Part 10

℞ Hyd. Chlor. Mit. ʒ i Balsam. Peru ʒ iss Acid. Carbol. gr. xx Lanolini ℥ i

M. et sig. Apply after hot sponging.

℞ Ol. Cadini ʒ i Acid. Salicyl. gr. xv Ung. Zinci Oxidi q. s. ft. ℥ i

℞ Saponi viridis } Ol. Cadini } ā ā ℥ i Alcohol. }

M. (Kelsey).

℞ Liq. Carbon. Detergentis (Wright’s). Glycerinæ ā ā ℥ i Zinci Oxidi } Calamini Prep. } ā ā ℥ ss Sulphuris Precip. } Aquæ Puræ ℥ vi

M. (Allingham).

DIVULSION.

Forced dilitation as a means of relief and cure for certain forms of rectal trouble, although a much abused and somewhat barbarous practice, has positive and undoubted merits. It is only justified, however, in peculiar and isolated cases.

The wholesale stretching of the sphincter ani muscles as a “cure all” is certainly to be deprecated as unscientific, illogical, and without the advantages or benefits claimed for it by rattling and noisy fanatics. Divulsion injudiciously employed may be followed by a long and tedious recovery, complicated with very undesirable sequelæ and thereby excites much adverse criticism.

The case of a lady recently came under my observation, who, although in average health, complained a little as many women do, and thought she was troubled with hemorrhoids. Through the advice of her physician, a college professor, she submitted to the operation of stretching on general principles. Irritability of the rectum followed, with soreness and continued pain. Finally two large sympathetic buboes developed, which suppurated, and were slow in healing. This happened a little over a year ago, I am reliably informed, and she has not yet fully recovered.

A number of cases have come to my notice where stretching was practiced for the cure of piles, imaginary spasmodic stricture, etc., without the least benefit, except, possibly, that accruing to the physician.

A young married man, foreman of a printing-office, complained at times of slight pain in the region of the liver. His physician, an editor of a medical journal, made an examination of the rectum with a speculum, and informed him that it would be necessary, to preserve his health, to undergo the operation of stretching the sphincters.

The day was appointed and hour set for the operation, which, fortunately for the young man, was “nipped in the bud” by the physicians arriving a little late; and through the advice of a friend he seized the opportunity and “skipped out,” came to my office, and was examined. His bowels were regular, there was no history of rectal disease, and not the least sign of any; nor was there a shadow of an excuse for an operation.

The cases in which divulsion seems to be of greatest benefit are found mostly among women of a peculiar high nervous tension or organization, where the muscles become hypertrophied from repeated spasm, and constipation resulting from ineffectual efforts to expel the feces. In such cases forced dilitation is followed by the most satisfactory results.

It should be accomplished with patient lying on the side, and under the most profound anæsthesia. Rectal dilators, which distribute the force evenly all around, may first be used, then the thumbs, or the thumb of right hand and index finger of the left, or two fingers of each hand, to completely paralyze the muscles. The process should be slow and gentle, and caution exercised lest the tissue give way from the application of undue force.

Local causes should always be sought, and excluded if practical, before heroic measures are adopted for the relief of spasmodic sphincter. There are instances where tightness of the sphincters exist, superinducing constipation, etc., not traceable to any appreciable cause. These cases may be relieved without the aid of general anæsthesia, by graduated dilators or rectal bougies, accomplishing little at a time, daily or tri-weekly.

When constipation depends upon inertia, or a lack of expulsive power of the rectum, I think moderate dilitation advisable and decidedly beneficial.

POLYPUS.

These innocent growths can be successfully removed, when within reach and most of them are, without the loss of blood or the infliction of pain, by carbolic acid injection to act as a styptic and deaden the sensibility, while the scissors is used to sever their connection with the bowel.

Allusion is made, in speaking of the diagnosis of hemorrhoids, to the different forms and varieties of polypi, consequently no further description of them will be given here. Polypi, being more dense and fibrous than hemorrhoids, are not readily permeated by the injection compound. Neither can the hemorrhoidal needle be used with any advantage unless they be large and soft in structure. Therefore a small hypodermic needle is selected and 95 per cent. carbolic acid. This strength of carbolic acid is not only a powerful styptic and cauterant, but its fluidity permits it to be forced throughout the fibrous structure with ease.

The action of the acid should extend fully to the base of the polypus, which is then clipped off a little outside of the line. The stump goes through similar changes to that of hemorrhoids after injection. In long or pediculated polypi, it will only be necessary to apply the acid at the base sufficiently to intercept the circulation before excision.

A little cocaine may be used first, if the parts are very sensitive, and the same precaution should be taken with regard to the protection of the adjacent and surrounding parts from the excoriating effects of the carbolic acid, as recommended when operating on hemorrhoids.

PROCTITIS.

Inflammation of the rectum, like any other phlegmasia, may arise traumatically or idiopathically; by contiguity of structure or continuity of surface. The acute symptoms are very much like acute dysentery, which disease, in my opinion, nearly always extends to the rectum, causing the characteristic symptoms of weight, tenesmus and straining at stool.

Irritable rectum in the absence of diarrhœa is diagnostic of the complaint. The bladder and prostate may be affected through sympathy, and colicky pain reflected to the small intestines or stomach. In the more chronic forms, constipation, tenderness and the cul-de-sac partially filled with mucous are distinguishing features.

Carbolized hot water irrigation, prepared hot corn starch, slippery elm water, bismuth, etc, together with a suppository of iodoform, bismuth and opium, or bismuth, opium, belladonna and calomel, will be found serviceable in the acute stage. About a half tumbler full of a saturated solution of chlorate of potash, injected slowly and retained for ten or fifteen minutes, is said to effect a cure by one or two injections.

Chronic proctitis, also called irritable rectum, and sometimes rectal catarrh, with symptoms that might be expected to emanate from a disease of the mucous membrane, rarely amounting to a diffuse thickening of the rectal walls, is treated similarly, except less palliative. Combinations of eucalyptol, iodoform and bismuth; or eucalyptol ½ dr., oxide of zinc 1 dr., vaseline 1 oz., are highly recommended after the rectal douche.