W. P. Agnew

“ Concerning the carbolic acid treatment Allingham says: “Since the publication of my last edition I have cured many patients by dilitation of the sphincters and the use of the bone stud and carbolic acid. One practical point I would mention. The further the external aperture is from the sphincter the more likelihood is there that the sinus will heal. This is shown as well in the cases of spontaneous cure as in my own successes. You must always enjoin rest after a strong application, and watch that not too much inflammation be set up.” ”

“ Beginners should use a common bulb syringe, with water rather hot, varying in quantity as they become accustomed to the process, from a quart to a gallon or more, and a bulb-full squeezed out slowly, with intervals between, giving it time to pass out of the rectum into the colon. On regaining the erect posture, if the rectum be loaded with feces or distended with water, the desire to expel its contents may be irresistible, especially if air has passed through the syringe; although a little practice will enable any one to exert great control over his or herself in this respect. ”

“ It would not be reasonable to suppose that all cases will behave alike. The local and constitutional disturbance will, of course, depend upon the size or surface of attachment of the tumor or tumors and the nervous and physical condition of the patient. It is best to require patients to lay up for a few days after operation on large hemorrhoids, or when more than one of small size are taken, even though they do not complain.
In people enjoying average health, with internal hemorrhoids located on both sides, take one side at a time, making two operations of the treatment. ”

“ A tumor, properly injected, cannot inflame, because there is nothing to inflame, the circulation is stopped and thus it is as effectually strangulated as by a ligature, with the advantages of the immediate local anæsthetic, antiphlogistic, [17] auterant and antiseptic properties of carbolic acid. The base of attachment heals, while the dead tissue, which is rendered non-inflammatory and antiseptic, disintegrates and is thrown off between the third and fourth day, a process that fortifies against secondary hemorrhage. ”

“ A little practice will enable any one to see the simplicity of the entire procedure. If you should make a mistake when operating through a speculum, and land the whole charge into a fold or saggened portion of the bowel do not be alarmed, as it will only be a little more painful and longer in healing. Injection into internal hemorrhoids is not painful to any degree, therefore if the patient complains much you might suspect that you are invading the tissue of the bowel. ”

“ Rectal ulcer is a more common disease than is generally supposed. Unfortunately the symptoms are generally obscure, and the patient suffers but very little, if any pain, and consequently consults his physician for some of the reflex symptoms, rather than for the initial disease itself; and very often these reflex symptoms are vainly treated till the patient and physician are both thoroughly disgusted and disheartened. There is one maxim which every physician should always bear in mind, and that is, always suspect rectal ulcer in every case of protracted or chronic diarrhœa. ”

“ But unfortunately, piles are by no means limited to people of large means. The greater number of sufferers must take what the general practitioner can give and will not take the cutting and crushing operations until compelled by dire necessity, and are only too glad of a less heroic alternative which offers them hope of relief. For this body of sufferers, the operation by carbolic acid injection offers a means of relief to which they will readily submit. ”

“ A method, the discovery of which, I feel prepared to say, marks an epoch in the history of medicine, unrivaled in advancement by the treatment of any other disease or class of diseases to which the human family is subject. ”

“ A weak, thin, watery solution, aside from doing poor work, is much more liable to diffuse itself and be carried into the circulation like a hypodermic of morphia, than a solution sufficiently strong to act as a cauterant, destroying the tissue, forming a compact and an insoluble coagulum and strangulating the circulation at once.
A solution, weak or strong, when deposited to any depth beneath the surface, with live tissue and the circulation passing on all around it, will of necessity excite pain, inflammation and a slough, the same as a splinter in the flesh. ”

“ In all cases of rectal ulcer of any considerable gravity, absolute rest, both of the parts and the body, is to be maintained. Hot water irrigations and a complete destruction of the diseased surface by carbolic acid, are the first things to be thought of, together with a liquid diet.
Convert the ulcer into a carbolic acid sore and use an iodoform suppository. In fact the treatment is very similar [62] to that recommended as an after treatment in a bad case of hemorrhoids, with such variations as the ingenuity will suggest. Bismuth, oxide of zinc, eucalyptus, mercury, resin cerates, etc. ”

“ Nowhere in medical lore do we find suitable instructions whereby the beginner may knowingly and intelligently engage in a rectal examination—what to expect, where and how to find it, and how to pursue each succeeding step in applying the treatment. ”

“ It is these bad cases, where the patient knows the importance, prepares and lays up for treatment, that we should make as short work of as possible; those who have been great sufferers, and possibly the operation on one small tumor would so arouse the others that the suffering would be as much, if not more, than if all had been treated at the same time. Not unfrequently the piles on the opposite side, and left for a second operation, will set up the howl and cause more pain and suffering than the side treated ”

“ If, after withdrawing the needle, some of the injection fluid runs out, unmixed with blood, take it up with absorbent cotton, since it indicates that the quantity at that particular part is superfluous. Now dry the surface of the tumor or tumors with absorbent cotton, smear with vaseline and return within the bowel.
A tumor properly injected immediately becomes hard. There are septa or compartments in elongated growths which do not permit the medicine to pass through readily, and if a soft section is noticed, it has not been penetrated, although will doubtless break down with the general mass. ”

“ It is always better to precede by an injection of warm water, which may not only unload the rectum and give the patient greater confidence in the effort to extrude the parts, but washes away the mucous and retained feces in and about the sphincters. When the examination has been carried to this point and no satisfactory cause found to explain the trouble complained of, the finger and speculum will be required to complete the diagnosis. ”

“ The most happy and the most marvelous results that I have ever seen in the practice of medicine and surgery have followed the removal of pockets and papillæ, and in thus bringing them to your notice, I do so in the confident belief that a proper appreciation of their importance on your part will add materially to your resources in battling with disease, and in helping those who apply to you for relief. ”

“ 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. ”

“ There sometimes exists, as a symptom of rectal ulcer, a desire to go to stool when cold drinks are taken. But generally the diarrhœa and tenesmus subside soon after breakfast, and the patient has no more trouble until the next morning. A great many, or I might say a majority of those suffering from rectal ulcer consult the physician for some symptom or other that suggests anything else but the rectum, but by close questioning, and following up the symptoms, one can soon tell whether they are reflex or otherwise. ”

“ As a precautionary measure in all operations by injection, to prevent the medicine from extending too deeply into the tissue of the gut by gravity, or the overflow from running down on the outside of the pile and over the bowel, let the patient lie on the side opposite to the tumor to be treated, so that the preparation will gravitate to the apex rather than its base of attachment. ”

“ In point of frequency fistula is next akin to hemorrhoids, but a much less desirable complaint to treat. Allingham states that the number of cases occurring in hospital practice is greater. That two-thirds of all the cases operated upon of the in patients at St. Mark’s Hospital, London, were fistula. The most frequent cause assigned being abscess. A failure of the abscess to heal, leaving a sinus or sinuses, is explained by the presence of loose areolar tissue and fat, excessive mobility of the parts by the action of the sphincters, respiration, coughing and sneezing, and a strumous diathesis. ”

“ The patient will oftentimes complain of severe tormina, checking the current of water for a few seconds, and will be followed by complete relief. The presence of such a strange foreign body in the intestine as hot water in many cases excites [89] prodigious peristaltic activity, thus producing the tormina. Plain hot water is all that is necessary to use; the water should be hot; cold water, or tepid water, will not do. It will produce great suffering. One patient took the flushings for a fortnight, returning vowed she would never use any more because they produced such terrific cramps. ”

“ Daily movements of the bowels are no sort of a sign that the colon is not impacted; in fact, the worst cases of costiveness that we ever see are those in which daily movements of the bowels occur. The diagnosis of fecal accumulations is facilitated by inquiring as to the color of the daily discharges. A black or a very dark green color almost always indicates that the feces are ancient. Prompt discharge of food refuse is indicated by more or less yellow color. It would be interesting to inquire why fresh feces are yellow and ancient feces are dark. ”

“ In consequence of an occasional failure of the muscles to regain their power after division by the knife, elastic ligature or galvano-cautery wire in the treatment of fistula, leaving the subject in a pitiable state of incontinence of feces, which has resulted in several well authenticated cases in suicide, new and rational methods have been devised for the relief of this very troublesome and unpleasant affection. ”

“ Should the large growth be taken first, it may be impossible for the patient to hold down the bowel sufficiently afterwards to operate on any one of the five small fellows, and a speculum will be called into use; this will prolong the treatment, as few will submit to the operation on and the manipulation of all five tumors through the slot of a speculum at one sitting. Small isolated piles can be treated [25] singly, and the patients allowed to go about their business. ”

“ Should any portion of the injection compound fall on the muco-cutaneous surface, unless the latter be heavily coated with vaseline, or protected with cotton, it will excoriate and probably cause a great deal more pain and soreness than the operation itself. In operating through a speculum such risk is avoided by the sides and floor of the instrument, which afford a protection to the surrounding parts; that is, if the precaution regarding position when operating is duly observed, to wit: always operate with the tumor pendent, or with its attachment on the upper side. ”

“ It matters not what form of tumor presents itself for treatment, whether of the capillary variety, distinguishable in being of small size, flat or sessile, made up of the terminable branches of the arteries, the beginning of the veins and the capillaries which join them, punctated, granular surface with thin covering and likely to bleed on the least provocation, or the arterial hemorrhoid with the arteries and veins freely anastomosing, larger, and presenting the glazed appearance of a very ripe strawberry, liable to inflammation, erosion, prolapse and hemorrhage ”

“ Whenever it be decided that no local or constitutional disease can be found as an assignable cause, and that it is purely neurotic in character, we commence to grope in the darkness for remedies. What relieves one will not another ”

“ The persistent use of bougies will be necessary for a long time after divulsion.
Stricture is mostly of syphilitic origin. Of the seventy cases, tabulated by Allingham, ten of the number were found in men and sixty in women, showing a great predominence in the latter; and none were more than three and a half inches above the rectal orifice.
It is not an easy matter to diagnose between the advanced stages of non-malignant rectal ulcer and cancer. Both may be accompanied by tender, condylomatous growths or flaps of skin outside the anus, bathed with an ichorous fluid. ”