■^ w I87J € ■-.>"■ :Pii Scientific and Medical Books, Minerals, Etc., For sale by A. E. FOOTE, M. D , 1223 Belmont Ave., N. 44th St Philadelphia, Pa. ^ NATIONAL LIBRARY OF MEDICINE NLtl D05AD557 1 SURGEON GENERAL'S OFFICE Section, No > LH^ NLM005805279 RETURN TO NATIONAL LIBRARY OF MEDICINE BEFORE LAST DATE SHOWN 3?t" BOOK ON STRICTURE, FISTULA, PILES, IMPOTENCE; DISEASES OF THE GENITO-URINARY ORGANS; DEFORMITIES OF THE EYES, NOSE, AND FACE. HENRY A. DANIELS, M.D., to Sometime Teacher of Anatomy and Surgery in eevebal Medical Schools ; Authoe or a Treatise on the Fifth Pair oe Nerves, AND NUMEROUS WORKS ON ANATOMY AND SuROEBY. 144 Lexington ^venue, Neab 29th Street 1873 f«7 Entered according to act of Congress to the year 1863, By HENRY A. DANIELS, n the Clerk's Offioe of the District Court of the United States for the Southern DUtriot of New York. PREFACE. This little book was first published in 1863 and is intended to give a clear idea of the nature of a class of diseases that are extremely prevalent. It has been unnecessary to alter the text, excepting that the article "Impo- tence " has been enlarged. The Author's practice in cases of Stricture, Fistula, and in diseases of the Genito-Urinary organs, is very extensive. He. has brought before him every imaginable complication, and this has given him a knowledge of the best method of treatment, and a precision in the use of instruments and appliances which none but an expert with a like large field of experience can hope to obtain. 144 Lexington Ave., New York. 1869. TABLE OF CONTENTS. Pate Anal and Rectal Diseases, - - - - . . ig Anal Excrescences,.......28 Burns,.........5 Deformities of the Ear,.....-11 " Eye, :.....7 " " Face,......4 " Mouth, - - - - - .12 " " JTose, - - - g Diseases of the Genito-Urinary Organs, - - - .32 Fistula in Ano,..... 19 " Lachrymalis,......--8 Fistulas, .------.. g Fissure of the Anus,...... -27 Gravel, - - - - - -.- ; -42 Harelip, - - - - - - . . -12 Impotence, - - - - - - - . -49 Inflammation of the Urethra, - - - . .33 Inflammatory Stricture, -----. 33 Leucorrhea, - - - - - - . -48 Mother's Mark,.......5 Of Tumors in General, - - -_ . .2 Permanent Stricture,......39 Piles,..........14 Polypus of the Rectum, ...... 27 Prolapsus Ani, ------.-24 Pruritus Ani,......--31 Spasmodic Stricture, - - - - . . .37 Stone in the Bladder, ----- . 45 Stricture of the Rectum, - - - . . - 2-9 " " Urethra, - - - - . 37 Surgical Diseases, . - - - - . . _i Syphilis, ----•--..47 Seminal Weakness, ---.-..49 Whites, - - - - - . . . -48 Entered according to Act of Congress, in the year 1863, by HE"JRY A riAViPTa Di^o7N'.w"foCrk.0fthe ^"^ Courtoftha Unit9d State, for the 8ou,h.rB SUKGICAL DISEASES, Multitudes perish' prematurely, or suffer for years, in consequence of neglecting slight deformities, swellings, or ulcers, which, al- though they may give little or no pain, do nevertheless often lead to .deplorable results; therefore it is thought a public benefit may result from making some plain statements in reference to .ailments which require surgical treatment. It is a common but„very erro- neous opinion that surgical interference must necessarily be accompanied with great pain and danger to life. The fact is, that in the hands of a skillful surgeon; the cases are rare which .require any thing more than a very small amount of heroism to bear. In cases where the patient is of a very nervous temperament, a slight inhalation of ether or other anaesthetic will render him insensible to pain during the very few moments of the 2 SURGICAL DISEASES. operation. In the majority of surgical opera- tions there is a lessening of pain from the use of instruments, especially such as are required for strictured passages, displacement of various organs, the application of topical remedies, and the adaptation of the various kinds ol mechanical support, and the like. Surgery is a science based on physiological law, and an art founded on anatomical know- ledge, and experience in the use of proper in- struments and remedies, hence its practice is not uncertain. The success of a surgical operation can be predicted with great confi- dence if properly performed, provided the vital status is not too much impaired by ex- traneous or unforeseen circumstances, such as great loss of blood or nervous depression from some terrible injury, or exhaustion from some wasting or malignant disease. The writer's labor as a practical anatomist during many years, and his experience in sur- gical diseases, authorize him, he hopes, to speak and act with authority in the premises. OF TUMORS IN GENERAL. A tumor is a preternatural eminence ex- isting in any part of the body; when ex.- OF TUMORS IN GENERAL. 3 ternal, it is more or less a deformity; Yery often painful, and inconvenient, especially when large. Sometimes after remaining in- active for years, they suddenly become ma- lignant and prove speedily fatal. A tumor may be transient, as when caused by effusion or inflation ; these the skillful surgeon will remove by promoting their absorption, or will otherwise cause them to disappear without violence. Permanent tumors may be caused by the impaction of a foreign substance, by some un- natural growth of parts or organs, deposits of water or blood, of calcareous and other matter; by hernia, and by the dilation of large vessels, as aneurisms. They may be of all sizes, from a small wart to a mass equaling in size the whole body; they may be cancerous or other- wise extremely dangerous. When there exists the slightest doubt as to their true character, an honorable, conscientious, and experienced surgeon should be promptly consulted. Many, very many cases are on record, where incal- culable mischief has been done by ignorant interference. In July, 1859, the writer was called upon by a distinguished physician of Philadelphia to examine a tumor on the back 4 SURGICAL DISEASES. of a lady, extending from the neck to the loins, forming a most unsightly hump. It was at once pronounced an encysted tumor, and its immediate removal advised, not only on account of the deformity, but because it was on the point of ulcerating, which event would have given rise to a most offensive dis- charge, that might have continued for a life- time. Although nursing a child at the time, the lady consented to an operation, which the writer performed, without administering ether, and with but little pain. The tumor weighed four pounds. The patient never kept her bed, and resumed her usual active duties within a fortnight, well pleased with being rid of a superfluous burden with but really a slight inconvenience. It must not be inferred that all tumors are to be removed by the knife. Many can be got rid of by absorption, some by tapping, and others, as aneurisms, by tying a string around a blood-vessel. DEFORMITIES OF THE FACE. Sometimes persons are born with a want of the features, with deformities in the skin, such mother's mark, burns. 5 as "mother's mark," (aneurism by anastomo- sis,) moles, and the like. Deformities may arise after birth from -disease or injury, such as pitting from small-pox, scars from scrofu- lous abscess, burns, scalds, cuts and fistula; then, again, there is a loss or deformity of features by disease or violence. mother's mark, When small, or of a form which facilitates removal, should be removed as soon as possi- ble in infants and young children, in order to prevent increase in size. BURNS. When the skin has been destroyed by a burn, the wound contracts during the process of repair, and draws the adjacent skin with it, pulling down the side of the mouth or eyelids, or exposing more or less of the mu- cous membrane of the lower eyelid, which, by dust lodging on it, and by the constant change of temperature, causes a permanent irritation to be set up, endangering vision. In extensive burns about the neck, the skin contracts so much that the lower jaw is drawn 1* 6 SURGICAL DISEASES. down to the extent of preventing the mouth from completely closing, causing a hideous appearance, while the constant dribbling of saliva from the corners of the mouth is an incessant and mortifying, annoyance. Here defects, large and small, can be remedied by proper operative procedure. Moles, hair, dis colorations of the skin, and other unsightly appearances can be removed without danger or suffering, .scarcely leaving the slightest trace of their previous existence; and yet there are multitudes of parents who, under the impression that these things can not be remedied, allow their children to grow up with these blemishes, which in too many cases are a life-long martyrdom, owing to the constantly growing sensitiveness in relation to them. Such a result is greatly to be deplored, and many a heart-ache may be prevented as to a promising son or daughter, if different and more truthful views in regard to such things can be disseminated. FISTULAS. A fistula is an ulcerated channel extending under a surface; hence it may exist in any DEFORMITIES OF THE EYE. 7 part of the body. It is sometimes caused in the face by a stoppage of the ducts which convey the saliva from the glands or springs from which it comes; or by some disease in the gland itself; or from an unhealed wound or dead bone. In any case, the cause of the . mischief should be ferreted out and the pro- per remedy promptly applied. Yery often after the healing of an abscess, there remains an unsightly puckering of the skin. In almost all such cases a portion of the surplus skin can be removed with great nicety. DEFORMITIES OF THE EYE. One of the most common of these is "Stra- bismus," or squint. It is a want of uniformi- ty in the position and motion of the eyes. The radical cause is the contraction of one of the muscles which move the eyeball. A cure is effected by a division of the tendon of the . muscle. The operation is simple, safe and effective, without in any way involving the. eye itself or endangering the sight. The eyelid may be inverted, and the eye- lash being in contact with the surface of the 8 SURGICAL DISEASES. eye, inflammation arises, ending in opacity and blindness unless the defect is remedied; or the eyelid may be everted, turned out- wards, and come in contact with foreign mat- ter which will damage the sight. Sometimes small tumors are found in the eyelids; these can be easily and promptly removed, with the most perfect safety. FISTULA LACHRYMALIS Is caused by a stoppage of the canal which conveys the tears from the eye to the nose, hence the water overflows and runs down the cheek, causing considerable discomfort and inconvenience, and sometimes inducing irritation and ulceration; this defect can be perfectly remedied. When an eye is lost or very much deform- ed, it can be safely removed and an artificial one substituted, which will give the outward appearance of a good eye. THE NOSE May be lost or deformed by internal and external tumors; of the latter variety nasal tumors or polypi are the most common; these 611 up the nostril, impede breathing and speak- THE NOSE. 9 ing, and are a source of incessant annoyance; they are readily taken away, and the sense of relief is instantaneous and most agreeable. Sometimes a part, or even the whole of the nose may be wanting or lost by disease, acci- dent, or otherwise. In such cases repairs are made from the adjacent living skin, and a new nose of natural flesh and blood can be sup- plied ; in rare cases, where there is a grievous disfigurement of the face, the misfortune can be remedied in whole or in part by means of skin taken from the arm, and with compara- tively little suffering. A young girl of this city was introduced to me, in November, 1862 ; she had lost her nose through an injury; there was no ul- ceration, the wound having entirely healed. I restored" the organ by building it up from the adjacent skin; the parts heated rapidly, without any unfavorable symptom, she fol- lowing her usual domestic avocations from the time of the operation. In November last I restored the tip of the nose of a soldier. A few days later I was consulted by the mother of a young lady for a deformity of the nose of rather a singular character. From a blow received at 10 SURGICAL DISEASES. school, causing inflammation, a portion of the nasal bones came away, resulting in a sinking in of the bridge of the nose, with the tip pro- jecting preternaturally. The daughter was extremely anxious to have an aquiline nose. By the use of an instrument devised and made to meet the case, the patient was rewarded by the angle of the profile of her nose being very much reduced. The mucous membrane of the nose is often diseased, and a most offensive discharge, ac- companied by disgusting odor, is the conse- quence. Some portion of this discharge is continually being removed by the patient, but another portion becomes lodged in the cavities of the cheek-bone and forehead, caus- ing destructive ulceration and death of the contiguous bone. The parts can only be properly cleansed and made healthy, by direct applications to the diseased structure. Catarrh, and the poisonous effects of certain drugs, are the most common excitants of this malady. Some of my most grateful patients have been those who, in a measure, have been restored to society by being cured of this disease. THE EAR. 11 THE EAR May be congenitally wanting or deformed. A lady recently presented herself to me who was born with but the right ear; the site, how- ever, of the left was marked by a small fleshy prominence on which an artificial ear could be easily attached. Portions of the organ may be destroyed and the lobe may be cleft by the violent tearing out of an ear-ring; in this case the edges can be vivified and the parts united without leaving a visible scar. Polypi may grow at the entrance of the ear and impair hearing; they should be carefully removed as soon as discovered. Inflamma- tion may be diffused from the nose and throat into the middle ear, and deafness result. This is a common sequel to catarrh. In these cases I have been fortunate in restoring the sense,, and stopping destructive inflammation of the drum and aural cavities. Note.—The reader should bear in mind that in all operations, where a wound is made, "surgical re- pair " is necessary to a perfect cure; this is a pro- cess by which lymph, or the fibrous portion of the blood, is thrown out, wakes into life, and becomes a part of the living body, and by this means all divided or fractured parts are repaired and become united, and cavities are filled up or obliterated. 12 SURGICAL DISEASES. THE MOUTH. The appearance of the mouth is often spoiled by enlargement of the gums, and morbid growths having their seat in the mu- cous membrane lining the oral cavity—such as "ranula," a tumor that forms under the tongue. The tongue may be bound down in infancy by a small fold of mucous membrane which interferes with the child's sucking; it can be instantly remedied by snipping the part with a pair of scissors, care being taken not to wound the lingual artery; occasionally the tongue is more closely adherent to the lower jaw. Whilst residing in Philadelphia, I had to make a considerable deep incision under the tongue of a young girl, for the pur- pose of giving her greater freedom of articu- lation, an arrangement, it is hoped, that may ever be satisfactory to all parties. HARELIP Is a congenital fissure of the upper lip — the fissure may be «ingle, direct in the middle line, or there may be one each side of the nose. Conservative surgery has very much ANAL AND RECTAL DISEASES. 13 improved on the old operation for remedy- ing this deformity, and it is advisable that the defect should be remedied early after birth. It is not an uncommon thing to see persons who have been operated on by in- experienced persons to still retain a very noticeable cleft; this is caused by the unne- cessary removal of a portion of the lip; the disfigurement can be removed by a slight plastic operation. ANAL A2JD RECTAL DISEASES. Operations in these cases are comparatively painless and very transient; the aggravating symptoms generally subsiding from the-com- mencement of the treatment. Sometimes it is necessary to divide a bridge of skin or flesh, or remove a slight impediment with the knife; but when this is done, the affair is really so small as hardly to cause a murmur from the most tynid. Children may be born with a closed or imperforate anus; the defect is often slight and easily remedied; sometimes it is of so grave a character that a skillful surgeon should be called without an hour's delay. 2 14 SURGICAL DISEASES. Foreign bodies sometimes obstruct tne pass- age along the track of the lower bowel, such as fish-bones, chicken-bones, melon or grape- seed, and the like, or they may be intro- duced from below. The proper remedy is to dilate the bowel, and withdraw the obstruc- tion with appropriate appliances. PILES OR HEMORRHOIDS Are tumors which grow near the anus, and constitute a disease of greater frequency than perhaps any other; these tumors vary so much in character and the urgency of the symptoms to which they give rise, as to re- quire division into two distinct varieties: the first, External Piles, are found at the margin of the anus, covered half with skin and half with mucous membrane; they are oblong ridges of skin or round hard tumors; these are commonly called blind piles, because they do not bleed, and are external to. the sphinc- ter ani muscle, the muscle that closes the rectal orifice. Internal Piles are generally firm tumors, varying in size from that of a pea to that of a walnut, of a pale or reddish-brown color PILES OR HEMORRHOIDS. 15 when indolent, but dark or bright red when congested or inflamed. They generally cause great inconvenience by protruding at each motion, and are exceedingly liable to bleed from straining and pressure. Causes.—The predisposing causes are any circumstances that produce fullness and pres- sure of the abdominal vessels, or impede the return of blood from the veins of the rectum. When the bowels are evacuated, more or less of the lining membrane of the anus is everted and distended by the resistance which is then opposed to its venous circulation. Constipa- tion, by rendering the expulsive efforts more continued and laborious, must increase this effect and tend to produce permanent enlarge- ment of the protruded part. Constipation usually depends on errors of diet or regimen, particularly redundant nourishment, and de- ficient exercise, and other causes that derange the healthy action of the digestive organs, such as mental excitement and annoyance whilst eating. The disease, being once estab- lished will promote its own increase by im- peding evacuation of the bowels, and from the pain as well as hemorrhage attending it, disordering not only the healthy action of 16 SURGICAL DISEASES. the digestive organs, but the whole system. Pregnancy, enlargement of the liver,.abdom- inal tumors, and tight stays will, by oppos- ing a free circulation in the large veins, favor the production of piles, and they may also be excited and aggravated by large doses of aperient medicines, and worms. Piles may be either indolent or inflamed; while they remain indolent they merely produce the in- conveniences that necessarily result from their bulk and situation, and pain from get- ting within the gripe of the sphincter. When inflamed, they are exceedingly painful and give rise to heat, itching, fullness and tension about the anus, with a sensation as if there were a foreign body in the rectum. These symptoms may, in violent cases, be compli- cated with irritation of the bladder, frequency of micturition and pain in ,the back extend- ing down the thighs. All the symptoms of dysentery are simulated by piles. In women they cause aching in the back and uterine irritation, with discharge. The symptoms which attend internal piles may be divided into three sorts, namely, painful sensations, protrusion of the tumor, and hemorrhage. Some patients complain of these symptoms PILES OR HEMORRHOIDS. 17 equally; others complain of them singly, but in general they are all present, though one may so predominate from its severity as to call particular attention to it. The painful sensations are either in the seat of the disease itself or in the urinary organs, which have a strong, sympathy with the rectum. The pro- trusion is often extremely painful, and from the fact of its soiling the linen with blood and discharge, is a constant source of vex- ation. The bleeding which proceeds from internal hemorrhoids is the most alarming symptom attending the disease; the blood may either ooze from the surface or be expelled in jets, . and in quantities varying from a few drops to several ounces. When this bleeding becomes habitual it weakens the constitution, the countenance pales, the lips lose their ver- milion color, the action of the heart will be greatly affected, and with incidental compli- cations, the patient at last dies from exhaus- tion. Ulceration of the parts also is greatly to be feared, for purulent matter may be ab- sorbed into the system and give rise to pul- monary trouble, or disease in any organ or part in which it may be deposited. The del- 18 SURGICAL DISEASES. icacy of females often incites them to conceal their being afflicted with this disease, but in any case where there is a suspicion as to its existence, it is the duty of the surgeon to in- sist upon a most thorough examination of the bowel before he gives an opinion in the case. The person afflicted can do little toward alleviating his suffering further than attention to diet and the keeping of the parts clean. The radical cure of hemorrhoids can be effected in two w&ys, by absorption of the tumors and gradual obliteration of the veins, or at once by ligation. Under no circum- stances should an internal hemorrhoid be removed by cutting, because copious bleed- ing would follow, and great exhaustion be the inevitable result. Perfect relief may be relied on in the most severe cases when the patient places himself under the care of an experienced surgeon. In July, 1862, a young woman who had only been recently married, was induced by her husband to consult me, and by his affec- tionate solicitations she at last consented to an examination. I found several internal tumors complicated with ulceration of the mucous membrane, and a severe vaginal dis- FISTULA IN ANO. 19 charge. In a short time, without subjecting her to any pain, she was entirely cured. In December, 1862, a physician of this city, persuaded his cousin, a gentleman from the State of Maine, to consult me. He had been suffering for many years with piles, losing a considerable quantity of blood at evary stool, and was consequently emaciated, and had the characteristic sallow complexion. As it was of consequence to him that he should be delayed as short a time as possible, I operated on him by ligation the day of his arrival, and he left for his home six days afterward, cured and in perfect health, in which state he has remained ever since. FISTULA IN ANO Is an ulcerated canal or canals in the neigh- borhood of the anus. The opening may be single, double, or more; it may be in the skin or mucous membrane, or there may be a track •direct from the skin to the gut; and in some cases there may be several fistula?, either com- municating with each other or solitary. The general origin of fistula is a collection of matter formed under the integuments of the hip, near the anus, and to one side of it. 20 SURGICAL DISEASES. The abscess may be rapid in its formation, and accompanied with the marked symptoms of acute inflammation, heat, redness, swelling, and pain ; at other times the deposit is made more slowly and insidiously, attention being first drawn to it by a sense of uneasiness in the seat, accompanied by tension and the pre- sence of an ill-defined flat swelling, which re- sults from the contained fluid and thickening of the surrounding tissues. In whichever way the abscess is formed, the matter, if left to itself, must sooner or later make an outlet on the surface, according to the law that the pressure of a foreign substance produces absorption of the surrounding sub- stance. One opening will generally be found to exist in the skin, about an inch from the anus, and another at a variable distance of one to four inches from it, on the mucous sur- face of the rectum. The opening in the ex- ternal integument is often very small, and sometimes its existence is ascertained by press- ing on the parts with the fingers, when the spirting of matters shows its exact locality ; when the aperture is well defined, it exists in the form of a small, pimple-like protuberance. When a fistula has but one orifice, it is called FISTULA IN ANO. 21 a Blind Fistula; but most frequently there are two, and in this condition it is called a Complete Fistula. The process which has been "described as leading to the formation of Fistula in Ano, occurs in both sexes, and at every time of life. The symptoms of Fistula in Ano are gene- ral uneasiness about the anus, with a dis- charge, more or less copious, of purulent and sometimes thin and sanguineous matter, stain- ing the linen and otherwise annoying the pa- tient. Besides the evacuation of the fistula and special uneasiness of the part when going to stool, sensitive persons are distressed by a sense of weakness and imperfection which renders them excessively unhappy. Fistula in Ano never heals spontaneously; being in close proximity to the muscles of the anus, it is continually disturbed by their move- ment ; this, and the fact of its being always dilated by foreign matter, prevents its walls from uniting. All palliative treatment, furth- er than perfect cleanliness, is worse than use- less, for valuable time is lost. Drugs injure the general health, without having the slight- est possible good effect on the fistula itself. 22 SURGICAL DISEASES. Louis XIY. suffered from Fistula in Ano, and being unwilling to undergo the operation which his medical attendants assured him was necessary, listened to various proposals for otherwise curing the disease. Instead of try- ing these methods on his own person, however, he collected a great number of his subjects who labored under the same infirmity, and caused the proposed experiments to be tried on them. Some he dispatched to the waters of Bareges, others to those of Bourbon, and many more he shut up in rooms provided with every thing that could be suggested for the purpose in view. At the end of the year, finding that not a single person had been cured, his majesty yielded to necessit}r, and permitted his surgeon, M. Felix, to do what he judged proper. The King completely re- covered, and Felix, with his assistant, two physicians, and an apprentice, divided fees to the amount of $75,000, M. Felix's fee being $30,000. Obliteration of a fistula can be effected at once by division, or gradually by ligation, if the patient is totally opposed to slight pain. Through progressive improvements the use of the knife has been at length circumscribed FISTULA IN ANO. 23 within such narrow limits as hardly to deserve the serious title of an operation. The ultimate tendency of this disease is gradually to break down the constitution; the ulceration spreads, and more vital parts are attacked; absorption of pus and morbid matter takes place, to be deposited elsewhere in the body, endangering life. As before noticed, on account of the small- ness of the mouth of a fistula, and its conceal- ed position, it is difficult for the patient to detect it: when there is any suspicion as to- fts existence, he should be examined, and if his fears are correct, be cured at once, as los? of time must add to the difficulty of the case It is also important to bear in mind that no presumption of pulmonary disease should pre vent an examination; on the contrary, it is still more important that it should be made. Dur- ing the last year, I have operated on several business men without detaining them a day from attending to their affairs. 24 SURGICAL DISEASES. ' PROLAPSUS ANI Is an eversion of the lower bowel and its pro- trusion through the anus. This is caused by a defect in the structure itself, or through violent strainings, as a result of piles, stric- ture or stone. The disease generally exists in children, and persons of an advanced age who suffer from a relaxed state of the sphinc- ter ani muscle. The size of the protruded part varies con siderably, from a small ring of mucous mem- brane to a large mass. Some years ago there was a patient in Bellevue Hospital who had a tumor of this kind, which in form and color looked like a common flower-pot. Its size could no doubt be accounted for by the common practice of introducing different sub- stances, such as sticks, bottles and stones into the rectum for the purpose of keeping up the gut, increasing their size as the parts ex- panded under the pressure, which expansion is the natural result of such a procedure, .and proves that no truss having any appliance to be worn within the rectum should be made use of, though proper bandages and trusses may be of considerable service in treatment. PROLAPSUS ANI. 25 The more the prolapsed part comes in contact with the clothing, the greater will be the irritation. When a portion of the bowel has descended in violent straining, it soon, by friction, becomes inflamed, swol- len, and very painful, through being held tightly by the grip of the muscle, the symp- toms becoming aggravated at each evacuation, owing to the resistance they present. Cases have been known where, by the want of proper attention, the sufferings of the pa- tient have become extreme, terminating even in death, or the mortification of the con- stricted part. Wherever the protrusion oc- curs, the patient should kneel down on a lounge or bed, the parts should be carefully washed, then smeared with oil, and be gently pushed inwards; if not too painful, the fore- finger should be passed into the rectum, so that it may carry the protruded part with it. In most cases this operation is easily accomplished. But when the tumor has existed for many days, the coats of the bowel become so thickened and painful, that the manipulation requires to be con- ducted with the greatest caution. 3 26 SURGICAL DISEASES. Eelapse must be guarded against, in accord- ance with the circumstances that gave origin to the defect. If by stone or piles, the pro- per treatment for those disorders will have to be enforced. If by the presence of worms, they must be expelled by appropriate medi- cine. But when the disease is dependent. on an unhealthy condition of the membrane itself, it will have to be treated with astring- ents, anodynes, and attention to diet. In children, these means very often produce a permanent cure, especially when proper applications are applied to the mucous sur- face. A radical cure may be made in a variety of ways, the surgeon being guided by the state of the parts and certain anatomical dis- tinctions. In France, M. Dupuytren intro- duced the practice of excising a portion of the skin, but although this plan may be all that can be desired in most cases, the opera- tion has been followed by very deplorable results, in inexperienced hands. It has now been almost • entirely superseded by the use of the ligature, an eminently • successful me- thod. The plan, however, which I have found to be equally efficacious in numerous FISSURE OF THE ANUS. 27 cases, and the one which I now usually adopt where the parts exposed are of no very con- siderable size, is the use of powerful astring- ents—these give scarcely any annoyance, do not confine the patient, and are entirely re- liable. POLYPUS OF THE RECTUM Is a growth from the mucous surface of the rectum, and resembles a pear in shape, its attachment being at its constricted portion or stalk; the symptoms attending its pre- sence are similar to those of internal piles. It should be removed at once by tying the stalk to prevent hemorrhage and then snip- ping the body off. It is a rare disease; the exact nature of the difficulty can not be re- cognized by the patient, who generally mis- takes it for piles. The surgeon will be made aware of its presence by moving it on its pedicle. FISSURE OF THE ANUS. At the various orifices in the body where the skin becomes thin and delicate and impinges on the mucous membrane, sensation is more than usually acute, and is very liable, when slightly inflamed, to crack and ulcerate, as 28 SURGICAL DISEASES. is the case with the lips. If a person passes the finger over the skin of the lower lip just as it nears the vermilion border, he will re- cognize the sensitiveness of the part. A sim- ilar fissure at the anus gives rise to an amount of suffering almost unendurable, especially during the act of defecation, when the parts are put on the stretch. Various, applications may cure this, but sometimes it is exceeding- ly persistent, it is necessary that the patient should be very careful of his diet. The irri- table ulceration should be fully discovered, and applications made daily to its surface until it.is entirely healed and there is no longer any danger of a relapse. ANAL EXCRESCENCES. The secretion of the skin around the anus has, in many individuals, a remarkably irri- tating quality, redness and thickening, with slight ulceration, is a frequent result of it. In certain cases, if great cleanliness be not attended to, the thickening increases, and in that condition is called condyloma. In other instances warts vegetate in this region and often attain considerable size. It is impossi- ble to keep these completely clean, owing to the hundreds of little prominent studs which STRICTURE OF THE RECTUM. 29 have furrows between where water can not reach, and from whence a most offensive dis- charge is constantly exuded. They can be got rid of by a variety of means, either by appli- cations, the ligature, or excision. The latter method is perhaps the best, as it certainly is the quickest, but a good surgeon can almost always in this case follow the caprice of his patient. STRICTURE OF THE RECTUM. In this affection there is a chronic thicken- ing and contraction of the mucous coat of the rectum, so as to form an impediment to the proper evacuation of the contents of the bowels. The complaint almost always steals on insensibly, so as not to attract attention until fully formed. The symptoms of a con- firmed stricture are the frequent discharge of thin, feculent matters, owing to the copious secretion of mucus which results from the irritation of the disease. The feces passed are in small, narrow, flattened fragments tinged with blood, the patient suffering con- siderable pain during the expulsory effort. The remedies for this disease are aperients' and injections, so as to produce daily soft, 30 SURGICAL DISEASES. unirritating stools, and the bougie. A bougie that is capable of passing the stricture with but slight inconvenience, should be passed once in two or three days, and be maintained in position from ten to fifteen minutes—the greatest care being taken to use the instru- ment with gentleness. The cure is effected by the stimulus arising from gentle pres- sure, producing absorption of the adventitious matter that has been thrown out, and not by the mechanical action of stretching. The rectum varies in length from seven to eight inches, and to the right side of the body it makes a curve against the bone, consequently at this point an obstruction is felt which pa- tients and ignorant persons have mistaken for stricture, and have produced great injury and fatal results from tearing the parts during their mischievous manipulations. Like sim- ple stricture in other parts of the body, this can be surely cured by adopting proper means; it may, however, be caused and com- plicated by cancer of the rectum, in which case a cure can hardly be hoped for, but much may be done to alleviate the misery of the patient. Spasmodic stricture of the rectum is a PRURITUS ANI. 31 rare affection, unless caused by fissure and the consequent contraction of the sphincter muscle. When persistent, it generally depends on a vitiated state of the secretions, and is most frequently relieved by a regulated diet and alterative medicines and the use of in- jections. PRURITUS ANI Is an unendurable itching of the parts, com- monly coming on as one is about getting warm in bed. Generally palliative measures are resorted to. It is better at once to seek competent advice from a surgeon; a perfect cure need not be expected otherwise. In August, 1862, a gentleman applied to me for relief who had literally scratched holes in the flesh. The trouble whs caused by matter lodging in some obscure little pouches of mucous membrane in the rectum. After a short course of treatment he was radically cured. 32 SURGICAL DISEASES. DISEASES OF THE GENITO-URINARY ORGANS. Perhaps in the whole range of diseases those of the genito-urinary organs, both male and female, endure longest for want of pro- per treatment. The general practitioner and apothecary imagine they know all about these maladies, and give advice in the most unhesi- tating manner in cases which they have not sufficient knowledge to treat. The result is, that valuable time is lost, money is squander- ed, the disease burrows in the system, and botji mind and body lose their vigor. It stands to reason, that, in a complex and hid- den part of the body, such as these organs are, where topical applications and instru- ments have to be made use of, it is necessary that the professional man should be well ac- quainted with the structure and its condition, both in a healthy and abnormal state. These requirements can only be obtained by fre- quent dissections, and time for observation and reflection, such as a doctor engaged in ordinary medical business can hardly be ex- pected to have. INFLAMMATION OF THE URETHRA. 33 INFLAMMATION OF THE URETHRA May take place from a variety of causes, but by far the more common is by the applica- tion of a contagious material from one indi- vidual to another. These inflammations give rise to a discharge, (gonorrhea.) In males, the discharge comes from the inside of the urethra or passage to the bladder ; in females, from any part of the membrane which lines the genital parts. The infectious matter which excites the inflammation is generally communicated during unclean coition ; but it has been proved beyond all doubt, that, under certain circumstances, it may be produced by connection with a woman whose life is irre- proachable. A common clap is' generally first noticed, from the third to the seventh day, by an itching at the orifice of the ure- thra, which, if examined, appears to be un- usually red and a little swollen. Soon after- ward a slight running takes place from the urethra, of a whitish fluid, and this gradually increases in quantity, while at the same time it becomes more thick, until at last thick yel- low matter issues from the canal. The dis- ease is now fully established, and gives rise 34 SURGICAL DISEASES. to a scalding pain during the passage of the urine. In this peculiar inflammation of the urethra, its under surface becomes hard, feels like a cord, and is very painful to the touch; the stream of urine is diminished in size from the swelling of the parts that surround the urinary passage, and blood is often discharg- ed with it from the bursting of small inflam- ed blood-vessels. When the inflammation ex- tends from the urinary passage to the spongy substance that surrounds it, a very painful affection of the genital organ, called chordee, is excited. Gonorrhea is often attended with two un- pleasant consequences which arise from the irritation extending to the glands in the groin or testicles. In the first, a hard, painful swell- ing (sympathetic bubo) appears in one of the groins; in the second case, the inflammation extends along the seminal ducts, down to the testicle, which becomes- swollen and extreme- ly painful to the touch, (swelled testicle.) When a proper attention is not paid to clean- liness during the course of gonorrhea, or the extremity of the organ is unusually irritable, the discharge is apt to produce small sores on the end of the penis, and to cause inflamraa- INFLAMMATION OF THE URETHRA. 35 tion of the foreskin. If this state be neglect- ed, the foreskin will swell to such a degree as to render it impossible to retract it, or, what is still more dangerous, when it has been drawn back, it contracts, and is like a tight cord round the glans penis, can not be pulled forward, and sometimes gives rise to mortifi- cation of the part; under these circumstances, the parts will have to be skillfully manipulat- ed by a proper person. The time during which an inflammation of the urethra lasts, is extremely variable, and its duration is dependent on a variety of causes, such as the general health of the pa- tient, his habits, the comparative virulence of the infectious matter that had been absorb- ed, and the method adopted for its cure. I have had persons apply to me who have . suffered from the disease for years, but who have rapidly recovered under proper treat- ment. The constitution of others seems to have a peculiar tendency to hold to an in- flammation of the mucous membrane, and in these persons the whole of the canal is gen erally involved down to the neck of the blad- der. On inquiry, I have found that the course of treatment generally adopted has been the 36 SURGICAL DISEASES use of injections and the taking copaiba and cubebs. The injections very frequently have been of that strength as to lay the foundation of a permanent stricture ; and notwithstanding they mayr cause this serious mischief, they are not by any means generally efficient on ac- count of the great difficulty there is of bathing the whole of the urethra with the injection ; even in the hand of the surgeon it can only, as a general thing, be pressed down the canal to a certain point, when the urethra closes, and prevents its further ingress. The use of drugs can not be spoken of with any degree of certainty as being specific; very often they im- pair digestion and affect the constitution in a most injurious manner, without in any way benefiting the diseased structure. What, then, may be asked, is the most reliable way of treating inflammation of the urethra ? I an- swer, by a proper attention to the general health, and applications to the whole diseased surface of the urethra. This latter procedure I manage without giving the patient any pain; and with the most perfect assurance that it is a physical impossibility that he can incur stric- ture from, the treatment. SPASMODIC STRICTURE. 37 STRICTURE OF THE URETHRA. When a part of the canal or urethra which conveys the urine from the bladder out of the body is rendered narrower than it is in a natural state, in consequence of inflam- mation or change of structure, the disorder is called stricture. Writers on this subject generally agree in describing strictures under three forms — the spasmodic, the inflamma- tory, and the permanent. SPASMODIC" STRICTURE, Not associated with inflammation, is a rare disease. Various causes are said to give rise to this kind of stricture; it may proceed from exposure to cold and damp, or excess in drinking wine or spirits. It may also be caused by cantharides, whether taken by the mouth or absorbed from blister applied to the skin. Eetaining the urine too long in the bladder, irritation of distant parts, or even an irritated state of mind, will occasionally in- fluence the nervous system to such a degree as to produce spasmodic stricture of the urethra. The symptoms are sudden retention of the 38 SURGICAL DISEASES. urine—that is to say, the patient finds himself unable to pass his water, although he has a great desire, and makes repeated straining efforts to do so. If not relieved at an early period, fever sets in, and the most dangerous results may ensue from the bursting of the lower end of the urethra or bladder. Eelief should be obtained at once from one thorough- ly used to passing a catheter, and the urine be drawn off. Strict attention should be paid to the patient's health for several daj^s afterward. As an instance of how spasmodic stricture may occur, I would mention the case of a gentle- man who had sat very long at a card-table, and who delayed relieving himself at the proper moment; on rising, he found himself unable to urinate; an instrument was intro- duced and the water evacuated; slight fever set in the day afterward, but in a short time he was perfectly well. INFLAMMATORY STRICTURE Is caused by a lessening of the calibre of the urethra through the swelling of its mucous membrane. The most severe cases that have come under my observation have arisen from the improper use of caustic injections. PERMANENT STRICTURE. 39 PERMANENT STRICTURE Is a contraction of the urethra, caused bv chronic inflammation, and in the majority of cases is the result of gleet or frequent attacks of gonorrhea. At first a small portion of the mucous membrane, perhaps only an eighth of an inch in extent, becomes thick- ened and deprived of its usual elasticity; this is conveniently termed a "point of stricture," because two or more such points may exist in the same urethra. It frequently happens that persons, either from ignorance or inattention, are affected with stricture for a considerable length of time without their knowledge. But, as the disorder gains ground, the symp- toms become sufficiently urgent to attract the patient's attention, and convince him of the nature of his ailment. In what may be call- ed the first stage, the patient finds that he wants to make water oftener. than usual, and that he has an uneasy sensation in the crotch after doing so; he also notices that a few drops remain in the urethra, and gradually dribble from him, and his linen becomes slight- ly wetted. The next circumstance observable i3 the division of the stream, the reason of 40 SURGICAL DISEASES. which is, that the urethra is in an uneven state from the irregular swelling that surrounds it, and consequently the urine is thrown with an inequality of force against its different sides; sometimes the stream splits into two, becom- ing forked; sometimes it is spiral; at other times it forms as it were a thin sheath. Itch- ing of the end of the penis and gleety dis- charge are common concomitants, especially if the stricture is situated near the bladder. If the disease proceeds to its second stage, the bladder becomes irritable, obliging the pa- tient to rise in the night to void his urine. A man in health will sleep for seven, eight, or nine hours without being obliged to empty his bladder, but when he has a stricture, he may feel an uneasiness after four or five hours, and frequently in much less time even than this. Finally, if the complaint is permitted to continue, the constitution suffers, inflamma- tion sets in and is diffused, the bladder and kidneys become diseased; the complexion / becomes wan; the appetite fails, and there is great languor and depression of spirits, ac- companied by aching and weakness in the back; the patient complains of chills and flushes, and the urine is of an unhealthy de- PERMANENT STRICTURE. 41 scription. He is liable to attacks of spasm, with complete retention, and during one of these the urethra may ulcerate or burst, giv- ing rise to urinary abscess, or to extravasation of urine, and death is the result. In treating stricture the general state of health must be vigorously attended to, but a cure can only be effected by mechanical means, and these are three—Absorption by pressure, Cauterization, and Cutting. Cauterization is now very seldom resorted to, because, if mismanaged, it produces inflam- mation, retention of urine, hemorrhage, ab- scess, and any other conceivable mischief. The puncturing or cutting procedure should only be resorted to in the most extreme cases, but the operation, when necessary, can be performed with perfect safety. Absorption by pressure is the only proper or justifiable way to treat stricture in ninety- nine cases out of a hundred, where the stric- ture is permeable. A cure is always certain when the case is managed by a skillful sur- geon, and that without giving pain. No one without thorough instruction should attempt to pass an instrument, for fear of making a false passage. 42 SURGICAL DISEASES. GRAVEL. Gravel and stone are the terms applied to concretions formed in the kidneys and bladder, by a morbid deposition from the urine. This fluid, when in a healthy state, contains in so- lution, at least, twelve different ingredients. Of these, some belong to the class of acids; others are alkaline or earthy substances. Now, in certain morbid conditions of the sys- tem, the urine undergoes changes within the body, and some of these ingredients accumu- late until they are no longer held in solution, but are deposited in a solid form in the kid- neys and bladder. The salts, which form the depositions, are chiefly of two classes, depending on two dis- tinct states of the constitution, with which they are respectively associated. In the first class, which is by far the most common, the lithic, or uric acid, and lithates form the de- posit which is called, in popular language, red gravel, whether it appear in the form of sand or distinct concretions. In the second class, the deposition consists of the phosphatic salts. This species of the disorder is known under the denomination of white gravel. GRAVEL. ' 43 In the great majority of cases, urinary concretions and calculi are formed in the kid- ney. The calculous matter is either deposit- ed in the form of sand, which passes off with- out giving much pain or inconvenience, or it assumes the form of small stones, which may remain in the kidney during a longer or short-, er period; these, after a time, either escape from the kidney into the ureter, or tube which conveys the urine to the bladder, and cause the most severe pain (fit of the gravel) during their passage to the latter organ ; or they may remain permanently in the kidney, and attain a considerable size. Sometimes they produce inflammation, which may terminate in abscess of the kidney ; or they may cause chronic disease"and wasting of the organ. The passing of red sand or gravel is preceded, during a considerable length of time, by a copious deposition from the urine, of a tawny, reddish-brown, or brick-dust color, or of a more or less vivid pink hue. Few subjects in medical science are involv- ed in greater obscurity than the formation of gravel. But the testimony of all the best medical men who have particularly attended to this disorder, concur in showing that red 44 SURGICAL DISEASES. gravel is more frequently met with in persons of sedentary habits, who indulge in eating animal and other kinds of highly nutritious food, and drink freely of wine and other strong liquors. All authors who have written on this sub- ject have noticed the connection which ex- ists between gravel, rheumatism, and gout. These diseases, in numerous instances, appear to derive their origin from the same source. Although the urine may continue for a long time to deposit a red-colored sediment without the general health appearing to suf- fer, yet the individual should be on his guard, for this state of the urine indicates an un- healthy state of the system, and if not check- ed, will be sure, sooner or later, to terminate in the formation of gravel. This, as we have already mentioned, may be the source of ve*ry distressing and even dangerous disorders, or give rise to stone in the bladder. The individual, therefore, should take warn- ing from these premonitory symptoms, and adopt the necessary measures to avert evils of so formidable a character. STONE IN THE BLADDER. 45 STONE IN THE BLADDER Arises, in the great majority of cases, from a portion of gravel being deposited and gra- dually increasing in size. Occasionally the nucleus of the stone consists of a clot of blood, or a foreign body which has accident- ally got into the bladder, such as the broken end of a catheter, or a portion of a bougie. The symptoms of stone are—irritability of the bladder ; frequent irresistible desire to make water; occasional sudden stoppage of the stream of water during micturition, from the stone falling on the orifice of the ure- thra, the stream probably flowing again if the patient throws himself on his hands and knees; occasional pain at the neck of the blad- der, usually severest after micturition ; pain in the glans penis. If the patient be a child, he is always attempting to alleviate pain by pulling at the foreskin, which becomes elong- ated. But none of the above symptoms must be depended on alone. The existence of the stone must be evident to the surgeon by his ear and fingers; this is accomplished by the introduction of a smooth steel, sound into the 46 SURGICAL DISEASES. bladder, and if there is a stone, it will be heard to strike, and felt to grate it. Palliative treatment may occasionally be of great benefit to those afflicted with stone; and the stone may, when its composition per- mits, be dissolved by injections. No certainty of cure, however, can be promised by any other means than that of extraction. This may be accomplished in two ways—the first is lithotripsy, removal by crushing into small atoms. The second is lithotomy, which con- sists in making an incision into the blad- der sufficiently large to allow the surgeon to lay hold of the stone with forceps, and ex- tract it entire. My experience would lead me to advise the operation of lithotomy in almost all cases of stone. If an anaesthetic is taken, of course no pain is felt. The operation can be performed in a few seconds, and the stone is at once got rid of. SYPHILIS, 47 SYPHILIS. This term comprises all diseases resulting from a certain virus. Primary Symptoms. — After one or two days' incubation of the virus, the pustule forms, and the ulcer is established about the sixth day. It is first attended with redness, itching, and heat; then a vesicle appears, becomes purulent, breaks, and an ulcer is formed. If the virus touches an abrasion, the sore may appear at once. Bubo is an inflamed lymphatic vessel or gland leading from a venereal ulcer. Buboes vary in the rapidity of their development. Some are termed acute, others chronic ; the former hastening to suppuration, whilst the latter are indolent. Constitutional Symptoms. — These are se- condary and tertiary. The secondary symptoms follow the pri- mary, usually during the second month; con- sisting chiefly of general eruption, affection of the throat, fever, change of complexion, dryness of hair, rheumatic pains in shoulder and knee, headache. Secondary symptoms are transmissible from mother to child. 48 SURGICAL DISEASES. Tertiary Symptoms. — The periosteum and bones are affected by a chronic inflammatory process; suppuration, caries, and death of the bone result; also, stiff joints, tubercular form- ations of the skin, and condylomatous tu- mors, destruction of the gums and cheeks, deafness and blindness, are also among the consequences. Some of the worst cases of deformities of the face that the author has ever seen, have been caused by the improper treatment of syphilis, and the rash use of mercury. THE WHITES, Or Leucorrhea, is an unnatural discharge from the mucous membrane of the vagina and womb. The discharge is far from being always white, as the term applied to the dis- ease would lead us to suppose; it presents va- rious shades of color, and degrees of trans- parency and consistency, according to the cause of, and continuance 6f the irritation. It is the most common of all female disor- ders, and the results arising from it are very far more serious than commonly imagined —deterioration of the blood, and ulceration of THE WHITES. 49 the lungs or consumption, owing to an ab- sorption of the matter into the system, being a frequent consequence. Besides this, domes- tic unhappiness is often caused from the fact that the male urethra is liable to inflamma- tion through contact with leucorrheal matter. This accident has very frequently been the foundation of unjust aspersion of character. The disease may occur from displacement of the womb, bladder, and other causes. t Constitutional treatment alone is ineffective. It is absolutely necessary that the extent of the injury should be ascertained. When of a chronic character, this disease requires time and patience to eradicate. SEMINAL WEAKNESS AND IMPOTENCE. The serious and distressing malady com- monly known as seminal weakness, sperma- torrhea, or partial impotence, may originate from a variety of causes, and it will affect, in a more or less marked degree, the mind as well as the physique. There may be an ori- ginal weakness and want of development of the genital organs. After a severe and tedious illness, the gen- 50 SURGICAL DISEASES. itals may remain incapable of performing their functions long after health is restored. In other respects, certain diseases are always attended with a diminution, and sometimes with a loss of sexual power, especially dia- betes, diseases of the kidneyT, some forms of dyspepsia, and the latter stages of most chron- ic diseases, and the excessive use of tobacco and alcoholic drinks. When impotence arises from excessive ven- ery, or by the practice of self-pollution, the symptoms, or rather the disastrous effects, are more particularly marked. The sexual organs become weak and irritable, and the least excitement, the friction of the clothes, or even a lascivious thought, brings on an im- perfect erection, followed immediately by the discharge of a thin fluid. The erection is so imperfect, and followed so soon by the dis- charge, that the patient is quite incompetent for sexual connection; and the frequent abun- dant losses of seminal fluid, together with the patient's consciousness of his own imperfec- tion, bring on a most miserable state of bodily weakness and mental despondency. The prostate gland may be inflamed, (pros- SEMINAL WEAKNESS. 51 tatitis,) and give rise to preternatural irrita- tion. This gland is about the size of an or- dinary Spanish chestnut, and generates a spe- cial fluid of its own ; it is situated at the base of the bladder, and is pierced by the urethra and the seminal ejaculatory ducts ; it can, therefore, be readily imagined how inflamma- tion may be diffused from one point of the generative apparatus to another ; and this condition of the parts at the origin of the seminal ducts tends greatly to keep up an ex- cessive secretion, and to promote the action by which it is expelled. A vast number of cases of impotence have come u«der my treatment. It would be of no service to illustrate this article with one or two cases out of so large a number, as, in the majority, the cause has been different, and the time of endurance and other particu- lars have varied in each. Patients, of all ages, have applied tome, as well as the guardians of youth, and I think it worthy of remark, that these persons have, almost without ex- ception, been previously under the charge of either professionals or amateurs whose know- ledge of anatomy and surgery, judging by 52 SURGICAL DISEASES. the results of their interference, has not been very profound. The treatment I have found most efficacious, in conjunction with attention to the general health, are applications to the diseased surface. These can only be made by instruments passed within the urethra. They give no pain when skillfully applied, but may be made to do con- siderable damage in the hands of the unin- structed. Perhaps the most frequent cases of impotence that present themselves are those of middle aged men, who, from various causes, have their nervous system affected. By proper treatment they will certainly be cured. • 144 Lexington Ave., N. Y. NOTICE! I desire to correct the common error that the cure of surgical disease is neces- sarily dependent on the use of the knife. It is quite the reverse; in most cases cutting is unnecessary. Surgical disease is generally defined from ordinary dis- ease by being cognizant to the sight or touch, for example ; affections of the skin and portions of the mucous membrane, are visible. Strictures, are recog- nized by touch, and a large number of ailments and deformities by both. I am, continually treating, with perfect success persons residing in every State of the Union and in foreign countries, by correspondence, and in many cases it is unnecessary that I should see them to effect a radical cure ; as in cases of disease of the rectum and genito- urinary organs, including stricture, syphilis, impotence, and many affections of the nervous sys- tem. HENRY A. DANIELS, M. D., 14:4: Lexington Ave., JV. Y. /° ifyj-yr '0 NLM005805279