CHAPTER Xni. (Part 4)

; for the operation is one 288 DI8BA8BS OF THB BBOTUM AND ANUS. requiring judgment and skill, and on the success of the method depends the life of the patient in most cases. It is always well to empty the bowel by a simple enema before administering nutriment at least once a day. With proper care in using the syringe, the rectum and sigmoid flexure will generally be found to submit kindly to this method of treat- ment, but when once they become irritable, unless the injections can be. intermitted for a day or so, and suppositories of opium be substituted, the treatment is practically at an end. In a few cases I have succeeded in re-establishing a tolerance by rest and careful treatment, but it is much better so to manage the case from the first that no irritation be excited. An enema, for this reason, should never be administered at a lower temperature than that of the body. Dr. Spencer^ has described a suppository which he recommends in the place of enemata. It consists of the extracted product of artificially di- gested meat, from which the insoluble matter has been removed, mixed with a little wax and starch. Twenty ounces of meat thus prepared may be made into five suppositories, one of which should be given every four hours. Practitioner, Feb., 1882. This look is the property oj COOPER MEDICAL COLLEGE SAN FRANCISCO. CAU and is vot to Jn^ rctVJ^ri'd from the J/'lror^l Vor .1 hi/ ("'// liry.^o^i or- INDEX. Abscess, boundaries of ischio-rectal, 73 causes of deep rectal, 73 classification of, 71 clinical history of superficial, 72 course of pus in deep, 74 diagnosis of, 76 distinction between treatment of, and of fistula, 77 due to diffuse inflammation of subcutaneous tissue, 72 due to disease of urinary organs, 74 due to disease of neighboring parts, 74 due to foreign bodies, 73 due to perforating ulcer, 74 due to rupture of the rectum, 74 due to stricture of rectum, 74 due to submucous inflamma- tion, 74 due to suppuration of haemor- rhoid, 72 early incision in, 76 following surgical operations, 78 horseshoe, 75 how to avoid the formation of fistula in, 76 involving skin of anus alone, 71 not to be cut into the rectum, 77 of superior pelvi-rectal space, 73 of ischio-rectal fossa, 73 originating in cutaneous glands, 71 prognosis of, 76 19 Abscess, reasons for not healing sponta- neously, 75 results of deep, 76 rupture of, into neighboring organs, 75 symptoms of ischio-rectal, 74 symptoms of pelvi-rectal, 74 treatment of deep, 76 treatment of superficial, 72 Absorption by the rectum, 283 Adenoma, malignant, 218 Adenomatous polypus, 188 Albumen, digestion in rectum, 285 Alimentation by the rectum, 282 Allingham, case of spasmodic stricture, 182 ligature holder, 84 on spontaneous cure of fis- tula, 81 on treatment of deep rectal abscess, 76 operation for haemorrhoids, 106 results of colotomy, 216 spring-scissors for fistula, 87 symptoms of ulceration, 174 Alveolar sarcoma, 222 Amussat, operation for imperforate anus, 89 Ano-rectal syphiloma, 149, 172 syphiloma, cause of stric- ture, 140 syphiloma, definition of Foumier, 149 syphiloma, primary seat of, 149 syphiloma, use of anti-sjrph- ilitic treatment for, 149 290 INDEX. Anus, abnormal, 84 absence of, 32 congenital malformation of, 80 description of, 5 double, 84 erectile tissue of, 5 imperforate, 81 imperforate, child living thirty days, 37 Arteries of rectum, 18 Baum, case of colectomy, 244 Benign fungus, 148 fungus, composition of, 148 fungus, haemorrhage from, 148 fungus, treatment of, 148 Billroth, case of colectomy, 245 report of thirty-three cases of excision of cancer, 23^ Bivalve speculum, 59 Blood for rectal alimentation, 286 Bougies, how to pass, 57, 192 varieties of, 56 Boyer on fissure, 160 Bridge, case of colotomy, 216 Broadbent, on puncture for relief of ob- struction, 132 Broca, fatal case of excision of polypus, 142 Bryant, case of colectomy, 245 villous polypus, 187 Bulteau on invagination, 125 statistics of colotomy, 216 Bursa mucosa coccygea, 10 Byrd, case of formation in anus in nat- ural position after colotomy, 45 Calculus projecting into rectum, 4 Callisen's operation for imperforate anus, 41 Cancer, 218 age of patients, 228 causes of suffering in, 247 causes of mortality after exci- sion, 232 causing oedema of lower ex- tremities, 230 caustic applications in, 249 chances of radical cure by ex- cision, 284 comparative frequency of, in the sexes, 228 cure of, 231 Cancer, diagnosis of, 229 dUatation of, 249 distinguishing marks from be- nign polypus, 218 division of sphincter for, 248 examination for, 280 excision of, 281 excision of, as a palliative measure, 235 excision of, bibliography, 233 . excision of, contraindications, 286 excision of, compared with colotomy as a palliative mea- sure, 285 excision of, dangers of opera- tion, 237 excision of, early history of, 238 excision of, how to perform, 288 excision of, history of opera- tion, 231 excision of, when justifiable, 237 extension into neighboring organs, 229 general character of, 218 generalization of, 220 generally painful, 229 haemorrhage from, 229 indications for colotomy, 248, 250 insidiousness of, 228 involvement of lymphatics in, 230 location of, 228 microscopic anatomy of, 219 mode of development, 220 of sigmoid fiexure, excision of, 243 of sigmoid flexure, diagnosis of, 231 operation of crushing, 250 opium for, 248 osteoid, 225 palliative treatment of, 247 partial removal of, 248 peculiar feel of, 230 prevention of obstruction by, 248 proctotomy for, 249 regulation of passages in, 247 results of excision, 283 INDEX. 291 Cancer, secondary ulceration in, 229 secondary deposits of, 281 significance of pain, 229 symptoms of, 229 treatment of, 231 Carcinoma, melanotic, 224 Cartilaginous tumors (see enchondroma) Cauliflower excrescences, 143 Cellulitis, gangrenous, around anus, 75 Chancre, 169 frequency of, 169 Chancroid, 167 as cause of stricture, 168 great extent of, 167 spontaneous cure of, 167 Clamp and cautery in treatment of col- lapse, 118 for removing haemorrhoids, 108 Clark, A., villous polypus, 136 Coccyx, excision of, for imperforate anus, 89 Coccygodynia, 281 Colectomy, 242 analysis of cases, 246 conclusions concerning ope- ration, 247 history of cases, 243 Colloid cancer, 222 case of, 223 distinction from encephaloid, 254 malignancy of, 228 mode of progress, 224 Colonoscope, 60 Colotomy, accidents attending, 42 after-treatment of cases, 217 choice between lumbar and inguinal operation, 43 description of operation, 41 for stricture, 214 history of, 40 in cases of imperforate anus, 40 limits to the operation, 215 re-establishment of natural passages after, 253 statistics of operation, 215 Columnse recti, 8 Concretions, intestinal, 252 Condylomata, 146 as sign of syphilitic ul- ceration, 172 definition of, 146 Condylomata, description of, 146 diagnosis of, 147 non-syphilitic nature of, 146 undefined use of term, 138 treatment of, 148 Congenital cysts, 156 malformations, rules for treatment, 37 stricture, 31 Constipation, 272 causes, 273 infantile, 273 treatment, 274 Crippson cancer, 218 Curling, villous polypus, 137 Cusack, clamp for haemorrhoids, 108 Cysts, 151 congenital, 156 containing foetal remains, 155 containing hair, 152 dermoid, 151, 153 Czamy, case of colectomy 266 Defecation, physiology of, 19 Depraved sexual appetite accounting for foreign bodies in rectum, 262 Depressor for rectal examinations, 59 Dermoid cysts, 151 Diagnosis in rectal disease, 48 cases illustrating errors, 48 necessity of physical exami. nation, 49 position of patient, 52 questions to be asked, 51 Digital examinations, 54 Dilatation of stricture, 199 Discharge caused by polypus, 141 Divulsion for stricture, 200 Douglas' i>ouch, 6 Dumarquay on treatment of fissure, 177 Dupuytren, operation for closing artifi- cial anus, 46 Dupuytren's operation, modified by Barker, 47 Dysentery, 166 treatment by injections of nitrate of silver, 180 Eczema marginatum, 270 Edward II., murder of, 259 292 INDEX. Ecrasement lineaire in the treatment of fistula, 88 Elastic ligature for fistula, 84 Emmet, rare case of spina bifida, 155 Encephaloid, 222 diagnosis of, 222 enucleation of, 250 rough test for, 222 Enchondroma, 151 Enemata for constipation^ 275 nutritive, 286 nutritive, how to administer, 287 Enterotome, 47 Epithelioma, 220 comparative frequency of, 237 cylindrical, 226 Ergot, injections in prolapse, 115 Erythema, 272 Esthiom^ne, 164 Examination table, 50 T^xcision of cancer (see cancer), 281 Extirpation of anus, control of passages after, 28 Pascal vomiting, 284 Tatty tumors, study by Virchow, 151 tumors (see Upomata), 150 Fenestrated speculum, 59 Ferrand, case of prolapse treated by in- jections, 115 Fibromata, 149 Fibrous polypus, 149 Fissure, 160 associated with polypi, 162, 178 associated with spasm of sphincter, 160 division of sphincter, 177 due to hard faeces, .166 due to congenital narrowness, 160 due to leucorrhoea, 160 due to herpes, 160 due to inflammation of a sinus of Morgagni, 161 general location of, 161 I in children, 178 nothing peculiar in ulceration, 160 ointment for, 176 pain accompanying, 174 painless and painful, 160 Fissure, passage of bougies for, 176 shape and appearance of, 162 stretching sphincter for, 177 subcutaneous division of sphincter, 177 symptoms of, 178 theories concerning causation, 160 tolerant and intolerant, 160 treatment, 176 without spasm, 160 Fistula, blind external, 78 blind internal, 78 cases in which operation is con- tra-indicated, 81 causes of blind internal, 80 caused by stricture, 187 classification of, 78 complete, 78 deep, 78 diagnosis of deep from super- ficial, 76 dressings after operation, 88 due to ulceration, 80 due to previous abscess, 78 haemorrhage in operation, 88 how to detect internal orifice, 78 how to treat in phthisical pa- tient, 82 knife of author, 86 in connection with abscess, 79 in connection with phthisis, 81 multiple, 80 scarifying old tracks, 87 spring-scissors for, 87 spontaneous cure, 81 structure of track, 79 subcutaneous, 78 submucous, 79 submuscular, 79 superficial, symptoms of, 80 symptoms of blind internal, 81 • treatment, 81 treatment by cauterization, 88 treatment by ecrasement line- aire, 83 treatment of blind internal, 89 treatment of deep, 89 treatment of horseshoe variety, 88 treatment of multiple tracks, 88 INDEX. 293 Fistula, treatment by elastic ligature, 84 treatment by incision, 85 treatment by simple ligature, 88 treatment when there is no in- ternal orifice, 87 value of history in diagnosis, 80 with deep and extensive tracks, 80 with double track, 79 Flattened fsBces in diagnosis, 188 Foetal inclusions, 154 Forceps for ligating hsemorrhoids, 107 Foreign bodies, 256 bodies causing abscess, 78 bodies causing ulceration, 159 bodies causing perforation, 259 bodies, complications of, 258, 264 bodies, general treatment of, 258 bodies introduced per anum, 260 bodies, prognosis, 263 bodies, pelvic abscess caused by, 259 bodies remaining long time in rectum, 268 bodies, removal by laparo- enterotomy, 265 bodies swallowed, 256 bodies swallowed, prognosis, 258 bodies, treatment of, 264 bodies*, ulceration caused by, 258 Foumier, ano-rectal syphiloma, 149 Fungus hsBmatodes, 222 Galvano-cautery for fistula, 88 Gangrenous cellulitis, 75 Gangrene of rectum after confinement, 178 Gariel, pessary of, 54 Glandular polypus, 139 Gonorrhoea as a cause of stricture, 167 Gonorrhoeal proctitis, 69 Gorget, 86 Grosselin on chancroidal stricture, 169 Gummata, 148 authorities upon, 148 rarity of, 148 Gussenbauer, cases of colectomy, 244 HsBmorrhage from rectum, how to con- trol, 63 secondary, after applica- tion of caustics to pro- lapse, 117 Hasmorrhoid, arterial, 97 associated with uterine disease, 101 associated with preg- nancy, 101 capillary, 96 curative treatment, 101 cases and results of car- bolic acid injections, 104 cases unsuitable for oper- tion, 101 definition, 91 description of external, 92 division into external and internal, 91 division of external into venous and cutaneous, 92 due to phymosis, 101 external, acute inflamma- tion of, 94 ' external, formed by dila- tation of vein, 93 external, in a child, 101 external, treatment of cu- taneous, 96 external, treatment when inflamed, 95 first passage after opera- tion upon, 107 forceps to be used in ligating, 107 formed by extravasation of blood, 93 internal, diagnosis of, 98 internal, varieties of, 96 internal, method of cure by carbolic acid injec- tions, 105 Internal, operation by clamp and cautery, 106 palliative treatment of internal, 98 suppuration of external, 72 suppuration of internal, 72 294 INDEX. Haenaorrhoid, symptomatic, 101 symptoms of internal^ 98 treatment by caustics, 102 treatment of external, hj incision, 98 treatment by ligature, 106 treatment w)ien straiigu- lated, 100 treatment by injections of carbolic acid, 108 ulceration following ope- ration, 108 various operations for, 109 venous, 97 Hairy cyst, 158 Helmuth's ligature holder, 84 Herpes, 272 Hilton, white line between external and internal sphincters, 5 Horseshoe abscess, 75 Hodges, on pilo-nidal sinus, 158 Hydatids, 154 Impaction of faeces, 252 of faeces, causes of, 252 of faeces, cases, 253 of faeces, dilatation of sphinc- ter for removal, 256 of faeces, diarrhoea caused by, 253 of faeces, errors in diagnosis, 253 of faeces, location of, 258 symptoms of, 253 treatment of, 255 Intestinal obstruction, treatment, 198 obstruction, mechanism of, 191 obstruction, coming on sud- denly, 190 obstruction, fatal when call- bre of bowel is considerable, 190 concretions, 252 Invagination, 124 acute, 129 change in evacuations, 128 chronic, 128 diagnosis of, 129 degrees of, 125 Invagination, extravasation caused by, 127 frequency with which different parts are af. fected, 125 faecal vomiting in, 128 immediate effects of, 126 laparatomy for, 133 of large intestine, 128 pain in, 128 pathological changes in, 126 peritonitis caused by, 127 relative frequency of, 126 sloughing of included portion, 126 symptoms of, 127 taxis for, 130 treatment by injections* 130 treatment by puncture, 132 terminations of, 126 tumor caused by, 128 ulceration and perfora- tion caused by, 127 Imperforate anus, 31 anus, rules for treatment, 39 Incontinence of faeces, 77 of faeces, cure, 77 of faeces, treatment, 77 Incision of fistula, 85 Inflammation of rectum, 66 Inferior haemorrhoidal arteries, 13 haemorrhoidal veins, 13 Inspection of anus, 53 Instrument case, 52 Iodine as cure for fistula, 88 Irritable ulcer (see fissure) Ischio^occygeus muscle, 11 ICleberg, operation for prolapse with elastic ligature, 122 Kohlrausch, plica transversalis recti, 23 case of stricture due to hy- pertrophy of valves, 184 EIronlein, case of attempt to re-establish anus after colotomy, 46 Lamp for rectal examinations, 51 Laparatomy for obstruction, 138 INDEX. 296 Laparo-enterotomy for foreign bodies, 255 Laugier's instrument for examining for stricture, 57 Levator ani, 11 ani, spasm of, 13 licorice i>owder, comi)ound, 99 lieberkfLhn, follicles of, 9 Ligament, anterior sacro-coccygeal, 7 pubo-prostatic, 12 Lipomata, 150 cretaceous formations on, 151 as cause of invagination, 151 attached far up, 151 divided into pedunculated and non-pedunculated, 150 study of by Virchow, 151 Little, examination table, 50 Littre, operation of, 40 Lumbar colotomy, dangers in children, 43 nerve-centre governing sphinc- ters, 17 Lupus exedens, 164 exedens, treatment, 165 Lymphatics of rectum, 19 Mackenzie, on the treatment of dysen- tery by injections of nitrate of silver, 180 Malformations of rectum and anus, 80 Manual examination of rectum, 61 Marshall, case of colectomy, 245 Martini, case of colectomy, 246 Mason, on chancroidal stricture, 168 Mathieu, rectal supporter, 115 Melanoma, 224 analysis of cases, 225 cases and literature, 224 diagnosis of, 225 duration of, 225 general character of, 225 location of, 225 malignancy of, 224 Meso-rectum, 5 Middle hsemorrhoidal arteries, 13 haemorrhoidal veins, 18 Molk on foetal inclusions, 154 Molliere, ablation of prolapse, 121 experiments in producing pro- lapse, 113 Morgagni, columns of, 8 siniises of, 8, 22, 24 Mucous membrane, glandular layer, 9 membrane, muscular layer, 9 membrane, valves of, 21 Muscles of rectum, 10 Muscularis mucosaB, 8 Nerves of rectum, 16 Neuralgia of rectum, 280 Nitric acid for hsemorrhoids, 102 Non-malignant growths, 135 stricture, excision of, 214 Nutritive suppositories, 288 enemata, 286 Operations, haemorrhage after, 63 preparations for, 62 retention of urii^e after, 65 Osteoma, 225 Osteo-carcinoma, 225 Osteo-sarcoma, 225 Owen, attempt to le-eBtabliflh anoBsfter colotomy, 45 Packing the rectum for haemorrhage, 64 Paget, syphilitic ulceration, 171 Pain, anatomical explanation of, 17 Papilloma, granular, 134 Papillomata, 143 Paquelins thermo-cautery, 63 Pederasty, 5, 159 Pelvis, measurements in children, 38 Pelvi-rectal abscess, 73 Perforation of bowel by foreign body, 259 Peristalsis, reverse, 284 Peritoneum, contained in prolapse, 118 in polypus, 142 relations to rectum, 5 Peritonitis due to stricture, 187 from perforation, 129 Pig's tail in rectum, 259 Pilo-nidal sinus, 153 Plica transversalis recti, 23 Polyadenomata, 139 Polypus, 185 adenomatous, 188 composed of hypertrophied villi, 185 diagnosis, 141 296 INDEX. Polypus, diagnosis from hsemorrhoid, 142 difficulty of distinguishing from cancer, 141 danger of haBmorrhage in ex- tirpation, 142 discharge mistaken for dysen- tery or cancer, 141 double pedicle, 138 examination for, 141 fatal extirpation, 142 fibrous or hard, 189 large vessels in pedicle, 142 of adults, 135 recurrence of, 140 reduction by taxis, 113 sarcomatous, 189 secondary diseases associated with, 141 soft and hard, 185 spontaneous expulsion, 141 symptoms, 140 treatment, 142 villous, 136 Polypi of childhood, 135 associated with fissure, 162 Posterior umbilicus, 153 Proctitis, 66 causes, varieties, and symp- toms, 68 treatment, 70 Proctoplasty, 38 Proctotomy, for imperforate anus, 88 author^s knife for, 205 after-treatment of , 213 cases of, 206, 209 cases suitable for, 213 favorable results of, 213 in cancer, 211 indications for, 213 internal, 202 external, 204 literature of, 213 Prolapse, a cause of stricture, 160 ablation of old and extensive, 122 causes of, 112 , changes which occur in, 119 containing peritoneum, 118 of second degree, 118 of mucous membrane alone, 112 palliative treatment, 114 Prolapse, production of, by inflating submucous tissue, 113 reduction when inflamed, 121 reduction in case of circular slough, 121 removal of first variety, 115 removal with elastic ligature, 123 strangulation of, 119 third and fourth varieties, 124 treatment by clamp and cau tery, 118 treatment by cauterization, 116 treatment by injections, 115 treatment of first variety, IIB treatment when operation la contra-indicated, 119 varieties of, 110 Pruritus ani, 269 ani, symptoms, 269 ani, causes, 269 ani, treatment, 270 Puncture of intestine for relief of ob- struction, 132 Quain, bleeding tumor, 136 stricture due to hypertrophy of valves, 184 Raised mucous patch, 147 mucous patch, development of » 147 mucous patch, diagnosis from simple wart, 148 Rectal absorption, 283 alimentation, 282 depressor, 59 supporter, 115 touch, how to practise, 54 Rectitis, hyperplastic, 149 fibro-sclorous, 149 Recto-coccygeus muscle, 10 Recto-vesical muscular fibres, 7 Rectum, arteries of, 18 congenital malformation, 80 curves of, 2 definition of, 1 development, 30 divisions, 3 dressings after operation, 65 o .< INDEX. 297 Bectum, ending by abnormal anus in perineal or anal regions, 84 ending