■■r?-» -, NATIONAL LlBRARv Qt MiDICINf NLM D013b3b3 3 Surgeon General's Office ) p ftk* ■y f) CONTENTS. Page. Preface,........- - - - 3 Introduction, ---------- 9 CHAPTER I. Hygiene of the Rectum,.........9 CHAPTER II. Ulcers of the Rectum,.......- - 12 Classification of the Non-malignant varieties. - - - 13 Diagnosis of Rectal Ulcers, - - - - - - - 16 Treatment, Medical and Surgical, ------ 17 CHAPTER III.. Fissure or Irritable Ulcer, -----.:. 20 Treatment, Surgical, --------- 23 Medical treatment of Fissure, ------- 25 6 CONTENTS. CHAPTER IV. Puritus Ani,...........29 Itching of the Anus,.......- - - 29 CHAPTER V. Prolapsus of the Rectum,........33 CHAPTER VI. Polypus of the Rectum,.........39 The Fibrous Polypus, - -......40 CHAPTER VII. Haemorrhoids or Piles,.....----42 External Haemorrhoids,........42 Cutaneous Tumors,.......--49 CHAPTER VIII. Internal Haemorrhoids, --------- 50 Treatment of Internal Haemorrhoids, ----- 66 Surgical Treatment of Internal Haemorrhoids, - - - 58 CHAPTER IX. Abscess of the Rectum, - -......- 61 contents. 7 Simple Abscesses,.........gl Medical and Surgical Treatment. - - - - - - 62 Dermoid Abscess, - ......63 Location of the Abscesses, - -.....63 Ichio-Rectal Abscess,........64 Pelvo-Rectal Abscess, ......- - 64 Treatment of Abscess,........65 CHAPTER X. Fistula in Ano,..........-66 Complete, Blind External and laternal Fistulae, - - 66 Varieties of Fistula,......... 66 Surgical Treatment of Fistulae, ----- - 68 Medical Treatment of Fistula, -.....70 CHAPTER XL Constipation,.....---... 71 Varieties, Causes and'Treatment,......71 Varieties of Constipation, ------- 71 Causes of Constipation,.....- - - 72 Hygiene Treatment of Constipation, ----- 74 DISEASES OF THE RECTUM. CHAPTER I. HYGIENE OF THE RECTUM. It is usual to commence a work of this nature with a description. of the anatomy and physiology of the parts, but as these are more or less carefully considered in discussing the diseases that are treated in the following pages, they are here omitted, except so far as they bear on the hygiene of the rectum. This is a subject in regard to which great indifference and even ignorance prevails. There is hardly a physician of the most limited experience, but who has noticed how many of the complaints con- nected with the rectum seem to have their origin in carelessness and neglect, through ignorance. Lack of cleanliness is a fruitful source of disease at this outlet of the body. The individual who sits straining to get rid of the contents of the rectum is, perhaps, not aware of the damage he is doing to the parts which he is subjecting to violence, and how surely he is courting pro- lapsus or piles, if not abscess or fistula. In habitually neglecting the call of nature, he fails to recognize the danger incurred in loss of expulsive power from over distention, consequent costiveness from atony, inflammation, stricture and abscess. Let us glance for a moment at what anatomy and physiology teaches ws concerning the rectum. The muscular coat of the rectum consists of an external and internal layer. The external consists of a lot of dbres which run in a longitudinal direction. The internal consists of 10 DISEASES OF THE RECTUM. a layer of circular fibres which circle around the rectum and grow larger and more powerful as they approach the outlet, where they are collected into two main bundles called the external and internal sphincters. A large proportion of the external longitudinal fibres when they reach the first ring of circular fibres (internal sphincter) double around its lower border, pass upward to be inserted into the fibrous substratum of the mucous membrane of the gut. From this arrangement it results that, when in the act of defecation these longitudinal fibres contract, they tend first to draw down and then evert the mucous membrane of the lower end of the rectum. When the evacuation takes place naturally, this protrusion is promptly retracted by the action of the levators and the natural contractility of the parts, but when the evacuation is difficult or impossible and the effort is prolonged or frequently repeated, the protruded mass becomes congested and swollen and is retracted with more difficulty; perhaps a portion remains outside, then the tumid and tender protru- sion leads to the announcement on the part of the patient that he has had "an attack of the piles." It is our duty then to teach those who intrust their health to us how to care for themselves intelligently in this matter, for preventive med- icine takes rank before curative measures, inasmuch as it requires a wider scope of knowledge and involves a greater exercise of power. The regular performance of this function is then one of the primary conditions of physical well being and its derangement is recognized as one of the first evidences of a departure from perfect health. Its periodical fulfillment should be insisted on, for periodicity is oue of nature's favorite habits. This should be solicited with gentle- ness. The danger of straining with violence should be inculcated from earliest childhood. If the evacuation can not be accomplished by moderate effort, then the cause should be sought for and removed. No person is "naturally costive," as the popular belief and the mode of expression would seem to imply. Sometimes in the act of defecation little particles of hardened fecal matter are caught within the folds around the anus and act as sources of irritation and should be carefully removed. The anus should be wiped clean after every evacuation. The best article is soft tissue paper; all hard articles, like brown paper, corn cobs, grass, leaves, Bticks, etc., should be scrupulously avoided. It is believed by many HYGIENE OF THE RECTUM. 11 that the use of newspaper is a fruitful cause of piles and pruritus. There is a variety of medicated paper, but the carefully selected water-closet paper is the best.* One should never wipe the anus violently, nor when the sphincter is dilated and the mucous membrane exposed. The rectum should be emptied, the sphincter closed and then the cleansing should take place. Sufficient time should be allowed for the rectum to completely empty itself. I cannot however, speak in too strong terms against the unnatural habit that some people have of remaining long at the water closet. It is a great help in slight as well as in severe rectal troubles if one can assume the horizontal position a few moments after stool. The haemorrhoidal vessels have then a chance to empty themselves from the engorgement produced by straining, before the weight of the yiscera is thrown upon the rectum. When we consider how little instruction is given on the care of the rectum, we wonder that diseases of these parts are not more common, even now we will venture to say that but few persons pass thiough life without some disorder of this outlet of the body. •Duncan Bros, of Chicago, carry a supply of paper medicated with Hamnmelis which is excellent. 12 DISEASES OF THE RECTUM. CHAPTER II. ULCERS OF THE RECTUM. All ulcerations within the rectum will be classed under the two heads, malignant and non-malignant. But when we speak of rectal uleers we mean the non-malignant variety, but they are so often con- founded by our authors that I think a few words on the distinctive dif- ference between the two will not be unnecessary, for on the one hand, you can safely say to your patient, it is curable, on the other you would be very slow in making such a positive statement. In all new growths within the rectum, when non-malignant, the tendency is to increase very slowly, and to grow away from the wall of the intestine and form pedicles for themselves, to remain movable, to project into the cavity of the intestinal canal, and not to involve sur- rounding parts; while with the malignant or cancerous variety the tendency is directly the opposite. With these points carefully attended to, the diagnosis between a benign polyp and a cancerous nodule in the wall of the rectum is generally very easy. Recent careful study has shown that there is a class of tumors occupying the border line between the benign and malignant, which, either clinically or with the microscope, it is almost impossible to diagnose the difference, and Dr. Cripps,* who has made some most careful and earnest work in this department, groups all growths in the rectum as malignant, semi-malignant and simple adenoid. Gen- erally, but not always, it is possible to distinguish between them. He says: "In the more malignant varieties, the new growth frequently spreads as a thin layer between the muscular and mucous coats. In this form it often occupies several square inches of the bowel, while its thickness does not exceed a quarter of an inch. At first the "Cancer of the Rectum, London, 1880. ULCEUS OF THE RECTUM. 13 mucous membrane lies intact over such a layer, but eventually it gives way by ulceration. This ulceration sometimes begins at more than one point, so that the mucous membrane becomes honey-com- bed, and portions of the subjacent growth may even sprout through it. The destructive process not only destroys the mucous membrane over the growth, but after a while the new growth is itself destroyed by ulceration. While destruction is proceeding toward the center, the growth is advancing toward the circumference. In this way a crater- like mass of disease is produced, the centre of which consists of dense fibrous tissue belonging to the muscular coat of the bowel, which appears for a long time to resist the ulcerative process. The margin of the crater consists of the mucous membrane of the bowel, heaped up by the extending growth beneath it, tucking it over in such a manner as to overlap the healthy membrane. The border is at times so irregular as to represent a series of nodules rather than a contin- uous line." Of all the varieties of malignant growths of the rectum epithelioma is the one most frequently met with, and this presents, here, as else- where in the body, under two forms. The first or cancroid or lobu- lated epithelioma is the same form so commonly seen in the lip, but seldom attacks the anus. The other variety (the cylindrical epithel- ioma) chooses the rectum proper for its development, and is formed above the sphincter. It is very soft and very vascular, and therefore, prone to bleed from slight causes, and rapidly undergoes degeneration and ulceration, and infiltration of the surrounding tissues. Next we may have scirrhus, encephaloid, colloid, etc., but they are more uncommon and present their distinguishing features here as elsewhere in the body, and are here spoken of because they may be mistaken for simple rectal ulcer. CLASSIFICATION OF THE NON-MALIGNANT VARIETIES. I have adopted the following classification for non-malignant ulcers of the rectum : 1. Simple; 2. Tubercular, including scrofulous; 3. Dysenteric ; 4. Venereal; 5. Those due to stricture. Simple Ulcers.—II we examine carefully into each case of simple ulcer, it is my belief we will always find it to be of traumatic origin. The pressure and passage of hardened feces is the most frequent cause of the traumatism. For by this means a fissure is often pro- L4 DISEASES OF THE RECTUM. duced within the grasp of the sphincter, and a projecting hemor- rhoidal tumor may become ulcerated for a considerable extent. Among other frequent causes may be mentioned, pressure of foreign bodies, as fish-bones, fruit stones, etc., which have been swallowed. Any direct violence to the rectum may produce ulcers, and in women the injury to which they are subject in child-birth, viz., the bruising of the rectal wall between the head of the foetus and sacrum, is believed by many to be the cause of the greater frequency of ulcer- ation and stricture than in men. Tubercular Ulcers.—Some authors speak of two varieties of ulcera- tion met with in persons of tubercular diathesis, one due to actual deposit and softening of tubercle, the other a simple ulceration, con- taining no tubercular deposit, but modified in its course by the patient's condition of mal-nutrition. The former may properly be called tubercular ulceration, and the latter the ulceration of the tuberculous. The former certainly must be very rare. To my knowledge I have never met one. Of the latter it is truly, a simple ulcer in the phthi- sical patient, modified in its course and characteristics, by the general condition. It may result from any of the causes previously men- tioned. It may occur either within the rectum or at the anus, and be of any size from a small spot to a sore covering the whole lower part of the rectum. It may commence quite small and extend on the surface, or it may extend in depth and perforate the wall of the rectum and produce an abscess ending in a fistula. Anyone who has treated many cases of tubercular consumption will know how frequently they meet abscess and fistula in this neighbor- hood, and it is my experience that the majority of these arise from simple ulcer. Case I. C. C., aged twenty-three, came to me on September 2,1875, for relief from a chronic diarrhoea. He was a victim of that fell destroyer consumption, and was very weak and very much emaciated, Ids bowels were moving about four to six times a day, very small in quantity, and consisted mostly of pus often streaked with blood, n« pain, but exhausting; examination revealed an ulcer, pear-shaped, with the small end nearest the anus; local applications of many kinds were tried with but little relief. On November 2d he came complain- ing of pain and swelling and, on examination, found the ulcer had per- forated near its lowest end, and there was considerable swelling and tenderness in the ischio-rectal space. Treatment seemed of no avail in aborting the abscess, which gradually gathered and pointed near ULCERS OF THE RECTUM. 15 the anus, where, upon opening it, I saw some dark little bodies pass- ing, which, upon close examination, proved to be blackberry seeds. These seeds no doubt lodged in the end of the ulcer, perforated their way through the wall and set up an abscess which became a fistula. TUBURCULAR ULCER OF THE RECTAL WALL. Dysenteric Ulcers.—In dysenteric ulceration the fibrous exudation which is infiltrated into the tissues produces compression, and as a result we have a slough which, when it is cast off, leaves an ulcer, and if superficial, may soon regain its usual state, but if deep, still may heal by the usual callous cicatrix, and a stricture be the result. The ulcers found in these cases vary much in size, location and appear- ance, but they are generally large and their favorite site is the rectum or sigmoid flexure. Venereal Ulcers.—These may be gonorrhoeal or syphilitic in origin, and, if the former, the inflammation may be very severe. During ite height the rectum will be swollen, hot, red and granular, with an abundant discharge issuing from the anus. 489091 Hi DISEASES OF THE RECTUM. chancroids.—These ulcers are said never to pass above the sphincter, and are generally seen on the skin just around the anus or just within the canal. They present the same characteristics as in other parts of the body, and are more common in women than in men. The class of women in whom they exist is a valuable aid to their diagnosis. Stricture.—Not only is ulceration a common cause of stricture, but any form of stricture is liable, by its obstructive action, to set up ulcer- ation in the walls above. There is dilatation of the rectal pouch, with its accompaniment—hypertrophy of the walls—produced by the effort to overcome the obstruction. Next an ulcerative action is set up in the mucous membrane, probably due to theirritationjand traumatism of feces. DIAGNOSIS OF RECTAL ULCERS. From what has been said of the etiology of these benign ulcers, it ia plain that they must present many variations in appearances, yet the diagnosis of each from the other, will not generally be difficult if we give careful attention to the history, the appearance of the lesion, and its course. A small ulcer within the grasp of the sphincter, might easily escape observation in a superficial examination, but all ulceration within four inches of the anus are within the reach of actual touch or vision, and should not escape detection when the examination is properly conducted. In some cases a gentle pulling apart of the lips of the anus, with some straining on the part of the patient, will bring into view a small ulcer. In others a digital examination will reveal an eroded and painful spot, and on withdrawing the finger it will be found to be stained with blood. But I would say in all cases the diagnosis is easy, and there is but one way to make it, and that is with Ether and the speculum, and from my experience with physicians this is the least used. If we have a lady for a patient it is much easier to prescribe some remedy in conjunction with a local application, and trust to a kind provi- dence, than it is to gain her consent to a thorough examination. The existence of a chronic diarrhoea or a discharge of any kind from the rectum is a good and sufficient reason for a thorough examination; with ULCEUS OF THE RECTUM. 17 an anaesthetic, a good speculum and a dilated sphincter, no one need Rectal Speculum. be in doubt as to the existence of ulceration of the rectum. The exis- tence of an ulcer being decided, its nature alone remains to be deter- mined, and we have, as we proceeded, given some of the principal points in diagnosis, and to them we refer the reader. In the majority of cases, the ulcer will be found to be of the simple variety first described, only modified more or less by the general condition of the patient, there- fore in the treatment of ulceration we need only consider the simplest form, leaving out irritable ulcer of the anus (as that is worthy of an article by itself) and the question of stricture, as our space is too limited. TREATMENT, MEDICAL AND SURGICAL. There are few maladies more baffling to the surgeon than ulcera- tions and strictures of the rectum. I believe that my failures have been almost as frequent as my successes. And in a severe case of ulceration, let the general condition of the patient be as it may, I have never been able to benefit the patient unless absolute rest was persevered in for some weeks. Even with resi, diet, and appropriate treatment, your task will be no easy one. In the way of local applications, suppositories answer the best purpose. The menstrum should be of some substance which may be easily dissolved at the temperature of the body. I have found gelatine* the best, and in the way of drugs I have found more satis- faction with Iodoform and Hydrastis. I was brought to the use of these suppositories by finding out that a speculum examination two nr three times a week caused too much irritation. These are sold by Duncan Bros., Chicago. 18 DISEASES OF THE RECTUM. To render the patient's rest in bed more endurable, and to secure local rest to the part, I have found it best to combine about one-tenth of a grain of Morphine with the suppository. In some cases where the ulceration is quite high up in the rectum, good results may be obtained by the daily use of injections, which is best accomplished by a long rubber tube, obtained of any instrument maker, attached to an ordinary Davidson's syringe. With the syringe the best results have been obtained by me with Nitrate of Silver, fifteen grains to three pints of water. It is very difficult to point out a general constitutional treatment, for each case will have to be treated according to the peculiar symp- toms present. I generally begin my treatment of rectal ulcers with Sulphur, especially if the case is complicated with piles. The general indications for the use of Sulphur are : diarrhoea early in the morning, stitches and soreness in the anus, stools almost involuntary, cramps in the calves and soles at night, extreme emaciation, whole abdomen sore to touch. My note-book gives the following cases, which I am sorry are not more complete. Case II. Mr. W., aged forty-six, had chronic diarrhoea since leav- ing the army, much worse lately, diarrhoea of pus and mucus, hurrying him out of bed in the morning, generally about once in three days would have a hard costive stool. Any labor brought on an increased number of stools. Examination revealed an ulcer with ragged edges on posterior surface of rectum,extending upwards. Prescribed Sulphur 6x with complete rest, to be maintained four weeks, and longer if required; he reported in two weeks much better, and put up a pitiful face about his poverty and that he must work; after warning him of his danger, allowed him to do as he pleased. He reported in about six months afterward, that he was as bad as before, but that he must work. I tried local applications, but he soon passed from under my observation, and two years afterward I heard of his death, but no particulars. After Sulphur I place Arsenicum as next on the list. It is suitable in the run-down constitution, induced by extreme weakness, pros- tration, diarrhoea, with painless, offensive stools. Case III. Sam E., aged forty-three, suffered with offensive stools and flatus for years, worse at times. Carpenter by trade; could only work about one-half his time on account of extreme weakness; exam- ination revealed a large irregular shaped ulcer just above the sphinc- ter, discharging an offensive fluid, and several small patches at dif- ferent parts of the canal, reminding one of aphthae of the mouth. Complained of burning and itching, was extremely restless, worse at ULCERS OF THE RECTUM. 19 night. Arsenicum 3x brought relief in two days and in one week was at work contrary to all orders. It is now three years since I first pre- scribed, but he continues his work most of the time and when he gets very bad takes Arsenicum. He refuses all further treatment than that. Being a government pensioner will probably explain his reason. Nux vomica and Phosphorus will often be valuable helps in the cure of cases, and in relieving particular symptoms, these with Lyco- podium, Ignatia and Graphites, the well known symptoms of which it is not necessary for me to mention here, complete the list, except ^sculus hippocastanum which of late has given me much satisfac- tion. When there is much aching in the back, worse from exercise of any kind, constipation, and if the case is further complicated with haemorrhoids it is much, more successful. Yet with the best chosen remedy you will often fail unless complete rest is enjoined, and some local application is used, and even with th m you will sometimes fail. But if the above treatment is followed, you will be reasonably satisfied with the result. 20 DISEASES OF THE RECTUM. CHAPTER III. FISSURE OR IRRITABLE ULCER. This is a longitudinal crack or wound in the mucous membrane that is grasped by the sphincter. It is an exceedingly painful, and by no means an uncommon affection. Frequency.—It is incident to all ages, but is more commonly met with in those of middle life. Age.—Dr. Mabboux gives an account of a child two months old with a fissure, but none so young have fallen under my observation. It is a much more frequent disease of childhood than is commonly supposed. Nature.—There may be two or more fissures, but generally only one exists and that at the posterior or dorsal border of the anus, but it may be perineal or lateral. If we are called upon at an early stage in the disease, we find it looks just as if the mucous membrane had been torn by a hard costive stool. It has about the same appearance as a crack we often see in the middle of the lower lip of some individual, which is very slow to heal; bleeding readily from laughing, or any motion which puts the lips upon the stretch. Fissure of the anus follows for a time about the same course as the crack upon the lip; at first the edges are sharp and the surface florid but later the edges become raised and indurated and the surface assumes an ash color. Causes —Syphilis is the remote cause of many fissures, but the immediate cause is straining in passing large hard, and dry stools; fissure may sometimes result from a severe diarrhoea. It is frequently the sequela of confinement and the accompaniment and occasional result of piles and polypus. FISSURE OR IRRITABLE ULCER. 21 Diagnosis.—As a rule fissure is supposed to be haemorrhoids ; patients tell you that they have a discharge of blood and matter, a swelling out- side the bowel, and pain at and after stool, and they believe they have piles. Unfortunately, not unfrequently the medical attendant is satisl fled with the patients diagnosis, and treats the case as one of externa- haemorrhoids. But I would say, generally when a patient complains of great pain during or after defecation, that it is not piles he is suffer- ing from and certainly not uncomplicated piles. I have known patients who for hours could not bear to stir from one position, the least movement causing an exacerbation of the pain. This agony induces the sufferer to postpone relieving the bowels as long as possible, even for days at a time, until the costive condition of the bowels becomes almost a second nature, and they only move when cathartics are used; then the pain is almost unbearable. In some cases after the bowels move the pain ceases and perhaps does not return at all until another evacuation takes place, but often it continues very severe, of a burning character, or it is a dull heavy pain, with throb- bing that lasts for hours. In some instances the pain does not set in until a quarter or half an hour after the bowels have acted. As the disease progresses, there is a constant desire to urinate, or retention of urine, dilatation of the bladder,pains, cramps, and numb- ness, even loss of muscular power in the lower extremities, generally of the left side. When the disease is fully established, the pain will be induced by sneezing, coughing, or micturition, and in time so violent does the agony become, that individuals thus affected even avoid taking sufficient nourishment in order to lessen the quantity of feces. Sitting is painful and riding almost impossible, even at time the patient is obliged to remain in a recumbent position. Case IV. James A. presented himself to me in December, 1876, for treatment for what his medical adviser had called liver complaint and heart disease. He reported that he was very costive, passed large, hard and difficult stools, with so much pain at defecation that his physician had advised him to restrain the movement of the bowels for two or three days and then use injections. He was very anaemic and complained of great distress about his heart, loss of breath upon exertion of any kind. Constant desire to urinate, the pain after defecation was of a burning stinging nature and would last from two to six hours, although it would not generally com- mence until about fifteen to thirty minutes after each evacuation. 22 DISEASES OF THE RECTUM. He had never received any treatment for the fissure (actually did Dot know any existed, his physician having told him it was piles) due to his liver trouble. Upon examination I detected a fissure, the largest and deepest I had ever seen. The sphincter muscles were contracted and appar- ently enlarged, and the examination was productive of great pain. The next day, being assisted by Dr. F. A. Noyes, of Ray, I made an incision the full length of the fissure, and deep into the sphincter ani. The relief was immediate. I put him upon the use of Nux vom. 3x, four pills every three hours, which gradually relieved his costiveness, and up to this time (1883) has had no return of his fissure trouble. Curling relates the case of a patient of his who adopted the danger- ous habit of inhaling Chloroform, while at stool, and could not be persuaded to go to stool without this anaesthetic. Sex.—It is stated that women are more subject to fissure than men. I have observed it frequently in both sexes, and am unable to say that the one is more susceptible to it than the other. Want of proper exercise certainly predisposes to it. Women are sedentary, both from habit, and the usages of society; in them also, constipation, one of the exciting causes is frequent, partly ensuing from their habitually neglecting to obey nature's calls, which, for a time, they can do with less inconvenience, in consequence of the greater capacity of the pelvic cavity than in the male. Men are sedentary from the various occupations in the affairs of life; and among the working class, many are compelled, by the nature of their business, to maintain the sitting posture for a number of hours consecutively, and in these, all diseases of the rectum aie extremely prevalent. The predisposing causes are constriction of the anal orifice. The exciting causes are constipation, induration of the fecal matter, and the violent action of the expulsive muscles requisite for its evacua- tion. The examination necessary for ascertaining the nature and extent of the disease is always attended with some pain, and is best made by lying on the side; the patient raising the upper buttock with his hand, then with the fore-finger the surgeon gently opens the anus, telling the patient at the same time to strain down. You will then be able to see just within the orifice an elongated, club-shaped ulcer. In some cases the examination, though made as gently as possible, will be so painful that you will be obliged to use Chloroform or some other anaesthetic. FISSURE OR IRRITABLE ULCER. 23 Frequently the side of the fissure is marked externally by a small clavate papilla; sometimes by a swollen and inflamed piece of skin, and in this case it frequently ulcerates through the portion of the integement, and forms a small but extremely painful fistula. When upon examination you find this club-shaped papilla protrud- ing from the anus, you may be certain that an ulcer exists; and I may here mention that when operating, this growth should be snipped off, or the case may not do well, as it falls down into the wound and retards or quite prevents healing. My experience fully justifies me in saying that, in children and recent cases, it is not necessary to resort to an operation. For strict atten- tion to cleanliness,—the use of some soothing application and the Hom- oeopathic remedy to relieve the constipation—will remove the diffi- culty in a few days. TREATMENT—SURGICAL. In the treatment of cases of long standing, if the base of the ulcer is gray and hard, and if on passing the finger into the bowel you find the sphincter hypertrophied and spasmodically contracted, feeling, as it often does, like a strong india rubber band with its upper edge sharply defined, nothing but the adoption of such means as will utterly and entirely prevent all action of the muscle, for a greater or less length of time, is likely to effect a cure. Some authors specify the time during which this disease may be ourable without an operation. If it has existed three months they gay that the attempt is hopeless. But really the time is not of impor- tance, the question is : what pathological changes have been brought about ? The credit of originating the operation for the cure of this painful complaint is due to the distinguished French surgeon Boyer. His operatiou was a free division of the sphincter muscle, a procedure unnecessarily severe. Dupuytren practiced a slighter incision than the operation performed by Boyer, and the late Mr. Copeland, of England, was content with making a simple superficial incision of the part. I am convinced that this is not sufficient, but that at least a few of the fibres of the sphincter muscle must be divided. Dr. Curling writes that he once had an opportunity to examine the rectum of a lady suffering from this affection whilst she was under the influence of Chloroform, and the parts being very lax, and in a 24 DISEASES OF THE RECTUM. good light, he was able to bring the ulcer well into view, and could distinctly perceive the fibres of the sphincter forming the bottom of the ulcer. Now it is clear, that in such a case, or in an ulcer which has destroyed the mucous membrane, an incision through the base of the wound must reach and divide muscular fibres. The operation is best performed by placing the patient on his left side with the nates close to the edge of the bed, and the knees well drawn up and opposite a good light, then with a straight probe- pointed bistoury carried well up into the rectum, an incision is made through the whole length of the ulcer from within outwards, dividing a few fibres of the sphincter muscle. The operation is over with in such a short time that it is generally unnecessary to give an anaes- thetic, although the pain from cutting is very severe. There is another mode of operating which is praised very highly by a great many, that is, after placing the patient in the same position, use a sharp-pointed bistoury, cutting from without inward, having previously introduced a speculum to protect the mucous membrane on the opposite side, from the point and edge of the knife. I have never been troubled with haemorrhage, but if any vessel should be seen pumping blood, it may be seized and tied. I always insist upon moving the bowels with an injection in the morning before the operation and use the injection every day, after- wards for a period of ten days. With this precaution the after treat- ment becomes very simple, the parts being left very much to them- selves. The effect of the operation is remarkable. It at once relieves the severe symptoms, the pain experienced afterwards being merely the soreness of the wound, and it rarely fails to secure the healing of the ulcer in the course of ten days or two weeks. The progress of the healing must be watched from time to time, for I have known of dis- appointment ensuing, and the painful symptoms returning after the case had been given up, under the supposition that the patient was well. Case V. Nathan W., aged fifty-one, reported October 2,1879, that he had great pain after each stool lasting about two hours. He had suffered with this pain for the past two or three years, but lately the pain had increased very much. He had formed the habit of having his operation of the bowels every evening, so he could lie down after- wards. Had tried several physicians with no benefit. His stools were FISSURE OR IRRITABLE ULCER. 25 Sarge, hard and difficult to pass, sometimes the constipation alternated with diarrhoea; at these times he was much worse. He is tall, thin and very irritable. He refused any operative measures whatever. Prescribed Nux vom. 3x, ter a die, to report in a week. October 9th no better, and apparently suffering more pain. Gave Phosphorus 3x. October 16th reported much worse, now having morning diarrhoea; stools brown with slimy mucus and often escaping when attempting to pass wind. Gave Aloes 3x. October 26th reported, diarrhoea was controlled almost immediately with the medicine, but the pain was no better, would not be relieved for three to five hours after stool, and therefore gave his consent to an operation, so on November 1st, assisted by Dr. J. W. Mitchell, without any anaesthetics; I operated, cutting through the ulcer and about one-third of the sphincter, the pain from operating was very great lasting about fifteen minutes, then the relief was permanent. On January 6,1880, while suffering with a slight attack of consti- pation, some pain returned, but was removed very soon under Nux vom. 3x, since which time he has remained well to this date, Febru- ary, 1884. MEDICAL TREATMENT OF FISSURE. In the treatment of fissure Homoeopathic literature is almost silent, having very little to say about it, and in most instances when men- tioned it has been confounded with, or in complication with haemor- rhoids. I have been able to find only two * articles on the subject in our pub- lications, and both are excellent and will repay perusal. Many physicians ignore the possibility of successful medicinal treat- ment entirely and rely on the knife; while others look with some degree of contempt on the knife, and pretend to accomplish every- thing with remedies. I do not doubt for a moment that the opposite opinions are both the offspring of honest convictions, but I do not believe that large experience can corroberate them. For myself I am of the opinion that a fair proportion of the cases can be cured by remedies, yet the majority will require the knife. Old School authors recommend mild laxatives; figs soaked in sweet oil, the latter being a favorite domestic remedy, and advise to have the bowels moved in the evening, which is a splendid suggestion, as the rest is very beneficial and the pain does not continue as long when one is lying down. They also recommend ointments of which the * North A m. Jour, of Horn., p. 10. Trans, of Am. Inst, of Horn., 1883, p. 422. 26 DISEASES OF THE RECTUM. following, from Allingham's work on Diseases of the Rectum has proved to be the favorite : Hydrag. sub. chloride ----- grs. iv. Pulv. Opii., ----.-. " ij- Ext. Belladonnse, - - - - - *' ij. Ung. Sambuci, - - - - - " 3j. To be applied frequently. If ointments do not agree, a resort is had to lotions, such as Goul- lard water with opiates and sedatives, but nowhere in Allopathic literature (to my knowledge) can a case be foynd that has been treated successfully with internal remedies alone, nor are they recommended; their treatment being the combined internal and external treatment, the latter including surgical measures. How different is our mode of treatment. I shall try to lay down here my own experience as well as that I am able to cull from our literature. First it will be necessary to discriminate between cause and effect, for it will be impossible to effect a permanent cure if the cause remains unremoved, for it follows that if displacement of the uterus, haemorrhoids or constipation, etc., are the cause, or even if they are only disturbing elements, they must first be removed. I do not intend here to point out a line of treatment affecting the causes, but I shall give only the indications by which a remedy may be successfully employed in cases of uncomplicated fissure, or in cases in which the complication has been removed while the fissure remains. The remedies employed are not many in number. Nitric acid stands at the head as the one most frequently used. It is the general observation of most Homoeopathic physicians that Nitric acid acts most favorably upon those points where the mucous membrane merges with the skin, and it is just in this situation that fissures present themselves. A glance at the symptoms of Nitric acid would indicate its useful- ness in this disease even to the most inexperienced eye. On going to stool, pain in the rectum, as if something were torn away. Burning sensation in rectum and anus. On going to stool twitching in the rectum and spasmodic contraction of the anus, many hours afterward. Heat and burning in the anus after stool. Proctalgia. Prolapsus ani. Humid moisture on the anus. In addition to the symptoms having special reference to the rectum and anus, Nitric acid is Homoeopathic FISSURE OR IRRITABLE ULCER. 27 to a mind disturbed about its disease, desponding or irritable, as well as to a constipated condition of the bowels, and we have before us all the characteristics of a bad case of fissure. Graphiies.—Next, after Nitric acid, most practitioners place Ignatia amara, but my personal experience places Graphites next, with the following indications for its use ; those cases of fissure which seem to be caused by large fecal masses which tear the mucous membrane. The difference between Nitric acid and Graphites is that, in the latter, there is no irritability of the parts, no urging desire for stool (contra Nux), no spasmodic contraction of anus, but there is a smarting and soreness and itching in the anus, worse after stool. Graphites has been more successful with me in children, where the fissure is of recent origin and seemingly produced by the constipated condition of the bowels. If there be varices of the rectum and burn- ing rhagades between them the remedy is better indicated. Case. VI. Willie C, aged seven, June. 1876, brought to the office by his father who reported that the boy suffered from excessive pain at stool, and he says his wife told him to be sure and tell the doctor th; 11 his stools were slimy and that the slime was so tough that it would seem to hold the lumps of fecal matter together, stools large and difficult to pass. Examination recorded : fissure at \ osterior border, but no con- striction of sphincter, all the tissues were v.jrylax and the fissure was brought plainly into view by a little straining. Prescribed Graphites 6x twice each day, reported in a week, some better, not much pain and but little itching, continued same. 1 did not see him again till January, 1877, when he reported having no further trouble after taking last bottle of medicine. Ignatia.—This remedy has done me good service in cases of fissure complicated with haemorrhoids or prolapsus, but it has not proved as serviceable as one would suppose, from its valuable list of symptoms. It is especially suitable to nervous,hysterical females of mild, easily excited nature, with some of the following symptoms : Contractive sore pain in the rectum. Constriction of the anus in the evening, returning the next day at the same hour. Stitches from the anus deep into the rectum, one or two hours after stool, pain in the rectum as from blind piles, stools large and soft but passed with difficulty. This closes the remedies that I put in the first class and I think,you will hardly ever need to go beyond these three, but if so, you can con- sult the indications under Natrum mur.,Thuyaoccidentalis, Arseni- cum, Sulphur, Rhatany. 28 DISEASES OF THE RECTUM. You will find in the N. A. Jour, of Horn, a very interesting case cured by Rhatany 3x ter a die, with the following symptoms : Pain after stool as if splinters of glass were sticking in the rectum ; heat and pain so intense he could not keep still after stool, sensation as if the rectum protruded and then went back with a jerk, with most horrible pain ; frequent and ineffectual desire to urinate. Dr. Eggert in Transactions, of the American Institute of Homoeopathy reports a very interesting case cured by Paeonia, but of this remedy I have no experience. It may be worth trying. Other remedies have been recommended, viz., Hydrastis, Phyto- lacca, Lachesis, Hamamelis, Calc. carb., Rhus tox.,etc. For particu- lar indications I refer to our text books on materia medica. In conclusion, I can only give you my experience and that is this : In recent cases and in children, the well selected Homoeopathic rem- edy rarely fails to cure the case in a very short time, but in those of long standing, I have never been successful in relieving by anything but division of the sphincter. Forcible dilatation as recommended by Recamier of France, has been reported as very successful in curing these fissures, but I have never tried it. It seems to me to be better practice to cut through the ulcer, freshening the wound,than forcibly tearing the sphincter muscle as must be done in extreme dilatation. ITCHING OF THE ANUS. 29 CHAPTER IV. ITCHING OF THE ANUS, {Pruritus Ani.) Nature.—Itching at the anus is a very common affection, and is an accompaniment of several disorders of the lower bowel, although it exists as a distinct affection, being due to a peculiar hyperaesthesia of the skin. In some cases it is a most distressing malady, rendering the life of some patients almost unendurable. It is a very intractable disease, but I am confident it is always curable, if the patient will strictly and patiently follow the advice of his medical attendant. Age.—It is a disease almost peculiar to those who have passed the meridian of life, although no age is exempt. Causes.—Of the several causes inducing this distressing malady, congestion of the mucous membrane of the rectum, is the most fre- quent. Among other causes, we find the presence of worms, or other entozoa infesting some part of the intestinal tube; accumulation of the feces in the rectum and colon, the improper use of purgatives, irritation about the neck of the bladder. I had one very severe and intractable case following an attack of dysentery ; several cases have been reported as consequent on affec- tions of the womb. Symptoms.—The itching is most teasing and annoying at night, when it keeps the patient awake for hours. Rubbing the part to arrest the irritation only aggravates the mischief afterward, yet few- persons have sufficient self-control to prevent their seeking the 30 DISEASES OF THE RECTUM. temporary relief induced by friction; and some, though capable of controlling themselves while awake, unconsciously rub the part while asleep. It is generally stated that there is very little alteration in the aspect of the part affected and nothing is to be observed beyond a roughened, thickened and more wrinkled appearance of the skin just around the anus. This, I think, is by no means usually the case, for I have never met a patient who could control that irresistible desire to scratch, and that alone would excoriate the skin, and in cases where long con- tinued, the skin would become either harsh, dry and of a leathery appearance, presenting cracks from slight causes, or little ulcers which are but little disposed to heal, or the part would be moist from exudation. But what seems to be the characteristic condition- is the loss of the natural pigment of the part, which in some cases even extend as far back as the sacrum, and as far forward as the scrotum, the skin presenting a dull dead white appearance, and look- ing more like parchment than natural integument. I have seen a similar condition in women produced by general pruritus. Treatment.—In pruritus ani, by whatever cause produced, the habits of life should be regulated. The patient should sleep on a mattress, and be as lightly covered as is consistent with comfort. Cold bathing or sponging should be resorted to daily, and sufficient exercise taken in the open air. All hot condiments and stimulating drinks, with tea and coffee, must be strictly avoided. Every effort should be made to avoid friction, and the patient assured, that if he yields to his inclinations his complaint will be rendered worse and more difficult to cure. The remedies most frequently found useful are: Arsenicum, Calc. carb., Cantharis, Carbolic acid, Collinsonia, Graphites, Hamamelis, Lycopodium, Nitric acid, Sepia and Sulphur. Of these, Sulph., Graph., Arsenicum, Nit. acid, are the most often indicated, and I think their value stands in the order in which I have named them. Sulphur.—Violent itching and crawling in the anus in the evening, constipation, frequent ineffectual desire for stool, after stool, tenes- mus, constriction of the anus, with frequent micturition with small emissions; and the following case from my record book will show the value of Sulphur. ITCHING OF THE ANUS. 31 Case VII. March 12,1874, G.C., aged forty-one. Presented himself to me complaining of itching and burning in the anus which had then existed for two years, itching was worse from any exertion, ploughing was almost a torture yet his circumstances (being a farmer) were such that he must work; his bowels were constipated with hard,knotty stools, yet this alternated with a diarrhoea every two or three weeks; appetite good, sleep very much disturbed until late every night, he was in the habit of applying a cloth wrung out of cold water to get relief, hoping to drop to sleep before the itching commenced again. His weight had averaged about one hundred and fifty pounds, but was now reduced to one hundred and twenty-five. The skin around the anus, presented a dry and hard appearance with a few dull white patches. I directed him to bathe the parts frequently while at work during the day with water to which was added a little Borax, and take Sulphur 6x internally. November 6,1874, reported that the medicine had given such great relief that he was able to do his spring and summer work in great comfort, but that lately the itching was returning, and he said he had been using the Boiax water which seemed to relieve the intensity of the itching, yet he noticed he was gradually getting worse. Gave Sulph. 6x and use Unguentum Zinci oxidi, every evening on going to bed after washing the parts in a solution of Borax, report in ten days, but never heard from him again until April 1875, reported having very little trouble during the winter, but this spring his work had increased the trouble and he was anxious to get relief, continued the Sulphur and Unguentum Zinc oxidi, which he now used faithfully until September, when he reported that he had not felt any itching since June. Discontinued all medicine and since which time he has remained entirely well to this date, January 1884. Graphites.—I have found that the field of usefulness for Graphites is limited and is confined to those cases of pruritus, when instead of dry, hard, and leathery appearance of the parts around the anus, there is moisture and tendency to formation of little vesicles, which condi- tion I consider characteristic of Graphites. (When dry and scaly, Lycopodium. Dry and cracked, tendency to bleed, Nit. acid.) Other symptoms of Graphites are constipation of hard, knotty stools in lumps united by a thread of mucus, itching in the anus accom- panied by the same condition in vulva, worse just before menses, especially adapted to those persons inclined to obesity. Case VIII. Mrs. G. M.,aged forty-six, a large fleshy woman weigh- ing two hundred and seventy-six pounds, reported July 5; 1875, with great and intense itching and soreness around the anus extending up and including the lower half of vulva, there was a great deal of 32 DISEASES OF THE RECTUM. moisture between the nates. She had a very profuse leucorrhoea of thin white mucus which was quite offensive. Prescribed Graphites 6x. July 12, reported being better, continued Graph. August 3, much improved, she continued taking Graph, until October, when she dis- continued all medicine. September, 1883, reports no return of the trouble. Arsenicum has proved beneficial in those cases of broken down constitutions and when thus pruritus seems to be a senile condition ; when the itching is more of a burning nature, aggravated by scratch- ing, accompanied by great restlessness, worse from cold applications and cold in general, better from warmth. Nitric acid is especially indicated in cases with a history of syphilis or scrofula, when the skin around the anus is dry and cracked with tendency to bleei from scratching; sometimes accompanied by anal fissure. Collinsonia.—Hale (New Remedies page 187,) recommends Collinsonia in pruritis ani, and he gives in the key note, the presence of haemor- rhoids, and the same author says, page 286 that Pond's extract of Hamamelis will often give relief when used as a wash, but of this I have no experience, preferring the Ung. Zinc oxidi or a solution of Borax or Carbolic acid. Besides the usual internal remedies to be given, it will often be found necessary to use some local means to control the urgency of the symptoms. The application of a solution of Nitrate of Silver (gr. x— H) with a camel's hair brush on going to bed often gives relief. In some cases Chloroform ointment may be used to great advantage, it produces a smarting sensation at first but that is soon followed by ease. But I have found the greatest benefit in most cases to be derived from the application morning and night of the Benzoated zinc ointment. In those cases where there is a considerable moist secretion, I prefer a weak solution of Carbolic acid or Borax used topically two or three times a day. PROLAPSUS OF THE RECTUM. 33 CHAPTER V. PROLAPSUS OF THE RECTUM. [Procidentia liecti.) A great confusion of ideas has been occasioned by the use of the words procidentia and prolapsus. Internal haemorrhoids, when they have come down outside the anus, are said to be prolapsed, and the case is frequently called prolapsus ani; but there is a very marked pathological distinction to be observed between prolapsed internal haemorrhoids and prolapsus of the rectum. The descent of internal haemorrhoids is often attended with more or less eversion of the hypertrophied mucous membrane of the lower part of the rectum, similar to what takes place, although in a slighter degree and only temporarily in the ordinary act of defecation. In relaxed states of the sphincter muscle and coats of the bowel, loose folds of mucous membrane alone are liable to protrude and require replacement. This protrusion and exposure of the thickened mucous membrane with or without internal haemorrhoids, have been errone- ously described by writers as prolapsus of the rectum. In the true prolapsus, however, there is a great deal more than an eversion of the lining membrane of the bowel. The gut is inverted; there is a falling down and protrusion of the whole of the coats —a change in many respects analogous to intussusception but differing from it in the circumstance that the involved intestine, instead of being sheathed or invaginated, is uncovered and projects externally. Varieties.— There is a variety of procidentia which one may call intussusception, the upper part of the rectum descending through the lower part; this is diagnosticated from ordinary procidentia by 34 DISEASES OF THE RECTUM. there being a more or less deep sulcus around the inner column of the intestine, so that there are, as it were, two cylinders of rectum, one outside the other. This condition is often associated or caused by the growth of a polypus, it gives rise to a train of very distressing symptoms, which may continue long after the removal of the growth which has been the starting point of the malady. In the adult, it is the descent of the mucous membrane and sub- mucous areolar tissue alone that constitutes the majority of the cases that come under our observation; and this is what we are necessarily led to expect by taking into consideration the firm attachments of the muscles to the surrounding parts, and which. from its function, is also less liable to protrusion than the mucous membrane, this tissue being more voluminous and more loosely con- nected. But instances of the descent of the muscular and other tissues are by no means so rare as is generally supposed; in children it constitutes the ordinary form, few cases occurring in early life in which the muscular coat does not descend, and this desceusion is favored by the formation of the pelvis, the sacrum being nearly straight, moreover, all infants strain violently when their bowels act, even when their motions are quite soft. There appears to be some physiological necessity for this, which I do not pretend to explain or understand ; but these facts are quite sufficient to account for the proneness of children to this malady; there is always, in addition, some inherent weakness or extraneous source of irritation present by which excessive straining is caused, we may mention diarrhoea, • worms, stone in the bladder, polypus recti, etc. (See Duncan's work on the Diseases of Children.) There are many cases, however, to which we can assign no special cause when the child is not manifestly unhealthy and no source of irritation can be detected. I am sure that the very bad custom of sit- ting a child upon the commode and leaving it there for an indefinite period, as practised by many mothers, is a fertile cause of prolapsus. The causes of the prolapsus in the adult are constitutional and depend upon some peculiarity of the general health or of the habits or occupation of the individual; or they are local, either from disease or irritation existing in the rectum, or as an effect of functional disorder or organic disease in the contiguous pelvic viscera. In this affection as well as several others to which the rectum is liable, PROLAPSUS OF THE RECTUM. 35 costiveness is one of the most general causes; the existence of some other rectal disease may produce it, such as haemorrhoids or polypi ; it occurs in close stricture of the intestines, consequent on the strain- ing and violent expulsive efforts attending that disease. Enlarge- ment of the prostate gland is another common local cause in the male subject; it may depend on a relaxation of the sphincter ani, arising simply from muscular debility; inflammation of the bladder in either sex and various diseases of the womb and vagina will likewise pro- duce it. Women are more prone to the disease than men ; but it is found the most frequently in children and in those who are badly nourished or living in close and unhealthy habitations. Character.— The length of the protruded bowel in prolapsus varies greatly, from an inch to six inches, or even more. The shape and appearance of the swelling depend partly upon its size, and partly upon the condition of the external sphincter. When not of any great length, the protrusion forms a rounded swell- ing, which overlaps the anus, at which part it is contracted into a sort of neck. In the centre of the swelling there is a circular opening communicating with the intestinal canal. An inversion of greater extent usually forms an elongated pyriform tumor, the free extremity of which is often tilted forward or to one side, and the intestinal aperture assumes the form of a fissure owing to the traction exerted upon it by the meso-rectum. In the relaxed condition of the sphincter the surface of the protru- sion has the usual florid appearance of the mucous membrane, but in other cases it is of a violet or livid color, and tumid from congestion, the return of the blood being impeded by the contracted sphincter. The exposed mucous membrane is often thickened and granular, and sometimes ulcerated from friction against the thighs and clothes. A thin film of lymph may be occasionally observed coating its surface. Treatment.—In the treatment we have to consider the removal of the cause, the replacement of the protruded intestine and the retention of it in its natural position as the first and necessary conditions to com- plete a cure. In the adult the best mode to secure the replacement of the pro- truded bowel is to direct the patient to kneel on the bed and rest on his elbows ; the buttock being separated by an assistant, the surgeon, 36 DISEASES OF THE RECTUM. having previously oiled his bands, grasps the tumor and makes firm compression, the patient being directed not to strain, ordinarily the tumor will slip easily within the sphincter. If not reduced by these means, I would recommend the plan of Sir Charles Bell, to cover the finger with oiled paper and then carry the bowel up with it, while the other hand prevents as far as possible the return of the intestine, this oiled paper allows the withdrawal of the finger without bringing down the bowel. If these means fail, by too firm contraction of the sphinc- ter, the patient may be put under the influence of Chloioform, when the obstacle to replacement will probably be removed. Sometimes when the prolapsus is returned, we find there still remains around the anus a ring of haemorrhoids. I may here mention that these cases are amongst the most satisfactory to treat, as any treatment applied that will remove the haemorrhoids will almost certainly cure the prolapsus. Having returned the prolapsus, a pad of lint must be applied and retained with a bandage. The attention must then be turned to the constitutional treatment, and the removal of the cause if known. The remedies most frequently employed in the treatment of prolap- sus ani are, Podophyllum, Sulphur, Ignatia, Nux vomica, and Ruta. Podophyllum is indicated in those cases of prolapsus where the rec- tum descends from the least exertion, and where the prolapsus pre- cedes the feces, with early morning aggravation. In children it is more frequently indicated than any other remedy. Other symptoms indicating Podophyllum are frequent, large, painless, watery, fetid stools gushing from the rectum. To me the guiding symptom in the choice of this remedy is that the prolapse always takes place before the stools and even in those cases where constipation is present, with feces hard and dry, if accompanied by the above symptom it will always relieve. Sulphur is found most useful in those cases accompanied by consti- pation. The stools are hard, knotty and insufficient with frequent ineffectual urging. Case IX. The following case will well illustrate its action. Mrs. P. aged twenty-three, mother of four children had been of a costive habit all her life, but in the last three months had noticed her bowel would descend at every stool, often bleeding. After reduction there would be intense itching and stinging in the anus with frequent micturition, tenesmus with feeling that there was more of the stool to PROLAPSUS OF THE RECTUM. 37 pass, but experience had taught her it was best to lie still a while after stool, and a tew hours afterwards take an injection of water. She had periodical attacks of headache with dizziness. Sulphur was prescribed and in a week she reported herself as free from any prolapse, with but one operation of the bowels since taking the medicine. Did not see her again for over three months, when she reported that soon after commencing the last package of powders she had had regular and healthful passages, without any prolapse. Considered herself well. Ignatia.— I have never had any benefit from Ignatia but in one case, and its action then was so remarkable that I give the case entire, and in the words of the patient. Case. X. M-----, a young married lady, aged twenty-five, and a mute : '* I began to suffer with constipation when thirteen years old, the bowels only relieved once a week. I took a great deal of medicine, but with only temporary relief. After graduating I became a teacher, and taught in a mute school, where I was obliged to go up and down stairs a great deal. I noticed one morning that there was something came down at stool, and was much frightened, but the doctor there told me it was piles, and gave me some medicine which relieved me for awhile, but afterwards it returned, and kept returning at irregu- lar intervals. Teaching disagreed with me. I kept running down in health, had leucorrhoea and great pain every month, when unwell, lost much flesh, and could not sleep nights. The doctors advised me to quit teaching. After that, I got better of everything but this prolapse of the bowel, which would be better for awhile, then worse again. At present, have frequent discharge of large quantity of urine. Am very nervous and afraid of doctors, for one told me I must have piece of bowel cut out. After my marriage my leucorrhoea returned, and I have palpitation of the heart, do not sleep well at night, and wake up very tired. The slightest exertion causes fatigue ; stools are now hard, small and round." I prescribed, at different times, Podophyllum, Sulphur, Lycopo- dium, etc., with little benefit. Under Ignatia there was rapid improvement of all her symptoms. After taking the medicine ten days, had no more prolapse. Nux vomica will be found useful in prolapsus accompanied by con- stipation, with frequent, ineffectual desire for stool. Feces large, hard, dark, and often streaked with blood. It is indicated where the patient has been taking all kinds of drug mixtures. Useful in bad effects from highly seasoned food, coffee, and spirituous liquors. 38 DISEASES OF THE RECTUM. Ruta graveolens.— Of this remedy I have no experience, but the fol- lowing, from Hoyne's Clinical Therapeutics, will well illustrate its action : Case XL Mr. N---, aged twenty-seven, nervous temperament, dark hair, blue eyes; has been troubled with prolapsus for years. It is a family complaint. Has frequent, lumpy, slimy stools, at times bloody; much flatus; stools often unsatisfactory, passing nothing but flatus ; empty eructation and distended abdomen. Feces often escape while bending over. Weakness in lumbar region ; frequent urination; prolapsus always occurs when at stool, and at times without stool; usually has four or five stools a day. Ruta, 200, one powder every morning, cured. Arnica is recommended by Prof. R. Hughes. There is one case in the fifth volume of the British Journal of Homoeopathy in which Arnica in mother tincture cured. Other remedies are Lycopodium, Mercurius, Arsenicum, Calcarea carbonica. POLYPUS OF THE RECTUM. 39 CHAPTER VI. POLYPUS OF THE RECTUM. The rectum like all other mucous surfaces, viz., vagina, nose, etc., is occasionally affected with polypus. By the word " polypus " I must be understood to mean a pedunculated growth attached to the mucous membrane of the rectum and generally not less than an inch from the anus. It is rather an uncommon disease, and is found more frequently in children than in adults, at least that is the experience of most writers on the subject. With myself, it has never been my fortune to meet but three cases and they were in persons above the age of twenty-five, and all of one variety. Varieties.—Polypi has usually been described as two kinds, the soft: or follicular and the hard or fibrous. Dr. Allingham says the former occurs in children and the latter in grown persons, this coincides with my experience, as my cases were all in grown persons and all of the fibrous variety. The follicular polypus usually makes its appearance after a stool resembling a small strawberry, being of soft texture, granular on its surface, and of a red color, varying in size from a pea to a walnut, the pedicle is generally about one and one-half inches long and rooted just above the sphincter. They bleed very freely at times and occasion in the young great debility. When the pedicle is more than an inch in length, they usually protrude at stool, and require to be returned after the bowels are relieved. The child's mother is very apt to describe them as piles or "falling of the bowel;" the real nature of the complaint can usually be detected by the introduction of the finger, but it sometimes happens, owing to the polypus being very movable that it passes up the bowel and gets out of reach. 40 DISEASES OF THE RECTUM. The treatment of polypus in children is very simple and always effectual. The tumor should be strangulated by a ligature secured around the pedicle and then returned within the bowel, it is unneces- sary to cut off the pedicle after ligating it, as the polypus will separate in two or three days and come away. A polypus should not be excised without ligating, as dangerous bleeding is likely to occur. This once happened in a case operated upon by Sir A. Cooper, to such an extent as to occasion alarm. I can find no record of any cases of polypi of the rectum being treated and cured by Homoeopathic remedies, but if any one desires to try remedies I would have more confidence in the efficacy of one of the following : Calcarea carb., Lycopodium, Phosphorus, Silicea, Teucrium and Thuya. THE FIBROUS POLYPUS. The fibrous polypus occurs more often in the adult. It generally origi- nates in hypertrophy of the sub-mucous areolar tissue, and is generally smaller than the mucous polypus of children. Persons who suffer with rectal polypi generally experience a sense of weight and uneasi- ness in the lower part of the pelvis, with a frequent desire to relieve the bowels, with more or less straining during stool. The feces are usually somewhat flattened, and there is almost always an abundant discharge of mucus of a glairy, reddish appearance, not unlike thin currant jelly. Polypi are often complicated with abscesses, fistulae ulcers or fissure. Case XII. J. H., aged forty-seven, May 5,1878, came to me complain- ing of great pain after stool, with falling of the bowel. This falling of the bowel had existed at intervals for about three years, but the pain after stool was of recent origin. Upon examination I detected a fis- sure and set the next day for the operation, which gave him relief from pain for a couple of weeks. But the pain returned as severe as ever. Examined again and on requesting him to strain, he brought down what 1 supposed at first to be an internal haemorrhoid, but on further inspection found it to be a polypus. I applied a ligature immediately and concluded to let the fissure alone until some other day. The polypus came away on the fourth day and as the fissure was giving him no pain and seemed to be healing, I let it alone and in two weeks it was entirely healed. The diagnosis of polypus is usually not difficult. Its tardy growth ; occasional protrusion at the anus, and the functional disturbance which it causes in the bowel, with its occasional haemorrhages are generally sufficiently characteristic, but all doubt will be dispelled by POLYPSUS OF THE RECTUM. 41 a digital examination which should be made only after an injection has been administered. It will then be always possible to feel it or see it. If it be one of those with a very long pedicle, its attachment can be felt. It is possible to mistake this disease for internal piles, prolapsus, or dysentery ; an examination will clear up the first two points and the absence of fever, and the appearance of the stool will settle the last. Case XIII. C.W.D .,aged twenty-eight,Rock Island, 111., occupa- tion, civil engineer, was sent to me by my friend. Dr. Lawrence, in the fall of 1875. An examination revealed a fibrous polypus, about the size of a chestnut, with an attachment to the posterior surface of rectum, just above the internal sphincter, with a pedicle about one and one-half inches long, protruding at every stool, also when cough- ing or loud laughing. I used a bivalve speculum, and ligated the pedicle as high as I could reach, and cut off the tumor. He went home the same day Reported in February 1876 that the operation gave immediate relief and that he had no farther trouble. I cannot explain why these growths should arise. They are not often connected with haemorrhoids or any other disease of the rectum save fissure. I have not observed that constipation, even, that potent factor of bowel affections, is a common accompaniment in these cases. As I stated before, I have no experience with remedies in the cure of those cases, as the ligature has been such a quick, easy and certain mode of cure. I have not been tempted even to try anything else. 42 DISEASES OF THE RECTUM. CHAPTER VII. HEMORRHOIDS OR PILES. EXTERNAL HEMORRHOIDS. Haemorrhoids or piles are terms used by which we understand a cer- tain kind of tumors occurring at the verge of the anus or within the rectum. They acquire great importance and demand the careful attention of the practitioner, in consequence of their great frequency and the immense amount of suffering and the great discomfort they produce, as well as from the great benefit and perfect relief obtained by appropriate treatment. Varieties.—From as early a period in the history of medicine as we are able to trace, haemorrhoids have been divided into two varieties, external and internal, and this classification is founded upon a true pathological distinction. Pathology.—The ancient physicians from a defective knowledge of anatomy and pathology were unacquainted with the true nature of these affections, and held very erroneous opinions of the structure of the tumors forming haemorrhoids; they entertained the notion that they performed the function of evacuating black bile and melancholic humors from the system. After the discovery of the circulation by Harvey, a new but equally erroneous theory was generally received, it being conceived that bleeding from external piles depleted the sys- tem generally, and that haemorrhage from internal piles depleted the portal system only. By later and even recent authors, haemorrhoids are considered to be varices, and analogous to that condition of the spermatic veins, constituting varicocele, and to the dilatation of the superficial veins of the legs which cause so much distress and so often give rise to very troublesome ulceration. These two varieties of HEMORRHOIDS OR PILES, 43 haemorrhoids (external and internal) differ in their situation, in their structure, and also in regard to the treatment required for their relief. The more common variety of the two is the external haemorrhoid. It consists essentially in an extravasation of blood into the cellular tis- sue of the part caused by a rupture of a haemorrhoidal vein, the tumor being covered wholly by skin, or partly skin and partly by mucous membrane. As the effused blood always speedily coagulates, the tumor soon becomes hard, firm and inelastic, its contents rolling out, after an incision, as a solid mass of a dark purple color and without any admixture of serum. The poum in which the blood is contained is usually composed in part, of the ruptured coats of the vein, the remainder being formed, as already stated, by the connecting areolar tissue, the cells of which are speedily closed by plastic matter. It is the opinion of a great many physicians that external piles are formed by the distension of a loop of a haemorrhoidal vein, but I do not think that to be the case, for the following reasons: It is not the nature of veins to contract even when they have been slightly dilated, and we frequently observe external tumors subside and the tissues assume a normal condition. Further, when these tumors are incised, the blood is turned out as a clot; or if fluid, it is not at all commen- surate in quantity with that which would flow from a dilated and con- gested vein. Etiology.—There is no doubt that some occupations and modes of life tend to the productions of external haemorrhoids, yet this affection is so prevalent that few persons either male or female arrive at mid- dle age without having in some degree suffered with it. They occur in the rich and the poor; in the robust and the weakly ; in those of active as well as sedentary life. They are supposed to be caused by certain anatomical peculiarities of structure in the rectum and its veins ; obstructions of the liver or portal system, fecal accumulations, indeed anything rendering the return of blood from the rectum diffi- cult, is likely to conduce to the same end. From this we can readily imagine that a great variety of causes may bring on an attack of piles; of which a few may be mentioned, ■constipation often associated with chronic spasm of external sphincter muscle, diarrhoea, (indeed most of the cases of external piles that have fallen under my observation have arisen during an attack of diarrhoea,) sedentary occupation, uterine displacement, pregnancy, and straining, however induced. 44 DISEASES OF THE RECTUM. SANGUINEOUS TUMORS. Most authors describe two varieties of external haemorrhoids, viz : 1st, a sanguineous venous tumor. 2d, cutaneous excrescence or out- growth. Appearance.— When you look at either of these in an uninflamed state, you would think them harmless enough; in the one case you would perceive veins, blue, rather raised above the surface, resembling a varicose vein ; in the other you would observe around the anal orifice a certain redundancy of the skin, forming little flaps or tabs more or less pendulous, in addition to the small radiating cor- rugations seen in the normal state. How these conditions, so inno- cent in appearance, are prone, at a trifling provocation, to take on active inflammation and to cause the patient an amount of suffering quite out of proportion to the pathological appearance. Let us look at them when inflammation, set up by any of the causes we have before mentioned, has set in. These small tabs of skin are increased in size ; they may be very much swollen, oedema- tous and slimy; exceedingly painful to the touch. Sometimes they ulcerate, or suppuration may take place if the inflammation runs very high, hence small but painful little fistulae arise. (See article on fistula.) At times the oedema is so considerable as to extend into the bowel, and form a large swollen ring of skin and everted mucous membrane all around the anus. So with regard to the sanguineous venous tumors. They are swollen into ovoid or globular bluish tumors, very hard and exquisitely painful. When pinched up between the finger and thumb, from the tissues beneath, they feel as if a foreign body were present there. These tumors may be single, or two or three may be present at the same time. By irritation they set up spasm of the sphincter and levator-ani muscles, so that they are drawn up and pinched, thus adding much to the patient's suffering. Just as he is falling asleep, a spasm takes place, and wakes him up. In addition, there is a con- stant throbbing, and a sensation as if a foreign body were thrust into the anus ; this excites the desire, every now and then, to attempt to expel it by straining, which, if indulged in, of course aggravates the pain. Often, the patient cannot sit down, save in a constrained atti- tude, nor can he walk, and when he coughs the sensation causes acute suffering. When the bowels act, and for some hours afterwards, the HAEMORRHOIDS OR PILES. 45 distress is greatly increased, and the patient, if not absolutely con- fined to bed, is quite incapable of attending to his business. Accom- panying all this, there is general feverishness, furred tongue, and usually constipation. Such, then, are the symptoms of an acute attack of external piles, and if not a serious matter, it is one causing great worry and loss of time—an important point in these hard working days. Moreover, one invasion predisposes to another. Treatment.—In the treatment of external haemorrhoids, it is very desirable to notice the premonitory symptoms of one of these attacks, as by this knowledge it may possibly be warded off, or at all events, much mitigated. The earliest symptom is a sensation of fullness, and dragging or plugging up, and a slight pulsation in the anus. There is often a slight diarrhoea, which induces a great deal of strain- ing ; in some cases, we find constipation. If the patient be a very 'observing person, he will notice after a motion, a slight show of blood, and the anus will be a little swollen and tender. Now all this may pass off with the simplest care, and the slightest medication; but if the patient neglect himself and seek no advice until active inflammation has set in, and the symptoms described above are in full force, you will save your patient much time, pain and often trouble by snipping off the inflamed cutaneous excrescences; or in the case of the sanguineous tumors, by laying them freely open, and turning out the clot. The tabs of skin may be seized with a pair of forceps, and snipped off with a pair of strong scissors. The pain soon ceases, and the wound heals kindly under any simple dressing. The physician should be careful not to recklessly cut away too much skin by making a clean sweep of it, but take off a small portion only. The remaining portion will contract in the process of healing. The best mode of opening the venous tumor is to transfix the tumor at a point nearest the anus with a curved bistoury, and cut out. And here let me give this direction in regard to the use of the knife in the region of the anus : All incisions should radiate from the anus as a centre. The reason for this is, you avoid cutting across the general course of any of the blood vessels in this region, and escape the pos- sible effects of subsequent contraction in healing. (See organic con- traction of the anus.) After the incision is made and the clot turned out, I have found that 46 DISEASES OF THE RECTUM. the best mode to dress the wound is, to take a small piece of cotton,. smeared with Cosmoline, and lay it in the sack, with a small portion projecting out. This is to be removed the next day. The pain from the operation soon subsides, and the patient will make a speedy con- valescence. Case XIV. J. D., aged thirty-five, sent for me September 20,1875, to come to the house, where I found him in bed, unable to get up, he had two external haemorrhoids one on each side, and every motion was very painful, both being in an active state of inflammation. He had been troubled with attacks like this about every three or four months for fifteen years. I immediately laid open both of the tumors turning out large clots, and in an hour he was at his work, (wagon making) and to this time has had no further trouble. Case XV. C. L. aged thirty-three, Fehruary 24, 1879, presented himself with the following history : The week previous was troubled with a slight diarrhoea caused as he said by errors of diet and in the night while atstool, he felt something give away, but gave him no pain. The next morning he noticed slight soreness and some swelling at the verge of the anus, which had increased from day to day, until to-day he had given up business to seek relief, his bowels were now costive and on moving this morning gave severe pain which has not passed away yet, there is throbbing beating in the anus with burning, much increased by exercise, stools large, hard, dry and streaked with blood, frequent desire to go to stool, he feels better by wearing a pad that presses up against the tumor. Examination revealed a single blue sanguineous tumor on left side of anus, highly inflamed. Has had several attacks like this before, the last three months, from which he was obliged to lose over two weeks away from business. He says "if you have anything or can do anything to give relief, go ahead." I immediately incised the tumor and turned out a black clot as large as a filbert. I then placed in the sack a piece of cotton smeared with Cosmoline. and gave Nux vom. 3x to control constipation. Told him to go about his business as usual and report next day. February 25, returned reporting having been perfectly free from pain since operation and from then till this time (1883) he has never had any further trouble. Although the above is the treatment I would recommend, yet you will find patients who will not submit to any operative interference, and to these we can say that Homoeopathy possesses medicines that in a great majority of cases render unnecessary the knife, ligature, or caustic, in such cases I always prescribe one of the remedies recommended below, and use locally an ointment of the HAEMORRHOIDS OR PILES. 47 extract of Belladonna and Opium, equal parts, with warm poultices or cold applications—the one which seems to be the most soothing to the patient. Some authors insist that the inflammation should be reduced before incising the tumors. I do not think there is any need of this, for it is my experience that there is no danger in any way if the operation be properly performed. And I am further convinced that con- valescence is much retarded by waiting till the inflammation has subsided before operative interference. I have said that one attack of external piles predisposes to another; it is therefore necessary so to live as to ward off, if possible, this repetition. If the attack was originally accompanied by diarrhoea, it will be necessary to so guard his diet that diarrhoea will not take place ; if accompanied by constipation, he should select his diet so as to have the bowels move daily. (See constipation.) Pills and all laxative medicines are to be avoided, and if any means are necessary to move the bowels, a simple injection of warm water and soap will answer the purpose. Of all the different remedies recommended by our school, I have never found it necessary to go beyond Aloes, Nux, Podophyllum, Sulphur, Hamamelis, iEsculus hipp. and Arsenicum. JEsculus Hipp.—The indications for this remedy are : piles always accompanied by constipation ; stools large, dry, hard, and difficult to pass; no bleeding. Always with aching pain and lameness across lumbo-sacral legion, affecting sacrum and hips; pains worse by exercise. Dryness, heat and constriction of the rectum; rectum feels as if full of sticks. [Dr. Hart's special indication for its use is throb. bing in the abdominal and pelvic cavities.] Case XVI. Mrs. G.S., aged thirty-two, married, with one child, says that since her confinement, two years previous, she has been troubled with piles. The tumor being constantly present outside the sphinc- ter, from its position producing frequent and urgent desire for stool, passing with difficulty, aching in the back and through the hips ail the time; occasionally the pile would seem to inflame from slight causes and become very sore and painful. She had used all the patent medicines that she could find recommended, with no perma- nent good. She sent for me April 7,1878, to see if I could give her relief as the piles were now giving her a great deal of pain. I found one dark •18 DISEASES OF THE RECTUM. purple tumor on left side of anus, mostly covered by skin, but seemed to be grasped by sphincter muscle. She gave me to understand the first thing that no cutting should be done. Gave iEsculus hipp. 2x, twenty drops in one-half glass of water' teaspoonful every three hours during the day. April 10, soreness mostly gone, but tumor same size. April 21, no change, could tell no difference in size of tumor. May 20, sent for me, piles very sore and painful, caused by riding in a wagon. Arn. 2x to be given four days then ^Esculus as before. May 26, soreness gone. June 22, reported much better, and to-day was the first in which I felt satisfied the tumor had decreased in size. From this time till September, she continued taking ^Esculus at which time she reported her condition, much improved, no soreness, no sensation of plug in anus, and I found only a small tab of skin remaining; advised her to have that removed, but she declined. Since that time have heard nothing from her, and am satisfied I should have heard, if she had had any more trouble. Aloes.— Protruding piles, like bunches of grapes, with constant bearing down in the rectum, always accompanied by diarrhoea; stools small, brownish, slimy, half filled with jelly-like mucous tinged with blood ; much sputtering of flatus ; feces often escape without beiug noticed, seeming like paralysis of sphincter ani. Better from apply- ing cold water. When urinating has feeling as though some liquid discharge from the bowels would or had taken place at the same t.me. Constant rumbling in the abdomen, as though he must have stool, but no evacuations follow the effort. Case XVII. Capillary Haemorrhoids.—B. W. A., aged thirty-one, a merchant who was on his feet constantly, from morning till night, was troubled with diarrhoea and sensation of foreign body within the sphincter, with constant bearing down, with heat and burning in the anus, and passing blood at every stool. There were two small tumors situated on same side, that were protruded without much difficulty, and looked like very small ripe raspberries. Aloes 3x stopped the haemorrhage in a week, and the tumors were entirely gone in three months. Hamamelis virg.—Piles bleeding profusely at every stool, burning soreness, fulness and weight in the rectum; at times, rawness of the anus. The back feels as if it would break. Piles may or may not protrude, but when they protrude, the remedy is more successful. Bleeding is the key-note; Ham. is used empirically as a pronounced topical remedy, and very successful. HAEMORRHOIDS OR PILES. 49 Arsenicum album.— Piles which burn like fire, particularly at night, when walking and sitting; better when at stool. Anus red and sore. The rectum is pushed out spasmodically, with great pain, and remains protruded after haemorrhage from the rectum. Diarrhoea of slimy, green mucus, watery; always after drinking, or eating soup, immediate discharge from the bowels, as though the fluids were rolled through without stopping. Podophyllum.— Internal piles, when accompanied by prolapsus of the bowel, and with diarrhoea; frequent, painless, watery discharge, gushing out (also Croton tig.) worse always in the mornings. Constipation, with flatulence and headache; feces hard and dry, and voided with difficulty. Morning aggravation is characteristic of Podophyllum. CUTANEOUS TUMORS. The second form of external piles consists of a flattened prolonga- tion of skin. They are generally the chronic result of the first form, a projecting fold left after absorption of the coagulum having under- gone further growth. The cutaneous excrescences contain no clots, and no enlarged or varicose veins, but clots and dilated veins may often be found at their base. There is sometimes only a single broad, flat excrescence at the side of the anus, but there are often two, one on each side and occasionally more. Similar excrescences occur as the result of irritating discharges from the bowel, and are common in stricture and ulceration of the rectum. Treatment.—I have never found any treatment satisfactory in these cutaneous excrescences, except snipping off the superabundant tissue, and here I cannot be too particular in warning you not to cut too much, for in healing it will shrink very considerably, and if not very care- ful you will have a constriction of the anal orifice. 50 DISEASES OF THE RECTUM. CHAPTEK VIII. INTERNAL HEMORRHOIDS. Internal haemorrhoids or bleeding piles, as they are sometimes called, constitute a disease which is much more serious than the external variety. It is more insidious in its approach and more persistent in its character. It tends to undermine the general health of the suf- ferer, and in extreme cases to place even life in danger. Causes.—All those causes that I have mentioned as likely to induce external hemorrhoids, tend also to the production of the internal variety. There is a network of good sized veins surrounding the lower end of the rectum, for an inch or two, in the rather abundant con- nective tissue between its mucous membrane and the layer of circular muscular fibres surrounding it,, which is known as the haemorrhoidal plexus, and that the veins immediately around the verge of the anus form a continuous network by anastomosis with the haemorrhoidal plexus within, and these veins anastomose even in the substance of the sphincter muscle. Now it is a remarkable fact that none of these veins are provided with valves, and consequently whenever the abdominal circulation is obstructed, there is a strong tendency to stagnation in its lower- most tributaries, hence the haemorrhoidal veins are often found in a state of varicose enlargement, with thickened walls and pouch-like dilatations. Such is the common explanation of the cause of haemorrhoids, but the French physicians for a long time past have not been satisfied with this explanation of the etiology of piles ; they do not consider that any causes which are occasional can induce such an afflux and stasis of blood in the rectal veins as shall be productive of haemorrhoids. INTERNAL HEMORRHOIDS. 51 Neither, say they, sedentary occupation, excesses at the table, ven- ereal abuses, the immoderate and prolonged use of enemata, drastic purgatives, nor habitual and severe constipation can one or all initiate true haemorrhoids. They therefore with praiseworthy diligence, sought for the true predisposing cause in the anatomy and physiology of the rectum. Pathology.—Professor Verneuil,the distinguished Parisian surgeon, says he has discovered that cause in the peculiar distribution of the veins and the course they take in the coats of the rectum a few inches above the anus. The preparations and dissections made to illustrate and prove his views are now in the Dupuytren museum at Paris; and the correctness of the anatomy, and the deductions made from it, have, says recent French authors, not only been confirmed, but even proved by the dissections of Gosselin,in 1864. Dubreuil and Richard, in 1868, and lastly by Duret, in 1877. I shall endeavor, as briefly as I possibly can, to place before my readers the anatomy as stated by M. Verneuil, because it is considered to give the reasons for a method of treating haemorrhoids strongly advocated in France; but, as far as I know, little practised in America and England ; (and from it we can explain why the recent American mode of treating piles by injections is so successful.) 1. Professor Verneuil considers that the superior hemorrhoidal veins only are connected with the portal system and solely form inter- nal haemorrhoids; external piles being formed from the middle and external haemorrhoidal which are connected with the general venous system, and do not, or only in the most remote degree, form connec- tions with the superior haemorrhoidal veins, and thus the two venous systems, portal and general are practically distinct. 2. That the superior haemorrhoidal veins commence at the upper bor- der of the external sphincter, and lie under the mucous membrane of the rectum. At a definite height of about four inches they perforate abruptly the muscular coats of the bowel, and unite to form the five or six large veins found in the meso-rectura, these then join the inferior mesenteric veins, which pass into the splenic and portal veins and thus into the liver. 3. When the superior haemorrhoidal veins perforate the wall of the rectum, Verneuil claims to have discovered that they pass through "veritables boutonnieres musculaires," which muscular button-holes not being surrounded by any protective fibroid tissue, have the power 52 DISEASES OF THE RECTUM. of contracting and causing such stasis and congestion in the superior haemorrhoidal veins as to constitute the "primum mobile" in the for- mation of internal piles. Dubreuil further calls attention to the fact, that the muscular but- ton-holes are double and at right angles to each other, the first being formed by the circular fibres, and the second by the longitudinal fibres of the rectum, not only, says Verneuil, do these contractile button- holes constitute the passive, but also the active cause of haemorrhoids, any intestinal irritation will produce violent and spasmodic contrac- tions of the muscular apertures, these contractions are communicated to the levator and sphincter ani muscles, and a rapid development ot internal haemorrhoids will take place. Commonly in addition, those occasional causes (formerly considered as first cause) come into play, and the small varicosities found at the lower border of the internal sphincter (present even in infants, say the French) soon become fully formed piles. The practical outcome, from the above anatomy and physiology by the French authors, is very important, viz : that for the cure of the great majority of internal haemorrhoids, nothing is required but the gentle and thorough dilatation of the external and internal sphincter muscles, no ligatures, no cautery with or without clamp, is wanted and no immediate removal of the piles need take place. The anatomy of the rectum, given by M. Verneuil, has been known for many years, but only recently (in 1874) has the practice of dilata- tion been recommended for the cure of haemorrhoids by that gentle- man, and it appears to me that the discovery of that treatment was rather the result of accident than reflection and deduction from any known anatomy and physiology. The case which opened the eyes of Professor Verneuil to the advantage of dilatation is thus related by him. Case XVIIL I was consulted by a distinguished gentleman who had for fourteen years suffered anal pains supposed to be caused by fissure, but they in reality were caused by internal haemorrhoids which had become procidented and irreducible ; with this state not only had the patient's pains been redoubled, but he suffered such loss of blood as to bring him near to death; his anaemia was so profound that I con- sidered the usual operative methods too dangerous to be undertaken and as the sphincters were very contracted I contented myself by dilating them, and from that day the pain and loss of blood ceased the piles were cured and did not return. Encouraged by this happy experiment," says M. Verneuil, "I hastened to put it into practice in other cases with excellent results." INTERNAL HAEMORRHOIDS. 53 M. Fontan, a little later, not knowing, I presume, of M. Verneuil's success, also accidently discovered that forcible dilatation of the sphincters cured haemorrhoids ; for says he, having dilated the mus- cles for the purpose of curing a fissure in a patient who also suffered with haemorrhoids (June 1875,) I found with the cessation of the symp- toms of the fissure, disappeared also the haemorrhoids, the constipa- tion, the daily bleeding, and the prolapsus, and I was struck by this unhoped for result. (Vide Fontan on the Cure of Haemorrhoids by Forcible Dilatation, Paris, 1877.) It would be presumptuous in me to dispute the anatomical facts set forth by Professor Verneuil and endorsed by such men as Gosselin, Dubreuil, Duret, and others; indeed the dissections that I have been able to make, induce me to concur in the main points set forth by the learned professor; but with all due deference, I cannot admit, as a fact, the almost absolute separation of the portal and general venous sys- tem. I am quite confident that in the dissections of morbid speci- mens, near the anus, you do find a considerable communication between the superior, inferior and middle haemorrhoidal veins. One fallacy I would suggest, arises in M. Verneuil's physiology, from the fact of his having injected the superior haemorrhoidal veins from the portal vein, thus forcing the injection in a direction opposed to the natural flow of the stream of blood. Again, admitting the correctness of the presence of the "button-hole" aperatures through the muscular walls of the rectum, I should demur as to the deductions made by M. Verneuil, that they cause by contraction an obstacle to the return of blood from the lower portion of the rectum ; and on the contrary I should infer that these contractile apertures really play the part of valves to support the column of blood to the liver, and in place of causing stasis, prevent it by opposing regurgitation in congested states of that organ and I would rather, in accordance with general physiological principles infer, that the contraction of the circular and longitudinal muscular fibres of the bowel favor, and do not retard the upward flow of the blood ; and I am not convinced, whatever may be the value of dilatation of the sphincters in treatment that the theory of M. Verneuil explains in a wholly satisfactory manner the causes and pathology of haemorrhoids. One more point I would mention. In Professor Verneuil's thesis he makes no allusion to the part played by the arteries in the formation of piles, yet I should think no one could fail to note that haemorrhoids are not merely varicosities, but tumors, into Pie structure of which considerable arteries enter. . 54 DISEASES OF THE RECTUM. Varieties.—In structure, internal haemorrhoids present three princi- pal varieties. The first consists of loose folds of mucous membrane, with thickening of the submucous tissues and with the capillaries increased in number and size. When these tumors are prolapsed they present a deep red, velvety appearance, which bleed very readily, and the blood is generally arterial in character. The second form, the tumors are more solid, nearly round, and have a smooth dull surface sometimes a portion of these tumors have the same anatomical structure as the first variety, in such cases haemor- rhages may occur, otherwise loss of blood does not take place. The third variety will be more clearly indicated by the term vascu- lar excrescence, it being a florid excessively vascular granular condi- tion of the mucous membrane, it is in these cases that the haemorrhage is a permanent symptom. Some of these tumors lie quietly within the internal sphincter and are only protruded by violent efforts at straining, others come down always at stool and whenever the patient makes any exertion or stoops or walks much, these various conditions depending in a great measure upon the duration of the disease and the strength of the sphincter muscles. Size.—Internal haemorrhoids vary much in size and number as well as in amount of pain and hemorrhage. They may be so small as to exhibit little more than an increased number and size of capillaries, or they may be large solid tumors the size of a walnut. Symptoms.— A hemorrhoidal tumor, situated near the verge of the anus, will be very liable to be prolapsed at stool, thus giving rise to pain, spasm of the sphincter, and other distressing symptoms. Those that are situated higher in the bowel are not prolapsed so early in the disease; but by the repeated irritation and dragging down they experience during the time the feces are being evacuated, they become elongated, and at length protrude externally. At first they readily return within the sphincter, but after a time the patient is obliged to replace them with his fingers. In some cases, this is done witli facility,but in others greater difficulty is experienced, owing either to the size of the tumors, or to their being constricted by the sphincter muscle. In many cases, when the tumors are large and numerous, and have been subject to prolapse for a length of time, the sphincter and tissues of the anus lose their tone, are much relaxed, and the INTERNAL HAEMORRHOIDS. 55 patient is subject to constant annoyance by their protrusion when- ever he attempts to walk or ride or stoop ; nor is the prolapse confined to the tumor alone, for the bowel having lost its support, is easily dragged down by these morbid growths, and the expulsive efforts at stool. So great is the suffering, and so annoying to the patient is this constant protrusion from slight causes, that the patient is induced to postpone the call of nature till evening; as he has probably found by experience that on those days in which he has had no movement of the bowels, his suffering has been much less. By attending to his operations in the evening, he can lie down for awhile, and finds it much easier to return the tumors while he is in a horizontal position, in which he also experiences more speedy relief from pain. As a rule, patients do not suffer much pain from internal hemorr- hoids, unless they are constantly coming down and getting compres- sed by the sphincter, or become inflamed from any cause. Hemorrhage is a prominent symptom in internal piles, for when the tumors come down, they nearly always bleed, and this flow only ceases upon the return of the tumors within the sphincter. Complications.— The symptoms produced by internal hemorrhoids are not always confined to the seat of disease. Irritation frequently extends to the urinary organs, the patient being occasionally troubled with a frequent desire to pass water, and even with difficulty in voiding it. On the other hand, disease of the urinary organs is a very common cause of hemorrhoids. The connection between piles and disease of the urinary organs is a matter of considerable importance ; and the surgeon should be careful to ascertain the original and chief source of the patient's sufferings. Persons with stricture of the urethra, stone in the bladder, or enlargement of the prostate gland, are accustomed to strain so much in passing water that they are fre- quently unable to empty the bladder without at the same time relieving the rectum. After the cure of the stricture in the urethra, or the removal of the stone from the bladder, the inconvenience suffered from the hemorrhoids often ceases without any treatment directed to the latter complaint. Owing to the close relation of the uterus to the rectum, many of the diseases of the former organ have an inj urious effect upon the latter. Women usually suffer more from piles during the catamenia than at other periods. 56 DISEASES OF THE RECTUM. TREATMENT OF INTERNAL HAEMORRHOIDS. Treatment.— It sometimes happens that when internal piles protrude at the anus, and are severely strangled by the external sphincter, that they slough off, the patient being relieved of a serious complaint by a sort of natural process ; an occurrence entirely free from danger, but attended by a great deal of pain and suffering. The treatment of this very common and most distressing malady is best considered under two different heads, medical and surgical. Medical.— The surgeon, however successful he may be in the radical treatment of piles, and in spite of all that he may say to his patient, of the advantage of a surgical treatment, he will still have many more chances in the way of medical treatment than will fall to him under the surgical head. It is therefore of great advantage to know what can be done for a timid and reluctant sufferer, without the knife, ligature or caustic; and indeed it cannot be too widely or too clearly known that Homoeo- pathy possesses medicines which, if properly used, will make all patients with internal piles more comfortable, and cure, in the great majority of cases. And it might claim the gratitude of mankind, on this alone, if it had done nothing else for the healing art. Of all remedies for the control of this complaint, my experience places Nux and Sulphur at the head. I will admit that the impediment to the circulation, of which piles are a symptom, does sometimes consist of an engorged liver, and that a remedy which is applied to relieve this engorgement will cure the hemorrhoids, yet generally it is only necessary to take into con- sideration the totality of symptoms presented in each case, and that will decide the remedy. Nux and Sulphur seem to act better conjointly (in alternation) than when either is given separately, and it is in the " abdominal plethora " of the old writers, showing itself by weight, fulness and heat in the bowels, slow digestion, delayed stools, and scanty and pale urine, and in all those cases where purgative medicines have been used exten- sively; where the person has been addicted to the use of liquors, spices, coffee, etc.; constipation, with stools difficult to pass, burning and pressure in the rectum during a stool, with frequent ineffectual urging. Indeed I have found it very beneficial to commence the treatment in the majority of cases with Nux and Sulphur. INTERNAL HEMORRHOIDS. 57 Aloes.— For hemorrhoids in women with pelvic congestion, the truly Homoeopathic remedy is Aloes. But it lias of late found a rival in Collinsonia. The latter has obtained its reputation in cases of congestive inertia of the rectum. With Aloes we find that heat, pressing and burning in the rectum, with the tumors protruding like a bunch of grapes, are very sore, painful and tender to touch, and is especially useful in those cases where there seems to be a relaxation of the sphincter ani, the patient being afraid to attempt to pass wind on account of a little, thin, brownish, watery, offensive stool escaping. Case XIX. Nine days after confinement, Mrs. L.C. sent to me tor relief from an attack of piles coming on immediately after confinement ■and getting worse daily, pain in back all the time, severe burning, pain in rectum lasting two hours after every evacuation. She had been using twice daily an injection of warm water, which afforded much relief, much worse at night, declared she had not slept any since her child was born. Gave Graphites, supposing it was a case of fissure, sent for me the next day being no better, when I obtained the following additional symptoms: Tumors protruding and were very sore, seemed to be grasped by the sphincter like a vice, yet there was a lack of control of the muscle, for at every effort there was an oozing of thin fecal mat- ter from the bowel. Aloes relieved in a few hours and in three days was as well as usual at such times. I was much in doubt in this case whether to prescribe Aloes or ^Esculus, but better by warmth and worse at night decided me in my choice. This case had sent for me expecting to submit to an operation, as her physician told her nothing but an operation would relieve. As a result, made her a firm convert to Homoeopathy. Hepar sulphuris will be indicated when the clay colored stools are present and in those cases where there are obstruction to the abdom- inal venous circulation giving great distress to the patient, p revent in the abdominal respiration and producing oppression of breathing, it will also be found very useful in those cases where there seems to be ulcers in the rectum in connection with piles. Podophyllum, like Hepar is especially useful in those cases where there is a chronic engorgement of the liver, where there is a great tendency to prolapse of the rectum, and here I might give what is my key note for the use of Pod. in prolapsus, that is the prolapse always •occurs before the stool. 58 DISEASES OF THE RECTUM. j?Esculus has been very serviceable in piles of very recent growth where they seem to be produced by an attack of constipation which has lasted only a few days. The symptoms which guide me in the choice of ^sculus are constipation, aching pain in the lumbo-sacra region, and the piles are of the bleeding variety, and I can say -ZEscu- lus has never failed me where those symptoms were all present. Case XX. Mrs. W. R., aged forty-two, had been subject for a > great many years to attacks of piles upon becoming the least costive. Would not bleed, but she said it felt to her as if her whole bowel turned out; severe pain in the back,always worse on the least motion, if these attacks came at the time of her catamenia, they were much worse and she could not get out of bed for a week. Wanted some- thing to prevent return of paroxysm. Prescribed Nux and Sulphur with some relief, but after continuing for three months, and having two severe spells, although she said they were not quite as bad as the average, I was much dissatisfied, and gave ^Esculus 2x and she has had no return of piles or constipation for over two years. Muriatic acid has been highly recommended in those cases where the piles are very large and are very painful to the touch, but of this I have had no experience and can only say if I had such a case would try it. Hamamelis is especially suited to the hemorrhagic variety of piles. I have repeatedly cured case after case of "bleeding piles" by Hama- melis internally, and I know of no remedy that is so certain in its results when properly indicated. Case XXI. Mr. Ed. D., was attacked with piles first during the sum- mer of 1875, but did not give much annoyance until the fall of 1879, when they commenced to bleed at every stool, and had continued to flow freely up to this time, February, 1880. Is now very anemic, unable to do any wTorK on account of extreme prostration. Complains of considerable pain in back and loins, repeated attacks of headache confined to left side of head. He took Hamamelis tincture two drops three times a day. In April reported himself very much better, he moved to Nebraska the same spring and in September, 1888, in answer to a letter said he never had any further trouble. SURGICAL TREATMENT OF INTERNAL HEMORRHOIDS. When you have determined that there is no constitutional impedi- ment to the use of surgical measures, I know of no operation in sur- gery, that will reflect as much credit upon the surgeon and give more satisfaction to the patient than the removal of internal hemor- INTERNAL HEMORRHOIDS. 59 rhoids by the use of injections into the tumors. As to the que stion of danger of the operation, I have never witnessed any unpleasant results. In the operation which I have now performed for several years, with a result highly creditable to myself, there is required no great amount of anatomical or surgical skill, and if you will faithfully fol- low the direction 1 am about to give you, you will need fear no evil consequences. If called to see a patient when the tumors are down, as you will often be called upon at this time, you will find the patient generally in bed and in a most excellent humor to be operated upon, as the piles which have been prolapsed perhaps three to four hours will be swollen, con- gested, livid and more or less oedematous, and any attempt to replace them will cause exquisite suffering. The prolapse of the tumors has generally been caused by defecation a short time previous, so there is often no necessity to move the bowels by injections. I then commence the operation by greasing the tumors and all the surrounding tissues with Cosmoline and then with a hypodermic syringe filled with a fluid in the following proportions : Carbolic acid and Glycerine, equal parts, added to four times the amount of distilled water, plunge the needle into the tumor, passing the needle into as near its centre as possible, and on gently and slowly withdrawing the instrument, force from three to ten drop- into the tumor. This will give no pain whatever, unless some of the fluid gets upon the surrounding tissues. I generally wait about three minutes, watching the hole made by the needle, to see that no oozing takes place, for if it does, the operation for that time will be a failure. Then gently but forcibly replace the mass above the sphincter, telling the patient to lie still for an hour, then if not contra indicated, to get up and go about his business as usual. I never operate but upon one tumor at a time, and never more fre- quently than once a week. It from any cause whatever the patient should experience any pain I always give an injection of about an ounce of Olive or Castor oil,. and that will bring relief instantaneously. This procedure is simple enough upon the first tumor,but when your patient returns the second time, he comes under similar con- ditions to what the majority of patients have with internal hemor- rhoids, that is, the tumors are not down, but above the sphincter. 60 DISEASES OF THE RECTUM. If gentle straining will not bring them down, you wall be required to use an anesthetic and dilate the sphincter, but this is not neces- sary, only very seldom, as gentle straining will bring them completely into view, if only partially, gentle manipulation will accomplish all that is required. The second operation is similar to the first, except if the first tumor is not entirely absorbed, I operate upon it again, using an amount of fluid according to size. At each successive operation, always inject a new tumor, besides treating any of the older ones that require it. The injection of this strength never produces a slough, but seems to cause an atrophy of its internal parts, and nature removes it by absorption. I consider that the use of this fluid in strength sufficient to cause a slough is unnecessary and extremely dangerous. Ergot and Subsulphate of Iron have been recommended as injections in internal piles. Of the latter I have no experience, and of the former, in two cases in which used, I found it very inefficient. There are many other modes of operating recommended, but I have never seen cause to change from the above, as the result has always been favorable. ABSCESS OF THE KECTUM. til CHAPTER X. ABSCESS OF THE RECTUM. SIMPLE ABSCESSES. Abscess in the neighborhood of the rectum and anus is quite a common affection. There is hardly a physician, even of an ordinary practice, who will not meet one or more cases every year, and to our surgeons and specialists it is an every day occurrence to meet these cases of abscess of the rectum. Let me say right here, that the prac titioner who is familiar with the different phases of this disease has it in his power to prevent great suffering and inconvenience and often save life. And to the Homoeopathist it is of the greatest importance to early recognize this trouble, for with the knife to give vent to the discharge at an early day and his well selected remedy to follow, that most dreaded disease, fistula can most frequently be avoided. An abscess here as in other parts of the body arises from alteration or actual death of a portion of tissue. This necrosis or change in quality of tissue, the ultimate cause of every abscess, when not due to the presence of a foreign body introduced into the body, may originate in traumatism. Abscess of the rectum may be caused by perforation from substances that have been swallowed, and have lodged in the rectum, ulcerating into the connective tissue surrounding, where they are often found after lancing. They may be pins, needles, fish bones, seeds, etc.; abrasions caused by impacted feces, or substances intro- duced through the anus may cause a perforating ulcer which will be the origin of an abscess. Other causes, such as contusions from kicks or riding horseback, pressure of stricture or cancer of the rectum and finally the tubercular diathesis. 62 DISEASES OF THE RECTUM. Before describing any of the various forms in which we encounter abscesses in the neighborhood of the anus in practice, it is important to observe that they all have characteristic features in common, viz., 1. They can rarely be made to abort, going on almost always to sup- puration. 2. They do not heal readily but as a rule tend to degene- rate into chronic sinuses and fistule. 3. The pus they discharge is offensive in odor in consequence of the exosmosis of gases. Abscesses in the region of the rectum and anus vary much in size and gravity. I have been called to patients whose first expression was "Doctor I have piles, and they are so painful that they prevent my moving or doing any work, even sitting down is painful." Further inquiry will develop the fact that this is of very recent origin, some- times only a few hours, seldom over forty-eight, and upon examina- tion I found a little round enlargement formed just at the verge of the anus, hot and painful, the presence of which excites spasmodic contraction of the sphincter, by which it is pinched, adding much to the patient's sufferings. These little abscesses are very much like those which appear on the eye lids, (hordeoli) and apparently originate in the glandular follicles and cause an amount of pain out of all proportion to their size, they often leave behind them a minute "blind" external fistula, which keeps up a discharge of a small quantity of pus or a watery offensive discharge which is very disagreeable to the patient. MEDICAL AND SURGICAL TREATMENT. Treatment.—If called at an early period in the formation of the abscess, you can often abort it by the application of Iodine or Turpen- tine applied with a camels hair brush, combined with the internal use Belladonna, Sulphur or Pulsatilla, etc. If called upon later when pus has formed, open it with a lancet, and save your patient great pain and suffering, for it may not open spontaneously for from two to five days, giving great pain in the mean lime. And here let me add a few direc- tions in regard to the use of the lancet in this disease, and what I say will apply to all cases where it is necessary to use a knife in the region of the anus. "All incisions should radiate from the anus as a centre'' The reason for this rule is that you avoid cutting across the general course of the blood vessels, and escape possible effects of subsequent contraction in healing. ABSCESS OF THE RECTUM. 63 DERMOID ABSCESS. There is another kind of abscess that forms near the anus, and is sometimes called the "dermoid" abscess, it is generally as painless as the first described was painful, it often discharges and leaves a little fist da without the existence of the abscess having been known. As it is generally so free from pain, it is not usually brought to the notice of the physician or surgeon until the constant slight discharge attracts the atention of the patient, who is often a delicate phthisical person. A locil stimulant is generally all that is required to cure the case, LOCATION OF THE ABSCESSES. The most common form of acute abscess in this region is where the forms of pus formation is situated farther from the verge of the anus and beyond the grip of the sphincter. The pain in the most acute grade is not so constant or severe as the first variety, although we have a gieater redness of the skin and more febrile reaction. The complete relief that is experienced upon the evacuation of the abscess, whether Ertificial or spontaneous, leads the patient to dismiss the trouble from his mind, and it is only some weeks later that the fact is forced upon his attention by the soiled condition of his clothing. Sometimes when the collection of pus is near the level of the upper limit of the sphincter muscle, it may fail to reach the surface exter- nally, and discharge its contents into the bowel, forming what is sometimes called the blind internal fistula. Generally ~ve find, however, this condition is not permanent, for sooner or later we find the abscess again forming and it may break externally, aid thus complete the fistula. In these las; two varieties the exciting cause is generally a perfora- ting ulcer which forms at the bottom of one of the lacunae of the rectum. The ulceration being generally provoked by the lodgement of some substance in these pockets, from the passing feces. Here you see we have an explanation of the fact that when a complete fistula follows one of these abscesses, its communication with the bowel is most frequently found just above the limit of the external sphincter muscle ; sometimes the starting point of the abscess is in the substance of the sphincter, and the resulting fistula actually traverses the muscular mass. [See cut p. 67.] 64 DISEASES OF THE RECTUM. ISCHIO-RECTAL ABSCESS. When the abscess extends entirely out of the sphincter it occupies the space called the ischio-rectal fossa, where in the loose connective tissues the abscess finds room for development, and its progress /a much slower and more insidious, and more dangerous, for the yield- ing power of the connective tissue tends to force the growth of the abscess more internal, than toward the strong, unyielding skin And fascia. In these cases we find the skin brawny and thickened over considerable extent, with a good deal of febrile excitement ant fre- quent evidences of septicemic depression. If the surgeon is not familiar with these cases, and wai:s for evidence of fluctuation before interfering, extensive destruction of tissue may take place, and be a source of the greatest danger to the life of the patient, but if a finger is inserted into the rectum, it will readily recognize the increased heat and doughy feel. The surgeon should make an early and free opening through the integument. This affords the only assurance of safety. There is plainly a wide difference between the little, round, painful abscess first described and the grave form last given; yet in practice we encounter many varieties of abscess, intermediate with these, and I would have you bear in mind that the same rule of treatment applies to all, viz , an early and free opening with the dotble object of shortening the period of pain and tissue destruction, and securing a cure if possible without a fistula. PELVO-RECTAL ABCESS. Occasionally abscesses form in what is called the superior pelvo- rectal space. The symptoms accompanying the formjtion of an abscess in this region are very obscure, and its progress irery slow, in consequence of the difficulty with which the pus finds an outlet, ultimately the pus discharges high up in the rectum, or by a circuitous route, gradually finds its way out from the pelvis through the sacro- sciatic notch, gravitating downward beside the rectum points exter- nally near the anus, constituting a variety of fistula very difficult to diagnose as well as cure. This is one example of a variety belonging to our category of abscesses near the anus and rectum which we cannot open early, simply because we cannot reach them even if accurately diagnosed. I could not have covered this subject, nor could I have completed the etiology of fistula (as far as fistula takes origin in abscess) without mentioning them. ABSCESS OF THE RECTUM. 65 TREATMENT OF ABCESSES. The treatment of abscess in the region,of rectum and anus is the same as in any other portion of the body ; in the first stage, by the appropriate remedy to abort the disease — which is often done by the well selected Homoeopathic remedy. When pus is formed, give it a& early and free an opening as possible, and by appropriate local treat- ment, such as Carbolic acid injections, etc., wash out the sac and get adhesions between the walls as soon as possible, which if you are unable to do, it will become a fistula, the treatment of which will follow in the next chapter. 66 DISEASES OF THE RECTUM. CHAPTER JX. FISTULA IN AXO. COMPLETE, BLIND EXTERNAL AND INTERNAL FISTDLJE. It is not often that one sees a rectal abscess very early, either the patient is not aware of the importance of attending to the early symp- toms, or he temporizes, using fomentations or poultices, or when seen by a physician the proper treatment is not always promptly adopted. In the majority of instances, the physician's attention is not called to the case, until it has become a complete fistula, when examination may reveal it to be the most trivial matter which can be operated upon at the office and the patient sent about his business, or he may find it to be a most serious affair, demanding extensive surgical interference. I have seen a fistula so insignificant, that it was almost impossible to make the patient believe it was a fistula and needed treatment, and again 1 have seen others where the buttock was so riddled with sinuses as to resemble a rabbits warren more than anything else. Fistula may exist for years without causing much pain or incon- venience to the patient. I know one person who has had an anal fistula for over twenty years, and it has caused him so little trouble that he never has had anything done except the occasional passing of a probe when one of the external apertures (there being three) gets blocked up and pain caused by the retention of matter. VARIETIES OF FISTULA. Anatomically considered there are three forms of fistule, viz., com- plete, blind external and blind internal, the first being the most com- monly met with, and it is one where there is an external opening near the anus and an internal one with a more or less crooked sinus between the two. A blind external fistula is one where there is an external, but no FISTULA IN ANO. 67 internal opening. A'blind internal fistula is so-called from there being an internal opening without any external one. I said anatomi- cally considered there are three forms of fistula but practically we need consider but one, the complete, for the blind internal will soon make itself into the complete if let alone, and the most experienced surgeons adviee you to make it a complete one at as early a period as possible. The blind external is most successfully treated by trans- forming it as soon as possible into one of the first vaiiely. Abscess and Fistula. The best manner to make an examination in a supposed case of fistula, is to place your patient on a table on th* side upon which the fistula is supposed to be situated, with the buttocks close to the end and the knees flexed close against the abdomen. You will then see the orifice of the sinus or some discoloration of the skin indicating the site of the disease. The sinus may often be detected by passing the finger gently around the anus where it will be felt like a pipe stem beneath the skin. Then pass a probe into the external aperture hold- ing it very lightly in the hand, it will almost find its own way, when it has been passed as far as it will go without using any force, intro- duce the finger into the rectum, where you will ordinarily find the probe, or detect its position still beneath the covering of the bowel. s 68 DISEASES OF THE RECTUM. Now with the finger explore the rectum for the internal opening, an educated digit will nearly always detect it. Having found the open- ing, you can with the other hand guide the probe towards it. It is said that occasionally you will find more than one internal open- ing, it is well to examine for extra ones, but it has never been my for- tune to meet with one of these cases. It is very important that this internal opening be felt with the finger for in operating it shoukLbe included in the incision. SURGICAL TREATMENT OF FISTULJE. Being satisfied that a fistula exists, the next question is naturally what is the best mode of treatment, and here you will often be asked, can it be cured without the use of a knife. To this I am in the habit of replying that fistule have been known to get well with and even with- out treatment, but as a rule these are the exceptions and should not be depended upon. If the fistula be a blind external one, or of the simplest variety of complete, you stand an excellent good chance of curing your case by the following treatment: Enlarge the external opening by a tent or with the knife, this you will find very necessary and apply Carbolic acid in solution of Glycerine, (one part of acid to two of Glycerine,) and put in a drainage tube. This mode of treatment if carried out with care and perseverance, offers, in my opinion, the best chance for the patient, yet with this you will frequently fail, and then it will be necessary to adopt either the knife or ligature. The mode of cure by the elastic ligature has the strongest advocate in Dr. Allingham, who has invented a set of instruments for facilita- ting the passage of the ligature. Dr. Helmuth, of New York, has modified the instrument and I think with advantage, but the least elaborate and most effective and least costly instrument for the pur- pose is a simple eyed probe, which is threaded with the elastic cord and passed through the fistula and out at the anus, drawing the cord as tight as possible and then fasten it in that position by slipping over it a soft metal ring and squeezing its two sides together close up against the tissue. The ligature will be found to have cut its way through the included mass in the course of a few days, the time depending on the quantity and quality of the mass to be cut. The great advantage claimed for this mode of treatment, is that the patient is allowed to go about his ordinary pursuit, there being no hemorrhage and it is not particularly painful in its application. FISTULA IN ANO. 69 My experience in the first few cases were very gratifying but after that I had two cases which complained most bitterly of pain for at least forty-eight hours, and I must plead guilty to the preference for cutting with the knife when cutting is necessary. I now use the knife in all cases except where there is danger of hemorrhage or where the patient refuses positively to submit to a cutting operation. Before proceeding to operate upon a case of fistula by incistion, he observance of several minor details will greatly facilitate matters, viz., the thorough emptying of the bowel the day before, and a thorough cleansing with injection immediately before the operation, then with the patient placed on a table in the position described when making an examination and thoroughly under the influence of Ether, (and you will always find it to your advantage to use an anesthetic,) introduce a probe director well oiled, and pass it into the external opening through the sinus and internal aperture if possible; then insert your finger into the rectum, and on feeling the point of the director draw it down and turn it out at the verge of the anus, this being done, with a curved probe pointed bistoury divide the tis- sues bridge over the director. This seems simple enough, but there are several things to be considered here. 1. You may not find any internal opening. 2 After division there may be considerable hemorrhage. 3. The director must be forced out of the anus on the same plane as the sinus. If there be no internal opening, you will probably find some point where only mucous membrane intervenes between the probe and your finger, gently work the director through and bring down the point as before. If you have severe hemorrhage, control it by torsion, or any means at your command. If the director is not brought out of the anus on the same plane as the sinus, you will find your tissues will be cut on a slant, and one side retracting more than the other prevents healing. This accident will give your patient considerable trouble afterwards by one side being raised above the other. This happened to one of my patients and it was over a year before the patient felt entirely comfortable. Having now opened the fistula, search for lateral sinuses, and if any and not too many nor too extensive, they should be laid open, but it is impossible to give here anything but general directions. It has been my principle never to lay open more than two sinuses besides 70 DISEASES OF THE RECTUM. the main one, at one operation, for fear of imposing too heavy a task upon the reparative powers of the patient. After the completion of the operation, take some finely carded cot- ton and carry if. clear to the bottom of the wound, packing it carefully in every part, being the more particular as the incisions have been extensive or high up in the bowel, then place a firm compress between the buttocks and over the wounds, and apply a T bandage firmly. I do not disturb this dressing until the third day when it will generally be found that the bowels have moved and the cotton has all come away, if not I remove it gently, and either replace it or let the patient alone, according to circumstances, and am not an advocate of repeated dressings unless the wound becomes unhealthy or sluggish. I always make it a point to watch my patient until the wound is completely healed, watching during the healing process for any burrowing or for- mation of fresh sinuses, the first symptom of which will generally be a sudden increase in the purulent discharge. MEDICAL TREATMENT OF FISTULA. Some physicians have claimed their ability to cure this disease by internal medication. I can only say that I can not, or at least have not been able so to do. CONSTIPATION. 71 CHAPTER XI. CONSTIPATION. VARIETIES, CAUSES AND TREATMENT. The great frequency of this affection in the different grades and classes of society, and the serious consequences which occasionally follow its presence, will, I trust, plead my excuse if I enter somewhat fully into the discussion of this subject. Nature.—By constipation we understand a state or condition of the bowels in which the evacuations do not take place as frequently as usual, or are inordinately hard and expelled with difficulty. VARIETIES OF CONSTIPATION. Physiological Constipation.—I may here observe that to a certain extent constipation may be relative. One person may be constipated, though he may go to stool every day, while another person may be considered relaxed in his bowels, although he may have but one evacu- ation every three or four days. If the former habitually had two or three stools in one day, and the second ordinarily had but one in six days, the quantity evacuated might in each case be about the same, and both might come within the bounds of physiological constipation and enjoy perfect health. If we seek the cause of these differences in the periodicity of the evacuations which are unaccompanied by any disturbance of health, we find that they depend almost exclusively upon purely individual variations from the average normal activity of the peristaltic action. Pathological Constipation is a symptom of different pathological processes,-and of very varying significance. As a temporary condition, or as the accompaniment of various affections, it has scarcely any real clinical interest, yet in other cases 72 DISEASES OF THE RECTUM. as in constriction or occlusion of the intestine, it belongs among the symptoms which are most important in the diagnosis and prognosis. In a third set of cases, constipation has a certain independence ; it •causes a series of symptoms in different and distant organs, and is the starting point and the most prominent symptom of an affection which the practicing physician meets with constantly, and for which, considering the uniformity of the symptoms composing it and the differences in the individual cases in its very often uncertain etiology, the symptomatic title of "habitual constipation" is justly main- tained. CAUSES OF CONSTIPATION. Causes.— If we exclude all those cases in which the constipation i3 due to mechanical obstruction, we will find the ultimate cause of most of the other kinds lies in a sluggishness or weakness of the per- istaltic action of the intestines. The causes of this condition are extraordinarily manifold. Fre- quently there are many forces at work at the same time, and it cannot often be determined which was the primary one or the most important. An increased excretion of water through the skin and lungs, or the kidneys, causes constipation, unless compensated for by abundant drinking. On the other hand, free drinking of water, if the amount absorbed is less than that taken, often causes diarrhoea. In this case the diarrhoea depends upon an increased peristaltic action; and in the former, the constipation is caused by a diminution of the same — and some of the most remarkable cures in cases of chronic constipation have been made by advising the patient to drink water more freely than usual. Among the many causes of chronic constipation, chronic intestinal ■catarrh may be mentioned as the most frequent. Whilst diarrhoea usually accompanies acute catarrh, in consequence of increased excitability of the intestinal mucous membrane, the ehronic catarrh of adults is always associated with constipation. The principal cause of which is to be found in the muscular coat itself, which in all protracted cases participates in the abnormal nutritive changes carried on within the mucous membrane and becomes flaccid, in the same way as does the muscular coat of the bladder in chronic cystitis. As a result of this relaxation of the CONSTIPATION. 73 muscular coat, together with the inelasticity of the intestinal walls, (which is produced by the same cause) the production of meteorism is favored. Under healthy conditions every great accumulation of gas within the intestine is relieved by the increased peristaltic action, produced by the intra-intestinal pressure, but on the other hand the diminished elasticity of the walls prevents the accumulation of gas from increas- ing the intra-intestinal pressure, therefore peristaltic action is not excited and the condition becomes chronic. These cases of habitual constipation are often associated with hypo- chondria, and from their history we learn that the trouble has usually lasted a long time and developed very gradually, the mental depres- sion appearing later as a secondary symptom. The patients are generally men of sedentary habits between twenty and forty years of age. The symptoms in these patients are most various. A sense of oppression and obstruction of respiration, palpitation of the heart, a feeling of pressure and fullness in the abdomen, symptoms which are due to the existing meteorism and the elevation of the diaphragm caused by it. In addition they often complain of faintness, ringing in the ears, rush of blood to the head, headache, sensation of heat or cold in the extremities, pains in the back, dragging and dull pains in the genitals, etc. The favorite theory is that these pains are caused by pressure of the overloaded intestines upon branches of the lumbar plexus, hut the truth is we are far from being able to give a sufficient causative explanation of even a small part of th-se abnormal sensations. Chronic constipation may have its origin primarily in the large intes- tine for it is plain that an abnormal weakening of the peristaltic action of the colon united perhaps with insufficiency of the abdominil pressure which is essential to the emptying of the rectum, causes constipation even when the peristaltic action of the small intestine is normal. A detailed consideration of the causes of constipation arising in the colon would render many repetitions unavoidable for th^ causes already described affect the colon as well as the small intestine. Nevertheless it will be necessary to mention some of them, because 74 DISEASES OF THE RECTUM. many of the circumstances belonging to it have a certain independ- ence in their causes, symptoms and course, the principal one of which is the abnormal length and arrangement of the colon. This abnormal arrangement of the colon was often mentioned by the oldest writers as something important, described with great detail and not unfrequently illustrated by many sketches, but more modern researches have proven that this anomalous disposition of the colon is in most cases, so long as it does not become excessive, an entirely insignificant symptom. Normal peristaltic action over-com- ing all obstacles offered by the numerous curves as it does for those of the normal flexures. But if there is a notable diminution of the forces which advance the feces and empty the rectum, be added to the above described disposition of the colon, constipation follows, and is severe in proportion as the abdominal flexures are more numerous. Constipation is frequently caused temporarily by change of diet, scene or habits, among which latter may be included, anything which interferes with the regular performance of defecation. It is an accompanying condition in most cases of chlorosis and dyspepsia. It occurs too often, perhaps as a result of habit, in persons young and old. in which no special cause for it can be recognized, and indeed, in many of the most remarkable cases that come under obser- vation it is quite impossible to assign a definite cause for it. HYGIENIC TREATMENT OF CONSTIPATION. The treatment of constipation to be successful must be made to depend more or less upon its cause, on its antecedents, and on its effects. Where it is a mere temporary matter, depending on acci- dental circumstances, or arising in the course of acute diseases, its treatment is simple enough, but when it has become a chronic affec- tion, its causes should be investigated and as far as possible obviated for its sympathetic effects extend to every organ in the body and often occasion great distress and anxiety to the sufferer leading them to apprehend the existence of the most serious organic disease. It is too frequently the case, that the most inappropriate means are adopted to remedy this condition. Many people are in the habit of dosing themselves with Calomel, blue pills, or some saline purgatives which, besides teasing and tormenting the upper part of the alimen- tary canal for no fault of its own, is productive of only temporary CONSTIPATION. 75 relief and often much permanent harm. I could cite many instances which have come under my own observation of the mischief that has thus been induced, and indeed all authors on this subject make the same remarks. In overcoming habitual constipation, much may be accomplished by proper hygienic measures, and indeed in many cases you will signally fail if you do not insist upon dietetic and hygienic measures. In attaining this object, it is essential that the patient should " solicit nature " at a certain period of the day, immediately after breakfast being the best time. Exercise is most important to the proper performance of defecation, and it is highly essential that all who are able should take daily exercise; if, from bodily debility or other causes, the patient is unable to leave the house, frictions of the abdomen at the closet or while in bed, should be resorted to. A glass of cold water taken early in the morning, will materially assist in promoting the peristaltic action of the intestines. Enemata of cold water after an operation is an important adjunct. Brown bread is very useful in promoting the action of the bowels, yet in some cases it will produce pain in the epigastrium, flatulence and heartburn. No plan of diet can be set down that will suit all cases, but each case must be individualized and a diet prescribed that will suit it. The secret of success here is, getting a diet that is easily digested and assimilated, and that of nourishing material. MEDICAL TREATMENT OF CONSTIPATION. Remedies.— For morbid states wherein constipation is the prominent symptom, the following have been found the most effectual remedies in my hands : Bryonia, Lycopodium, Nux vomica, Natrum muri- aticum, Alumina, Belladonna, Opium, Plumbum, Phosphorus, Sul- phur, Hydrastis, and iEsculus hippocastanum. Sulphur.—Br. Richard Hughes says the treatment of chronic constipation may be advantageously commenced with Sulphur. A statement that I have found of the greatest practical importance. He advises that it be discontinued or changed to some other remedy at the end of a week. That I have always followed except when the following symptoms are present, when I find it far preferable to con- tinue it longer. Where we have hard, knotty stools, alternating 76 DISEASES OF THE RECTUM. with diarrhoea, particularly if the subject is hypochondriacal or hemorrhoidal, with the well known symptom of goneness in the stomach at 11 a. m. Sulphur and Nux vomica in alternation have proved valuable in many cases where we have periodical attacks of constipation alternating with a fair condition of the bowels preceding the attacks of constipation. We have the general malaise, slight nausea, eructa- ions, bloated abdomen and coated tongue, with headache, a condition so often spoken of as bilious. Nux vomica is of great value in constipation connected with sedentary habits when there is a general condition of dyspepsia. Often with ineffectual urging before stool, the stools being large, hard and dry, with oppression of spirits, no desire for work, passive frontal headache, which is worse in the mornings; bloating of the abdomen which produces dyspnoea from pressure on the diaphragm. The following case will illustrate the sphere and action of Nux vom.: Case XXII. Mrs. S., thirty-three years of age, says she has been costive all her life. Had previously taken a great deal of medicine, with only temporary relief. Says her stools are large and painful to pass, only moving about once in five or six days. Feels much better after an operation, but in a day or so begins to suffer with bloating and pressure in the bowels, aggravated after meals, inclined to wake up in the night about the same hour. Very sleepy in the morning. Was confined about a year ago. Her condition has been worse since. Says she has headache all the time, and her tongue is never free from a coat, with a bitter taste in the mouth every morning. Does not drink coffee; it always made her worse. Thinks she is now begin- ning to suffer from piles. Nux 2x three times a day cured in a month, and she has remained so now for three years. Bryonia is most useful in constipation occurring in the summer, and in the rheumatic diathesis, when the stools are hard and dry, as if burned. Acute attacks of constipation occurring in women during the lying-in period (possibly depending upon some inflammatory irri- tation of the abdominal organs.) It is the best remedy in my hands for constipation in infants who are being raised on cow's milk, or in cases of acute constipation in children following an attack of gastro- enteritis. Alumina.— I have never had occasion to use Alumina but in one case, and then its effects were so remarkable that I feel that it must be recorded here. CONSTIPATION. 77 Case XXIII. Mrs. G. S., aged thirty-three, constipated for ten years, never having an operation without the use of some medicine or injections, had gone as high as thirteen days without moving. Thei e seemed to be a dryness of the rectum. The fecal matter would accumulate in the rectum until it seemed distended to its fullest capacity. It might well be called a case of inertia. Alumina 6x cured entirely in six weeks, and after a great many other remedies had been tried and failed. Opium's sphere of action is limited to those cases where there is great torpidity, which we are apt to find in persons of sedentary habits, who do much head work; with sensation of fulness and heaviness in the abdomen, dryness of the mouth, with attacks of congestion to head, red face and headache. Plumbum is allied closely to Opium in its action in constipation, and is chosen in preference to Opium in those cases where we have the same torpidity, etc., but the stools, instead of being large, are composed of small, hard balls, sometimes enveloped in a light, greasy pellicle. Hydrastis.— Dr. Hughes says he does not know of a remedy which is of greater service in simple constipation than Hydrastis. This statement 1 have verified many times, but its sphere of action is limited to one particular kind of cases, and I have never obtained any benefit from its use in any other, viz., those cases of so-called bilious- ness, where symptoms of malaria, headache, gastralgia, etc., are always preceded for about two days or more with constipation. And we generally find the patients have regularly indulged in purgatives of some kind, with relief, and they lay great stress on the constipa- tion, saying if they could keep their bowels regular they would have no trouble. It is in those cases alone that I have found Hydrastis useful. Phosphorus.—I had always been taught and supposed that Phos- phorus was especially indicated in tall, slender persons with a weak- ness of the procreative system, and in my efforts to cure constipated persons of that temperament the result was too often failures to be satisfactory, until at last I almost discarded Phosphorus from my list of remedies for constipation. But my eyes were opened to its proper use in prescribing for a cough in a large fleshy female with a violent short hacking cough, with aphonia. Under Phosphorus her cough rapidly disappeared and with it her constipation which had 78 DISEASES OF THE RECTUM. been troubling her for years. Since then I have used Phosphous in the lymphatic temperaments, where we have the long slender hard stool, and it has proved eminently successful. JEsculus hippocastanum.—My record book shows but few cases of constipation cured with iEsculus and none unless accompanied by hemorrhoids. In cases of piles when constipation is a prominent symptom, this remedy is highly recommended by all authors and I can only add my testimony to theirs. Lycopodium.—Dr. J. P. Mills, of Chicago, in a paper read before the American Institute of Homoeopathy considers Lycopodium as the rem- edy for infantile constipation and colic. Since reading that article I have followed his recommendations and have found it almost a panacea in cases of constipation in children. In this it very much resembles Bryonia, but the point of distinction between Lycopodium and Bryonia is, the former is accompanied by great flatulency. Lyco- podium has also proved useful in constipation of old people and in those whose vitality is very low when there is no desire for stool, the stools are semi-solid, or first part solid and last part thin and watery. Case XXIV. G. H. N. aged eighty-qne, had been very costive for years, now very feeble, he suffers very often with flatulent colic brought on apparently by indigestion, generally obtained relief from Asafcetida. Lycopodiun 12x relieved in two days, and after continu- ing had no further trouble. Natrum muriaticum.—My list of remedies closes with Natrum mur- iaticum, which is indicated if there is fissure at the anus with throb- bing, tearing and burning pains in the rectum. When the constipa- tion is increased and aggravated from unwillingness to go to stool on account of pain produced by defecation. It supplies the place usually given to Phosphorus in tall slender persons, when there is a dry state of the system and the sallow complexion characteristic of the drug. Advertisements. 79 DR. BOTSFORD'S NEW ANAL SPECULUM. DESOR.IPTIOX: Fig. 1 represents the Speculum with the interior portion inserted and slightly turned, so as to show a part of the opening through which the treat- ment is effected. Before inserting the Speculum this opening is entirely closed, by turning the interior por- tion by means of the handle. Fig. 2 is an outline drawing show- ing the parts of the Speculum in posi- tion. Notice that the interior portion A, has one side cut away, which may be adjusted to coincide with opening in outer shell. Fig. 3 shows the interior part mark- ed A, removed from the outer shell. The inclined portion B, is for the pur- pose of facilitating with drawal, as it offers less resistence than an abrupt shoulder. It will be seen that the Speculum admits of being perfectly cleaned in every part. INSTRUCTIONS WILL ACCOMPANY THE INSTRUMENTS. Please send for Circular to A. B. Botsford, M. D., Grand Rapids, Mich. For Sale by DUNCAN BROTHERS, 133 and 135 WABASH AVE., CHICAGO, 80 Advertisements. S O Xj TJ IB T_< IE BULB SUPPOSITORIES. Manufactured by the Western Suppository Co. GENERAL DIRECTIONS.—Before using, dip in warm water, unless it makes them too limber, in that case dip in cold. For the vagina use a little cotton or periodical bandage to prevent in any case soiling the linen. These Goods are put up in Boxes of one dozen, and are the ONLY Sup- pository that does not lose its medication. List of Formulas sent free on application. Price, 50 cents per Box. Sent free by Mail. DUNCAN BROTHERS, General Agents, 133 & 135 Wabash Ave. CHICAGO. ILL Advertisements. 81 M'lNTOSH'S GALVANIC & FARADIC BATTERY CO. Manufacturers of the Celebrated MUTOSH COMBINES Table, Office and Family Batteries, Electrodes, Electric Bath Appar- atus, Statical Electric Machines; Stereopticons ; Solar Monocular and Binocular Microscopes, AND ALL KINDS OF Schools, Colleges, Physicians or Hospitals wanting mw apparatus, will do well to favoi us with correspondence and obtain estimates. Men of Scientific experience have charge of the manufacturing department. We employ the most skillful mei hanics, and have the largest facilities in America tor manufacturing. We would call the special attention of the M< dical Profession to our COMBINED GALVANIC AND FARADIC BATTERIES PHILOSOPHICAL ELECTRICAL APPARATUS. These Batteries are recommended by the Medical Faculty of Doth Ameuca and Europe4 and have beenadopted bv the U. S. Gov't, for use in Medical Department of the Army and Navy. They are the first and only Portable Batteries ever invented which can give both the galvanic and lara- dic currei t. Two distinct Batteries in one case. No, physician can afford to be without one. This Celebrated Battery is constructed on an improved plan. The zincs and carbons are fastened to hard rubber plates in sec- tions of six each ; this manner of connecting brings the plates nearer together than in any other Battery, thus giving less internal resistance. The cells are composed of one piece of hard rubber, are made in sections of six each with a drip-cup, thus one section can be handled emptied and cleaned as easily and quickly as one The drip cup is to receive the elements icn The-Battery is not in use. The fluid car not spill or run between the cells, and there is no danger of breaking as with glass cells. This is the only Battery in which the zinc and carbon plates can be kept clean and alway in order by simply rinsing them. An extra large cell (with a zinc and car- bon element) is added to the combined Batteries for the purpose of producing the iFaradic current. This cell gives as much I force as is ever needed, and avoids ex- hausting the current from the Galvanic cells. All the metal work is finely nickel- plated and highly polished, and every part is puttogother so that It can be easily replaced by the operator. Our Batteries weigh less, occupy less space, give a current of greater intensity and quantity than any othei Battery manufactured. Our Illustrated Catalogue, a handsome book giving full description of all our goods and other valuable information, sent free on application. Mcintosh Galvanic and Faradic BatteryCo.? Nos. 192 and I 94 Jackson St., CHICAGO, ILL. For Sale by DUNCAN BEOS., 133 and 135 Wabash ave. 0479 DUNCAN BROTHERS' MEDICAL AND SCIENTIFIC Publications. The special attention of the Profession and Trade is called to our own Medical and Scientific Publications. Most of them are new, or new editions. They are written by able men in the specialties represented, are profusely illustrated and substantially bound. Skin Diseases and their Homoeopathic Treatment. By John R. Kippax, M. D., LL. B., Professor of Principles and Practice of Medicine and Medical Jurisprudence in the Chicago Homoeopathic Medical College; late ClinicalLecturer and Visiting Physician to Cook County Hospital; Member of the American Institute of Homoeopathy; Member of the College of Physicians and Surgeons, Ontario; Author of Lectures on Fevers, etc., etc. Second Edition. Price, $2.00 What is said of this valuable work: The Hahnemann Monthly says: " Dr. Kippax has given us in this book excellent material briefly disposed and well described. The Homoeopathic indications art excellent." tThe Homoeopathic Physician says : "To the busy practitioner, as well as to the student who desires to quickly gather a hint as to the diagnosis or treatment of any skin affection Dr. Kppax's Hand Book will be of service." The Physicians and Surgeons Investigator says: "No matter whether a doctor is a Ho mceopath, or any other, he will do well to read this work. Ho can obtain an understand- ing of the diseases of the skinmore thoroughly from this book than from almost any other. We congratulate the author and publishers on producing such uninteresting work." The American Homoeopath says : "The book will be found a useful guide in the study of skin affections and their treatment. We lave been in the habit of commending it to students, and find the new edition still more useful as a Hand Book." The North American Journal of Homoeopathy says : "That the second edition is a great Improvement on the first one, even a superficial glance will snow; and the therapeutics of each disease are given more thoroughly. Alphabetically the diseases are mentioned an easy plan, as it passes over the difficulty of dividing them scientifically. (How that word is abused), but authorities differ, and who shall be the judge ?" Having thoroughly examined the " Hand-book of Skin Diseases," it gives me pieasur. to accord it my hearty approbation. Its chief value is its conciseness, while in every detail it fulfills perfectly its office as a valuable treatise for study and reference by both Btudents and practitioners, being a neat, systematic, reliable, compact and comprehensive work upon diseases of the skin. I shall take satisfaction in recommending this book to the classes attending my lectures upon the skinvaswell as to the profession generally Phil. E. Ascularius, M. D. Lecturer on Skin Diseases in the New York Homoeopathic College. Catalogue of Medical and Scientific Books. 83 In these days of massive books it is refreshing to read a brochure which condenses the pith of a large work into a small compass. Such is Dr. Kippax's " Hand-book of Skin Diseases." To these advantages to the busy practitioner and the student are added in this book excellent type and paper, and plenty of interspace to prevent the wearying of the eyes. The classification of skin diseases is concise and very useful. This is a diffi- cult task well performed. Part H. contains the description and treatment of skin affec- tions arranged in alphabetical order. The definitions are printed in small caps, which brings them prominently before the eye, and helps in their comprehension. Part III, comprises a chart of characteristics, wilh diagnostic, therapeutic, dietetic and hygienic hints. The remaining three parts include a glossary, metric tables, and bib- liography of works consulted by 1he author. In regard to the treatment, the work is quite complete for a hand-book.— Hahnemannin Monthly. A Hand-Book of Homoeopathic Practice. By George M. Ockford, M. D., Member of the American Institute of Homoeopathy etc. Just out. Price, free by Mail, $2.50. This work has already been accorded a hearty welcome by the profession. It is excellent I have recommended it to our students.—H. F. Biggar, Cleveland Hos- pital Medical College. Dr. Ockford has given in his hand-book as good a condensation of treatment as any one can give.—Homoeopathic Physieian. I am pleased with it.—T. P. Wilson, M. D., Professor of Practice, Medical Department Michigan University, Ann Arbor. We are particularly well pleased with the indications for the remedies mentioned under each heading. The volume is filled with good hints and characteristic symptoms. —The Clinique. I shall commend the book to my classes as a neat and reliable epitome of treatment. — R. J. McClatchey, M. D., Professor of Pathology and Practice of Medicine, Hahnnemann Medical College, Philadelphia. The work is very well arranged for any one who wishes to try Homoeopathy on a small scale. Our physicians will find something of the kind an advantage for reference.—The Eel die Medical Journal. The most concise and practical work of its kind extant. It is well adaptedto the needs of beginners in Homoeopathic therapeutics.—M. T. Runnels, M. D., Secretary Indiana Institute of Homoeopathy. A very handy 12 mo. volume of 425 pages neatly bound in cloth, presenting in a con- densed form, practical descriptions of the principal diseases and their treatment for the use of students and busy practitioners.— American Observer. I have looked it over carefully and find it agood book for students, and just the thing for the busy practitioner.—G. J. Jones, Surgeon-in-Chief of Relief Associaion of the S. L. & M. S. Ry., and Surgeon at Cleveland of the N. Y, p\ & O. R'y Co. Please accept my thanks fot the work, which, from a cursory perusal, I can but regard a valuable addition to our current literature.—A. E. Small, M. D., Professor of Theory and Practice of Medicine and President of Hahnemann Medical College and Hospital Chicago. I think it an excellent work, very convenient for practitioners for ready reference. Just fills a long-felt want in my library. The classification of disease is a great help and the indications for the remedies are very explicit.— F. Luncan, M. D., Physician to the Osage Sanitarium. 1 am much pleased with its appearance.—J. W. Dpwling,IM. D.,Professor of Physica Diagnosis and Diseases of the Heart and Lungs, New York Homoeopathic Medical Col- lege, 84 Duncan Brothers' Placing the book on its merits, it will be able to hold its own with the best of its class yet issued. It it concise and does the author credit. I shall take pleasure in recom- mending it to " the boys" here at Pulte. Such a book means hard work and plenty of it.—J. D. Buck, M. £>., Proiessor of Practice and Dean, Pulte Medical College, Cincin- nati, Ohio. The peculiarity of the work lies in its brevity; there is no waste of words, and con- siderable variety is crowded into a volume of very moderate size ; of course, it would be follv to look, in such a work, for elaborate descriptions of diseases, so-called, or for minute indications for remedies to be applied in treating them; but, so far as the writer goes, he shows good judgment and acquits himself creditably. Dr. Ockford has here presented to the Profession a thorough and concise compilation on homoeopathic practice. The symptoms and treatment of nearly all diseases are given in brief, and the work constitutes a most reliable guide. It is one of the best hand- books on the subject with which we are acquainted.—Phys. and Surg. Investigator. A Treatise on Diseases of Infants and Children, and their Homoeopathic Treatment. By T. C. Duncan, M. D., First Presient of the American Psedological Society, Professor of the Diseases of Children. The third remsededition is now ready. Complete in one octavo volume of 1,006 pages. Cloth $6.00; leather $7.00. What is said of the work that is adopted as a text-book of the leading Medical Colleges: These (diseases) are all treated in a masterly manner.—American Observer. The author has made such a concise compilation that his work may be adopted as a textbook of our school, and we trust no Homoeopathic physician will allow himself to be without it.—Horn. Times. Each subject is treated exhaustive and compiled from the very best and latest liter- ature on the subjects. Much time and labor have been expended in gathering and arranging the material for publication. The therapeutic indications are fully and admirably given, having been taken from all Homoeopathic sources, native and foreign. —Hahnemannian Monthly. Having frequent occasions in college work to refer to the Text-book, I have learned to appreciate your contributions to the profession, and take great pride in recommending it to the "Pulte" students as worthy of acceptance. It is systematic, scientific and thor- ough both in theory and practice.—C. D. Crank, Prof esssor of Diseases of Children, Pulte Medical College, Cincinnati. Duncan's Text book fills a long neglected want. It is the only Homoeopathic book on diseases of children, written on a scientific basis. We feel glad that Duncan gives such prominence to physiological therapeutics a branch too much neglected in many other- wise fair text-books. How and when to feed a child is at lea^t of equal importance as to heal it when from sheer ignorance it is made sick. As old a physician as I am, I thank Dr. Duncan for this instruction, and I promise him to investigate his other volume with equal zeal. May others do the same.— North American Journal of Homoeopathy. The third edition of Duncan's Diseases of Children has been put into one volume, a form in which it is much more convenient, for study and reference, and without doubt will be much more acceptable to the profession at large. Portions of the work have been rear- ranged and rewritten, and all the changes we have noted, have been judiciously made. This is now the most extensive work on Diseases of Children in the Homoeopathic school of medicine. The author, who is the founder of the American Psedological Socie- ty, has given a great deal of study to this specialty, and the present large and hand- some volume is a monument to patient and tireless industry.—R. N. Tooker, Prof, of Diseases of Children in the Chicago Homoeopathic College. Catalogue of Medical and Scientific Books. 85 This book has become pretty widely known, as the many editions and the large sales Will attest. Little remains, therefore, to be said concerning it. When we take down a medical book we are generally looking for help. The pertinent question then is, are we liable to find what we want? When we affirm that the book consists largely of extracts from the best sortings extant, we have answered the question, but not wholly. Few books of this class have woven into them as much of their author's individuality as appears between the clippings and in whole pages of personal thought and experience, which latter may be dignified as authority in itself. Since the author's experience in former years at the Foundlings' Home have made him pregnant with facts not commonly known. Much space is taken up with the beginnings of every- thing e. g., Ante-natal developement. This is a good feature in a text book. It corresponds to "red tape" in official life, not needed so very often, but essential at times, hence should be chronicled. All the diseases of children find place in this plethoric work. Advice regarding diet and hygiene is in the main excellent. Remedial medicines, quite full. No Physician should be without Diseases of Children.—J. P. Mills Physician to the Chicago Foundlings' Home. A Hand-Book of Diet in Disease. By Ch. Gatchell, M. D., Formerly Professor of Practice, Homoeopathic Department, Michigan University. Clinical Lecturer in Cook County Hospital. Second edi- tion, now ready. One compact volume. Cloth, $1.00. It will be useful in the office and in the kitchen. The book embraces much valuable material.—Eclectic Medical Journal. This is a small volume of 150 pages designed to answer the question every day asked by the sick, " Doctor what shall I eat?" It contains much good advice to invalids, and many recipes for food and methods for its preparation. It is often a turning-point in disease and life or death results from the diet. It is a book as valuable for every home as for the shelf or pocket of the physician.—Inter Ocean. The question which forms the title of this little work is often asked; and an answer in such an available form as here furnished will be most welcome not only to the physician who may occassionally desire the answer, but to the household where there is sickness, and to the nurse, particularly. Prof. Gatchell presents a large fund of dietetical infor- mation in an agreeablv condensed form, and tells what should be fed to the baby, the fever-patient, the dyspeptic, the consumptive, the sea-sick, the corpulent, the conval- escent ; and what food is best in diabetes, Bright's disease, gravel, scrofula, rickets, scurvy, chlorosis, rheumatism, asthma, heart-disease, alcoholism, diarrhoea, dysentery, cholera, cholera infantum, etc., and how the food should be prepared in each case. Nu- merous recipes are also added for beverages, meats, oysters, broths and soups, breads, gruels, etc. The work has been compiled from the most reliable sources and is most trust-worthy.—Phy. and Surg. Investigator. Diseases of the Brain and Nervous System. By J. Martine Kershaw, M. D., Professor of Brain, Spinal and Nervous Diseases in the Homoeopathic Medical College of Missouri. Ei^ht parts. Price per part, 50 cts. Parts I and II of this valuable work are now ready. Each part is com- plete in itself. Part I treats of Facial Neuralgia; Cervico-brachial Neu- ralgia; Dorso-intercostal Neuralgia; Angina pectoris; Gastralgia; Mas- todynia; Neuralgia of the Ovary, Uterus, Testicle, Urethra, Bladder, Kidney and Diaphragm. Part II. is very practical, as it considers Spinal Irritation; Chorea; Labio-laryngeal Paralysis; Facial Paralysis and Wri- ter's Spasm. *• 86 Duncan Brothers' Teething and Croup By W. V. Drury, M. D. Formerly Physician to Children's Department, London Homoeopathic Hospital. One neat little volume. Price, 25 cents. This little work is full of practical suggestions as to the management of children suffering from teething disorders and that much dreaded disease, croup. The notes by the American editor add to its usefulness. How to See with the Microscope. By J, Edwards Smith, M. D. Professor of Histology and Microscopy, Cleveland Homoeo- pathic Hospital College. In one elegant volume of 410 pages. Cloth, $2.00. There is at present no work in the English language which gives instruction in the best methods in handling the most modern microscopes and objectives. Prof. Smith's work will,therefore, fill along felt hiatus in our microscopic literature.— Monthly Journal of Microscopy. The hints he gives are really useful— more than that, they are highly instructive. Every word proves the great experience of the writer, and the pleasant agreeable style of his language makes the book a fascinating lecture. And that is just a point which deserves great praise, for we acknowledge never to have read a book so full of teaching, written in such an amiable style, such as this one: certainly not in the line of books on microscopy.—North American Journal of Homoeopathy. We come to pure applied science in the book before us. As its title almost suggests, this is a work of interest to the thorough-going microscopist rather than to the student or the practitioner who only use the instrument for clinical purposes. It is, therefore, Bomewhat out of the range of our critical surveys; and we can only congratulate *he Cleveland Homoeopathic Hospital College at having so scientific and original thinker as its professor of histology and microscopy.—British Journal of Homoeopaihy. Diseases Of the Pancreas. By Professors A. R. Thomas. J. C. Morgan, A. Korndoerfer, and E. A. Farrington, Hahnemann Medical College of Philadelphia. Cloth bound, 50 cents. Just out. All that is known about disturbances of this little-understood gland has been carefully compiled in this book.— N. E. Med. Gazette. We believe that this is the first work on diseases of the pancreas, and it is no small honor that it hails from the Homoeopathic school. It will serve as a useful guide, and at the same time as a nucleus for the observations of the profession.—Cal. Horn This little book of seventy pages, by four of our best writers and thinkers, contains all that is known on the subject treated in any school, and is a timely contribution to our literature of the digestive organH.—St. Louis Clinical Review. This work is upon a subject which has interests to all. Pancreatic diseases are so ob- scure, and their literature so meagre, that the book is welcome. We recommend all to get the work, as it gives a very thorough resume of the subject. Those who do not like the treatment will certainly be pleased with the other chapters of the work.—Physicians and Surgeons' investigator. It gives a thorough history of the pancreas, its anatomy, physiology, etc.; the thera- peutic portion is very scant. But, fortunately for us, we base our prescriptions upon the totahtyof symptoms, general and local, hence a paucity of therapeutics as relating to any one organ does not greatly lessen our efficiency to heal. The pancreas cannot be "sick" without its possessor being so also.—The Homoeopathic Physician. Catalogue of Medical and Srientific Books. 87 Medical and Surgical Diseases of Women and their Homoeo- pathic Treatment. By R. Ludlam, M. D., Professor of Medical and Sur- gical Diseases of Women, Hahnemann Medical College and Hospital, Chicago. Fifth edition. Rewritten and systematically arranged. Enlarged to 1029 octavo pages. Profusely Illustrated. Cloth, $6.00; leather, $7.00. This work takes up in a systematic manner the diseases of the seven critical periods of women. Part I. General Pathology and Diagnosis. Part II. Diseases of Puberty. Part HI. Diseases of Menstruation. Part IV. Diseases of Pregnancy. Part V. Post-Puerpural Diseases. Part VI, Diseases of Lactation. Part VII. Diseases of the Climacteric. VIII. General Diseases of Women. Part IX. Surgical Diseases of Women. The general verdict is that this is the largest, latest and best work on Gynae- cology. The work is an excellent one, and one that, as we have already said, ought to be in the library of every Homoeopathic practitioner.—Homoeopathic Keveiw. Dr. Ludlam's book includes a wide range of subjects : The functional diseases of men- struation; of pregnancy, hysteria, etc., as well as the organic diseases of the ovaries, uterus, etc. The work is well and profusely illustrated; its descriptions are brief and good, etc.—Homoeopathic Physician. The book records the most recent advances in gynaecology, and exhibits clinically its science and art, in accordance with the standards of the present day. It is well printed and illustrated, showing the instruments and armamentaria of the accomplished gynae- cologist. We recommend it as a reliable manual for the student, and a text-book for the student and busy practitioners.—T. Griswold Comstock, M. D. " A somewha hasy examination of the book leads me to think that you have issued a work of which Dr. Ludlam, yourselves, and the School at laige may well be proud."— H. K. Arndt. M. D. This is no mere reprint with added matter, but a complete recasting and development of the whole work. While the clinical form is (with advantage) preserved, the lectures are so arranged and multiplied that they present a systematic picture of ovario-uterine pathology and therapeutics. It is thoroughly scientific, thoroughly practical; it is the teaching of a man who has seen and done that of which he speaks, and knows how to speak about it witn clearness and elegance. It affords delightful reading and instruc- tive reference.—British Journal of Homoeopathy. It is perhaps needless to remark that this edition, which practically amounts to a new book, is incomparably the best treatise on gynaecology ever published. Although this branch of medicine, having been cultivated with great assiduity, has made wonderful progress within a few years, Dr. Ludlam has not only kept fully posted in the discoveries of others, but has also himself introduced many valuable improvements. That this work should pass through five editions in ten years attests it popularity. The last con- tains almost four hundred more pages than the fourth, and sixty lectures instead of thirty-two. We are greatly pleased at the change in the arrangement of the lectures which now followeach other systematically, instead of discussing certain subjects j;ist in the order in which patients happened to come into the clinic. In short, there is no book on the subject that can more profitably be put into the hands of our Homoeopathic stu- dent or physicians than this. If you car, afford but one book, buy this.—New England Medical Gazette. A Treatise on Ovarian Therapeutics. By W. Eggert, M. D The object of this work is to show the power of Homoeopathic remedies ti curiuo varian diseases, tumors, etc. Price, 25c. 88 Duncan Brothers' Helps to Hear. By James A. Campbell, M. D., Professor of Diseases of the £ye and Far, Homoeopathic Medical College of Mis- souri. A neat volume in cloth. 75 cents. This little book is well compiled and well arranged.—The Medical Record. The little book which Dr. Duncan kindly gave me to read on the journey, set me a thinking, and let us hope that with constantly improving instruments and by a closer study of that beautiful organ, the ear, that deaf-mutism may be so much amelior- a ed that music may lend its charms even to these defective in hearing.—North American Journal of Homoeopathy. One of the most interesting books that we have seen for a long time is Helps to Hear. Duncan Brothers have profusely illustrated it and are entitled to credit for its tasty ap- pearance.—The Climque. "Helps to Hear" is a neat little volume, which very intelligently discusses the ear, in health a d disease, and the methods to restore it to healthful condition. The various me- chanical means are described, and the character of deafness to which each is adapted.— Inter Ocean. There are many persons in the world looking for "helps to hear" and paying their money for worthless devices which are now so exclusively advertised. It would be a great economy, as well as a matter of great interest for them to read this little book, and learn what can be done, and the merit of the various instruments which have been de- vised for this purpose. It is not only a matter of interest to the deaf, but to a great many physicians who are called upon for advice.—Eclectic Medical Journal. The object of this little work "is to offer to the profession and the general public a brief, practical review of the subject which is discussed", and the author has succeeded in so doing. Too little attention has been given this subject by the general practitioners, and in these lu8 pages he will find much that will be of service to him and his deaf patients. The most important aids to hearing are well illustrated by cut and letter-press. We advise all to invest the small amount that, is asked for it, with the assurance that they will find the money well spent.—Homoeopathic Physician. This little w irk describes, illustrate^ and discusses the value of all the various appli- ances in use to aid defectivj hearing. It is written in a readable and popular style. It describes the parts concerned in the act of hearinar; explains the principles of sound con- nected with it; discusses and illustrates all the different kinds of ear trumpets, hearing faorns and conversational tubes in use; besides numerous other forms of instruments to go into the ear. It introduces a variety of artificial drumheads, explains their use and tells where and when they are of value. Besides this, it ha3 several other chapters devoted to topics closely conne tfd with the subject, making a book which cannot fail to interest and instruct every reader.—Chicago Evening Journal. The skill of Dr. Campbell as a specialist of the diseases of the eye and ear is well-known and this work will prove a blessing to 'hose who are deprived of the inestimable boon of perfect hearing. The numerous mechanical appliances for the assistance of the deaf are named and described with rare clearness and knowledge. Of course the inventor of each claims superiority over all others, and these who seek relief are confounded by the rival arguments presented. Dr. Campbell, with scientific discrimination, has given the facts as he found them, and from his evidence the afflicted mav intelligently determine for themselves. The number of helps to heating described will be a surprise to those whose attention h s been called to the subject. As this work covers an unworked field in scientific literature, success will surely follow.—The Spectator. "Helps to Hear" is the title of a li'tle volume written by Dr. James A. Campbell, a professor in the Homoeopathic Medical College of Missouri, and just published by Dun- can Brothers, of this city, who are also publishers of a great many other medical and semi-medical works. Tt opens with a brief exposition of the anatomy of the ear, of the nature of sound and of the method of its transmission, and then proceeds to a description of all the various a tificial aids to hearing from the simplest form of th=> ear trumpet down to the andiphone, and even the telephone of our dav. These descriptions include a statement of the principles of construction of all these, and of the theories of their oper- ation, and the little volume closes with some rather enthusiastic speculations as to the possibilities of the use of the principles involved in the operation of the telephone in devising further aids to the deaf. The number of those whose hearing is more or less weakened either congenitally, from disease, or other causes, is very much largerthan one would at first suspect, and these comparatively few have any knowledge of the various meci'nni^al appliances for a«si«tinal practitioners this knowledsreis comparativelv rare. Scarcely anything has -„een written on the subject and this little book, which seems to be very fair and very full, containing descriptions, with illustrative cuts, of all known devices in the direction named, oreht to be very wel- come to both professional and non-professional readers.—Chicago Times. Catalogue of Medical and Scientific Books. 89 A Hand-Book on the Diseases of the Heart, and their Hom- oeopathic Treatment. By W. P. Armstrong, M. D., formerly ecturer on Diseases of the Heart; Member of the American Institute of Homoe- opathy, etc. One volume, 271 pages. Just out. Cloth bound, $1.50. The author has written concisely, and has aimed to supply in a compact and convenien form that which is most important with reference to diseases of the heart, their pathol ogy. diagnosis, and Homoeopathic treatment.—Phys. and Sur. Investiator. So many authors have tried to bring order out of the chaos of murmurs, so carefully described in text-books, and still it takes long personal experience to become an adept in percussionaud auscultation. We can recommend the hand-book to the student, as it gives him hints, which by and by he can fully study out in larger works. We have known Dr. Armstrong as a conscientious therapeutist for some time and his indications may be therefore considered up to the mark.— North American Journal of Homoeopathy. Dr. Armstrong's Hand-Book on Diseases of the Heart posssesses points of considerable merit, and torms a by no means insignificant addition to our literature on this subject. While not rich in originality, it gives a resume of pretty much all the important facts in con ection with the subject which have been developed, and point out, in a concise form and n clear and well-chosen language, those characteristic and diagnostic symptoms of the lnrious affections of the heart which it is lmportnnt for the practitioner to under. stanva The book will repay careful study.—Meoical Counsetor. A Clinical Assistant. Diseases and Symptoms and their Homoeopathic Treatment. By R. W. Nelson, M. D., M. R. C. S. L. Sec- ond edition, revised and enlarged. Justout. Price,$1. Interleaved$1.50. This little pocket volume is evidently the work of a careful student and close observer, and will prove of real assistance to the physician's memory.—The Homoeopathic Times. Convenient for the pocket, containing a large number of valuable hints and sug- gestions for the busy practitioner.—American Observer. Ready for the pocket and thus "a friend in need is a friend indeed. It does not over- burden you with too many remedies."—North American Journal of Homoeopathy. Take the book and add your own experience on the margins and you will have a handy, trustworthy and practical reminder of your daily practice. We find much that is original and suggestive, and predict that in many an emergency it will be found a friend indeed. —Homoeopathic News. The Clinical Assistant is at hand, and I am greatly impressed with it as a work of incal- culable importance to the practitioner. Its alphabetic headings and brief symptomatic detail of disease are wonderful, clear, full and definite, and still more to be commended is that of its suggestive remedies, with a practical statement of potencies. H. C. Cone. Diet Rules for Children of Different Ages. These are plain, practical directions, designed for general circulation, and are abstracts from a paper read before the Illinois Homoeopathic Med- ical Association, by Dr. T. C. Duncan. Those who have distributed many of these Rules speak highly of them. Price 1 cent each, or ten cents per dozen copies. Analysis of Acute and Chronic Diseases and their Supposed Causes. By C. P. Jenning, S. T. D. Price, 10 cents. The basis for acute and chronic diseases is well established in this pam- phlet and the thereapeutic procedure for both well marked. The Prevention of Congenital Malformations, Defects and Diseases. By J. C. Burnett, M. D., editor of the Homoeopathic World. ondon. Price, 25 cents. This little treatise suggest the possibility of a great work. If congenital malformations can be prevented it will prove a great blessing. Every mother as well as every physician should read this book. 90 Duncan Brothers'1 The Homoeopathic Therapeutics as Applied to Obstetrics. By S. Leavitt, M. D., Clinical Professor of Obstetrics, Hahnemann Hos- pital, Chicago. Just out. Price, cloth, $1.00. It fills a most important field and will prove valuable alike to student and practitioner. Dr. D. S. Smith, says: " 1 have critically read the 'Therapeutics of Obstetrics' and find it a very useful and convenient little book of reference, and take pleasure in commend- ing it to the profession, more especially to students, who will not fail to appreciate its merits." This little book apparently embodies the experience of its author in the use of drugs of which it treats. The subjects are intelligently worked up from a clinical standpoint in such a manner as to enable easy comparison and individualization, thus making a hand-book of value to the practitioners in this department.—Homoeopathic Times. I have examined the book, "Therapeutics of Obstetrics," and am very much pleased with it. It seems to me that it will prove to be of great value to the busy practitioner; and I know of n& otLier work from which one can gain as much information in the same time on the choice of a remedy in any obstetrical emergency.—H. P. Skiles, M. D„ This is a neat little book, giyingthe clinical and pathogenetic indications for remedies in Obstetrics and a repertory of remedies as applied to Obstetrics. The arrangement is simple and the symptoms are presented without the customary needless repetitions with which our literature is burdened. We heartily commend it to the profession as a reliable, trusty and convenient guide. It is a practical little book, and deserves a large and rapid sale, which we doubt not it will obtain.—Horn. Journal of Obstetrics. This new advocate for professional favor claims that, only the "most characteristic features of a limited'number of remedies, and these only, are embraced" in its design. In pursuance of this object, there is given the condensed symtomatology of ninety remedies, with a repertory. The indications for the remedies are short but in the main good; the repertory will be found especially useful. This brochure will be of service to those who are in the habit of searching for the similimum; to ail such we re- commend it.—Homoeopathic Physician. The Ophthalmoscope; Its Theory and Practical Uses. By C. H. Vilas, M. A., M. D. Professor of Diseases of the Eye and Ear in the Hahnemann Medical College, and Clinical Professor of Eye and Ear Diseases in the Hahnemann Hospital. Just issued. Cloth $1.00. This practical treatise rills a most important field. We take pleasure in commending this manual on the Principles and Practice oi Ophthalmoscopy. The work is a very good one, and will be a great aid to the beginner in studying the subject.—Physicians' and Surgeons' Investigator. The treatise now before us is calculated to do just what it indicates: it tells us what the Ophthalmoscope is, how to use it, and what use to make of it. It is a most interesting work, written by one who is master of the subject under discussion, and who has the ability to make himself well understood ; the volume is profusely illustrated, printed on good paper, and should have a rapid sale. We can heartily recommend it.—Medical Counselor. "The Ophthalmoscope" by Dr. Vilas, sent by you was duly received. On a careful examination of the work, I am convinced that it is fully up to the times, and reflects credit on the author. The instruction given in the manner of using the Ophthalmoscope, and the practical manner of treating refractive disorders, make the work as valuable to the Practitioner as to the specialist. There is now no good reasou why every practi- tioner of medicine shall not make free use of the Ophthalmoscope in diagnosing disease. — Wm. L. Breyfogle. M. D., President of the American Institute of Homoeopathy. Catalogue of Medical and Srientific Books. 91 Text-Book of Materia Medica, Characteristic, Analytical and Comparative. By A. C. Cowperthwaite, M. D., Ph. D., Professor of Materia, Medica and Diseases of Women in the Homoeopathic Depart- ment of the State University of Iowa. Second edition, revised and en- larged, making an elegant, compact volume of 576 pages, Cloth. $4.50: halt morocco, $5.50. Just out. A new edition of this valuable characteristic, analytical and comparative work on Materia Medica is now ready. The first edition was highly en- dorsed by Professors of Materia Medica in Philadelphia, New York, Cincin- nati, St. Louis, and Chicago. The fact that a second edition of any work should be called for within the time which has elapsed since the issue of the first edition of the book under consideration, is suffi- cient evidence that it has met an appreciative demand. The text has been thoroughly revised, and a number of additional remedies incorporated. We can justly say that it is multum in parvo '.—The Homoeopathic Times. In less than six hundred pages Prof. Cowperthwaite gives a clear, but necessarily brief synopsis of the characteristic symptoms of nearly three hundred drugs. Some remedies not in the first edition, have been added ; others, thoroughly revised, and many new "comparisons" added. These comparisons are a new and special feature of Prof. Cow- perthwaite's book.—The Homoeopathic Physician. The first edition of this text-book was issued three years ago, and received the general commendation and praise of the Homoeopathic profession. This edition has been much improved, and the work as it now appears cannot fail to be received with increased favor. The author has endeavored to furnish the beginner with the prominent features of the most important remedies and to so arrange them as to facilitate their study. He has written clearly and concisely, and eliminated much that is of little or no importance, and serves only to stagger, discourage and disgust those not familiar with, or beginning the study of Homoeopathy. He therefore confines himself to " characteristic symptoms," and mostly gives those which are "pathogenetic" and have been made known by prov- ings on healthy persons. He does not, however, " throw out altogether those distinctly curative symptoms, which have been so repeatedly verified as to render them charac- teristic." Kemedies having similar symptoms are recorded in the text for comparison. Diseases of morbid conditions are also mentioned, in which the symptoms of the drug arc most apt to occur, and in which clinical experience has most often verified its use. We believe this to be one of the best text-books of Homoeopathic Materia Medica pub- lished, and heartily recommend it to the student and practitioner.- Physicians and Sur- geons Investigator. A New Similia. First Principles of Homoeopathic Therapeu- tics. By A. VV. Woodward. M. D., Professor of Materia Medica and Therapeutics. Chicago Homoeopathic Medical College. This is a unique presentation of the study of remedies and their thera- peutic application. The selection is based upon the similar order of succession of symptoms—a new similia. Physicians read this brochure with profit. Price, 25 cents. Sun Stroke and its Homoeopathic Treatment. By c. B. Knerr, M. D. Price, 15 cents. This brochure treats a grave emergency in a plain, practical manner; coming from an associate of Father Hering, it bears the marks of scientific exactness and reliability. 92 Duncan Brothers'1 An Illustrated Repertory of Pains in Chest, Sides and Back ; their direction and character confirmed by clinical cases. By R. R. Gregg, M. D. In one octavo volume. Third edition. Cloth, $1.00. This work illustrates the direction, character and location of pains in a unique and valuable manner. Gregg's " Illustrated Repertory " is an old and valued friend, and in many a disputable case the arrow's point divided our choice of the remedy.—N. A. Jour, of Horn. The idea of helping our sadly overladen memories with the aid of pictorial symp- tomatology is very laudable .... This book teaches us one very useful lesson, whi-.-h our careful author has evidently learned well, viz., the very great importance of noting the direction of pains.—Horn. World. We think the idea a very happy one and likely to prove of much usefulness. Patients often complain of anomalous pains, and are glad to get relief from them, though neither the sensations they have nor the remedies we employ are related to deeper complaints for which we may be treating them. We can best help them by administering a drug which has caused similar pains on the he^I-hy subject; and such a drug can be much more rapidly found by looking at one of Dr. Gregg's plates than by turning over the pages of an index to the Materia Medica. It may sometimes happen,j moreover, that these pains have a true pathological relation to the patient's whole moroid state ; in which case the remedy Homceopathically indicated by them, may do good, general!<', and may even prove to be the true simile of the malady. Dr Gregg gives some instances in which this seems to have obtained.—British Journal of Homoeopathy. Surgical Therapeutics. Surgical Diseases and their Hom- oeopathic Treatment. By J. G. Gilchrist, M. D., Lecturer on Surgery, Homoeopathic Department, Iowa University. Third edition. Now ready. One large volume of 461 pages. Cloth, $4.00. This valuable work, endorsed by many surgeons, gives the Homoeopathic Treatment of Surgical Diseases. It is very popular having run through three editions. I look upon it, in its new edition, as an extremely valuable book, and exceedingly useful, not only to the Surgeon, but the general practitioner, as well. I have read and consulted it in my practice, with much pleasure and profit.—Chas. M. Thomas, Prof. of Surgery in Hahnemann Medical College. This book has become so well known to our profession in its earlier editions, that it is only necessary here to say that the present edition is a very great improvement on its predecessors. It has been so thoroughly revised and rewritten, albeit, keeping the same object in view, that those who appreciated the first edition will want to supplant it with this.—New England Medical Gazette. " This is the third edition of the first work on Surgical Therapeutics in our school, entirely rewritten and brought down to date, enriched by the clinical and therapeutical researches of a hard student. , . - The chapters on 'Tumors,' " Diseases of the Nerves,' and especially that on the 'Genito-Urinary Diseases'are exhaustive in their remedial indications, and invaluable to the practitioner removed from easy access to surgical consultation."—Medical Advance. How to be Plump, or Talks on Physiological Feeding. By Prof. T. C. Duncan, editor of The United States Medical Investigator, etc. Fifth thousand edition. Neatly bound in cloth, 25 cents. This is a treatise on leannens and how to correct it. The difficulties and advantages are well brought out in a conversation between an artist and the author who relates the story "How I Became Plump," and explains this physiological condition. It has been very favorably received. • Excellently written for its purpose and should have a large sale.—Homoeopathic Times. Catalogue of Medical and Scientific Books. 93 A Treatise on the Decline of Manhood. By A. E. Small, M. D., President of Hahnemann Medical College, Chicago. One neat volume. Cloth, $1.00. Sexual Neuroses would have been a good title for this book, for it deals with such innervating troubles as spermatorrhoea, masturbation in both sexes, and sexual excesses and weaknesses; but thu author has chosen the caption used by the quack to frighten and to bleed his victims. This little book gives to the profession and the poor sufferers some practical sugges- tions and advice. It is essentially a treatise on the various causes that induce the premature decline of manhood and the most judicious means of removing them and curing their effects. The wise, fatherly counsels of the veteran author especially adapts it to be put into the hands of erring and despondent young men. The work abounds in practical hints for the med- ical adviser. " A popular treatise, pure and helpful, on masturbation in both sexes, spermatorrhoea, the sexual relation in marriage, etc."—New England Medical Gazette. This is a very sensible book on a most delicate subject, and Dr. Small must be a very brave man to write it. On the whole it will do good ; it can do no harm, for its style is pure. We have long felt that medical men are to blame for allowing the treatment of man's sexual sphere to lie almost entirely in the hands of the unclean advertising quack, for such is indeed the case.—The Homoeopathic World. " This is a subject to which most physicians have given a good deal of attention, and have had more or less of success in the management of the cases that have come t< them. Perhaps no work will be more welcome to the profession— filling as it does, e most important vacancy in medical literature with its wise counsels. This work in many ways is a most healthy one to put into the hands of young men, and will tend to save them from the grasp of quacks whose flaming advertisements tend to frighten and de- coy their deluded victims. The work is dignified in tone and full of practical sugges- tions.— United States Medical Investigator. This little work by Prof. Small will find many readers. It will do this because it treats of a subject which is of universal interest, viz: the impairment of the sexual organs and functions ; the causes which lead to it; the consequences, and the means of restora- tion of sexual vigor. Again, the subject is handled with great delicacy and conciseness. The author deals with his theme in a very clear and systematic way, and impresses the reader as one having authority to speak. The treatment of sexual weakness in the form of spermatorhcea, etc., is decidedly Homoeopathic ; but, if the experience of the author is worth anything, it recommends itself to the afflicted. Other measures, such as hygiene, electricity, etc., are not ignored.—Physician's and Surgeon's Investigator. Abridged Therapeutics; Founded upon Histology and Cellular Pathology. New Treatment of diseases by the Inorganic Tissue Cell- Salts, the Natural Constituents of the Human Body, with an Appendix. ''Special Indications for the Application of the Inorganic Tissue-Form- ers." By Dr. W. H. Scnussler. Authorized Translation. Cloth, neatly bound, $1.50. Now ready. Practical Guide to Homoeopathy for Family and Private use. By Drs. Pulte, Laurie, Hempel, Ruddock, Burt, Verdi and others. Paper 25 cents ; cloth 50 cents. The demand for a compact and yet plain guide for the use of Homoeo- pathic remedies has produced this work that has had a very large sale. It is just the guide for the beginner. 94 Duncan Brothers'1 Spectacles, and How to Choose Them. By C. H. Vilas, M. D., Professor of Diseases of the Eye and Ear, Hahnemann Mediral College. One neat illustrated volume. Second Edition Cloth, $l.uu. This is a work that every student and physician should possess. It sup- plies a great need. Were the essay especially designed to give a hint to general practitioners as to how little they really know, or claim to know, of the scientific selection of spectacles and faintly indicated to them how much harm may result from a blunder in this matter, the same could not have been mere skillfully written.—The United States Medical Investi- gator. A very interesting and instructive book, not only for the general practitioner, for whom it is especially designed, but also for laymen, technicalities and obscure terms be- ing avoided. Its aim is to prevent the too common haphazard and often injurious custom of choosing one's own spectacles, or trusting to unprincipled or ignorant venders. The dollar for it will be well spent.—New England Medical Gazette. It tells everything which an intelligent layman or even an ordinary practitioner need know about the anomalies of vision and their correction. It would, we should think, be especially valuable to opticians in towns where no oculist is resident; and if we know of any such, we could hardly do them a greater service than by bringing it to their knowledge."— British Journal of Homoeopathy. Feeding and Management of Infants and Children, and the Homoeopathic Treatment of their Diseases. By T. C. Duncan, M. D., author of "How to be Plump," etc. 426 pages. Neatly bound in cloth, $2.00; half morocco, $2.75. This popular elementary work is essentially a treatise on the Hygiene of children. It is a valuable book for beginners, and also for physicians to supply their patrons. Evidently Dr. Duncan is a fine baby kenner, an eminent authority on paedology *nd a man of no mean merit.—Homazopathic World. Wo recommend this work especially to students and young physicians for the chapters on food and management, which they will find better treated than in any other small work on this subject, indicative of the words with which the author heads his introduc- tion: "An ounce of prevention is worth a pound of cure."—American Homoeopath. Prevention is better than cure," and many a babe will fare better if the mother follows the advice given by that great friend of our babies, T. C. Duncan. It is a work, whose first part we can fully endorse, and since I studied these alkaline and acid babies, my endeavors are to have my little patients alkaline. The artificial feeding of children is a most interesting study even to an old physician, and only by following closely the rules laid down, can we prevent the necessity of studying the second part,—North American Journal of Homceopsthy. A Treatise on Diphtheria. By A. McNiel, M. D., Member of the American Institute of Homoeopathy, etc. A neat compact volume of 145 pages. Cloth, $1.00. This is a prize essay and a valuable reference book. " Your book is excellent."—E. J. Lee. "The latest and best work published on the subject from a Homoeopathic standpoint." —The Homoeopathic Courier. Dr. G. M. Pease, of San Francisco, writes: " Your little book on Diphtheria is, I think, the best thing in the English language. Am now using it constantly, and believe it given me a great deal of support. . . . The practical use of a book is what will tell its worth." Catalogue of Medical and Scientific Boiks. 95 A Practical Guide for Making Post-Mortem Examinations, and for the Study of Pathological Anatomy. With Directions for Embalming the Dead, and for the Preservation of Specimens of Morbid Anatomy. By A. R. Thomas, M. D., Professor of Anatomy in Hahnemann Medical College of Philadelphia ; Lecturer on Artistic Anatomy in the Pennsylvania Academy of Fine Arts, and Philadelphia School of Design ; Member of the American Institute of Homoeopathy, etc., etc. Price, $2.00. This work is a valuable text-book and a ready reference for the busy prac- titioner on pathological questions relating to the living as well as to the dead. The directions for opening each grand division of the body are clear and thorough, and could have been written only by one who had been there himself. Chapters IV. and V. are alone worth the price of the book.— American Homosopathic Observer. We are glad to know tl at Prof. Thomas has consented to place in the hands of the pro- fession so valuable an aid in post mortem examinations. Not only do we learn how to perform the operation skillfully but the morbid anatomy of the parts is plainly set forth. This work should be placed in the hunds of our students, and made a part of the curricu- lum of our schools. It is well systematized, compact, and beautifully printed.— Medical Advance. It is not a mere guide as to how to cut open, how to dissect, and how to sew up a dead body, nor e\ en a bald catalogue of morbid appearance of various organs, but a h ghly readable, and we may say, a fascinating story of the ravage of diseases within ihe "hu- man form divine" indeed to be a perfect and exhaustive treatise on morbid anatomy; rfhich disclaimer, however, will prove an encouragement to the busy physician who has time to peruse only that of which he dare not be ignorant. * * * We say to every Homoeopath, (and Allopath as well), buy and study Dr. Thomas' work. You will thank us for the advice.—American Journal of Homoeopathic Materia Medica. The Law of Cure. By T. M. Triplett, M. D. This is a stirring pamphlet that awakes and arouses enthusiasm for Hom- oeopathy. Per hundred, $2.00; 200, with card printed upon them, $4.00. The Progress of Medicine as influenced by Homoeopathy. By A. J. Clark, M. D. This is a new tract that is destined to have a large run. Price, per 100 copies $1.00; if 200 is taken, and card printed on back, $2.00 ; 500 copies, with card, $4.00. How to Feed Children to Prevent Sickness. Bound in paper, 10 cents ; cloth 25 cents. This is the substance of an address, by Dr. Duncan, delivered before a com- pany of mothers, and bears chiefly on the avoidable causes of sickness among children. Physician's Memorandum and Account-Book. Price 75 cts. A compact and convenient book, having blanks arranged for month,date, name, visit, prescription, dr., cr., and remarks. Good for any date or year. It gives excellent satisfaction. One physician says : " It makes a very con- venient day-book." Another writes: " I use it as a diary, day-book and ledger." 96 Duncan Brothers'1 Minor Surgery and Surgical Principles. By J. G. Gilchrist, M. D. Formerly Lecturer on Surgery, Medical Department, Michigan University. Lecturer on Surgery, Homoeopathic College Iowa Univer- sity. One volume of 205 pages. Cloth $1.25. Surgery has its underlying principles as well as medicine. This work takes up surgical diagnosis and semeiology and then describes with great minute- ness and clearness the details of minor surgery. The description of the instruments needed for minor operations and the material for dressings precede the directions for dressing wounds and incisions. The whole details of bandaging of all kinds of all parts of the body are fully and carefully given. These are rendered very plain by numerous illus- trations. "Permanent dressing," and "splints," are practical chapters. The same is true of "vaccinations," "tongue tie" and "injections." The chap- ter on "catheterism" is remarkable for clearness of description. On the whole this is a compact practical work without padding with things that do not belong to minor surgery, but are often included to swell the size of a volume. The author has had in mind the needs of beginners. It is un- questionably the "first book" in surgery. This work is adopted as a text-book on Minor Surgery in tne leading medical colleges. It is written in a plain unassuming style, so that he who reads may understand.—North American Journal of Homoeopathy. Dr. Gilchrist seems to possess a rare union of surgical dexterity and medical skill and heuce we have all the greater pleasure in commending this excellent work as a sound Minor Surgery.—Homoeopathic Wo/ld. This work is intended as an aid to students, and as a compact and convenient resource to the busy practitioner who has but occasional need for surgical knowledge. The application of splints and bandages is well illustrated by means of white linear drawings on a black ground. We commend the book as eminently useful.— ahnemanian Monthly. The present volume is a very elementary work, and leaves out many topics usually discussed in books on minor surgery, confining itself to bandaging, dressings, splints, catheterism, etc. Everything is concise and practical. Dr. Gilchrist is a very pleasant writer, and has the knack of putting things very neatly.—New Eng. Med. Gazette. A Treatise on Typhoid Fever and its Homoeopathic Treatment. By M. Pannelli, M. D. Translated by G. £. Shipman, M. D., with cop- ious additions including a chapter on symptomatic indications for remedies by C. Hering, M. D., 300 pages cloth bound. Price $2.00. Typhoid fever is an insiduous and treacherous disease and the oldest, most experienced physician is glad of practical suggestions as to varieties, com- plications and management. This work including the observations of both European and American writers, is at once a most systematic aud practical tre itise and without a peer in medical literature. I am very much pleased with the book. Would not do without it. and recommend every one who treats typhoid fever to get a copy.—C. C. Oi-mstead. M. D. This book fills a vacant place in the catalogue of Homoeopathic literature. A glance through its pages will readily evince the fact that it is replete with sound practical sense and useful information; that it is prepared with great care and thoroughness, every phase of the disease brought under consideration and ably discussed ; the adaptability of Homoeopathic remedies clearly and faithfully portrayed, and altogether just such a book ~s io required in every-day life.—S. B. Parsons, M. D.. Surgeon Homoeopathic Medical College, Mo. * ^: O^hl^i^ Q ''A^^0 A.& A^0^ ■«—x —ff~ ■..--<&- - ■"/ —©---»?--«-- ■.'--» —, S"=;«ri_^ ™--"rT.y''" '^>','>-t/,'T! 'rv f .„tvx?Vx?■?■,;?.%£~7--a ?■$■£■'.:■; ^;^/'^,0M®:M^' >nUS :^'Fx 1 ^^^g^S^^g^S^'^ .— «=r- EWfeSli»l^E ■i l- ^'.d.b:'^,b';- ^^M^^W$$$^i^^^SMi ■ .y>yMwWm% NLM001363633