3RIFICIAI mi R(xT^R~\ Pratt t** <&&&.* 555555555O5555555555555555755555 4567 U.S. NATIONAL LIBRARY OF MEDICINE i Bl^Ti^As^A v~* * SURGEON GENERAL'S. OFFICE 5 LIBRARY. t ------ -f > -•*»* VPT.-O Section, JVo l%l oGo, r^ & .-.* S^TT**^*3 !-iV RETURN TO NATIONAL LIBRARY OF MEDICINE BEFORE LAST DATE SHOWN ^AR 1 1983 NLM005547905 99999 ORIFICIAL SURGERY AXD ITS' APPLICATION TO THE TREATMENT OF CHRONIC DISEASES BY V,--'' E. H. PfATT, A.M., M.D., LL. D. H'LOFESSOR OF PRINCIPLES AND PRACTICE OF SURGERY IN THE CHICAGO HOMtEOPATHIC MEDICAL COLLEGE ; FORMERLY ATTENDING GYNAECOLOGIST TO COOK COUNTY' HOSPITAL, CHICAGO. CHICAGO W. T. KEENER 1887 .<> _ ^ v. V\|0 WS7 Copyright, E. H. Pratt, il Chas. N. Trivess, Printer CHICAGO TO MY LOVING FATHER, WHOSE STERLING CHARACTER, STUDIOUS HABITS, AND PATIENT HANDLING OF AN IMPETUOUS NATURE, ARE IN GREAT PART RESPONSIBLE FOR ALL THAT I MAY BE ABLE TO ACCOM- PLISH, THE WORK, OF WHICH THIS LITTLE VOLUME IS BUT A POOR EXPRESSION, IS, WITH DEEP- EST AFFECTION, DEDICATED. \ ERRATA. Pao-e 89, 10th line from top, for introduction, read menstruation. Pages 121 and 122, for siphylis, read syphilis. Page 67,5th line from bottom, for eelecticism, read eclecticism. PREFACE. This handbook comprises the substance of a series of lectures delivered to the class of the Chicago Homoeopathic Medical College dur- ing the winter of 1886-87. While a larger treatise is in course of preparation, the demand for information on the subject of which it treats has been so great as to win my consent to its publication. Although conscious of its limita- tions, I am persuaded that it contains enough new material to be of some service to workers in this field of surgery. At the request of the students I have in- cluded reports of cases illustrating the practical application of orificial surgery. I would gladly have added the names of more of my good friends to the list of contributors had time per- mitted. I owe a debt of gratitude, which I here desire to express, to those who have favored me with reports of cases, to the present college class, for their active interest in orificial work, and to Dr. Chas. Gatchell for much valuable -assist- ance. Chicago, III. E„ H. P. February, 18.87. ORIFICIAL SURGERY. i. THE PHILOSOPHY OF ORIFICIAL SURGERY. * I HHERE is one chief agency by means of which man's physical being is developed, by which it is maintained in a normal condition, and, when broken down or impaired, by which it is restored to a condition of health. Hence, there is one principal thing to which measures for the relief of bodily ills should be directed. It matters not what these measures may be; whether they take the form of the admin- istration of medicines, of massage, electricity, bathing, mental influences, or any other agency at our command, all are directed to this one thing alone: I mean, the circulation of the blood. If the blood current is strong and free, we are well; if, on the other hand, the general cir- culation is sluggish, or if local congestions oc- 10 ORIFICIAL SURGERT. cur, disease is a necessary consequence. To re-establish and to maintain a normal circula- tion, local and general, is then, the great prob- lem that demands solution in the successful treatment of chronic diseases, both medical and surgical. It is well known that it is upon nerve-force alone that the circulation depends for its activ- ity. Hence, the proper supply of nerve-force means a good circulation, with all that that in- volves; a waste of nerve-force, or an insufficient supply, means a feeble circulation, with all its evil consequences. Should I ask to what special nerve-force I refer, you would all un- derstand that I mean that furnished by the great vaso-motor system. I shall leave to others the discussion of the question of how much of this system is formed by the cerebro-spinal and how much by the sympathetic nervous organization. It is admitted that both can influence vaso-motor function. Through the action of the cerebro- spinal system the various emotions can affect the rapidity of the heart's action, and can influ- ence digestion and assimilation. This influence can extend even to the changes which the blood undergoes in the lungs, as well as to ITS PHILOSOPHY. 11 cell-life in the various tissues, both as regards building up and tearing down — the growth and the disintegration of tissue. By means of the sympathetic force the functions of animal life may be carried on when waking or sleeping, when resting or toiling, under all conditions and at all times, without the aid of the cerebro- spinal system. Besides this common plane of action of the two systems of nerves, each one has its own special office to perform. The cerebro-spinal is the direct connecting link between the spir- itual and the physical man. It controls the action of every voluntary muscle of the body. The fibrillae of the voluntary muscles are crossed by striae, and the sole function of the voluntary muscles is to permit the body to move and to be acted upon in whatever manner the cerebro-spinal system may direct. But all muscles are not voluntary muscles. There are other muscles whose fibrillae are not crossed by striae, and whose movements are not presided over by the cerebro-spinal system. These are the involuntary muscles, and the influence which causes them to act comes from the sym- pathetic nervous system. 12 ORIFICIAL SURGERY. The fibres of the involuntary muscles are so placed as to constitute one of the coats of every tube in the body, from the great respir- atory, digestive and urinary1 tracts, to the more delicately organized arterial canals and glan- dular ducts. The mode of distribution of the fibres is a common one — an inner layer ar- ranged circularly, and an external layer arranged longitudinally — securing by their alternate ac- tion of constriction and shortening, the vermicu- lar motion by which all involuntary processes are carried on. Like the fibres of the voluntary muscular system, the individual fibres of the involuntary muscular system are in close sym- pathy. The spasmodic contraction of any part of them may, if sufficiently protracted, enlist the sympathies of the entire mass of involun- tary fibres, interfering thereby with the proper functions and circulation of the entire body. By relieving this tension, a corresponding relief will be universally experienced. With this introduction, let me now call your attention to the lower openings of the body. These openings are guarded by double sphincters. The upper ones are composed of involuntary muscular fibres, and, consequently, are supplied by the sympathetic nervous sys- tem. ITS PHILOSOPHY. 13 The lower ones consist of voluntary mus- cular fibres, and are supplied by the cerebro- spinal nervous system. This is true of the rectum, and it is true also of the male and fe- male urethrae. The sexual organs proper, in both sexes, take their nerve supply from the sympathetic nervous system. Hence, whatever wastes sex-' ual power in either sex, causes a waste of sym- pathetic nervous power, and therefore lowers the nervous tone of the entire sympathetic sys- tem. Spasmodic conditions of the os vesicae and internal sphincter recti, will produce, like- wise, similar disastrous consequences. The proposition which I now desire to present, will doubtless seem somewhat startling to those who hear it for the first time, because nothing but an extended experience can ever convince one that it has such a wide application as it really has. It may be that my own ex- perience, added to that of hundreds of co- workers in this field, has not yet been extensive enough to justify so radical a position (although a practice confined exclusively to the treatment of chronic diseases for nearly two years has multiplied that experience very rapidly indeed), yet it is now sufficiently well established to i 14 ORIFICIAL S URGER Y. justify my offering it for your approval or dis- approval, as the issue may be. The proposition is this: In all pathological conditions, surgical or medical, which linger persistently in spite of all efforts at removal, from the delicate derange- ments of brain-substance that induce insanity, and the various forms of neurasthenia, to the great variety of morbid changes repeatedly found in the coarser structures of the body, there will invariably be found more or less irritation of the rectum, or the orifices of the sexual system, or of both. In other words, I believe that all forms of chronic diseases have one common predisposing cause, and that cause is a nerve- waste occasioned by orificial irritation at the lower openings of the body. These irritations induce a rigidity of the sphincters guarding the parts, which either continues, sympathetically affecting the rest of the involuntary muscular system, and steadily draining the nervous power that supplies it, until the whole struggle terminates in a rigor mortis; or, tiring out in the hopeless grip, relaxes into the inertia of paralysis. Aside from this view of the relation of ori- ficial irritation to chronic suffering in all its forms, there is another worthy of mention in ITS PHILOSOPHY. 15 this connection. It is that of reflex effects of irritations in general. A rusty nail in the hand or foot, or anywhere else, may irritate, by reflex action, the central ganglia, and induce tetanus; pregnancy, by its tension at the internal os, may induce trouble in the stomach or head or heart, by reflex action, instead of being felt in the pelvis; and irritations at any of the lower orifices, instead of causing trouble at the seat of irritation, may be reflected to any of the other orifices, or, indeed, to any other part of the body. I desire, however, to call your attention more particularly to the close reflex relation existing between the rectum and the lungs. This is more important than many others, be- cause the chest, in its action, resembles a great suction-pump, and is the chief agent in drawing the blood from all parts of the body back to the center of circulation. Hence any influence that affects the respiration affects also the ac- tivity of the entire body. Under profound anaesthesia any surgical operation, major or minor, may be performed upon any part of the body (provided it does not involve the sphincters or the nerves of respiration) and the breathing of the patient 16 ORIFICIAL SURGERY. will go on uninterruptedly and regularly. It will, however, be a new revelation to those who are not familiar with the phenom- enon to observe the peculiar effect of rectal dilatation upon an anaesthetized person. Place the patient upon the side, and, with two fingers of each hand well introduced into the rectum, so as to secure a good grip upon the internal sphincter, carefully separate them so as to put the sphincter well on the stretch. The respira- tion will invariably be more or less oppressed, often responding to the stretching so keenly as to place the ability of the patient to breathe entirely in the hands of the operator, being suspended so long as the stretching continues, and resumed as soon as it is discon- tinued. A similar effect often is seen in the use of sounds in the sexual organs, but it is not so marked or so constant. Dilatation of the external sphincter ani alone will not produce this effect, showing the simple fact that it is entirely due to a reflex of the sympathetic system, and not of the cerebro-spinal. These two facts — the effect upon the res- piration, and the close sympathy existing be- tween all involuntary fibres contracting and relaxing in mutual sympathy — is the only ITS PHILOSOPHY. 17 philosophical explanation which I have at pres- ent to offer why orificial work has such instan- taneous and truly marvelous effects upon the entire circulation, warming at once all parts that before were abnormally cold, and cooling parts that were abnormally hot; starting, as if by magic, functions that had been long dor- mant, and subduing those that had been abnor- mally active ; in a word, more or less completely re-establishing uniformity of circulation and function. II. THE PATHOLOGY OF THE RECTUM. CINCE the whole problem of the treatment ^ of chronic diseases, is to re-establish and maintain a strong and steady circulation of the blood, this object will be kept constantly before your minds. The first step to that end is, by proper orificial work, to stop the invol- untary nerve-waste which is invariably found to exist, and in pursuance of this idea let us first consider rectal disorders. In approaching the subject of rectal sur- gery I am aware that my position is one involv- ing no little responsibility. I am introducing to this class of students and doctors of medicine, a line of work which is in some respects new, and one which, if poorly or imperfectly performed, can do much harm. On the other hand, when well and carefully done, it will result in infinite good. I do not wish to create such fears in your mind that you will fail to avail yourselves of the work whenever you meet with a case to which it is applicable; neither do I wish to paint PATHOLOGY OF THE RECTUM. 19 its possible results in such glowing colors that you will resort to it indiscriminately, regardless of consequences. The task of giving to all of you just the right impression of the value and the proper place for the work, is no easy one, because, like all assemblages of human beings, you are of different temperaments, and, while a mere suggestion would be sufficient to give some of you a right understanding of it, those who by nature are more conservative, require special emphasis to give you confidence. Let me caution you, however, one and all, that the work involved in this class of rectal surgery is a two-edged tool, which, according to its skil- ful or unskilful handling, may do exceeding good or exceeding harm. Hence the feeling of responsibility with which I approach the subject. Rectal troubles may very properly, it seems to me, be divided into two general classes: First, those of which the patient is made conscious by the attendant local symptoms. Second, those of which, by reason of an absence of local disturbances, the patient is unconscious. 20 ORIFICIAL SURGERY. The lesions belonging to the first class are well known, for those who suffer from them, whose lives are made miserable by the local irritation, have, time out of mind, applied to the members of the profession for relief. They are made painfully conscious of the existence of a rectum, and are not only willing to submit to an examination, but insist upon its being made, and hence, in the treatment of this class of cases the profession is experienced, and there exists, as a consequence, the usual variety of conflicting opinions and misleading statis- tics. The cases belonging to the second class — which are more serious, because the more prodigal of nerve-force — have almost escaped the notice of the profession. The reason for this is that they have remained unsuspected and therefore undiscovered, both by the victims and by their medical advisers. In entering into the details of the cases of the first class, I shall not review the great mass of work which has been done by others — by those who are looked upon as authorities on the subject — but I shall confine myself to giving you, in each instance, the method of treatment which an extended experience and PA THOLOGY OF THE RECTUM. 21 research have led me to adopt as being the most satisfactory and successful. This class includes but five forms of rectal lesions to which I shall invite your attention. These are: (i) Haemorrhoids; (2) Prolapsus recti; (3) Fistulae; (4) Ulcers; (5) Fissures. Considering first the much-vexed question of haemorrhoids, or piles, their common division into internal and external piles is convenient and satisfactory. INTERNAL PILES. As regards internal piles, there may be those among you who would not have sufficient confidence in yourselves to put into practice the radical method of treatment which I prefer, and for the benefit of such I would recommend what is known as the injection method. It is the method almost universally adopted in this country by rectal specialists. Brinkerhoffer, Rorick, Ives, and many others, have done much to bring this method into general use. It is a very simple process, and for its proper performance no special set of instruments is 22 ORIFICIAL SURGERY. necessary. Any speculum that will bring the last inch of the rectum into view will expose the tumors when they exist, and an ordinary hypodermic syringe with a long needle will serve your purpose. The tumors are situated between the two sphincters, and may be distinguished from hypertrophied rectal tissue by the fact of their bleeding when pricked. Usually their dark purple color identifies them, but the bleeding- test is the only reliable one. Now, charging your syringe with a quantity of whatever injecting fluid you propose to use, thrust the point of the needle well into the pile tumor, and inject the substance slowly, carefully watching its effect, until a pale white color creeping over the surface of the tumor indicates that it has been entirely permeated by the fluid. It may take two drops, and it may take ten, the guide being the change in the color of the tumor. The syringe should not be immediately withdrawn, but allowed to remain for thirty seconds or a minute until the blood is well coagulated, and thus prevented from escaping. Two or three tumors may be treated at a sitting, and it will take from one to three or four sittings, at intervals of two PATHOLOGY OF THE RECTUM. 23 weeks, according to the condition of the rectum, before the work is complete. If suppuration supervenes, or sloughing takes place, it will probably be from throwing the fluid through the vein into the areolar tissue beneath instead of into the tumor. This work may be done at the office with comparative impunity. The patient is not confined to his bed. The operation causes but little pain, and but slight subsequent in- convenience, with, perhaps, an occasional exception. If this process took away the re- dundant mucous membrane which is present, and were not so tedious, I would have a better opinion of it. A good injecting-fluid consists of equal parts of sweet oil and 95 per cent. Carbolic acid, mixed when the oil is cooled to a few degrees aboving freezing-point, and subse- quently heated. A better one is that recom- mended and used by Rorick: 5. Carbolic Acid, Glycerine, - - - - aa 3ij; Fl. Ext. Ergot, - - - 3J; Water, - - 3jss; Mix. 24 ORIFICIAL SURGERY. The method of employing the ligature for the removal of internal piles is preferred by many authorities, who report flattering results ; but it is so far from being a favorite of mine, that instead of inviting your attention to it I will simply refer those who may prefer it to the ordinary text-books of the day, in almost all of which it is fully discussed I greatly prefer the method which I have adopted because it is simple, rapidly per- formed, free from danger, and, so far as my own experience goes, is in every way satisfac- tory in its results. The operation is performed in the following manner: With the nates retracted, the speculum opened, and the pile tumor brought well into view, a simple tenaculum is thrust into its summit, and with a pair of double curved scissors a portion of the pile is ampu- tated, the portion removed varying in size with the redundancy of tissue present. The bleeding which immediately follows is checked by rotating the speculum until one of its valves presses evenly and firmly against the wounded surface. PATHOLOGY OF THE RECTUM. 25 The tri-valve speculum which I have the pleasure of recommending for this purpose, enables you to secure pressure in three places at the same time, thus facilitating your work. I would caution you to be careful not to dis- tend the speculum so widely as to weaken the sphincters, until the bleeding is well checked, for, with an active sphincter, quite profuse haemorrhage will immediately be controlled by the contractile power of the sphincter itself, as soon as the speculum is withdrawn. This tri-valve speculum, and the method just described — leaving the sphincter un- strained in the early part of the operation — enables you to accomplish with perfect safety and satisfaction what Allingham and other operators seem to regard as dangerous and unadvisable. 26 ORIFICIAL SURGERY. After the circuit of the rectum has been visited in the manner described, and relieved of all undue prominences, the subsequent stretching of the sphincters will not induce haemorrhage or be in any way objectionable. I prefer this method because it is rapid, because it is safe, because the haemorrhage it causes occurs in your presence, and is there- fore under your control, and because there is no subsequent sloughing or trouble of any kind. There is, consequently, greater satisfac- tion in it, for both patient and surgeon, than there is in any other method with which I am acquainted. EXTERNAL PILES. For the treatment of external piles there is but one method endorsed by the best authorities — that of removal. Forceps and scissors will accomplish this so neatly and so quickly, and there is so little haemorrhage at- tending their use, that I cannot understand why some operators still cling to the old- fashioned process of removal by cautery or ligature. The possibilities of this method of treating internal and external piles reaches its limit in those cases in which the piles are neither in- PATHOLOGY OF THE RECTUM. 27 ternal nor external, but both, consisting of long dilated blood-vessels which start above the internal sphincter and hang below the ex- ternal sphincter, usually accompanied by more or less hypertrophied tissue and prolapsus of the mucous membrane, which may be either constant, or attending each evacuation. A single clip of the scissors in these cases will quickly demonstrate, by the amount of the haemorrhage which follows, that it would be unsafe to operate on the complete circuit of the gut, in this manner, and the surgeon is recommended in all such cases, to resort to the use of Nott's clamp. Let me give you the details of this opera- tion. First introduce the speculum and dilate the anus. The upper end of a protruding mass to be removed, is seized by a trusted pair of self- retaining artery-forceps. The forceps, and the tissues they grasp, are now to be crowded out- ward beyond the speculum, which is to be revolved until another pendulous mass pro- trudes into the instrument. The upper end of this mass is to be seized by another pair of forceps and treated in the same manner, and the process continued until the entire circum- ference of the outlet has been carefully exam- 28 ORIFICIAL SURGERT. ined, and every redundant mass seized with a pendulous pair of forceps. The speculum is now to be carefully re- moved, and the view presented to the eye is that of a swollen anus, from which dangle from three to six or eight artery-forceps of uni- form size, and each one grasping an offending portion of the mucous membrane. Careful traction is now made upon the different pairs of forceps, one by one, until an even tension is secured, and they are held as in a bundle in the left hand of the operator. Now, while the nates are well retracted by an assistant, Nott's clamp is applied about the mass, being pressed snugly against the patient's body, and gentle traction is made upon the gathered forceps until, as the clamp is tightened, the instruments entirely es- cape its grasp. The screw of the clamp is to be well tightened, all the artery-forceps are to be removed, and the irregular line of crushed tissue is to be amputated by the scissors, close to the clamp. The anaesthetic should be dis- continued as the clamp is tightened, to prevent apncea, from the profound effect which the operation produces upon the respiration. In from three to five minutes, according to the amount of tissue included, the clamp may be PATHOLOGY OF THE RECTUM. 29 carefully loosened by an assistant while the operator quickly seizes the crushed ridge with four or five artery-forceps. This ridge is now to be removed with dull scissors, care being taken not to cut beyond the crushed surface. Very little haemorrhage ensues, and it will rarely be necessary to torsion a bleeding point or em- ploy other haemostatics. After waiting for a short time for the clots in the blood-vessels to be well formed, the speculum is to be again passed and carefully revolved. If a pile or pendulous mass of tissue has been overlooked it is to be seized and proceeded with as before. When the operation is properly done the field of the speculum, as it is afterwards carefully rotated, should present a smooth, neat appear- ance at the seat of amputation of the superficial tissue. The speculum is now to be removed and the sphincters slowly but thoroughly stretched, until, in the judgment of the operator, they are sufficiently weakened to give the parts a few days' rest from the painful and spas- modic grip which, otherwise, would be sure to follow. Beyond the application of hot fomenta- tions, no further attention should be paid to the rectum for some days. Injections may be needed 30 ORIFICIAL SURGERY. to assist the first few fecal discharges in their exit, and subsequent dilatation with a speculum will be required at intervals of one or two weeks to prevent contraction as the denuded surface cicatrizes. This dilatation should be continued even after the part is entirely healed, until the speculum can be passed and fully dis- tended, without undue force on the part of the operator, or pain on the part of the patient. A satisfactory result is sure to follow these meas- ures, although they may seem severe in their execution. PROLAPSUS RECTI, uncomplicated with piles, will sometimes re- spond to internal medication, while in other cases it will require nothing more than the well-established method of cauterizing longi- tudinal streaks of the gut with Nitric acid or the actual cautery, but it will often necessitate the use of the clamp, as just described. ULCERS of the rectum are of extremely rare occurence, and are usually syphilitic in their origin. A good scraping, followed by cautery and thorough dilatation of the sphincters, will effect a rapid cure. PATHOLOGY OF THE RECTUM. 31 FISSURE seldom occurs without other rectal complica- tions, which should first receive attention. A destruction of the sensitive groove with the knife or cautery, followed by thorough stretch- ing of the sphincters, will always cure them. The much-vexed question of FISTULA IN ANO is not so easily handled. Like fissures, they are usually accompanied by other rectal dis- orders. After these have received the proper attention they are to be dealt with according to their extent and number. There is rarely more than one internal opening, and that is usually a small one between the sphincters. But pus may so burrow, and ulcerate its way to the surface by so many devious channels, that more or less of the buttocks may become honey-combed. If there is more than one ex- ternal opening, each one is to be dilated with graded steel sounds until it will admit a uter- ine curette. This instrument is to be used freely in all the ramifications of the burrowing sinuses, until they are well denuded of their pyogenic membrane. Rubber tubing, of medium size, is now to be passed from one 32 ORIFICIAL SURGERY. opening to another until each opening is pro- vided with a tube, the two ends of the same tube being brought together and transfixed with a common safety-pin or secured by thread. The parent sinus which leads into the gut should now receive attention. If the case is to remain under your care, and be subject to your daily dressings, this sinus may be well dilated, curetted, and filled with a small rope of jute, which is to remain unmolested for forty-eight. hours. The active inflammation which follows this treatment will soon close the canal, if it is syringed da:ly with carbolized water, and the outer extremity daily packed with jute, until the sinus is entirely filled up with healthy granulations. If, however, you are not permitted to un- dertake the subsequent care of the case I would advise the passage of a grooved director along the track of the sinus, into the gut, severing with a bistoury all of the tissues covering the director. This will always in- clude one sphincter, and sometimes both of them. A thorough curetting of the track of the sinus should now be performed, followed by a careful stitching together of the denuded PA THOLOG Y OF THE REC TUM. 33 surfaces with carbolized cat-gut, the stitches to be entirely covered in their course. The ex- ternal tubes must remain for a week or two, to properly accomplish their purpose. Subse- quent dressings of jute will be required until recovery is complete. Stretching of the sphincters should accom- pany this operation, as in other operations on the rectum. The stretching should be done before the knife is used, in those cases in which you decide upon the immediate obliteration of the sinus, in the manner described. LESIONS OF THE SECOND CLASS. The lesions of the rectum belonging to the second class — which are the most mis- chievous of all, because the patient is, almost invariably, unconscious of their existence — include but two varieties, rectal pochets and papillae. The usual location of the pockets and pa- pillae is at a point about an inch from the anus, at the upper margin of the internal sphincter, where the large distended pouch of the middle portion of the rectum is abruptly puckered down to the narrow limits of its last inch. ORIF1C1AL S URGE It 1'. Rectal Pockets and Papilla*. These pockets are curious formations, and have been almost entirely overlooked by writ- ers upon rectal conditions, both anatomical and pathological. The facts which I gave in my first public report on this subject—made nearly two years ago—are as true to-day as they were at that time. I then stated that no mention of them can be found in current medical literature, and in but a few places in that of the past do they receive more than slight notice, and no-, where have they received that attention which their importance demands. As a result of the report which I then made, hundreds of observ- PATHOLOGY OF THE RECTUM. 35 ers have been studying this rectal condition, and the profession is to-day divided in opinion as to whether these pockets belong to the anatomy of the rectum — subject, at times, to degenerative changes — or whether, in their en- tire history, they belong to the domain of pathology. Leaving this question to be discussed in the pages of a text-book now in course of preparation, it is sufficient for present purposes to view them in the light of ascertained facts. I have gone far enough in my researches to be able to tell you that they are by no means a constant condition, and that they have no def- inite and uniform location. When present, they always occasion a spasmodic contraction of the sphincter ani, a condition which is most frequently observed in those cases which are developing some deep-seated constitutional disease. Their removal, in this class of cases, is invariably attended by more or less improve- ment of the patient's general circulation, while, on the other hand, the operation never appears to result in the slightest harm. After an extensive experience and obser- vation I am now, as I was two years ago, in favor of removal of these rectal pockets under 36 ORIFICIAL SURGERY. all circumstances, and in all cases in which they are found. In form and character these pockets may be long and narrow channels, ulcerated at the bottom; short ad de sacs, or broad-mouthed and pointed recesses of mucous membrane. Whatever may be their shape or condition, by their presence they create unnecessary irrita- tion, often productive of mischief, and I advise you to excise them. Pratt's Double-curved Scissors and Blunt Hooks. The removal of these pockets may be easily accomplished by means of the blunt hook and scissors, operated through the ex- panded tri-valve speculum. Occasionally, when the pockets are long, and there are many of them, and when, at the same time, the coats of the haemorrhoidal veins are weak, and lacking in tonicity, the removal of the pockets will in- duce an attack of acute piles in those subjects who do not rest long enough after the opera- PATHOLOG1 OF THE RECTUM. 37 tion. But the accident is of rare occurrence, and, although it is annoying, it will not deprive the patient of the benefit to the general system, which usually follows. Hot fomentations, or, if the piles protrude, slitting them open and evacuating their contents — which always con- sist of a blood-clot— will speedily remedy the trouble. PAPILL.-E are conical processes of mucous membrane of variable size, shape and location. They have no relationship with the pockets, for they very frequently exist independently of them. When the papillae are small, abundant, and transparent at their apices, they seem to be productive of the greatest amount of trouble. Each one always contains a central artery which bleeds viciously when the papilla is snipped off. The bleeding is never trouble- some, however, and requires no special atten- tion. Thorough stretching of the sphincter must always follow removal of pockets or papillae, in order to give the wounded surface rest and thus prevent subsequent soreness. I look upon these conditions as being the most mischievous of rectal disorders because they always occasion a tonic spasm of the 38 ORIFICIAL SURGERY. internal sphincter, and thus make excessive de- mands upon the powers of the sympathetic nerve. They are common in all forms of chronic disease. I know of no reason why these conditions which I have described should have been so long overlooked, and their importance have remained unappreciated, unless it be that their presence is unattended by local symptoms, and hence they have failed to attract the attention of either the patient or the physician. But in view of the fact that they occur in so many chronic conditions, and the additional fact that marked benefit almost invariably follows their removal, I insist upon it that no obstinate case of chronic disease has been properly examined until their presence or absence has been ascertained. The most happy, the most mar- velous results which I have ever obtained in the practice of medicine and surgery, have followed the removal of pockets and papillae, and in thus bringing them to your notice I do so in the confident belief that a proper ap- preciation of their importance on your part will add very materially to your resources in battling with disease, and in helping those who apply to you for relief. PATHOLOGY OF THE RECTUM. 39 I have chosen the rectal orifice as the first one for consideration, because work on the sexual system is unsatisfactory and disappoint- ing, when rectal irritations are present. These sources of irritation should, therefore, receive your first attention. The nervous connection between the rec- tum and the sexual system is such that violence done to one will produce irritation and spasmodic contraction of the other. The front orifices should therefore always be treated according to the suggestions of the next chapter as soon as the operation on the rectum is completed, double work being safest and most beneficial. III. THE MALE SEXUAL SYSTEM. TN speaking of disorders of the male sexual system, let me first call your attention to the fact that the entire reproductive apparatus, in both sexes, derives its nervous supply from that general reservoir of sympathetic influence upon which we mainly rely for the perform- ance of all the vital functions. A waste of sexual power, as you will readi- ly understand, must mean, also, a waste of sympathetic power in general, a veritable un- dermining of all the life-giving forces of the system. In view of its importance in this con- nection, is it not singular that greater attention has not been paid to the anatomy, physiology and hygiene of this part of the animal organ- ism? A male child is born, runs the gamut of childhood's diseases, passes on to maturity, with all its stirring changes, reaches the acme of strength in full-grown manhood, and then walks life's downward slope to a final exit, and THE MALE SEXUAL Sl'STEM. 41 through all this career one important element of his training has been sadly neglected. He is taught to walk, to dress, to bathe, to eat, to behave with propriety, to solve and achieve, and to play well every other part of the game of life, but as regards the control of his sexual system, he goes untutored, unadvised, unno- ticed. Whatever knowledge he may obtain on this important subject, comes by guesswork, by hearsay, or from far more questionable sources. The fact is just beginning to be appreciat- ed by mankind, that much of the disease and weakness — mental, moral and physical—of the male sex, may be entirely prevented by proper attention being given to the hygiene of the sexual system. I believe, after you have given sufficient attention to the matter, that you will believe with me that all the true manhood of the race, and all the strength, courage, valor, perseverance and virtue that the term implies, finds its chief representatives in those fortunate beings who, having escaped undue sexual irri- tation, have never succumbed to the still poison of its unresisted temptations. On the other hand, does not all the unmanliness of man- 42 ORIFICIAL SURGERY kind, all the weakness, effeminacy and enervat- ing sensuality which that term implies, have origin in abuses of the sexual function ? Wher- ever you find a man of strength of will, of honesty of purpose, one who is controlled by right motives and possessed of a vigor that knows no defeat, you will find one whose sex- ual system is under his own control, and whose body is his servant, and not his master. Such a man's course through life is steady and un- swerving, and marked by that success which is the nearest approach to the ideal life. In strong contrast to this, if you consider those who have made life-failures, those who are wanting in all the virtues enumerated, you may be assured that they have been weakened by a physically abused sexuality. Is it, then, not time for men to awaken to a keener apprecia- tion of this fact, and, by proper education in all cases, and by proper surgical methods when needed, to eradicate all possibility of such a perversion of life forces, and present a purer page for future generations ? I cannot leave this important topic without entering my most earnest protest against an idea that prevails with most men, and, alas ! with too many physicians, viz., that after matur- THE MALE SEXUAL SYSTEM. 43 ity periodical discharges of semen are essen- tial to good health. No more pernicious falsity was ever woven into the network of human beliefs. If the liver falters in its work, pathological lesions will follow. If the kidneys suspend their action, general harm invariably results. But who would be so simple as to claim that the general health of an individual could not be maintained unless at stated intervals the lachrymal glands suffused the eyes with tears ? Seminal losses are, like tears, a product of emotion which it is unbe- coming for anyone of dignified manhood to exhibit. Animals, with nothing but their in- stinct to guide them, voluntarily refrain from sexual indulgence, except for the legitimate purpose of the propagation of their species. Is it not too bad that man degrades him- self to a lower level than the beasts, by degen- erating into a condition ol sensuality of which a beast would never be guilty ? Sensuality feeds and grows on its own indulgence until in the end it fails to procure for its victim even the poor satisfaction it seems at first to promise. It is only when sexual power is not so wasted, but remains evenly distributed throughout the entire system, that true man- 44 ORIFICIAL SURGERY. hood with all its possibilities of strength and power is ever attained. When the race will generally accept this doctrine there will be some hope of a greater immunity than it now enjoys from many of its loathsome diseases and its pitiable moral and physical deform- ities. In coming, now, to a discussion of the practical part of this question — for I shall leave the educational problem for those whose special province it is — let us consider what can be done by surgical methods, both pre- ventive and curative. Since in most cases the condition of an organ corresponds to the con- dition of its outlet, so here you will find that the condition of the various orifices involved will demand your chief study. Observe the opening of the foreskin, the condition of the fraenum, the tension of the meatus, the orifices of the prostatic ducts, the openings of the vasa deferentia and the os vesicae, for these are the places to look for the beginning of mischief. At the birth of every male child a careful examination of foreskin and fraenum should be made. If steady pressure and careful handlino- are not sufficient to retract a foreskin, and THE MALE SEXUAL SYSTEM. 45 break up its tender adhesions to the glans penis, surgical interference should render this possible. When circumcision becomes necessary, I believe that you can improve upon the ordinary methods of operation. No foreskin should be amputated farther back than the apex of the glans penis, as the organ hangs untouched and pendant. If nature has already made the pre- puce of proper length, you cannot improve upon her pattern, and no ring of tissue should be removed, even though only a pin-hole os pre- sents. If, however, she has been too generous in her supply of tissue, and the prepuce is unduly long, it may be shortened to the ex- tent indicated. The operation is performed by removing a narrow V-shaped piece of tissue from the dorsal surface of the prepuce, the apex of the V pointing toward the body. The section should include both skin and mucous mem- brane. The prepuce will thus be sufficiently liberated to permit an easy retraction beyond the corona of the glans. By carefully stitching together the parallel margins of the skin and mucous membrane, no denuded surface will be left. 46 ORIFICIAL S URGER Y. If the glans penis is hypertrophied, as is sometimes the case, and the elasticity of the tissues tends to undue retraction of the pre- puce, the danger of paraphymosis may be averted by putting in a single stitch which shall draw closely together the lateral margins of the prepuce. Let this stitch remain but a day or two, until the danger of active inflammation is passed and the stitched surfaces have become well adhered; then this last stitch may be removed, and occasional retraction of the pre- puce, with the daily application of cold cream, should be used until all soreness and congestion have disappeared. The special indication for cutting the frae- num is its action on the glans penis with extreme retraction of the prepuce. If such action draws the apex of the glans downward, cut the fraenum, as you would the fraenum linguae in a case of tongue-tie. Fine silk sutures may be employed for stitches, although the use of catgut has the advantage of avoiding the necessity for their subsequent removal, since they are soon absorbed. The meatus urinarius will demand your attention under two conditions, viz., stenosis, and its opposite, hypospadias. In the one case THE MALE SEXUAL SYSTEM. 47 a single touch with the sharp edge of a knife- blade will enlarge the orifice. In the other, denuding of the surface and careful stitching will be demanded to atone for nature's abor- tive effort. Although all that I have said is meant to apply more particularly to childhood, yet you will occasionally meet with a case, even in adult life, that has been grossly neglected. You will all remember a remarkable case of this kind I presented to you at a recent clinic. The patient was an intelligent man, forty-seven years of age, the father of two children. This man had a prepuce which I had to examine very carefully in order to discover even a pin- hole opening. In your presence the prepuce was well slit up, and with difficulty separated from the glans penis, and the organs restored to their proper condition, in a man who for forty-seven years had paid the penalty in ill- health of the ignorance or carelessness of the doctor who presided at his birth. Stricture of the urethra from specific dis- ease does not properly belong to my present subject, and will, therefore, receive attention in the regular course. 48 ORIFICIAL SURGERY. The point of interest which I shall next discuss is the one of greatest importance con- nected with my present subject, for it is what might be called the very center of the sexual and urinary apparatus. The prostatic inch of the urethra contains greater possibilities for health or disease than all the rest of this por- tion of the human anatomy. The mouths of the prostatic ducts open within this space, and on their condition, according as they are free and healthy or obstructed and congested, will prostatic troubles be present or absent. The vasa deferentia also here have their final exit, and, according to their condition, will they freely discharge the contents of the testes and vesiculae seminales, or become congested and inflamed. Any trouble at this point is sure to be reflected throughout that system of delicate canals, of which this seems to be the common center. The sympathetic connections of this part, also, are very extensive. They are intimately connected with those of the rectum, there being a mutual action and reaction between the two, and, as rectal disorders may paint their signal of distress in a pallid ring about the mouth, as diseased lungs may, by sympathy, affect the THE MALE SEXUAL SYSTEM. 49 condition of the nostrils; as an obstructed orifice of the Eustachian tube may cause reflex irritation of the middle ear, so here, that law by which the extremities of canals are sympatheti- cally affected, finds wonderful expression in the certainty with which prostatic conditions may be reflected either to the meatus, or to the kidneys, creating disturbance in the one or the other. This point is, then, the centre of the male sexual system. By controlling the circulation and the nervous power of this one inch of the urethral canal, you control the male sexual and urinary apparatus. The method of treatment which I have to recommend for the relief of troubles at this im- portant point, is simple, and will require but brief mention. The results to be accomplished by it, however, are far-reaching, and sometimes marvelous in their nature, Many of the prob- lems connected with the treatment of diseases of these parts have been satisfactorily solved, and it is with no small degree of pleasure that I am permitted to present to you, as a result partly of the labors of others, and partly of my own, one simple measure that will allay sexual irritability in the young, that will restore the 50 ORIFICIAL SURGERY. lost powers of those advanced in life, that will develop atrophied testes, and reduce those that are hypertrophied, and, more important than all, perhaps, that offers the greatest re- lief for prostatic troubles, and extends its healing influence even to the bladder and the kidneys. The influence for good that this measure exercises over the entire system can only be appreciated by those who have seen the prac- tical results obtained by the method of orificial surgery which these lectures are intended to present. It was only last winter that two lives were lost in a vain effort to remove by the knife prostate glands whose only fault was their enormous size. With the method at com- mand to which your attention will now be called, such malpractice as this can never occur. Owing to its remote position, but few measures are available in applying local treat- ment to the prostatic portion of the urethra. Dry heat and cold, injections, moist heat and cold, electricity, and the knife, comprise your armamentarium. By dry heat and cold, I mean the use of steel sounds, either heated or cold. In intro- ducing to you the subject of the use of steel THE MALE SEXUAL SYSTEM. 51 sounds for these troubles, the questions which will first arise are — What sized sounds should be used ? How often should they be used ? and, Shall they be used cold or hot? I cannot advise the use of steel sounds of smaller calibre than No. 8, English scale. When the canal of the urethrals too constricted to permit the passage of a large sound, it should be treated by whale-bone, or graded French bougies, until the constriction is enlarged to the size of No. 8, English. If there has been no previous urethritis you can usually, with- out difficulty, begin the urethral dilatation with a No. 10 or 12 sound, English scale. The size of the sound used will be deter- mined by the size of the urethral canal. A sound which slips easily along the spongy por- tion, meeting with resistance at the membra- nous and prostatic portions, is too small to do efficient work. Larger and larger sizes should be used successively, until you can reach the bladder with a size which meets with even re- sistance throughout the entire length of the urethra. This will sometimes be a 10, or some- times it may take an 18 or 20, English scale, the average size being from a 12 to 16. The care with which you pass the sound cannot be too great. You must be extremely 52 ORIFICIAL S URGER )'. cautious. The patient may either lie or stand. If it is his first experience in having a sound passed he had better lie, for that peculiar sen- sation which creeps over the entire system when a urethra is for the first time explored by a sound may, for the moment, overcome him to such an extent as to interfere with respira- tion and the action of the heart. No force is required in passing the sound, and none should be used. The course of the urethra should be carefully studied and fol- lowed. The mistake usually made in passing this instrument is in depressing the handle be- fore the sound is sufficiently introduced. In a relaxed state of the penis it is not always possi- ble to follow the course of the urethra directly to the membranous portion, without careful manipulation and great patience. The mere pressure of the sound itself will usually stimu- late urethral contraction to a sufficient extent to straighten the tube and guide the instru- ment, under delicate handling. But in those exceptional cases in which this does not occur, extreme care must be used not to do violence to the urethra in the effort to traverse it. In cases in which your work is intended to allay irritability, the too frequent use of sounds THE MALE SEXUAL SYSTEM. 53 will invariably increase the trouble, and many an orchitis, prostatitis, cystitis and urethritis, has been occasioned by such overdoing. In cases marked by irritability, therefore, you should do thoroughly what you attempt; insist upon a proper amount of rest if the case is sensitive enough to demand it, but do not pass the sound too frequently. From one to four weeks is often enough for such cases, and even then you will occasionally find it neces- sary to follow your work by a few injections of hot water. Give the hot water injections twice a day until all unpleasant symptoms have subsided. On the other hand, when your object is to give tone to weakened organs, to restore lost power, a moderate amount of irritability is desirable, and twice a week is not too often, in the majority of cases, for the introduction of sounds. A galvanic current, with the nega- tive pole applied to the handle of the sound, well introduced, and the positive pole to the region of the anus and scrotum, will often aid you materially in restoring lost tone When mucous clings to a sound upon its withdrawal, indicating a catarrhal condition of the mucous membrane, the passage of sounds should be repeated at proper intervals until 54 ORIFICIAL SURGERY. this condition is entirely corrected. In de- ciding upon the temperature of the sound you should be guided as you would in the use of a general bath, by the re-active powers of the patient. The heat, while it is soothing, is also weakening, and keeping this fact in mind you can at once select the cases to which it is applicable. Cold is tonic and strengthening, provided it be followed by proper reaction. In cases in which you are in doubt upon this point, when you desire the effect of cold, and fear that the proper reaction may not take place, I would advise the use of a hot sound, to be immediately followed by the introduction of a cold one. Cases of spermatorrhoea will always re- quire delicate handling, and when you do not succeed in relieving them I believe that it will be due to one of two things, you have either failed to make a complete and satisfactory operation on the rectum; or, you have been clumsy and injudicious in the use of the sounds. In exceptionally difficult cases, whether there be a condition of irritability bordering on inflammation, or in the other extreme, which approaches a condition of paralysis, you may find it judicious to precede, and sometimes fol- THE MALE SEXUAL SYSTEM. 55 low, the use of sounds by urethral injections. Where you wish to obtain the simple action of heat, or heat followed by cold, plain water may answer your purpose. The water may be medicated with any of the remedies in common use. Nitrate of Silver, Hamamelis, Carbolic Acid, Permanganate of Potash, Sugar of Lead, Pinus Canadensis, Hydrastis, or Peroxide of Hydrogen may be used. No powerful irritant or astringents should ever be thrown into the urethra except when so very dilute as to avoid all unpleasant re- action. This line of work does not conflict with the employment of other remedial agents. By restoring tone to the sexual apparatus, and by stopping this one great source of waste of nerve power, you will find that the entire system will respond more promptly to the use of whatever medicines you may employ. IV. DISEASES OF THE FEMALE SEXUAL ORGANS. TN presenting this division of my subject it is necessary to consider all the orifices of the female sexual organs: the vulva, the external and internal os uteri, and also the entire uterine cavity, through which we come to the last ones in order, the orifices of the Fallopian tubes. The orifice of the vulva, like the others, may be spasmodically contracted, and require dilatation. The irritation which causes this contraction is almost invariably a redundant hymen. No harm ever follows this operation, while the results of carefully trimming away the relics of a hymen are generally highly satis- factory. In doing the trimming, be careful not to cut too deeply in the sulcus which bounds laterally the meatus urinarius, for by observing this caution you will avoid troublesome haem- orrhage. The vulva will sometimes require stretch- ing, on the same principle and for the same reason that any other orifice may require it. THE FEMALE SEXUAL ORGANS. 57 Before ceasing your attention to this locality, examine carefully the orifice of the urethra, dilating it when constricted, and trimming it when carunculae are present. Before considering the orifices connected with the uterus, let me remind you that there are two conditions of the vagina which will often demand your attention. The too con- tracted one of vaginismus, and the too relaxed condition which is commonly de- scribed as a "baggy" vagina. In the one there is excessive irritability; in the other there is loss of tone. Extreme dilatation has long been the favorite method of treating vaginismus, and I have nothing to say but to endorse it. For the other condition, that of a " baggy" vagina, I shall also recommend the same measure. As the repeated passing of steel sounds will strengthen and restore the tonicity of a dilated, flabby and over-distended urethra; as it will secure similar results in a patulous and flabby os uteri; as a proper amount of stretching will cause a rectum with weakened walls to recover its lost tone, so there is no reason why distension, properly applied, should not also give tone to a "baggy" vagina. Steady pressure, like the persistent 58 ORIFICIAL SURGERY. pressure of pessaries and other supporters, are liable to weaken the vaginal walls and increase the trouble. Hence, the pressure should be intermittent in order to secure the desired re- action. For this purpose I make use of an elongated rubber bag, of suitable size, with a rubber tube attached to one end, through which by means of a syringe, can be injected the desired amount of air, or, what is still better, a quantity of hot water, which can be confined for a brief time, and immediately followed by an injection of cold water, thus securing the tonic effect not only of dilatation, but also of the heat and cold. Stenosis of the external os will usually re- quire slight nicking with a bistoury, and frequently repeated dilatations by means of uterine sounds, until healing has taken place. I am not yet persuaded that a ruptured cervix which is not properly healed may not occasion- ally call for the operation for laceration of the cervix, but the majority of erosions, hyperpla- sias, and cases of cervical endometritis which demand your attention, will disappear promptly upon the proper treatment of the next orifice to which I shall call your attention. By this I mean the internal os, the very centre of the THE FEMALE SEXUAL ORGANS. 59 female sexual system. Pathologically, it is a point of great importance. It is the place where the neck and body meet, where the only fixed supports of the uterus are attached, and where the important blood-vessels, nerves and lymphatics find their entrance and exit. The condition of this portion of the female sexual organs is of the utmost importance to the well-being of your patient. Strength at this point means a normal position of the uterus and an equable circulation; weakness at this point, or irritation, spasm or other abnormal condition, means congestion, inflammation, flexion and all the other maladies to which the uterus is subject. Here, too, you will find the most frequent exciting causes of dysmenor- rhcea, and it also has a great influence over the process of conception, either to prevent or to favor it. If, in treating disorders in this locality, you deal with them as you would when connected with other orifices, you will be fully as success- ful in your results. Several years ago my friend Dr. S. P. Hedges first called my attention to the use of graded steel sounds in the treatment of dys- menorrhcea. At that time neither he nor I 60 ORIFICIAL SURGERY. fully realized the possibilities involved in the further development of that method of treat- ment. Uterine Sounds. The original set of sounds were but six in number, No. 11 being the highest. The ne- cessity of more extensive dilatation to pre- vent subsequent contraction of the os, and the consequent confining of discharges, secur- ing for the patient thereby the liability to congestions and inflammation, and the bruising consequent upon the use of the ordinary uterine THE FEMALE SEXUAL ORGANS. 61 dilators, together with the dangers of sponge and sea tangle tents, induced me to carry the idea of dilatation by sounds still further. You will therefore find instrument makers provided with graded sounds, varying in size from No. 35^2 to 23, increasing by a number and a half each time. Uterine troubles are often accompanied by disorders of the rectum, which should first receive attention, after which the uterine sounds may be used. The instructions already given regarding the method of introducing the male urethral sounds, will, in a measure, apply to these. In fact, there is little to add to the directions which I gave in my last lecture. In your first treatment the patient should be anaesthetized preparatory to operating. After securing a good hold upon the uterus with a tenaculum, for the purpose of steadying it, the sounds should be passed, one by one, beginning with the smaller sizes, until there shall be no greater resistance felt at the inter- nal os, as the sound passes that point, than is felt the entire length of the uterine cavity, even as far as the fundus. In the case of a virgin uterus, No. n, 12^ or 14 will probably be large enough to effect the desired degree of 62 ORIFICIAL SURGERY. dilatation, but with a sub-involuted uterus, sounds of larger sizes will be required. If the walls of the cavity of the uterus are covered with granulations, a careful curetting or thorough swabbing will be called for. In the use of the sounds the object in car- rying the instrument to the fundus of the uterus is to restore to a normal condition the mucous lining of the uterine cavity, and also to reach, and to exert gentle pressure upon, the uterine orifices of the Fallopian tubes. As the passage of sounds over the orifices of the vasa deferentia in the prostatic portion of the urethra will relieve an orchitis, so may a like beneficial effect be exerted upon salpingitis and ovaritis by the application of cold steel to the uterine orifices of the Fallopian tubes. If there should be much endometritis, cervical or corporal, or both, showing its char- acteristic strings of tenacious mucous, it is a good plan to thoroughly cleanse the entire surface of the uterine mucous membrane by the application of the Peroxide of Hydrogen, after dilatation is effected and before the specu- lum is removed from the vagina. After having received this treatment by means of the uterine sounds, the patient should THE FEMALE SEXUAL ORGANS. 63 remain in bed from four to seven days, accord- ing to the degree of irritability of the parts. No medicines will be required unless there should be a rise of temperature within the first twenty-four hours, when a few doses of Aconite would be called for. Vaginal irrigation will be demanded only in those cases in which there is considerable discharge. I do not believe in the prevailing practice of profuse bathing of mucous surfaces. My observation and experience have compelled me to come to this conclusion, although it is con- trary to my early teaching on the subject. The application of an excessive amount of water in this way is enervating and weakening; in the great majority of cases it should be carried no further than cleanliness demands. In regard to the subsequent care of cases of this class, I will make one suggestion which will apply, as well, to all cases of chronic disease. Do not run your patients through a routine course of treatment, regardless of the peculiar- ities of each case. In cases of uterine disease, apply the treatment, as already described, once; do the work well and thoroughly, giving to each case special care and study. After the patient has received the treatment, wait G4 ORIFICIAL SURGERY. patiently, and so long as unaided nature is carrying the case towards complete recovery do not hazard the well-being of your patient by meddlesome interference. You may visit her at regular intervals, and if you are satisfied at the time that everything is making favorable progress, do not even disturb your patient by making an examination, but be content to let well enough alone. If the case ceases to make favorable prog- ress, and recovery is not yet complete, the time has come — whether it be a week, a month or a year after the first operation ■— to start your patient anew on the road to health. I believe that the majority of physicians, in the earlier years of their practice, do more harm than good in their treatment of chronic dis- eases, their fault being due chiefly to excessive anxiety to see how their patients are getting along, which leads them to over-do. It is as wise as it would be for a child to dig up recently-planted seeds, to see what progress they have made in sprouting. V. THE AFTER-TREATMENT OF CHRONIC DISEASES. T ET me remind you once more, that the ■^ main object to be kept in view in the treatment of chronic diseases, is the import- ance of establishing a strong and active circulation of the blood. In stopping nerve- waste you conserve the vital forces, and help lay the foundation for attaining this object. In many cases the patient's natural recupera- tive powers will spare you the necessity of any further interference, but too often you find that the ravages which have been wrought by disease will be so great and so deep-seated as to require further attention in order to com- plete the work already begun. You must, in such cases, aid in the maintenance of a proper circulation until it has become so well estab- lished that it will be self-supporting. I would remind you again that your work in orificial surgery may be over-done — an error against which you must carefully guard. Sometimes it is advisable to prepare the system for the 66 ORIFICIAL SURGERY. required operation, by a preliminary series of baths, massage, or other treatment. By such means it will be placed in a condition to derive the greatest amount of benefit from the orifi- cial work when it comes time to perform it. We will suppose, then, that you have made use of all such rational measures, and that the patient has been operated upon. What means will you now adopt to maintain the circulation which you have aroused? What will you do for that large class of cases in which complete recovery cannot be attained without further aid? In order to do full justice to your patient, you must avail yourself of all the remedial agents which are known to have a favorable influence over the circulation of the blood. It would require much time to fully consider all the measures which present themselves, and volumes might be written on the subject. It is sufficient for our present purpose to con- sider briefly the more prominent ones, which consist of Medicines, the Tonic effects of Heat and Cold, Pneumatic Differentiation, Electricity, Massage, and Mental Therapeutics. THE AFTER-TREATMENT. 67 MEDICINE. This subject is so wide in its scope that it cannot be adequately noticed in the limits of a handbook. For my part, I am a thorough convert to the homoeopathic system of ther- apeutics. I believe that the application of remedies according to the law of similars in- volves the only scientific principle at present discovered. When the picture of a drug-prov- ing finds its counterpart in a diseased condi- tion, I believe that a proper attenuation of that drug may be confidently trusted to eradi- cate the disease. To the rich volumes of the homoeopathic materia medica, I therefore refer you for all the help that you may ever expect from medication. But as there are other measures, aside from drugs, which possess the power of modi- fying the circulation and giving force to the blood-current—upon which depends our physical well-being — I must urge you to be broad-minded, and to pursue a policy of true eelecticism. The true physician, in my estimation, should familiarize himself, so far as possible, with all available means for the relief of human suffering, and select those which seem to be 68 ORIFICIAL SURGERY. best adapted to the individual case. He whose mind is filled with drugs, and drugs alone, deserves no better title than that of " medicine man," which our aboriginal tribes bestow upon those who undertake to heal the sick. Do not, I beg of you, limit your sphere of useful- ness by any such narrow policy. HEAT AND COLD. The application of heat and cold, either dry or moist, will furnish you valuable aid in the accomplishment of your purpose. By their use, the cerebro-spinal and sympathetic nerve centers may be stimulated, thus giving in- creased impetus to the blood-stream. Capil- lary circulation may be promoted, or retarded, by the skilful use of heat and cold. Bags and bottles of hot water, compresses and poultices, baths and wet packs, are as deserving of a place in your armamentarium as any other agency that you may employ in your treatment of disease. When and how to use these agents are questions that will repay your earnest study. At present I will make but one suggestion. Remember that, since orificial surgery at once arouses to action the entire system, it starts THE AFTER-TREATMENT. 69 immediate reparative processes everywhere. As new material reaches the tissues, it is eagerly appropriated, and at the same time that which has served its purpose, and is broken down, is carried off by the blood-current, to be eliminated from the system. This scavenger work is sometimes very extensive, and you should always watch carefully the organs by which it is accomplished. But the two eliminating organs which are most apt to escape your watchful attention, and yet which need it most, are the skin and the kidneys. They generally suffer more or less in unison. You can take it for granted that the work of these organs will invariably be in- creased after the orificial operations are done; consequently it is well, by the adoption of ordinary hygienic measures, to provide for it. Frictions and baths over the entire surface of the skin will keep its glands free, and in a condition to meet all the demands which will be made upon them. And a slight change in the ordinary diet, consuming more liquids and less solids, and avoiding stimulants and ingesta which tax the powers of the urinary organs, will insure against undue renal congestion. 70 ORIFICIAL SURGERY. For the first few days following an opera- tion extremely delicate cases may be benefited by hot spinal compresses continued for ten or fifteen minutes, once or twice daily. Let me warn you, however, that the use of moist heat and cold requires extreme care to secure for your patient good results, instead of harm, and this matter should receive your personal atten- tion, and never be left to those who are inex- perienced or careless. PNEUMATIC DIFFERENTIATION. One great means of adding vigor to the circulation may be accomplished by deepening the inspirations. It is by means of the suction power of the chest-vacuum that the return circulation is encouraged, and congestion is prevented. Consequently, an increase of that power will add materially to the force of the blood-current, and, through that, to all the life- processes. Voluntary inspirations, by drawing the blood from all parts of the body, may be car- ried on with such rapidity as to produce a con- gestion of the lungs, as in running or panting. Thus the benefits to be derived from the greater chest-expansion are off-set by the congestion which the effort causes. THE AFTER-TREATMENT. 71 There is now an apparatus which is coming into general use by the profession, by means of which the powers of expansion of the chest may be marvellously increased, unaccompanied by any of the serious results already described. I refer to the pneumatic cabinet. While seated in a cabinet whose interior is a partial vacuum, one receives air into the lungs under the ordinary pressure of the atmosphere. Under these conditions it is a physical impossibility, by any amount of rapid breathing, to congest the lungs. The internal pressure is so great that, although the suction of the chest-vacuum would tend to draw the blood to the lungs, yet they cannot become congested. The effect is to produce a conges- tion of the veins and capillaries over the entire system. The face may be flushed, the extremi- ties warmed, and all the organs of the body correspondingly filled with blood. Stretching, when not over-done, has a tonic action on weakened tissues, and it is a nice point to know how far this process should be carried to secure the desired result. The inventors of the cabinet, and the majority of those who use it, regard it as being adapted to the treatment of lung-diseases alone. 72 ORIFICIAL SURGERY But I make use of it according to the general principle of its action on the circulation. I apply it to the treatment of all forms of disease in which I am endeavoring to secure repair by re-establishing a vigorous circulation, nor am I disappointed in my results. STATIC ELECTRICITY. Next in importance to the pueumatic cab- inet I prefer Prof. Atkinson's invention for the production of static electricity. The ozone that it generates purifies the atmosphere, and the marvelous electrical wind, which can be blown over the patient, regardless of clothing, and without contact or shock, acts as a gentle stimulant. It soothes the irritable, arouses the sluggish, and, by its stimulating influence on the blood-vessels, relieves them of the engorge- ment occasioned by the cabinet treatment. The use of the cabinet, followed immedi- ately by that of static electricity, will thus com- pel a rapid change of circulation over the entire body. And after you have, by the aid of orificial surgery, stopped the waste of nerve- force, which has been depleting the system, and prepared the way for this after-treatment, you will by the use of these two measures THE AFTER-TREATMENT. 73 afford valuable aid in completing the cure. In this connection I refer more particularly to the use of electricity in giving tone to the gen- eral system. In those cases which demand the local use of electricity the ordinary galvanic and Faradic currents are to be preferred. MASSAGE. In the absence of a cabinet and electrical apparatus, you will find in massage a valuable substitute. Let me caution you, however, in the employment of this measure, to begin its use very gradually. For the first week con- fine the manipulations to the extremities. Care- ful operators will always begin this work at the extremities, and endeavor to aid the return circulation by always rubbing towards the heart. A single treatment is of little avail; in order to derive full benefit from it, it must be faithfully carried out for one or two months. MENTAL THERAPEUTICS. Thus far in the treatment of chronic diseases the methods recommended have had for their object the removal of sources of irritation at the lower orifices of the body, in order to stop the waste of nerve-force. Every possible physical means of promoting the re-establishment of a 74 ORIFICIAL SURGERY. vigorous and healthy circulation have been adopted. The effort has been, by every or- dinary method, to repair and renovate the body so as to extend its lease of life. But it is well for us to bear in mind that the tendency of all action, mental or physical, is to the form- ation of habits. We are clothed in our habits, and never comfortable without them. When good, our habits contribute to our happiness. But when pernicious in their nature, the fruits which they bear are bitter indeed. As a result of this tendency to the formation of habits, you will meet with many patients who, instead of rebounding promptly after all appar- ent causes of disease have been removed, will perplex you by their persistent tendency to still imagine that there is, in their bodily condition, cause for complaint. Study carefully your cases, and remove all sources of trouble that you can discover, but stop when your work is done. Do not be beguiled into unnecessary procedures when no disease is present. The doctor alone is competent to decide when a cure is complete. As smoke lingers after a fire is out, so may a patient be troubled by imaginary ills. In such cases nothing but bread pills, good advice — if they will receive it — a THE AFTER-TREATMENT. 75 change of surroundings, or a proper nandling of mental as well as physical influences, will make the patient realize that recovery has taken place. Systems that have been subjected to un- remitting medication and repeated examina- tions for years, will, like any other child, need weaning. It sometimes requires, on the part of the physician, great acumen, and the exer- cise of a high degree of skill, to accomplish this purpose without doing violence to the feel- ings of the patient. With some you can be abrupt, and to them the mere announcement of the fact that their case calls for no further attention will be sufficient. But those of a timid and sensitive nature will require a longer continuance of your moral support. It is to this class of cases that those measures the late Dr. George M. Beard very happily termed "mental therapeutics," may be legitimately applied. VI. ILLUSTRATIVE CASES. REPORTED BY J. W. STREETER, M. D., CHICAGO. Case I.—Spasmodic asthma. Operation. — Removal of papillae and stretching of the sphincter ani. Mr. R., aged 38. This man had been a sufferer from asthma for many years; other- wise healthy. A residence in Colorado re- lieved him for the time-being. I was called early in June, 1886. I found him suffering greatly, so much so that he could neither sleep, eat nor lie down. I treated him for ten days without material benefit. On examination of the rectum I found a tight sphincter and sensitive papillae. The papillae were removed and the sphincter stretched. The moment this was done he said: " That is all right, I can breathe now." He had a slight return three months later, which was at once relieved by stretching the sphincter. He has been free from asthma ever since. Case II. — Gastralgia. Operation.—Removal of piles and stretch- ing of the sphincter ani. ILLUSTRATIVE CASES. 77 Mr. H., aged 35; State official from Iowa. This patient came to my office looking very ill; said he had come to see how much longer he could live. His trouble had been called can- cer of the stomach. He was thin, cadaveric, and undoubtedly suffered severely. I ex- amined him carefully and pronounced the case one of gastralgia of reflex origin. I stretched the anus, removed some internal piles, and sent him home the same evening with instruc- tions to write me in six weeks. The letter came in due time, to this effect: "Have not had a pain since I left your office. Have gained twenty pounds of flesh, and feel like a new man. None of my clothes fit me." Case III.—Anaemia, with persistent vom- iting. Operation. — Removal of papillae and stretching of the sphincter ani. Miss K., aged 18; tall, slender and anae-, mic. This girl was healthy until about one year ago, when she had a very violent attack of epistaxis, which was followed by gastric dis- turbances so severe as to reduce her greatly. She was very anaemic; vomited almost every- thing which she ate; had pain always after eating, and suffered from amenorrhcea. On examination, I found a tight sphincter and rectal papillae. I operated at once, and she returned home. When she met her father that evening she said, " I am hungry," and she has been able to eat regularly ever since. Her color 78 ORIFICIAL S URGER 1 \ returned and the menses appeared in about five weeks. She is now in a fair way to become strong and well [This case is peculiarly interesting as one of purely reflex trouble. Dr. Streeter leads us to infer that he paid no attention whatever to the uterus. As a rule such cases require the use of uterine sounds, as well as the rectal treatment, to accomplish a cure.—E. H. P.] Case IV.— Melancholia. Operation.— Removal of rectal papillae. Mrs. H.. aged 24. This patient said that for the past six or eight months she had not been like herself at all; she was depressed in spirits; could not see any cheerful thing in life; wept a great deal and was utterly wretched. She thought her trouble must be due to some uterine disease. She was about to start for the East to be gone some months. A careful examination failed to detect any disease of the uterus or ovaries, but showed sensitive papillae in the rectum. These were removed. One month later she wrote to me from New York: " I have been well from the hour 1 left your office. I am my old self. What did you do to me? Please tell me all about it so that I may be able to describe the operation to some physican here, if I should have any return of the dreadful depression." Case V.—Chronic diarrhoea and nerve-tire. Operation.—Removal of internal piles. Mrs. P., aged 40. She had had a painful morning diarrhoea for three years; distension and sensitiveness of the abdomen; dyspepsia; ILL US TEA Tl VE CASES. 79 headache; palpitation, and general depression. She had gone through unsatisfactory treat- ment with many physicians. I found no cause for her troubles until the rectum was examined. I operated for internal piles. The diarrhoea was at once relieved; the abdomen diminished in size and was no longer sensitive; she gained in flesh; her spirits re- turned, and the third week after the operation she went five out of six evenings to the opera without especial fatigue. Case VI.—Headache, and inability to study. Operation.—Stretching the sphincter am. Miss A., aged 19, had to be taken from school on account of severe pain in the back of the head, and inability to master her lessons. She was naturally clever, but from the time the pain commenced she lost her mental activity. Rest, tonics and specific medication gave very unsatisfactory results. Simple stretching of the sphincter ani relieved the pain within forty- eight hours, and she pronounced herself "as well as ever." REPORTED BY WILLIS DANFORTH, M. D., MILWAUKEE. Case VII.—Rectal tenesmus and chronic diarrhoea. Operation.—Removal of rectal pockets. The first case treated was one of rectal tenesmus of eight years' duration. It was the 80 ORIFICIAL SURGERY. worst and most persistent case of the kind that I ever saw. The patient was a young woman of about 24 years' of age. She had a diarrhoea every morning between two and four o'clock, which came with the regularity of the clock, calling her up two or three times every morning. The stools were diarrhoeic in character, and attended by pronounced tenes- mus. I was determined to stop this disturbance, and resorted to a great many expedients to do so. I prescribed enemas of every kind, in- cluding Morphine, Opium, Chloral, Stramoni- um, etc. I also used suppositories of the same and of other remedies, all to no purpose. I made a careful rectal examination, and found no piles, but, instead, a contracted sphincter which I dilated forcibly' not succeeding in this I cut the coccygeal attachments by sub- cutaneous section, when for one day only the tenesmus ceased. I gave the best remedies (high and low) I could find; and still my patient continued to suffer the constant tenesmus for five years (saving the one day ) without relief. Finally I heard Dr. Pratt's report to the State Society at Peoria in May, 1885, and im- mediately on my return home I examined my patient again and found pockets in the rectum which I at once removed, when all tenesmus and diarrhoeic disturbance ceased, and has not returned. ILL USTRA Tl VE CASES. 81 Case VIII.—Abdominal pains, headache, and general debility. Operation.— Removal of rectal pockets. Mrs. W.; American; married; aged 42 years. This woman had suffered for ten years with abdominal pains, mostly on the left side, and been subject to fearful headaches; bowels more or less irregular; had been under con- tinual medical treatment without satisfactory results. Consulted me in the spring of 1886. Her husband feared she would lose her mind. Her memory had failed, her digestion was very much impaired, she was emaciated, debilitated, and extremely irritable. She thought she had a cancer of the bowels, and was discouraged almost to death. She had been treated by several good physicians who had examined for piles and found none. Her monthly sickness occasioned her no especial trouble; she was regular, or reasonably so. I examined her rectum and found a close sphincter and upon the posterior rectal surface several pockets, the presence of which was determined by the finger impinging upon a slight depression which would not attract attention unless we were feeling for pockets, the more so because the finger passes over the surface without eliciting any pain, and it is only where (with brains in your fingers) you bend them backward, exerting pressure upon the depression, that you first discover its sore and 82 ORIFICIAL SURGERY. irritable condition, and then with the speculum and hook you can demonstrate it beyond a doubt. Having diagnosed my case, I removed the pockets, and to my great delight all the morbid symptoms of ten years disappeared (not in a day, but in a month), to return no more. Patient now well and happy. I could report other cases of equal inter- est by the dozen. [The presence of rectal pockets cannot be deter- mined with any degree of accuracy, even by a " brainy " finger. Nothing but a careful examination with the blunt hook, through the field of the speculum, as Dr. Danforth suggests, can make their diagnosis positive. Sometimes, but not often, the edges of irritable pockets will be so swollen as to render their detection possible by the finger, but ocular demonstration is the only certain method.—E. H. P.] REPORTED BY W. F. KNOLL, M. D., CHICAGO. Case IX.—Dysuria. Operation.—Removal of urethral polypi. Mrs. C, aged 24; married and mother of one child. When about four years of age she began to experience some difficulty in passing urine, a little pain and some delay. As she grew old- er both increased, and when she reached ma- turity she was the victim of a most distressing disease. She required from twenty to thirty minutes to perform the act, but the most pecul- ILLUSTRATIVE CASES. 83 iar part was a nervous chill, restlessness, and an uncontrollable desire to be alone with each call to urination. Although an excellent musi- cian, she avoided theatres, entertainments and public gatherings for fear that she might be overtaken with this feeling in the midst of her pleasures. She could not allow the presence of any person at this time, nor even the sound of conversation or music, in short, nothing but perfect quiet, time, and the most powerful effort of the will could accomplish the act. Following her confinement there was what her attendant called a cystitis. She could not void the urine, and a catheter had to be used; this produced the worst part of the suffering. At this time I saw the case, and on examination found three mucous polypi, with old fissures be- tween the bases, on the urethal mucous mem- brane within the grasp of the sphincter. With an Emmet's uterine dilator I dilated the urethra, snipped off the polypi, cauterized the base and the fissures with a forty per cent, chromic acid solution, and left the parts to heal. In ten days she was much improved, and in three weeks she was well. Three years have now passed and there has been no return of the trouble. Case X.—Neuralgia, urethral stricture, and general debility. Operation.—Passage of urethral sounds. Mr. H. M., aged 28. Single. This man 84 ORIFICIAL SURGERY. had always enjoyed good health until ten years ago, when he had gonorrhoea. The trouble seemed to be severe, as it continued for six months. The treatment was with injections, Oil of Copaiba, and the passage of the French filiform bougie. Throughout there was great sensitiveness of the urethra and bladder, and an unpleasant feeling in the spermatic cord, ureters and kidneys. From that time until his first visit to me he had had several attacks of pain in the ureters, spermatic cord and testicles, much as one suffers with a calculus passing the ureter. There was also a little gleety discharge at the meatus each morning, and a constantly rigid penis. He had become much reduced, and his nervous system demoralized to a point which incapacitated him for his work. On examination the urethra was found to be swollen, rigid, and painful to the touch, and indeed, it looked like a round piece of wood lying under the penis and holding it erect. The sound revealed a tight stricture in the membranous urethra, and the finger in the rectum excited pain at the neck of the bladder, as well as the passage of the sound in the urethra. The treatment was with Cannabis sat., internally, and the local use of the gradu- ated steel sounds. The latter were passed every four to six days, as the condition required it, until a No. 16 English was reached. I then gave him Phosphoric acid, and sent ILL US TRA Tl \ E CASES. 85 him to the sea coast for a month's rest. He returned much improved in his general health, but with no marked improvement in his local trouble. I then continued the use of the sounds, increasing the size until a No. 18 English was reached. This allayed the neuralgia and soreness in all the parts instantly. It was thought wise to pass the No. 18 sound at intervals of four to six weeks, for some time, but there has been no return of the neuralgia in any part of the genito-urinary tract in the past eight months. Case XI.— Restlessness, headache, and nervous debility. Operation.— Stretching of sphincter ani, and removal of pouches and fringes. Miss B. C, aged 18; for ten years has been severely constipated, and for five years has suffered severe pain with each defecation, some of the time fainting in the act. For more than a year she had not been allowed to go to stool without a nurse or her mother by her side for fear of a fainting fit. She had been exceed- ingly nervous, sleepless, and suffered with a "constant pain in the top of the head." On examination of her rectum, I found a large irri- table ulcer between the sphincters, which had burrowed under the mucous membrane to the muco-cutaneous junction, making a pouch, and on either side were several tags or fringes which, when touched, caused a spasm of the 86 ORIFICIAL SURGERY. sphincters. The patient was completely anaes- thetized, the sphincters paralyzed with the thumbs, the pouches and fringes cut off, and the ulcer cauterized with solid nitrate of silver. In a few weeks the patient was well and had a movement of the bowels each morning, The operation was made more than a year ago. and there has been no return of the trouble. Case XII.—Dysmenorrhea, vaginismus, headache and insomnia. Operation.—Removal of papilloma from the vagina, and dilatation of the uterine canal. Miss J. V., aged 22; of healthy parentage, and up to the time of menstruation, which was at fourteen, she enjoyed perfect health. The first few menstrual efforts were attended by some pain, but this gradually grew less so that in a year she was in compara- tive comfort, except an unusual nervousness and prostration. At the end of two years, or at 16 years of age, the old pain recurred with increasing severity, and at the time she applied to me it had reached a point which made her dread menstruation more than death itself, for she remarked, " I had rather die than go through those spells again." There was a persistent headache, sleep- lessness, and during the menstrual period, which lasted about four days, she confined herself to a dark room, suffering greater pain than a wo- man in labor. Although the flow was normal in ILLUSTRATIVE CASES. 87 quantity and quality, she was very uneasy, and became uneasy on the least exertion. On try- ing to find an explanation for these symptoms in the condition of the uterus, I was checked by the sensitive state of the opening and lateral surfaces of the vagina. By exposing the parts the fragmentary remains of the hymen appeared like a circle of warts, highly congested. On either side of the vagina, extending up almost half its length, there were the same papilloma- tous structures. They were all so sensitive that the finger could not pass to examine the uterus. The treatment consisted in putting the patient under ether and cutting off the hymen and papilloma with a scissors or Simon's sharp curette, and cauterizing the base with C. P. nitric acid. The uterus was found in normal condition, but in order to avoid every chance of neglect an Emmet's dilator was passed in, and the cervix dilated about five-eighths of an inch. The pa- tient was well in twelve days from the time ot the operation and has menstruated eight times since. With the exception of the first men- struation after the operation, which was very profuse, the periods have been normal and the patient has regained all the flesh and vigor of her youth. I am certain that the whole trouble arose from the state of the lower part of the opening of the vagina. 88 ORIFICIAL S URGER 1'. Case XIII.—Dysmenorrhea and chronic headache. Operation. — Dilatation of the uterine canal. Mrs. V. Z., aged 26; has had dysmenor- rhea during her whole menstrual life. Although of excellent parentage, and possessed of a per- fect physical form, she nevertheless wore an expression upon her face which indicated twice her age. Her condition was indeed a sad one. She had not been without a deep pressing pain in the base of the brain and upper part of spinal cord, for ten years, nor had she in all that time slept more than sixty consecutive minutes. Night after night she would sit up and rest the occiput on the back of a chair, drop the lower maxilla, and look at the ceiling, as the only way to procure a little respite from pain. Her menstrual periods were too frequent, irregular and prolonged. The pains usually began twenty-four to thirty-six hours before the flow and continued as long after. The blood was black, and either in shreds or clots. When the clots came she would roll and toss, one minute stuffing her mouth with the bedclothes, and the next pulling her hair, and the only change from this, for twenty to thirty hours, was either a convulsion or a fainting fit. The uterus, on examination, was retro-flexed, increased in depth, and so sensitive over its whole surface that the least touch of the probe would elicit ILLUSTRATIVE CASES. 89 screams. The canal was so much contracted that it admitted a Thomas' uterine probe only with difficulty. The treatment was to dilate with graduated steel sounds until an Emmet's dilator could be introduced; this was used every four to six days, and the dilatation carried to about three-fourths of an inch. In three months she was much improved in general health and the introduction was almost painless. She then moved into the country and I have not heard from her since. [These cases afford striking illustrations of the un- satisfactory, not to say criminal, practice, of simply pre- scribing for a case, without making a proper physical examination. Many of these patients would have been spared years of suffering, had their former physicians been as thorough in their work as was Dr. Knoll.—E. H. P.] REPORTED BY WM. E. LEONARD, M. D., MINNEAPOLIS, MINN. Case XIV. — Haemorrhoids; headache; nervous prostration. Operation.—Removal of piles, stretching of sphincter ani, and removal of rectal pockets and papillae. Out of a number of operations on the rec- tum, I choose at random the following as types of the others. In but one instance did no bene- fit seem to follow the excision of pockets and papillae, and this was in a hypochondriac who was determined to keep his bed and make all the 90 ORIFICIA L S URGER V. trouble possible. Nor do I make any note of numerous cases of benefit and marked relief from operations for phimosis, or soundings of the uterine cervix or the male urethra. Dr. O. H. Hall, of Minn., formerly presi- dent of the Minnesota State Institute of Homoe- opathy, had suffered for years from rectal troubles, had applied to all manner of special- ists and taken every treatment that seemed to him reasonable, but without relief. On May 19th my father, Dr. W. A. Leon- ard, and myself operated on his rectum, remov- ing several large pockets, cutting open a large internal haemorrhoid and stretching the sphinc- ters, all without an anaesthetic. The rectum was very much inflamed from frequent injections by the Brinkerhoff method and other treatments, and unusually sensitive, with the usual accom- paniment in such cases — very "tight," spas- modically contracted sphincters. He stood the operation well, but was very- pale and faint for a few moments. However, he took the train within an hour and rode to St. Paul (10 miles). About 5 p.m. he evacuated about " one pint of pure blood " from the rectum — probably from the opened haemorrhoid—and again the same at 8 p. m., after which last he fainted from exhaustion. These haemorrhages were preceded by pain in the bowels, "as though a diarrhcea would set in," but after the second only a dull heavy feeling in rectum and anus IL L US TEA TII 'E ("A SES. 91 remained. The medicine used was Ratahnia 3x, and after the bleeding Arnica ix. May 24. The doctor reports by mail as follows: "Very sore; constant oozing of blood, especially after stool. A haemorrhoidal tumor appears on the left side of the anus and is so painful as to prevent my riding. Ii Ratahnia 3x four times daily." May 25. "I ate my first hearty meal; no further haemorrhage, but an extremely offensive discharge from anus. No lumbar or sacral pain, but a general rheumatic soreness, H Sulph. high, dose." May 28th. " Return of former skin trouble which has harrassed me for years; a psoriasis. After riding some five miles terrible itching in the anus." May 31st. "General improvement. An intense itching about the anus, is relieved by clipping off the 'fringes' left about the anus." I have since learned to be very careful in trimming off all extra folds external to the anus after the operation, since they may be drawn in as the sphincters gradually contract, and become sensitive points. June 16th. The doctor writes: " I feel first-rate morally, physically and mentally; clearer, cheerful and happy, have no more fearful foreboding (a common symptom before being operated upon) headache mostly all gone, sleep well, (sleeplessness was an almost con- 92 ORIFICIAL SURGERY. stant trouble before), no dreams, excellent ap- petite." This operation, and perhaps the medicines used, had served to aggravate and bring out thoroughly the skin trouble above mentioned and careful prescription was necessary. This result I had in several cases, being precisely what every careful prescriber often obtains from the first doses of the indicated remedy in chronic diseases. June 22nd. " Same old symptoms about the anus having returned, our patient came up to Minneapolis again and was ' trimmed,' be- sides we found another pocket which we ex- cised." June 25th. Dr. Hall writes as follows: " I feel first rate, have an elasticity and bouyancy of spirits quite foreign to me in the past four years." July 21 st. "The skin trouble is much bet- ter, all irritation seems to be transferred to the anus, which becomes worse after any worry or over-exertion." Within two weeks of this writing (Jan. 25th, 1887), the doctor called on me to say that he had since operated on many cases, and found the result beneficial in every instance. He himself is "made over since last May," as he declares. [It is never safe to excise piles unless the patient can have an opportunity to rest immediately after the operation. Consequently this work should never be ILLUSTRATIVE CASES. 93 done at the office. Pockets and papillae can be re- moved at the office with impunity, and the patient be permitted to go about as usual, but piles require extra care in this respect. No trouble need ever occur in the treatment of rectal lesions if the physician attends well to the necessities of each case, and pi-events com- plications by anticipating them, and using preventive measures.—E. H. P.] Case XV. — Congestive headaches and rheumatism. Operation.— Removal of rectal pockets and stretching of the sphincter. O. R. E., a young married man of 32, has suffered much every summer from conges- tive headaches, taken from a partial sun-stroke some years ago. He is also subject to rheu- matic attacks, muscular, which has twice under my treatment, threatened severe endo-carditis. His heart sounds were very suspicious, the murmurs at times seeming to be due to valvu- lar lesions, at least enough so to make life in- surance impracticable. April 20th, 1886. I operated on his rectum without an anaesthetic, removing several pockets, and stretching the sphincters. April the 28th. He very enthusiastically reports excellent refreshing sleep, and he had dreamed much and awakened with headaches and coated tongue. Moreover, he is surprised to find less ardent and more normal sexual desire. June 1 st. Second operation.—Simply trimming up former work. 94 ORIFICIA L S URGER Y. June 14th. Continued improvement. F£ A dose of Sulph. high. Aug 27th. Mr. E. reports a successful examination for life insurance, by a competent physician of this city, to whom he honestly detailed his former heart symptoms. He de- clares himself better this summer than in years, and this general improvement of health has since continued, for I have been his constant medical adviser. Case XVI.— Chronic diarrhoea, head- aches, and general debility. Operation.—Removal of pockets, and piles. This case is recent and has gone hardly long enough to predict much upon. I intro- duce it in order to show one or two points. Mr. M., a man of 55, is a veteran whose health was first undermined in service during the rebellion, chiefly by a chronic diarrhoea. For three years he had suffered everything with his head and his bowels, for which he has received all manner of treatment. In one year he has had no natural movement of the bow- els, but has been compelled to resort to salts or some other purgative. His headaches are neuralgic in nature, being almost constant, the pain extending over the vertex or through the head from temple to temple. Besides he has become so debilitated that he cannot do a day's work, and is naturally completely de- pressed and discouraged. ILL US TRA TIIrE CASES. 95 Dec. 12th. The rectal operation of Prof. Pratt was performed, four large indurated pockets being removed. Several large piles formed a circle above the sphincter. He would not have these touched, as he thought too much had been done to them already. The operation was attended with much bleeding and pain, for the cutting was necessarily con- siderable. # Sulph. high, one dose. Before he left the office his headache was gone for the first time in months. I have several times noticed this immediate relief of congestive symptoms after the operation. Dec. 26th. The second operation of trimming was performed. He reports com- plete freedom from pain in head, and general better health. Jan. 10th. A sacral backache, of which such patients often complain, was relieved by Rhus 30. This remedy seems to suit many cases after the operation. Jan. 23d. On the third examination of the rectum, another pocket was found and excised. This probably accounted for a return of his headache, a week since, which disap- peared under Podoph. 3X. He reports himself in better mental state than in years, his complexion is clearer, and his strength daily increasing. He is now at his daily occupation, that of pattern making. The piles were much smaller than before, and less painful. 96 ORIFICIAL SURGERY. REPORTED BY DRS. MC AFFEE AND FINLEY, CLINTON, IOWA. Case XVII. — Insanity. Operation. — Removal of pockets and papillae. The patient, an American, married, aged 28, residing in Illinois, visited us in Oct. 1886, with her husband and parents. They informed me that, four years since, after she had been married one year, she gave birth to a child, an event she had looked forward to with a great deal of pride. After the child was born she was informed that it was dead, at which time she commenced weeping and in a short time signs of insanity were manifested. She continued to grow worse from day to day, and at the end of two weeks they were obliged to guard her con- tinually. She was treated by th e family physician for a few months, with no improvement. The friends became very much discouraged and ex- pressed a desire that a change should be made. After consultation they concluded to take her to Elgin insane asylum. After an examination they were not given any encouragement, and returned with her to Freeport, Illinois, and placed her in the hands of a specialist for one year. Her condition not improving, the friends decided to make another change, this time taking her to Iowa to another specialist, who treated her six months without benefit. The husband and parents thinking, after so many ILLUSTRATIVE CASES. 97 fruitless attempts, there was no help for her, abandoned treatment for some time. She had spells of insanity nearly every day. Every time that she menstruated she would be very much worse, requiring constant attention. October 18th I found her with the follow- ing symptoms: pain in head; giddiness; noise in ears; heat on top of head; eyes shining bright; deranged digestion; food distressing her very much; bowels obstinately constipated; pain in back and limbs; dragging sensation through back and hips, extending down the thighs; feet and hands cold. From the symp- toms our attention was directed to an examin- ation of the uterus. Aside from a slight erosion of the external os, and a partial retroversion, I could detect no further trouble. We next turned our attention to an examination of the rectum. A digital examination was attempted, but owing to the spasmodic contraction of the sphincter ani we had to abandon any further attempt in this direction until we had adminis- tered an anaesthetic. Then, with the Pratt speculum, we dilated the rectum to its fullest extent and at this time removed therefrom a large number of internal pockets, three large papillae and seven internal haemorrhoids of large size. She recovered nicely from the operation. But the most pleasing and interesting part is yet to tell. She has not had a symptom of 98 ORIFICIAL SURGERY. insanity since the operation, passing through her menstrual periods without any trouble, and says she feels perfectly well. Case XVIII. — Dysmenorrhcea, irritable stomach, and constipation. Operation.—Removal of rectal pockets and haemorrhoids. Miss Mary W., aged 26, light complexion, blue eyes, light brown hair, nervous temper- ament. Commenced menstruating at twelve years of age, the period always being painful and protracted ; general health otherwise rea- sonably good. In her twentieth year she fell backwards from a high table, striking on her head and back, after which her menstrual periods were much more painful than before. She was treated both locally and constitutionally for several years, by different physicians. What the local treatment was she is unable to state, but says it was necessary to give her an anaes- thetic every time, as it was so painful she could not endure it without. She was told there was a misplacement of the uterus, occasioned by the fall. We were called to see her in Febru- ary, 1886, while she was passing through her monthly period, and found her at times in con- vulsions which would last some minutes, and as consciousness returned she would faint. Sometimes she would have a period of rest, and at other times the spasms would succeed each other very rapidly for an hour or more. ILLUSTRATIVE CASES. 99 Her stomach was very irritable, and her bowels obstinately constipated; some pain across the back and down through the ovarian region and thighs; abdomen bloated and very hard and painful; limbs swollen and blue, and she com- plained of their being so very heavy; her feet so puffed it was difficult for her to walk, she saying they felt like clumps. She would get better under remedies, but it was only a rest from one month to another, and the trouble would be repeated at each monthly period. On the 18th of September last she was taken very sick, and finally consented to an examination of the uterus, which she had strenuously op- posed, as the experience of former treatment made her fearful of the consequences, and very suspicious. The examination disclosed the fact that the uterus was slightly retroverted, and after a little local treatment she improved in all respects and seemed to be in a fair way to recover, when, on the 18th of October, after having taken a severe cold, all the bad symp- toms returned worse than ever before, spasm succeeding spasm rapidly, the usual remedies seeming to have no effect. It was a very dis- couraging case indeed. We advised her to submit to a rectal ex- amination, which she consented to, and on the nth of November we operated on her, remov- ing several large internal pile tumors, two ex- ternal ones and several pockets. She rallied 100 ORIFICIAL SURGERY. nicely from the operation and on the 28th of November visits to her were discontinued. Jan. 31st, 1887, she says she is better than ever before. There is no swelling of the limbs or feet, no pressure of the head, and her step is light and elastic and her bowels regular. The painful expression of the face is gone, the com- plexion clear and fair, and the patient happy and contented. Since the operation was per- formed she has passed through two menstrual periods without any pain to speak of, and has never had any spasm since. Her feet and hands, which were cold, are now warm and comfort- able. Case XIX.—Gastralgia, persistent vomit- ing, and general debility. Operation.—Removal of haemorrhoidal tumors and pockets. Mr. M., a Scotchman, aged 64 years, dark hair and eyes, active nervous temperament. Has suffered for more than twenty years of what he calls stomach trouble, characterized by severe and persistent pain, sickness and vomit- ing, recurring at regular intervals and continu- ing from a few hours to a week or two, and sometimes a month. The stomach was very irritable, rejecting both food and drink, and especially cold drinks being ejected almost immediately. During the last eight or ten years he has used Bicarbonate of soda, in tea- spoonful doses, dissolved in water, from five to ILLUSTRATIVE CASES. 101 ten times a day. In August, 1886, after having eaten freely of ice-cream, a severe attack fol- lowed. Trusting to his Soda he did not call a physician for several days, his son being a physician and away from home. On his return he gave him Arsenicum 3X, Nux. 3X, Lycopod. 6x, Carbo. veg. 6x, with no improvement in any respect. At this time the case becoming very alarming, and the friends very anxious and dis- couraged, we were called as counsel. The vomiting was partially controlled by Ipecac and Arsenicum, and he obtained some little relief, only to be followed by severe pain in the stomach and bowels most of the time, the abdomen being distended and very sensitive, the liver also being very tender and swollen. He was given morphine hypodermically at times when the pain was unbearable. He seemed almost in a state of collapse, his son expressing himself by saying he could not recover. At this time, October 15, a rectal examination was decided upon, he calling for water and vomiting every time after drinking. We operated on him in his weakened and emaciated condition, and removed from the rectum several internal haemorrhoids, three external ones, and several pockets. The bowels had for a long time been obstinately constipated and would only move by an enema of warm water. In two or three days after the operation we could see quite a 102 ORIFICIAL SURGERY. decided improvement. The pain was not so constant nor was it so severe. The feet and hands, which before were cold, were now warm, and the bowels began to perform their proper function. The most remarkable part of it all was the rapid and decided improvement in the stomach symptoms. The vomiting, which had been persistent, had entirely ceased, and his food was eaten with a relish. On the evening of Nov. 17th, 1886, he came to our office in the cold and storm to express his gratitude and appreciation of the treatment in his case and said only for that, he believed, as did his friends, he would have been a dead man. His condition January 31, 1887, is as follows: Appetite good and food relished. The digestion is performed in a nor- mal and satisfactory manner. There is no vomiting, or even nausea. At times there is a little fullness over the abdomen, but he has nearly regained his usual weight and is able to attend to his business, that of a builder. REPORTED BY J. C. BURBANK, M. D., FREEPORT ILL. Case. XX. — Neuralgia and constipa- tion. Operation. — Orificial surgery. Mrs. S., aged 51 years; dark complexion; nervo-bilious temperament. Has not been free from pain, either in head, stomach, or back and hips, for twenty years; bowels more or less constipated; appetite variable; sleep unsatis- ILLUSTRATIVE CASES. 103 factory; frequent haemorrhoidal troubles, etc. She ceased menstruating over a year ago. This patient came to me for orificial treatment September 24th, 1886. I treated her according to the approved method as taught by Professor Pratt. In four weeks she was well in every respect and has remained so to this date. Case XXI. — Dyspepsia, insomnia, alter- nating constipation and diarrhoea. Operation. — Orificial surgery. Mr. R., aged 34; tall and slim; dark complexion; bilious temperament. Has had indigestion; sleepless at night; bowels irregu- lar, alternating constipation and diarrhoea; always a feeling of pressure and distress in the rectum; headache more or less constant; sore throat and colds almost continuously; loss of ambition; said he must either go crazy or die. I treated him by orificial methods Oct. 6th, 1886. Two weeks from that date he said he was better than he ever expected to be. November 13th said he was entirely well and did not need my services. I could give many more cases with similar histories and equally good results. REPORTED BY HOWARD CRUTCHER, M. D., CHICAGO. Case XXII.—Debility; headache. Operation.—Removal of rectal pockets, papillae and piles. • In the spring of 1885 Mr. C. A., aged 53, consulted me for the relief of what he termed 104 ORIFICIAL SURGERY. " bilious spells," which had troubled him for many years, and which recurred with almost semi-monthly frequency. He had a sensation of constant weakness. Diarrhoea was easily induced, he thought, by any change in drink- ing-water. The "spell" came on about as follows:— Headache, accompanied by dizziness, came on just after waking in the morning, and lasted till the following day; pains in stomach and bowels; nausea; general weakness, but no vomiting. After twenty-four hours of suffering the weakness increased and for days after he experienced an inconvenience in walking, " be- cause the legs felt very heavy." He had a haemorrhoidal history which induced me to ex- amine the lower bowel. I found hyperaemia; pockets, one or two papillae, two large haemor- rhoids, and a moderately tight sphincter. I operated the first day of May. The pockets were clipped out, the papillae excised, the piles injected with a 95 per cent, carbolic acid solu- tion, and the sphincter stretched forcibly and well. The patient was at work on the fourth day, having experienced no great amount of trouble in the meantime. The results of the operation were surprising to both patient and physician. He has remained well to this time (Feb. 1887), and says: "I have no more of my old tired feeling, no more 'spells,' and feel like a new man." ILLUSTRATIVE CASES. 105 Case XXIII.—Headache, irregular men- struation, and constipation. Operation.—Removal of pockets, papillae and haemorrhoidal tumors. Mrs. J. E. S„ aged 40, of sedentary habits, sallow complexion and slender build, had suf- fered for twenty years from menstrual irregu- larity. Generally speaking, the flow was too profuse, accompanied by pain in the ovarian region. Sometimes the menses would not appear for months, and at such times a feeling of suffocation tormented her day and night. Headache was present almost all the time, beginning in the morning and growing worse as the day passed away. Constipation was a source of constant annoyance, and caused most likely by the torpidity of the liver. The face was generally of a pale, yellowish color, and sometimes the conjunctivae presented the characteristics of a jaundiced condition. A cough, coming on at night, worse from cold air, accompanied by slight expectoration of whitish mucus, had resisted the application of remedies which seemed to be indicated. She had suffered from piles years ago but hardly suspected the presence of any present trouble in the lower bowel. I did, and pro- ceeded to make an examination. Hyperaemia was intense; soreness marked; papillae and pockets present; remnants of old haemorrhoids protruding from the orifice, and a tense sphinc- 106 ORIFICIAL SURGERY. ter. I operated on the second day of July, pursuing the usual course in such cases. So far as the menstrual troubles went, the operation was a complete success. She has improved in every respect right along since, until to-day the cough, which seemed hardest of all to dislodge, is almost a thing of the past. Recovery was prompt. As regards the menstrual trouble, the treatment was a complete success. REPORTED BY M. J. BLIEM, M. D., CHICAGO. Case XXIV.— Congestive headaches, and " sinking spells." Operation.— Removal of pockets and papillae. Miss H., aged 22, while engaged in wait- ing upon an invalid father, was taken with peculiar sinking spells. She steadily grew worse for six months, so that, when first seen by me, she suffered several attacks daily. The least exertion brought on a sinking turn. What- ever her position at the time, she would lose all muscular control and sink to the floor. Though retaining consciousness she would be unable to speak or move for five or ten minutes. Besides these attacks she sufferd from severe conges- tive headaches almost daily. Her menses were tardy and scanty, but comparatively free from pain. Appetite was fairly good and bowels very regular. ILLUSTRATIVE CASES. 107 The case had been under skilful medical treatment before coming into my hands. I at once thought of orificial irritation as a cause, but, deferring to her virgin state, first gave her two months' medical treatment, to the best of my ability. Then finding her steadily grow- ing worse, the attacks assuming more of a hysterical-epileptic condition, I determined to apply the methods of orificial surgery. The sphincters were so tight that no satisfactory examination could be made without an anaes- thetic. The mucous membrane was very red and irritable. I removed from the rectum a number of pockets and papillae. Among these were several of the type of double papillae, with a pocket between them. . There was a peculiar cribriform condition of the hymen, which was very tough — this was ruptured, and then neatly trimmed off. The uterine condition was one of chronic catarrh of the endometrium and cervix. The canal was dilated with graduated steel sounds up to i$}4, and the mucous membrane gently curetted, bringing out numerous granulations. The operation was performed three months ago. She has not had a single severe attack and only a few very light ones since. During the last month she has had no sinking-spells at all, nor any of her old headaches. The only after-treatment consisted in the general appli- cation of static electricity together with Ferrum phos. and Kali phos. as remedies. 108 ORIFICIAL SURGERY. Case XXV. — Constipation and prolapsus ani. Operation. — Removal of pockets and papillae, and stretching of the sphincter ani. Mr. B., aged 25, has always been of a constipated habit; though generally able to have stool daily, it was accomplished by great effort. About five years ago, during one of these hard passages, he suffered a prolapsus of the rectum, causing syncope. The bowel was replaced, but from that time on the most obsti- nate constipation was present. A movement could be obtained only by means of enemata, the continued use of which only increased the trouble. He finally ceased using them and then would have a difficult passage once or twice a week. A great many remedies were tried without avail, as well as careful dieting and the best attention to physical health. In fact, the constipation was the only difficulty, the patient enjoying otherwise splendid health. There never was the slightest indication ot local trouble in the rectum. Finally the possi- ble existence of pockets and papillae was suggested by the attention which Dr. Pratt was attracting to these conditions. Dr. W. F. Knoll kindly examined the case and, finding these conditions present, together with severe erosions, removed them and dilated the sphincters. Within three weeks the bowel was nicely healed and the patient began having a regular daily movement. The operation was ILLUSTRATIVE CASES. 109 performed almost a year ago, and the patient has ever since had an easy and natural daily passage of the bowels. [This case, with the consent of Dr. Knoll, is report- ed by the patient himself.] REPORTED BY L. PRATT, M. D., WHEATON, ILL. Case XXVI.—Anaemia and dropsy, with severe constipation. Operation. — Removal of pile tumorsj pockets and papillae. Mrs. P., aged 48 years, states that she has been an invalid for five years, during which time a number of physicians have tried their skill in treating her case, with no permanently good result. Among the number was an in- telligent homoeopath who had professional care of her for the last six months. Present condition: General debility, thin in flesh, with pale, anaemic appearance; ex- treme constipation, no stool except by use of ca- thartic or enema; small ulcers in the mouth; sub- acute inflammation of mucous membrane; loss of appetite; food causes "distress, and frequently a severe burning sensation in the stomach;" very nervous and irritable; restless at night; extreme depression of spirits; felt as though she would as " soon die as live, and a little rather." She had oedema of the feet and legs nearly up to the knees, also a moderate amount of ascites. Her catamenia were and are regular. 110 ORIFICIAL SURGERY. Yellowish, stringy leucorrhcea and sensitiveness of the vagina; ulceration around the os uteri and a small polypus in the canal of the cervix. Heat and tenderness in the region of uterus and ovaries. Could not stand on her feet long at a time. On examining rectum through a Pratt speculum found two haemorrhoidal tumors of small size; also pockets, commencing above the internal sphincter. These pouches, or "pockets" were very sensitive at their lower termination, and bled easily on being touched with a curved probe or blunt hook. The internal sphincter was so sensitive and rigid that the in- troduction of the speculum was somewhat difficult and extremely painful. A piece was cut off the haemorrhoidal tumors with curved scissors, the upper surface of the pockets elevated with the blunt hook and clipped off down to their apices. Six were thus excised and four papillae from the margin of the internal sphincter. The speculum was removed and the internal sphincter stretched with the fingers until its fibres could be felt to yield. She remained here nearly a week (her home being some fifty miles away) and during that time the oedema and ascites all disappeared; she could sleep at night. She had a stool daily, began to have an appetite, felt cheerful, had no desire to "die," in short, all her severe symp- toms had disappeared as if by magic. She said "I scarcely know myself, there has been ILLUSTRATIVE CASES. \\\ such a happy change." She took Hydrastin 3X every four hours, which remedy she had pre- viously taken with no apparently good effect. Some weeks later the polypus was removed, and the canal of the cervix dilated with graded steel sounds. She continued to improve with very little interruption, and at the end of two months considered herself a well woman, except that she suffers a little at times with uterine symptoms incident to females of her age. Her state of health is now good, and she is a happy woman. Case XXVII.—Chronic endometritis with retroversion; constipation and gastralgia. Operation.—Excision of pockets, papillae, and pile tumor. Mrs. M., aged 58. Suffered from chronic cervical endometritis and enlargement of the neck of the uterus, with retroversion. The canal of the neck denuded of its lining mem- brane and granulated. Almost constant pain in her back and region of the uterus; yellowish, stringy leucorrhcea; catarrh of the uterus; com- plained of a sensation of heat in the uterus and back; nervous prostration and extreme depres- sion of spirits; very sensitive to noise; wakeful and restless; much of the time confused feeling and dull pain in her head, and heat across the vertex; constipated; at times very difficult to defecate, even with the assistance of an enema; at times palpitation of the heart with faintness; 112 ORIFICIAL SURGERY. loss of appetite; much belching of gas and gastralgia, coming soon after eating and lasting one or two hours after a meal. This patient had been under my care at intervals for several years. Within that time she was several months under the care of an allopath (a lady practitioner who gave her narcotics, cauterized the cervix and prescribed cathartics). She became worse and returned to me. I used many remedies and gave her the best local treatment I knew of; frequently replaced the retroverted uterus and used tam- pons and pessaries with a view of getting them to stay in proper position. My treatment and prescriptions seemed to relieve her, and she would at times feel better for several weeks, but her improvement was only temporary. The old morbid conditions and symptoms would return. In fact, she did not get any better permanently. I examined her rectum, cut out a number of pockets and four papillae; one haemorrhoidal tumor was operated upon by clipping away about one half of it with scissors. The internal sphincter ani, which was extremely rigid, was thoroughly stretched. She soon began to improve. Twice subsequently I passed uterine sounds, small ones at first, lastly a No. 14. Prescribed twice afterwards, at in- tervals of two weeks, Hydrastin 3 x, and Macrotin 3 x, three doses daily, on alternate days. These remedies she had taken repeat- ILLUSTRATIVE CASES. 113 edly before, within the past four or five years. Did not see or hear from the patient again until November last (the rectal operation was performed in June, 1886). She called to tell me — " Doctor, I am quite young again. My bad symptoms have all left me. You see I am fleshy, and I am cheerful, happy and free from bodily suffering." Case XXVIII.—Chronic headache and melancholia. Operation.— Removal of rectal papillae and stretching of sphincter ani. Mrs. A., aged 48, complains of constant headache, at times "as though it would burst. " Loss of appetite, general weakness and ex- treme nervousness; gets "almost wild at times," and it seems as if she would "go deranged;" has frequent chills and flashes of heat with cold perspiration; constipation, with severe pain in the rectum when at stool; menses regular, but rather profuse; feet cold all the time; ex- treme depression of spirits; feels as though it " would be full as well to die as to live." She had consulted several physicians and taken their prescriptions, but experienced no relief. Is now in a state of "almost desperation." These symptoms have annoyed her more or less for several years past, and she has become worse lately. Says she almost despairs of ever being any better. 114 ORIFICIAL SURGERY. On examination I found ulcers in the rec- tum, above and below the internal sphincter ani and an extremely rigid muscle; also five papillae around its upper margin. I cut these off with a scissors, and weakened the muscle by dilat- ing it with the fingers until it was felt to yield. She was to call a week afterwards and re- port. She did not come at the appointed time. Two weeks afterwards I met her in the street of the town where she lives. She said: " The reason I did not visit you according to engage- ment was, I was very busy and felt well and concluded that unless I felt worse I did not need further attention at present. I have not felt so well for years. All my bad feelings are gone, have a good appetite, bowels regular, rest well and feel well all the time. I could not have believed that such a happy change was possible in so short a time." Case XXIX.— Sick headache and con- stipation. Operation.— Removal of pockets and papillae, and passage of urethral sounds, Mr. R., aged 34. For several years he has been subject to attacks of what he called " sick headache," at first perhaps every three to five weeks, but lately nearly every week. He is very costive, has no stool except from the action of cathartics, suffers some from haemorrhoids. His head feels dull, heavy, and dizzy most of the time. Food produces a ILLUSTRATIVE CASES. 115 severe pain in the stomach and a bloated feel- ing. The pain (gastralgia) has of late been so severe that he felt obliged to take some tonic or stimulant after each meal. In fact, he was becoming worse so fast that he feared he could not run his train much longer (he is a conduct- or). He had been under the care of an able physician of the old school for six months past, but says he gets worse all the time. Found pockets, papillae and haemorrhoids in his rectum. He suffered also from painful urination, caused by a stricture near the pros- tate gland. After having removed the pockets and papillae and operated on the haemorrhoids, his very rigid internal sphincter ani muscle was partially paralyzed, and a steel sound (No. 12) passed into his bladder. This was repeated every few days until a No. 14 sound could be easily passed. I gave him Nux vomica 6x, tobe taken a dose at noon and night, daily, and Sul- phur 12X, a dose every morning. He improved rapidly at once and within four weeks from the time of that operation (October, 1886) his head- aches were gone, bowels regular, appetite good, no pain in the stomach after meals and he felt so well he scarcely knew himself, lne primary symptoms were cured also. He has not needed a prescription for two months past and considers himself a perfectly sound man. 116 ORIFICIAL SURGERY. REPORTED BY J. R. BOYNTON, M. D., CHICAGO. Case XXX.— Blindness. Operation.— Removal of pockets and papillae. Mr. H., of Ohio, came to me for treatment last November. He gave the following history. "Father died several years ago. Mother living and well. Am twenty-five years old; have a wife and one child. I have always been healthy, active and strong; eat and sleep moder- ately well; am of a cheerful mind; have never been afflicted with diseases of any kind; tempe- rate in all my habits; never used tobacco, beer nor liquors; have never taken much medicine; entered in early life the minstrel profession; seven years ago my eyesight began to fail me; could not look steadily at objects on account of a cloud coming between me and the object; could not read print nor writing without losing sight of the line or place, and would be unable to find the place again; perhaps this would last for hours; sometimes, when talking to a friend, a dark cloud would suddenly come between us, and it would be several minutes before I could recover my sight again; frequently while on the stage, performing, the foot-lights and audience would disappear from my sight, and all would be total darkness for several minutes, and on one occasion for the entire evening. I dreaded to walk out alone on account of these prolonged blind spells. ILLUSTRATIVE CASES. H7 " Several eminent physicians of New York and Philadelphia were recommended to me, most of whom I consulted. They said I had progressive atrophy of the optic nerves, and gave me but little encouragement. This con- tinued for nearly five years, when all at once I became blind, could not see man, house, sun- light nor gaslight. I called on the best oculists in New York, Philadelphia, Baltimore, Cincin- nati, St. Louis, and Chicago, and all, without a single exception, told me that the nerves of vision were paralyzed, and that they could do me no permanent good." From this man's rectum I removed five papillae and three pockets. The patient re- covered so that in ten days from the time of the operation he could tell the time of day to a minute by my watch, see distant signs on the streets, get on and off horse-cars, read coarse print, and to all appearances he bids fair to become entirely well. Case XXXI.— Paralysis. Operation.— Removal of rectal pockets and papillae. Mr. S., a roller skate performer, accus- tomed to tumbling and falling. His last fall was so violent that he was stricken down with par- alysis of one side. He laid in bed for nearly six weeks without much relief. Medicine seemed to do him but little good. I was sent for to see him, and finding him so poorly I in- 118 ORIFICIAL SURGER Y. sisted on examining his rectum and found sev- eral papillae and one pocket. I removed these and thoroughly paralyzed the anal sphincter and left him on Nux v. Improvement began at once and in seven weeks from the time of the operation the gentleman reported to his com- pany for duty. Case XXXII.— Suspected phthisis. Operation.— Removal of rectal pockets and papillae. Mrs. L., of Sioux City, Iowa. I was called to the hotel where she was stopping; found her in bed. She was said to be in the last stage of consumption; but this I did not be- lieve, although her lungs were in a terrible condition, coughing and expectorating a yel- lowish-green sputum, tough, in large quan- tities, and smelling very badly. She was very much emaciated, had poor appetite, and could not sleep nights; had weakening night- sweats; could not retain heavy or solid food on her stomach. I insisted on examining her rectum, which was very sensitive to the touch. I had to administer chloroform. I found a very bad stricture, haemorrhoids and papillae, all of which I removed at that operation; gave her Iodine 3X, and improvement rapidly followed. The lady is now in this city, free from cough, and to all appearances well. ILLUSTRATIVE CASES. 119 Cases reported by the Author. Case XXXIII.— Nervous prostration. Operation.— Removal of pockets and pa- pillae, stretching of the sphincter, and passage of urethral sounds. G., aged 36, physician; in 1880 broke down with nervous exhaustion; for six months was unable to do mental or bodily work. Pro- longed rest and treatment produced twenty pounds in flesh, and much improved mental powers, when he gradually resumed work, at- tended his professional duties for five years with frequent rests and vacation, and consulted me in October, 1886. He said he was well ex- cepting a very irritable stomach, and having no reserve power; a little extra work or loss of sleep prostrated him and necessitated rest. His face was haggard, and when fatigued he was restless and depressed; bowels regular. He also complained of his spine; any long ride brought on soreness and pain the whole length of the spine and base of the brain, which was attended with great irritability, hypersensitive- ness, and some mental depression. I operat- ed upon this man Oct. 15, removing two papil- lae and one pocket, stretched the sphincter, and passed a sound. The third day after, in pass- ing a large and hard stool, the wounds were somewhat bruised, and severe pains down the legs and in the soles of the feet immediately followed, which lasted for some hours, and were 120 ORIFICIAL S URGER Y. attended by the same mental and bodily unrest which had characterized his former neurasthe- nia. An injection of Hypericum i to 20 relieved the rectum, and his pains vanished. He writes me under date of Jan. 17, 1887, as follows: " Since I left you in October I have been daily in active practice, one day making 20 calls, attending.two confinement cases at night without sleep, and working the next day. I have not had a single symptom of dyspepsia, and have eaten everything which is reasonable. Have not been tired, that is, exhausted, as be- fore, a single minute, and never any of the soreness or pain in the spine. I never knew such health before, and I am sure the great change is due to your operation. Without ex- aggeration, it has increased my working power fifty per cent., and my happiness and that of my family still more." Case XXXIV.— Insanity and insomnia, with constipation. Operation. — Removal of pockets and papillae, and stretching of the sphincters. This patient was about to be sent to the Elgin insane asylum when I took charge of the case. Examination under the usual anaesthetic — two-thirds ether and one-third chloroform — revealed a tight sphincter, displaying, when dis- tended, a^, half-dozen pockets and two or three papillae; scrotum relaxed and testicles flabby. ILLUSTRATIVE CASES. 121 The rectum was properly smoothed by re- moval of pockets and papillae, sphincter well stretched and sounds 12 and 14 passed. The mental condition began at once to improve; constipation! wakefulness and poor appetite continued a few weeks. Massage and elec- tricity, which were used persistently, ulti- mately succeeded in removing these conditions. Nux, Sulphur, Cantharis, and Opium, homceo- pathically prescribed, were also employed. In three months the patient was entirely recovered and again at his business. Case XXXV.— Secondary siphylis. Operation.— Removal of pockets and pa- pillae and passage of sounds. A laborer, aged 35, contracted siphylis two years ago. In a few months glandular en- largements followed in the cervical region, axillae and groins. His general health failed and for a year he had been unable to work. He was thin and pale. Careful medication under my own direction failed to cure him, as had all previous measures' for his relief. An ex- amination disclosed sexual enervation, the testes being soft and flabby and the scrotum relaxed to such an extent that it hung one-third down the thigh. A tight sphincter ani and four rectal pockets were observed. ^ Without an anaesthetic the rectum was relieved of its pockets and the opening stretched. Sounds up to No. 16 were also passed. All medicine 122 ORIFICIAL SURGERY was stopped. In one week the glands had perceptibly diminished in size, and for the first time the man said of his own accord, " I am better." In three weeks the glands were of normal size and the man's general condition so much improved that he was able to resume work. In the course of eight or nine weeks, by the weekly use of sounds, the sexual organs were entire- ly restored to normal condition and position. Case XXXVI.—Second- ary siphylis. Operation.— Removal of pockets and papillae. This man was one of the most pitiable sufferers imagin- able ; about 30 years of age. Siphylis contracted a year or two since. Cutaneous ulcera- tion so extensive that he was ordered photographed. Al- though he complained of no orificial irritation whatever, upon examination he disclosed an exceedingly irritable rec- tum, thickly studded with pockets and papillae, the internal sphincter, as always when such conditions are present, being abnormally contracted. ILLUSTRATIVE CASES. 123 Under an anaesthetic the rectal sur- face was carefully smoothed and dilated and urethral sounds were passed. As the sounds were withdrawn they displayed long strings of mucus clinging to their surfaces, showing a catarrhal condition of the urethral mucous membrane. During the next seven days he took no medicine whatever, nor was any atten- tion paid to his sores, he being denied even the privilege of a bath. On the seventh day after the operation, as he was again stripped. and placed on exhibition before those present, his condition presented a marked change for the better; the expression of his face was much brighter and his sores were fully one-half healed. The speculum was passed and dilated and the sounds again introduced. He took no medicine, nor was any attention paid him dur- ing the following week; at the end of that time he was again stripped and examined. 1 o the extreme delight and surprise of the two dozen witnesses who were present, his sores were entirely healed and the man apparently well. He was seen again, at the end of the third week, but was so well as to need no further care. He was asked to call once more and be photographed, but he never returned. For this reason the accompanying cut illus- trates the condition of the man only at the time of operation, and we are denied the privilege of one illustrating his recovery, but there were 124 ORIFICIAL S UR(, ER Y. so many witnesses to the case that it would be easy to obtain testimony. Case XXXVII.— Nervous prostration fol- lowed by cough, hectic fever and night-sweats. Operation.—Removal of pockets and pa- pillae, and use of pneumatic cabinet. A gentleman, aged 42; narrow-chested and pale, suffering from brain-fag and general nervous prostration; bowels regular, and com- plaining of no rectal troubles. An examina- ■tion, however, revealed several internal piles, and two papillae. A chronic epididymitis spoke of a sexual waste. The piles and papillae were excised, and sounds were passed. Immediate improvement in the patient's condition fol- lowed, his memory improved, his strength re- turned, and for a time he seemed perfectly well, returning again to hard labor. In a short time a slight hacking cough set in, which rapidly in- creased in severity, and was soon followed by slight hectic fever and night-sweats. He was now placed in the pneumatic cabinet daily for a week or ten days, at the expiration of which time all alarming symptoms had passed away, and the patient was discharged. Many months have since passed, but the patient still continues in perfect health. Case XXXVIII. — Constipation; conges- tion of the liver following operation. Operation. — Removal of pockets and stretching of the sphincter ani. ILLUSTRATIVE CASES. 125 A delicate young man, of 30, suffering from night losses and habitual constipation, was found upon examination to have deep, irritable rectal pockets, and atrophy of the prostate gland. After an operation which consisted in the re- moval of pockets, stretching of the sphincter, and passing of large urethral sounds, the patient was sent home, a distance of twelve miles, ex- periencing in the next few days an unusual ap- petite. He was foolish enough to gratify it; being deprived at the same time of his usual amount of exercise on account of the soreness of the bowel, his liver became congested, he began to develop a malarial tendency and he presented a marked jaundiced appearance. Arsenicum and Bryonia speedily controlled his complications, his constipation disappeared, and complete recovery rapidly followed. Case XXXIX.— Articular inflammation. Operation.— Excision of piles and dilata- tion of uterine canal. An acute inflammation of the synovial membrane and sheaths of the tendons in the left wrist had deprived a young woman of rest and comfort for a number of weeks. All internal medication and local measures seemed unavail- ing The period of suppuration seemed fast approaching and inevitable. Orificial inspec- tion revealed a mass of internal piles and a sub-involuted uterus, with its accompanying cervical and corporal endometritis. Without 126 ORIFICIAL SURGERY. an anaesthetic, the piles were excised, and the uterus dilated to number seventeen, and care- fully curetted. The pain in the wrist ceased in a few hours, never to return. The swelling in the inflamed member rapidly subsided, and a hand, of which past experience had taught me to fear the ultimate loss, was saved to its owner, not to mention the improvement in the general health of the patient which was also secured. Case XL.— Albuminuria. Operation.— Removal of pockets and papillae, and passage of sounds. A man, aged 28, had lost twenty pounds of flesh in three months' time. He was gener- ally prostrated, was troubled with periodical dimness of vision, but the worst feature of his case was the condition of his urine, being scanty and containing a large quantity of albu- min, with some pus, blood, and an occasional tube-cast. No rectal disorder was found, ex- cept a few pockets and papillae. These were removed, the sphincters stretched and urethral sounds passed. The results in this case were most gratifying; for the first ten days the patient gained nearly a pound a day, and an examination of the urine, which before was loaded with albumin, disclosed but a mere trace of it. The blood, pus and tube-casts were almost entirely gone. At this time the patient left the city, but has since been heard from, and, being a physician, I give credit to his statement that he is perfectly well. ILLUSTRATIVE CASES. 127 Case XLI.— Hyperaemia of the liver. Operation.— Removal of piles. A lady, aged 50, had suffered for several years from hyperaemia of the liver, having more or less pain in that region daily, being slightly jaundiced and the subject of continual mental depression. The bowels were regular, and although she complained of no rectal irri- tation, an examination revealed a large mass of internal piles and redundant mucous membrane. U nder an anaesthetic the piles were removed by means of tenaculum and scissors, the moderate amount of haemorrhage rendering this method possible. At the time of the operation she was quite enfeebled, having been confined to the house for several weeks with a mild form of intermittent fever, her temperature the even- ing before the operation being 100 ° F. The operation was performed out of town. I did not see the case again until about six weeks after the operation, and I had to look twice to recog- nize her, her appearance was so changed. Her complexion had cleared, she looked bright and happy, and came simply to thank me for what, to her, appeared like magical work. Her liver pains were all gone, her digestion perfect and her eyesight, which, she now told me, had long been poor, was better than it had been for twenty years. I knew nothing of the condition of her eyes previous to the operation, and so am unable to state just what had been relieved. 128 ORIFICIAL SURGERY. Other cases, however, have taught me to ex- pect results upon all muscular structures of the eye, and upon some conditions of the optic nerve, including that of progressive atrophy. Case XLI I. — General debility, with com- plications. Operation.— Removal of pockets and pa- pillae, and dilatation of the uterus by passage ol sounds. Mrs. A. was possessed of two lovely chil- dren, but has not been well since the last one came three or four years ago. Several good physicians made fruitless efforts to restore her to health. She was wakeful, nervous, pale, troubled with night-sweats, cold extremities, and was terribly despondent. Her appetite was poor, bowels regular, menstruation too frequent and profuse, uterus lacerated, eroded from cervical endometritis, and prolapsed; leucorrhcea profuse. The rectum presented a few pockets and papillae, and a tight sphincter. Under ether, pockets and papillae were re- moved, and the sphincters stretched. The uterus was dilated to No. 15^, English scale, by uterine sounds. For a few days the patient seemed to im- prove, but instead of continuing to gain, a slight rise of temperature, noticed every after- noon, a tenderness, and gurgling in the region of the caecum, and the other symptoms indicated the approach of typhoid fever. I was unable to ILLUSTRATIVE CASES. 129 abort it, and it ran its regular course of three weeks. The run was a mild one, and recovery from it was unusually rapid, and the subsequent complete release from all her previous maladies consoled the patient amply for all her trouble. Can it be that suddenly starting the blood current lighted a smouldering fire, and( that a preparatory course of massage and baths would have made the cure by the operation possible without the delay of the typhoid experience? Who knows? The lady is now fleshy, strong, and regular in all her habits, a perfect picture of health. Case XLIII. — Rheumatism, dropsy and heart-failure. Operation.—Passage of urethral sounds. Rheumatism, dropsy and heart-failure had put a man of 50 years in a chair, and kept him there for two and a half months. Owing to the dyspnoea, he was wholly unable to lie down and hence, for the length of time indicated, he had continuously eaten, slept and dwelt in a chair. The anasarca was so great that his legs were swollen to such an extent that the skin seemed ready to burst. His attending physi- cian had lanced the ankles in several places to relieve the pressure. There was some, though not excessive, ascites. Hydrothorax on the left side had progressed until clear resonance could be obtained only above the second inter- costal space. The only sound to be heard in 130 ORIFICIAL SURGERY. the apex of the left lung was sonorous rales. The heart's action was feeble and intermittent. The complexion was mottled and sallow, and the countenance showed great depression. Bowels regular; urine apparently normal. No history of local disorders of any kind. Examination of the rectum was rendered impossible by the man's inability to lie down. Urethral sounds, No. 12 and 14, were passed. No change was made in medicine. In five days the mucous rales in the left apex were entirely gone, the heart's action better, the face clearer, the anasarca diminished, and the hydro- thorax much less. The same sounds were again passed. On the eighth day the patient was sufficiently recovered to lie down for the first time. On the ninth day he walked half a block. The sounds were passed once or twice a week for a month when the case was dismissed entirely cured and the man was able to resume his accustomed labor. This seems like such a fairy tale that I will request those who desire to be convinced of its genuineness to address Dr. L. C. Grosvenor, No. 185 Lincoln Av., Chicago, who has kind- ly permitted me to make this reference to his name. Case XLIV.—Jaundice. Operation. — Cauterizing of rectal ulcer. Patient 60 years old, fairly bronzed with jaundice, wasted in flesh, weak, and confined ILL USTRATIVE CASES. 131 to his bed, where he had lain for six weeks, with no signs of improvement. At the first consultation no physical examination was made, but a change in medicines and diet suggested. When summoned again, two weeks later, as there had been no improvement, the rectum was examined and a small eroded spot discov- ered on the left side, between the sphincters. It was touched with 95 per cent. Carbolic acid, no other treatment being employed. This oc- curred before the time when the plan of double work was established, and before dilatation of the sphincter was a favorite practice. No sound was passed, and the sphincters remained undisturbed. Improvement began immediately, and in a week or so the jaundice was entirely gone and the patient ready to resume business. The same Dr. L. C. Grosvenor mentioned in the previous case will vouch for this one, for it is a piece of his own good work. Case XLV. — Chronic bronchitis, nervous prostration, slight paralysis agitans, and rheu- matism. Operation.— Passage of urethral sounds, removal of pockets, papillae, and piles. Mr. A., aged 59, has had bronchitis for years; now raises a half teacupful of heavy mucus daily; has suffered from rheumatism for past six months; is never without pain night or day; almost every joint in the extremities en- 132 ORIFICIAL SURGERY. larged and painful; appetite and sleep poor. Examination revealed the rare rectal combi- nation of pockets, papillae, erosions, piles, prolapsus ani, and enlarged prostate. The sexual organs were flabby, and much atro- phied; all medicines were stopped. Work was begun by partially distending the rectum, and passing numbers twelve and fourteen urethral sounds. In five days the speculum was again passed, after which the rheumatic pains suddenly ceased. In five days more the speculum was again passed, and also sounds numbers twelve and fourteen. The following day was cold, and in going out for a ride the perineum was not properly protected, and the urethra was consequently chilled. A summons in the evening disclosed incontinence of urine, and a temperature of 102 ° F; dry streak along the centre of tongue, indicating congestion of the kidneys. Poul- tices and electricity with Gelsemium and Apis internally, corrected the difficulty in four or five days. The pneumatic cabinet, followed by static electricity were then employed every second day until the chest capacity was much increased, and the patient ceased improving, the time occupied being about three weeks. The patient had employed massage for several months, and this with other measures were now stopped, and, under an anaesthetic-— two-thirds ether and one-third chloroform — ILLUSTRATIVE CASES. ' 133 the entire redundant rectal mass was removed by the clamp operation, and sounds Nos. 12 and 14 again passed. To my surprise the patient was up and dressed on the following day. No fever, pain or other discomfort fol- lowed. On the third day, however, as the bowels were sluggish, the speculum was care- fully introduced and partially distended to start peristaltic action; an injection of equal parts of sweet oil, glycerine and water, being used immediately afterwards. In five or six hours subsequently a series of involuntary discharges of the bowels began and continued for three or four days, involuntary urination also returning for a single night. Electricity soon terminated this complication, however. The prostatic enlarge- ment began at once to subside until at the end of a week or ten days it appeared but slightly enlarged. The cough, from which the patient had suffered for years, began now to disappear, and at this writing, two months after the oper- ation, is almost entirely gone. The involuntary diarrhoea was followed by constipation, which was corrected in the follow- ing manner — a female sound, No. 23, was passed daily into the rectum and placed in contact with the negative pole of a galvanic battery, the positive pole being made to follow the course of the large intestine. Four or five applications restored the regular habits of the bowel. 134 ORIFICIAL SURGERY. Fearing in so delicate a case to persist too frequently in the use of sounds, the urethra was injected every two and a half days with water as hot as could be borne, and medicated with Hamamelis, one-sixth strength. Rapid con- valescence has taken place, every condition being bettered; cough almost gone, rheumatic pains gone, paralysis agitans markedly im- proved and sleep and appetite everything to be desired. The patient has resumed business. The rheumatic enlargements are not gone, but steadily going. This was a delicate case to handle, and earlier attention would have saved the patient much time, suffering and risk. Case XLVI.— Melancholia. Operation.— Removal of rectal pockets, and circumcision. A stout, heavy man, aged 47, afraid of everybody and everything, has not left his room for months, and yet presenting no dis- cernible organic lesion; bowels regular. Under an anaesthetic a tight sphincter and four pockets were observed and corrected as recommended in the text. The prepuce was found so tightly contracted as to render its retraction im- possible. A dorsal slit overcame this deform- ity and the fraenum was severed and sound No. 14 passed. A brilliant, rapid and complete recov- ery at once followed, the patient being easily induced to walk out in one week after the oper- ation. He had been under the care of doctors ILLUSTRATIVE CASES. 135 more or less for ten years; dismissed cured in three weeks; buoyancy of spirits, appetite and sleep perfectly restored. Case XLVII.— Hydrocephalus. Operation.— Circumcision. Boy child 9 months old, weighs one pound less than it did when 3 months old. Whines and cries most of the time, vomits all nourishment; remedies, change of food and climate of no avail. Hydrocephalus developed to a consider- able extent, separating the frontal, coronal, sa- gittal and lambdoidal sutures, and protruding the forehead prominently over the eyes. No teeth or signs of any coming; bowels regular. Upon careful physical examination no pathol- ogy discernible except a long prepuce with small opening, not minute enough to deserve the name of "pinhole." The child was so weak that complete circumcision was deemed inad- visable. Accordingly the foreskin was simply well slit up and retracted; only small amount of smegma present. The immediate effect was surprising. The child slept well the very first night, it being the only good night's sleep it ever enjoyed. Its appetite improved at once and in the course of a week, to my gratification, the hydrocephalic condition was entirely gone and the case was dismissed. Two weeks sub- sequently, being again summoned to the case, I found it again restless, wakeful, and dropsi- cal symptoms returning, not, however, in the 136 ORIFICIAL SURGERY. head, but in the extremities. Examination re- vealed the fact that the foreskin had not been retracted and consequently the former condition had partially returned. He was now properly circumcised and improvement again began, and at the end of two weeks the dropsy was again gone and the child was perfectly well, and has remained so ever since, a strong, solid fellow, never ailing, and the pride of its parents. It is three or four years since, and if his troubles were intending to return they should have done so by this time. Case XLVI 11.— Chronic diarrhoea. Operation.— Removal of remains of the hymen. This patient suffered from chronic diar- rhoea of several years' standing. Medical attention, change of climate, and all efforts to relieve it had been unavailing. Careful pre- scribing on my part for three or four months was also unsuccessful. Finally at one inter- view she dropped the remark that sexual inter- course always aggravated her trouble; upon examination no orificial irritation was observed except at the attachment of the hymen, shreds of which were hypertrophied and' very red. Under an anaesthetic the vaginal orifice was nicely smoothed, and the wounded surfaces co-apted with fine silk sutures. Immediate and permanent relief from the chronic diarrhoea followed, and although four years have since ILLUSTRATIVE CASES. 137 •gone by, the lady is plump and lively and well, a marked contrast to her previously forlorn condition. Case XLIX. — Priapism. Operation.—Removal of a rectal papilla. Mr. Y., aged 27, was extremely nervous and wakeful, was constantly annoyed with pri- apism. Slight excitement or study would cause unnatural and irregular dilatation of the pupils. A specialist in nervous diseases examined the case carefully, including the rectum, which he pronounced to be in a normal condition, and called the case one of cerebral congestion, and treated the man for some weeks without bene- fit. Through the tri-valve speculum an elon- gated papilla was observed under the prostate. It was clipped off and the sphincter slightly stretched. Immediate convalescence ensued without medicine or further local attention, much to the delight of the patient and his last physician. Case L.-1—Supra- and infra-clavicular ab- scesses. Operation.— Removal of pockets and pa- pillae, and dilatation of the uterine canal. The lady was 20 years of age; she had been troubled with the abscesses, and also lymphatic enlargements on the right side of the neck, for some years, all local measures used failing to relieve her. Fragments of bone from the clavicle had occasionally been discharged. 138 ORIFICIAL SURGERY. Pockets and papillae were found and removed, and the uterus was dilated. Without medicines the abscesses were healed in about two weeks. Iodide of Mercury 3X, speedily reduced the en- largement of the glands. Case LI.— Abscess, with infiltration of pus. Operation.— Removal of piles, pockets, and papillae and uterine dilatation. A young brunette, aged 22, parted with a large lipoma by aid of a knife. The tumor was situated over the left sub-clavicular region. Instead of healing promptly and properly it displayed no reactive power, and instead of set- ting up an inflammatory zone and beginning the work of repair, the pus leaked out slowly into the areolar tissue, and promised pyaemic trouble. The wound was opened and packed with tow and carefully attended to twice daily, but to no purpose. For weeks the wound did poorly. The removal of a few piles, a pock- et or two, and uterine dilatation changed the state of things, and in a short time brought about complete recovery. Case LII.— Abscess of the groin. Operation.— Removal of pockets and papillae. A child of nine years suffered from a scrofulous sinus in the left groin, in spite of dilating, curetting, cauterizing, syringing, medicines, and all measures used for a period of six months, the child being under attention ILLUSTRATIVE CASES. 139 every week. Under ether miniature pockets and papillae were observed, and the accompany- ing spasmodic anus. The mucous surface was very irritable. The surface was properly smoothed and the sphincters well relaxed. The child being a little sore was in bed most of the time for two or three days. No attention was paid at the time of the operation to the sinus, and no medicines were given. The dis- charge of pus was stopped and the sinus healed in three days. There has been no return of the trouble, and it is now a year since the work was done. INDEX. After-treatment of chronic diseases--------------65 Circumcision---------------------------------- 49 Female sexual organs-------------------------- 5^ Fissure of the r-ectum--------.....------------ 31 Fistula in ano----------------------.------------31 Haemorrhoids, internal------------------------- 21 " external_________________________ 26 Hypospadias--------------------------------- 5° Male sexual system -----------------.....----- 44 Massage-------------------------------......- 73 Medicine------------------------------------- °7 Mental therapeutics--------------------......... 73 Papilla--------------.....-.....------------- 37 Pathology of the rectum----------------------- 1 ° Philosophy of orificial surgery------------------ 9 Piles, external-------------.....------------- 3° " internal---------------------------------2I Pneumatic differentiation......-----.....------- 7° Pockets______________________________________ 33 Prolapsus recti-------------------------------- 3° Rectum, pathology of-----.....----------..... *a Rorick's injection fluid------------------------- 23 Speculum, tri-valve------------------.....----25 Spermatorrhoea-------------------------------42 Static electricity--------------......-.....---72 Stenosis, urethral-.-.......-------------------- 5° Tri-valve speculum---------......------------- 25 Ulcers of the rectum---------------------- ..... 3° Uterine sounds--------------------------------DO ILLUSTRATIVE CASES. Abscess_______________________________137, 138, Albuminuria________......-------------------- Anasmia___________---...----------------77, Articular inflammation_________________________ Asthma, spasmodic____________________________ Bronchitis, chronic_____________________________ Blindness______________________________________ Constipation_____98, 102, 105,108, 109, 111, 114, Cough________________________________________ Diarrhoea, chronic.......__............78, 79, 94, Dysmenorrhoea _........_________________86, 88, Dropsy_________......_________—------106, Dysuria __.....______........____________..... Gastralgia_________________•......------76, 100, General debility____________________________81, Headache_________79, 85, 88, 89, 93, 94, 103, 106, Heart-failure____......_______________________ Hydrocephalus________________________________ Insanity____________________________________96, Insomnia__________________________-_______S6, Jaundice______________________________________ Liver, congestion of_____________________.._______ Melancholia__________________-.-______78, 113, Nervous prostration____________85, 89, 119, 124, Neuralgia........__________________________83, N ight-sweats__________________________________ Paralysis_______________......_________________ Paralysis agitans________........______________ Phthisis_______________a______..____......_____ Priapism____________....._____,__.___________ Prolapsus ani____________________......_______ Rheumatism_____________....._______......93, Sick headache_________________________________ Syphilis___________________________________121, Tenesmus of rectum___________________________ 79 Vaginismus____________________________________ 86 Vomiting________....._______-.„_____.____77, 100 SHARP & SMITH, MANUFACTURERS OF Surgical Instruments AND APPLIANCES. --------------■*--------------- A FULL LINE OF Dr. Pratt's Instruments CONSTANTLY ON HAND. 73 RANDOLPH STREET, Chicago, III, f^plC^T^ffWl^^^T^F^I £?t ?fM; )&>• ^ NLM005547905