The Secrets of Specialists/Chapter 22

Of the three lower orifices of the body the rectum is doomed to share in its percentage of diseases and disorders, and there are very few people indeed, who pass through the span of life without suffering, at some period, with some derangement in this part of their anatomy. These diseases are particularly suitable to incorporate in an office practice, as a large percentage may be treated at the office without detaining the patient from his daily duties. I will, therefore, only outline the treatment of such diseases of this organ as may be successfully operated upon, and treated at the office, and allow the more voluminous text books to discuss the theory and technique of the major operation.

Patients who consult the physician at his office, regarding rectal diseases, generally possess sufficient pride regarding personal cleanliness to thoroughly bathe the parts before ​submitting to an examination; this is all that is necessary for a superficial examination, to determine the nature of the disease, but before conducting a thorough examination it is best to detain the examination for one day, and instruct the patient to take light diet, and a thorough enema, and bathe before exploring the rectal walls. Of course this may be done at the office if necessary. Your examination rooms should be provided with good light, and if you examine and treat this class of patients during the evening hours, I have always found it a great advantage to use a small electric light bulb, attached to the speculum, as is illustrated here; this is of great assistance either day or night, for general examination and

operative work. I have provided myself with four speculums: Pratt's bivalve and Sigmoid, Sim's fenestrated and Brinkerhoff's speculum.

I also have the rectal case illustrated here, which con​tains nearly all the instruments for treating rectal diseases, and will be found indispensable to any office specialist.

After determining the nature of the disease you have to deal with, and suggest an operation, about the first question the patient will ask you is, "must I take chloroform or ether"? and what a world of significance that little word "no" has, as it comes from the lips of the physician, for once more we have conquered pain in the treatment of these painful afflictions, and our old friend Quinine and Urea hydrochloride is monarch of the territory it surveys.

Dr. Gant was the first to abandon cocaine and other toxic anaesthetics, and prove that local anaesthesia could be produced by infiltrating the operative area with sterile water; by reinforcing his method with the addition of a one-half to a one per cent. quinine and Urea hydrochloride, we can produce a perfect anaesthesia for nearly all rectal operations.

The technique for producing anaesthesia will depend upon the extent of the operation. In the operation for a simple fissure, it is only necessary to infiltrate the tissues under the surface; where complete anaesthesia of the rectal area is desired, the entire rectal walls should be completely anaesthetized; for this purpose I use the following solution:

Sterilize the water by boiling, and when nearly cool add the quinine and urea hydrochloride.

When we wish to make an incision through the skin and subcutaneous tissue, as in fistula, colostomy for hemorrhoidal operations, etc., the following technique will completely anaesthetize the operative area: Commence by pinching up a fold of skin at the line of incision and press firmly with the thumb and forefinger. This will lessen the pain caused by the needle, which is now inserted between the layers of the skin, and a few drops of the anaesthetic slowly injected; the needle is ​now inserted further and more anaesthetic used. This is followed until the entire operative area is distended, to resemble a water blister. Care should be exercised not to inject through the skin in this treatment, as it is only intended to obtund the skin. When you have anaesthetized the external surface which may require about one syringe full of the anaesthetic,

the deeper structures may be anaesthetized by injecting directly into the tissues, without further pain; therefore, to completely anaesthetize the entire rectal area, at least four more injections are made. These injections should be made external to the sphincter muscles, thus avoiding the diseased area and large blood vessels of the rectum. I usually divide the surface into four punctures: one at the top and bottom of the median line, and one at each side, as is illustrated here. During these injections the index finger of the left hand is inserted into the rectum, as a guide to the needle, and to ​prevent puncturing the inside walls, as the needle is inserted. Pressure is made upon the piston to deposit the anaesthetic at different points, and after the needle is withdrawn, the injected area is massaged with the finger within the rectum. One hypodermic syringe full of the anaesthetic, injected at these four points, as a rule, will produce complete anaesthesia; if you should fail, more of the anaesthetic should be used. The sphincter may now be dilated by the use of the mechanical vibrator, using vibratode P. and the lateral stroke, or with the speculum, and we are prepared for nearly any operation upon the anus or rectum.

While constipation is the primary cause of a large number of rectal diseases, it is also a great menace by retarding any curative measures we may adopt for their relief; therefore, when this condition exists in connection with rectal disorders, our first step towards success will be to restore the dormant bowels to new life and activity. The causes of constipation are manifold; it may be hereditary, or due to indigestion, etc., but the most frequent cause is simple neglect. Many people are so little concerned regarding their health that they will not find time to answer nature's call, and by continuing this neglect, in due time they not only find themselves afflicted with rectal disease, but often many other bodily ailments, as the result of absorbing toxic influences, which should be eliminated each day; therefore, the physician's first step towards success, in treating diseases of the rectum, is to "educate his patients to educate their bowels," and thus remove the cause. This, in many cases, is all that is required to effect a cure, not only of rectal diseases, but many other constitutional ailments. This condition is of such frequent occurrence that it requires more than passing notice.

There is much said in medical literature regarding "intestinal atony." I am inclined to believe, however, that the ​"atony" is located in the rectum more frequently than in the upper bowel, for direct treatment to the rectum will result in a permanent cure far more rapidly than when medication is directed otherwise. Retention of faeces in the rectum results in over distention, and thus weakens the walls by permanent dilation. This "plug" of faecal matter is particularly conducive to congesting the pelvic organs, by obstructing the return circulation, thus producing varicose veins or hemorrhoids, as well as displacements of the female organs, and other pelvic and constitutional disorders. Of all the treatments devised for the cure of chronic constipation, those directed to the rectum proper have been the most successful. Simple dilation of the sphincter, with graded rectal dilators, will give excellent results, as far as overcoming the tension

of the muscles is concerned, but this is not all that is required. Above these muscles we have a large pouch, formed by broken down muscular fibers, due to the continuous expansion of the rectal walls. This is the point where treatment is directed, with the best results for "atony," and the best means of restoring tonicity to these walls is by mechanical vibration and electricity.

We have already referred to vibrotherapy for constipation on page 91, to which you are referred.

To overcome the atony of the muscular walls of the rectum, electricity excels every other means. The modified Morton wave current described by Dr. Rice as follows: "The patient sits upon a chair on an isolated platform; ground the negative side of the machine to a water pipe or gas fixture. Connect to the latter the medium-sized condensers, and close the switch; the short rectal electrode, illustrated above, well ​lubricated and inserted. The conducting cord is connected to the top of the condenser, on the positive side of the machine; the prime conductors are closed, and the machine started slowly, gradually separating the former until the patient feels the current at the side of the electrode; this current is allowed to pass about two minutes, and then increase the length of the spark gap to from four to six inches.

If the prime conductors are separated gradually, there will be neither pain nor discomfort during or after the treatment. This treatment should be given for fifteen minutes; if it is followed by mechanical vibration, ten minutes is sufficient. These treatments should be given daily, at first, and lengthen the intervals, as the treatment progresses.

Many hygienic and physical measures can be adopted with excellent results. Patients who are constipated should drink plenty of water, two or three glasses of water before breakfast, and at intervals during the day, with regular hours to go to stool (preferably after breakfast), with plenty of exercise for those of sedentary habits, will relieve many cases. Our Materia Medica is congested with remedies advocated for constipation, and nostrum venders continue to herald their literature for candy cathartics and laxatives, until today we have thousands of pronounced victims of the pill habit. Drugs should be used as sparingly as possible, although they may be used to a good advantage in commencing treatment. Of the entire list, there are only three worthy of much praise for chronic constipation, although many may be given for temporary relief.

Fl. ext. Cascara Sagrada heads the list, and by reinforcing this remedy with nux vomica and phenolphthalein, we may obtain permanent results, if judiciously used, as follows:

Mix. Sig. A teaspoonful three times a day.

​I supply the patient with the above mixture, and another eight ounce bottle of simple elixir, and each day, as he takes the three drams from the four ounce bottle, he refills it with the simple elixir; in this way, it is gradually reducing the amount of medicine used, and by the time it is exhausted he is taking very little medicine, and is relieved from constipation. By following this rule, and instructing the patient regarding a regular hour for stool, diet, drinking water, exercise, etc., we can cure the majority of cases. I never pronounce these cases cured, however, until they can tell the time of day by nature's calling them to stool. They have thus systematized their habits.

This may be defined as "the biggest little disease" of the rectum, or perhaps the entire body; for there are few diseases involving so little space, which create such intense pain and gravely reflex disturbances as this innocent looking abrasion. at the muco-cutaneous border of the anal orifice. By referring to the minute anatomy (see accompanying illustra​tion), we find this area more than abundantly supplied with nerve fibers, which are laid bare by this rupture of the mucous membrane, which are more sensitive to touch than the eye.

Owing to the pain and discomfort endured by the patient, the treatment of fissure has always demanded a large fee for its relief by the unprincipled rectal specialists, who would greatly magnify the seriousness of the disease for the ​purpose of depleting their victim's purse. This is one of those little diseases where pain predominates, and "surgical operation is the only means of relief," and the patient is willing to pay almost any price to be relieved of his suffering. The fact is, the treatment of fissure is as simple as the disease itself. The first thing to accomplish is to relieve constipation, which is present in the majority of cases. Many of the superficial fissures may be cured by keeping the bowels in a semisolid state, and applying pure carbolic acid to the full length of the fissure. Complete dilatation of the sphincter muscles, to the full extent of a Pratt's bivalve speculum, or the older way of inserting the thumbs of both hands into the rectum and stretching the muscles to their full extent will produce a temporary paralysis and displace the exposed nerve fibers. This, followed with scarification of the open surface, and the application of aristol, or other antiseptic dressings, will give immediate relief, and cure nearly every case.

A popular, and what may be called "up to date" method is by producing complete local anaesthesia with quinine and urea hydrochloride, and dilating the sphincter by pressing vibratode P. (page 85) well against the anus, using the lateral stroke until complete relaxations exist; the ulcer may now be dissected away, and the edges united with the required number of sutures. The bowels should be tied up for a few days in order to permit healing, and the after treatment directed to keep the bowels open.

Rectal abscesses and fistula are of the most common occurrence; in fact, some authors have given this the first rank in rectal diseases, believing it to be more common than hemorrhoids. These diseases are so closely related that it would be almost impossible to discuss them separately, as fistula is the result of abscess, in ninety per cent. of all cases, and only a few consult the physician untl the fistula has formed, and ​when once formed it has little tendency to heal spontaneously. Where an abscess has formed, there is only one treatment, which is to make an incision, and remove the pus, and treat as an abscess in other parts of the body; if treated early this may avoid the formation of fistula by rapidly healing. The majority of cases, however, present themselves after the fistula has formed. There is little or no pain, and the chief annoyance to the patient is the continual discharge from the unhealed sinus.

Fistula has been classified as complete when it has a sinus leading from the rectum to the outer skin (see accompanying illustration) (1), internal, incomplete when the opening leads to the rectum, (2), external, incomplete when the opening is to the outside surface alone, (3), and the complex or horseshoe variety, which is complicated with one internal opening, with two or more external sinuses, (4). The first step towards treatment is to determine the character of the fistula we have to deal with; with the index finger in the rectum, and a silver probe it is not a difficult thing to learn the nature of ​the fistula. Colored injections have been made in the external openings to determine the location of the internal exit. The use of the speculum or a well trained finger will, however, locate the papillae, which opens to the sinus.

To cure fistula, without the use of the knife is the method advertised by the local irregular and itinerant specialists, and is the method preferred by most patients. "No knife and no detention from business" is the catchy caption; words which draw patients to their offices. It is well, therefore, to become familiar with their "tricks."

There are two principal things which prevent a fistula from healing spontaneously; the first is the tendency of the external opening to heal, and prevent free drainage of septic fluids, and second, the inlet of septic material through the internal opening. Overcoming these two obstacles has been the principal reason why these physicians have been so successful with non-surgical treatments.

Away back in the days of the Senior Brinkerhoff, when skilled rectal surgeons were few, and "quack pile doctors" were predominating, we find these rules most closely observed, and they have done much to favor the present non-surgical treatment of today. It will, therefore, be seen that absolute cleanliness, asepsis, and treatment to destroy old tissue and promote the development of new granulations is the method directed towards results; although the medication may improve as chemistry advances.

The patient should be prepared as for any rectal operation, and the nature of the fistula determined. A local anaesthesia is used, if desired, in sensitive patients as the use ​of quinine and urea hydrochloride will avoid much of the post operative distress.

The external opening is dilated with a small flexible bougie, to provide free drainage, and extent of the fistula outlined. A medium sized syringe, with flexible silver probe, pointed canula, page 364, is filled with peroxide of hydrogen, and injected deep into the sinus, and every effort made to reach its most remote parts by massage; after the froth has escaped, the sinus should be irrigated with plain water, and a saturated solution of nitrate of silver is injected in the same manner, completely covering the abscessed walls. Great care should be exercised that the solution is injected into the cavity, and not into the tissues; therefore, a pointed needle should be avoided. In order to prevent the escape of the fluid into the rectum, where it may be absorbed and produce destructive effects to the walls and constitutional symptoms, the index finger, covered with the rubber shield (to prevent staining the fingers), is inserted into the rectum, and pressed firmly against the internal opening. The external opening is protected by lubricating the skin with vaseline. The solution of silver should be allowed to remain a short time and the parts massaged to reach all sections of the tract. After the silver solution escapes, it is sometimes well to dilate the external opening with a flexible bougie, to provide free drainage. In a few days, the diseased, living tissue will slough away, and be replaced by healthy granulations. This may completely obliterate the canal. If it does not, the parts still left open may be treated in the same manner in a few days, until the operation is successful. The original "Brinkerhoff System" used the following solution instead of silver nitrate, known as "Ulcer Specific."

Dr. Mathews makes this method more energetic by di​lating the sinus with a laminaria tent, and then inserts an Otis urethrotome, and both dilates and scarifies the interior of the sinus, to promote healing. Scarlet red medicinal is the latest remedy advocated for the injection treatment of fistula.

This is also a very successful treatment, and is particularly suitable for office practice, as it does not detain the patient from his daily duties. A probe pointed copper wire electrode, attached to the positive pole, is inserted into the fistula track, so as to cover the entire surface, as near as possible. The index finger is inserted into the rectum, as a guide and to prevent the electrode to penetrate the internal opening, and contact with the opposite wall of the rectum. The negative pole is attached to the pad electrode, and placed upon the back or abdomen, and from five to twenty milliamperes used, according to the extent of the fistula covered, and the diameter of the electrode. The current is used for about ten minutes; the electrode is now removed with some force, as it has become attached to the walls of the diseased tissue, which is removed with the electrode, leaving in the fistula track, healthy tissue, which will unite and close the canal. There are many surgical procedures for the treatment of fistula, with which most physicians are familiar; we will, therefore, not discuss them here.

Hemorrhoids have been classified as internal and external. The internal are those which originate above the verge of the anus and the external below; the internal being subdivided into veinous and capillary, and the external into thrombotic and tags of skin, or they may present a complicated condition of both internal and external, as is illustrated here.

​The character of hemorrhoids may be easily diagnosed by having the patient strain as at stool. A large percentage of hemorrhoids may be treated and cured at the office, by the various methods of treatment we have at our disposal. The most unfavorable variety are those situated high up in the rectum and difficult to reach. These, however, may be treated to reduce the inflammation, and operated upon later, since we have such absolute control over pain by the use of local anaesthetics, there are very few cases indeed which can not be restored to health by office treatments.

The treatment of hemorrhoids is directed to palliative measures, for the temporary relief of the patient, and those which permanently destroy the tumors. Hemorrhoids, like other diseases, have a tendency to cure spontaneously, or at least subside, so as to cause the patient little or no inconvenience. The main obtacle to overcome is constipation, and the use of cathartics, especially aloes, which more than any other remedy congests this organ.

Suppositories for the relief and cure of hemorrhoids constitute one of the oldest treatments, and much good may be accomplished from this medication. The following is of exceptional value in mild cases, and will give the patient immediate relief, providing we relieve the constipation and straining at stool. Each suppository contains:

​

Sig. Apply a suppository into the rectal cavity two or three times a day.

In resuming the therapeutic value of the above formula, the Quinine and Urea Hydrochloride and Belladonna are given for their obtundant and anodyne effects. The Hamamelis for

its specific influence upon the veinous blood vessels, the bismuth and tannic acid for their astringent effect to strengthen the walls of the rectum. I have often been surprised at the expressions of gratitude received from patients who have used this suppository, but in order to obtain the best results full doses from five to ten grains of phenolphthalein should be given if the patient is constipated, to clear the bowel of impacted faeces, and allow the bowels to move with the least possible straining. In fact, they should be so loose as to run off without straining at all, and thus avoid the protrusion of the pile tumors.

This is another method of treatment which was ushered into the healing art under the clouds of mystery, and was formerly considered one of the "tricks" in the Medical World. It was slow in being kindly accepted by the regular physician when first introduced, but the venders of the "system" were successful in placing this method in the hands of the less skillful physicians, until the entire country was swarmed with itinerant "Pile Doctors," who were puncturing the piles and purses of patients by the hundreds. Then the Medical press commenced its campaign regarding the bad results from the treatment.

The fact is, the injection treatment for hemorrhoids is not the dangerous operation it was pictured to be, and the articles published by jealous physicians, regarding deaths from emboli, carbolic acid poisoning, etc., have very little weight when this method is used by skilled hands. Unfortunately, the "systems" were sold to many ignorant men who were not physicians, and entirely destitute of a sound Medical knowledge, yet in their hands the success obtained was remarkable, under the circumstances.

Prepare the patient as previously described, and he may be placed upon his side or back, as is most convenient for the operator; by requesting the patient to strain, as if at stool, he may force the tumors outside the sphincter muscles; if he is unable to do so, an enema of warm water may be given at the office, which will assist in forcing the hemorrhoids in full view of the operator. The tumors should now be bathed, and vaseline applied to the tumors and mucous membrane, to prevent any injury. If the injection fluid should overflow, and come in contact with the external surface, the syringe having ​a guarded needle (see illustration) is filled with the following solution:

The needle is now forced into the border of the tumor at its longitudinal diameter to the opposite side, being careful not to puncture the opposite wall, which is previously regulated by the guard on the needle, and as the needle is withdrawn, pressure is made upon the piston to deposit the medicine. The amount of medicine used will depend upon the size of the tumors, and should be regulated by the set screw on the piston stem before inserting the needle. This will vary from one to two minims for small, and four or five

for the larger tumors. It is always best to treat the small tumors first, as they are more accessible than they are later, after the large tumors have been destroyed.

After the injection is made, and the cauterization is completed, it will be observed that the tumors are of a pale bluish color, which indicates that the cauterization has been successful. They should be lubricated with vaseline, and placed within the bowel. If it is impossible to force the tumors outside the sphincter muscle by straining, and for the tumors higher up in the bowel, the Brinkerhoff speculum is used to throw them in view.

The bowels should be tied up for a few days with morphine, and when they should move a full dose of phenolphthalein should be given, to produce a profuse watery stool, without straining. Never inject over two small or one large ​tumor at each treatment, and at the end of ten days or two weeks continue the operation at these periods until they are all eradicated.

In summing up this operation, it might be compared with the injection treatment for hernia; they have both been more or less condemned by surgeons who wish to "knife" every case they come in contact with, yet the physicians who practice these methods are optimistic to their attack, and silently, yet successfully cure their patients, and reap the remunerative rewards attached to the operation. It is rather amusing to read the articles of some noted surgeon condemning this treatment as an unscientific and barbarous procedure, and later hear them boast of the results they have accomplisehd by pinching these delicate tissues in a clamp, and searing them with a hot iron; it is true that both methods destroy the tumors by cauterization; one can be done at the physician's office, with little or no pain, the other requires profound anaesthesia; but really, which method belongs to the barbaric ages of antiquity?

By observing the following notes regarding this treatment, you will be rewarded with success. If the piles or rectum are inflamed, reduce the inflammation by the use of the suppository, and other treatments previously given. Always see that the colon is unloaded before operating. Never use less than a 50 per cent. carbolic acid solution, for the stronger the solution the more complete the cauterization; inject under the tumor, and not into it, and do not try to accomplish too much at one treatment. One or two tumors is enough to treat at one time, and be sure that all soreness has disappeared from the preceding operation before continuing further treatment.

The following formulae have been advocated and successfully used by their originators for the hypodermic treatment of piles:

The little pamphlet furnished to the itinerants purchasing the "System" directs that the amount of injection inserted into the tumors shall be as follows:

"Brinkerhoff's System" forbids the injunction of any but internal piles.

Mix. Sig. Inject three to five drops in small and eight or ten or more in large ones.

Where surgery is resorted to, the best operation for office treatment consists of the clamp and suture. This is conducted by thoroughly anaesthetizing the operative area with Quinine and Urea Hydrochloride, as previously described. The sphincters are thoroughly dilated, either by mechanical vibration or the speculum, and the tumors brought to view; the ​parts are thoroughly bathed, and made aseptic as possible. The notched clamp is clasped about the tumor, and the hemorrhoids cut off at the border of the clamp; the sutures are now made between the notches, uniting the borders of the wound with catgut. This gives us a clean surgical operation, which is nearly bloodless and painless, and we have so completely closed the wound as to prevent post operative hemorrhage; the sutures are absorbed in due time, and will cause very little detention, if any, from business. This operation is applicable to all forms of internal or external piles, or the mixed variety.

Thrombotic hemorrhoids are caused by a rupture of a vein, and the extravasation of blood, which forms into a clot of a bluish color, and extremely painful. This may be clasped in the clamp, as described above, or if accessible, this is not necessary. A fine incision is made and the clot rolled out and the edges united with sutures. Tags of skin may sometimes be present, in large quantities, either as the result of thrombotic piles, or irritation from constipation and straining at stool. These small tumors may be injected with cocaine, and clipped off with scissors; if large, a suture applied to prevent bleeding.

This is another one of those apparently little diseases, which annoy the patient to the border of insanity through the irritation it creates, the loss of sleep, worry, etc.

A few years ago I was consulted by a patient who had been afflicted with this disease for about two years; he stated: "Doctor, I believe I have bugs around the rectum." He described a typical case of Pruritis, and I determined to treat his case purely from a parasitic origin. I therefore gave him a box of blue ointment, reduced one-half with vaseline, and directed him to apply it three or four times a day; he used the contents of the box; and although he has been constantly

under my observation, the disease has never returned, to my knowledge. This is only one case in hundreds where this simple treatment has proven effective in relieving this condition. Whether or not this disease is caused by a parasite, I am satisfied that treatment directed to this cause is more satisfactory than other methods of treatment. In extreme cases I use the ecorchement treatment as described on page 111, which thoroughly removes all the old skin, which has become like parchment, and involves the nerve filaments through continuous irritation. This will also prove very effective in stubborn cases.