure of the ulcers, in fact such remarkable benefit that I became more and more convinced that carbonic acid treatment is the most rational and most reliable of all in cases of dysentery. The physiological effect of carbonic acid gas inflation of the rectU1m suggests itself as a most rational remedy also in cases of enteritis membranacea and colica mucosa. And indeed this has been confirmed by my observations. In the year 1903 I have demonstrated that simple complete rectal fistula, provided it is neither of syphilitic nor tuberculous character, can be cured by a few applications of carbonic acid. This is a fact which cannot be taken out of the world, and it appears Strange to me that so little attention has been paid to this most remarkable observation of mine. To give the details of my cases which I have presented before two medical societies would only be a repetition of what I have written in the book quoted. The object of these remarks is to call attention to my numerous writings on the subject in order to induce specialists of rectal diseases to give the method of inflating the rectum with carbonic acid gas a trial. DOSAGE FOR SPINAL ANESTHESIA—Hofmann announces that he has been surprised to find that weaker dilutions induce anesthesia as completely as the customary dosage of cocaine. He used to inject a five per cent solution, but now uses only one per cent, increasing the amount of fluid to correspond. His experience has shown that the larger amount of fluid required aids the induction of the anesthesia while materially reducing the by-effects.-Munchener Medicinische Wochenschrift. 20 Herman, JA. Brav. DISEASES OF THE RECTUM A SPECIALTY. BY HERMAN A. BRAV, M.D.,” OF PHILADELPHIA. The rapid progress in medicine and surgery during the latter part Cf the last century brought about the so-called specialties. The ac- curate knowledge required in each specialty is so vast that it makes it impossible for the general practitioner to master them all. This cir- cumstance created a desire among physicians and surgeons to select a certain branch of medicine or surgery for their life work. While most of the Specialties, as Ophthalmology, gynecology, obstetrics, pediatrics, Orthopedics, neurology, otology, laryngology, etc., have all established their well-deserved reputation in this country as well as in Europe, there is one important province of practice which has not as yet received recognition by the profession at large, but has been highly appreciated by those suffering with diseases of the severest kind, which secretly impair and undermine the constitution and involve a degree of personal distress. The specialty I am alluding to is proctology. There is a consensus of opinion regarding this specialty. Some claim this specialty is confined almost exclusively to quacks, who have been practicing it from time immenorial with their nostrum remedies; others again think it absurd to be a pile specialist. This latter fact probably derives its origin from the fact that patients who present themselves for rectal treatment all say: “Doctor, I have 5 the piles.” It is to be regretted that the patient's statement is often taken for granted even by experienced physicians, who either from lack of knowledge or lack of professional duty fail to discover the patho- logical condition of the rectum. In a paper read before the North Branch of the County Medical Society last January, I had occasion to quote several such cases which were thus erroneously diagnosti- cated. It is a matter of deep lamentation that cases of fecal im- paction of the rectum and sigmoid flexure, which have resulted in ulceration, are only too frequently treated for intestinal indigestion or *Read before the Philadelphia County Medical Society, September 10, 1902. Discases of the Rectum, a Specialty. * . * 21 neuralgia; polypoid growths for hemorrhoids; hemorrhoids for pro- lapse of the rectum; stricture of the rectum for constipation; the reflex Symptoms of fissure or ulcer for uterine, prostatic or cystic trouble, and malignant growths for bleeding piles. With these facts staring at us, there is only too good reason to believe that the afflicted patients, having in many instances sought in vain for relief, have abandoned themselves to the unprincipled empiric, who, after exhausting their Scanty means, has consigned them hopelessly to a miserable existence or a premature grave. While I am radically opposed to the charlatan, I must admit that he has contributed more toward the furtherance and advance- ment of rectal knowledge than any regular physician. Not by virtue of his knowledge, but by his devotion to this work he has awakened the profession from its lethargy, stimulating and Spurring it to place this specialty on a scientific basis. The founder of this specialty was Frederick Salmon, Esq., M. R. C. S., of London, who, noticing how very many persons in the humble walks of life were suffering from certain peculiarly painful and distressing diseases, founded an insti- tution in 1835 which was called the Benevolent Dispensary for the relief of the poor afflicted with fistula, piles and other diseases of the rectum or lower intestines. Later on the title of St. Mark's Hospital was conferred upon the institution, which name it has re- tained up to the present day. Since the foundation of the institution there has been treated at St. Mark's no less than 80,000 patients. During the time Mr. Salmon was connected with the hospital he performed over 3,500 operations without a fatal result, an ample evidence of the good and efficient work conducted at St. Mark's. At the present time nearly every hospital in London has on its staff one or more rectal surgeons, who devote most of their time to this par- ticular branch of surgery. These men teach in various medical Schools and impart their knowledge and experience to students, enabling them to treat rectal cases successfully when they enter into the arena of the medical profession. Continental Europe has largely contrib- uted to the literature of this subject, but the profession in general has not yet given it the attention its importance demands. 22 - Herman, JA. Braw. To verify my statement, I will mention cases which Professor Hochenegg, of Vienna, related to me. On several occasions he has had cases of carcinoma recti referred to him for opinion and subsequent treatment by provincial physicians, with the statement: “I suspect for a long time some serious affection of the rectum, but since I have no speculum it is impossible for me to make a proper diagnosis.” Gen. tlemen, in making a diagnosis of carcinoma of the rectum a digital examination alone will be sufficient, and no speculum is necessary, as by the introduction of a speculum great damage may be done. Some of these cases were treated for koprostasis and hemorrhoids for years. The best time to operate is in this way lost, and if the surgeons cannot, despite their progressive technique, show many permanent cures, it is not their fault, because the patients are generally referred to them when the cases are too far gone. In our country two eminent men stand in the first rank as leaders in this specialty. Kelsey and Mathews have for many years been laboring most effect- ively in the advance of rectal knowledge. They have often called our attention to the many mistakes there are daily made by our faults to make proper diagnosis. The profession, however, has not yet embraced this all-important branch of practice and very little atten- tion is paid to the subject. I have only recently been called in to see a very healthy looking and robust man who was afflicted with internal hemorrhoids in the third stage of their existence, that is to say, piles which do not spontaneously return into the rectum but require manual reduction. The prolapse took place on slight exertion, such as standing or walking, as well as with every act of defecation. The patient suffered the most intense agony every time the bowels moved, but there was more or less distressing pain all the time. I suggested an operation, which the patient refused, on the ground that his former physician promised to cure him with Ointments and Opiates. He used diachylon and zinc ointment locally and internally, Opium to prevent a bowel movement, and so escape the intense pain connected with it. Nothing short of an operation will be effective in these cases, and the sooner it is performed the better the result. I be- lieve palliative treatment should always be tried in the early stages Diseases of the Rectum, a Specialty. 23 of hemorrhoidal disease—certainly in all cases in which the piles are never protruded, and also in the second stage, when the protrusion takes place only at the time of defecation, and the piles return into the rectum spontaneously after the act has been completed. However, in such a case as the one mentioned, it is not only not advisable to try palliative measures, but I consider it a crime, on the part of the physician, to delay the radical cure by operation. No delay should occur because the pain or distress that the patient suffers and the constant loss of blood must of necessity reduce the vitality of the patient. Such weak and exhausted patients cannot be considered the most favorable subjects for operation, and the final termination may not be a very satisfactory one; besides, the operation under such cir- cumstances is attended with more or less danger. It is true that accurate knowledge of rectal surgery and the skill- ful performance of rectal operations requires the study and experi- ence for years in this special branch; but there is no reason why the general practitioner should not be able to diagnose properly and treat successfully cases which may be relieved, and, in some cases, cured by simple measures based upon scientific principles. It seems to me that the best way to drive the rectal quack out of existence would be the introduction of a special course of instruction in diseases of the rectum in our medical schools. Clinical lectures should be de- livered on the following subjects: 1. A review of the anatomy of that part of the perineum which contains the anal aperture so as to draw attention to the structure and pelvic relations of the rectum, because diseased conditions can only be accurately determined by comparison with the normal. 2. The surgical importance of a thorough knowledge of the physiology of the rectum. 3. General diagnosis. 4. The various methods of examination. 5. Various diseases of the rectum, their etiology, pathology, symptomatology and treatment, palliative and operative. 6. Various methods of Operating. 24 JAbstracts. Great stress should be laid upon the systematic examination of the rectum, because therein lies the secret of a proper diagnosis. Such a course of instruction will not only prepare the future doctor to meet rectal cases with confidence, but it will teach the public at large that this specialty belongs to the regular physician, just as well as other specialties. I wish to emphasize this, because any one who has been in general practice even for a short time must have heard the remark so often made by patients: “Doctor, I have some bowel trouble for which I used salves which I saw advertised be- cause I did not think regular doctors treat such cases.” We all recognize that rectal diseases are quite common, and it may with truth be said that there are no more afflicting or distressing maladies to bear, or which are productive of more serious consequences, whilst it may be doubtful whether there be any branch of medical knowl- edge for the acquisition of which less facility has been afforded.— Pennsylvania Med. Jour. 926 N. Franklin St. ABSTRACTS FROM CURRENT LITERATURE. PRACTICAL POINTS IN THE OPERATION OF COLOSTOMY.—Charles B. Kelsey, New York, states that the operation has been abused. Pointing out the indications for colostomy, he says, no palliative meas- ure has approached colostomy in unoperative cancer of the rectum. He has had many patients where the cancer had existed fully as long as the allotted two years before colostomy was done, live in compara- tive comfort two to five years. He believes the duration of life with cancer of the rectum is longer after colostomy than extirpation. Colos- tomy relieves the constant bearing down pain; prevents the formation of abscess and fistula in the vicinity of the disease; and slows the growth by avoiding the irritation due to natural defecation. Danger when colostomy is done early is almost nil, when chronic obstruction has taken place it reaches 33 per cent. Technique.—Operator should have a clear idea whether it is to be a permanent or temporary colostomy, that he may produce the greatest control where it is permanent, and where it is temporary he should pay more attention to the future closing of the wound. After com- menting on several operations, he says his own method has changed but little. For a time the incision was unnecessarily large. It is now JAbstracts. 25 half the length and “gridironed,” as in appendicitis. In other words the muscles are separated and the fibers cut as little as possible, and an opening one inch long will usually allow the insertion of the index finger, the hooking up of the sigmoid, and pulling it out of the abdomen. In the temporary operation pass the sutures through the edges of the abdominal incision, the parietal peritoneum, and the wall of the gut. In the permanent operation do not include the peritoneum in the suture. In temporary colostomy make a free longitudinal incision, but cut away none of the intestinal wall. In permanent colostomy trim the gut freely down to fit the edges of the abdominal incision. In cases of severe or long continued chronic obstipation operate on the right side instead of the left. A temporary anus made as here described may generally, and a permanent one may frequently be closed by a plastic operation without opening the peri- toneal cavity.—Medical Record, Jan. 12, 1907. - CANCER OF THE RECTUM.—J. Petermann reviews rectal work and reports that since 1893, when the first radical operation was performed for carcinoma of the rectum, 155 cases (104 male and 51 female) have come under his observation at St. Hedwig Hospital. The statis- tics show that in 70.9 per cent of the cases a radical operation was done at the above hospital, with the clinics of Bonner 78 per cent, Heidelberger 71 per cent, Gottinger 78 per cent, Bergmann 80 per cent, Freiburger 75 per cent, Konigsberger 65 per cent, Witzel 25 per cent, and of Dr. Boas' 84 cases in the last ten years only 16-19 per cent could an operation be performed. He divides them into four classes, 45 resections, 40 amputations, 25 artificial anus, while in 45 there was no operation performed. The author refers to Dr. Rosenheim’s excellent article, on the difficulty in diagnosing tumors situated in the upper part of the rectum. In many cases symptoms of carcinoma are present, but on account of hemorrhoids or muco-enteritis a diagnosis is often very difficult. Operations were performed on the old as well as the young. In some cases part of the back wall of the vagina, the Seminal vesicle, and the uterus with adnexa, were removed; but of course when the tumor was firm and hard, and wide spreading over the above organs or attached to the sacrum, an operation was not performed. In one group of 43 cases in which the perineal, coccygeal or Sacral region were involved, Schlange's operation was used and 14 proved fatal. The death of 7 was due to sepsis, 3 to peritonitis, 1 to shock and 3 to cachexia; 10 were male and 4 were female. Of 42 patients, in the 26 JAbstracts. last three years, one male at the age of 76 died, and another at 65, after 4 days and the latter after 16 days, after amputation. - 41.3 per cent of the patients who survived the operation and its results have been permanently cured. This is a proportion of 27.8 per cent permanently cured of the total number of patients operated on.—Archiv. f. klinische Chirurgie, Berlin. º - INTESTINAL BACTERIA; How they Acquire Toxicity, and How to Determine this Experimentally for Clinical Purposes.—E. Palier, New York, says only two micro-organisms are constantly found in the colon of normal individuals, namely the coli bacilli and the cocci. He isolated coli bacilli from a dead mouse, and, by injecting into mice introperitoneally small doses of such an old agar culture, the mice thus injected invariably died within twelve hours. A fresh culture was then made from the three-months-old one, and the fresh One, when it was two days old, was injected into mice, and the new culture did not act as the old one. Of five mice injected three died in about eighteen hours, one died in four weeks, and on one there was no effect. The mouse that lived four weeks was unwell the whole time. After its death the abdomen was greatly distended, and on dissection the intestines and stomach were greatly distended with gas, and were very thin, appearing like big soap bubbles; but there was also an inflammation of the peritoneum, the intestines, and the stomach, and the bubbles were greenish, and in spots red. The idea suggested itself that the non-virulence of the coli bacilli, obtained from the feces of the mice and from that of the suckling infant, was due to the fact that such feces are deficient as a nutritive medium, and that the coli bacilli, in order to attain virulence, must have a medium of dead flesh. The writer draws the following conclu- sions from his experiments: “That a flesh medium enhances the virulence of the coli bacilli and in agar, the older cultures are, on the whole, more virulent than fresh ones.” He cites his studies of the feces of several adult cases and con- cludes that in meat eaters the coli bacilli is most apt to become viru- lent. This is especially the case when some of the ingested meat happens to pass through the stomach and duodenum indigested so that it affords a good nutritive medium for the coli bacilli. Once the coli bacilli becomes virulent they will in turn cause injury to the in- testines. Under a milk or vegetable diet some injury may also occur to the intestines from the ingestion of too much food or too irritating food, and the non-virulent coli bacilli may thus settle at the injured part, and thrive there as on dead flesh. - Writings of Interest to the Proctologist. 27 He was able to produce sloughing experimentally by Squeezing the tails of mice and allowing them to drag in their own feces. He concludes that the different cocci normally found in the in- testines are not virulent. He also speaks concerning the methods of testing the virulence of intestinal bacteria.-Medical Record, Jan. 8th, 1907. RECENT WIRITINGS THAT MAY BE OF INTEREST TO THE - PROCTOLOGIST. “Treatment of Chronic Constipation,” W. K. Sibley.—British Medical Journal, Dec. 1, 1906. - “Early Recognition of Cancer of the Rectum and Its Treatment,” D. Drew.—The Clinical Journal, London, Dec. 5, 1907. “Improved Technic for Removing High Rectal Cancer,” P. Kraske.— Archiv f. klinische Chirurgie, (LXXX, No. 2, pp. 765-780) Berlin. “Tropical Dysentery,” R. J. Blackham.—The Lancet, London, Dec. 1, 1906. - “Types of Bacilli of the Dysentery Group,” Y. K. Ohno.—Philippine Journal of Science, Manila, Nov. 1906. “Examination of the Rectum in Children,” K. K. MacAlpine, New York-Post-Graduate, New York, Jan. 1, 1907. “Ano-Rectal Fistula,” J. D. Potts, St. Louis.-Journal of the Missouri State Medical Association, January, St. Louis. - “Traumatic Recto-vesical Fistula,” H. T. Mursell.—British Medical Journal, Jan. 19, 1907. “Technic of Treatment of Fistula,” V. E. Mertens.—Centralblatt f. Chirurgie, Leipsic. “Proctitis,” C. J. Drueck, Chicago.—The Medical Standard, Chicago. “Operation for Cure of Prolapsus Ani and Internal Hemorrhoids,” D. Newman.—The Lancet, London, Dec. 22, 1907. “Prolapsus of Rectum,” C. J. Drueck, Chicago.—Chicago Medical Re- corder, Dec. 15, 1907. “Pruritus Ani,” T. C. Hill, Boston—Medical Record, New York, Dec. 22. “Spontaneous Rupture of Rectum,” H. Heineke.—Beitrage aur klin- ischen Chirurgie, von Bruns, Tubeingen. 28 Writings of Interest to the Proctologist. “Technic and Apparatus for Anesthesia by Way of the Rectum,” E. Vidal.—Presse Medical, Paris, (XIV, Nos. 96-97, pp. 765-780). “Technic of Local Anesthesia,” M. Dietze.—Munchener medicinische Wochenschrift, (LIII, No. 50, pp. 2425-2472). “Treatment of Hemorrhoids.” W. H. Stauffer, St. Louis-Journal of Missouri State Medical Association, St. Louis, Jala. “Mechanical Supports of the Pelvic Viscera,” A. M. Paterson. “The Appendix in Relation to Pelvic Inflammations,” T. A. Helme.— British Medical Journal, Dec. 15, 1907. “Chronic Constipation and Its Treatment,” G. F. Butler, Chicago.— Medical Fortnightly, St. Louis, Jan. 25, 1907. “Gastrogenic Diarrhea,” C. D. Aaron, Detroit, Mich.-Medical Fort- mightly, St. Louis, Dec. 10, 1906. “Treatment of Amebic Dysentery,” R. J. Smith, Smithfield, Utah, Northwest Medicine, Seattle, Wash. - “A New Proctoscope,” J. P. Tuttle, New York.-American Medicine, York, Pa. sº a ". . c. w - ---------- - - - º --- - - * * . . . ; * * * . . . . . . . . . . . . . .” at Pº . . sº as aft. a 1-, --, -º ~. º 1, •, I,..." ; , , , , , , , , , ‘’’ ‘‘, ‘. . . . . . . . . . . .",..., , , , "º," : , " tº 3., a . . . . . . . . . . . . . . . . . . . . . . . . . . . .” - . . . . , , , sº •,•,•º *:*::" ºr ºf . ; * † ~ - " .. - . . . . ºf , t , , , . . . . . . . " "... .''...' *,".", . . . . . . . . .". . * ...","...', ... * **** ...' ' - º, º' ' g ...'...', ºr º: , ". 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THE SAALFIELD PUBLISHING company Z v1%ron, Ohio, 156 Fifth Ave., Netw York city NAME ſ Apprºss º t E * If you want the half morocco style, alter $30,00 te $48,00, $2.00 to $3.00, 14 months to 15 months. ADVERTISEMENTS. The ſieneral Practitioner As A SPECIALIST. BY J. D. ALBRIGHT, M.D. A Practical Treatise Devoted to the Consideration of Legitimate Medical Specialties. An Indis- pensible Guide to the Development and Improvement of the Best Paying Branch of Medicine office PRACTICE Five to fifteen years of experience have taught thousands of physicians that Office Practice Pays Well and Pays Cash, and thousands who have bought this book say it is worth many times the price asked for it, and that no progressive, energetic physician can afford to do without it. 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R. D. MASON, M.D., - * - - - - Omaha, Neb. ARTHUR E. HERTZLER, M.D., A.M., Ph.D., - -*. Kansas City, Mo. WILLIAM M. BEACH, M.D., A.M., - wº- - -> Pittsburgh, Pa. H. A. BRAV, M.D., - tº- - - - -> Philadelphia, Pa. ACHILLES ROSE, M.D., sº - º - - New York City. GEO. B. EVANS, M.D., A.M., - - - -*. Dayton, Ohio. A. B. COOKE, M.D., Pres. Amer. Proctologic Soc. - - Nashville, Tenn. C. A. VOSBURGH, M.D., s - - - - St. Louis, Mo. COLLIER F. MARTIN, M.D., - - - - Philadelphia, Pa. W. J. M'GILL, M.D., - º - - - - St. Joseph, Mo. JEROME D. POTTS, M.D., - - - - - St. Louis, Mo. $1.00 a Year. QUARTERLY. : $1.50 a Year Postal Union. NEUROSINE Clinical Experience Has Proven that NEUROSINE is the most Efficient Neurotic, Anodyne and Hypnotic. A RELIABLE NERVE CALMATive, ABATING severE PAIN, CAUSINC, NATURAL SLEEP. Contains no Opium, Morphine, Chloral or other Deleterious Drugs. TRY NEUROSINE IN RECTAL CASES, SOOTHING AND SAFE. 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By Hugo These volumes will be sold separately—or in sets. TERMs For SET $2.50, and $1.00 per month until $11.50 have been paid. The C. V. MOS BY MEDICAL BOOK CO., Publishers, 2315 Washington Avenue, St. Louis, Mo. Annerican Vibrator American Vibrator Company, VICTOR1A BLDG., ST. LOUIS, MO. Summa, A.M., M.D., Professor Princi- ples and Practice of Medicine. Medi- cal Dept., St. Louis University, St. Louis, Mo. Price, $3.00. Nearly ready. Vol. IV. Golden Rules of Gynecologi- cal Practice. By Henry Schwarz, M.D., Professor of Obstetrics, Medical Department, Washington University, St. Louis, Mo. About 350 pages. Price, $3.00. Nearly ready. ----------------------- ----------- THE THERAPEUTIC VALUE OF MECHANICAL MASSAGE is more and more recognized by the profession. Every practitioner knows that there are many pathological conditions directly attributable to lack of exercise and deficient cir- culation of the blood. In Neural- gia, Insomnia, Dyspepsia, Lumbago, Rheumatism, and similar complaints, no matter what other treatment may be indicated, it will be found that vibratory stimulation is of vast assistance. The AMERICAN VIBRATOR is the only machine which in every respect meets the requirements of the profession. Send for booklet which fully explains the advantages of this little machine and our plan for a trial free from risk. An inquiry puts you under no obligation. ST. JAMES BLDG, NEW YORK, | | Çlir rurtuluuist PUBLISHED QUARTERLY A11 communications relating to THE PRocroLog IST should be addressed to Ro1.LIN H. BARNES, M.D., Editor and Publisher, 412 N. Sarah St., St. Louis, Mo. CONTENTS. PAGE THE ErioLogy AND SyMPTOMs of FISSURE-IN-ANo, by Collier F. Martin, M.D., Philadelphia, Pa. se s sº gº tº gº * STRICTURE OF THE RECTUM, by W. J. McGill, M.D., St. Joseph, Mo. wº 66 THE IMPORTANCE AND SIGNIFICANCE OF RECTAL SYMPTOMs, by Jerome D. Potts, M.D., St. Louis, Mo. - me *- g * . 74 Abstracts from Current Literature Relating to Proctology: Stricture of Rectum Caused by Calcified Uterine Fibroid, Page, Deut. 2eit. f. Chir. *-g yº º gº- tº- º ſº * 65 Signs and Symptoms of Mucous Colitis, Wilson, Edinburgh Med. Jour. 73 Treatment of Phlegmon of the Superior Pelvi-Rectal Space, Professor Robert Picque, Gazette des Hopitaux, Paris. * º * 82 Sigmoiditis and Perisigmoiditis, by Albert Catz, Gazette des Hopitaux, Paris. tº wº * * sº sº sºs * 83 Operation for the Removal of the Entire Rectum and Neighboring Lymphatic Area for Carcinoma, by P. Lockhart Mummery, B.C., F.R.C.S., British Med. Jour. - *-* tº: tº º ſº- tº- 85 Excision of the Rectum, Sigmoid, and Part of the Descending Colon with Implantation of the Colon into the Anus, Dr. Edward Archibald, Montreal, Canada. º º tºº º &E's *I &= 93 Society Reports. { American Proctologic Society.—Election of Officers, Etc.—President’s Address.-Report on Proctologic Literature, from June 1906 to June 1907, by Dr. Samuel T. Earles, Baltimore, Md.—Treatment of Hemorrhoids by Puncture with Electric Cautery, by Dr. Charles B. Kelsey. tº - - 87 Recent Writings That May Be of Interest to Proctologists, gº tº- 90 Book Notices—Reprints Received. * wº * gº gº 92 Subscribe to The Proctologist. . .”.”*.* - to Rectal subjects. By so doing you will not only help yourself, but assist the most neglected department of medicine. Fill out the following form and mail at once. I swbscribe for The Proctologist for one year, for which I agree to pay One Dollar. t Street Town, or City State THE PROCTOLOGIST is the only journal devoted to Rectal Diseases. ADVERTISEMENTS. im i I-II-II- (OO = (E-II-I WAGINAL SUPPOSITORIES (Maſhama) ####3 , 8% $8: ſº FOR THE TREATMENT OF Uterine and Vaginal Endometritis, Leu- corrhoea, Vaginitis, Urethritis, Gonorr- hoea, Ulcerations, Hypertrophy and Con- gestion. - - -- Especially Effective in Chronic Cases EAch suppository contains: Benzoborate Soda.---------------------------------------. 5, grs. Concentrated Thymic Solution 10 m. Sulphocarbolate Zinc -------------------------------------- 1 gr. Oil Cassia.------...-------. % m. Boroglyceride Solution.------...------------------------- 25 m. Alveloz Gelatine, Glycerine, Water...................----- Q. S. 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An Indis- pensible Guide to the Development and Improvement of the Best Paying Branch of Medicine OFFICE PRACTICE If interested in Rectal Diseases, Hernia, Cancer, Drug Habits, Diseases of the Prostate, Male Urethra, etc., as treated by modern conservative means, do not fail to obtain a copy of this valuable book. 360 pageS. Cloth, $3.00 ; H. L., $3.50 The All AroundSpecialist Giving the TECHNIQUE OF THE SPECIALIST IN THE MOST IMPORTANT BRANCHES OF MEDICINE, By J. R. McOSCAR, M.D. Uſ $3.50; Post Free. What You Are Looking For Has Just Been Published. The Secrets of Specialists One of the most interesting medical books ever published By A. DALE, COVEY, M.D. A Practical Treatist for the Progressive Physician. Over 300 pages; fully illustrated. Price, $3.50. Cut to - $2.00 Rectum and Anus. Agnew. Rectal Diseases. Ma-...-------...--------. Net $2.75 Allingham. Diseases of the Rectum. Wo...Net 3.25 Andrews. Rectal and Anal Surgery. C. M.--Net 1.50 Ball. Diseases of Rectum and Anus. 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If you with unquestionable refer- Doctors and Business men. 6% guaranteed interest, and It is paying many others, and YOU SOUTHERN LAND STYNDICATE 508 Missouri Trust Bldg. ST. LOUIS, MO. C. B. RICHMOND, Representative ^^^^^^^^^^^^ -º-º-º-º-º->~~~~~~~~~~~~~ Úhe rurtuluuist VOL. I. SEPTEMBER, 1907 NO. 3 THE ETIOLOGY AND SYMPTOMS OF FISSURE-IN-ANO. BY COLLIER - F. MARTIN, M.D.” Clinical Professor of Rectal Surgery in The Temple College Medical Department and Instructor in Rectal Diseases in the Philadelphia Polyclinic Hospital and College for Graduates in Medicine. PHILADELPHIA, PA. While a fissure of the anus differs little if any, pathologically, from other ulcers, yet its location, peculiar and distinctive symptoms, as well as its decided chronicity, all due to anatomic factors, gives us the right to dignify this little ulcer with a distinctive name. It has variously been described under the name of fissure of the anus, irritable ulcer, painful ulcer and the Ulcer of St. Fic. Molliere has suggested the term “intolerable” ulcer of the anus. A true fissure of the anus is not, as the name implies, a mere tear in the muco-cutaneous lining of the anus, but is a true ulcer, oval or circular in outline, usually representing a destruction of the entire thickness of the tegument. The ulcer is usually situated posteriorly and, where the typic symp- toms present, lies directly at a point corresponding to the “white line” of Hilton, this line representing a condensation of the fascia and cor- responds to the interval between the external and the internal sphinc- ters. The “white line” also represents the remains of that double layer of mesodermic tissue which, in the embryo, separates the rudi- mentary rectum from the proctodeum. As the ulcer varies in location either above or below this point the symptoms become greatly modified and lessened in intensity. Pennington explains the preponderance of fissures occurring pos- teriorly by the fact that the muco-cutaneous lining of the anus re- ceives less support from the external sphincter in this portion of its circumference. He points out that, at this point the fibers of the *Read before The American Proctologic Society, Atlantic City, N. J. June 3, 1907. . 62 Collier F. JMartin. external sphincter separate, as they do also in front, but he also claims that, as the distance from the posterior verge of the anus to the at- tachment of the muscle fibers into the coccyx, is greater than from the anterior verge of the attachment of the muscle to the central point of the perinaeum, the fibers in the posterior commissure may separate more widely, thus making tears in this locality more frequent. Clinically, he has proven this by passing a conical dilator into the anus and observing the point at which a break in the continuity of the anal lining first takes place. My own observations have coin- cided with his but, further than this, I have found that the tear first occurs directly over Hilton's line. This seems due to the lessened elasticity of the tissues at this point, as it is here that the muco- cutaneous tissue is firmly bound down to the underlying structures. In my own practice most of the fissures occurring from tears re- sulting from the passage of a hard stool and undue straining efforts have been located in the posterior segment of the anus. Those situated in the anterior portion have been observed mostly in women and have followed the pressure of the child's head upon the perinaeum during labor. Those Occurring in other portions of the anal circumference were generally caused by the erosion and ulceration of small anal thrombi or were formed by the extension and infection of cracks in the anal skin due to a fissured eczema. These tears, as a rule, do not present the typic symptoms of fissure unless they extend to or near the “white line.” Aside from fissures due to eczema and pruritus, multiple fissures are often syphilitic in origin. So far I have found more cases of fissure occurring in men, but this is probably due to the preponderance of this sex in my practice. Comparatively few of my patients showed any marked hyper- trophy of the anal papillae while most of them had a well developed sentinel pile. Ball's theory that the sentinel pile is formed by the remains of a torn-down anal valve seems rather more ingenious than probable. The sentinel pile is more often nothing but the hypertrophic skin border of the lower margin of the fissure. This is the result of the long continued inflammation. A well developed sentinel pile is rarely met with in recent cases of fissure. True hypertrophy of the Sphincters has rarely been noted, but in its place I have observed simply an extreme spasm of the sphincters, particularly of the external muscle. Where the sphincters were par- ticularly well developed, either the fissure had been present for a long time or there was every reason to believe that the condition was a The Etiology and Symptoms of Fissure-in-Ano. 63 congenital one, as the patients nearly all showed excessive develop- ment of the muscles or other portions of the body. Then, too, this excessive muscular development may have been a factor in the for- mation of the fissure, as severe straining was necessary in order to obtain an evacuation. - The distinctive symptom of fissure is plain in the region of the sphincter, or sphincteralgia. It rarely occurs until after stool and there is generally a well-marked “pain-interval” immediately after the act, during which time the patient has comparative comfort. There may be some slight burning or Smarting during the defecation and immediately following. In a short time, from a minute to an hour, the characteristic pain, or sphincteralgia, begins. This varies from a dull ache to an intense gnawing pain, often of such intensity as to incapaci- tate the patient from any occupation. The patient may become com- pletely exhausted and have to lie down until the pain has passed off. The pain is felt directly in the lower rectum and sphincter area but reflex pains are frequently associated with this disease. Pain is often complained of radiating down the leg, in the heel, in the testicle, the glans penis, the Ovary, and in the coccyx and sacrum. One patient had a pain radiating along the gluteal folds while another had reflex vonnit- ing following every stool. The pain of fissure, as the term sphincteralgia implies, is caused by spasm of the Sphincters compressing the inflamed nerves of the little ulcer. The spasm of the external sphincter seems to be most important. In addition to this compression the nerves are rendered more sensitive from lack of proper blood-supply, the normal anal and perineal circulation being practically at a standstill. This circulatory stagnation accounts for the chronicity of the ulcer as well as for the increased inflammatory deposit in the edge of the ulcer. The poor circulation, in addition to the constant tearing from stools and the continuous infection from bacteria in the intestinal discharges, pre- vents healing. The act of cleansing the anus with toilet paper, wiping the feces from before backward, would also tend to increase the irrita- tion of a fissure situated posteriosly. The “pain-interval”, which I must insist is an almost constant accompaniment of fissure, is easily explained. The straining, neces- sary during the act of defecation, temporarily brings more blood to the part, and, for a time, the inflamed nerves are properly nourished. After a time the irritable sphincters begin to contract, cutting off the normal blood-supply. The pain then rapidly increases and continues 64 Collier F. JMartin. with maximum intensity until the sphincters, worn out by their con- stant spasmodic contraction, relax, permitting a re-establishment of the normal anal and perineal circulation. From that time the patient has comparative comfort until the next stool or until something, like an instrumental examination, again excites the sphincters to contrac- tion. à The constipation accompaning fissure of the anus is as often the factor producing the ulcer as it is the result of the condition. The irritable sphincter may exist without the presence of the fissure and may produce no other symptoms than straining at stool and incom- Tylete evacuations. This straining, especially when accompanied by the passage of a particularly hard and large stool, produces the first tear in the anal lining. This tear becoming infected, constitutes the fissure. After the ulcer has once formed pain becomes the prominent Symptom. The constipation may then increase, due to the mental inhibition caused by the fear of the patient. Knowing the inevitable consequences of having a bowel movement he defers the act as long as possible. . If this theory as to the cause of the pain and of the “pain- interval” be true, then the treatment of the fissure becomes a simple proposition. Restore the normal anal and perineal circulation and the sphincteralgia will cease. With the addition of some slightly stimu- lating and antiseptic treatment, the fissure will soon heal. A simple divulsion of the Sphincters, paying particular attention to the external muscle, will usually fulfill all of the indications. The sentinel pile, if present, should be removed and curetting and trimming out of the ulcerated area will seldom be required. The operation of division of the external sphincter is mentioned only to be condemned. While it must be admitted that the same result will be obtained as with divulsion, and also that incontinence rarely follows, why we should seek to destroy the function of a muscle which kind Providence has placed to guard the portals of the alimentary canal, is beyond compre- hension. In all other rectal Operations, the one thing we seek to pre- serve is the sphincteric control, and while we may be forced to make a virtue of necessity in Some cases of fistula, this is certainly not true of fissure. - Divulsion, properly performed, is never followed by incontinence, except in those cases where there is some underlying disease of the central nervous system, such as the Sphincteric paralysis of tabes dor- salis. I have seen three cases, where the external sphincter was The Etiology and Symptoms of Fisswre-in-Ano. 65 divided for the relief of a fissure, in which this muscle had not only united but was so atrophied from lack of use that it could hardly be detected by the most careful palpation. Had not necessity made the internal sphincter perform the functions of both muscles incontinence would surely have followed. One of these cases had a very annoy- ing prolapse of the rectal mucosa, accompanied with Some ulceration and a constant dull aching in the rectum. It must be pointed out that we cannot paralyze the sphincters by divulsion unless the process involves so much traumatism that the return of normal function would be problematic. We simply stretch the muscle sufficiently to thoroughly stretch the nerves supplying the part. This probably acts in two ways; first, the nerves themselves are stretched, thus lessening their irritability; secondly, it is just pos- sible that the inflamed nerve endings are broken loose from their ad- hesions to the inflammatory exudate. In this way we do not paralyze the muscle but simply substitute a normal condition for an abnormal irritability of the sphincters. While divulsion may be relied on to cure a simple fissure, where we have other complications more radical surgery will be indicated. Frequently the infection of a fissure travels upward or downward, resulting either in an abscess or a fistula. These must be divided and drained to complete a cure. Another annoying complication of fissure, not often mentioned, is fecal impaction. This should be rec- ognized and receive appropriate treatment. sº STRICTURE OF RECTUM CAUSED BY CALCIFIED UTERINE FIBROID. —Page (Deut Zeit. f. Chir., Vol. LXXXI, pt. 5-6) writes of a woman, 70 years of age, subject for several years to obstruction, painful defeca- tion and colic, occasionally varied attacks of profuse diarrhea. Emaciation became very marked. On rectal examination a hard tuberous tumor could be felt in front of the bowel, the mucous mem- brane of which was intact. It was diagnosed as a cancer. As the patient's general condition was unfavorable for a prolonged abdominal operation, it was decided that the symptoms should be relieved by colotomy. In the course of that procedure it was found that the mass which had caused the obstruction, was a calcified uterine fibromyoma expelled from its capsule. It occupied Douglas’ pouch and was strongly adherent to the rectum and other adjacent parts. It was de- tached from its adhesions and removed, the patient recovering. 66 Jſ". J. JMcGill. STRICTURE OF THE RECTUM. By W. J. McGILL, M.D., ST. JOSEPH, MO. The object in presenting this paper is not so much to present something new as to call the attention of the profession more particu- larly to this condition and its treatment, and to insist upon an early examination in all cases of suspected stricture, in order that suitable treatment may me inaugurated in time to relieve this condition before symptoms of obstruction exist. e A stricture of the rectum is a narrowing of the lumen of the bowel from any cause; it may result from contraction or from mechanical pressure outside of the bowel, caused by an enlarged prostate, a dis- located uterus or a tumor. Strictures may be broadly classed as congenital, neoplastic, spasmodic and inflammatory. They are spoken of as to their shape as annular, valvular, tubular and linear ; they are also spoken of as benign and malignant strictures, but Cripps says that every stricture, if left alone eventually results fatally; if not from the disease itself, from the symptoms that follow in its wake and shorten life. Stricture of the rectum is usually located in the lower portion, though no part of the rectum or colon is exempt, but it is usually found within 2% inches of the muco-cutaneous junction. Stricture is but rarely found in the young. It is the exception to find a case of stricture in a person under 30 years of age. Women are much more prone to stricture than men; One reason is that they are more subject to constipation, and the rectum is often damaged from the pressure of the child's head during labor. Etiology.—The rectum is more frequently the site of stricture than any other canal opening upon the surface of the body; this is dependent upon its anatomic arrangement and function which con- stantly exposes it to injury and stretching, and also the presence at all times of pathogenic bacteria, also its relation to adjacent organ's renders it particularly liable to infection from disease of these organs. Congenital stricture is frequently not observed until later in life, when on account of change of food and habits, the patient's stools be- come more solid and difficulty in the passages begin to be felt. Pa- tients assume that the condition is due to constipation and pay little attention until the necessary Straining produces fissure, hemorrhoids or Stricture of the Rectum. 67 *--- other inflammations of the rectum or anus. These cases can give no history of any rectal trouble other than that of gradually increasing constipation. Many of them will be able to recall the fact that consti- pation has existed from early infancy. In these cases, gradual dilata- tion will usually effect a cure. Neoplastic Stricture.—The rectum may be obstructed by a new growth inside of it or within its walls. These growths may be malig- nant or benign. Malignant growths obstruct the rectal caliber by protruding into it, but they also narrow it by fibrous contraction of the walls of the gut. When malignant growths have once been estab- lished, total extirpation offers the only ground of hope for the patient and the stricture is always included in this. Spasmodic Stricture.—Under this head two conditions have been described which are entirely dissimilar. In one there in stricture in which there is no organic change in the walls of the rectum. It con- sists in a spasmodic contraction of the muscles without any actual shortening. In the other condition is described in which organic change and permanent constriction of the tube is produced through persistent spasmodic contraction, resulting in shortening and fibrous transformation of the muscular fibers involved. In this class of cases forcible or gradual dilatation will usually give relief. Under the head of inflammatory strictures, I will include stric- tures due to simple, tubercular, dysenteric and syphilitic inflammation. The simple type comprises diffuse inflammatory, cicatrical and peri- rectal strictures. Diffuse inflammatory strictures consists in an in- flammatory or fibrous deposit beneath the mucous membrane. In all inflammatory strictures whether simple, tubercular or syphi- litic, the process must involve the tissue beneath the mucosa. Ulcera- tion of the mucosa or injury to the mucosa membrane alone will not produce a stricture, and for this reason it is rarely if ever caused by simple catarrhal diseases. Cicatricial strictures, if we exclude those which follow surgical operations, are not of a very frequent occurrence. Whenever the nor- mal Surface membrane is restored without intervening fibrous tissue, 110 cicatrix can be said to exist. Phlegmonous and gangrenous ulceration, such as results from diffuse gangrenous, peri-proctitis may result in a cicatrical stricture of the rectum. Operations in which considerable areas of the rectal tissue have been removed and healing by granulation takes place, will also cause a stricture, such as Whitehead's operation and excision or resection of the rectum. 68 TW. J. JMcGill. |Peri-rectal strictures are those which develop from conditions outside the rectum; displacements, enlargements and tumors of the uterus, ovaries, bladder and prostate or other pelvic Organs may cause obstruction in the rectum or sigmoid by pressure, but these are not true strictures. Tuttle reports one case of absolute Occlusion of the rectal canal due to extra uterine pregnancy. Local or general peritonitis may produce rectal stricture due to adhesive bands passing across the rectum. Tubercular stricture of the rectum is denied by some ; this is largely on account of the fact that tubercular ulcerations are SO rarely primary and when they occur in persons who have already de- veloped the disease, death usually results before healing takes place. The consensus of opinion of the best authorities is that tuberculosis may result in the formation of true fibrous stricture of the rectum, without the ulcer having healed, and that around every tubercular focus there is a fibrous wall tending to limit its extension. The fibrous deposit which causes the stricture is inflammatory, but that inflamma- tion is caused by localized tuberculosis. Syphilitic Strictures.—Experience and widened observation have established the fact that a large number of the patients suffering from stricture have been the victims of syphilis and it is now generally ad- mitted that syphilis is one of the potent causes of stricture. Tuttle expressed his positive conviction that syphilitic strictures are preceded by ulceration. Microscopic examination of syphilitic strictures of the rectum show that the condition consists in a chronic inflammatory deposit characterized by nodular or gummatous formations around the blood vessels and distinct endarteritis. The fibrous development of the stric- ture itself differs in no other way from those strictures due to simple traumatism, and infective ulceration of the rectum. There has been no histological examination of an ano-rectal syphiloma in its early stages, or if so, I have been unable to find a record of it, and Tuttle maintains that no stricture of this type has been seen by him in which the probability of previous ulceration of the rectal wall could be eliminated and that all of his cases which had suffered from this con- dition were either ulcerated at the time of examination or gave a his- tory of previous discharges of blood, mucous or pus from the rectum, showing the inflammatory nature of the process. It is my firm belief that the rectum and anus should be examined in the secondary and tertiary stages of syphilis to see if there is any evidence of ulceration, Strictwre of the Rectum. 69 for many cases of syphilis develop a diarrhea and discharge of mucous during the secondary stage which are generally attributed to the mercuric remedies administered, when in fact they may be the result of the mucous patches or ulcerated processes in the rectum itself. Under the influence of mercury these symptoms disappear, the ulcers in the rectum heal and the patient supposes himself well. The discontinuance of the treatment often results in the re-establishment of the pathological process in the sub-mucous tissue along the arteries and veins in the shape of minute gummatous deposits around the vessels and muscular walls as a hypertrophy of the unstriped muscular and connective tissue fibers which lie between them. Here there are two distinct processes; one a specific involvement that extends in the line of the blood vessels, the other a purely inflammatory condition that extends in the line of the sub-mucous, muscular and fibrous tissues. This sub-mucous inflammation set up by the original ulcer and con- tinued by hard fecal passages, and the presence of abnormal, gum- matous deposits is really the cause of the contracture, and forms the true fibrous portion of the stricture. Pathology.—In studying the pathology of stricture there are sev- eral points to be observed ; for changes will be found not only at the stricture itself but both above and below and in the surrounding parts. A stricture which is not the direct result of a deposit of a new material in the rectal wall as in cancer, will be composed either of cicatrical tis- Sue such as is found in other parts of the body or else hypertrophied connective tissue which is firm and dense, and creaks under the knife on section. All of the connective tissue in the rectum at the diseased point is increased in quantity and this accounts for the increased thick- ness of the rectal wall. The mucous membrane at the seat of the stricture will generally be found destroyed and replaced by granula- tion tissue on this fibrous base, which bleeds easily when irritated. Above the stricture will be found a dilatation of the bowel and a hypertrophy of the mucous membrane. Later the mucous membrane due to irritation from retained feces will show all the stages of ulcera- tion, from simple congestion at Some points, to a complete destruction in others and an exposure of the muscular tissue beneath. The ulceration process may extend for several inches up in the bowel. The wall of the bowel above the stricture may be as thin as paper in spots, and at Such points perforation may take place. Kelsey reports two such cases. Abscesses are always liable to occur in the neighborhood of the stricture, which accounts for the numerous cases of fistula in this disease. 70 T}^. J. JMcGill. Symptoms.-These may be grouped under two heads; those due to ulceration and those due to mechanical obstruction. In most cases the signs of mechanical obstruction will be preceded by those of the ulceration which caused it. The one positive sign of stricture is the obstruction. This may show itself in several ways; generally, at first, by alternate attacks of constipation and diarrhea. I do not lay much stress on the shape of the stools as a diagnostic point. A very close stricture may be very high up in the rectum or sigmoid and feces may be reformed in the rectum below and be passed normal in size. After a stricture has existed for some time, we have intestinal catarrh, followed by discharges of mucous and blood. These patients are troubled with more or less constant tenesmus and a desire to empty the bowel that cannot be gratified. The diagnosis can be made by digital examination or by the use of the anascope or proctoscope and a good light. * A stricture should be examined with the greatest care and gentle- ness, and one must always remember that a diseased bowel may be easily ruptured. For that reason I do not favor the Wales bougie for diagnostic purposes. If one is in doubt, I would favor giving the patient ether and make a careful exploration of the rectum high up, and in some cases an exploratory laparotomy may be necessary. After the stricture has been located, it will often be found difficult to decide whether it is malignant or benign. By careful attention to the history, the nature of the affection can very often be determined. A microscopical examination of a section of the new growth will usually clear up the diagnosis. Prognosis.--So far as a cure is concerned, the prognosis in strict- ure is usually unfavorable unless the contraction is slight and situated near the anus and uncomplicated by grave constitutional disease. Such cases are rarely seen by the surgeon on account of the condi- tion not causing sufficient annoyance to cause them to seek medical aid. The surgeon cannot be too guarded in his prognosis and should inform the patient that they may never be entirely well, but if they are willing to follow instructions for weeks, months or perhaps years, that their lives can certainly be prolonged; that they can be made comfortable and that an apparent cure can be effected in many cases where the after treatment is persisted in for a sufficient length of time. Treatment.—The treatment of stricture of the rectum is gen- Stricture of the Rectum. 71 erally surgical. If one believes the stricture is syphilitic, he may use an antisyphilitic line of treatment. The comfort of these sufferers may be increased by giving them principally liquid diet and keeping the bowels very loose. The bowels should move daily without strain- ing if possible. A mild laxative will usually be found sufficient, such: as rochelle salts or the various laxative mineral waters. The ad- ministration of an enema of warm water through a rectal tube will often give the patient great relief. The general health of these patients should be supported in every way by good tonics and codliver oil when it is well borne. The surgical means at our command are dila- tation, internal proctotomy, external proctotomy, excision, colostomy and anastomosis around the stricture. Dilatation either alone or in connection with incision is one of the most reliable agents for the treatment of stricture. The dilatation should be gradual stretching; not forcible divulsion. Nothing is productive of more evil than forcing a bougie through a stricture when the instrument is too large to be passed without pain and vio- lence, and no good is ever accomplished in this way. The instrument best adapted for this purpose is the Wales bougie. A size should be selected which will pass through the stricture without force, and One which may be left in place some time without pain. In this way absorption of the stricture tissue may be caused and result in great benefit. The introduction of an instrument that causes great pain, will soon cause so much irritation as to render its use impossible, but with gentleness and time most non-malignant strictures may be greatly benefited. - Internal proctotomy is simply a division of the stricture tissue by an incision in the median line posteriorly; the cut being deep enough to completely divide all the fibrous tissue. I have never performed this Operation and consider it very dangerous on account Of the wound not having proper drainage, thus increasing the danger of infection. The external or complete operation divides the stricture and all the tissues below the anus and back of the coccyx, including the Sphincters; thus allowing drainage and avoiding the dangers of septic periproctitis. This is my favorite operation for non-malignant stricture. Care should be taken to make the incision in the posterior median line well above the stricture. The after treatment consists in irriga- tions, passing a bougie daily and packing a small strip of iodoform 72 . W. J. JMcGill. gauze loosely in the wound to cause healing from the bottom and to effect drainage. - * Colostomy is applicable in that class of cases where the stricture is malignant or inoperable from any cause. The artificial anus should be established in the left inguinal region and it can be closed later, and the anus restored to its natural site, should the surgeon be able to perform excision successfully at a later time. A colostomy re- lieves the patient of the pain and difficulty of having an evacuation, and they ofter quickly regain strength. Tuttle advises bold excision of the rectum above the point of stricture in cases of malignancy, and bring the rectum down and Suture it to the anal margin, or should this not be possible make an anus in the sacral region. While this is a bold procedure and one not without danger, yet it is the one procedure that offers any hope to the patient, and I believe that after the condition is thoroughly explained, if the patient elects to have it done, that it is the duty of the surgeon to perform a complete excision, even to removing a portion of the neigh- boring organs should they be involved in the growth. - Tuttle reported a case at the American Proctological Meeting in 1904 where it was necessary to remove the rectum and a large portion of the bladder, and the patient made an apparent recovery and was still alive and in good health four years after the operation. Intestinal anastomosis around the stricture is applicable when the disease is high enough in the rectum to permit of making a lateral anastomosis between the gut above and below. This is in many respects an ideal treatment. The operation was originated by Baker and consists in forming a new channel around the stricture by folding the gut immediately above the constricted portion of the bowel down over the stricture and anastomosing with the rectum, just below the narrow part of the gut, then at a subsequent operation clamping away the Sep- tum that has been formed by the union of the approximated surfaces of the folded piece of gut with the rectal wall. This method has not been very extensively employed owing to the small number of strict- ures that are suitably located for it. Now as to the relative value of the different operations, no one method is entirely satisfactory. The dangers of sepsis and hemorrhage in internal proctotomy would contraindicate its use in most cases. Complete proctotomy is less dangerous, but has the disadvantage in resulting in prolonged ulceration and incontinence for an indefinite period, but in spite of this, it is the least dangerous method for the radical cure of non-malignant strictures; but to obtain the best results Stricture of the Rectum. 73 from this operation, it must be followed by the use of the bougie indefinitely. Many favorable results have been reported from excision of the rectum for non-malignant strictures, but in the hands of the best operators, the immediate mortality is about 16 per cent with recur- rences in about 50 per cent of the cases, yet in stricture due to malig- nant disease. . Excision offers the only hope and should be resorted to as soon as a diagnosis is made. - SIGNS AND SYMPTOM'S OF MUCOUS Colitis.-Wilson says that mucous colitis in its varied forms, and cases whose symptoms are directly traceable to absorption of toxic products from the large in- testines, are commonly to be met with. Abdominal symptoms are not always by any means marked, and it is a mistake to imagine that a patient Suffering from the disease must pass mucous in very obvious quantity. Errors of diagnosis may readily occur if cases are looked at in the light of their secondary symptoms only. One would like to insist upon the necessity of making the thorough examination of the colon as much of a routine as is that of the stomach, heart, or other important organs. The use of balneotherapeutical measures for the treatment of this disease is attended with excellent results, often after the usual methods have met with little or no success. Special baths for the treatment of mucous colitis are now greatly in favor. The baths consist of two parts, which may be given either together or separately as the medical attendant may direct. (A.) The intestinal douch is administered while the patient lies on a special couch. A rubber tube, the length used varying from 14 to 17 inches, according to prescription, is passed into the bowel by an experienced attendant, and the prescribed amount of hot mineral water allowed gently to flow from a jacketed cylinder, the pressure being graduated according to directions. The patient's position is altered during the time the douch is retained, the bowel emptied, and the process repeated. (B.) The Tivoli douch. This consists of an ordinary bath, in which the patient lies covered, except for the head and neck, with warm mineral water. While lying in this way hot water is played on the abdomen from a special apparatus, and is usually prescribed at a much higher temperature than that of the bath. These methods are carried out in conjunction with special dieting, massage, and the drinking of mineral waters.-The Edinburgh Medical Journal, July, 1907. 74 Jerome D. Potts. THE IMPORTANCE AND SIGNIFICANCE OF RECTAL SYMPTOMS. By JEROME D. POTTs, M.D., Professor of Proctology in Barnes' Medical College. ST. LOUIS, MO. We may state without much stretch of the truth that the doctor is proverbially a student of symptoms. From the very incipiency of his work he is found observing and striving to interpret symptoms as evidence of disease somewhere within the human body. Yea, even before a faint conception of disease enters his mind he is observing and interpreting the signs along the way. “Four miles to Bingtown,” where he attends the primary school is perhaps the first that attracts his attention. This is plain and easily interpreted. No intricate pro- cess of reasoning is required to reach a correct conclusion. He under- stands at once that it means no more—no less—than four miles. A little later he, perhaps, notices these words upon a board : “What, do you think I will shave a man for five cents and give a glass of beer to boot?” The meaning of this is not quite clear to his mind. The words On the board apparently say One thing while they mean an entirely different thing. A process of speculation begins in his childish mind, and he wonders why they do not mean the same thing to him that they do to other observers. A little closer investigation soon con- vinces him that some seemingly insignificant points must be taken into consideration before a correct solution of the problem can be reached. Thus, it has ever been, we encounter the simple, then the more complex problems of life. We learn to read by first learning the alphabet or its equivalent Sounds. Step by step we advance in all Our intellectual processes and not by leaps and bounds. In the study of disease according to the older methods we first learn the simple names of the symptoms and later their significance and relative importance. A single symptom is selected and the ques- tion mentally asked—Is this an evidence of disease in a given part of the human body, or is it one of many evidences of many diseases in different parts? If it be the only symptom of a given pathological process we SOOn learn its significance and importance, but if it be one of many symptoms of many diseases we are often sorely perplexed. It is here that one man shows his superiority over another in his ability to detect the finer variations in the meaning of the symptoms. To Importance and Significance of Rectal Symptoms. 75 some the meaning of symptoms is always the same—gradations and distinctions are never made. Pain is pain regardless of modifying characteristic. Red is red regardless of variations of shade. Accurate, acute discrimination is a sine qua non to satisfactory differential diagnosis. Vague generalizations amount to nothing. Each symptom must be considered in all its relations to the morbid process before anything like definite conclusions can be reached. All conditions which in any way modify the symptoms must be carefully weighed. Bodily conformation, temperament, color and condition of the integument should be noted, before any effort is made to begin a careful historical examination of the patient. The confidence of the patient in the examiner's skill should be established by the methodical and painstaking manner of the latter. This is important for the reason that the patient may feel disposed to conceal certain facts or shrink from the necessary exposure of his person. In every instance the patient must be led to see the importance and necessity for a complete exploration of the anal and rectal canals before he can reasonably expect a definite opinion from the proctologist. In asking the medical profession to join with me in the study of rectal symptoms I offer no apology for, I dare say, there is no one who will deny the importance of this much neglected field. Only within the last twenty years have such men as the Allinghams, Thorn- ton, Cripps, Bardenhuer, Bergman, Gerster, Hemmeter, Hochenegg, Kelsey, Tuttle and other proctologists been able to gain an audience with general practitioners of medicine and surgery. Only a little while ago did a surgeon of more or less local reputation remark to me that he regarded the proctologist as a Superfluous surgical append- age. It is possible that there is a semblance of truth in this unpro- voked statement, but the proctologists of this and other countries are ready to reply that they are not allowing people to sicken and die of malignant disease of the rectum without an effort to detect and remove it. Indifference to symptoms arising in this region has recently consigned one of the most brilliant men in this country to an early demise, and I appeal to you in the name of suffering humanity to give to these symptoms the consideration they demand or refer them to some one who will. Disease is disease regardless of the part of the body in which it is located, and as such it imperatively demands the attention of every intelligent physician. Would it be necessary to ap- peal to the medical man to consider the significance and importance of pulmonary, cardiac, nasal, or laryngeal symptoms? I answer, No, 76 Jerome D. Potts. a thousand times, No. Then, bear with me while I endeavor to inter- est you in the consideration of some of the symptoms which originate in the rectal region. The subjective symptoms, pain, tenesmus, and itching are of more or less relative importance and should be considered carefully. The objective symptoms, such as skin diseases, fissures, fistulous openings, inflammations, indurations, discharges, hemorrhages, changes, in the color of skin, condition of the sphincters, condition of the rec- tum, flatulence, and tympany should be considered consecutively and carefully. Reflea symptoms, or those which are referred to some part of the body other than that in which they originate, should have their con- nection with the local morbid process established or disproved. The value and significance of constitutional symptoms in the study of rectal disease must be learned chiefly through experience and close observation. Little can be learned through text book, current medical literature, or lectures upon the significance of this type of symptoms in rectal affections. There are so many other conditions that produce . constitutional conditions which simulate the cachexia of carcinoma and the anaemia of long-continued intestinal ulceration, that the ordin- ary observer is often misled. To make the subject more interesting to the general reader each symptom of different classes will be taken up and discussed in a practical manner. Of course, there may be something of the text book character about this for it is well nigh impossible to deal with the subject of rectal symptomotology without it. Every writer, however, has his peculiar way of expressing his views and although the lesson to be taught remains the same, and the manner of teaching the same, there are some who learn more easily from one teacher than another. Pain is a symptom of very variable value because of the variety of temperaments of the individuals who suffer from it. A high-strung nervous female is much more inclined to exaggerate her statements concerning pain than is a lethargic or stoical male. In children there is often so much fear aroused by the investigation that it is impossible to determine whether or not it has a condition that would give rise to pain without the use of a general anaesthetic. There is perhaps no other subjective symptom that requires the exercise of more careful consideration and discrimination in determining its value than this one. Even the histological nature of the pathological process must be taken into consideration, and its relation to certain regions that are Importance and Significance of Rectal Symptoms. 77 abundantly supplied with sensory nerves must be remembered. Some- times a lesion so small that it can hardly be seen will produce excru- ciating pain, while another extensive and rapidly destructive one will produce only slight discomfort. Sometimes it is confined to a very limited area in the anal or rectal canal, at other times it is diffused over the entire pelvic cavity and abdomen, or reflected to the thighs and legs. - - Constant, burning pain is present in any of the types of acute proc- titis, though the severity of the pain is not always the same. - Dull, heavy, aching, throbbing pain in the coccygeal region which is intensified by movement of the fecal mass and the passage of flatus is characteristic of acute peri-rectal inflammation. The character of the pain in this disease is a fair index of the stage the inflammatory process has reached, and clearly indicates the course of treatment to be pursued. Pain originating from inflammatory processes within or around the anal canal is likely to be radiated to the thighs and legs because of the indirect connection of these parts through the sciatic nerves. A Small anal fissure often being the cause of a very painful sciatica or a lumbago. Pain is not a prominent symptom of any type of hemorrhoid, save the thrombotic, and strangulated and inflamed internal. Pain is never present in chronic fistula except when the duct—or tract—is obstructed or temporarily closed so the secretion cannot escape. Occasional attacks of pain in the rectal region followed by an escape of a small amount of blood and pus should lead one to suspect the presence of an incomplete fistula, or some type of ulcer. Pain is not a prominent symptom in any type of tumor—benign or malignant—that is situated above the sphincter muscles. This should be indelibly impressed upon the memory of every doctor so he will not wait till the disease has passed beyond the hope of relief before he makes a thorough rectal exploration. So thoroughly ought the physician be imbued with this idea that he would not hesitate to inform his friends with rectal symptoms that they must not wait for the development of pain before submitting to a thorough investigation and exploration of the entire rectal region. No harm can come to the patient by having him fear the development of a malignant disease, and why should the physician hesitate to tell him of the possibility of such a condi- tion being present without attracting his attention. - 78 Jerome D. Potts. Pain may be of the most intensely agonizing character and con- fined to the coccygeal region, or reflected to the back and legs, and yet there may be absolutely nothing in the condition of the parts that is appreciable to the eye or touch that is responsible for it. These are the cases that occasionally confuse the general practitioner. They belong to the so-called neurotic class, and the condition may be attributed to some abnormality in the nerve Supply. Pain in the rectal region may be due to disease in the neighbor- ing structures. It is no uncommon thing to find One suffering from an acutely inflamed prostate, ovary, or tube, complaining of pain in the rectum. Here, again, nothing short of thorough exploration will satisfy the investigator. Tubal abscess and acute prostatitis must be eliminated. Cystitis and vesical calculus frequently attended with pain in the anal region must be considered. Tenesmus may indicate disease in any portion of the large intes- tine, but is more particularly noted when the disease is located in the lower portion of the rectum and anal canal. It is most marked in the diseases of the acute inflammatory type which involve the mucosa and submucosa. As a symptom it is of no special importance. Straining at stool may indicate a disproportion between the size of the fecal mass and the anal outlet and unusual firmness of the mass which does not allow it to conform to the outlet, or it may indicate the presence within the lumen of the gut of tumors, hemorrhoids, cicatricial bands, foreign bodies, etc. Enlargement of the prostate, tumors of the prostate, bladder, uterus, ovaries, tubes, or in the peri- rectal Spaces may press upon the gut and cause straining. Chronic catarrhal proctitis, with diminished secretion and imperfect lubrication of the descending mass may be regarded as one of the most frequent causes of the symptom. One other cause of the symptom, and one which is not given the credit to which it is entitled, is malposition of the sigmoid and movable portion of the rectum. In many of these cases we find that it cannot be relieved by any other means than that of lifting up the Sagging portions of the gut by firm pressure, from below upward, Over the lower part of the abdomen. In early childhood this symptom may indicate congenital nar- rowing of the gut or the presence of transverse membranous bands which retard the descent of the fecal mass. Conditions may be found here by painstaking exploration that will satisfactorily explain many cases of apparent constipation. Every case of inordinate Straining during the act of defecation should be carefully examined by the at Importance and Significance of Rectal Symptoms. 79 tending physician. The real reason why should be determined before treatment is instituted. Itching is not characteristic of any particular diseased condition in the ano-rectal region. It may be present in many diseases of the mucous membrane and the integument of the region but is most per- sistent and annoying in old chronic eczemas, where the skin is dry, thickened, and indurated. Adenomata, fibromata, hemorrhoids and other tumors in the lower portion of the rectum which occasion ab- normal secretion of mucous that leaks out through the sphincter and dries upon the surface may be the cause of troublesome itching. Pediculosis, Scabies, eczema marginatum and other parasitic diseases may be the cause. In fact there are so many causes that no inquir- ing mind will be satisfied without a thorough exploration of the region and microscopic examination of any abnormal exudate. The external signs of itching which result from rubbing or Scratching of the parts vary greatly in different individuals, partly on account of the nature of the trouble causing it and partly on account of the difference in temperament of the patient. The long scratch of pediculosis, the more or less irregular and limited scratch of scabies, and the torn papule of urticaria are characteristic of the diseases pro- ducing the pruritis. The relation of peri-anal pruritis and certain constitutional dis- turbances and pruritis in other regions should be established by thor- ough investigation before treatment is begun. Sometimes deplorable results follow errors in diagnosis. Pruritis is positive evidence that there is something wrong with the skin or in the vicinity of the orifices which open onto it. Bulkley says it is highly important to recognize the exact nature Of the disease in this region, for Ordinary remedies for eczema will be of little avail, while proper parasitic treatment will arrest the itch- ing and promptly remove the trouble. The importance and significance of the various discharges from the anus remain to be considered. These will be discussed in the Order of their relative frequency of occurrence, regardless of their apparent or real significance. The normal fecal mass will be passed up with simple mention because every one is sufficiently familiar with its characteristics. The abnormal fecal mass may contain almost anything from car- pet tacks to angle warms—from small shreds of mucus to particles of disintegrated tissue. It may vary in color from a very light yel- 80 - Jerome D. Potts. low to almost tarry blackness. In consistence it may vary from fluid to that of dried clay. In odor it may vary from that of faded violets to that of putrefying flesh. Each departure from the normal character has its peculiar Sig- nificance which can be learned only by frequent and close Observation and investigation. In fact so much is to be learned from the fecal mass that no doctor does his full duty toward his patient who refuses or neglects to have it saved for his inspection and examination— macroscopically and microscopically. Mucus in the stool is without special significance. It may indicate any pathological process from acute catarrhal proctitis, sigmoiditis, colitis, or enteritis to carcinoma. Nothing short of a careful detailed clinical history and repeated investigation will enable one to even approximately determine its source. If it precedes the discharge of the fecal mass it indicates that its source is in the rectum ; if it coats the fecal mass its source is in the sigmoid; if it be mixed with the fecal mass its source is most probably in the colon, though it may be at some point higher up in the intestinal tract. Mucus, unaccompanied by blood corcpuscles, means that the mucous follicles at Some point in the canal are working under some abnormal stimulus within the lumen of the gut or in its wall. Blood in the stool signifies that there is somewhere within the lumen of the alimentary canal an open or easily broken blood vessel. The location of the open vessel is largely conjectural so far as the macroscropic or microscopic appearance of the blood is concerned. The exact source cannot be determined without seeing the bleeding point, but it is inferred that fresh blood comes from some point below the sigmoid, probably near the anal Orifice, and that red, coagulated blood, mixed with the fecal mass, comes from some point above the sigmoid, and that dark colored or black coagulated—coffee ground —blood comes from the stomach. These are mere inferences with which no one should be satisfied. Bleeding points located at any point below the descending colon can and should be seen through the proc- toScope or sigmoidoscope. It would be rank injustice to tell the pa- tient that the hemorrhage was probably coming from a hemorrhoidal mass when it was really coming from an ulcerated area or a malignant growth. Summarized and reiterated, in part, blood in the stool may indi- cate fissure, fistula, hemorrhoids, ulcers of various types, benign tumors, malignant tumors any where in the intestinal canal or stomach, duodenal ulcers, tubercular ulcers at the ileo-caecal junction, obstruc- Importance and Significance of Rectal Symptoms. 81 tion, intussusception, and the presence of foreign bodies which lacerate the mucous membrane. - Hemorrhage, whether occasional, semi-occasional, or frequent, calls for repeated investigation unless the source can be at Once de- termined. - The presence of pus in the fecal mass means that there is some- where in the intestinal tract, or connected with it, a destructive pro- cess. The real nature and location of this process is often difficult to determine, but the difficulty should not deter one from making per- sistent effort to locate and name it. Perhaps the most frequent Source of pus in the fecal mass is from a fistulous tract. In these cases the pus may be regularly or irregularly present. Sometimes it is seen with each stool for a month or two, then without apparent reason it disappears. Pure pus is rarely seen with the fecal mass. It is almost invari- ably mixed with mucus or blood. If the amount of pus discharge be large it indicates that a large area is involved in the suppurative process. If the amount of mucus be large and the amount of pus be small it indicates a large inflammatory area in the intestinal mucosa with small suppurative area. Such conditions are frequently seen in diphtheritic and dysenteric colitis. - Pus mixed with blood comes from ulcerating areas which are covered with easily broken granulations, or from fistulous tracts. Few sources for bloody pus are recognized. Negative bichloride test indicates closure of the common duct. Over twenty per cent of fatty substance in the stool shows lessening of the quantity of bile poured into the bowel, derangement of the pancreatic Secretion, or intestinal disturbance. Connective tissue remnants in the feces shows imperfect gastric digestion. Remnants of muscle fibres signify imperfect intestinal di- gestion. Starch granules show deficiency of intestinal juices. The investigation of the various intestinal bacterial flora is in its infancy and no field in clinical medicine offers greater induce- ment for thorough work. Many of these flora have been separated and identified but their function remains to be determined. Much that is irrelevant may have been said, but the purpose of this paper will have been accomplished if I can sufficiently impress the importance and significance of rectal symptoms upon the reader to make an early diagnosis. of the disease condition that gives rise to them. - Lister Building. 82 - JAbstracts. ABSTRACTS FROM CURRENT LITERATURE. TREATMENT OF PHLEGMON OF THE SUPERIOR PELVI-RECTAL SPACE. . —By Professor Robert Picque. The following case forms the basis for this paper. An insane male patient, 54 years old, was suffering from vague general symptoms. Six days after onset surgical aid was called in. Examination of the anal region showed protruding, inflamed piles with a foetid discharge from the anus. The perineum was bulging, tumefied, and of a violaceous hue. The tumefaction seemed to extend from the deeper tissues, having extended to the right gluteal region. Immediate operation was performed. An incision on the right side of the anus, the full extent of the perineum was made liberating a great quantity of gangrenous pus. The exploring finger found an extensive cavity extending anteriorly and upward through the levator ani. A posterior incision and a left lateral one were made thus surrounding the anus like a horse-shoe. The source of infection was found to be a round perforation of the rectum just above the attachment of the levator ani. The bowel was split vertically on the right side from the anus to the perforation. A drain was placed in the bowel, and the bowel drained with gauze. The temperature fell rapidly and the wound granulated rapidly. Incontinence persisted for five months. The favorable outcome of this disease depends on early diagnosis and free incision. - AS to the diagnosis, frequently these cases are seen late by the Surgeon when there is extensive suppuration and severe general infec- tion, the patient dying before or in spite of surgical intervention. The severe general symptoms in a measure point to trouble arising from the alimentary canal. Here investigation of the pharyux and abdomen are necessary and if fever the pelvic cavity must be care- fully examined. - Pelvic and rectal troubles are frequent in the insane. The diag- nosis of local disease is usually easy, being recognized by tumefaction, prominence, violaceaus color if ischio-rectal abscess alone is present. But in the deeper phlegmon the whole perineum becomes prominent, the skin is not discolored. Palpation reveals a deep seated indura- tion and extreme sensitiveness on both sides of the anus. This bilateral sensitiveness on deep pressure is indicative of abscess of the Superior pelvic rectal space. - Treatment.-Since these phlegmonous processes tend to exten- sive and rapid gangrene with severe sepsis, early and free incision is .Abstracts. 83 necessary. A consideration of the anatomic arrangement of the tissues in the pelvis will indicate the best point for attack. Below the peri- toneum is an area filled with cellular tissue which extends to the levator ani. This muscles descends from the sides of the bony pelvis to the median line surrounding the rectum, uniting with it and pass downward, helping to form the anal sphincter. This muscle divides the pelvic cellular tissue into regions; a superior and an inferior pelvi- rectal space. The inferior space is divided into two by the fusion of the muscle and fascia in the median line. An infection in this region is unilateral in the beginning. The superior pelvi-rectal space consists of one continuous cellular space and infection rapidly be- comes general, Surrounding the rectum. On this anatomic arrange- ment rests the principle of retro and latero-rectal incision. The in- cision is made midway between the anus and the tuber ischii from the transversus perinei back to the margin of the gluteus maximus down to the levator pelvi-rectal space and the finger introduced to find and open up any pus collections present. The same is done on the other side, the posterior ends of these incisions being united by a transverse incision which passes just in front of the tip of the coccyx. Splitting the rectum from the anus to the site of perforation may be necessary. Incontinence and slight eversion of the mucosa will follow, but after about a year the natural control and appearance will be restored to a satisfactory state. If the point of infection be the bladder or pros- tate the transverse incision should be made anterior to the rectum.— Gazette des Hopitaur, No. 9, 1907. Translated and abstracted by A. Edward Meisenbach, M.D. SIGMOIDITIS AND PERISIGMOIDITIS.—By Albert Catz. Perisig- moiditis may be due to an extension of sigmoiditis or arise from in- flammations from the tubes, Ovaries, appendix, etc.; i. e., an intestinal and an extra-intestinal origin. - Mayor, of Geneva, was the first to use these means for these inflammations. Two forms, a suppurative and an adhesive are recognized. Sedentary habits with constipation in adults and aged are the factors most often responsible for sigmoiditis and perisigmoiditis. The Stasis in the sigmoid predisposes to inflammation. Lumbricoid worms are known to have caused this disease. The chronic cicatrizing type affecting the meso-sigmoid may pro- duce obstruction of the bowel. Riedel has operated on twelve cases 84 - JAbstracts. of volvulus due to this disease of the meso-sigmoid. The origin of this type of inflammation is not definitely known. Diverticula and venous dilatation have been held as the starting point of this process. Acute sigmoiditis has pain and swelling in the left iliac region, nausea, and constipation which may become absolute. The patient frequently lies with the left thigh flexed. A cylindrical tumor can be felt, which is freely movable. Fever is absent as a rule. The trouble subsides when the bowels are thoroughly emptied. The sigmoid walls are thickened and can be readily demonstrated. Acute sigmoiditis with perisigmoiditis resembles appendicitis, however, being on the opposite side of the abdomen. These patients frequently have suffered from chronic colitis and are taken abruptly with acute pain in the left iliac region with gen- eralized abdominal sensitiveness, chilly sensations, temperature rise, vomiting and cessation of peristalsis. A tumor the size of a fist will be found in a day or so which is slightly, if at all, movable. This is the picture of adhesive sigmoiditis lasting about two weeks. The swelling, however, does not subside entirely for some time. Suppurative perisigmoiditis shows the same picture as given above, but it does not begin to subside after seven or eight days. Septic signs develop and the temperature remains high. The swell- ing varies. After an indefinite period the abscess may disappear, which is rare. The symptoms may subside, leaving a swelling, or it may point under the skin being readily evacuated by incision. Chronic perisigmoiditis is either of the chronic shrinking kind which is very difficult to diagnosis, leading often to volvulus; or chronic inflammation with tumor formation. In this case chronic obstruction or septic symptoms may arise. The examination shows an irregular mass in the left iliac region of firm consistence surround- ing and fixing the sigmoid. Here the diagnosis from cancer may be difficult or impossible. Treatment.—Sigmoiditis acute—control pain, apply ice, empty the bowels, and regulate diet. Sigmoiditis with peri-sigmoiditis— avoid catharsis, put the bowels to rest, apply ice, and regulate the diet. If after eight days' time there is sharp pain in the tumor mass, with high fever, operative interference is indicated—open and drain. Chronic perisigmoiditis must be treated according to what dis- turbance it produces—expectant, and operative means along general Surgical lines will suggest themselves.—Gazette des Hopitaur, No. 10, 1907. Translated and abstracted by A. Edward Meisenbach, M.D. JAbstracts. 85 * OPERATION FOR REMOVAL OF THE ENTIRE RECTUM AND NEIGH- BORING LYMPHATIC AREA FOR CARCINOMA.—P. Lockhart Mummery, B.C., F.R.C.S. Treatment for cancer of the rectum is far from Sat- isfactory, as regards the function of defaecation and Sepsis. From the patient's point of view the functional control is of the greatest importance. Operation for cancer of the rectum will not be satis- factory until we can obtain aseptic healing of the wound after Opera- tion. Sepsis accounts for nearly 80 per cent of the mortality. The great object for preliminary colotomy is aseptic healing. It also renders the operation easier. The objection is the drawing down the stump in order to secure perineal function and that it requires three separate operations. Author does not advocate preliminary colotomy in all cases. When there is narrowing of the lumen of the gut so that it cannot be thoroughly cleaned, advocates preliminary colotomy. At the time of colotomy you are able to examine from above the extent of the glandular involvement. Colotomy should be done in all cases where the sphincter muscles are involved. When it is necessary to remove the sphincter muscles a permanent colotomy should be done. The operation.—Place the patient in the lithotomy position and a Small cushion underneath the sacrum. The first step is to dissect up a cuff of mucous membrane as in Whitehead's operation. (Scissors are used for this and then put aside.) The rectum is closed by a clamp and the portion of the mucous membrane sterilized with pure car- bolic acid. A purse-string ligature may be used in place of the clamp. The next step is to thoroughly clean the field of operation and to dis- card the rubber gloves used in the first stage. An incision now made posteriorly through the sphincter to a little beyond the base of the coccyx, which is next removed. The posterior rectal space is next opened and the rectum and all glands, cellular tissue and lymphatics peeled off the sacrum with the finger in one piece. The levator ani on each side is pulled down by passing the finger behind the muscle and divide close to the rectum. Next attention is turned to the separation of the rectum in front, from the prostate and urethra, or in the female from the vagina. This is a difficult stage as one cannot have finger in the rectum for a guide, and it is easy to open the rectum, urethra, or vagina. As soon as the peritoneal cul-de-sac is reached it is opened and the attachments of the peritoneum to the rectum divided first on one side and then on the other, care being taken to keep as close to the rectum as possible. The rectum is now free in front and at the 86 JAbstracts. sides, except some fascial attachments, which are easily divided. The rectum will now come down several inches, and is only attached by the meso-rectum. This is divided by placing a clamp close to the sac- rum and dividing in front of the clamp. The rectum now comes down freely and the sigmoid comes into view. The meso-sigmoid can be cut until a sufficiently desired portion comes outside, until the entire growth is exposed, and the next step is to repair the parts. The clamps must be tied off. No mistake must be made as there is large vessels in them. The perineal floor of the pelvis is now restored by stitching the peritoneum all around to the sides and front of the sigmoid. Sterilized gauze is now placed in the wound and its end brought out at the posterior part of the wound. The rest of the wound is sewn up completely, and the sphincters carefully brought to- gether. Smear the whole wound and the portion of the sigmoid near- est to it with sterilized iodiform ointment. This seals up the wound and forms a complete protection to the wound from infection. The bowel is now cut through about three-quarters of an inch from the sphincter and the edges roughly stitched to the skin, all around and half an inch more from the skin edge. The object is to separate the junction of the skin edge and the peritoneum covering of the bowel from the septic edge of the mucous membrane. A week after the opera- tion the extra mucous membrane is cut away with Scissors. It is very important in choosing the point at which the bowel is to be divided, to see that the mesentery or meso-sigmoid comes quite to the point of division, and is not on the stretch. A piece without a mesentery will probably slough. If no portion of the meso-sigmoid is sufficiently long to reach the anus, the gut should be sewed up and pushed into the abdomen and the wound closed and colotomy performed. The advantages of the operation are: 1. That the entire rectum and growth, cellular tissue, and lym- phatics are removed. 2. That it renders it possible for the opperation to be performed aseptically and for the wound to be kept clean after the operation. 3. That it enables the normal opening of the bowel to be restored in almost all the cases that do not necessitate removal of the sphincters. 4. That is permits of the removal of more extensive growths than either the perineal or Kraske methods. 5. That there is none of the mutilations of the pelvis which is a necessary accompaniment of the Kraske operation—the removal of the coccyx does not seem to cause any subsequent inconvenience.— British Med. Jour., June 1. - Society Reports. 87 SOCIETY REPORTS. AMERICAN PROCTOLOGIC SOCIETY. Ninth Annual Meeting, held at Atlantic City, N.J., June 3 and 4, 1907. The President, Dr. Samuel G. Gant, in the chair. OFIFICERS ELECTED. - The following officers were elected: President, A. Bennett Cooke, M.D., Nashville, Tenn.; Vice-President, Louis J. Krouse, M.D., Cin- cinnati, Ohio; Secretary-Treasurer, Lewis H. Adler, Jr., M.D., Phila- delphia, Pa.; and the Executive Council, J. Rawson Pennington, M.D., Chicago, Ill., Chairman; Samuel G. Gant, M.D., New York City; A. Bennett Cooke, M.D., Nashville, Tenn.; Lewis H. Adler, Jr., Philadelphia, Pa. The place of meeting for 1908 is Chicago, Ill., the time to be announced later. - ELECTION OF MEMIBERS. The following were elected members of the Society: Dr. Jerome M. Lynch, of New York City; Dr. James A. McVeigh and Dr. J. A. MacMillan, of Detroit, Mich. The following is an abstract of the principal papers read: PRESIDENT'S ADDRESS. The President, Dr. Samuel G. Gant, of New York City, said “that the annual meetings of the Society were like a post-graduate school where advanced information in proctology could be obtained by the members. He considered it unwise to admit to membership in the Society the general surgeon and young rectal specialists of less than five years' experience in this special work, because the member- ship would become too large and the papers contributed by them would not meet the requirements.” He maintained that the proctologist of the future, in order to be Successful, must have a thorough literary and medical education, a hospital training and clinical facilities, and that he must be clever, industrious and persistent. He emphasized the necessity of educat- ing both the profession and the laity, as to the remarkably improved methods now employed in the handling of patients suffering from disease in the lower bowels. He also said it was the duty of the proc- tologist to demonstrate by his work and writing that most tubercular fistulae were curable and that the curing of ordinary fistulae did not 88 Society Reports. tend to bring about lung or skin affections as was formerly believed; that fecal incontinence does not follow fistula operations, when the muscle is cut at a right angle and the wound is properly dressed; that many rectal diseases, such as fissures, ulcers, small fistulae and some hemorrhoids can be operated upon under local anesthesia; and that in the majority of instances, constipation and chronic diarrhoea are curable by local and Surgical measures. Finally, he emphasized the fact that the etiology of many dis- comforts, nervous and reflex phenomena, usually attributed to the genital organs is frequently to be found in some pathologic process located in the sigmoid rectum or anus. REPORT on PROCTOLOGIC LITERARURE FROM JUNE, 1906, To JUNE, 1907. Dr. Samuel T. Earles, Baltimore, Md., read his report on Proc- tologic Literature, covering a period from June, 1906, to June, 1907, in which he said, “that while there has been nothing startling in proc- tologic literature in the past twelve months, your committee is grati- fied with the steady progress in this branch of medicine and surgery, as has been reflected in the literature on this subject. Especially gratifying have been the recommendations for the radical treatment of carcinoma of the upper rectum and sigmoid, as set forth in the papers of Samuel G. Gant, W. J. and C. H. Mayo, and James P. Tut- tle, in which they all recount the combined advantages of the abdominal and perineal routes, which we think will greatly lessen the likelihood of recurrences, and increase the number of permanent cures. We note with pleasure the systematic efforts that are being made in the study of the etiology of pruritus ani. The paper of Wallace, of London, in 1905, on the study of this question, stimulated the efforts of others in this direction, and we find an excellent paper by J. C. Hill, of BOS- ton, on the same, in the Boston Medical and Surgical Journal, 1906. In this article, he takes the stand with Wallace that there is always a cause for this malady in which the pruritus is only a local symptom. We quote him as follows: “Pruritus ani is the symptom, caused by unnatural moisture or discharges, produced either by lesions about the anus or by congestion, or some pathologic condition in the rectum or sigmoid. It is due to one of five causes. First, and by far the most important are superficial ulcerations, or abrasions of the anal canal. Second, catarrhal diseases. Third, external hemorrhoids. Fourth, inflammation or irritation of the crypts of Morgagni. The free borders or valves of these crypts consist chiefly of nerve fibres, Society Reports. 89 ganglion cells and connective tissue. When inflamed or infected, they may give rise reflexly to pruritus ani. The writer calls attention to the tits which project from the margin of these valves as accessory sense organs. When hypertrophied or elongated they cause many dis- tressing Symptoms about the anus, viz., creeping, crawling Sensa- tions and itching. Fifth, small polypi of the anal canal.” It is not only necessary to remove the exciting cause of the dis- ease, but, also to direct appropriate treatment to the unnatural condi- tions of the skin. In this connection your committee is glad to be able to report a number of cases of the aggravated form of this dis- ease, which had failed to respond to the usual local and consitutional methods that were successfully treated by Dr. Ball's recommendation of dividing the anal nerves. These have been reported by Drs. Mattin and Earle. Dr. Charles B. Kelsey calls attention to the office treatment of hemorrhoids by puncture with the electric cautery. The method is to make numerous punctures with a pointed cautery to the internal hemorrhoids. This method has been used for the past ten years in lieu of that by injection, with most satisfactory results, and without any unfavorable effect. For the details of the method, I would refer to his article in the Therapeutic Gagette for March 15, 1906. The re- viewer would respectfully report with reference to this suggestion, that about ten years ago he tried in a number of cases, but with only temporary success where the hemorrhoids were large. It answered very well in Small capillary hemorrhoids. J. A. Hartwell in the An- mals of Surgery, Philadelphia, for 1906, Vol. 43, page 146, reports a case of resection of the rectum for syphilitic stricture, with end to end anastomosis. As might have been predicted, it recurred, and while it was necessary to continue dilating, he was not hopeful of results. Your committee would remind its members that such radical meas- ures seldom accomplish the desired results, as recurrence is almost inevitable. Dr. A. Rose, New York, who had an article in the March PRoc- TOLOGIST, has been elected a corresponding member of the Medical Society of Athens. “CONGENITAL PILES.”—Notes on three cases in which a pile-like condition was noticed from birth-F. Victor Milward, N.B., B.C., F.R.C.S., The Lancet, London, June 1. 90 Writings of Interest to the Proctologist. RECENT WRITINGS THAT MAY BE OF INTEREST TO PROCTOLOGISTS. “Obliteration of the Dead Space Following Perineal Extirpation of the Rectum,” Jerome M. Lynch- New York Amer. Jour. of Surg., June, p. 167. * º “Extirpation of Cancer of the Anus and Rectum through the Peri- neum,” X. Delores and A. Chalier.—Revue de Chirurgie, Paris, May 10, 1907, p. 784. º “Dysenteria Baccile et aboes du foie,” L. E. Bertrand.—L' Academie de Medicine, Paris, Jan. 2, 1907. “Rectal Dilatation,” John Albert Burnett.—Dean Springs, Ark., Cal. Med. Jour., San Francisco, April, 1907. “Presentation of a Model of Recto-Sigmoidscope,” M. M. G. Leonard, R. Bensande.—Gag. des Hopitaur, Paris, June 4, 1907. “Carbolic Acid Poisoning by Rectal Injection,” Geo. N. Archer, Washington, D. C.—Archives of Pediatrics, May 7, 1907. “Ulceration of the Anal Canal, Rectum, and Sigmoid,” U. S. Grant Deaton.—Amer. Med. Compend., Toledo, O., June, 1907. “Inflammatory Neoplasms of the Pelvic Colon,” P. Cavaiton and Bardin.—Gag. des Hopitaur, Feb. 5 and 12, 1907. “Imperforate Vagina and Absence of the Anus,” E. T. Hargrave, Nor- folk, Va.-American Journal of Obstetrics, New York, August. “Wounds of the Colon Treated without Operation,” P. R. Egan. The Military Surgeon, Carlisle, Pa., August. “So-Called Syphilitic Stricture of the Rectum,” E. Schwartz—Presse Medicale, Paris, (XV. Nos. 44-77). “Examination of Feces,” G. H. Jones, Toledo. The Therapeutic Ga- gette, Detroit, May. “Study of Normal and Diarrheal Stools for Detection of Dysentery or Allied Organisms,” J. W. Fisher, Middleton, Conn. Jonſºnal of Medical Research, Boston, May. “Surgical Treatment of Cancer of the Rectum in Women,” W. B. Craig, Denver, Colo.—Medicine, Denver, May. “Determination of Bacillus Coli in Water,” F. B. Longley and W. U. C. Baton, Washington, D. C.—Journal of Infectious Diseases, Chicago, June 15. “Carcinoma of the Rectum,” J. F. Mitchell, Washington, D. C. h’ashington Medical Annals, Washington, D. C., May. “Hemorrhoids,” W. H. Stauffer, St. Louis. The Medical Fortnightly, St. Louis, June 10. “Acute Colitis and Ulcerative Colitis,” S. Philips.-British Medical r Journal, London, June 8. “Successful Treatment of a Case of Idiopathic Dilatation of Colon,” J. Schdieber. Same. “Dry Powder Treatment of Sigmoiditis and Proctitis,” E. Rosenberg. —Archiv, f. V. erdauntngs-Krankheiten, Berlin. S > “Serum Treatment of Bacillary Dysentery,” Vaillard and C. Dopter— Annales d l’Institut Pasteur, Paris, XXI, No. 4. Writings of Interest to the Proctologist. 91 “Combined Method of Removing Cancers of Rectum and Colon,” J. Rotter—Archiv. f. Klinische Chirurgie, Berlin, Vol. LXXXI, Part 2. “Gonorrheal Proctitis and Its Complications,” Brunswick-le-Bihan and Fournier.—Bulletin de l'Académie de Médecine, Paris, LXXI, Nos. 18–21, p. 497. “The Nature and Treatment of Piles,” Arthur E. J. Barker.—The Lancet, London, England, June 22, 1907, p. 1691. “Recto-Colonic Feeding,” Charles J. Drueck, Chicago.—The Medical Brief, St. Louis, Mo., August. “Case of Papillo-Adenoma of the Sigmoid Flexure,” A. L. Stavely, Washington, D. C.—Washington Medical Annals, Washington, D. C., July, 1907. “Amebic Dysentery in Sailors at the Port of New York,” Jas. A. Nydegger.—The West Virginia Medical Journal, Wheeling W. Va., July, 1907. “The Importance of a Routine Examination of the Feces for Intes- tinal Parasites: Based on Observations in Forty Cases,” J. C. Sosnowski, Charleston, S. C.—The Journal of the South Caro- lina Medical Association, June, 1907. “The Office Treatment of the Commoner Rectal Diseases,” Louis J Hirschman, Detroit.—Detroit Medical Journal, July, 1907. “The Indications for Diseases of the Rectum” (Homoepathic). The New England Medical Gazette, Boston, Mass., June and July, 1907. “Treatment of Rectal Fistula,” Chas. J. Drueck, Chicago.—The Medi- cal Standard, Chicago, July, 1907. “Relations of Sigmoid to Adjacent Viscera,” Byron Robinson, Chicago, Same. "Volvulus of the Sigmoid,” Byron Robinson, Chicago.—The Medical Standard, August, 1907. “Polypus of the Intestines and Its Relation to Cancer,” Hans Doer- ing-Archiv. f. klinische Chirurgie, Berlin, Vol. LXXXIII, pt. I. “Purulent Proctitis and Ulcerative Proctitis, Therapy and Pathology,” Ernst Ruge.—Archiv. f. klinische Chirurgie, Berlin, Vol. LXXXIII, pt. I. “Treatment of Chronic Constipation with Regulin,” H. Meyer.— Therapie der Gegenwart, May, 1907. “Perineal Extirpation of Cancer of the Rectum and Anus,” X. Delver. —Revue de Chirurgie, May, 1907. “A Clinical Lecture on the Simulation of Malignant Disease by Chronic Inflammatory Affections of the Sigmoid F lexure,” K. W. Mon- Sarrat—British Medical Journal, July 13, 1907. “Serotherapy of Dysentery,” Vaillard and Dopter.—La Presse Medi- cale, June 5, 1907. “Imperforate Anus, Case Report,” John A. Gibbons, Mitchell, Ind.— Central States Med. Monitor, Indianapolis, July, 1907. 92 JBook, JWotices. “Sacral Operations on Rectum and Uterus,” F. Goldschwend.—Archiv. f. klinische Chirurgie, Berlin, Vol. LXXXII, No. 3. * “Experiences with Rectoscopy,” G. Sultan.—Deutsche Zeitschrift f. Chirurgie, Leipsic, Vol. LXXXVI, Nos. 5-6. “Essay on the Pathology of Muco-Membranous Colitis,” Dr. Neppen. Gazette des Hopitaux, June 20, 1907. “Etiology and Treatment of Pruritus Ani,” H. A. Brav, Philadelphia. —New York Medical Journal, August, 1907. BOOK NOTICES. DISEASEs OF THE RECTUM. Their Consequences and Non-Surgical Treatment. By W. C. Brinkerhoff, M.D., Chicago, Ill. Pub- lished by Orban Publishing Co., Chicago, Ill. Price $2.00. This book deals with what is known as the Brinkerhoff method of treatment of rectal diseases. Dr. Brikerhoff says that his father took up the Miller method of injecting piles after he had been cured by it and improved it. Dr. W. C. Brinkerhoff has followed in the footsteps of his father and in this book places before the profes- Sion his conclusions on rectal diseases derived from the experience of his father and himself. His ideas are somewhat radical, but we be- lieve they are worth reading, especially by the proctologist. SURGERY OF THE RECTUM. By Fred C. Wallis, B.A., M.D., B.C., Cantab., F.R.C.S., London, England. Published by William Wood & Company, New York. Price, $2.00. This book presents the surgery of the rectum in a concise form and contains a number of original ideas. Especially interesting are his ideas of the etiology and treatment of inflammatory processes of the lower rectum and anal canal. REPRINTS RECEIVED. “Pruitus of the Anal Region,” by Bernard Asman, A.M., M.D., Louisville, Ky. - JAbstracts. 93. EXCISION OF THE RECTUM, SIGMOID, AND PART OF THE DESCEND- ING COLON WITH IMPLICATION OF THE COLON INTO THE ANU.S.-By Dr. Edward Archibald, Montreal, Canada. Paper was based upon a case of chronic ulcerative tuberculosis of the rectum and colon oc- curring in a young man and existing for three years. A left colos- tomy was done. This afforded a measure of relief and was kept open for more than a year without, however, effecting a cure. It caused So much trouble to the patient and the pain of the disease was so great that he insisted on the performance of a radical operation. The technique of the operation was the important part of the contribution. It consisted in the cutting of the meso-sigmoid, or meso-colon, to a sufficient extent to obtain adequate mobilization to enable the splenic flexure of the colon to be brought down to the anus. The speaker showed a most instructive series of preparations from the cadaver, the arteries of which had been injected after the ligation of the vessels necessary to effect this mobilization. In all cases in which ligation and injection was performed there was shown to be full and adequate blood supply to the entire region mobilized. He discussed the feasibility of utilizing this technique for radical opera- tions on malignant neoplasms of the rectum and lower sigmoid. The Kraske's operation was attended by a very high mortality, and the combined abdominal-perineal operation as advocated by Mayo even in his skilled hands, had a dangerously high mortality rate. There were in the operations upon this region three important points to consider, viz., the mortality, the post-operative control of the bowel contents, the permanence of cure. One chief advantage of the form of technique offered by the speaker lay in the fact that by its employ- ment all glands could be removed. That this was a matter of the highest importance was demonstrated by the fact that Kraske now combines his original operation with abdominal section. The Ob- jection to the Mayo operation lay in the fact that the artificial anus was always bad and further there was an immediate high mortality due to shock. The ideal operation was a complete removal of the bowel with its lymphatics and a subsequent fecal control through the natural channels.-Read before the American Medical Association, Atlantic City, 1907. ADVERTISEMENTS. Uhe Irurtuluniat A THE ONLY RECTAL JOURNAL LIBERAL Quarterly COMMISSION (pite Bullar per jear TO Within the reach of the General Practitioner AGENTS who did not receive instruction on rectal diseases in IN ALL PARTS Medical School. FRED B. MURPHY, President A. T. GREGORY, Vice-Pres. and Manager BOGY NOONAN, Secretary Manhattan Laundry Company NEW LOCATION : 4228–30 FINNEY AVENUE We Guarantee High-Class Service with Latest Improved Machinery BELL, PHONE, LINDELI, 2715 KINI, OCH PHONE, DELMAR 738 L. GIVE US A TRIAL AND BE CONVINCED PHYSICIANS’ LIABILITY INSURANCE. Ask any prominent lawyer if he will accept $10 a (J f | * f year and agree to defend, free of any other charge, any . ! P 1 III II III]tſ; suit for alleged malpractice, error or neglect that may be brought against you. Require also that he must not “settle” any it without #2". º sº that he must carry the case to the courts of last resort ; that he must finally pay the damages himself if the case IS PRINTED BY goes against him and he loses; also require that he give - a bond backed by a thoroughly responsible surety com: pany that he will faithfully perform his contract—and all for ten dollars per annum ! Will he? The FIDELITY & CASUALTY COMPANY OF - . NEW YORK, a company backed by more than $8,000,- - 000 assets and the prestige of thirty years’ active ser- || - vice along similar lines, has done so, is constantly, do- ing so, and will continue to do so for physicians of re- - - pute throughout the United States. 3O6 - 3O8 NORTH THIRD This is what we do: . - - * *...*. º pºp; ai. º to protect the reputa- tion of the physician. o do this we must win suits. To win suits we must employ the very best legal aid. ST. LOUIS Were we to lose even a small percentage of the suits - that we defend, we could not afford to offer defense and indemnity at $10 a year. We cannot settle any suit without the assured’s consent. Our lawyers have no THERE you can get promptly any more right to perform a lºgal º up On º physi- cian’s reputation without his consent than . a physician tº * - & has to perform a surgical operation upon a lawyer with- kind of printing needed, and out his consent. As we must fight, we must win or te suffer severely financially, which we do not propose to executed in good shape. do if we can avoid it. That is what you want, for winning suits means, vindication FOR YO In brief, our policies provide : 1st—Any suit for alleged malpractice (not criminal), any error, mistake or neglect for which our con- tract holder is sued, whether the act or omission IF F was his own or that of an assistant—is defended. - 2nd–Defense to the courts of last resort, if necessary, all at our expense, with no limit as to amount. 3rd—If we lose, we pay to the limit agreed upon in the contract. R. A. HOFFMANN, Gen. Agt., A S K T H E VI Both Phones. 308-314 Rialto Bldg, St. Louis. Typewriter Bargains Thes; and sº uſos THE ORIGINAL “AUTO=BUGGY'' (PA tented) (Registered) --- -- - - w - - º º \º - --- |\ºvº º Pºº-ºº: M--º-mº --- Wºr" . - ** - A11 Standard Makes, $15 to $65. Most of these machines have been only slightly used — are good as new. Shipped on approval. - Don't buy a Typewriter before writing us. Two .." of “ jºg, Q. º of º -- - - - - running all over the U. S. peed from 4 to We will give you the best typewriter bargains 40 miles per hour. Runs from 50 to 100 miles that can be offered. Address on one gallon gasoline. MºLAUGHLIN TYPEWRITER | Success Auto-Buggy Mig. Co. EXCHANGE, GENERAL OFFICE AND FACTORY 211 N. Ninth Street. ST. Louis, Mo. 530-540 DeBalivière Ave., ST. LOUIS, M0 THE DOCTOR'S WHO's WHO Now READY. It is vol. x11, AND completes THE SET AJJOCIATE The Doctor’s Recreation Series - E101 Torº doctors: 12 ºp.1endid Octavo Volumes Nicholas sann The set—titles wn, warran II. The Doctor’s Leisure Hour VIII. The Inn of Rest Potter II. The Doctor's Red Lamp VIII. Doctors of the Old School wim. Henry III. In the Year 1800 IX. The Shrime of Aesculapius IV. A Book About Doctors X- The Doctor's Domicile drummond V. The Doctor’s Window John C. *M*T* | VI. Passages From the Diary eſta XII. The Doctor's Who's who XI. A Cyclopedia of Medical History Titus Munson coan *Late Physician al-eart" - - - P THE PUBLISHERS announce to the Maploan, Paorºasion the completion of a notable undertaking, unique - wander veer in the annals of literature. - - Sept. and others. THE DOCTOR'S RECREATION SERIES presents as complete and varied a collection of the best - E701 TOT--IN literary medical literature as oan be brought within the compass of a dozen volumes. Beaurºrul Illus- The - trations, chiefly in photogravure, lend their charm to each volume. The paper is specially made. The chief binding, whether cloth or half moroooo, is rich in effect and in harmony with the taste of the limited and Saalfield criarles wells oritical circle of readers for whom the set is exclusively designed. The price is moderate. Subsoribers Publishing reason it does not satisfy you, return it at our expense. 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If for any- ' co., Akron, o. Send on approval, prepaid, a complete set of The Doo- ton's Recausation Smanas at $30.00 per set. If satisfactory, I will pay $2.00 within five days after receipt of the goods, and º per month for 14 months. If the set is not satisfactory, I am to notify you and hold it subject to your order. 156 Fifth Ave., New York city Mºron, Ohio. Address........................... ---------- -------- if you wºn the hºirmoºsºº". $48,00, $2.00 to $8.00, 14 months to 15 months. ADVERTISEMENTS. e—s ENTEReNeL * THE GREATEST Gastro-Enteric Antiseptic and Germicide KNOWN TO MEDICAL SCIENCE. aſ a Discovered by E. L. HINMAN, M.D. 2 aſ Late Examining Surgeon, United States Army. Gº Gº Gº Gº The Most Effectual Treatment for TYPHOID FEVER CHOLERA MORBUS DIARRHEA - ENTERIC TUBERCULOSIS DYSENTERY ASIATIC CHOLERA CHOLERA INFANTUVI YELLOW FEVER Advertised to Physicians Only. Endorsed by surgeons of both the British and U. S. Armies professors in medical institutions, and officers of National and State Medical Associations both at home and abroad. Formula on every package. General Guarantee and Serial Number 391 7. PRICES: (NET) 125 Tablets, $1; 250 Tablets, $1.75; 500 Tablets, $3.00 (Sent Prepaid if cash accompanies Order) Gł R. G. G. THE ENTE-RONOL CO. Manufacturing Chernists, ô) OSWEGO, NEW YORK @ T--~~~~ -- St. Louis College of Physicians and Surgeons The course of instruction, which is a graded one, extends over four years of study in college, devoted to Dissections, Laboratory Work, Didactic and Clinical Instruction, Recitations and Quizzes, Demonstra- tions and Manual Training in the use of instruments and appliances. -- FACULTY. WALDO BRIGGS, M.D., Dean. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Professor of Surgery. EDWARD B. KINDER, A.M., M.D... Professor of Bacteriology, Pathology and Histology. JAMES MooREs BALL, M.D.. Professor of Ophthalmology and Lecturer on the History of Medicine. OSCAR F. BAERENS, M.D. . . . . . . . . . . . Professor of Diseases of Ear, Nose, and Throat. OTTo SUTTER, M.D. . . . . . . . . . Professor of Diseases of Women and Clinical Gynecology. A. FULTON, M.D. . . . Professor of Mental and Nervous Disease and Clinical Medicine. W. J. MILLER, M.D. . . . . . Professor of Clinical Surgery and Demonstrator of t A. Operative Surgery. H. G. NICKS, M.D. . . . . . . . . Professor of Physical Diagnosis and Practice of Medicine. W. S. WIATT, M.D. . . . . . Professor of Fractures and Dislocations and Cerebral Surgery. J. C. MURPHY, M.D. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Professor of Obstetrics. Joseph L. BOEHM, PH.G., M.D. . . . . . . . . . . . . . . . Profesor of Genito-Urinary Surgery. H. J. KRUSE, PH.G., M.D. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Professor of Pharmacology. A. T. QUINN, M.D. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Professor of Materia Medica. H. A. CABLEs, B.S., M.D. . . . Professor of Principles and Practice of Medicine and of Hygiene. LEO L. C. LEMOINE, M.D. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Professor of Minor Surgery. JoHN W. VAUGHAN, M.D. . . . . . . . . . . . . I’rofessor of Orthopedic and Clinical Surgery. C. ALEX. JoRDAN, M.D. . . . . . . . . . . . . . . . . . . . . . . . . . . • * * g e e Professor of Dermatology. ROLLIN H. BARNES, M.D. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Professor of Proctology. ROBERT KELLEY, Counsellor at Law. . . . . . . . . . . . . . Professor of Medical Jurisprudence. C. W. SCHERY, M.D. . . . . . . . . . . . . . . Professor of Chemistry, Toxicology and Urinalysis. H. S. FRAZER, M.D., Professor of Anatomy and Director of the Anatomical Laboratory. BERNARD BLASS, M.D. . . . . . . . Professor of Physiology and Director of the Physiological Laboratory. EDWARD L. COOLEY, M.D. . . . . . . . . . . . . . . . . . . . . . . . . . . Professor of Diseases of Children. MAJOR H. E. FERREL, M.D. . . . . . . . . . . . . . . . . . . . . . . . . . . . Professor of Military Surgery. JOHN W. Bond, M.D. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . WALDO M. BRIGGS, M.D., Dean, Jefferson Ave. and Gamble St. ST. LOUIS, MO. cAMPHo PHENIQUE Liquid A Cº-ow LEDGED PEREMIER IN THE FIELD OE ANTISEPTICS FOR CASES OF MINOR AND MAJOR SURGERY LIQUID. IN 25c and $1.00 Containers For samples and literature address the Powder THE SUPERLOR DRY DRESSING FOR CUTS, BURNS ULCERS AND ALL SUPEREICIAL WOUNDS POWDER IN 1 oz. and 1 lb. C on tainers campºo-phénoue Co., ST. LOUIS, MO. CACTINA PILLETS PEACOCKS BROMIDES A Cardiac Tonic Stimulant THE BEST FORM OF BROMIDES From Cereus Grandiflora (Mexicana) Each Pillet containing One One: Hundredth of a grain of Cactina Indicated in functional cardiac troubles, such as tachycardia, palpi- tation, feebleness; and to sustain the heart in chronic and febrile diseases. It is not cumulative in its action. DOSE. One to three Pillets three or four times a day. ºut up in bottles of 100 pillets Free sampº to ºn request Sultan Drug Co., St. Louis, Mo. ºhºrº Cº. Each fluid drachm contains 15 grains of the neutral and pure bromides of Potassium, sodium, ammonium, Cal- cium and Lithium. In Epilepsy and all cases demanding continued bromide treatment, its purity, uniformity and definite thera- peutic action, insures the maximum bromide results with the minimum danger of bromism or nausea. Dos E-one to three teaspooniu's ac- cording to the amount of Eronides desired. Put up in 1-2 pound bot- tles only. Free samples to the profession upon request Peacock Chemical Co., St. Louis, Mo. Pharmaceutical chemists. - VOL.I. DECEMBER, 1907. No. 4. * A. |The Proctologist ROLLIN H. BARNES, M.D. ST. LOUIS Those Who Have Contributed : JOSEPH M. MATHEWS, M.D., - tº- - gº Louisville, Ky: R. D. MASON, M.D., - - º º - Fººt Omaha, Neb. ARTHUR E. HERTZLER, M.D., A.M., Ph.D., - - Kansas City, Mo. WILLIAM M. BEACH, M.D., A.M., - sº - * Pittsburgh, Pa. H. A. BRAV, M.D., - e- tºp * - - Philadelphia, Pa. ACHILLES ROSE, M.D., º - º * tºº New York City. GEO. B. EVANS, M.D., A.M., - tº- wº * Dayton, Ohio. A. B. COOKE, M.D., Pres. Amer. Proctologic Soc. - - Nashville, Tenn. C. A. WOSBURGH, M.D., - - -- - - St. Louis, Mo. COLLIER F. MARTIN, M.D., - * * - Philadelphia, Pa. W. J. M'GILL, M.D., - - - e- - * St. Joseph, Mo. JEROME D. POTTS, M.D., - - - - - St. Louis, Mo. LOUIS J. HIRSCHMAN, M.D., - - - º Detroit, Mich. H. M. BISHOP, M.D., - - - tº- - - Los Angeles, Cal. JOHN A. HAWKINS, M.D., - sº - - - Pittsburgh, Pa. $1.00 a Year. QUARTERLY. $1.50 a Year Postal Union. have secured from the publishers, a limited number of a most complete PERPETUAI, VISITING AND POCKET REFERENCE Book, containing 128 printed and ruled pages, substantial vellum binding. Partial con- tents: Table of Signs, Obstetrical Memoranda, Clinical Emergencies, Poisons and Antidotes, Dose Table, Weekly Visiting List, 52 pages, Clinical and Obstet- rical Record, etc., which they are offering to furnish free by express with full size bottles of DIOVIBURNIA, NEUROSINE AND GERMILETUM to Physi- cians who have not already received same, they paying only the express charges. This is an opportunity seldom offered of securing a most complete Pocket Reference BOOk (Perpetual) F REE The Visiting and Pocket Reference Book. The DIOS CHEMICAL CO., 2940 Locust St., St. Louis, Mo., Entered as Second-Class Matter, Sept.10, 1907, at the Post Office at St. Louis, Mo., under the Act of Congress of March 3, 1879. Mº AC HIDI, LIQUID tº TABLET FOR MI - - Therapeutic Range of Melachol: - Melachol has established itself as a specific for constipation, uterine congestion, etc. NER ve. Diseases: Its effect upon nerve tissues . indicates its use in nervous exhaustion and especially in melancholia depending upon overwork. As a regenerator it is indicated during convalescence from all diseases. Not to relieve, but to prevent hepatic º colic; to prevent an impending sclerosis of the liver; to correct conditions causing hepatic diabetes; to correct conditions causing jaundice and bilious sick headaches; to feed nursing mothers; to stimulate dentition and alimentary vigor in ill conditioned children. In boils, carbuncles, acne indurata, cerebral soft- |ening, its theoretic indication has been practically established. In the treatment of acute and chronic alcoholism, --- º morphia mania, clinical reports indicate it to be a - º º º most valuable adjunct. - Sample and literature upon request. º - MELAEFºl pharmacAL COMFNY. ST. LOUIS, MIS SOURI. Annerican Vibrator THE THERAPEUTIC VALUE OF MECHANICAL MASSAGE is more and more recognized by the profession. Every practitioner knows that there are many pathological conditions directly attributable to 1ack of exercise and deficient cir- culation of the blood. In Neural- gia, Insomnia, Dyspepsia, Lumbago, Rheumatism, and similar complaints, no matter what other treatment may be indicated, it will be found that vibratory stimulation is of vast assistance. The AMERICAN VIBRATOR is the only machine which in every respect meets the requirements of the profession. Send for booklet which fully explains the advantages of this little machine and our plan for a trial free from risk. An inquiry puts you under no obligation. American Vibrator Company, VICTOR1A BLDG., ST. LOUIS, MO. ST. JAMES BLDG., NEW YORK, Do not fail to mention. The Proctologist. The truttulunist PUBLISHED QUARTERLY A11 communications relating to THE PROCTOLOGIST should be addressed to ROLLIN H. BARNES, M.D., Editor and Publisher, Metropolitan Building, St. Louis, Mo. CONTENTS. PAGE' HYPERTROPHY OF THE ANAI, PAPILLA, L. J. Hirschman, M.D., Detroit, Mich. tºº * * ſº se tº- * tº tº- 95 BLOODLESS OPERATION ON THE RECTUM, Herbert M. Bishop, M.D., Los Angeles, Cal. tº * * * * tºº tº- - 102 CONSTIPATION : CAUSE, PREVENTION AND TREATMENT, John A. Hawkins, M.D., Pittsburg, Pa. *E- amº * * * sº - 105 Abstracts from Current Literature Relating to Proctology: Treatment of Perianal and Perirectal Abscesses, E. H. Thrailkill, - 110 A New Operation for the Radical Cure of Hemorrhoids, Jerome M. Lynch, 104 A New Operation for the Complete Removal of Hemorrhoids, A. Haygate Vernon, & - sº * 111 Lesions of the Sigmoid Flexure as a Cause of Colitis, P. Lockhart Mummery, 111 Entero-Colitis and Muco-Membranous Entero-Neurosis, Lebeaupin, - 112 Mucous Colitis, Arthur D. Dunn, tºº º gº - * - 113 Society Reports. American Proctologic Society.—A New Method of Operating for Ano-Rectal Fistula.-Occult Hemorrhage from the Rectum.—Local Versus Gen- eral Anaesthesia in Rectal Surgery.—The Sigmoidal Factor in Constipation.—A Report of Two Cases of Sigmoidopexy.—Fecal Impaction.—Pruritis Ani.—New Hemorrhoidal Clamp. —Report of Case.—The Treatment of Ischio-Rectal and Pelvi-Rectal Abscesses.— Cryptitis.--Observations on Certain Points in the Anatomy and Physiology of the Rectum. 115 Recent Writings For The Proctologist, * * - * - 124 Subscribe for The Proctologist. * *.*.*.*.* to Rectal subjects. By so doing you will, in part at least, make up for that lack of instruction of your Medical School. I swbscribe for The Proctologist for one year, and wntil further notice, for which I agree to pay One Dollar per year. JWayne Street City - - - * * * * Słaże THE PROCTOLOGIST is the only journal devoted to Rectal Diseases. ADVERTISEMENTS. Y-II-I - (OO = ( – (I-I WAGINAL SUPPOSITORIES (Maſhama) º i sº - 33 º Fº º ; Design Pat. sept. 17, 1901. FOR THE TREATMENT OF Uterine and Vaginal Endometritis, Leu- . corrhoea, Vaginitis, Urethritis, Gonorr- - hoea, Ulcerations, Hypertrophy and Con- gestion. Especially Effective in Chronic Cases EACH SUPPOSITORY CONTAINS: . Benzoborate Soda...... • - - - - - - - * * * * * - - - - - - * * * * * - - - - - - - * * * * 5 grs. I Concentrated Thymic Solution 10 m. - Sulphocarbolate Zinc -------------------------------------. 1 gr. Oil Cassia.------------------------------------------------------- % m. Boroglyceride Solution 25 m. Alveloz Gelatine, Glycerine, Water........................ (I. S. The combination represented in this Suppository assures the full physiological action of each ingredient, all of them work- ing together to secure the general result desired—restoration to normal function of the tissues involved. There is nothing in this preparation which forms a simple coat- ing over the affected parts, thus giving temporary relief only, but each ingredient is brought into direct contact with the diseased surface. I One dozen will demonstrate the superior therapeutic value of the Kahama Vaginal Suppository—the price of this quantity to physicians is 75c postpaid. I I &Thama Preparations: RECTAL SUPPOSITORIES, VAGINAL SUPPOSITORIES, URETHRAL BOUGIES, CERVICAL BOUGIES, SYR. HYPOPHOSPHITES, The Kahama Chemical CO. ST. LOUIS, MO. |== Pºſ = {OO-(IºIR-I | i f # Cactina Pillets. Cactina Pillets deserve every compliment that can be paid them as a remedy in the treatment of smokers’ or tobacco heart, weak heart in tuberculosis, and in every condition where a general heart stimulant is required.— J. Mount Bleyer, M. D., Eac-President Ameri- can Congress on Tuberculosis, New York City. Pain. This is the condition, we are most often called upon in a hurry to relieve. Our therapeutic measures employed will be gauged by the cause, location, severity, etc. A hot water bag should always be accessible. Hypodermics of morphine should be used as Sparingly as possible. Papine is an ex- cellent paingreliever that is devoid of the danger and unpleasantness of ordinary opiates. It relieves pain promptly, but does not produce narcosis, constipation, etc.—W. T. Marrs, M. D., Medical Herald. Better Results than from any Combination. I must Say that Neurosine has given better results and more universal satisfaction than any combination ever used by me. I have tried it in many nervous affections and in epilepsey of long Standing. In some it is a specific, in others a therapeutic agent of great value.—W. L. Cahagam, M. D., Coroner of Hamilton County, Chattanooga, Tenn. Relief in Rheumatoid Conditions. Dr. Pettingill, of New York City, under the head of “Intestinal Antisepsis,” says: ‘‘ Every physician knows full well the ad- vantages to be derived from the use of antikamnia in very many diseases, but a number of them are still lacking a knowledge of the fact that antikamnia in combination with various remedies, has a peculiarly happy effect. Particularly is this the case when com- bined with Salol. Salol is a most valuable remedy in many affections ; and its usefulness seems to be enhanced by combining it with antikamnia. The rheumatoid conditions so often seen in various manifestations are wonderfully relieved by the use of this com- bination. This remedy is a reliable one in the treatment of diarrhoea, entero colitis, dysentery, etc. In dysentery, where there are bloody, slimy discharges, with tormina and tenesmus, a good dose of Sulphate of magnesia, followed by two antikamnia and salol tablets every three hours, will give results that are gratifying.’’ Do not fail to mention The Proctologist. ADVERTISEMENTS. º º - TO EVERY DRACH M OF FLUID ARE ADDED 15 GRAINS EACH OF PURE CH LORAL HYDRATE AND PURIFIED BROM. POT.; AND 16 GRAIN EACH OF GEN. IMP. Ex. CAN NABS IND. AND HYOSCIAM. – IS THE ONLY HYPNOTIC THAT HAS STOOD THE TEST FOR THIRTY YEARS IN EVERY COUNTRY IN THE WORLD. ECTHOL ODA PAP Nº. BATTLE & G0, tº ST.LOUIS, MD, U.S. A. - - - - - - ºwntºmº Codeine Tºsº in Grippa conditions Do not fail to mention The Proctologist. ADVERTISEMENTS. LISTERINE The original antiseptic compound (fl. Gold Medal (Highest Award) Lewis & Clark Centennial Exposition, Portland, 1905: Awarded Gold Medal (Highest Award) Louisiana Purchase Exposition, St. Louis, 1904; Awarded Bronze Medal (Highest Award) Exposition Universelle de 1900, Paris. Listerine represents the maximum of antiseptic strength in the relation that it is the least harmful to the human organism in the quantity required to produce the desired result; as such, it is generally accepted as the standard antiseptic preparation for general use, especially for those purposes where a poisonous or corrosive disinfectant can not be used with safety. It has won the confidence of medical men by reason of the standard of excellence (both as regards antiseptic strength and pharmaceutical elegance), which has been so strictly observed in its manufacture during the many years it has been at their command. The success of Listerine is based upon merit The best advertisement of Listerine is—Listerine Lambert Pharmacal Company St. Louis, U. S. A. Antiseptic NOm-Irritant Prophylactic Katharin 111 NOIl-Pois0nſ US Detergent KA-T H A R - NZ O N Allays Pain tº º V lººtiº º; º º 11 y * is, t ID w S. Aci GBrmicidſ, §::::::::::::::::::::, ;... .º.º. #: Destroys Fºtor Dist. Extract Witch Hazel. FOR LOCAL AND INTERNAL USE LOCALLY as wash for Abscesses and Fistula, Ulcers, Catarrhal Inflammation of Mucous Membranes, Phagedenic inflammations, Pruritis and Derma- titis. Gives relief and promotes healing of painful and bleeding Piles, Fissures and Tears of the Rectum, etc. INTERNALLY controls Sympathetic Vomiting. Unsurpassed as an Intestinal Antiseptic in all inflammatory processes of the Alimentary Tract, Diarrheas, Ulcerations and Cholera Infantum. A 16-Oz. Bottle for trial, to Physicians who will pay Express Charges. KATHARMON CHEMICAL CO., St. Louis, Mo. Do not fail to mention The Proctologist. (Ultr Irurtuluuiat VOL. I. DECEMBER, 1907 NO. 4. HYPERTROPHY OF THE ANAL PAPILLAE.* BY L. J. HIRSCHMAN, M.D., DETROIT, MICH. Attending Proctologist, Harper Hospital. Clinical Professor of Proctology, Detroit College of Medicine. Fellow American Proctologic Society. In selecting the subject for this evening's discussion, the writer has done so with the view of bringing before the profession a condition which is practically never recognized by the general practitioner, and overlooked by the general surgeon who includes rectal surgery as an incident in his practice. It is one of the many minor conditions which originate in the anal canal which, while never causing such serious symptoms as to endanger health Or life, or to cause such great suffer- ing as to incapacitate the patient from his or her daily occupation, nevertheless, is of considerable interest to the medical practitioner because of the amount of discomfort and uneasiness, Out of all pro- portion to the size and severity of the lesion,--which it causes. The general practitioner of medicine, as a rule, when a case presents him- self complaining of rectal or anal symptoms, usually prescribes one of the proprietary ointments supposed to be an “absolute panacea” for “all rectal diseases, as well as diseases of the skin and all the Organs therein.” When one complaining of rectal symptoms is referred to or consults a general surgeon, he examines to see if there is anything to operate upon, and if some very definite lesion such as hemorrhoids, polypus, or other neoplasm does not present itself to view, he has the patient take a general anesthetic and divulses the Sphincter, and con- siders that he has done his full duty to the patient. It is because diseases of the rectum, that is, surgical diseases of the rectum, are considered by the general surgeon in the same light as surgery of any individual organ or part, such as a finger or a *Read before the Surgical Section of the Wayne County (Mich.) Medi- cal Society, October 28, 1907. 96 L. J. Hirschman. toe, or a joint; instead of being affections of an Organ or organs, unique in their relation to the economy, that he fails to do full justice to many proctologic conditions. It is a case of “cut a fistula and tie a pile,” and that's all there is to it with him. When one considers that One person out of every seven has some diseased condition which involves the anus, rectum or colon, it can be readily seen that the study of affections of these organs is of consid- erable importance—enough importance to demand practically the entire attention of men who are especially trained in the study and treatment of diseases of this region. Until the regular reputable profession took up the scientific study of proctology as a separate special branch of medicine in the same way that gynecology, Orthopedic, genito-urinary, abdominal Surgery, are re-. garded as separated from general Surgery, the patient who was suffer- ing from a non-operative disease of the rectum was in a very bad plight. If he had one of the Ordinary Surgical diseases of the rectum mentioned above the general Surgeon would operate, but the general surgeon takes no interest in the non-operative or semi-operative dis- eases of the rectum, and the general practitioner does not care to equip himself with the necessary paraphernalia and cannot afford the time which the careful treatment of non-Surgical rectal diseases de- mands. It has also been the writer's observation that the after-care given by the average surgeon following Surgical Operation on the rec- tum practically amounts to nil. After the Operation he loses his interest; the after-care is delegated to an assistant or interne; and in- asmuch as it is supposed to be very unpleasant work, it is done in a more or less shiftless and unsatisfactory manner; with the result that we hear of many failures or imperfect cures following operation for fistula in ano, fissure and hemorrhoids, and cases of incontinence of feces have been not of infrequent occurrence. Just as the treatment of both medical and surgical diseases of the eye, ear, nose, throat, have been Segregated from general Surgery on account of the fact that those organs demand both medical and sur- gical treatment of a Special nature; SO in the leading hospitals and colleges of this country to-day diseases of that most important ex- cretory organ, the rectum—with the anus and sigmoid—has been separated from general Surgery. Careful and conscientious workers are devoting their entire time to the treatment of these diseases, with the result that on account of the careful personal attention to the patient in medical cases, and intelligent after-care in the surgical, better results and fewer failures are being met with. Hypertrophy of the Arval Papillae. - 97 The Special Study of the rectum and its allied organs the anus and Sigmoid, has brought to view many interesting conditions which have been Overlooked in the past, and it is with the view of clearing up Some obscure and indefinable symptoms which originate in the region Of the anus, that the writer has selected one of these so-called minor conditions, Hypertrophy of the Anal Papillae, for discussion this even- ing. It is in the anal canal where most of the pathological conditions which cause pain and suffering and innumerable reflexes originate. Nature has been unusually lavish in her nerve supply to these organs and lesions in this region produce reflex disturbances in many other and remote organs. When one considers that the anus measures from two-thirds to one inch in length and its circumference is from one and one-quarter to three inches in ordinary health, one can readily see that it is not a large area to examine, and study, and pathological conditions in this region should not be difficult to discover and diagnose. The anus is peculiarly susceptible to injury and disease: First, be- cause its lining membrane being neither skin with its tough resisting power, nor mucous membrane with its generous vascular supply, but a transitional tissue neither one nor the other—is easily injured. Secondly, any lesion occurring in this region has a small chance of re- covery, because of its meagre blood supply, its constant shifting posi- tion, and because of the contents of the bowel, which are constantly passing over it. In order to understand more intelligently the condition under dis- cussion, it might be well to say a few words about the normal anatomy of the anal papillae. These papillae occur as an irregular line of Small saw-tooth like projections encircling the point of the juncture of the anus with the rectum, sometimes called the linea dentata. These papillae, varying in number from five to a dozen, are usually situated at the edges of the semi-lunar anal valves or crypts of Morgagni. Andrews considers these papillae the normal tactile Organs of the rec- tum and endowed with a special rectal sense. They have an abund- ant nerve supply, which accounts for the many reflex disturbances which originate when they are diseased. More will be said about these crypts later. In examining the patient digitally, unless one is rather expert, these papillae are not always evident to the touch but are apt to be overlooked unless an ocular inspection is made. Where diseased, these papillae may vary in size from a quarter of an inch in length by the same breadth at the base, to an inch and a quarter or inch and a half in 98 - L. J. Hirschman. the longest diameter. (Fig. 1.) They are usually composed largely of over-growth of normal tissue. Often by everting the anus, the tips, and even considerable of the hypertrophied papillae themselves can be brought into view. They are of a pinkish color, slightly paler than the normal mucous membrane of the rectum. A distinguishing FIG. 1. Longitudieal section of Anus. P-Hypertrophied Papillae. N-Normal Papillae. C-Morgagnian Crypts. point between hypertrophied papillae and polypi in the fact that the hypertrophied papillae is always wider at its base than the apex, while the polypus is always larger than the pedicle by which it is attached. The polypus is usually rounded or oval in shape, while the papillae is more or less triangular, or ribbon shaped. Enlarged papillae have been incorrectly diagnosed as connective tissue piles. They never show the characteristic varicose appearance of the internal hemorrhoid and are attached at the ano-rectal line. Containing some erectile tissue, on examination through the anoscope, they will often be Hypertrophy of the Anal Papilloe. 99 seen to stand out at right angles from the mucous membrane, giving the anal canal at this point somewhat of a fringed appearance. (Fig. 2.) The general surgeon when he can discover no pathological lesion but finds a tight sphincter, and advises divulsion of that sphincter, overlooks what he may call little tags of the mucous membrane. These are very frequently the cause of the tight sphincter; for let it be said here that no sphincter is abnormally tight unless there is some patho- logical lesion causing it, and a simple divulsion of the sphincter will not relieve the symptoms, as many a surgeon and patient have found to their chagrin and disappointment. These papillae being situated on the edge of the Morgagnian crypts, are pushed and dragged downward during the passage of feces which are more firm and harsh than normal. At each bowel movement there is a further push and drag on the papilla, which is - - - - - - Fig. 2. Anoscopic view of extreme case of Hypertrophied Anae Papillae. gradually stretched and hypertrophied. After it has become sufficiently hypertrophied it will not retract at once after a movement, but will remain in the grasp of the internal sphincter causing it (the sphincter) to contract. This contraction gradually becomes more tonic, and eventually we have what has been called the “tight contracted sphinc- ter.” This gives rise to one of the most characteristic symptoms of hypertrophied papilla, or that of an unsatisfied feeling after stool, a feeling as if some small particle of fecal matter were still in the grasp of the sphincter and could not be expelled. Also a feeling of irritation and uneasiness, short of itching. As one patient described it to me, “It felt like the bite of some small animal,” and he was sure that he 100 L. J. Hirschman. had a tape-worm, because he “could feel it nibbling at the anus.” Another stated that it felt like a burr, held in the grasp of the sphinc- ter. This feeling can be immediately relieved by the insertion of the lubricated finger and pushing up and replacing the enlarged papillae which will be found in the grasp of the internal sphincter. If they are left to themselves, it will often take from fifteen minutes to an hour and a half or two hours for them to gradually retract, when symptoms will entirely disappear. They cause spasm of the Sphincter, and the constantly repeated spasm brings on a hypertrophy of the circular muscular fibres, forming the sphincter muscles, and the hyper- trophied sphincter is the so-called tight sphincter. Another symptom which the hypertrophied papillae cause is so- called neuralgia of the rectum, being transferred and transmitted pains from pressure on the nerve endings of the papillae. One of the most common symptoms, however, for which hypertrophied papillae is responsible, it pruritus ani. I do not wish to be misunderstood as saying that hypertrophied papillae are the only cause of pruritus ani, because the causes are legion; but it is a common and probably the most frequently overlooked cause. It will be remembered that the papilla is found at the edge of a semi-lunar anal valve, which semi-lunar valve is the outer boundary of one of the crypts of Morgagni, also known as rectal pockets or mucous crypts. These crypts, whose function is not thoroughly understood as yet, become clogged with fecal matter, which on account of the shape of the crypts or sac is not readily extruded. The enlarged anal papilla overlying the crypt assists in preventing its escape. The de- composition of this fecal matter or retained secretion and the conse- quent irritation to the crypt sets up an inflammation or cryptitis which may go on, and does frequently, to pus formation. The accumulated discharge originating here overflows from the crypt and as it runs down the mucous membrane of the anus sets up an irritation, which is made manifest by itching or pruritis, and the moisture complained of by many patients suffering from pruritis will be found to Originate from this cause. The feeling of uneasiness following stool, which some patients complain of, is unlike that produced by any other condition. It has been described to me by one patient as a feeling as if he had thorns or pine needles in the anus, a sort of a prickling Sensation—not pain- ful but very uncomfortable, and he would find himself constantly shifting from side to side as he sat and occasionally the shifting would relieve him when assisted by some pressure on the anus—thus releasing the papillae from the grasp of the sphincter. - Płypertrophy of the Anal Papillae. 101. It is not only the extremely long papilla that we must look for to cause these symptoms, as those which are only half an inch in length, the tips of which are just engaged in the sphincter, are sufficiently long to cause these symptoms. - Another condition which has been found to follow the hyper- trophy of an anal papilla is fissure in ano. This is caused, as has been demonstrated by Wallis, of St. Mark's Hospital, London, by Sufficient pressure during stool to tear the papilla downward from the edge of the crypt, and Succeeding stools continuing the tearing process, the edge of the crypt is brought down to the outside of the anus; leaving in its wake a raw, ulcerated furrow which is split open further by each stool, and gives rise to the many severe and intolerable Symptoms attending upon fissure in ano. The treatment of this condition is extremely simple, and consists in the removal of the papillae when they are enlarged or cauterization of the crypts when inflamed,—usually both conditions being present, coincidently. The papillae are removed under local anesthesia, using a one-tenth to one-quarter solution of eucain lactate, or distension with sterile water. Ofter the anoscope or fenestrated speculum is not Inecessary, as the papillae, if few in number, can be drawn into view by eversion of the anus by traction on the skin at the Outer margins. Even where the anoscope is used, it is not necessary to anesthetize the sphincter. The papillae are injected at the base until they are dis- tended and the tissues blanched, and they are removed either by ex- cision, the snare, or crushing. The anal pockets or crypts are opened by incising through the lower lip to the base, and are cauterized by chromic acid, tri-chlor-acetic acid, or carbolic acid, the actual cautery not being advocated by the writer. In excising the papillae one must be sure to get the entire base so as to leave a clean granulating Sur- face. y The after treatment consists in keeping the bowels confined for three or four days, and then moving them with an oil enema preceded the night before by a drachm or two of compound licorice powder, the patient being kept in the meantime on an absorbable semi-fluid diet. It is not necessary for the patient either to be confined to the bed or to the hospital as, under proper aseptic surroundings, the little Opera- tion can be performed in one's office as well as not. Where the symptoms are due simply to the inflamed crypts and the papillae are of normal size, simple incision into the crypt and cauterization, without interference with the papillae, is all that is indicated. 604 Washington Arcade. 102 Herbert J.M. Bishop. BLOODLESS OPERATION ON THE RECTUM. By HERBERT M. BISHOP, M.D., LOS ANGELES, CAL. As the mathematician seeks to reduce the complex factors of his problem to their simplest terms, in the process of solution, so should the Surgeon in Operative rectal exeresis keep constantly in mind the de- sirability of these elementary indications: An aseptic field, clean-cut, bloodless incisions, perfect and smooth coaptation of the lips of the wound, primary union and freedom from secondary hemorrhage. These principles were enunciated in a paper which the writer had the honor to furnish for the section on Military Medicine and Surgery of the Pan-American Medical Congress held at Washington, D. C., in September, 1893, entitled, “A Contribution to Rectal Surgery and Bloodless Operations of Membraneous and Lax Tissues by Means of an Elastic Quilled, or Welted Suture,” and were reiterated in a paper that I was invited to write for the American Medical Associa- tion in 1894 entitled, “A New Bloodless Operation for the Excision of Hemorrhoids with Healing by First Intention,” which was pub- lished in the June number of the Therapeutic Gagette of the same year. This hemostatic method of operating, originated and devised by me, applies with marked emphasis to all operations on the rectum, whether for the removal of piles and other angiomatous growths or the ablation of redundant folds, prolapsus ani, etc. Owing to the number and size of its blood vessels, its system of valveless and vari- coid veins, one of the greatest difficulties to encounter is the control of hemorrhage. Previous to the development of my method, careful operators on the rectum relied upon the ligature or clamp and cautery, for few had the temerity to brave the dangers of the Whitehead or the so-called American operation, which were usually accompanied by an environment suggestive of the shambles of a bloody butchery, while some of the subjects of this heroic plan pass the remainder of their days in mourning the loss of a dependable fundament. But the object in writing this paper is not to engage in any con- troversy regarding the merits or demerits of this, that or the other operation for hemorhoids, but to emphasize the principles that govern in plastic operations on the exterior of the body, and to prove that the same ends may be attained in the various Operations called for in the rectum by following out certain rational devices. Years ago, Bloodless Operation on the Rectum. 103 after removing an epithelioma from the lower lip of an old sea captain, requiring an ablation through the entire thickness of the lip of a section resembling an equilateral triangle of one inch dimension, the sides of the wound were evenly and snugly approximated by means Of harelip pins, and in a few days not a mark of the incisions could be perceived externally and only a very fine line of union on the mucosa. The thought then occurred, that if an incision of the walls of the rectum could be held as smoothly and immovably in coaptation, similar results should follow. Harelip pins being out of the question, I thought of a quilled suture, as in restoration of a lacerated perinaeum; but here the rigidity of such a quill would not be tolerated by the rectum. Finally, I bethought me of a flexible quilled suture, that without any stiffness, should hold fixed the margins of the wound, firmly, accurately and gently, allowing the contiguous parts to conform to their natural envir- onment. It was found that rubber tubing or cord about five milli- meters in diameter accomplished this desired end. Not only this, but also, by applying this flexible, elastic, quilled suture before excising the part to be sacrificed, a bloodless operation would ensue. In fact, this form of elastic, compressing suture is to the proctologist what the Esmark bandage is to the general surgeon in operations on the ex- tremities. The following is the method for operating for which I claim originality: With the patient prepared according to the favorite technique of the operator, a convenient pair of forceps gently clamps the base of the offending tumor or fold of the rectum, care being exercised to smooth out the tissues so that no duplications, twists or corrugations become enclosed between the blades of the clamping instrument; then place the pieces of rubber tubing or cord along these blades so as to parallel each other, and bind them in situ with thoroughly anti- septicized catgut loops sutured at intervals greater or less according to the vascularity of the structures involved. Now remove the clamp and with scissors excise all the parts outside the elastic quilled suture, cutting evenly and smoothly, which will leave a wound ready to heal by first intention. With the tissues unroasted by cautery, uncontused by ecraseur, uncontorted and unstrangulated by ligature, and free from buried suture tracts liable to become infected, the plastic healing process goes uinterruptedly on and in due time the rubber quills are lib- erated and pass harmlessly from the bowel, leaving the smallest possi- 104 Herbert J.M. Bishop. ble trace of Scar; no hemorrhage, primary or secondary, no thrombus. or abscess, no ulceration or stricture. This method applies equally to internal or external piles and their various subdivisions; it clears. the field of the morbid growth and leaves no complicating sequelae. Each operator will vary the details of suturing to meet the circum- stances and preferences of individual dexterity. At first I used as many threaded needles as designed stitches, tieing one of the rubber quills beforehand at spaced intervals with the catgut of the several threaded. needles, then passing the needles through the clamped tissues and tieing Over the rubber on the opposite side. Latterly I have found the opera- tion abbreviated by using a helical or perineal needle curved at right angle to its handle, passing all the sutures below the clamp, slipping the rubbers through the loops and tieing. When the rubber tubes or cords are cut to the required length, the sharpness of their severed edges can be smoothed off with a hot iron so that there shall be absolute freedom from irritation of the rectal lining—less than when a kernel of undigested corn is passed. 2627 HOOver St. A NEW OPERATION FOR THE RADICAL CURE OF HEMORREIOIDS.— Jerome M. Lynch, M.D., New York, recommends that the patient is placed in the Sims' position, on the right or left side, with the knees well flexed on the abdomen, and asked to strain. When the hemor- rhoid to be obliterated is selected, a needle, threaded with plain catgut, is now placed beneath the mucous membrane into the cellular tissue at the base of the hemorrhoid, where the blood-vessels enter, and brought out on the other side, thus embracing both vessels and a little of the mucous membrane. The suture is now tied, the loose ends cut off, and the hemorrhoid allowed to recede into the rectum. As the base of the hemorrhoid is within the sphincter and outside of the sensitive zone, there is no pain attached to the operation. An opium supposi- tory is now inserted. The hemorrhoids do not slough off, as one might expect, because only the blood-vessels entering the hemorrhoid are tied off, and the mucous membrane has sufficient blood supply to nourish itself without these. The tumors swell for the first 24 hours, but afterwards gradually subside, leaving nothing but a hard, blood- less mass of connective tissue. This is absorbed in time.—Medical Review of Reviews, October, 1907. Constipation ; Cawse, Prevention, and Treatment. 105 CONSTIPATION ; CAUSE, PREVENTION AND TREAT- MENT.< BY JOHN A. HAWKINS, M.D., Professor of Rectal Diseases, Medical Department Western University of Pennsylvania; Rectal Surgeon of St. Francis Hospital and IKauffman clinic; Rectal and Genito Urinary Surgeon to Ohio Valley Hospital, Pittsburg. An abnormal condition of the body, characterized by altered func- tion, is not a Symptom but a disease. Should a condition be a conse- quence of any disease then it may be a symptom and not a disease per se. Should a patient complain that his bowels move at irregular inter- vals or that the amount is smaller than he thinks it should be, we are inclined to diagnose the case as one of constipation. This is prac- tically the definition of constipation as given in the books and is only partly true. Writers have, time and again, mentioned that patients have gone for weeks and in several instances months, without the bowels moving, with no apparent distress to the patient. We are all familiar with the fact that the quantity excreted is usually governed by the amount ingested. It is no uncommon occurrence to find people whose bowels move very irregularly, but who enjoy the best of health and many quite fleshy persons are found in this class. Therefore, my idea of constipation is that often it is a disease in which the patient does not have regular and sufficient evacuation of the bowels and suffers from absorption of the fermentative and putrefac- tive products of the intestines. This disease may be due to a number of causes, some obstructive, when it is known as obstipation. For example: Obstruction due to congenital or acquired abnormalities, as malformations, tumors or hypertrophied valves of Houston. Congenital atresia recti is not considered under the head of constipation. When the acid stomach contents pass gradually into the duode- num its union with this secretion and the alkaline pancreatic and hepatic juices results in the evolution of gases. These gases, to- gether with the solids of the feces, stimulate peristalsis if generated in normal quantities; but if too large in amount, they may cause distress unless passed onward toward the anus or backward toward the stom- *Read before Western Pennsylvania Medical Society, September 13, 1907. 106 John A. Haw/cins. ach, and then expelled. If the stomach and intestinal juices are not of the proper reactions or proportions there may be a diminution of the quantity of the gases with the result of lessened peristalsis. Part of these gases are normally absorbed with the chyme or by the blood vessels, the remainder passing away with the feces. The feces travelling through the duodenum, jejunum, and ileum become less fluid as it nears the ileo-cecal valve through which it easily passes to the cecum. In its passage up the ascending colon, it is greatly re- tarded by gravity and by the time it reaches the hepatic flexure it is of the consistency of soft putty. This fact in itself would teach us that right-sided colostomy is less desirable than the opposite owing to the fluid condition of the feces. Under normal conditions there is little difficulty in the passage of the feces along the transverse colon and, although the nearer the rectum the drier the feces, when they reach the descending colon their onward passage is facilitated by gravity until the sigmoid is reached. It is at this point that the feces begin to accumulate, being packed most tightly in the transverse por- tion of this part of the large gut until it is full, when it is further dammed back into the descending colon. Should the desire to evacu- ate the bowel be appeased, the action of the transverse part of the sig- moid is to straighten itself, thereby removing the kinks and allowing the further onward movement towards the rectum. In its downward course precipitous descent is here prevented by the valves of Houston which gives the descending bolus a rotary movement through the TectU11m. The abnormal character of the secretions, per se, manifest them- selves, as is so often seen, in the diarrhea due to acid fermentation in the duodenum, jejunum and ileum. On the contrary, the continued ir- ritation of acid fermentation may over stimulate the nerve endings in the intestinal mucosa, reducing sensation therein which is necessary to peristalsis, and thus producing fullness and Overdistension without evacuation. The causes of constipation then are: Too rapid absorption of fluids; insufficient secretion of these fluids, producing excessively dry stools; abnormal amount of gases in the intestines; diminished Sensi- bility of the nerves in the intestines; intestinal muscular atony; im- proper diet; incomplete gastric digestion; drugs and poisons, as lead, etc.; habit, which includes lack of exercise; voluntary inhibition due to absence of an opportune time or place, or fear of pain, etc. Also Seden- tary occupations; drinking small quantities of fluids and excessive Constipation ; Cawse, Prevention and Treatment. 107 perspiration are certainly factors in the etiology of this disease; brain and cord lesions as in tabes; hereditary predisposition; age, as infants and old persons. - - The most prominent symptom of this disease is irregularity of th movement of the bowels. This is sooner or later followed by signs of autointoxication, headaches, mental hebetude, inability to concentrate One’s mind and the desire to put off as much as possible for the mor- row; the throat may become dry and the face flushed, symptoms simi- lar to that of some of the vegetable alkaloids; the mouth is sticky and pasty; the breath becomes foul or sour; digestion is impaired with flatulence as a sequence; elevation of temperature, usually accompanied by rapid pulse are very common symptoms of this disease. Vaso- motor disturbances are very common, as local asphyxias, etc. In Some instances the degree of brain irritation is so marked as to indicate an organic rather than a functional origin of the disturbance. These grave symptoms are thought to be due to hemic alterations due to absorption of putrescent products and poisonous gases from the accumulated fecal mass. The skin becomes muddy or even yellow, rough and itchy or even smarting. - Later we may have the sumptoms of recurring and prolonged dilatation with its atony and even ulceration or impaction. Symptoms of pressure on the pelvic organs are so numerous and of so much consequence that we cannot do them justice in a paper of this scope and simply call your attention to them. In no other disease is knowledge of more value in the prevention than in constipation. In fact knowledge of its causes is not only the basis of its prophylaxis but also of its therapeutics. I know of one case where a child of 8 years went without a movement of the bowels for more than 4 weeks without the mother being aware of that fact. The truth is that mothers rarely pay any attention to the habits of chil- dren in this respect, and should they neglect the call of nature while playing or at school, there is no one to tell them that this one neglect may be the fore-runner of a disease which can doom them to invalidism of either mind or body or both and which might have been prevented had the children only known. Then, the first and chief factor in the pre- vention of constipation is acquiring the habit of going to stool at a reg- ular time whether it be the first thing in the morning or the last at night. The installation of a pleasant, well ventilated, well lighted and comfortable closet is, in itself, suggestive. If one is inclined to ex- cessive perspiration they should drink large quantities of cool water 108 Jo/v7, A. Hawkins. but not at meal time. A tumbler of cool water upon arising and an- other three hours after each meal will compensate for loss of water by body evaporation and urination. Treatment of Constipation.—You will observe that I have spoken Only of constipation as a disease in itself. Where it is a symptom of another disease its treatment is governed entirely by that disease. The suggestions under the head of prophylaxis are prime factors in the treatment of this disease, particularly the habit of going to stool at a regular hour. In many cases where the disease has not progressed to the stage of dilatation, the observation of this rule together with a mild laxative will often produce a cure. In the more chronic cases the physician will often be taxed to the limit to effect a cure. In one patient, I recall, there had been no movement of the bowels for many years without the aid of enemas. I had tried almost everything as simple remedies and in combination. What would produce an evacua- tion would also cause intestinal pain. In desperation I handed the patient a dozen tablets I removed from a sample box of a remedy which I had received that morning and told her to take seven, the maximum dose, and to let me know the result. To my surprise she reported that she had had the first satisfactory movement of the bowels in many years. She ultimately reduced the dose to one-half tablet and some- times goes a week or more without repeating the dose. This I con- sider as near a cure as we can get in this disease. This same drug I have given in other cases without the least effect and in some cases it produces a very unsatisfactory watery stool in doses sufficient to move the bowels. Exercise is quite beneficial in all cases. The use of coarse foods. The avoidance of the young meats as veal should be advised. Baths are always indicated. Massage has been of little value in my experi- ence. Occasionally we find patients with very tight sphincters. These are often benefited by divulsion of these muscles. I tie principally to diet, exercise and drugs, together with the advice under prevention. Regularity must be impressed upon the patient. Liquors vary in their action on different persons. Beer constipates one person and acts as a laxative with another. So also with tobacco. Tea and coffee are as a rule constipating. Fruits should be taken of freely. Usually the indi- gestion of these patients is the result rather than the cause of the con- stipation and should be treated accordingly. In the treatment of constipation the first object of the physi- cian is the evacuation of the patient's bowels. The feces must not Constipation ; Cawse, Prevention, and Treatment. 109 be allowed to accumulate, for the longer they lie in the sigmoid the drier and harder they become, and the stimulus required to pro- voke peristalsis must be greater. Therefore, when the patient is seen for the first time try to move the bowels. The history will oftimes give the required cue. I usually try a capsule of B. Cascarin Ø grain; aloin 96 grain; resin podophylin V4 grain; Strychnine sulphat 1/30 grain, Once, twice, or three times daily before meals as indicated. This formula I usually have to modify somewhat after the first ten days, and, after the patient finds that at a certain hour by the use of this he has a movement, and that he is thereby feeling better, I then be- gin to try for the drug that will do the work with decreasing instead of increasing doses. It is at this point that we sometimes get the best results with phenolphthalein. This drug has for many years been used in chemistry as an indicator, and as its color would change by the addition of chemicals its use was suggested to the makers of a certain wine to facilitate tests for substitution. It was soon noticed that the users of this wine were troubled with diarrhea, and investigation re- sulted in the discovery of phenolphthalein as the purgative. This drug produces watery stools in large doses and should be cut down from the original dose of 3 to 7 grains until the smallest dose will give the desired effect. With some persons it does not produce the desired effect at all but forms large quantities of gas without a bowel movement. Trial alone must teach us just where it will do good. Belladonna has been very disappointing in my hands. The A. B. S. & I. pill has been very much over-rated. Belladonna dries up the secretions and is best omitted from all remedies used for con- stipation. Ipecac is a good remedy and rarely causes annoyance ex- cept where there is an idiosyncrasy present. Cascara usually does best when combined with other drugs. Strychnine is a valuable drug in constipation when combined with other drugs, but must be given in sufficient doses. 1/60th grain three times daily is useless. Give the patient 1/30th to 1/20th grain or more if you want results. As to the treatment of obstipation, due to displaced transverse colon, massage, with the drugs mentioned, is indicated. Should exam- ination show hypertrophy of the rectal valves their division by Martin's or better Pennington's operation frequently produces Surprising re- sults. I have one case in mind where no drug did good, but after removal of segments from two of these valves the patient was freed from trouble and continues so after five years. Several other patients 110 John A. Hawkins. who formerly required purgatives to produce even an unsatisfactory stool are in good condition by the occasional use of a mild laxative. Impaction is the result of neglected constipation or obstipation. The accumulation of feces in the lower bowel is usually followed by the symptoms of constipation but in addition the patient may have a diarrhea at the same time that the lower bowel is filled with feces. In these cases if the rectum is examined it will be found filled with feces with a hole through the mass through which liquid feces from above are passing. In all cases of impaction the treatment is to remove the mass by softening it with soapy water or a solution of Ox gall, and if this is not sufficient, then the mass must be broken up, pre- ferably with the fingers or a delicate scoop, and removed with the douche. . Constipation in babies is usually due to the absence of fats and the correction of the diet; administration of fats and the use of soap pencils are, as a rule, all that is necessary. In patients suffering from hemorrhoids, aloin must be used with caution, as it generally aggravates that condition. Fulton Building. TREATMENT OF PERIANAL AND PERIRECTAL ABSCESSES.—E. H. Thrailkill, Kansas City, Mo. Summary.—A physician should never take a patient's diagnosis for a disease of the rectum. But examine him thoroughly before treatment is instituted. (b) As much anti- septic precaution should be employed here as in surgery of other parts of the body. (c) A straight bistoury is preferable to a curved one, because the surgeon can be more certain as to the exact location of its point. (d) The incision should be wider than the widest por- tion of the induration or abscess. (f) A curette should never be used in cleaning out these abscess cavities Owing to the danger of opening up a new field for bacterial invasion. (g) The abscess cavity should be packed firmly in the first dressing to prevent subsequent hemor- rhage, (h) The patient should be kept on the best of nourishment and allowed the freedom of his room as early as possible.—The Journal of the Kansas City Medical Society, October, 1907. - JAbstracts. - 111 - ABSTRACTS. A NEW OPERATION FOR THE COMPLETE REMOVAL OF HEMOR- RHOIDS.—A. Heygate Vernon, F.R.C.S. In preparing the patient wash out the lower bowel well with two or three enemata of either plain hot water or water mixed with oil, turpentine, or tincture of asafoetida. It is better not to use an alkaline or soap enema, as the coagulating power of the blood is distinctly lessened. After anesthesia and the Sphincter is dilated, a hollow metal cone or plug, shaped like a bullet, 2% in. long and 1 in. in diameter, being held in a temporary handle, is passed into the rectum. A large pin, like a lady's hatpin, is thrust from about three-quarters of an inch outside the anus above the Sphincter into the bowel, through a channel made in the metal cone, and out above the sphincter at the opposite side. A similar one is passed at right angles to this, so that the lower part of the rectum and the whole pile area are transfixed upon this metal cone. A piece of rub- ber tubing is fixed upon one of the pins, wound around two or three times behind the pins, and finished by fixing it to the pin started from. This causes the piles to stand out, and acts as a turniquet, effectually stopping all hemorrhage during the removal of the piles. The handle of the instrument is now removed. With a pair of scissors an incision is made all around the anus just outside where the skin joins the mucous membrane, the piles are removed togther with all the veins lying below sphincter into the bowel, through a channel made at right angles to the sphincter, and as much of the thickened muco-cutaneous and cellu- lar tissue as may be thought desirable. The rubber tube should be re- moved and all bleeding points crushed or tied. The mucous skin sewed together with catgut. The pins withdrawn and the cone re- moved.—British Medical Journal, October 5, 1907. LESIONS OF THE SIGMOID FLEXURE AS A CAUSE OF COLITIS.—P. Lockhart Mummery, F.R.C.S. Thorough examination should be made with the sigmoidscope. Palpatation of the abdomen is an important method of examining the sigmoid. A careful examination of the dis- charges should be made. Laparotomy is justified in a few cases but the majority can be made without it with sufficient certainty. Inflamatory Lesions: (1) Simple sigmoiditis; (2) granular signmoiditis; (3) hyper- trophic sigmoidits; (4) follicular sigmoiditis; (5) ulcerative sigmoid- itis. In a series of 36 cases of chronic colitis were found 24 inflamma- tory lesions of the sigmoid mucosa, ulceration in 7 cases, and 7 cases of cancer of the sigmoid. Treatment.—Rest in bed is essential. The ordinary slop diet is a great mistake. Milk aids the excessive bacterial growth. The patient needs building up and a full diet is advised. 112 JAbstracts. Fat is recommended, in the form of butter, cream, etc.; as it makes the stools soft, and prevents formed motions. Some patients cannot take sufficient fat and in these cases mineral fat is recommended, as petroleum. Irrigation should be given in the semi-prone position, and afterwards placed for a short time in the genu-pectoral position, and the solution retained as long as possible. At first sodium bicarbonate, 1 dram to the pint, afterwards argyrol 0.5 per cent, and potassium permanganate 1/2000. At least a pint should be used at a time. Ulcers which do not heal should receive direct applications. Malig- nant growths should receive early and radical operation. Operation should be done for adhesions. Left inguinal colotomy is seldom necessary. The main reason why the treatment of colitis has often been unsatisfactory is inaccurate diagnosis, and treating as a disease what should be regarded as a symptom.—The British Medical Journal, October 5, 1907. ENTERO-Colitis AND MUco-MEMBRANoUs ENTERO-NEUROSIS.– Lebeaupin points out the necessity of differentiating these two affec- tions, since their treatment is different. Entero-neurosis occurs espe- cially in nervous women, but also in neurasthenia or hypochondriacal male patients. These patients have a distinct neuropathic history— hysteria in women and neurasthenia in men; they complain of having always suffered from abdominal pain and from uneasy digestion, and they examine their stools with minute care; they read up their cases in medical books; consult numerous doctors; and try every method of treatment. Entero-neurosis shows itself by appearance of nausea and vomiting, followed by very painful peristaltic movements of the intestines; these painful peristaltic waves are worse during the 1menstrual period, and are particularly prone to occur at night time. Constipation is usually present; the stools are small in caliber, and generally take the form of small pellets or ribbons, sometimes accom- panied by mucous or false membranes. Sometimes there are numer- ous motions per day, but these are not of a diarrheal character. Crises of intestinal pain of an extremely acute character may occur, the seat of pain varying, sometimes in the region of the ascending colon, some- times that of the transverse colon or iliac fossae, and the whole of the large intestine is often painful on palpation. Pain over the bladder, in the genital organs, and in the sciatic nerve may be present. During the crisis of intestinal pain the abdomen is usually retracted, the muscles tense, and palpation cannot be tolerated by the patient. In entero- colitis constipation alternates with diarrhea, the intestinal pains are never so severe as in entero-neurosis, and symptoms of peritoneum JAbstracts. 113 (distended abdomen and excessive meteorism) are the dominant feat- ures; the painful intestinal crises of entero-neurosis are accompanied by great agitation of the patient, or even by convulsive attacks, but with passage of a motion all these signs disappear, the stool usually con- taining no fecal matter and being composed of false membranes, Sometimes in enormous quantities. If fecal matter is present in the stool, it usually is hard and white. In entero-neurosis various ptoses may occur. In entero-colitis one never finds enormous quantities of false membranes expelled after the intestinal crisis. In entero-neurosis the false membranes contain very few epithelial cells. There are no pus cells or red cells or eosinophiles, all of which are present in con- siderable numbers in entero-colitis. Further bacteria are far more abundant in the false membranes of entero-colitis than in those of enterO-neurosis. In entero-colitis suitable treatment for the inflamed mucous membrane by diet, drugs, tonic, etc., are sufficient to effect in many cases a cure. In entero-neurosis the most important point to remember is that the general nervous condition must receive appro- priate treatment if success is expected. Moral and intellectual repose must be insisted upon, and if necessary the patient must be isolated, and the hysteria or neurasthenia should receive appropriate treatment. —Jour. de Med. et de Chir. MUCOUS COLITIS.—Arthur D. Dunn, M.D., Omaha, says this dis- ease is so involved with constipation, neurasthenia, and various surgi– cal conditions that any illumination will be worth the effort. The analy- sis of its etiologic and irritative relationship is of prime importance from a curative standpoint. This is, indeed, a territory in which the surgeon and internist should work hand in hand if end results are the desiderata. After reciting a number of etiological factors from dif- ferent authors, the author says constipation, taken in its broad sense. with its sequelae, is the Sinc qua non. For clinical purposes and to show its relationship with mucous colitis, constipation may be schemat- ically divided into, atonic, catarrhal, and spastic constipation ; mem- branous enteritis; colica mucosa; and mucous diarrhea. The vast majority of the cases belong to the category of severe constipation and hold in themselves only the potentiality of ever fitting the frame of colica mucosa. It is this that has given us our trouble in diagnosis. The well-sketched type of colica mucosa is one of the end stages. It is only by considering the disease as a form of constipation that we can gain an adequate conception of its pathogenesis. The constipation is nearly always of the spastic variety. Neurasthenia is almost always present and it is often a question to determine whether the neuras- thenia or the mucous colitis is the primary condition. Malnutrition is 114 JAbstracts. due to the lack of eating sufficient food. Mucous colitis is often re- sponsble for the symptoms of visceroptosis, or vice versa. Pelvic dis- placements are often an aggravating and irritating cause which tends to accentuate or prolong the condition. It is probable that mucous colitis exists occasionally with chronic constipation, forming a vicious circle, as it were, in the production of abdominal distress and neurasthenia. Chronic cholecystitis may act in the same way. Chronic adhesive peritonitis may act as an exciting cause and render medical treatment unsatisfactory. We may safely say that the pathogenesis of the dis- ease will not be satisfactorily elucidated until the nerve supply of the colon with its relations has been worked out. Trauma has been re- ferred to as a cause. Arthritic diathesis is only another way of stat- ing the individual differences in cellular physiology and susceptibility to noxious influence based upon heredity. The pathology of the dis- ease may be considered as (1) pathology of the colon, (2) pathology of the exciting cause. There are no pathognomonic findings of the colon. The disease is protean in its manifestations. A careful and painstaking history is essential to the diagnosis, as it is of much more importance than the physical findings. When approached with a spirit free from prejudice, and when a careful anamnesis is taken, and an examination is made, the diagnosis is comparatively easy. Differential diagnosis is made from, appendicitis, renal colic and Deitl’s crisis, cholecystitis and gallstones, and chronic cholelithiasis. Treatment.—To be successful must be based on an accurate diag- nosis. An exciting anatomic cause should receive proper operative attention. A Weir Mitchell treatment may be necessary. Psychother- apy is important in individual cases and malnutrition must be looked after. A change of climate, laying aside duties and cares, will often accomplish remarkable improvement. Visceroptosis usually demands fattening. A Rose bandage may accomplish the desired result. Con- stipation must receive attention. Various diets have been advanced, the cellulose is popular. In cases where the Spasticity is marked the diet should a priori be of a bland character, switching as rapidly as possible to a diet rich in cellulose. In the spastic cases opium and belladonna will often bring about desired results. Nocturnal injections of one-half pint to one quart of olive or cotton-seed oil to be retained until morning. Hot fomentations in the painful stages are agreeable and tend to allay spasm. In combating constipation we may be com- pelled to resort to our entire therapeutic armamentarium. The treat- ment of each case is a problem in itself. Results can be obtained, however, which if not as spectacular as in some other fields of medi- cine, are nevertheless fully as gratifying and permanent.—Jour. A. M. A., Sept. 14, 1907. Society Reports. 115 SOCIETY REPORTS. AMERICAN PROCTOLOGIC SOCIETY. Ninth Annual M eeting, held at Atlantic City, N. J., June 3 and 4, 1907 5 The President, Dr. Samuel Gant, in the chair. (Continued from page 89.) A NEW METHOD OF OPERATION FOR ANO-RECTAL FISTULA, PRESERVING THE CON TOUR OF THE AN US AND THE FUNCTIONS OF THE SPIHIN CTER MUSCLES. Dr. J. Rawson Pennington, Chicago, said: I have found that the employment of a Seton greatly aids in preserving the contour of the anus and the functions of the sphincter muscles in operating on many cases of anorectal fistula. The technique of the operation is as fol- lows: After all of the fistulous tracts, external to the sphincter, are divided, a probe pointed director is passed into the bowel through the remaining tract and an incision made on its distal side. This incision should extend far enough, distally, to divide all or a part of the fibers of the external sphincter; and in such a direction as to locate the distal side of the transferred internal opening, at or near, the anal margin. Then, turning the knife, make an incision, Salmon’s “back cut”, on the proximal side of the tract. A seton is then passed through the opening entering the bowel and tied loosely around the tissues remain- ing and undivided. The wound is dressed as after the ordinary incision operation for fistula. At the end of twenty-four to thirty-six hours it is redressed, care being taken to dress it so that the opening entering the bowel will be made to heal from the proximal toward the distal side. The object in doing this is to advance the final fistulous tract as far distally (toward the skin) as the case will permit, so that, if possible, it will pass through or distally to the fibers of the external sphincter, when the healing process is complete. . As a rule the enlarged tract entering the bowel soon closes, with the exception of that part through which the Seton passes. As soon as this has occurred the seton may be removed, and by the time the external wound is healed the tract entering the bowel will possibly have closed also. Should it not, at any time later this little tract, which will usually not be more than one-half inch in length, may be dissected out and the remaining fibers of the muscle sewed together, thus pre- serving the contour of the anus and the functions of the sphincters. 116 Society Reports. By Operating in this manner no deep sulcus is left to mutilate the anus as there frequently is following the usual incision method of dividing the muscle. Instead of this the contour of the anus is pre- served. Should the seton be left in situ until the wound is completely healed a small non-secreting fistula will be seen entering the anal canal. This may be left alone or dissected out and sewed together at will. Sometimes the opening will give no annoyance and finally close without further interference. - - The anus not being divided at the first sitting aids the healing of the external wound and prevents much of the contraction and atrophy usually observed after these operations. Furthermore, we simply have an external wound with which to contend. The anus not being disturbed to any great extent, and in Some cases not at all, the patient is usually up and around in a few days. Moreover, the bowel movements do not soil the wound, and the likelihood of loss of control over fecal contents is minimized. “OCCULT HEMORREIAGE FROM THE RECTUM.” Dr. William B. Beach, Pittsburgh, Pa., stated: 1. Occult blood in the stool indicates disease high up in the gas- tro-intestinal tract. 2. Accompanied by certain rational symptoms as pain localized, the origin of occult blood can be noted. 3. The discovery of blood in the stool may enable us to predict hemorrhage or prevent disaster. 4. The most frequent sources of occult blood are in the order named: Stomach, duodenum and caput coli. 5. The Aloin-turpentine test as practised by Dr. J. Dutton Steele, of Philadelphia, is recommended. 7. Proctologists should make an examination for occult blood a routine practice in cases of anaemia accompanied by diarrhoea or con- Stipation. “ETIOLOGY AND syMPTOM'S OF FISSURE,” Dr. C. F. Martin, of Philadelphia. Printed in full in the issue of September, 1907, page 61. “LOCAL VERSUS GENERAL ANESTHESIA IN RECTAL SURGERY,” Dr. C. B. Evans, Dayton, Ohio, stated that “pain naturally is the common curse and dread though relatively essential of the human family. The law of self-preservation when an individual is threatened Society Reports. 117. with pain is at Once a law of resistance, manifest by intense expectancy and defiant attitude. The shock incident to the terror of pain is incomparable to that which is likely to follow an abbreviated use of a general anesthetic. In consideration of the evolutionary plane occupied by the average American of to-day and the more remote period of his removal from the gorilla peripherial sensibility of the jungle, we are forced to con- clude that he is more sensitive, and in need of greater consideration for the relief of pain. Because an operation can be done painlessly, it does not follow that there will not be subsequent suffering and some and perhaps severe shock. But in this nerve block period of Crile and Pennington, and the Gant period of dermal and sub-dermal distention we are told there is scarcely any use any more for a general anesthetic. Do we not be- lieve, as Proctologists, that in our operative field, sensibility is most difficult to abolish, and would it not naturally appear that more nar- cosis is necessary in this kind of Surgical work and as a consequence more shock? Again, would it not be possible by the combined use of general and local anesthesia less shock would ensue, and more opera- tions could be made with success. I believe that by using the local anesthetic preceding the general anesthesia we lessen the amount of the general anesthetic appreciably, diminish the dread and fear, and consequently diminish shock and danger thereby. Therefore, the combined method of narcosis, less anesthetic, suspending shock inci- dent to conscious dread, as well as anesthetic shock, rendering more complete operative area—consequently more satisfactory work. It is simple to operate upon prolapsing piles, but not So Simple to Operate upon piles above the sphincters yet demanding operative interference. The injections of sterile solutions disturbs the parts antomically. The frequent punctures through the tissues invite infection, and in- fection trouble. You can never measure the nerve and seldom the surgical all of your patient. Its chief advantage is that Occasionally, you are able to do work in your office and, even then, unsatisfactorily. I fail to see the advantage of operation under local anesthesia in your office and follow your patient home and give hypodermic of morphia, over the usual custom of Operating at home in the first place. An operation for hemorrhoids is a matter of Some seriousness— often attended by some shock—often bloody, and the greatest caution should be observed that asepsis be obtained. I do not think it best for our patients that general practitioners should be taught that aseptic precautions at the time of Operation and 118 • Society Reports. rest at home for a few days, is unnecessary. Do we not magnify the applicability of local anesthesia, will not accidents occur, are we not Sacrificing perfect Scientific work, are we not belittling our chosen work—a class of operations that are important and not free from danger?” § “THE SIGMOIDAL FACTOR IN CONSTIPATION.” Dr. E. A. Hamilton, Columbus, Ohio, said: “In a certain per cent of intractable cases of constipation, organic change in the wall of the sigmoid is the controlling factor. This change is en- tirely independent of any disturbance which may occur on the outer Surface of the viscus; e. g., malposition and pathologic flexures due to adhesions. The change in the gut occurs in the sub-mucous and muscular coats and consists of a round cell infiltration of these coats which subsequently contracts, thereby to a greater or less degree nar- rowing the lumen of the bowel. The round cells change into spindle cells subsequently undergoing a metamorphosis into the true connective tissue. The contraction of this connective tissue so narrows the cali- ber of the signmoid that constipation of an obstinate type must result. This change is not always limited to the signoid, it frequently involves the descending colon as well; in addition to the contraction of the gut it loses also its resilience which further adds to the difficulty of the passage of fecal debris. The etiologic factor is the absorption of bac- teria and toxic products from the sigmoidal contents. The mesentery is also involved and is thickened and shortened. The whole process is chronic, several years being required to bring on the condition. Surg- ery offers the only relief, an anastomosis must be effected by any suitable surgical procedure between the unaffected position of the intestinal tract above and below the lesion.” A REPORT OF TWO CASES OF SIGMOIDOPEXY, Dr. S. T. Earle, Baltimore, Md., said: “That in one of the cases there was the third degree of prolapse of the rectum, the invagination of the upper part into the lower portion of the rectum ; in the other case there was a very acute flexure of the sigmoid upon the rectum, both of the conditions, as is well known, are frequently due to an abnormally long meso-sigmoid. The symptoms in each case were obstinate and persistent constipation, frequent bearing down pains in the lower pelvis, a sense of weight and especially a feeling of unrelief for some hours following a stool, or an attempt at the same; associated with these local symptoms were darting pains in various Society Reports. 119 parts of the body, nausea, anorexia, frequent headaches and the various neurotic Symptoms that go to make up a typical case of neuras- thenia. The case of invagination was diagnosed positively by a digital examination while straining at Stool, the sulcus being distinctly felt with the finger; the case of acute flexure was diagnosed by means of the protoScope, the flexure being so acute that it was only possible to enter the sigmoid with the protoscope by getting the end of the latter around the flexure, and pulling it aside. The flexure was so acute that it obliterated the lumen of the bowel, at this point. The technique of the operation is such as is given in Tuttle's and Gant's works on “Diseases of the Rectum and Anus.” I met with no special difficulty in performing the operations. The meso-sigmoid was very long in both. I was particular in pulling off the abdominal peritoneum where the sigmoid was to be held in apposition and also in attaching the sig- moid to the transversalis fascia. Both cases made good recoveries, except that one was retarded by a stitch abscess. The results in both cases were most satisfactory and pronounced, with almost immediate relief of the persistent and obstinate constipation, with the gradual disappearance of the neurotic symptoms. Dr. Gant has recently re- ported a number of sigmoidopexies and colopexies with most satisfac- tory results. Dr. Clark in a paper read before the Medical and Gynecological Sections of the Medical and Chirurgical Faculty of Maryland, on February 15, 1907, called attention to the frequent associations of gas- troptosis; floating kidney and enteroptosis in the same individual.” “FECAL IMPACTION.” Dr. Lewis H. Adler, Jr., of Philadelphia, Pa., in a paper entitled “Fecal Impaction,” called attention to the result of obstipation, or an attack of constipation causing an accumulation of feces in the caecum or in any part of the colon; but the term impaction,-the subject of the paper, should be usually employed when such an accumulation Oc- curs in the pouch or ampulla of the rectum, or in the sigmoid flexure. Attention was called to the difference between an ordinary per- sistent constipation and an impaction,--as the latter may follow from a single attack of constipation; whereas obstinate constipation may never, or only after a long period cause impation. The Symptoms of the two conditions are also very different, as an impaction is usually marked by a diarrhoea, whereas chronic constipation is associated with costiveness. After calling attention to the various causes of the malady under consideration and the symptoms of the same, the treat- 120 - Society Reports. ment was detailed as consisting primarily, in the removal of the mass, and, secondarily, in the relief of the inflammation of the mucous mem- brane occasioned by the irritating presence of the fecal mater as well as the removal of all causes which contribute to the constipated habit, which is undoubtedly the prime factor in most cases in producing an impaction. The easiest manner of breaking up the fecal mass is to put the patient under an anaesthetic and then forcibly divulse the sphinc- ters, after which the mass may be disintegrated by means of the finger, a lithotomy scoop or an old-fashioned iron spoon. In women consider- able assistance may be rendered by passing a couple of fingers into the vagina and by this means steadying the mass so that it may be the more readily broken. In some instances the writer was able to break up an impaction without resorting to anaesthesia, simply by using the finger and some- times by the additional use of a bivalve speculum and a rectal scoop or Spoon. Previous to resorting to instrumental aid in the removal of the im- paction, the fecal mass may be softened and its passage facilitated by the use of enemas, especially is this so in cases in which the sigmoid is the part affected, in which situation material assistance cannot be gained by the employement of instruments. For the purpose of admin- istering the injection a douche-bag holding several quarts is to be pre- ferred. The injection substance should be composed of soap and water to which I have found the addition of glycerine of considerable benefit, a dessert-spoonful to a quart. When the impaction is in the sigmoid, the injection should be given through a Wales bougie, pre- ferably the one modified by Dr. Dwight H. Murray, of Syracuse, New York, which is stiffer than the ordinary article sold ; which latter is frequently useless for the purpose intended as it readily doubles on itself, and a high injection is rendered impossible by its use. When this method is employed the patient should be placed in the knee-chest posture. A word of caution should be given here as to the danger sur- rounding the unguarded use of drastic purgative drugs in cases of impaction. By their employment peristalsis is increased and the fecal mass softened but the bowel in its inflamed and distended condition may be thereby the more easily ruptured, and, if in addition, a stricture is present, the caliber of the gut may be entirely occluded by forcing into it the hard fecal mass with the attendant symptoms and conse- quences of total obstruction of the intestines. So much for the treat- ment of the actual impaction. Society Reports. 121 “PRURITUS ANI—IS IT A DISEASE PER SE OR MERELY A syMPTOM P’’ Dr. Louis J. Krouse, Cincinnati, Ohio, who quoted from the works of Bodenhamer, Agnew, Wright, Ball, Cripps, Gant, Matthews, Tuttle and others, their opinions regarding the etiology of this disease, and then Stated “Pruritus ani is essentially a disease which is due, not to a local, but to constitutional cause, and is due to some trophic changes in the nerves supplying the parts.” He further stated, that the changes occurring in the skin of the anus and surrounding parts, namely, the hypertrophy, the loss of pliability, and the absence of pig- ment, can only be explained on the faulty nervous supply of the parts. He showed that an increase of pigment ought to accompany severe itching, and not a total disappearance, and finishes his article by saying that “The absorption of the normal coloring matter of the affected area does not occur, notwithstanding that the epidermis was not de- stroyed,” and said, “A similar process of absorption takes place in leucoderma. All authorities acknowledge that the case of the latter disease is to be found in the nervous system,” and concluded with the statement “That pruritus ani, at least in such cases, is a disease per se and not a symptom.” (a) Dr. Dwight H. Murray, of Syracuse, New York, presented a new hemorrhoidal clamp which had the following qualities in com- bination, that make a first-class instrument, viz.: Scissors shaped, parallel jaws: can be closed and released instantly without the use of a thumb screw, thereby saving much time while Operating. The Goodell dilator reversed is used as the ground principle for the lock. (b) Dr. Dwight H. Murray, Syracuse, New York, reported the case of a man 48 years old who had been troubled with sciatica in the right leg for two years and had also been a sufferer from hemorrhoids for ten years, having frequent profuse hemorrhages therefrom. The hemorrhoids had not been treated. The sciatic nerve had been stretched and treated by various methods, by a physician at his home town, included in which was the following completed in three sittings two days apart: - At the first sitting, six hypodermic injections 1/150 grain of atrophine each were given into the sheath of the sciatic nerve. At the second sitting, seven injections of the same amount, and at the third sitting, eight injections were given as before and One extra into the nerve before it leaves the pelvis. The patient was unconscious for fourteen hours after the last sitting ; very little improvement re- sulted. 122 Society Reports. In November, 1906, the author was first consulted, and on De- cember 12, 1906, Operated on him for internal hemorrhoids. He made the usual recovery up to the ninth day, when there was a sudden pro- fuse Secondary hemorrhage. The patient was almost ex-sanguinated before the author arrived. - f He immediately examined, found the superior hemorrhoidal artery was throwing a full sized stream, this was secured, the patient stimu- lated and made an uneventful but slow recovery. The patient has had no Sciatic pain since the operation. Dr. Murray concluded that inasmuch as sciatica is often sympto- matic, that no such severe treatment is justified until all possible reflex causes are first removed. The cause of the hemorrhage was probably due to the thrombus or eschar at the end of the vessel being thrown off before thorough healing had taken place, and was influenced largely by his general anemic condition before operation. “THE TREATMENT OF ISCIIIO-RECTAL AND PELVI-RECTAL ABSCESSES.” Dr. T. Chittenden Hill, of Boston, Mass., said: “That he em- ployed general anesthesia produced with ethyl chloride for the ischio-rectal abscess and ether anesthesia for the pelvi-rectal abscess. His experience with infiltration anesthesia has been unsatisfactory. He emphasized the importance of an early incision for peri-rectal ab- Scesses, claiming that when acute symptoms have existed for a day of two, with pain and tenderness, even before there is much edema or discoloration of the skin, long before fluctuation can be detected, an incision may prevent abscess formation by allowing the escape of blood or serous exudate from the engorged blood vessels. He advised a T incision and breaking up the existing septa with the finger, after which the sphincters are divulsed. He believed squeezing, scraping or disinfecting an acute abscess to be a great mistake, as it only serves to destroy the new granulation tissue and to spread the infecting bacteria. For the deeper ischio-rectal and in all pelvi-rectal abscesses he recommended rubber drainage tubes, dis- carding their use as quickly as possible in the after-treatment. He believed that the great majority of pelvi-rectal abscesses should be reached by perineal dissection.” “CRYPTITIS.” Dr. J. Coles Brick, Philadelphia, Pa., said: “The anal valves and crypts, first pointed out by Morgagni, and called after his Society Reports. - 123 name, are found as vestigical remains of the junction of the rectal mucous membrane with the skin. They vary in number and size, but are absent in the anterior and posterior commissures. They have no known functions, but are the cause of obscure symptoms, when dis- eased, and from the fact that the valve or covering part of the crypt may conceal the diseased area, repeated examination will fail to show the lesion, unless each crypt is probed, when tenderness or pain will be felt. A conical fenestrated speculum is the best to use, and when the diagnosis has been made, the valve should be removed and the crypt converted into a raw, surface, so that healing will obliterate it.” “OBSERVATIONS ON CERTAIN POINTS IN THE ANATOMY AND PHYSIOLOGY OF THE RECTUM.” Dr. A. B. Cook expressed the view that the usual conception of the external sphincter muscle is erroneous, that under normal con- ditions it is not in a state of tonic contraction, but, on the other hand, is at rest and passive, the shape of the muscle and the arrangement of its fibers being such that the anal aperture is maintained in a state of passive closure. It is not conceivable that a voluntary muscle should require the constant action of nerve force to keep it in a state of rest. The only action of this muscle is to voluntarily oppose or terminate the act of defecation by tonic contraction. With reference to the internal sphincter, the essayist observed that there is no occasion to credit this muscle with any special action in addition to that of the circular coat of the bowel, of which it is a part. By reason of its location and thickness, it probably exercises some passive sphincter, control, but its chief action is undoubtedly that of a detrusor, serving to complete the expulsion of feces and keep the anal canal free of contents. - The levator ani muscles, acting together, constitute the Sphincter of the proximal extremity of the anal canal. To understand this it is only necessary to remember (1) that the upper or pelvic surface of these muscles presents a deep, funnel-shaped concavity, the begin- ning of the anal canal being at the lowest point; (2) the strong bundles of fibres which unite immedately behind the rectum arise in front from the pubis and anterior portion of the fascial line and pass downward and backward in close relation with the lateral walls of the rectum, crossing it obliquely at the upper limit of the anal canal. The well-known difficulty of voiding urine while a costive stool is being expelled, which is usually attributed to the action of the levatores 124 Recent Writings for the Proctologist. ani, is due rather to the pressure of the fecal mass upon the prostatic and membranous portions of the urethra, since, at the time of defeca- tion, these muscles, like sphincters, must be in a state of relaxation. The part played by the anal canal in defecation is purely passive, except at the completion of the act when the volutary muscles which enclose it are strongly contracted, expelling any remnant of feces and bringing its walls again into their normal relation when at rest of close apposition. . The essayist dissented from the commonly accepted teaching that there is an inhibitory center in the cord which presides over the action of the external sphincter and which is called into action at the time of defecation to inhibit its tonic. The relaxation which occurs at such times seemed to him fully explained by the mechanical pressure of the descending mass upon a structure which only offers passive resistance unless contracted by voluntary effort, and which possesses sufficient resilience, independent of any nerve influence to regain its normal form and tone as Soon as the pressure is removed.” RECENT WRITINGS FOR THE PROCTOLOGIST. “Fecal Toxemia,” W. F. Waugh, Chicago.—Medical Record, New York, Aug. 31, 1907. “Villous Papillomata of the Rectum,” B. M. Rickets, Cincinnati- New York Medical Journal, Aug. 31, 1907. “Bacteriologic Examination of Feces for Early Diagnosis in Tubercu- losis,” M. Solis Cohen, Philadelphia.-New York Medical Jour- mal, Aug. 31, 1907. “Pruritus Ani,” L. J. Krouse, Cincinnati.-Lancet-Clinic, Cincinnati, Aug. 31, 1907. “Imperforation of Rectum and Anus,” A. P. C. Ashhurst, Philadelphia. —University of Pennsylvania Medical Bulletin, Philadelphia, July-August, 1907. “Surgery of the Rectum,” A. E. Cox, Helena—Journal of the Arkan- sas Medical Society, Little Rock, Aug. 15, 1907. ‘Study of the Infant's Stool,” P. Selter, Solingen, Germany.—Detroit Medical Journal, Aug., 1907. “Pruritus,” J. F. Boquoi, Colomb–New Orleans Medical and Surgical Journal, July, 1907 “Cintinuous Administration of Fluids by Rectum in Acute General Peritonitis,” B. G. A. Moynihan.-The Lancet, London, Aug. 17, 1907. “New Operative Procedure for Anus Vulvo-vestibularis,” E. Niessner. –Wiener klinische Wochenschrift, (XX. Nos. 25, 33.) Jęecent Writings for the Proctologist. 125 “Pruritus Ani,” B. Foster, St. Paul.-St. Paul Medical Journal, Aug. 1907. “Rectal Ulcer,” O. C. Strickler, New Ulm, Minn., same. “Hemorrhoids,” W. H. Valentine, Tracy, Minn., same. “Colon Bacillus Infection,” H. Fehling, Munchener medigische Woch- inschrift, July 2, 1907. z “Notes on Constipation,” A. Lewandowski.--Die Therapie der Gergen- wart, No. 7, July, 1907. “The Blood Supply of the Rectum and Its Relations to Gangrene Fol- lowing Operation,” P. Sudeck.-Munchener mediginische Woch- enschrift, July 2, 1907. - “A Case of Rupture of the Rectum,” Heineke.—Munchener medigin- ische Wochenschrift, Aug. 13, 1907. “Septic Infection about the Rectum,” Charles J. Drueck, Chicago.— The Chicago Medical Recorder, Sept., 1907. “Muco-membranous Colitis,” D. Barty King.—The Scotland Medical and Surgical Journal, Edinburgh, Sept. and Oct., 1907. “Chronic Constipation,” Albert C. Geyser, New York City.—Journal of Therapeutics and Dietetics, Aug., 1907. “A Case of Imperforate Anus,” Charles A. E. Codman and John H. Jopson, Philadelphia-Archives of Pediatrics, Sept., 1907. “Treatment of Chronic Colitis by Weir's Appendicostomy,” A. E. Rockey, Portland, Ore.—Medical Sentinel, Sept., 1907. “Menopause Complicated with Muco-colitis,” C. Woodward, Chicago. —The Chicago Medical Times, Aug., 1907. “Diarrheal Disorders,” R. J. Smith, Schenectady, N. Y. —Denver Medical Times, Aug., 1907. “Surgical Treatment of Fistula in Ano,” Arthur Hollingwort, Provi- dence.—The Providence Medical Journal, Sept., 1907. “Suggestions as to Cause of Low Percentage of Cures in Operations for Fistula in Ano,” J. R. Pennington, Chicago.—American Journal of Surgery, Oct., 1907. “Is There a Surgical Treatment for Constipation,” Charles B. Kelsey, New York-New York Medical Record, Sept. 28, 1907. “Constipation in Children,” F. W. Schneerer, Norwalk, Ohio.—The Eclectic Medical Journal, Cincinnati, Ohio, Oct., 1907. “Mucous Colitis,” Ernest Henry Harrison.—The Lancet, London, Sept. 21, 1907. “Deep Rectal Abscesses,” J. M. Frankenburger, Kansas City, Mo.— International Journal of Surgery, New York, Oct., 1907. “Rectal Anesthesia,” J. H. Cunningham, Jr., Boston.—Boston Medical and Surgical Journal, Sept. 12, 1907. “Volvulus of the Sigmoid,” B. Robinson, Chicago.—Medical Standard, Chicago, Aug., 1907. “Surgical Treatment of Chronic Colitis,” W. H. Beach, Pittsburgh.- Pennsylvania Medical Journal, Athens, Aug., 1907. “Constipating Action of Morphine,” R. Magnus.-Munchener Medi- sinische Wochenschrift, July 16, 1907. “Operation for Rectal Cancer,” F. Berndt.—Ibid, July 23, 1907. 126 Recent Writings for the Proctologist. “Purulent and Ulcerative Proctitis,” E. Ruge.—Archiv. f. klinische Chirurgie, (LXXXIII, No. 2.) “Sigmoiditis and Perisigmoiditis,” Maurice Patel-Rev. de Chirurgie, Paris, Oct. 10, 1907. t “Fissure of the Anus,” Jerome M. Lynch, M.D., New York-New York Medical Journal, Oct. 26, 1907. “A New Operation for the Complete Removal of Hemorrhoids,” A. Heygate Vernon, F.R.C.S.—British Medical Journal, Oct. 5, 1907. “Cathartics,” James Burke, M.D., Manitowoc, Wis.-American Medi- cal Compend, Toledo, O., Nov., 1907. “A New Rectal Sign,” A. K. Bond, M.D., Baltimore.—Maryland Medical Journal, Nov., 1907. “Reasons for Unsatisfactory Results in the Treatment of Ano-rectal Diseases,” B. Asman, Louisville.—The American Practitioner and News, Louisville, Oct., 1907. “Treatment of Inflammatory Strictures of Rectum,” P. Clairmont.— Archiv. fur klinische Chirurgie, Berlin, Oct. 19, 1907. “Lesions of the Sigmoid Flexure as a Cause of Colitis,” P. Lockhart Mummery.—British Medical Journal, Oct. 5, 1907. “A Case of Subperitoneal-Pelvic Fibroid, Complicating a Four Months’ Pregnancy. Hysterectomy. Enucleation of Fibroid. Sec- ondary Hemorrhage One Week after the Operation. Pelvic Abscess. Rectovaginal Fistula. Recovery.” E. Gustav Zinke, Cincinnati-American Journal of Obstetrics, New York, Nov., 1907. - “An Operation for Hemorrhoids Practically Painless and Bloodless,” R. R. Kime, Atlanta-Jour.-Record of Med., Oct., 1907. “The Etiology and Pathology of Acute Dysentery,” Wm. B. Maister, M.D., New York-Pediatrics, New York, Nov., 1907. “Constipation and Nervousness,” W. T. Marrs, Peoria Heights, Ill.— The Southern Clinic, Richmond, Va., Oct., 1907. “Rectal Traumatism,” A. P. Barfoot, Decorah, Iowa.-Railway Surgi– cal Journal, Sept., 1907. “Habitual Constipation,” Nellie M. Johnson, Perry, Iowa.-The Medi- cal Era, St. Louis. - w “Sigmoid Dilation,” Byron Robinson, Chicago.—The Medical Stand- ard, Chicago, Nov., 1907. “Rectal Feeding,” F. Craven Moore.—The Practitioner, London, Nov. 1907. “The Etiology and Pathology of Occult Dysenteria,” Wm. M. Meis- teria, New York, N. Y. —Pediatrics, New York, Nov. 1907. “The Fascia of the Pelvis,” John Cameron.—Journal of Anatomy and Physiology, London, Oct., 1907. “Pelvic Muscles and Fascia,” Douglas E. Derry, same. “On the Real Nature of the So-called Pelvic Fascia,” Douglas Derry, S2UIT1C. “What You Cannot Do with Purgatives,” Edwin Walker, Evansville, Ind.—The Lancet-Clinic, Cincinnati, Nov. 16, 1907. Çhe Irurtulunist EDITED BY ROLLIN H. BARNES, M.D. ST. LOUIS. CONTRIBUTORS. JOSEPH M. MATHEWS, M.D. - Louisville, Ky. R. D. MASON, M.D............................................................ ... Omaha, Neb. ARTHUR E. HERTZLER, M.D., A.M., Ph.D.....Kansas City, Mo. WILLIAM M. BEACH, M.D., A.M....................... ........ Pittsburgh, Pa. H. A. BRAV, M.D. ........................................................ Philadelphia, Pa. ACHILLES ROSE, M.D..... - * * * * * * * * * * * * * * * * * * * * * * * New York City. GEO. B. EVANS, M.D. ............ Dayton, Ohio. A. B. COOKE, M.D., Pres. Amer. Proctologic Soc...Nashville, Tenn. C. A. VOSBURGH, M.D. .................... ** = & º – ºn º º ſº gº & 4 º' ºr sº º ºs s * * * * * is e s = e as a tº a St. Louis, Mo. COLLIER F. MARTIN, M.D....................................... Philadelphia, Pa. W. J. M'GIL.L., M.D. St. Joseph, Mo. JEROME. D. POTTS, M.D.......................... ........................ St. Louis, Mo. LOUIS J. HIRSCHMAN, M.D................................... -------- Detroit, Mich. H. M. BISHOP, M.D..….Los Angeles, Cal. JOHN A HAWKINS, M.D................. * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * , Pittsburgh, Pa, VOL. I. PUBLISHED BY THE EDITOR, METROPOLITAN BLDG., ST. LOUIS, 1907. THE FREEGARD PRESS ST. LOUIS INDEX OF VOLUME. I. Abscess; Treatment of Phlegmon of the Superior Pelvi-Rectal Space, (Pique) - 82 Abscesses, Treatment of Perianal and Perirectal, (Thrailkill)....... 110 Adeno-Carcinoma of the Rectum, (Vosburgh) 42 Anal Papillae, Hypertrophy of the, (Hirschman) 95 Anesthesia, Dosage for Spinal, (Hofmann) 19 Bacteria, Intestinal, (Palier).….....….................................................... 26 Book Notices 92 Cancer of the Rectum, (Beach), (Petermann) * *s 15, 26 Cancer, Two Cases of Carcinoma of the Rectum, (Evans)............... 29 Colitis, Entero-, and Muco-Membranous Entero-Neurosis, (Le- beaupin) …~~~~~~~~~~~ 112 Colitis, Lesions of the Sigmoid as a Cause, (Mummery).................... 111 Colitis, Mucous, (Dunn) * 113 Colitis, Mucous, Muco-Membranous and Membranous, (Tuttle). 53 Colitis, Signs and Symptoms of Mucous, (Wilson) - 73 Colopexy, (Lenormant) & Gº - sº º & 4 48 Colostomy, Practical Points in the Operation for, (Kelsey) ............ 24 Constipation, (Hawkins) 105 Constipation, Treatment of Habitual, (Kohnstamm)........... ~~~~ 14 Dysentery and Diarrhea, (Jelks)............... * * 42 Excision of the Rectum, Sigmoid, and Part of the Descending Colon with Implantation of the Colon into the Anus, (Archi- bald) …~~~~~ - - 93 Operation for the Removal of the Entire Rectum and Neighboring Lymphatic Area for Carcinoma, (Mummery).................... 85 Editorial …~~~~~~~~~~~~~~ 2 Eosinophiles in the Circulating Blood, (Blumgart) .............................. 55 Fistula in Ano, Excision and Immediate Suture, (Hertzler) .......... 9 Fistula in Ano, The Etiology and Symptoms of, (Martin) ............... 61 Index. Hemorrhoids, A New Operation, (Lynch), (Vernon) ............... 104, 111 Inflation of the Rectum with Carbolic Acid Gas, (Rose),................. 18 Introductory, (Mathews)......... ------------------------------------. 1 Operation, Bloodless, on Rectum, (Bishop). 102 Pathology, Due to Extra-Rectal Causes, (Cooke)................................... 35 Proctologist, The Reasons for His Existence, (Mason).......................... 3 Reprints Received........ - - * * 92 Sigmoiditis and Perisigmoiditis, (Catz)........................................................ 83 Society Reports, Program of the American Proctologic, 1907.......... 47 Society Reports, Report of the American Proctologic, 1907.......... 87, 115 Specialty, Diseases of the Rectum a, (Brav) ......................... * * * * * * * * * * * * * * * * * * * * 20 Stricture of the Rectum, (McGill) .......................................... ... w - - - * * * * * * * * * * * * * * * * * * 66 Stricture of Rectum, Caused by Calcified Uterine Fibroid, (Page) 65 Symptoms, The Importance and Significance of Rectal, (Potts). 74 Writings, Recent, for the Proctologist........................................ 27, 57, 92, 124 ADVERTISEMENTS. Printing—All Kinds Wel)efend D0ctors AGAINST Any suit for alleged malpractice, error or mistake. We carry the case to the Court of last resort at our own ex- pense, with no limit as to the amount. If we lose we PAY DAMAGES (only with the doctor's consent). THE PROTECTION costs only $10.00 or $20.00 (according to amount) yearly. Our lawyers are the best, because we cannot afford to lose. THE FIDELITY AND CASUALTY CO. Medical and Other Publications turned out OF NEW YORK. promptly, correctly and in good style. R, A, HOFFMANN, General Agent Tº I * y y A. G. BAARE, Asst. General Agent, 306 – 308 NORTH THIRD ST. 308 = 314 Rialto Building, ST. LOUIS, MO. BELL, Main 4695. KINLOCH, Central 1155. ANTINAUS A Remedy for the Control of Womiting ESPECIALLY MORNING SICPKNESS THIS PUBLICATION IS A SAMPLE. AN INTESTINAL ANTISEPTIC THERAPEUTIC USEs : Reflex Vomiting from whatever cause. Vomiting of Pregnancy. Vomiting from diseases of the Genito-Urinary Organs and Intestinal Tract. 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You collect your own accounts and pay us 1% when collection is made. Organized 1895. Incorporated 1905. * CAPITAL (Fully PAID), $50, OOO 2 408 Olive Street - - ST. LOUIS, MO. ST. LOUIS College of Physicians and Surgeons The course of instruction, which is a graded one, extends over four years of study in college, devoted to Dissections, Laboratory Work, Didactic and Clinical Instruction, Recitations and Quizzes, Demonstra- tions and Manual Training in the use of instruments and appliances. WALDO M. BRIGGS, M.D., Dean, Jefferson Ave. and Gamble St. ST. LOUIS, MO. Improved McDANNOLD Surgical and ſynecological Chair SIMPLE, STRONG and ORNAMENTAL In the McDANNOLD Surgical and Gynecological Chair we have endeavored to combine all the elements necessary to the successful examination and treatment of surgical, gynecological and rectal diseases, besides its value as a general utility chair, . . . . º for examination of the eye, ear, nose, throat, chest, 4. \ º, abdomen, and many other uses that will suggest .*.*.*.* themselves to the practical physician. fºr ACTICALLY INTE structible The motions of this chair are universal, including the Rotary motion, raising and lowering, and there are no complicated mechanisms, noisy or intricate fastenings. One important feature is the universal head rest which can be put to any position with a single set-screw. Awarded Highest Prize at Louisiana Purchase Exposition, 1904 Send for Catalogue and prices of this A. MCD ANNOLD 9 Improved Chair and the McDANNoLD WooD CABINET. Manufactured by 1416 N. Sarah St. ST. LOUIS, MO. Do not fail to mention. The Proctologist, cAMºo PHENIour Liqui A Cº NOWLEDGED --- - REMLLER SL-º-º-º-º: IN THE FIELD D - O. E. - Dºº-º-º-º: ANTISEPTICS FOR E"O R. - CUTS, CASES OF - U - Nº. MINO R. - *Oºlººl ULUE Lºs AND A ND. A. L. MLA. O. R. SUPERE". CLAL SURGERY WO, UNIOS LIQUID. IN POWDER IN 25 tº and $1.00 Lºs ----- 1 oz. and 11, Containers | º, For samples and literature - - - address the camero-erºnoue co., st. Louis, Mo. Powder CACTNA PILLETS A Cardiac Tonic Stimulan From Cereus Grandiflora (Mexicana) Each ºthet containing One One- Hundredth of a ºn ºf Castina indicated in functional cardiac troubles, such as tachycardia, palpi- tation, feebleness, and to sustain the heart in chronic and febºe diseases. It is not cumulative in its action. Dosº one to three ºilets three or four times a day. ºut up in bottles of 100 pºets Free samples to ºscisº ºn rºups: Sultan Dºug Co., St. Louis, Mo. ºn EEacocks BROMIDES THE BEST FORM OF BROMIDES Each nuid drachm contains 15 grains on the neutral and pure brºnºs on Potassium, sodium, Amnonium, Cal- ºn and Lithium. In Epilepsy and all cases demanding continued bromide treatment, its purity, uniformity and definite thera- peutic action, insures the maximum bromide results with the minimum danger of bromism or nausea. Dosº one to three teaspoonius º- co-dinº to the announ of ººoººº- desired ºut up in 1-2 pound bºot- tles only Free samples to the pºssion upon reques Peacock Chemical Co., St. Louis, Mo. ºn armaceutical Cº-ºn-tº- - Do not fail to mention. The Proctologist. -