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rectal digital examination, which was very was found to be intimately adherent in painful, revealed an ulcer on the anterior places to the chest wall. Marked adhesion wall of the rectum, above the sphincters, also noticeable between pericardium and the size of a dollar. This extended root of left lung, with considerable quanthrough the mucous membrane into the tity of coagulated lymph between the pleumuscular coat of the bowel. At a corre- ral walls of heart and lower lobe of left sponding point on the posterior wall there lung on anterior side of thorax and lateral was a ragged hole entirely through the side, also dense adhesions at the apex. gut wall, through which the finger passed Both lobes of the lung adherent in places. freely. There was a cavity extending up- Where not adherent large abscesses were wards from this hole, behind the rectum, noticeable, containing purulent material, farther than the finger could reach, and the largest one of these abscesses being its walls felt like a soft, sloughing mass of about an inch and a half in diameter. No connective tissue. There was a general abscess in lung tissue proper, but the inflamed condition of the lower rectum lower lobe of this lung had suffered from and anal region. Dr. Potter found ex- pneumonic process and was very firm and tensive inflammation of the left lung, solid. At apex of upper lobe on cut secwhich, he said, was due undoubtedly to tion there was noticed one small tubercle, infection from the pelvic region. There which had evidently undergone calcarious was no evidence of disease of the kidneys degeneration. Right lung: With the exor liver. The lower part of the rectum, ception of hypostatic congestion at base and especially the cavity behind the rec- of lower lobe, no abnormality was found tum, was washed freely with hot bi-chlor- on this side. ide solution, and appropriate treatment “Abdominal Cavity-All organs and given for the lung complication. The pa- viscera normal. No evidence of metastatic tient did not improve, but grew gradually abscesses in liver, spleen or kidney. On worse and died January 26th. Four days examination of pelvis and removal of sigafter death post-mortem examination was moid flecture, there was found the beginmade and report written by Dr. Nelson D. ning of a large abscess at the brim of the Bravton:
pelvis on the left side behind the peri“Post-mortem on Mr. A. P. January 30, toneum. On further examination of the 1901, four days after death, made by Nel- post-rectal fascia, by means of introducson D. Brayton for Drs. Cook and Potter: ing the hand through an opening of the Body that of a male, well-preserved, five abscess cavity, a large gangrenous slough feet ten inches height, weight about 130 was found about the size of the palm of lbs. Skin very pale, mucous membrane the hand, and which was readily removed of eyes and mouth anemic. No marks of when the abscess cavity was entered. No external violence on body.
opening existed between the gut and this “EXTERNAL EXAMINATION.
cavity, with the exception of the primary
opening just above the sphincter, nor was “Thoracic Cavity-Panniculus adiposus, there any evidence of any peritonitis or muscular tissue moderate. On removal of intra-peritoneal infection. The bladder sternum, pericardial sac found to be was not involved. On anterior wall of slightly bulging. Heart evidently some- rectum was an ulcer the size of a dollar; what dilated. On incision of pericard- otherwise there was no evidence of any ium, pericardial fluid was found to be pathologic condition anterior. normal in quantity and consistency. Fat “Conclusion—That the deceased came moderate. Left auricle considerably dis- to his death from septic metastatic process tended, also the right ventricle. On re- in the lung, the primary lesion being in moval of heart from cavity, on cut sec- the post-rectal fascia." tion the heart was found to be filled with I received the following report of a case blood. No abnormalities of valves or in- from Dr. J. W. Snider, of Fairland, Ind. : ternal structure, with the exception of the “T. L., age sixty, robust constitution, thin walls already referred to.
excellent habits, er-County Commis"Lungs-left lung: On insertion of sioner, farmer, was operated on for rehand into left pleural cavity, the lung moval of hemorrhoids
hemorrhoids by injection
method, by an irregular practitioner, in liver of firm consistency, brownish-red in the latter part of May, 1901. He suffered color; markings of acini indistinct. In greatly from the operation. A second the portal vein, or rather, in that branch and third injections were given, the last of it passing to the right lobe of the liver, about the 12th of June. On the 19th of there is an ante-mortem thrombus almost June he had a hard chill. The 20th, tem- completely occluding the lumina of the perature 101°, pulse 120, profuse sweat- vessel. Kidneys: Left kidney large, pale, ing, diarrhoea, utter prostration, delirium. in cortex a cyst of the size of a small egg; Abscess found in left rectal region, with on section, cortical marking indistinct; discharge of pus from rectal washings. capsule not adherent; right kidney large, Death on the 23d. Collapsed condition but not so large as the left one; darker in forbade surgical interference.”
color than opposite kidney; one section, Dr. W. G. McFadden, of Shelbyville, cortex and medulla about as distinct as Ind., was called in consultation in this normal; capsule not adherent. case, but saw the patient only a few hours sponding to the rectum there is a ganbefore death. In a letter regarding the grenous cavity; a portion of the rectum case the doctor reported as follows: projects into it, but is gangrenous for a
“On the 22d of June I was called in distance of two inches above its lower consultation by Dr. Snider, of Fairland, end, which hangs free in the cavity; no to see T. L., ex-County Commissioner of periproctitic abscesses." this county. I found him semi-conscious; The following report of case was kindly he could only be aroused for a few mo- furnished me by Dr. C. P. Bacon, of Evments and could scarcely swallow. The ansville, Ind. : rectum was full and dilated by a mass of "I was called on the evening of May 10, diseased tumors, and one buttock was in- 1900, to see Mr. T., a prominent wholeflamed and a hardened mass extended to sale merchant of this city, who had been the verge of the anus. All the usual in the hands of an advertiser for the symptoms of pyemia were present in a treatment of hemorrhoids by the injection marked degree, and, being in a dying con- method. I found the patient in a severe dition, there was no indication for fur- rigor, which lasted one hour and was folther treatment."
lowed by a temperature of 105°, severe For the following autopsy report of a headache, delirium, profuse perspiration, case of death following the treatment of great restlessness and nausea and vomitinternal hemorrhoids by injection method ing. I learned that a week previous to I am indebted to Dr. Daniel N. Eisen- the time of my visit a very large pile had drath, of Chicago:
been injected, causing great pain, which “AUTOPSY REPORT OF JOHN BURKE, 42 lasted two or three days and was followed YEARS OF AGE.
by a feeling of soreness in the rectum. "Extremely pale, well-nourished cad- Examination revealed a foul, ragged, aver; venesection wounds on the anterior sloughing ulcer, the lower edge being aspect of both elbows; puncture marks about one-quarter inch above the upper from transfusion over thorax and abdo- margin of the sphincter ani, extending up men. Lungs, normal. Ante-mortem clot the rectum about one inch, and having a in pulmonary artery (left), extending width of two-thirds of an inch, and in from the main trunk into the branches of depth extending through the entire thickthe second and third dimensions and com- ness of the rectal wall and involved the pletely occluding the lumen of the same. underlying connective tissue. It was eviHeart, somewhat larger than normal; no dent the patient was suffering from septidilatation; valves normal; heart muscle cæmia, and that this ulcer was the point pale and friable. Spleen, normal in size of infection. and color; very friable. Peritoneum, “Although the ulcer was thoroughly smooth and shiny, especially that of pel- cleansed, all sloughing tissue removed vis; no evidence of infection. Intestines, and antiseptic dressing applied, and other both large and small, extremely pale. appropriate treatment at once instituted Liver, normal size; right lobe almost uni- and vigorously pursued, the symptoms versally adherent to parietal peritoneum; steadily grew worse, the rigors occurring from two to three times a day, tempera- the verbal report of another case of death, ture being variable, ranging from 100° the result of injection of internal hemto 104° F., almost constant headache, per- orrhoids. This report was not from the sistent delirium, nausea and vomiting. physician in attendance, but from another The patient died on the eighth day from physician who was familiar with the facts. septic infection.
This case had a history similar to those "Although Mr. T. had carried these
given above-a person in good health had pile tumors for years, and had suffered hemorrhoids injected; in five or six days much from frequent attacks of inflamma- abscess formed around rectum, resulting tion, his general health had not been im- in septic infection and death. paired, and at this time of going under In 1882, Kelsey, of New York, was treatment his condition seemed excellent. quite enthusiastic regarding this treatThe patient had been duly warned of the ment of piles and said regarding it: danger incident to the treatment of hem- “This treatment may now, I believe, be orrhoids by injection, but, fearing any- accepted as a surgical procedure of defithing that was called an operation, and nite value, and one worthy of a place being fascinated by the promises of the among the recognized means of cure at doctor that he would effect a perfect cure our command. With solutions of a proper without causing pain or the loss of a sin- strength the danger of causing sloughing gle day from business, he could not be of the tumors is very slight, and I am not deterred from undergoing the treatment. at all sure that once more surgery is not It would be well if the laity could be edu- indebted to the 'quacks' for a valuable cated to keep close to the regular profes- discovery which may do much to modify sion when in need of medical or surgical the at present accepted plans of treatment aid.
of this disease.” Kelsey had then treate ? “For some days previous to my first near 200 cases by this method. About visit the patient had suffered from general that time he began to have some bad remalaise, slight fever and headache, with sults, and these bad results occurred with pain in the rectum, but was told by his increasing frequency. doctor that he had malarial fever, and In 1890 he again writes: "For a year that the pain in the rectum was the result or more I used this treatment almost exof a small anal fissure. It would be inter- clusively, and was much pleased with the esting to know how many patients die results. A succession of bad cases has led from septic infection following the in- me to modify my views of its value; jection of hemorrhoids, the death certifi- though I now use it occasionally, it is only cate showing malarial fever or some other in selected cases. All of the cases I had disease as the cause."
supposed cured by this method, and upon: The following brief report of case of which cases I based my former favorable death resulting from injection of internal report, are now returning to be again: hemorrhoids is furnished me by Dr. Wm. cured by some more lasting method. The H. Gilbert, of Evansville, Ind.:
relief afforded by this method lasts about "A male patient, aged about fifty-seven four years." years, came to me from Southern Indi- I quote Dr. Kelsey's experience with
Had had his piles injected about this treatment, as it is about the experiten days previous. Found a large slough- ence of everyone who has done much ing mass where piles had been injected, work in this field of practice. It is very line of demarkation quite plain; tempera- difficult to explain why, on taking up a ture from 103° to 106° F.; delirious; new line of treatment in certain dis 'ase leaky skin, tongue dry and furred; all or class of diseases, we may have wondersymptoms of septicamia. Sloughing ful success for a time, then, without apmass was excised and wound irrigated parent reason, failures begin to occur and with antiseptic solution and packed with recur with wonderful frequency, and we iodoform gauze.
Pulse began to fail are forced to discard the new and return about twenty-four hours after, and patient to the old. The method or technique in died on the following day.”
injecting piles is given about the same by In addition to these five cases, I have all authors. The solutions used by vari
ous ones vary from 10 per cent. of car- tracts the tissue, and when the speculum bolic acid to pure acid. They direct that is removed the flow of blood is towards the patient must force the piles out the pile from the veins above, but the pile through the anus, being assisted, if neces- tissue is contracted and not much blood sary, by an injection of hot water, then
can enter it, and there are no clots to be inject the carbolic acid into the center of forced into the surrounding vessels. each pile; then, after injecting as many When an examination is made the followof the tumors as the operator decides ing day we do not find a large tumor just proper, the mass is forced back through within the sphincter muscle, but a vertithe contracted sphincter. When we care- cal induration well above the external fully consider this method, we may find sphincter corresponding to the rectal colgood reason for so many bad results. umn in which the pile started, and the When the piles are forced out through the mucous membrane is firmly fixed to the anus, each vessel is distended to its utmost tissue beneath. capacity with blood; when the carbolic I advise this treatment only in cases acid is injected, this blood is coagulated, when treatment is demanded and the pathen the tumors are forced back, which tient cannot safely take a general anæscannot be done without displacing some thetic; I have had four such cases reof the coagulated blood, forcing it out of cently. Two of them had lost blood from the pile vessels into the surrounding tis- the piles until they were very anæmie, sue. Certainly we could not have a more the heart was very weak, and I would not favorable condition for the development give a general anæsthetic; the piles were of the conditions before named, viz. : still bleeding at every stool and treatment Pain, ulceration, abscess, fistula. In the was demanded, so I used injection, which cases which I have related the fluid must promptly stopped the flow of blood and have been thrown into the gut wall be- the patients are rapidly regaining their neath the mucous membrane, or else the health. Another case had weak cerebral clotted blood was squeezed out of the pile arteries; for this reason I treated him tumors into the large veins leading from also by injection; and another had serious them.
organic heart disease, which prohibited an I have treated quite a number of cases anesthetic, and I injected her bleeding of internal piles by injection of carbolic piles. I consider that this method of acid, and have only had two cases that treatment is the most dangerous of all gave me trouble. In these two cases sec- methods of treating internal hemorrhoids, ondary hemorrhage occurred on the sev- as statistics show. The relief, as a rule, enth or eighth day, when the pile sloughed is temporary, averaging about four years. and opened a vein. I was called imme- Of course, there are cases in which the diately in each case and had no trouble piles never return, but they are a small in stopping the bleeding by the applica- minority of the cases treated. Compare tion of per-sulphate of iron, which I made the statistics of treatment by injection directly to the bleeding point through a and that by the ligature or clamp and tube speculum. My method of injecting cautery: piles is different from that usually given. Allingham, no deaths in 1.600; AllingÍ do not have the piles protruded through ham, three deaths in 2,000; Copeland, ong the anus, but, on the contrary, push them death in all the cases he treated; Brodie, up in the rectum as far as possible. I do no death in all the cases he treated ; Syme, this through a tube speculum. By proper no death in all the cases he treated; Curlmanipulation of the speculum the blood ing, one death in all the cases he treated; can be pressed out of the tumor, when it Quain, one death in all the cases he will have the appearance of a thickened treated; Ashton, no death in all the cases fold of mucous membrane, and when the he treated; Cooper, no death in all the rectal walls are made tense by the specu- cases he treated; Gross, no death in all ium the collapsed pile can be drawn out the cases he treated; Van Buren, no death from the gut wall with a long forcep. in all the cases he treated; Bodenhamer, With the pile in this condition I inject no death in all the cases he treated ; Ball, the carbolic acid, which immediately con- no death in all the cases he treated; Goodsal, two deaths in all the cases he treated; thread; beginning at this point the mass Mathews, one death in all the cases he is clamped with a special clamp devised treated; Kelsey, no death in all the cases by Dr. Earl, including only about an inch he treated; Andrews, no death in all the at a time, the clamp being placed parallel cases he treated.
with the anal margin and closed tight The treatment of internal piles by enough to hold the tissues, and then with forcible dilatation of the lower end of the scissors cut the portion clamped close to rectum, including both sphincter muscles, the upper surface of the clamp. The was a favorite method with some French clamp should grasp the edge of the skin surgeons a few years ago, but the method and the healthy mucous membrane. When met with little favor outside of France. the tissues are cut, then, with the needle It is regarded now only as an important and thread used to make the first stitch, preliminary measure to other operations. make a continuous suture, passing the The patient experiences great relief and
needle under and over the blades of the may think he is cured. The contraction clamp, leaving the thread loose. When at the anus and resulting constipation is the end of the clamp is reached it is relieved and an examination will show loosened and withdrawn and the thread the pile tumors much contracted, but I drawn tight, which brings together the have never yet seen a case in which they
edge of the skin and mucous membrane, were made to entirely disappear by divul- then the clamp is applied to another secsion alone. About fifteen years ago White- tion of the anal ring and continued until head devised a new method for curing the entire circle of the anus is made. piles, which consists in excision of the en- When the thread is drawn tight each time tire hemorrhoidal plexus of veins. This after the clamp is removed all bleeding is was quite popular for a few years, but stopped and the two edges are held firmly they soon found it difficult compared to together, though I usually put in a few the old methods, while the good results interrupted stitches to strengthen the line were no better and the bad results were of suture. much more numerous. Sometimes the The other operations for removal of inskin and mucous membrane would fail to ternal hemorrhoids will be presented by unite, and a circular ulcer and finally a
Dr. Graham. stricture was the result. In other cases
224 North Meridian street. the upper portion of the skin was removed, which resulted in the mucous membrane being drawn out over the edge
TREATMENT OF INTERNAL HEXORof the external sphincter, thus being ex
RHOIDS.* posed to friction, and the secretion kept the parts moist and sore. To-day this BY ALOIS B. GRAHAM, A. M., M. D., INDIANAPOLIE, operation is limited to a comparatively Lecturer on Gastro-intestinal and Rectal Surgery small number of cases in which the entire
in the Medical College of Indiana. hemorrhoidal plexus is involved, and when the mass is protruded forms a con
Any disease which can be felt and seen tinuous lobulated tumor. I have had a
is generally easy of diagnosis. In diagfew of these cases during the past vear,
nosing hemorrhoids the physician should but I used Earl's modification of White- never take anything for granted. They head's operation for the removal of the can be seen and felt if he will only take tumors. This consists in drawing the the necessary trouble to go about it in the mass down until all vou wish to remove proper way. The physician who fails to is outside and the healthy mucous mem
detect hemorrhoids or even the nature of brane is in contact with the edge of the any rectal trouble is generally the one who skin, then an incision is made posterior
has refused to employ the necessary and through this mass until it reaches the yet simple methods by which alonė a diagedge of skin on the outside and the nosis can be reached. healthy mucous membrane on the inside, and then these two points are stitched *Read before the Marion County Medical Society,
March 11th, and before the Indiana State Medical so together with strong catgut, using a long
ciety, at the Evansville Meeting, May 22, 1902.