WIB mm :i> i!*ll!{- jm M'JKni 1 WBa'jmM TIONAl LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDI I3IQ3W JO AHVaail 1VNOI1VN JNIJIQJW JO A.HVS8I1 1VNOIJ.VN 3NI3IQ3W jo xavnan 1VNC ATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MED 13 10 3W 30 All Villi 1VNOI1VN 3NI3I03W 30 A»V a 8 I 1 1VNOI4.VN 3NI3IC33W 30 lll«llll 1VNI Sr^-' ^ «r IV 3NI3IQ3W JO AVVIiail 1VNOHVN 3NI3IQ3W JO A»V* a II IVNOIIVN 3NI3IQ3W JO AHVS8I1 V NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF ME { \ NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF ME c 3NI3I03W JO AHVlail IVNOIIVN 3NI3I03W JO A II V II 8 I 1 IVNOIIVN 3NI3IQ3W JO A II V II 8 I 1 IV' NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF ME 3NIDI03W JO A II V US II IVNOIIVN 3NI3I03W JO AVVIiail IVNOIIVN 3NI3I03W JO A IIVII8 II IV' NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF ME 1NI3K13W JO AHViail IVNOIIVN 3NI3I03W JO A II V II 8 I 1 IVNOIIVN 3NI3I03W JO A II V II 8 I 1 PRACTICAL OBSERVATIONS ON SOME OF THE DISEASES OF THE TECTUM, ANUS, AND CONTIGUOUS TEXTURES; GIVING THEIR NATURE, SEAT, CAUSES, SYMPTOMS, CONSEQUENCES, AND PREVENTION; ESPECIALLY ADDRESSED TO THE NON-MEDICAL READER. / Uoib r BY W. BODENHAMER, M. D. " I have always thought it a greater happiness to discover a certain method of curing even the slightest disease, than to accumulate the largest fortune ; and whosoever com- passes the former, I esteem not only happier, hut wiser and better too."—Sydenham. " The Science of Medicine, like the Doric Column, should stand simple, pure, and majes- tic, having Fact for its Basis, Induction for its Pillar, and Truth alone for its Capital." " Time overthrows the illusions of opinion, but confirms the decisions of nature." CINCINNATI: PRINTED FOR THE PUBLISHER, BY A. G. SPARHAWK, N. E. Corner 4th & Sycamore Sts. 1847. wre P-ttt pc 1^7 PREFACE. The object of the present work, is simply to call attention to a class of diseases, but imperfectly understood at the pre- sent day; by pointing out their location, their nature, their principal causes, their most prominent symptoms and their consequences; so as to enable those who are yet free from their annoyance, to continue so, by avoiding their causes, and to encourage those who are laboring under any of them, by in- forming them that they can not only be treated but cured, by a new, safe, mild and scientific method. It is admitted by all practical surgeons, that those diseases are difficult to treat, under the most favorable circumstances. Any attempt, therefore, at the diminution of that difficulty, should be meritorious, and any degree of success attending it should be a subject of congratulation. It is not, however, the intention of the author to give, in the present work, the pecu- liarities of his method; but he refers with pleasure to his tri- umphant success in the treatment of the diseases of the Rec- tum and Anus, as furnishing the most satisfactory and unan- swer able evidence of its superior excellence. As the work is especially addressed to the unprofessional, it is as much as possible divested of the technicalities of the science, so that the non-medical reader can comprehend all that is important to be understood. The author would here bespeak the patience and the candor of the reader—the first, that he may duly appreciate the extent and importance of the subject—the second, that he may judge of the manner in which it is treated with forbearance and lenitv to its admitted defects. IV PREFACE. It may not be improper here to remark, that it is the design of the author, at no distant day, to present also to the medical profession, a practical work on those diseases, containing a plain statement of their seat, nature, cause, symptoms, and treatment. The work to be illustrated by a number of colored plates, and exemplified by numerous cases. Louisville, Ky., September 1846. CONTENTS. Page. CHAPTER I.—Introduction,.......1 CHAPTER II.—Why are Anal and Rectal affections of more frequent occurrence now than formerly 1 -------- CHAPTER III.—Statistics,........H CHAPTER IV.—Haemorrhoids—Piles,.....12 CHAPTER V.—Fistula in Ano,.......32 CHAPTER VI.—Abscess near the Rectum and Anus, - - - 58 CHAPTER VII.—Complication of Anal Abscess, or Fistula Ani with Phthisis Pulmonalis,.......... 65 CHAPTER VIII.—Fissure of the Anus,.....70 CHAPTER IX.—Prolapsus Ani, - - - - - - - 76 CHAPTER X.—Ulceration of the Rectum,.....81 CHAPTER XL—Inflammation and Excoriation of the Anus, - - 85 CHAPTER XII.—Pruritus of the Anus—Itching of the Anus, CHAPTER XIII.—Excrescences of the Anus,.....89 CHAPTER XIV.—Polypi of the Rectum,.....91 CHAPTER XV.—Neuralgia of the Anus, - - - - * 93 CHAPTER XVI.—Spasmodic contraction of the sphincter Ani, - CHAPTER XVII.—Organic stricture of the Anus, - CHAPTER XVIII.—Stricture of the Rectum, - CHAPTER XIX.-Malignant Degeneration of the Rectum, - u CHAPTER XX.-Fistula in Perina.o-UrinaryFzstula, _ '_ "_ ^ CHAPTER XXL—Vaginal Fistula, " . . 126 CHAPTER XXII.—Testimonials, - - CHAPTER XXIII.-Concluding Observations, - - - - 146 CHAPTER I. INTRODUCTION. The diseases incidental to the Rectum and Anus are of fre- quent occurrence among all classes, and in consequence of their seat, as well as their nature, are perhaps the occasion of more annoyance and of more suffering to the patient than, with few exceptions, any other class of diseases. Of extreme frequency we know of none more difficult to treat successfully, we find none less generally understood, and none in which a rational treatment is of more service. Who will attempt to affirm that they are as well understood as they should be, or that they have been studied with that care and discrimination which their importance demands? Indeed the idea already prevails to a considerable extent, that "beyond the treatment of fistula in ano and haemorrhoids, the surgery of the rectum and anus is a sort of land of the Cimmerians, where quacks alone can breathe and humbug darkens the air." But those diseases are as susceptible as any others, of exact observation, of scientific analysis, and of simple and appropriate treatment. It is true, the rapid progress of modern pathology and surgical practice, is daily introducing many improvements, but no successful attempt has yet been made to apply these accumulated and daily accumulating facts to this class of diseases. It is owing to these various causes that so many patients, laboring under these diseases, fall into the hands of empirical, unprincipled or reckless practitioners, whose deceptions are favored by the locality of the disease, and who are thus en- couraged and emboldened to perform and to repeat, painful, dangerous and unnecessary operations. 8 INTRODUCTION. From these considerations, and from the fact that those affections are of very frequent occurrence, particularly here in the west and south, the author was induced to turn his atten- tion directly to them, and some ten years have placed under his immediate care and observation a very large number of patients, both male and female, from the different states of the Union, many of these having undergone previous treatment by some of the best surgeons in our country, without being cured. His opportunities, during this period, for observation and experiment, have been quite ample, and he has not failed to avail himself of every source of information within his reach. He has consulted and studied with great care all the authorities on this subject, both ancient and modern, both American and European. And although the labor in this field of investigation has not been inviting, has not been pleasant, but rather repulsive and disgusting, yet it must be admitted to be of much importance, and upon which the life, health, com- fort and convenience of so many, so much depend. No sub- ject, however, should be thought unworthy of anxious atten- tion, which involves such serious consequences, the improve- ment of the healing art, or the extension of our knowledge of nature's operations. ABUSE OF PURGATIVE MEDICINES. 9 CHAPTER II. WHY ARE ANAL AND RECTAL AFFECTIONS NOW OF MUCH MORE FREQUENT OCCURRENCE THAN THEY WERE FORMERLY? That those diseases have, of late years, greatly increased in their ratio, is a fact confirmed by the experience of the oldest and best physicians and surgeons of our country. And to me, the causes of this increase are very obvious indeed, and all who will investigate the subject as I have done, will come to the same conclusion. The abuse of purgative medicines, by so many of this day, is one of the most common causes of these diseases. The idea that it is either necessary to obviate constipation of the bowels, or on every slight indisposition, to swallow some of the numerous and various drastic purgative nostrums which lite- rally fill our country, is a popular error, and a source of incal- culable mischief. It has laid the foundation of some of the most serious diseases of the lower viscera. The habitual use of such medicines to obviate constipation, I repeat, is the cause of more diseases of the rectum and anus than any one cause that has come under my observation.* I have ascer- tained to a certainty, that in one half of the cases I treat for those diseases, it can be traced up to this origin. In all such * A Southern gentleman consulted me a short time since, for a fistula in ano. He stated, that for a year previous to the appearance of the disease, he could never have any evacuation from his bowels, without resorting to Brandreth's pills. That he frequently took as many as sixty and even eighty at one dose. And said he, when they would commence to work, they would operate like a saw mill. This is but OHe example out of hundreds that might be given. 10 TIGHT LACING. cases a proper attention to diet, to exercise, and to the occasional use of an enema of cold water, or flaxseed tea would obviate the difficulty without inflicting any injury whatever. The motto of most all the quacks of the present day for the Cure of all diseases, is, physic ! physic !! physic !!! Purgative medicines are good in their proper place, but to purge for every thing is absolutely absurd. Therefore, all such drastic purga- tive nostrums in the form of pills, bitters, &c, &c, should be eschewed as the cholera.* Another cause is Tight Lacing. By this practice all the viscera of the abdomen suffer. The function of the liver is impeded, the stomach is compressed, and the result is indiges- tion, with all its train of evils on the lower viscera. The rec- tum as well as the uterus and bladder are forced down much lower than natural, from which often result the very worst consequences. To these causes I might add many more which tend to increase the list of such patients, especially in the west and south, but I deem these sufficient for the present. *Since the text was written, I have read with much pleasure, the following re- marks of Dr. Flint, of our city. They will be found in the form of a note, in his valuable edition of Druitt's Surgery, page 446. Phil. Ed. 1846. I was much gratified to perceive, that his and my own views so fully harmonize. The subject is of great importance, and has been too much overlooked by medical men; and I am highly pleased that the Doctor has so ably and so justly spoken on it. The note is given entire. " Nothing has been more remarkable, in my surgical experience in the west, than the disproportioned frequency of diseases of the rectum and adjacent textures--fis- tula, piles, prolapsus, &c, and I advert to the fact chiefly for the purpose of adding a cautioning remark respecting the causes of it. Doubtless it is partly to be refered to the chafing and contusions, incident to horse-back riding, which is a much more common mode of travelling here, than at the east; but it is mainly attributable to the habit of indiscriminate and excessive purgation, so prevalent both as a remedial and prophylactic measure. A large portion of the practitioners of the valley of the Mississippi, have been educated under a system of medicine whose theory regards portal congestion and hepatic derangement, as the essential elements of all diseases, and whose practice consists, almost exclusively, in the exhibition of drastic purgatives. It is natural that the people should imitate the therapeutics of their medical advi- sers, when so simply and easily applied; accordingly they are as much in the ha bit interesting statistics. 11 CHAPTER III. STATISTICS. From the very nature of the diseases of which I am treat- ing, and their causes, it is very difficult to obtain available data, as there are scarcely any means of arriving at any thing like the exact number of such cases that really do exist. A Very large number, doubtless, of both male and female, but especially the latter, never apply for relief; being deterred by the idea that it is absolutely necessary to submit to some for- midable surgical operation, as is the popular practice of the day, in such cases; or they endeavor, from a false delicacy or some other cause, to conceal their disease. I am, therefore, not yet prepared to make out an available report, or to give full and satisfactory answers to the following questions: What is the ratio of persons laboring under those diseases, to the entire population? Are particular classes more liable to be affected than others 1 What influence has climate in the production of those dis- eases ? Are they more prevalent in males than in females ? of drenching themselves, and teasing the alimentary canal, on every occasion of illness, with some concentrated purgative in the form of pills. Under one of the most constant laws of irritation in mucous canals, the termina- ting portions of the apparatus of defecation, are thus perpetually suffering under propagated, as well as direct stimulation, and reacts in the various forms of disease under notice. Besides these direct mischiefs, and others, involving the health in other ways, occasioned by the pernicious doctrines referred to-which are indeed in themselves essentially empirical-they encourage the grossest species of quackery, . by promoting the consumption of vast quantities of patent pills, and other purgative nostrums. . ■ . In proportion as a more rational pathology shall prevail among physicians, the habits of the population will undergo a corresponding change, and the preponder- ance of diseases of the rectum in the duties of the surgeon, may be expected to disappear accordingly." 12 NUMBER OF CASES TREATED. I will, however, give the result of my own practice in the treatment of fistula in ano, the second most common of this class of diseases. From the first of July, 1S37, to the first of September, 1846, I treated of this one disease alone three hundred and five cases. Of this number 275 were whites; and 30 were blacks; 225 were males and 80 were females ; of the 225 males, there were 4 boys under three years old; of the 80 females, there were 3 girls under four years old; of the 30 blacks, 26 were males, and 4 were females. The blacks were all adults. Of the 195 adult white males, there were 74 farmers and agricultural laborers; 41 mechanics of various kinds; 20 mer- chants; 12 clerks; 10 judges and lawyers; 9 clergymen; 6 physicians; 5 sheriffs; 5 gentlemen without professions; 4 steamboat engineers; 3 steam boat captains; 3 teachers; 2 stage drivers; 1 hotel keeper, and 1 sailor. I doubt whether any other surgeon, in this or any other country, has ever treat- ed so large a number of this one disease in so short a time, and with such complete success. No better testimony can be giv- en of the excellency of my peculiar method of treating this disease than this list. Of the correctness of it, any gentleman can assure himself, by calling on me, and examining my jour- nal, in which he will find the name of each patient, his age, his occupation, his residence, &c. They can in this way, be found and referred to. But I ask the reader's pardon for this digression. CHAPTER IV. HAEMORRHOIDS —PILES. This disease is of great antiquity. It is minutely described in all the early works of the Greek and Roman physicians. Some Biblical commentators affirm, that the " emerods," with BIBLE--PHILISTINES--EMERODS. 13 which the Philistines were so sorely afflicted, as recorded in the fifth and sixth chapters of first Samuel, were haemorrhoids of a most severe and aggravated kind.* Be this as it may, it is doubtless a very ancient disease, and one that has caused much annoyance, and still continues to interfere greatly with the comfort, the convenience, and the happiness of thousands. Not only does it indispose the mind to exertion, and the body to exercise, but it casts a gloom over the spirits, and is pro- ductive of that general discomfort which ruffles the temper, and embitters the ordinary enjoyments of life. The number of persons laboring under this vexatious disease, in our own country, is immense. The ratio in the west and south, is about one in every five. From the causes which will be named hereafter, the vessels * Webster defines Hsemorrhoids to be " A discharge from the anus, the piles; in scripture,' emerodsy " Sanctius, on the 6th verse of the 5th chap. 1st Samuel, says,' In summa mor- bus est, qui illam prsesertim corporis partem infestat, per quam confecti cibi reliquiae et sordes segunter quas groaci hazmorrhoides ; Latini, ficus aut mariscas appellant.'' He however says that what befel the Philistines, was something even worse than mere hsemorrhoids. The Hebrew word is " Apholim," which by modern interpreters is translated in Latin, ficus or mariscai that is, piles or hsemorrhoids. Sanctius also says, on the ninth verse of the same chapter, that the Septuagint Chaldaic and ancient Spanish version explain "apholim " by " hsemorrhoids." Cornelius A Lapide represents that this disease was " Fistula in Ano." Jose- phus says, "it was a peculiar kind of dysentery." Aquila, in the seventh century, translated it " Cancer.'' This disease is mentioned by Herodotus, who calls it Theleia, that is papilla, which means pretty much the same as marisca. Theleia comes from Thele, the apex of the "Pap," and by similitude, tumors arising on the body from vicious humors (as was supposed) were called papilla. Hence Serenus, speaking of that disease,'in which the seat, or anus is swolen, says, "Excruciant turpes anum si forte papillse." . , Lyra Abulensis, Gregorius, Sanctius, and other distinguished and learned com- mentators, think that the Philistines, besides being afflicted with hemorrhoids or piles had their intestines to emerge, hang down, and at length putrify. '1 he Latin text of the ninth verse has "Et computrescebant, prominentes extales eorum, - 14 SYMPTOMS. of the rectum and anus become preturnaturally distended with blood, which, in the course of time, either gives rise to haemorrhage, to the formation of tumors, or spontaneously sub- sides ; being generally attended with inflammation and mucous discharge.' This congestion is evidently the primary and sub- stantive disease. The tumors, which are one of its conse- quences, have been divided into internal and external; the former being situated within, and the latter without the anus. Some have also distinguished them into bleeding piles, such as discharge blood, and into blind piles, such as do not discharge blood. The best division, however, and that having the most practical bearing, is into functional 2ind. structural; or, in other words, into accidental and permanent. Whatever opinions may be entertained, and they are indeed, many and various, with regard to the essential nature of these tumors, yet all agree that sooner or later, their contents coagulate; they become solid; and their coats increase in thickness; changes, which greatly modify and obscure their first organic alteration. These are what we call permanent or organized tumors. The accidental or primary tumors are generally easily compressible: and at an early stage, can be easily made to disappear altogether by proper means. Per- sons who labor under this kind of piles, may, for months, feel no uneasiness whatever; but at length, from some cause, they will take what they call "a fit of the piles." They will suffer the most excruciating pain when stooling, and for several hours after; caused chiefly by the involuntary and violent and their projecting entrails became putrid. The Hebrew has for extales " Apho- lim," and represents that the "Apholim," or vicious tumors, were hidden, or unknown to them, which Vatablus and Rabbi David (and evenlsidorus, seemingly) explain to mean, that the plague of piles or hsemorrhoids, was again drawn into the interior of the body, and thus hidden." The above note is given as a matter of mpre curiosity. Whether the unfor- tunate Philestines had piles, or fistula, or "something even worse," seems to be no more than an opinion, with small prospect of our ever being able to come to a satisfactory decision. DESCRIPTION OF PILES. 15 spasm of the sphincter muscle on some of the tumors about the anus. There will sometimes be a coldness, or languid cir- culation in the extremities, especially in the lower; nervous or neuralgic pains in the head, neck, and along the spine; sometimes attended with vertigo; dull throbbing pain in the rectum; with increased heat, straining and mucous discharge; palpitations of the heart; a feeling of weight in the back, hips and groin; weight and pain in the forehead; flatulence; scanty and high colored urine, with a frequent desire to void it and faeces; sometimes there is profuse bleeding. These attacks generally continue four or five days, and then disappear, as suddenly as they came on ; leaving nothing where the tumors were, but some shrivelled up membrane. The permanent, or organised piles, produce, in many in- stances, a degree of inconvenience which interferes most seri- ously with the active duties of life. Itching of the anus, is, perhaps, one of the earliest symptoms ; a sense of heat and fullness of the rectum; sometimes fever and great local un- easiness; the patient will suffer the most severe agony whilst stooling; and the tumors, whether internal or external, will become swollen, tense and extremely tender; so that they can scarcely be touched; they sometimes have quite a pulsation in them. When the internal tumors are much swollen, they will fill up a large portion of the cavity of the bowel, and excite a sensation as if some foreign substance was in it; sometimes the tumors bleed profusely, which immediately relieves all 'the local pain and irritation: sometimes, however, they bleed more or less at each evacuation of the bowels, without affording but partial relief. The haemorrhage usually occurs during defeca- tion, but may, however, take place either before or afterwards. The appearance of the blood is of a bright vermillion color; it is fluid, and usually runs in a stream, the amount lost at each stool, varies from a teaspoonful to a pint. I have seen patients having neither internal nor external tumors, discharge several ounces of blood at each evacuation of the bowels, and experi- 16 CAUSES OF PILES AND ence no pain or uneasiness whatever. When haemorrhage takes place from the intestines high up, it is manifested by the blood being black, coagulated and mixed with the faeces; whereas, when it takes place from piles, it is never mixed with, but may cover the faeces, and is fluid; Haemorrhoidal tumors vary very much in form and color. When they are highly inflamed, they are red or purple, tense and hard; but when they are in an indolent condition, they are more or less pale or flaccid. Some are hardly larger than a pea, whilst others exceed a hen's egg in size. They generally have a broad base, but frequently, they are pedunculated. They may be con- founded with the following diseases : polypi of the rectum, and prolapsus of the rectum and anus. Their diagnosis, however, is not difficult. Polypi may be distinguished by their very soft, spongy feel, when they are of the mucous species; by their incapability of sudden erection or colapse, by their very pale red color, and by their very slow growth. When they are however, of the fibrous structure, they are exceedingly hard. The protruded membrane may be distinguished by its entire freedom from erection, and our ability to glide its folds be- tween the fingers and thumb. Prolapsus of the rectum and anus, is often mistaken for haemorrhoidal tumors, even by sur- geons; and some of the most serious consequences have re- sulted from the treatment in such cases. The causes of haemorrhoidal affections are multifarious; but they all doubtless act much in the same manner; that is, by preventing the proper return of blood from the inferior mesen- teric vein. Chronic affections of the liver, constipation of the bowels, indigestion, obstructed menstruation, obliteration of the inferior mesenteric vein, tight lacing, aloetic or other stim- ulating purgatives, dysentery, diarrhoea, pregnancy, parturi- tion, prolapsus of the rectum, prolapsus of the uterus, enlarge- ment of the prostate gland, stricture of the urethra, stone in the bladder, sitting much on pierced seats, ascarides, (worms.) high seasoned and stimulating food, free use of heating wines, HEMORRHOIDAL AFFECTIONS. 17 such as champaigne, &c, the intemperate use of spirituous drinks, generally, excessive venery, hurried and rapid straining at stool, quite a common cause, application of leeches to the anus, irritating applications to the anus after stooling, such as printed paper, &c, riding much on horseback, constant sitting, filthiness of the parts; sedentary habits tend greatly to the pro- duction of the disease; warm climate, the passions, rage, fear, sorrow, restlessness, ennui, &c, also powerfully influence and keep up this disease; hereditary predisposition; we have seen children of haemorrhoidal parents, but three weeks old, who had piles; thus early manifesting a hereditary predisposition. These are some among the frequent and familiar agents in in producing piles. Warm, as well as stimulating rectal injections, also occasion pile.?. Hsemorrhoids are much more common in the higher classes of society, owing to their free living, and their sedentary habits. They generally take but little exercise, and hence are more liable to constipation of the bowels. The lower classes live on simple diet, and take much exercise in the open air. Males are more liable to this disease than females; and adults more than youths. The spring of the year is the period most favorable to the developement of this disease. It was the opinion anciently, that haemorrhoids were a salu- tary provision of nature; an especial effort of the vis nature medicatrix, for the advantage of the constitution; hence their cure or suppression was very much dreaded. Many of these notions, it is true, have long since passed away, yet it is aston- ishing how many are still advocating them. But inasmuch as it is a most painful and disagreeable disease, arising in most cases from known local causes, the cure of it should not by any means be delayed even a day or an hour; as it is so very liable at all times, to cause or terminate in, some other more serious disease, such as fistula in ano, of which we have seen numerous cases; ulceration of the rectum; prolapsus of the rectum; stricture of the rectum, a most dreadful disease; 2 18 RIDING ON HORSEBACK. sometimes it produces the most obstinate leucorrhoea (fluor albus;) also, fissure of the anus, one of the most painful dis- eases of these parts. We have seen the most violent paroxysms of neuralgia of the spine, caused by the piles; and even cancer of the rectum may be caused by an old indurated pile tumor. Mr. Calvert, who traveled both in Greece and Turkey, sayTs that, "The great frequency of haemorrhoidal diseases among the Turks, may be traced to the indolent habit of sitting, dur- ing almost the whole day, on warm, soft cushions; to the peculiarity of their diet, which in addition to their general habits, often produces an indolent and torpid state of the bow- els ; and, perhaps, also to an excessive indulgence in venery." (A Practical Treatise on Haemorrhoids, &c. By George Cal- vert, M. D., p. 60. 1824.) " Hoffman, who practised forty years in Saxony, observes that haemorrhoidal affections had greatly increased in his time, from the progress of luxury and the increase of idleness and sedentary habits. A confirmation of this remark is found among people who have led an active life, till a certain period of life, when, on leaving off business, and indulging in repose, they have become, for the first time, affected with piles." (Medico-Chirurgical Review, Vol. VI., p. 286. April, 1825.) "It was long an opinion among the ancients and moderns, that riding on horseback was prejudicial to hsemorrhoidarians. The fact is just the reverse. There is not a more certain pre- servative from piles, than regular horse exercise. But if a person unaccustomed to equitation, takes this exercise in a sud- den and violent manner, especially if he have the piles in the least protruded at the time, then he may suffer from what, at another time, and more judiciously managed, would prove an excellent preventive. This fact is substantiated by our cavalry surgeons—and we need only refer to the testimony of Baron Larrey on this subject, for ample proof of the position laid down. Larrey was long in the habit of causing soldiers affected with piles, to ride on horseback at full gallop; and he avers that he never saw any bad effects follow, but generally BARON LARREY--MONTEGRE. 19 on the contrary, the most salutary consequences." (Medico- Chirurgical Review, Vol. vi. Jan.—April, 1825, p. 289.) The talented and lamented Montegre, in his invaluable trea- tise, has also recommended horse exercise in moderation, as a powerful means of preventing and curing haemorrhoids. He also recommended cold water, either as a lotion, a " douche ascendante," or an injection, as a preventive and sometimes as a cure. He gives two cases that were cured by the " douche ascendante" which is throwing water forcibly, by means of a syringe, against the anus. Case 1. A man thirty-four years of age, of good constitu- tion, but haemorrhoidinary from an early period, had during the last few years, experienced long and painful attacks of the complaint under consideration. The last attack had now con- tinued three months, without any relief from pain, though a great number of remedies had been used in vain. Each eva- cuation was followed by the excruciating pains already described, so that the poor man was often deprived of sleep for whole nights together, was reduced to despair, and almost entirely abandoned food, for fear of the sufferings attendant on the evacuation of the faeces. In this state, he commenced the use of the "douche ascendante" by means of a syringe with a crooked pipe. The first effect of this application, was a diminution of the pains, and a reduction of the haemorrhoidal tumors, so as to be reducible within the sphincter. The pro- cess was continued for three or four days, and the pains ceased entirely. He has now been five years free from complaint. Case 2. A man forty y/ears of age, of plethoric constitution, had been ten years affected with internal piles, without any discharge. A sedentary life, without any regular rest for some months, had caused an haemorrhoidal swelling, attended by inflammation, and finally by ulceration. To this state was added the excruciating pains in question. Having a water closet of English construction, he contrived to have the jet of 20 A MORE INFALLIBLE CURE. water thrown against the anus, which gave him instant relief, for a time. He renewed the application every time the pain came on, which was sometimes very often in the twenty-four hours, and always with the same effect. By persevering in this plan a month, or six weeks, the ulcerations healed, the haemorrhoids disappeared, and the pains ceased." (Des He- morroides, ou Traite Analitique de Toutes les Affections He- morroidales, Deuxieme edition, Paris, 1830.) I have never adopted the horse exercise or the cold water, as a remedy for the cure of this affection, being in possession of a much more certain and infallible one. Although I have recommended that the cure of piles should not be delayed, for the very best of reasons, yet there may. be some few exceptions, cases in which it might not be prudent to meddle; those for instance, who have a regular periodical bleeding, much like the menses in women, who are not too much debilitated by it, nor injured in their general health in other respects. In such persons, it might not be prudent to suppress it, as it may, perhaps, supply some other evacuation which nature either ceases to carry on, or does not furnish in due quantity. It would also be imprudent to interfere with this disease in persons in whom it has appeared suddenly, on the suppression of either of the following haemorrhages, epis- taxis, (bleeding from the nose;) hcemoptysis, (spitting blood, or bleeding from the lungs;) hcsmalemesis, (vomiting blood, or bleeding from the stomach.) If in either of the preceding haemorrhages, the patient is improved by the supervention of hsemorrhoids, then they should not be interfered with. The same rule will apply in all cases where there is a full, ple- thoric habit, and a predisposition to apoplexy, to head ache, and to vertigo. The piles, however, in any of those cases, should they have been cured, can very easily be repro- duced, if desirable, by resorting to some of the numerous pills of the day, as they all contain more or less aloes and other drastic ingredients. One would suppose that so ancient and so common an CHARMS--INVOCATIONS--VAN II ELMO NT. 21 affection as the one under consideration, one which causes so much suffering, too, and one which is constantly falling under the immediate observation of every physician, would at this day be well understood by the profession generally ; that every thing in relation to its anatomical characters, its pathology and its treatment, would be clearly made out, and well defined. But, in reality, the very reverse of this happens to be the truth. So far at least, as the treatment, both medical and surgical, is concerned, it always has been and still is, to a great extent, highly impirical; and frequently no better reason can be given for the use of a remedy, or an operation, than that it has some- times succeeded. Hence the multitudinous, contradictory, and useless means now resorted to, for the cure of piles. The catagory of the remedial measures of the present day, for the cure of this disease, I have neither time nor inclination to sum up. The following, however, are a few of them; the ointment of galls; Ward?s paste; Hay's liniment; Buckeyes carried in the pocket; various kinds of suppositories; cream of tartar and flour of sulphur; excision, aloes, ligation, cauterization, &c, &lc. It is true that some one of these means may occa- sionally afford relief, at least temporary, but they never cure the disease; they never remove the cause; and should the patient get well, it would certainly not be owing to the remedy. Various superstitious notions, such as charms, incantations, invocations, &c, have also from time to time been put into requisition for the cure of piles, doubtless owing to the usual empirical practice in this affection. Monardes mentions the lapis sanguinaris, (blood stone,) found in Mexico, as being put in rings and worn on the fingers of those who were afflicted with haemorrhoids, for their relief. Van Helmont affirms that he had a metal, of which, if a ring were made and worn, not only the pain attendant on haemorrhoids would cease, but that in twenty-four hours, whether internal or external, they would vanish altogether. When the practice of medicine was con- fined to priests and monks, as it once was, particular diseases 22 PILES--DR. BUSHE. were appropriated to particular Roman Catholic Saints. Saint Phaire against haemorrhoids. This Saint was to be invoked for the cure of piles. And in our own enlightened age and day, the buck-eye, fruit of the Aesculus, is carried about the persons of those who have piles, for their cure. We have often been astonished to hear intelligent persons extoling in the most eloquent manner, the superior virtues of this remedy. But the stock of credulity in this world is inexhaustible. Excision and cauterization are practised by some surgeons for the removal of piles. With regard to the actual cautery (hot iron) as practised by some in burning out pile tumors, we will only remark, that it is a most barbarous practice, and should not be countenanced. Very few sane persons we should think, would submit to it; except those in hospitals, who can- not help themselves. The excision of internal pile tumors with the knife, is an exceedingly dangerous operation. It is now, however, discountenanced by some of the best surgeons in the world. Sir Astley Cooper, stamped his reprobation upon it, by relating numerous disastrous and fatal cases which came under his immediate notice. Indeed, not one patient in a hundred would submit to this operation, were he to be made acquainted with the serious danger of haemorrhage, which always must attend it. Dr. Bushe, in his valuable work on the diseases of the rectum and anus, page 183, says, " That ex- cision is not likely to be attended with danger from haemor- rhage, I deny; for I performed the operation several times, and after it, have had to tie up arteries, plug the rectum, and in one instance, to apply the actual cautery. Indeed, I so nearly lost two patients, that when left to my own choice, I no longer have recourse to this operation. In the cases I have operated on, the haemorrhage has never been alarming during the ope- ration, but in one instance; and in it, I was compelled to make firm pressure with the two first fingers of my left hand, for a considerable length of time; a procedure, which appeared necessary to prevent a most frightful haemorrhage. Generally, however, after these operations, the haemorrhage does not HORNE TOOKE'S ILLNESS. 23 occur for a few hours; then the patient who may have been perfectly comfortable, becomes anxious, restless, and is seized with rigors, spasms of the extremities, cold perspiration, sick- ness of the stomach, swelling and tension of the abdomen, particularly in the left iliac fossa, and colic pains. His pulse becomes small, frequent and irregular; his respiration anxious, his countenance pale; he is vertigous, and faints. All this time, the blood is accumulating in the colon, and he may die, without discharging it; but frequently, the tenemus is so great, that he goes to stool, evacuates large clots of blood, faints, and sometimes dies. More commonly, however, the discharge of it takes place in the recumbent position, and brings relief; but after some time, the haemorrhage returns, and in this way some patients have died." Neither this, nor any other painful and dangerous operation is now necessary to cure this disease, as hundreds can testify, who have submitted to my treatment. Sometimes, pile tumors of the permanent kind, whether in- ternal or external, are spontaneously cured. This natural cure is brought about in external piles, by inflammation, consolida- tion, and subsequent absorption of the lymph. In internal piles, it is brought about by strangulation and mortification. The tumor or tumors are prolapsed, and cannot be returned, owing to the resistance of the sphincter muscle which encircles them firmly, like a ligature; thus completely strangling them, and cutting oft' their circulation. Mortification soon takes place, sloughing follows, and the tumors are destroyed. Sir Benjamin Brodie, in one of his lectures, gives a case in point. " The late Doctor Pearson, who was for a very long period of time, physician to this hospital, was the physician and friend of the celebrated Mr. Home Tooke. Many years ago, I was diniiKi- vnth Dr. Pearson, and after dinner he gave an account of Home Tooke's illness. He said that he had long labored under piles; that at last mortification had taken place; that there was no chance of his recovery; and he added, that he had that morning seen him for the last time. I remember that in the middle of this history, there came a knock at the door, 24 JUDGE OF THE SUPREME COURT. on which Dr. P. said, ' Here is a messenger with an account of my poor friend's death.' However, it was some other mes- senger; but by and by, a messenger did arrive, saying that Home Tooke was much the same, or a little better. It turned out, as I have been informed, that the piles sloughed off, and from that time, he never had any bad symptoms. In fact, if I have been correctly informed, he was cured of a disease which had been the misery of his life for many years preceding, and he lived for some years afterwards." I might have entered into a minute investigation of the pathology, the anatomy, &c, of haemorrhoids, by giving my own views, as well as the views and speculations of others; but this would have been foreign to the object of this work; and inasmuch as it is not intended for the experienced medical practitioner, I have excluded all novelty and ingenious specu- lation, and admitted nothing, but admitted truths, of a useful kind. This chapter will be concluded by giving some extracts from letters (hundreds of which I have on file) from persons, who themselves labored under this disease, and who had been treated by the most eminent of the medical profession, and had also tried all the nostrums of the day. They will do more to en- lighten the common reader, regarding the nature, the causes, the symptoms, and the consequences of piles, than any thing else. These letters speak a plain, familiar, and perfectly intel- ligible language to all; no medical knowledge, no peculiar strength of intellect, nothing, in short, but plain common sense, will be requisite for their complete appreciation. [The following letter is from a judge of the Supreme Court of---] LETTER I. M----A----Nov. 1, 1841. Dear Doctor:—I have lately learned that you have been quite successful in the treatment of diseases of the rectum &c. I am now laboring under one of those diseases, piles, in their PROLAPSUS--PILE TUMORS. 25 most aggravated forms. I have suffered with this painful and distressing disease, for about two years; and although I have obtained occasionally, partial relief, from my physicians, and from the use of Hay's Liniment, and several other remedies; yet still the cause of the disease has not been touched, and I am now suffering the greatest pain. I am forty-five years of age; habits sedentary; by profession a judge; general health quite delicate, and bowels always constipated. I am certain that my piles were caused by my being compelled constantly to use harsh medicines to relieve my costiveness. When I go to stool I suffer the most acute pain; and I defer it as long as I possibly can, on this account. When stooling, a large portion of the bowel comes down, together with four or five large tumours, sometimes they bleed very much, which relieves me. They never return of themselves; but I have to return them with my fingers, which is always a truly painful operation. I lately consulted an eminent Physician, who, at once said he could cure me by aloes. He gave me a preparation, composed of nearly all aloes. I tried it about four days, and was render- ed very much worse by it; indeed it completely disqualified me for any business. I have been so little benefitted, that I had lost all confidence in physicians ; but hearing you so favor- ably spoken of, I have concluded to make one more effort to be cured. I have lately discovered a small ulcer on the bowel when it protrudes, it is about an inch up the bowel. I am fear- ful that either ulceration or fistula is about to take place. The object of this communication, is to learn from you, whether you think you can relieve me, and if so, I will visit you as soon as I get through holding my court at----at which place I wish you to address me immediately. I am respectfully, yours, &c. LETTER II. A----Ga., July 3, 1S43. ------- From a boy I was subject to a prolapsus of the bowel, which was attended with but little pain, or incon- 26 A MISERABLE OPERATION. venience, as the protruded parts would always assume their natural position immediately after stooling, without any trouble. Within the last six years, however, several large tumors have made their appearance, and now, when the protrusion takes place, it is as big as the largest size orange. The least exertion causes the parts to come down, which causes the most severe pain and spasm of the muscle at the end of the bowel. The parts are covered frequently with mucus, streaked with blood; and sometimes there is quite a quantity of mucus discharged, which has the appearance of red currant jelly. I am usually con- fined to my bed for three or four hours after stooling, owing to the parts remaining out, and my inability to return them, and to the continued action of the muscle, and the feeling as if something was stuck in the bowel. At such times there is a great fullness of the head, and a numbness of the extremities, with pain and weakness of the back, and great derangement of the urinary organs; so much so that I have often to use the instrument to draw off' the urine. From my continued and accumulated sufferings, my general health is daily growing worse; my nervous system is completely racked, and I have become quite irritable, and the slightest excitement, either mental or corporeal, will bring on a paroxysm of my disease. To avoid the suffering, I have an evacuation from my bowels only every alternate day. I had two external tumors cut off with the knife, without the least benefit whatever. I am a lawyer by profession, and am thirty-eight years of age. This is«a general outline of my disease. I have employed various physicians, and all the quack preparations of the day, to no purpose. LETTER III. H----, Ohio, June 6, 1844. ----" I have been troubled with piles for a number of years, but not badly, until within the last two years. I have been informed that you can cure me, and if you think you can do so, after hearing my statement, I will come to Louisville. INTERESTING LETTERS. 27 They are what is termed blind piles. There are three or four lumps, (one as large as a hen's egg) which get much larger at times, and pain me very much. When I evacuate my bow- els, the tumors come out, and have the appearance of a large rose, or ripe tomato. My bowels are always confined, and I have constantly to resort to purgative medicines------ LETTER IV. P----P----C----, La., Aug. 5, 1846. Dear Doctor—By mere accident, as it were, I learned that you were celebrated for curing diseases of the lower bowel; and being afflicted with, as I conceive, such a disease, I take the liberty to address you. My disease is a discharge of blood at every time I stool, without giving me the least pain. Indeed, up to this day, and it has been of some eight or ten years standing, I have never suffered, consciously, a single moment from it, and were it not that it may run to some other disease, more serious in its character, I would not trou- ble you nor myself about it. But I am now forty-two years old, and am aware that the decline of life is not the time to " heal old sores." I have consulted many physicians, but they make light of it, and put me off by saying it is only the piles. The discharge of blood is always after the evacuations from the bowels, and distinct, having no mixture with it, and amounts to from one to two gills daily. LETTER V. B----, Ky., July 9, 1S45. I suffered but little from my piles until the spring of 1841, when four or live tumors projected, and became hard, and almost as black as if mortified, attended with the most excru- ciating pain: no applications which my physicians could make could give me relief. Lately these tumors have got worse, and when I am stooling, there is quite a stream of blood run- ning all the time, so that I have to hurry and return them as soon as possible; for some time after there is a burning and throbbing of the parts, as if a red hot iron was there, which 28 DESPERATE CASES CURED. often forces tears from my eyes. I dare not walk about; my bowel falls down in a few minutes if I am on my feet, and I am so weak that I am scarcely able to stand. I have heard that you have cured many desperate cases of piles. I am confident I can get no relief from physicians here, for I have tried them all to my sorrow. Can you not cure me? I do dread the effects of this painful disease, and am anxious to be cured immediately. LETTER VI. F----, A----, Oct. 30, 1843. I write you at the request of Mr.------, who has been afflicted with piles for seven or eight years, and has been get- ting gradually worse for the last four years. He has submitted already to two operations of the knife, by Doctor----, of----, without any beneficial result. He is gradually getting worse, and unless he is cured very shortly, death will relieve him of his sufferings. One of his symptoms is profuse bleeding when he stools, which has reduced him very much, and makes him look as pale as death. He is now confined to his bed, suffer- ing nearly all the time, and has never been the least benefitted by the operations, or any thing else that has been done for him. He has seen Mr. C----whom you cured two years ago, and who advised him by all means to make immediate appli- cation to you. He is now not able to visit Louisville. Can you not visit him? LETTER VII. C----, Mo., Aug. 24, 1841. My wife has, for several years, been grievously afflicted with piles. There is often copious discharges of blood, with considerable inflammation and much pain of the parts affected. She has great weakness, and considerable pain in the back, head ache, and in fact, the whole nervous syrstem is highly affected. I have tried all the physicians here of eminence, but she has not been cured and is gradually getting worse; my fear is, that her piles will terminate in fistula. WIFE-- CLERGYMAN. 29 LETTER VIII. C----L----, April 20, 1841. Dear Sir—My wife, having labored under that unpleasant and untractable disease called piles, for the last three years; having in the mean time tried all the nostrums vended for its cure, besides trying the prescriptions and the advice of all the medical men of this vicinity, without the least benefit, I have determined to make another effort to obtain relief for her, by applying to you. It may be proper for me to state, that there is but a slight protrusion of the parts, and these only whilst at stool. They are easily pushed back, and frequently return of themselves. She has often pains and numbness of the lower extremities, which she attributes to this disease. The tumors most always bleed when she has an evacuation from the bow- els, and the amount of blood lost is considerable, and seems to increase; and at this time makes her appear very pale indeed, and effects her head, producing as she terms it, "strange and wild feelings of the head." LETTER IX. B---, Md., Sep. 21, 1843. Dr. Bodenhamer: Dear Sir—A clergyman, Mr.----, from your state, has informed my aunt that you cured him of a desperate disease, the piles, which he had long labored under. She requests me to write you, and inform you, that she has been subject to the most painful attacks of piles for the last six years. She is thirty- five years old, and has been a widow five years. Her health in other respects is tolerably good; but whenever her bowels become either too loose or too costive, she will have a sudden attack. The piles swell up suddenly, as large as hen's eggs; she has two or three of them. They are then so painful that she cannot bear to have them touched; they frequently bleed, and most always protrude. WThen the attack comes on, she is confined to bed, and suffers the most excruciating pain. Nothiiif vet has done her any good, and she has consulted all the best doctors in this city. These spells sometimes last four 30 BUCKEYES--DELUSION. or five days, and then the piles go away entirely, and she is completely relieved, and between the spells she is as well as usual. LETTER X. N----, Ind., July 28, 1840. Dr. Bodenhamer: Dear Sir—I have been afflicted for the last ten years with haemorrhoids to such a degree, that I am unable to be on my feet but a small portion of the time. Whenever I stand on my feet, or walk any distance, and at every evacuation of my bowels, there is a protrusion something similar to a large rose, made by the formation of five or six lumps near the extremity of the bowel. These 1 have always to press back into the rec- tum, by pressing gently on each side of them with my fingers, and it is with much difficulty that I can keep them from pro- truding even when sitting or lying down. I cannot pass urine unless the tumors are down. When they are inflamed and swelled they are awfully painful, the pain extending down my legs to my feet, with cramps in my feet and toes. I have paid hundreds of dollars to physicians and to quacks, and for various nostrums, all to no purpose. I have even been foolish enough to carry buck-eyes in my pocket for my disease! This last remedy, I believe, has done me just about as much good as any of the rest!! LETTER XI. p----e, Ky., April 3, 1840. Dear Doctor—-I have just seen Mrs, T----, whom you cured some time since of piles', she says that her case was as bad as mine, as I am also laboring under this disease. Mine are the blind piles, and I have had them for three years, and for the last thirteen months, confined to my room. I have been the patient of four doctors, and have found no relief. I had one tumor cut off last June; and since that time, two more have appeared. From what Mrs. T. says, I am fearful that I am about to have fistula, which I awfully dread. She A LADY--PERFECT CURE. 31 says that your treatment was so mild, that you did not hurt her at all. My age is forty-two years, and I have been the mother of four children. If I was cured of this wretched dis- ease, I would be entirely well I believe in other respects. I hope you will write me an encouraging letter. LETTER XII. C----, Ky., June 16th, 1842. Dear Doctor—This will be handed you byr my friend, Mrs. H., who visits you for the purpose of obtaining your skill in the treatment of her case, which is piles, and similar to what mine were. She has been the victim of the regular, as well as irre- gular practice of the day in this disease. I gave her every encouragement to call on you, knowing that you could cure her. As regards my own case, I am entirely well, and have been ever since I left you, two years ago. Indeed, my general health is now better than it has been for twenty years. I have not taken one single drop of purgative medicine since I left; this you will think strange, as I was always taking two or three large doses of pills every week, to keep my bowels open. Whenever I find that my bowels are becoming costive, I use the means you directed occasionally, and they relieve me. I would not exchange this simple and excellent remedy, for all the drugs in our country in such cases. I have recom- mended it in many cases of piles, as a palliative, with the most happy results. All who have tried it, say that it has relieved them more than all the applications they have ever tried. I could never have forgotten you, had you never done any thing else than relieved me entirely of my obstinate constipation. I am very respectfully your friend. [With regard to the use of the means of which our friend speaks, I have always (as a paliative) found it to be in such cases more effectual than any other single or even than all other remedies known to us.] To conclude, I would remark that haemorrhoids are too little 32 HIPPOCRATES--CELSUS--GALEN. attended to by the profession generally. Physicians are too apt, .after hearing their patients describe their sufferings, to treat them lightly, by merely replying, " O, it is nothing but the piles, it is not dangerous; you will be well in a day or two," &c. In all such cases, a minute examination should be made; for two chances to one, if some serious complication will not be found to exist. The reasons, however, that this is not done, are obvious. An examination is not a very plea- sant thing, either to the medical attendant or to the patient. But if he consults his own reputation, or the welfare of his patient, he will insist on an examination, especially when the most positive symptoms are complained of, or when suspicious ones, not otherwise well accounted for, do exist. CHAPTER V. FISTULA IN ANO. This disease, like haemorrhoids, is of very ancient date. The first distinct and comprehensive description of its nature and treatment is given by Hippocrates, the father of medicine, in his Liber de Fistulis. It is also treated of by Celcus, in his De Medicena, and by Galen, in his Methodus Medendi. From these early times to the present, medical literature has been most prolific, in furnishing us with a countless number of monographs on its nature and treatment. These records con- tain the most indubitable evidence, that it is a disease very difficult to treat successfully, under the most favorable circum- stances, and that its treatment heretofore, has been inefficient. Mr. Syme, in his work on diseases of the rectum, quotes from Dionis an interesting circumstance in relation to this disease. " Louis XIV. suffered from fistula in ano, and being naturally unwilling to undergo the operation which his medi- cal attendants assured him was necessary, listened to various EXPERIMENT OF LOUIS XIV. 33 proposals for curing the disease without having recourse to the knife. Instead of trying 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 of them he dispatched to the waters of the 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 a year, finding that not a single patient had been cured, his Majesty yielded to necessity, and permitted his surgeon, M. Felix, to perform all the incissions which he judged proper." We have here a striking illustration of the necessity of the operation,* and the importance, attributed to its perform- ance as formerly practised, may be estimated from the nun> ber of medical men, who were present on this occasion, toge- ther with the amount of their remuneration. Besides the sur- geon and assistant surgeon, there were two physicians, four apothecaries, and an apprentice, and the sum total of their fees was upwards of seventy thousand dollars. "Those were," says the editor of the Medico-Chirurgical Review, "royal days for surgeons. The fee which the operator on the Grand Monarque, M. Felix pocketed was some thirty thousand dol- lars. The name of this gentleman is emblematic of the palmy days of surgery, in which he had the luck of flourishing. If an operator now receives five thousand dollars for giving sight to one of our millionaires, he is thought a marvellously fortu- nate fellow." * It is somewhat curious, that some surgeons are in the habit lately of refering to the case of Louis XIV., as illustrating the most positive necessity of the use of the knife, and the knife only, in the treatment of this disease. If this case illustrates any thing, it illustrates the complete ignorance of all the parties concerned, as it regarded the nature and the treatment of the disease. It also illustrates the great "pomp and circumstance of" an operation. We are not at all surprised that the Grand Monarque was naturally unwilling to submit to the operation. We have yet to see the first patient who was naturally willing to have his rectum split open !! As the narrative does not give us the result of the operation, we are left to conjec- ture, not being, by any means, one of those who believe that the operation is synony. mous with a cure. 3 34 T II R E F. CLASSES OF FIST I L A . It is said that Henry VIII. of England, died of this disease. The term fistula, signifies a pipe, and in surgery, it denotes the tube, or narrow hollow conduit, leading from an abscess. As applied, however, by the old surgeons, as well as by the majority of those of the present day, it includes nearly every suppurating excavation about the anus. This departure from its strict definition, is doubtless caused by the fact, that an abscess always precedes fistula, and that it is the initiative in the production of fistula. Abscess and fistula stand in the relation of cause and effect. An abscess may exist without being fistulous, but as soon as it begins to take on this action, the original cavity gradually diminishes in size, until it becomes a simple tube or sinus. Hence this complication is usually confounded, and this term made to embrace too much. An abscess becomes fistulous in the following manner; after the pus in the first instance is evacuated, its parietes do not approximate, and its cavity is not spontaneously obliterated, but becomes lined with a pseudo-mucus membrane; and estab- lishes in its parietes one or more canals or openings which are also lined with the same membrane, and through which it con- tinues to discharge its secretions. This discharge may pre- sent characteristics of pus, gleet, sero-purulent sanguineo- serous or mucous matter, according to the general health of the patient, the length of time the affection has subsisted, &c. Fistula in ano, then, is the result of an abscess in the vicinity of the rectum or anus, which continues to secrete and to dis- charge matter through one or more sinuses or openings. Fistulas have been divided into three classes: complete fis- tula; external blind fistula, and internal blind, or ocult fistula. The first signifies that the sinus communicates with the bowel, and opens externally, forming a continuous canal from the cutaneous surface up into the intestine; the second denotes that the sinus opens only externally, and the third, that the sinus opens only into the bowel. These two last are also called incomplete fistulae. Some authors deny the existence of any other but complete EXTERNAL AND INTERNAL. 35 fistula?, but this is a great error, as I have demonstrated by minute desection, in numerous cases, some of long standing. With regard to the number and form of the external and internal orifices, they vary materially. Generally, there is but one external opening, yet often, there are as many as three, four, and six, and I have seen in consumptive patients as many as ten and twelve. All these, however, usually com- municate with each other, and converge to one internal aper- ture. There is but rarely more than one internal opening, yet I have seen as many as two and even three, in patients in the last stage of phthisis; they are usually round and callous, some- times, however, they are quite soft. The external openings are commonly round, and studed with exuberant granulations which sometimes very easily bleed when touched; they may be regular without granulations, especially if the disease is recent. Owing to the action of the discharge in old cases, the parts surrounding these openings, generally become hard, cal- lous, and project, forming, in many instances, quite large tumors or excressences. The direction and situation of the sinuses vary; sometimes they open at quite a distance from the outer circumference of the anal opening, and extend obliquely upwards and inwards through the external sphincter and cellular and adipose tissue, until they open into the bowel. Sometimes they pass through the fibres of the internal sphinc- ter; at other times they run between the sphincters, and then they ascend a little before perforating the mucous membrane. Thev are nearly always exceedingly tortuous in their route, and sometimes most difficult to trace to their internal opening. They may frequently be felt externally and traced towards their origin. If the fistula be large and complete, it will be usually found at some distance from the anal opening; but if it be small, it may be concealed beneath the folds of the fine skin, close to, or at this orifice. This kind of fistula is very apt to be overlooked: and great care is necessary' in conduct- ing the examination. I have seen many cases of this kind: the patient having previously been often examined, without 36 M. RIBES STATISTICS. the disease being detected; if yrou ask him, he will perhaps tell you, that his linen is daily soiled by a discharge which he attributes to piles; but which is usually from such a fistula. The seat of the internal orifice, for the last ten or twelve years, has been the subject of considerable debate. M. Ribes of Paris, contends that the internal orifice is almost invariably found very near the anus, and visible externally, on minute ex- amination, and never more than five or six lines above the junc- tion of the skin with the mucus membrane. He gives the re- sult of eighty observations to confirm this position. It was the opinion from the earliest times, and it still prevails to a considerable extent, that these sinuses usually penetrate the bowel high up. I will not enter into this controversy in the present work, but merely give the result of my own experience. In one hundred and sixty cases of complete fistula in ano, which I treated; I found that in fifty-nine cases, the inter- nal orifice entered above the upper margin of the internal sphincter muscle ; in thirty-four cases, it entered between the sphincters, and in the balance, sixty-seven, I found it to enter low down, so that it could be seen by everting the edges of the anus. These cases were examined most minutely with espe- cial refference to this point. I will here name some difficulties that are met with in con- ducting examinations of anal fistula, which have often doubt- less led to the most serious mischief. Those who are ignorant of the nature of the disease, and the anatomy of the parts, use a large, thick, stiff, strait probe, to examine an exceedingly tortuous sinus; they of course do not find the internal orifice, and conclude there is none; and should even the sinus be tol- erable strait, by using considerable force on the probe, in a par- allel direction with the bowel, they may be enabled to get it up three or four inches, owing to the elastisity of the tissue on the outer side of the rectum, which makes but little resistance to the passage of the instrument; they imagine that the probe has followed the track of the sinus, and conclude that the in- ternal orifice is still higher up, or that there is none. CAUSES OF FISTULA. 37 This disease is found among all classes in society, and in persons of very different constitutions; in some who are in excellent health, in other respects; and in some, who are re- duced by other diseases. It is generally met with in persons advanced in life, and rarely in childhood. I have treated the disease in seven children, under four years of age. Persons of acute sensibility, who labor under fistula, usually suffer great uneasiness about the part, especially when stooling ; and they are often distressed by a feeling of weakness and imperfection which renders their existance almost intolerable. Others of less sensitive constitution, frequently give themselves no con- cern about their disease, and are able for a long time to bear up under its undermining influence. I have treated some five or six cases, in whom the disease had existed from fifteen to thirty years. As this disease is preceded by anal abscess, it may originate from all those causes, whether local or constitutional, which produce that disease. They will be enumerated under their appropriate head, in the chapter on anal abscess ; yet it may not be improper to give some of the causes here. Perhaps the most frequent cause of fistula, is piles. Owing to the con- tinued irritation which they produce suppuration finally takes place at the base of some old pile tumor, which results in fis- tula, and in this way hundreds of cases are caused. Obstinate constipation, and the abuse of purgative medicine, the great sine qua non in relieving this condition, are both fruitful sour- ces of the remote cause of this disease. The concussions oc- casioned by efforts in leapiug, riding, &c, acting as they do, upon the whole amount of blood in the portal system which is unsupported by venous valves, produce injuries of the blood vessels, and are therefore an important remote cause of this disease. I am now treating a gentleman of Natchez, Miss., for a fistula in ano, who sustained an injury by the leap- ing of his horse over a bayou. The result was an abscess, and finally a fistula. Contusions from horse-back riding; hence this disease is common among troopers, and those who are much 38 CONTINUED. on horseback, such as medical men who reside in countiy situ- ations &c. Leech bites are a frequent cause; they are very liable, especially, if the general health is not good, to termin- ate in suppuration, and finally in fistula. Four or five marked cases of this kind have come under my own observation. Fistula sometimes follows the operation of lithotomy. Excres- ences about the anus, excoriations, stricture of the rectum, ul- ceration of the rectum, external violence; these are all causes of this disease, injuries inflicted by the Introduction of the enema syringe, bougies, speculum &c. The records of surgery afford numerous cases of this disease being caused by the pres- ence of sharp pointed foreign bodies, which are swallowed in food, such as pins, needles, fish bones, chicken bones, splinters of wood, and little speculae of bone, generally swallowed in broth made of fowl. These substances are detained in the rec- tum, or they make their way through its coats, and lodge in the cellular membrane, exterior to it, thus causing the most serious mischief by producing abscess and fistula. I have met with numerous cases of this kind. I am now treating a gen- tleman from New Orleans, who has an abscess at the side of the anus, extending up into the perineum, from which I ex- tracted a splinter of wood, half an inch long. He had previ- ously submitted to two extensive operations with the knife by an eminent surgeon, without affording any relief. On one oc- casion, I extracted a sharp pointed piece of the breast bone of a chicken, one inch long, from a fistulous abscess at the side of the anus. The gentleman Mr. H., of Owen County Ky., had undergone one operation with the knife previously, without being benefitted. On two or three occasions, I have extracted fish bones. Irritation caused by the lodgement of foreign bo- dies and hardened feces in the rectum, are also a cause of this disease—gun-shot wounds are also a cause, In some persons, the early symptoms of this disease are scarcely noticed, and the first thing the patient observes is the escape of matter; in others however, the first symptoms are severe, the patient begins to feel an uneasiness or pain in the CONTINUED. 39 rectum, he cannot sit comfortably, as these symptoms continue to increase, he finds that his stools are voided with great diffi- culty, and that whilst voiding them, he suffers the most excru- ciating pain, and sometimes he is unable to pass his urine. All this time there may not be any external appearance of dis- ease, but by pushing his finger up the bowel he will find some one spot exceedingly painful to the touch, this is the place in which suppuration is going on. If the abscess is not lanced it will sooner or later break of itself while straining at stool, and then the patient will be entirely relieved of all the pain &c, but the discharge of matter will continue. In an external blind fistula, the patient sooner or later finds that an abscess, or as he would call it, "a bile'''' is forming near the anus, and usually to one side of it. In this, suppuration sometimes takes place very rapidly, with heat, redness, pain and swelling of the part; at other times, it takes place slowly, and insidiously, without any sign of inflamation, so that the first thing that attracts attention, is aflat swelling, that results from the pres- ence of fluid. The matter if left to itself, sooner or later, by absorption of the neighboring textures, makes its way to the surface. But as it is situated between the skin of the hip, and the mucus coat of the bowel, it may effect evacuation through either the one, or the other, of these coverings. In conformity, however, to the general law, as to progressive absorption, oc- casioned by the presence of matters foreign to the healthy con- stitution of the body, it most frequently escapes by an aperture through the external integument. But the cavity of the abscess, though it contracts, does not become obliterated, but continues to discharge a matter of a thin, watery consistence, and the patient by this time becomes convinced that it is not a bile. Indeed, it is the worst place in the world to have a bile located!! The matter discharged varies, both in quantity and in quality. It often seems on the point of ceasing, when per- haps another abscess forms, or the same one opens and dis- charges and closes again, or at all events, no actual cessation takes place. Sometimes it has a very offensive smell, especially 40 OBJECTIONS TO MODERN if the patient's general health, in other respects, is not good. It is sometimes of the most acrid character, and excoriates all the skin, and mucus membrane with which it comes in con- tact. In a complete fistula, there is sometimes a discharge of wind, and when the faeces are fluid, portions pass through the preternatural canal. The methods resorted to for the cure of this disease, from the days of Hippocrates to the present, are so numerous and so various that the mere enumeration of them would be a task. I shall not attempt it, but confine myself to the consideration of a few of those to which I most seriously object. They are incission and extirpation, by the knife; cauterization and caustic. These methods were introduced from erroneous opinions, entertained by their inventors, respecting the callosities and induration, consequent on inflammation, by which fistula and abscesses are surrounded. They imagined that these were malignant alterations of structure, which required a complete removal, before a cure could, by any means, be effected. It was this false notion that led Celsus to adopt the method of complete extirpation of the diseased parts. He was the first one who dissected out the whole parieties of the sinus. This method is still, at the present day, pursued by some of the French surgeons. About four years ago, I treated a gentleman of Indiana for a fistula ani, who had previously submitted to this operation by a French surgeon, without being at all benefitted. It was the same error that led Albucasis, Jean de Vigo, Durand Sacchi and Severinus, to apply the red-hot iron to the parts, after they had previously been laid open with the knife; that induced Guy de Chauliac to make his incissions with a red-hot bistoury, introduced on a grooved sound; that caused Leoni- das carefully to remove all the callosities by means of a for- ceps, a knife, and a peculiar speculum ; that led Dionis to scar- rify the indurations after previously having laid open the whole route of the sinus; which last method is still followed by some French surgeons. It is the same error that induces some surgeons of the present day to use the actual cautery in MODES OF CURE. 41 burning out the disease. The cauterization is adopted by means of an iron, corresponding in diameter to that of the sinus, and the temperature of which is scarcely elevated to that of red heat. This iron is pushed up the sinus, and in this way it is intended to burn out the disease. It is on the same prin- ciple that the various caustics are recommended, especially the caustic potash, or lapis infernalis as used by Dr. Beach, of New York, and his followers, for the cure of this disease. The most popular method, however, and that which is now most universally adopted, is that by incission. The mode of operating for complete fistula, according to Dr. Bushe, is as follows: " After the patient is placed in the usual position, for operating on this region, the surgeon should intro- duce his right or left fore-finger into the anus, according to the side affected; then with a probe-pointed bistoury, he ought to traverse the sinus, and having placed the finger in ano, on the extremity of the bistoury, he should cut his way out, either by steadily depressing both hands, or else, by projecting the knife through the anus, and pushing it downwards, and to the opposite side. If the operator be inexperienced, he may first pass a director, and on it, the bistoury. When the fistula does not open externally, the surgeon, says Dr. B., may follow one of two methods in the performance of the operation. " In the first, the orifice being discovered by the finger in ano, the ope- rator should carry the knife along his finger, dividing the sphincters, &c. In the second, having hooked a strong probe, and passed it into the fistula, he should press it down, until it appears by the side of the anus, and then cut on the extremity, so as to convert the incomplete into a complete fistula; after which he ought to finish the operation with a probe-pointed bistoury, as above described." It is a question whether this re- fined operation succeeds any better really in curing this disease, than any of the old methods. Whether with all the improve- ments of the day, with regard to superior instruments and modes of operating, a better knowledge of the anatomy and structure of the parts, the pathology, &c, whether, with all these ad- 42 A CUT NOT A CURE. vantages, it really succeeds in curing the disease more certainly than formerly. But whether it does or does not, it is greatly to be prefered, to some of the methods which I have named. I care not, however, to what perfection the operation may be carried; it cannot succeed in the majority of cases. The very principle is a bad one, and should therefore be abandoned. My objections to the method by incission are the following: It is very ineffectual, very uncertain, even when performed under the most favorable circumstances. It has frequently to be repeated as often as two, three, four and five times, and even then failing. I am well acquainted with a .highly respectable gentleman of this city, a commission merchant, who submitted to twenty-two incissions for this disease, before he was cured. Indeed, I have the most positive testimony, which I will cheer- fully give whenever called on, to prove that this operation in hundreds of instances, has utterly failed, even when performed by the most eminent surgeons in our country. This is posi- tive proof, that the principle is not a good one. The follow- ing language of an eminent medical writer, may with propriety be applied to this operation. " The healing of the cut, and the dismissal of the patient, are not always synonymous with ultimate recovery. Too many patients are said to have been cured by operations, which have ultimately failed. Those bloody beacons, like the false lights of wreckers, have blazed but to betray; and the surgeon and the patient have often been lured on, by their lying lustre, to perform and to submit, to barbarous repetitions of equally unsuccessful butchery." I have therefore, no hesitation in stating explicitly and boldly, that it is essentially an objectionable operation; that it is both irrational and ineffectual. The operation by incission, is attended with iminent danger from haemorrhage. "Among the untoward consequences," says Dr. Colles, " that may result from the operation, is that of haemorrhage, and you may not be immediately aware of its occurrence, because of the blood not coming out through the wound; although there should be little or no bleeding exter- KNIFE OPERATIONS FATAL. 43 nally, there may be internal bleeding. What are the symp- toms that indicate this internal bleeding? The patient com- plains of uneasiness about his rectum—he gets weak—he feels an inclination to make water, and tries to make it, but cannot —he strains a good deal, but not a drop will come; he has great desire to go to stool, which at length becomes so urgent, that he cannot resist it, and then he passes a large quantity of blood by the rectum, and perhaps falls off the night chair in a faint. Haemorrhage is one of the occurrences from this opera- tion that should deter the surgeon from carrying his incission too high up; as, if it extends above the upper margin of the deep sphincter of the rectum, there will be the dilated pouch of the gut, ready to receive a large quantity of blood, with diminished hopes of making an effectual compression on the bleeding part." I cured a gentleman of Pittsburg, Pa., a few years ago, of an extensive fistula ani, who was near losing his life from haemorrhage caused by such an operation. The bene- fits confered on him from the operation, were, that it destroyed the power of the sphincter muscle, and nearly destroyed his life, without curing his fistula. In some cases, the operation, in a short time, proves fatal; particularly in diseases of the chest, from the effects of haemorrhage, even if slight. Ner- vous exhaustion, from loss of blood, may be a cause of death after this operation. The operation is extremely dangerous, from inflammation. It not unfrequently proves fatal from erysipelatous inflamma- tion, which is so liable to extend itself along the mucus mem- branes. I once saw a case where this kind of inflammation spread rapidly up the rectum, in consequence of an operation on its lower extremity'. It terminated fatally, as such cases usually do, when attacked by-this kind of inflammation. This operation sometimes causes inflammation of the cellular tissue immediately exterior to the peritoneum, and causes death. Owing to the peculiar anatomical structure of the parts, in females, the operation is always hazardous; especially if car- ried up into the rectum, in consequence of the peritoneum 44 DANGER OF THE being so differently arranged. When the sinus is anterior to the rectum, because of the proximity of the vagina, the opera- tion may give rise to recto-vaginal fistulce, a most aggravated case of which I cured a few years since, in a lady in this State. This operation is objectionable on account of the pain. Indeed it is one among the most painful operations in surgery, owing to the large amount of nerves distributed to this region. And often, after the division of the sphincter muscles, the patient is ever after unable to retain his stools, and they pass off invol- untarily, if they are fluid. This is a most miserable condition to be left in, even if cured of the original disease. Nineteen cases of this description have come under my observation: and in but five, was the original disease cured. In order to give the reader some further information with regard to the beauties of this refined species of cruelty, I will quote a few remarks from one of Dr. Colle's lectures, who was an uncom- promising advocate for the knife in this disease. " Now, sup- posing a fistula had no opening into the rectum, that it was what is called a blind external fistula, you will often find con- siderable difficulty in pushing the bistoury from the fistulous canal through into the rectum, and particularly if there was much distance or thickness of parts between them ; from push- ing it in an awkward manner, I have more than once seen the knife break, and half its blade left in the wound. The manner in which you are to proceed is to scrape your way through, by repeated touches of the knife, until you come to the gut, when you can easily push it through its coats. Now, when you have gotten the point of the knife, into the gut, you are, of course, to cut it out, and this is a part of the operation that many surgeons bungle at;—I have seen a surgeon use so much force, in pulling the knife through, that, when, by some acci- dental turn of his hand, the knife suddenly cut its way out, he ivas near falling on his back ; the way you are to cut through the parts is by a sawing motion, &c. " There is another very different appearance of the external opening of a fistula from what I have described—instead of the little fungus projecting KNIFE OPERATION. 45 from the opening, and the opening itself small and hard, round its edges, you will sometimes find the opening a mere slit in the skin, the edges of which are flabby, and sometimes over- hanging—the slit is sometimes the length of the eye of the probe;—if you operate on this patient, this will happen—that although your incission was but just of the proper extent when made, yet (and it is a curious fact) in a few days it will be like a chimney, so large that you can see up it,—there will be a profuse discharge from it, and dreadful pain. I remember a man coming to the hospital one morning, in this state, and one of the pupils, who just saw him, asked him if he was cut for fistula with a spade!! In such a case, the patient cannot live three weeks after the operation." Indeed it is not easy to pronounce on the amount of danger which may follow operations on the lower bowel. I have seen one, and read of several cases proving fatal from mere manuel examination; from the introduction of bougies, of the dilator, speculum, &c. Inflammation is liable from these causes, in some particular cases, to be produced, and extend to the loose cellular tissue, immediately external to the mus- cular tissue; from this, it may extend to the cellular tissue external to the peritoneum, and thus terminate in the destruc- tion of the patient. There is no necessity whatever for subjecting individuals to an operation, painful and hazardous in the extreme, frequently without any good result, but often much injury. I know from extensive experience, that it holds out, scarcely any chance of permanent benefit. What individual, then, in his sober senses, will consent to have his rectum or anus, or both, split open— to be confined, as in some cases, to his bed for weeks,—to be compelled to wash out the cut, after each stool,—to be sub- jected to repeated operations of the same kind,—and finally, liable to be rendered miserable for life, when he might be cured perfectly, by a safe, mild and scientific method? Such is a list, a very formidable one even on paper, and a thousand times more so in practice, of the inefficiency and 46 FISTULA AND PHTHISIS. dangerous consequences which attend this operation. A milder, safer and more certain substitute, candor must admit, would be a boon to humanity. Spontaneous cures of fistula in ano, are of rare occurrence; yet some do recover without the aid of surgical measures. Cases of this kind have been noticed by different writers, Pott, Ribes, Velpeau and Beach, among the number. I have seen but three cases. Such cases prove most positively, that this disease might be cured by much milder and safer means, than those I have been considering. Some of the most enlightened surgeons of the present day, think the idea of euring a fistula in ano, without the division of the sphincter muscles, is both chimerical and preposterous. What will they do with those cases of spontaneous cures? It will not do to call them excep- tions to the general rule. This is a subject well worthy of their consideration, and we recommend it to them. I have found that this disease, like many others, should not be treated upon any one exclusive plan. There is such a great variety of differences in different cases, and in the general condition of the patient, that it sins against our general experience of dis- ease, if those differences are to be made of little account, and one kind of treatment, be it what it may, indiscriminately followed up. Sometimes fistula in ano is complicated with some other disease, such as phthisis; and is an effect of it. In all such cases, it must be remembered, that the primary disease must be cured, before its consequent can be. But this subject will be fully investigated under an appropriate head, in a seperate chapter. The reader's attention will now be called to a few brief extracts from letters. These were written by those who la- bored under this disease; and the object of publishing them, is to familiarize persons with the nature, causes, symptoms ami consequences of this formidable malady, and acquaint them with the results of the popular treatment of it; so that they may avoid, as much as possible, both. Those persons speak a A LADY--INTERESTING LETTER. 17 language which cannot be mistaken. They were not deceived themselves, neither can they deceive others; as this is, by no means, an imaginary disease. By diffusing this kind of infor- mation, it is not the intention to excite the groundless fears of any, but to call their attention to the early symptoms, so that they may secure the best surgical aid that may be near them, at an early stage of the disease. It will also go very far towards exposing the many empirics who are "going about, seeking whom they may devour!" LETTER A. [The following letter was written by Mrs.----, who had a fistula ani, caused by leech bites, which her family physician had applied to haemorrhoids. I subsequently cured her of her fistula, and she remains well to this present time.] M------, Ky., December 30, 1S42. Dr. Bodeniiamer—Sir: I take the liberty of addressing you a few lines, on the subject of my ill health. Since my father saw you, I have been mending slowly, and am now able to go about the house. Since I have got better of the piles, I have noticed an abscess formed inside of the bowel, which discharges a large quantity of matter daily. On the outside, there is a substance about the size of a pea; it feels hard like a grissle, and by pressing on it, it causes the discharge of matter from the inside. Sometimes, I thought that matter came out of this lump externally. The lump is situated at the back part of the anus, and immediately under the back bone. It was at this spot that one or two of the leech bites never got well, and I am convinced that they caused this sore lump, and the abscess under it. When I stool, and immediately after, I suffer very severe pain. I am also troubled with a most distressing burn- ing and itching of the parts, especially at night. I expect to visit vou in eight or ten days. Please write me immediately, and inform me how long you think I will.have to remain under your treatment. Respectfully, &c. 48 RECOMMENDATION OF CLERGYMEN. LETTER B. C------, Ohio, January 17, 1842. Dear Doctor—Through the recommendations of the Rev. Mr. C----, of the Reform Church, and the Rev. Mr. P----, of the Presbyterian Church, I have been induced to address you. The object of my communication is to inform you that I have, what my physicians call fistula in ano. I have had this disease about five months, and within this time, I have had two operations performed on me with the knife by Drs. L----and M----, It is unnecessary for me to describe my case, for I intend, as soon as I receive y'our answer to this let- ter, to visit you forthwith, determined never again to submit to another operation. The Doctors proposed to operate again, stating that they "think they did not cut up the bowel high enough, and that the next cut will cure me, &c. But each cut, so far, has rendered me worse, and I sincerely regret not having heard of you before submitting to those horrid opera- tions. [This gentleman was subsequently cured by me, and had still remained so when I saw him in this city about one year ago.] LETTER C. C------, 111., April 16, 1842. I was first afflicted with fistula, about fifteen months ago, after a long period of suffering from chills and fevers, peculiar to this climate. It remained in an inflammatory state, with- out any formations of matter, for about three months. Our physicians appear to have known little or nothing about it, merely recommending ointments, &c. It was very painful while sitting. In the summer of 1841, copious discharges commenced from a small orifice on the left side of the anus, and within a short distance of it. The discharge was of a bright yellow color, and at times very offensive indeed. I washed it daily with casteel soap and cold water. During KNIFE OPERATIONS UNSUCCESSFUL. 49 this time, I was severely troubled with flatulency; irregular shiverings, followed by great heat and night sweats. Its pro- gress since has been painful, troublesome, and with aggravated symptoms; the most disagreeable of which are a painful tenes- mus or bearing down, occasional strong pulsations in the ab- scess, and offensive discharges; leaving the neighboring parts much heated and irritated. It is probably a blind external fistula, as I have no sufficient evidence of an internal opening. I have been thus far particular in describing my case, so that you might form some estimate of it before I came on to see you. [I never heard any thing further from this gentleman. He was clerk of the court of------.] LETTER D. L------G------, Ohio, October 2, 1842. Dear Doctor—In communicating with you, I need not make any apology. The object of my letter is to inform you, that about one year ago, a very painful swelling commenced on the left side of the anus; and while suppuration was going on in it, I suffered the most severe pain, attended with fever. In five days it pointed, and the matter was let out with the lancet. It continued to discharge, and in January, 1840,1 had the usual operation performed with the knife, about two months after its appearance. The operation was, I think, ju- diciously performed, but it has not resulted in a cure. I con- fined myself to my room all winter, and thought the cavity was filling up well, but my hopes were blasted. It is now as bad as ever. [This gentleman is a physician, and was cured by me in 1844.] LETTER E. V------, La., July 27, 1841. Dr. Bodenhamer:— Dear Sir—A friend the other day directed me to you, for advice in a case of fistula. At the present writing, it has been six weeks since the disease made its appearance on the left side 4 50 PHILADELPHIA SURGEON. of the anus, in three places. For the last four weeks, I have had the advice of two able physicians; they have operated with the knife; but two of the cuts, seem incurable ; it appears impossible to heal them. [In a subsequent letter, dated Sep- tember 1st, 1841, he writes:] Dear Doctor—Your polite note, dated August 10th, came duly to hand last Saturday. Please accept my thanks for your prompt reply. Relative to my case, at present, I scarcely know what to think, I am not well, and still under the advice of Drs. J----and P----, both skilful surgeons and practition- ers. My situation is truly deplorable, the wounds are not healed up, and but little hopes of their doing so for weeks to come, and perhaps never. At this time, I cannot leave my business. It would be fatal to do so. Sometime in October or November, I will visit you, and put myself under your care. [I regret exceedingly to say, that this gentleman, sometime after writing the above, and before visiting me, met with a serious accident, by which he lost his life.] LETTER F. H----, Ala., Jan. 6, 1841. Dear Sir—My attention was called, a few days since, by a friend, to your card on fistula, &c. For more than four years, I have been afflicted with fistula in ano. It formed without my knowledge, and first attracted my attention in consequence of its continued itching. Apprehending that it would ulti- mately impair my general health, I determined to undergo an operation with the knife. I went to Philadelphia, and placed myself in the hands of Dr.----, an eminent surgeon. Upon examination, the fistula was found, after having passed up the rectum spirally, about two inches, to have entered the bowel. I was operated on in the usual way, but not successfully. I have recently discovered a new sinus, immediately opposite the old one. My surgeon says that my fistula was caused by the piles. But I was never conscious that I had piles; for if I had, they never gave me a moment's pain. There is a con- A PAIL U RE. 51 stant discharge of matter from the sore, and I suffer very much pain, since the operation; before I suffered none. My age is thirty-three, and my general health good. [This gentleman was a merchant. I never heard any thing more from him.] LETTER G. C---, Mo., December 7, 1842. Dr. Bodenhamer:— Dear Sir—I heard sometime since, that you had cured Mr. Noah Spears of a fistula; he is personally known to me. This has induced me to address you on my own account. I have also the same disease. Several years ago, I noticed that some- thing was wrong, from an intolerable itching, occasionally, about an inch from the anus, to one side. Some two years ago, I discovered that a small opening had formed, out of which a small quantity of acrid matter was continually dis- charged. This has lately increased very much, and causes great pain. In other respects, my health is tolerably good. If nothing interferes, I shall visit you as soon as the river opens, which I fear will not be before spring. [In a few weeks after writing the above, this gentleman came here, and I cured him in four weeks, and he was still well last winter, now nearly four years.] LETTER H. M---, Ala., March 17, 1841. Dr. Bodenhamer:— Sir—Having heard, through a valued friend in Kentucky, that you are very successful in treating diseases of the rectum and anus, I have taken the liberty of addressing you on the subject, being afflicted with that horrible disease called fistula. I have suffered dreadfully for about ten years with this malady, and have had recourse to various remedies, without receiving any benefit. Several physicians to whom I applied, have advised me to have recourse to the knife ; but the pain, danger, and uncertainty attending this operation, have hitherto deterred me from it. It has now become very extensive; three sinuses 52 a case and cure. having now formed, which extend considerably into the bowel. My age is fifty-five, and my general health not good. My situation is such, that it would be attended with great pain aad inconvenience to me, if I have to go the distance from here, to where you reside. [I never heard any thing further from this gentleman. He was a clergyman.] LETTER I. F----, Va., Aug. 16, 1841. Dear Doctor—I have just heard that you are remarkably successful in treating various diseases of the lower bowels. I have been laboring under one of those diseases, called fistula, since March, 1840, at which time there came a sore, about one inch from the anus, which gave me a great deal of pain until it broke out and run freely. As it continued to discharge and not heal up, I became alarmed, and called on a physician, who examined it, and found that the sinus run straight up into the intestine. He got his probe up about two inches. I had frequently before, felt the wind come out of the external sore. The doctor tells me I cannot be cured unless this canal is laid open with the knife. I understand that you do not use the knife or any dangerous or painful remedy. I am a farmer, my age is forty-four, and my general health tolerably good. I wish you to write to me as soon as you receive this, and say what time would be most favorable for me to visit you; how long I will have to remain, and as near as you can, what my boarding in your place will cost, and what your bill will be, &c. I forgot to name that this place breaks and heals up once almost every week. [I cured this gentleman about two months after the date of his letter, and two years after he still remained well.] LETTER J. F---, Ky., June 30, 1840. Dr. Bodenhamer:— Dear Sir—Permit me, though a stranger, to inform you that I am afflicted with that tormenting disease fistula in ano. FISTULA AND CONSUMPTION. 53 I think it was occasioned by riding a hard-going horse. About eighteen months ago, a hard lump made its appearance at the side of the anus, like a bile, which was finally lanced by a physician, and which continued afterwards to discharge a thin acrid matter. My general health is far from being good, and I am constantly suffering pain in the part, as well as in my back and hips. I have heard of your skill in the treatment of such diseases, and intend to call and see you. I am fearful of the knife. [The writer of the above is a clergyman of the Methodist Episcopal Church. He subsequently called on me, and upon examination, I found a complete fistula in ano, complicated as I thought with phthisis. I advised him to defer having his fistula treated, until his general health improved, thinking I would never see him again. I heard nothing further from him, until a few months since, to my great surprise, I saw him in this city, entirely restored to health. He informed me that soon after leaving me, his fistula, as well as his disease of the chest, commenced improving, until he got well of both, with- out either medical or surgical treatment.] LETTER K. M----, Ky., Jan. 12, 1S38. Dr. Bodenhamer:— Dear Sir—Though a stranger to you, I take the liberty of writing you on a subject of much importance to me. I was attacked more than a year ago with a disease called fistula. I was a perfect stranger to such a disease, never having heard of it, until I enquired of physicians. A tumor formed and broke, about an inch from the anus, which I thought was nothing but a bile, and had it not continued to discharge mat- ter, I would have still thought it a bile. I at times suffered a great deal of pain. All the surrounding parts are hard and callous, and I can feel something like a cord under the skin, running towards the bowel. I have taken a great deal of medicine and am very much reduced. For the last two or three years, I never have a stool without taking some kind of ' 54 I N TERESTING. pills. I suffer much pain in my back and hips, and great derangement of the urinary organs. My eyes are also con- stantly sore; and I have thought it was caused by this disease. [The writer of the above, is a farmer. I cured him about two months after the date of his letter, and he remains well to this present time.] LETTER L. S----, Ky., May 5, 1841. Dear Sir—I have lately seen your card, in which you pro- pose to treat all diseases of the rectum and anus. I have a disease which my physician tells me is fistula. About two years ago, a rising came on, situated between the lower end of the back bone and the anus. When it was lanced about eighteen months ago, it commenced to pain me more than ever, and continues to discharge freely ever since. I am now sixty-nine years of age, and if I was cured of this horrid dis- ease, and could get my bowels regulated, I could still enjoy excellent health. I have taken bushels of pills within the last three or four years, to keep my bowels regulated; but they seem only to relieve for the present. [This old gentleman was cured by me some short time after writing the above. 1 saw him in 1843, he was then well, and had no occasion to resort to his pills.] LETTER M. C---, Ky., Nov. 17, 1839. Dear Sir—At the request of Mrs. T----, of this county, I write you. She has a fistula in ano, which has now nearly spread all around the anus. She has been cut three times for this disease, all to none, but the very worst of purposes. The last operation was performed by Professor M----, of C----. The cut was extended far up into the rectum. This last ope- ration was performed last April, and the gash still remains unhealed, and a new place is forming on the right side of the rectum, where there is a hardness and a constant large dis- charge. [I never heard further from this case. Death I sup- pose, relieved the patient.] LETTERS. 55 LETTER N. B----C----H----, Va., Aug. 27, 1841. Dear Sir—I see from your card, that you have met with great success in curing fistula in ano, without having recourse to the knife. 1 have had that disease about eight years, and have tried many remedies for the cure of it, without success. The knife I am determined never to submit to. [The above was written by a highly respectable physician. I have never heard from him since.] LETTER O. M----N----, Tenn., Sep. 14, 1840. Dear Sir—I have been plagued with a fistula for the last twelve months. A small lump came near my lower bowel, which troubled me much by itching, and occasionally a dart- ing pain through it. I counselled a physician, who told me to leach it freely, which I did. It was also blistered, but all to no purpose. It finally broke, and it now issues a thin watery matter. The mouth of the opening shuts every now and then, and breaks out again and runs. While it runs freely, I do not suffer any pain, but as soon as the opening closes, it begins to pain me, until I either open it myself, or it breaks. When it pains me much, and wants opening, I fre- quently ride on horseback, which soon breaks it, and gives me relief. The matter often galls me very much, especially in warm weather. The opening is about an inch and a half from the anus, and there is a grisly substance running from the opening, up to the anus. I frequently find that the wind comes out of the opening, and when my discharges are thin, some little comes down from the bowel, and out of the open- inf. [This gentleman I subsequently cured.] LETTER P. R----, N. C, Sep. 1, 1S40. Dear Sir—I have been kindly informed by a friend, of your o-reat skill in the treatment of fistula and other di- eases. I 56 DOCTOR BEACH. have been annoyed for several years with a fistula in ano. It has nothing peculiar in its character, it is a simple fistula, sometimes discharging freely, and at other times less so. I have consulted various physicians, and tried many remedies, all to no purpose. The last physician whom I tried, was from New York. He told me he could cure me without the knife, which I was truly glad to hear, for I greatly dreaded the knife. He showed me Dr. Beach's work, in which he recommends the vegetable caustic; it appears that Dr. Beach has cured many- cases. This doctor commenced my case by Beach's plan, and continued it for six months; at the end of which time, I was rather worse than better; and the treatment was almost im- possible to bear. After he found that he could not cure me, he advised me to go to Dr. Beach; but I believe that I would rather be operated on with the knife, than to submit again to have it burned out with caustic. The object of my writing you; is to know whether your treatment is similar to Dr. Beach's, in this disease, as this same doctor who attended me, when I told him what I had heard of )'ou, remarked that your method must be Beach's, he knew; but the gentleman who informed me of you, said he thought it was not. I am fearful that the distance between us, is too great, for me to visit you, if I conclude to employ you in my case, and if it is necessary for me to be with you. [I never heard any more from this gentleman. With regard to my method of treating diseases of the rectum and anus, being Dr. Beach's; there is nothing more foreign from the truth. This falsehood has been again and again repeated, especially at a great distance, where my treatment is not known. I neither cut nor burn out these dis- eases, but am opposed to both,] LETTER Q. M----, O----, July 20, 1S44. Dr. Bodenhamer: Dear Sir—I lately saw a merchant from your city, who told me that you could cure fistula without the knife, and THE WATER DOCTOR. 57 named many persons whom you have cured, some of them were well known to me. I have had that disease for the last two years. About two months before it broke out, I felt a dull heavy pain in the bowel, extending to the small of the back, and whenever I went to stool, I suffered severely. My urine was high colored, and I could never pass it, only when I was sitting down, while at stooling. It completely disqualified me from business. I had two of the best doctors in this place, but they did me no good. I imagined that it must originate from my urinary organs, and concluded to visit a celebrated water-doctor, (not a cold-water doctor,) who resides at------, and to whom persons from all quarters go, to be treated for all diseases. He appears to give pretty much the same medi- cine for all cases; yet he is truly celebrated for making many cures. I applied to him, and at once he told me that my dis- ease was in my kidneys, and that he could soon cure me. I remained under his treatment about three weeks, and gradually grew worse, and at length got so bad, that I could not return home. I finally dismissed my water-doctor, and called in ano- ther physician, who gave me a large dose of pills, which ope- rated very severely, and while straining at stool, an abscess near the lower end of my bowel, broke, and about one pint of corruption came out at once. In eight days from this time, I was entirely relieved from all my pains and suffering, and ena- bled to go home. But this place has continued to discharge matter ever since, and has terminated in what I told you, fis- tula.* [This gentleman was cured by me six months after the date of his letter.] • In reading my friend's description of his water-doctor, the temptation was so great to quote Butler's description of Sidrophel, that I could not resist it. Butler writes— " To whom all people, far and near, On deep importances repair; When geese and pullen are seduc'd, And sows of sucking pigs are chows'd ; When murrain reigns in hogs or sheep, And chickens languish of the pip; 5S FISTl'LOl'S ABSCKSSKS CHAPTER VI. ABSCESS NEAR THE RECTUM AND ANUS. In the preceding chapter, much has been anticipated in rela- tion to this kind of abscess. I have there shown that it pre- cedes fistula, and that the latter is a consequent, of the former. The reason that this chapter does not precede that on fistula, as it naturally should do, is in consequence of my not treating as many cases of simple abscess, as I do of fistula. Patients do not, at this stage of the disease, invoke surgical aid, as they by all means should do, but defer it until the abscess becomes fistulous. Hence, in the arrangement of this work, I have placed it wrhere it is. The vicinity of the rectum and anus is very subject to vari- ous kinds of purulent collections, in consequence of the abun- dance of free cellular tissue by which it is invested. This tis- sue, it is well known, is very liable to suppuration, especially in this region, where the slightest inflammations, sometimes result in it. This is not surprising, when we take into consi- deration its dependent situation, its exposure to compression, to contusion, to accumulations of blood, and to numerous other causes. These abscesses are of various kinds, and may be either inde- pendent of disease of the rectum and anus, or be produced by a morbid condition of these organs. I will not, in this work, adopt the division of them into numerous kinds, as some authors do, but simply include all under a few simple heads. The commencement of an acute phlegmonous abscess of the rectum or anus, may be known to the patient, by increased When butter does refuse to come, And love proves cross and humorsome; To him with questions and with urine, They for discovery flock, or curing." OF VARIOUS KINDS. 59 heat and pain of the parts, followed by a swelling, and by a throb- bing sensation, which renders him indisposed to motion, or com- pells him to remain at rest, by rendering every movement of the parts, as well as the lower extremities, distressing. On exami- nation, if the abscess is about to point externally, an enlarge- ment, or tumefaction, a circumscribed hardness, can be seen and felt. There is great intolerance of pressure and some- times a blush, more or less livid, of inflammatory redness of the parts. Sometimes there is a constant desire to urinate, and a difficulty in voiding it. In a few days, matter forms, and is discharged externally by one or more openings. After which, the pain and inflammation cease. When the abscess points internally, the anal canal becomes diminished in size by the swelling, which imposes a mechanical impediment to the passage of the foeces, and renders defecation excessively pain- ful. Constipation of the bowels, and a great dread of stooling, usually attend such cases. The irritation extends to the blad- der and urethra, and the discharge of urine is attended with difficulty—sometimes impossible. If the finger be introduced into the anus, a round tumor is detected at a greater or less distance from the orifice, encroaching upon the canal; it is often as large as a nutmeg, or larger; well defined, hard, or exhibiting signs of fluctuation, according to the stage of the complaint; and almost always confined to one side of the bowel. In a short time, the tumor breaks into the bowel, and finally causes an internal blind fistula. These kind of abscesses are usually rapid in their progress. Fatigue, deterioration oi health, and insufficient nourishment, dispose to this form of them, and in some instances, seem sufficient for their produc- tion; while contusions, sitting on wet seats, and riding on horseback, may also be causes of them. The chronic abscesses of these parts are usually attended with irritative fever. They are generally large, deep seated, and accompanied with a sense of weight, accasional throbbing, and spasm of the sphincter muscle. The swelling, though not very great externally, is however, very perceptible to the fin- 60 GANGRENOUS--CRITICAL--SYMPTOMATIC ger, if introduced into the bowel. The urinary organs sympa- thize, but not to the same extent, as in the acute form just described. These abscesses are slow to burst; they usually open externally, but sometimes they open into the rectum. They sometimes come on almost imperceptibly, the cellular tissue and the skin being much less extensively diseased, and not attended with fever and local suffering. The gangrenous species of abscess, differ very much from the last described; they are usually more extensive. They appear to be various in their mode of attack, and in the rapidity of their progress. The patient first complains of deep seated pain, by the side of the anus, where a hard point may be easily detected, which soon spreads; then the pain assumes a burning character, there is considerable tenesmus, and great difficulty in discharging urine. All these symptoms are much more severe than in any of the other forms of abscess. The swelling becomes diffused, the tension increases, though not to a very considerable extent, and the skin turns livid. Finally, partial openings arise from the mortification of the integuments, and the pus, with portions of cellular tissue are discharged very slowly. I once saw a case where there was complete slough- ing of the parts all round, leaving the anus and the lower por- tion of the rectum quite bare. This form of abscess occurs in bad constitutions, especially in such as have lived free and luxuriously, and are advanced in life. The critical abscesses of this region, occur after fevers, and repelled eruptions. They usually resemble the other forms of abscess. They sometimes occur in children after eruptive dis- eases, one or two cases of which I have met in my practice. In those cases they had become fistulous. The symptomatic abscesses are those which arise in other organs, and extend downwards by the side of the anus; and those which arise from sympathy with the lungs. The first include spinal, urinary and uterine abscesses. The second occur in those who labor under consumption, of which I will speak in the next chapter. In diseases of the spine, uterus, or uri- STERCORACIOUS--TRAUMATIC ABSCESSES. 61 nary organs, or in the soft parts of their immediate vicinity, the collections of matter may work their way downward, until they appear at the side of the anus, without producing any pain, inflammation, or hardness of the surrounding parts. I have treated a number of such kind of abscesses, some despe- rate and of long standing. About five years ago, I cured Mr. Boone Montgomery, of Decatur, Ohio, of a spinal abscess of long standing. His spine was injured by a fall from a horse. He had submitted to various treatment without benefit. About the same time, I cured a gentleman in Clark county, Ky., of a spinal abscess, for which he had previously submitted to three operations with the knife. His letter will be given at the conclusion of this chapter. And about eighteen months ago, I cured the Rev. Mr. Elliott, a catholic clergyman of Fairfield, Ky., of a spinal abscess of fifteen years standing. He had previously been once operated on with the knife. His spine was injured by being thrown from a carriage. Stercoracious abscesses, are such as have either a primary or secondary communication with the intestinal canal, into which, portions of faecal matter enter. Not long since, I opened an abscess at the side of the anus, partaking somewhat of this character. It had no direct communication with the intestine, yet the matter discharged, was of a brownish color, and had the peculiar odor of faeces. This can only be explained, upon the principle, that all collections of fluids in the vicinity of the rectum, will imbibe the odor, as well as the color, of the faecal matter, by transpiration, which is now well known to take place, through all animal membranes. M. Velpeau lays par- ticular stress on this fact. The patient was a lady in very delicate health. Traumatic abscesses, are induced by the passage of balls, punctures; the irritation produced by the presence of a foreign body; incissions in lithotomy, &c. M. Ribes relates the case of a lieutenant, "who received a musket ball in the centre of the right buttock, which fractured the tuber ischii, and passed into the rectum, as proved by the 62 LE DRAN--PETIT. immediate flow of blood from the anus, and the exit of the ball on the sixteenth day, by the same outlet. The external wound suppurated freely, and in six weeks had healed; but the right side of the perineum inflamed, and seemed, from its bluish ap- pearance, about to become gangrenous, so as to lead Ribes to suspect stercoraceous abscess; however, he punctured it, but could not detect any opening in the rectum, on the contrary, he found that the walls of this bowel were much thickened. In a few days he extricated a fragment of bone, and some pieces of cloth, after which the abscess healed. I once saw," continues Dr. Bushe, "a case not unlike this, in a soldier who was wounded in India; the bone, however, was not injured, but the ball passed into the rectum, and was ejected from the anus. The wound in the intestine healed, while the cutaneous one re- mained fistulous, until I extracted two pieces of cloth from it, several months afterwards." Punctured wounds may produce abscesses in this situation. I have seen but one such case, and it was in a porter, who had sustained the injury in climbing a spiked railing. I have seen but one case, in which a stercora- ceous abscess resulted from the presence of a foreign body, and this was in the person of a boy, eleven years old, who swal- lowed, between three and four months previously, a portion of the thigh bone of a chicken, about half an inch long. He had suffered severely before I was called; but the nature of his com- plaint was not suspected. I laid the parts freely open, and ex- tracted the bone. There are several interesting cases of this kind on record, of which the following are the most remarkable. Le Dran relates a case which occurred to M. Destendau, of a man, who for nine months labored under a fistula, caused by the lodgement of a piece of bone. Petit mentions some cases of this kind. In one, he extracted a needle, which for six months, had given rise to extrordinary pain, during defecation. In a second, he removed a small triangular bone, which for four or five months, had created great suffering. In a third, there was extensive mortification of the parts, surrounding the anus, in consequence of the lodgement of a chicken bone, after STALPART--VANDER VIEL. 63 a years duration. Finally, in a fourth, he opened an abscess, which contained faecal matter and shot. The disease was of ten years standing. Stalpart Vander-Viel relates a case of a man, who swallowed the jaw of a fish, and seven months after- wards, had it extracted from an abscess near the anus. Sher- man mentions a case, in which a fish bone was swallowed, and discharged twelve months afterwards from an abscess by the side of the anus. Harrison describes a case of abscess, which resulted from the retention of an apple core, eight months after it was taken into the stomach. M. de la Peyronie extracted a beef bone, M. Feburier removed a pullet bone, and M. Du- bois, a piece of an earthenware pot, from stercoraceous ab- scesses." (Bushe, On Diseases of the Rectum and Anus, pp. 237-S.) In the preceding chapter, I encroached extensively on mat- ters which might have been discussed here. This, however, seemed necessary, from the fact, that abscesses of this region are nearly always confounded with fistulae—so that nothing more now remains but to call the reader's attention to a few letters, &c. FIRST LETTER. W----, Ky., April 20, 1840. Dear Doctor—About two years ago, I was affected, as I thought, with a bile on the lower end of the spine, which first appeared in the form of a bump, as large as the end of my thumb; and continued some six months, coming and going. At last it broke and run, and continued to discharge for some time; it then healed up, and remained about two months; but one day as I was riding on horseback, it broke again, and run for several months. I applied to Dr.----, who pronounced it a fistulous abscess, and said he could cure it by operating on it with the knife, to which I consented. But the operation did not succeed; so that he was compelled to operate the second time, without any better success. I then applied to Dr.----, who also operated on me, and it appeared to heal 64 YOUNG LADY--INTERESTING CASE. up, but it was only on the outside; as it always pained me about the scar and the surrounding parts, until it broke again. There are now three openings, through which are discharged a thin yellow water, sometimes a bloody water. There is another abscess forming in the same neighborhood; it is like a bile, and has been coming for eight or ten days. The old abscess is about three inches long, and my phy- sicians have told me that it does not enter into my bowel, but up the back bone, which they say is much diseased. It has never been very painful, only when about to rise. It was caused by a fall from a horse. I have never been well since. [This gentleman I subsequently cured, and as far as known to me, he still remains well.] SECOND LETTER. Ky—July 30, 1841. Dear Doctor—My sister has consented to employ you, in- stead of Dr. D----. We will visit you in eight or ten days. She despairs of ever being cured, having, as you know, been twice operated on by the knife, by two able surgeons of Phil- adelphia. The last cut extended along the spine at least four inches, and down to the bone, which was actually scraped, as it was thought the bone was much diseased. I asked her particularly, since I saw you, with regard to the cause; she cannot assign any whatever. [This young lady I cured some five months after the date of the above letter. She soon re- gained her general health, and subsequently married. She was of a scrofulous diathesis.] About five years ago, I cured a negro man belonging to Mr. McDewitt of Shelby county, Ky., of one of the largest abscesses I ever saw. It was caused by caries of the ischi- um, (hip bone.) One sinus extended from the hip down to the knee. This poor fellow had previously been operated on by an eminent physician of this city. Four or five deep and extensive incisions were made, two extending high up into the rectum. LAENNEC--BORDEU--PHTHISIS. 65 CHAPTER VII. COMPLICATION OF ANAL ABSCESS, OR FISTULA ANI, WITH PHTHISIS PULMONALIS. That there is a connexion between pulmonary disease and anal abscess, or fistula ani, is a point as well established, per- haps, as any other in pathology; yet, by many it is denied, or considered extremely difficult to trace, or of a highly mysteri- ous character. The many cases, however,, that have come under my observation, have fully satisfied me, not only of such connexion, but that it may be satisfactorily explained. It is well known that there is a large amount of the cellular mem- brane investing the lower extremity of the rectum ; that this tissue, in this vicinity, has a large number of veins, that these in the last stages of phthisis, can have but little adventitious support, in consequence of the absorption of fat, the emacia- tion of such cases being strongly marked in the adipose cellu- lar membrane and muscles. Tubercular depositions, in the lungs too, must, in a greater or less degree, interfere with the return of the blood from the veins; and the constant impulse communicated to the anal rigion by coughing, must also greatly tend to the production of these abscesses. From these consi- derations, and from the proneness to suppuration in the cellu- lar tissue, we can at once account for the frequent occurrence and concurrence of these diseases, with pulmonary affections. They are associated with phthisis in two different ways; first, as a contemporaneous, but independent accident, and secondly, as a consequence. Laennec has seldom seen phthisis complicated with fistula, and when it does exist, he does not believe that it exerts any influence over it. He says, " It is a common opinion, strength- ened by the adoption of it by Bordeu, that phthisical subjects are particularly liable to fistula in ano, which helps to protract 5 66 A FATAL ERROR. the termination of the disease. I have seldom observed this complication; and where it existed, it has appeared to exert no influence over the progress of the case." (Laennec, On Diseases of the Chest, p. 294.) Andral has come to the same conclusion; he says that he has met with only one instance of fistula in ano, in about eight hundred cases of phthisis. This is remarkably strange. I meet with one case of this compli- cation in about every twelve cases of abscess, or fistula ani, which I treat. A very popular opinion prevails, both in and out of the pro- fession, that it is improper to attempt the cure of abscess or fistula, in persons laboring under phthisis, or in those in whom there exists a strong disposition to it; believing that such a disease acts beneficially on the lungs, operating as a sort of derivative remedy, &c. This, to a great extent, is a fatal error, and has proved so in numerous instances. As a general rule, these diseases tend greatly to aggravate the pulmonary affection, by impairing, as they always do, the constitutional powers; therefore, the sooner they are cured the better. I readily admit, that to attempt to cure them with the knife, would be highly improper, and would hasten the patient to the grave; and it was doubtless in reference to this operation alone, that this opinion was first founded, and not to proper and judi- cious treatment. It is true, that in all cases where anal abscesses appear in the very last stage of phthisis, when all hope of the patient's recovery is gone, it would be improper as well as useless, to attempt their cure, if it ever could be done. I have seen such cases apparently benefited on the first appearance of an anal abscess; they were unexpectedly, as it were, restored to better health; and their pulmonary disease became quiescent for the time being, but the improvement proved not to be permanent; it did not last long; the discharge from the abscess either dried up or continued, and the patients sooner or later sunk. The patient should, however, under all circumstances, except the last named, have by all means, the advantage which a proper and judicious treatment offers, recol. AN INTERESTING CASE. 67 lecting that an anal abscess, or a fistula ani, may more fre- quently be the primary cause of consumption, than the cure of it. I have yet to see the first bad results from attempts at curing those diseases in such patients by my method; it has never been productive of any injury, but on the contrary, in producing the most happy results. Indeed, according to my method, no harm can result in attempting to cure such cases, even if it should not prove successful; but this cannot be said of the knife, which is always pre-eminently fatal in such cases. If I should find my patient getting worse under my treatment, I can at once stop; this cannot, be done when the knife is used. I repeat, that according to my method, no harm can result; for if nature finds herself relieved or benefitted by a discharge of this kind, she will generally continue it, in spite of the most officious endeavors to the contrary. About three years ago, I cured Mr. John C. Evans, a respec- table gentleman of this city, of a fistulous abscess at the side of the anus, which he had previously labored under for several months. It was complicated with a serious disease of the chest, and pronounced consumption by the best physicians of this city. He was very much emaciated, had violent cough, pro- fuse expectoration, together with night sweats, and hectic fever, &c. All the physicians whom he consulted, advised him not to have any thing done for his fistula; stating, that if that was cured, it would only accelerate his pulmonary affec- tion, and hasten his death. He consulted me, I gave him an opinion directly the reverse of this. He however, at that time, still continued to take the advice of his physicians. Three months after this I saw him again, very much worse, and despairing of ever being cured. He however determined to take my advice, and submit to treatment. In about eight weeks I cured him of his abscess, and almost entirely relieved him of his cough, and all other bad symptoms. In nine months his general health was entirely restored, and now, he is one amonp- our most hearty, stout and hale citizens. This is but one case out of numerous others of a similar character. I have 68 AN IMPORTANT CURE. received and continue to receive, many letters similar to the following: LETTER 1 . N----, Ind., Feb. 26, 1840, Dr. Bodenhamer : Dear Sir—In December, 1837, I was attacked with a most dreadful cough, and pain in my side, something like inflamma- tion of the lungs. I immediately called on a physician who attended me for several months, but did me very little good. I then called in another, who soon got me out of bed, so that I was enabled to attend to business again. But I never got entirely relieved of my cough. About eight months ago a tumor formed at the side of my bowel, which was very pain- ful for several days, until I had it lanced. It discharged almost a pint of matter, and has continued to discharge ever since. Lately, my cough has got much worse, I have chronic diar- rhoea, night sweats, and acid stomach constantly. I spit up a large quantity of the worst looking corruption, and it looks exactly like the matter which comes from my fistula. My physician has never done any thing for this sore, telling me that if I have that cured, I would die of consumption. I am becoming very uneasy about it, as I believe if I was cured of it, I would get well of my other diseases. I am now scarcely able to walk about. What do you think? Do you think it would do to have this fistula cured or not? Please write immediately, and if you think that it should be cured, I will visit you immediately. I forgot to tell you that I am forty years old; and that whenever I touch the fistula, it brings on a spell of coughing. [I cured this gentleman three months after the date of his letter, and two years afterwards, when I heard from him, he was entirely well.] LETTER II. M----, Ky, June 16, 1842. Dr. Bodenhamer: Sir—I take the liberty of asking your opinion of my case. I am laboring under a disease of my lungs, which commenced a year ago. I spent last winter in New Orleans, and while DEATH FROM NEGLECT. 69 there, was attacked with a fistula in ano, for the cure of which you are no doubt very justly celebrated. A large tumor formed at the side of the bowel, and broke, and has been discharging ever since. Now, doctor, do you think that curing the fistula would interfere with the restoration of my lungs to a healthy state, which my physician says they are gradually attaining? He advises that the fistula should be let alone until my lungs are restored; but I am fearful that in this he is mistaken, as the fistula is a great annoyance to me, and I am certain that it weakens me much. I saw your friend, Mr. F., the other day, whom yrou cured a few years since. He gave me much encouragement, telling me that when he first called on you, he was in every respect, as bad as I am. [This gentleman was prevailed on by his physician not to submit to treatment for his fistula, that he was getting well, &c. In about two months after the date of the above, he died.] Whilst at New Orleans, last winter, a young gentleman consulted me (the first of February, 1846,) for a fistula, com- plicated with a slight affection of the lungs. I advised him not to delay the cure of his fistula a day, as it wras evidently the cause of his other affection, and very much aggravated it. The slightest touch of the probe about the sinus, would excite coughing. He told me that he was compelled to attend to his business for a month or two, before he could submit to treat- ment; but that he would see me at Louisville about the first of May. He called on me the first of June, but he had emaci- ated so, that I could not recognise him. I advised him to return home as soon as possible; that I could not do any thing for him, and that it was impossible for him to live but for a short time. He thanked me kindly for my candor, and told me he seriously regretted the folly of his course, in not taking my advice at New Orleans. He died in three weeks after this interview. Persons should never defer a day, the treatment of such diseases, as they are so liable to terminate in consump- tion, or some other serious organic disease. A very large number of cases of this kind could be given. 70 FRENCH SURGEONS--BOYER. CHAPTER VIII. FISSURE OF THE ANUS. This disease was so called by Boyer. It appears to be a very common affection in France, as all the French surgeons speak of it, and it is to them chiefly, that we are indebted for what has been written on the subject. It is a very painful disease, very difficult to treat, and very liable to be overlooked, without a very minute examination, and it is becoming quite common in our own country. This disease consists in a superficial ulcer, about the eighth of an inch wide, and from a quarter to an inch in length, located with the anal canal, and most commonly on one or both sides; sometimes, however, it is found on the posterior as well as the anterior part of the orifice. It is generally con- fined to the mucus membrane, but it sometimes extends to the muscular tissue. When the disease is recent, its edges are soft and pliant, but as it becomes chronic, they become hard and elevated. The appearance of the ulcer is generally red, it is, however, sometimes grey. Its situation may be perceived, as it is low down, by simply separating the converging folds of the marginal skin. If the disease is high up, the speculum will have to be used. It is said that females are more subject to it than males. It generally occurs in the meridian of life. This disease is often caused by pile tumors, and when this is the case, it will generally be found between two of them. A very common cause, is laceration of the mucus membrane of the anus, by expelling hardened faeces; the edges of the rent or crevice do not unite and heal, but become hard and ele- vated, and thus form a fissure. Inflammation as well as ulce- ration of the mucus membrane of the anal canal. Laceration from the introduction of the pipe of the enema syringe, may also be a cause. M . MERAT--VELPEAU. 71 The essential symptoms of this disease are contraction and pain. In the early stages of the disease, the pain is not severe, amounting to nothing more than a pricking, stinging, or smart- ing sensation, at a certain point in the anus. But as the dis- ease advances, the pain gradually increases, and becomes exces- sive. "The pain is, according to M. Merat, sometimes parox- ysmal, which he attributes to the presence of accumulated faeces pressing on the sphincter. At its greatest height, this complaint is, says Velpeau, accompanied by horrible suffering. The patients compare the pain they feel at the moment of an evacuation, to that which would be produced by the passage of a red hot bar. This sensation of burning, is sometimes so severe, as to produce an inexpressible anguish, with threaten- ings of convulsions or syncope. Others say it seems as if something was tearing in the fundament. In the intervals, between the stools, there sometimes remain only smarting or lancinating pains, more or less severe; a sensation of weight, and some griping. On the approach of defecation, on the con- trary, the pains become obviously augmented. They do not acquire their greatest violence, until the moment of the expul- sion of the faeces; and go on decreasing for some hours. The constipation becomes so obstinate, that the alvine evacuations take place but once in eight, ten, and twelve days, if they are not promoted by art. The patients, having an incredible dread of going to stool, postpone the moment as long as possible, although they are aware that they suffer more by the delay. Some patients think themselves under the necessity of taking purgatives on alternate days. A woman treated by M. Boyer, resorted to the use of a canula, which she fixed in the anus. A patient at the Hotel Dieu, insisted that he would prefer death to the necessity of going again to stool. Although some persons are able to walk, sit, or occupy many hours in employ- ment during the intervals between their attacks, others are obliged to remain in bed, although they suffer cruelly with the heat and fatigue. In certain cases, the lancinating pains shoot- ing towards the bladder or the uterus, according to the sex, 72 SYMPTOMS OF FISSURE. extend even to the greater part of the hypogastrium. Diges- tion is disturbed. From the fear of evacuations, the patient eats but little, and he looses his natural color. His features soon begin to express the sufferings he endures; so that one might believe that he labored under some profound organic lesion. Spitting, coughing, or even singing; in short, all sud- den, or rather strong efforts of the lungs, sometimes aggravate the pain. (American Cyclopedia of Practical Medicine and Surgery, Art. Anus, p. 118.) When the faeces are solid, they are sometimes streaked with blood and matter. The introduc- tion of the finger into the anus, is attended with great difficulty and torture; sometimes producing the most violent spasm of the sphincter muscle. " There is one symptom," says Dr. Col- les, " that will better explain the nature of this case, than even an examination through the rectum—and it is so constant and so obvious, that I wonder very much it has escaped writers on the subject—it is, that there is always a distinct interval of time, from ten minutes to an hour or more, between the pass- ing of faeces and the occurrence of the pain." The popular method of treating this disease, is by dividing both sphincter muscles through the fissure, with the knife. This operation is described by Dr. Bushe, as follows: " The patient should be placed opposite a window, couched on his side; an assistant ought to separate the buttocks, and retain them so during the operation. The surgeon having oiled the fore-finger of his left hand, inserts it into the anus, as far as the second joint, and uses it as a conductor for the knife, having a blade two inches long and one eighth broad, with a blunt extremity. Having passed the blade flatwise, as high as the superior border of the internal sphincter, he then turns its edge towards the fissure, provided it be on the side of the bowel, and divides both sphincters, by cutting from within out- wards, gradually increasing the pressure, so as to ensure the complete section of the external muscle. Provided a fissure exists on the opposite side, it ought to be treated in the same manner." AN INTERESTING CURE. 73 According to my method of treating this serious disease, there is no necessity whatever, for this painful and dangerous operation. I have demonstrated this, in the successful treat- ment of thirty-one cases of this disease, within the last ten years. Two years ago, I cured Samuel P. Weisiger, Esq., a highly respectable gentleman of this city, of a fissure of the anus, complicated with an internal blind fistula and haemorrhoids. This gentleman, for several months previous to consulting me, had suffered the most violent agony from this complication of diseases. Within this time, he had submitted to medical and surgical treatment, having had one or two external pile tumors removed, without any benefit whatever. The main disease having been mistaken for haemorrhoids, was entirely overlooked by his medical attendant. Such was Mr. W.'s suffering, that after having an evacuation from his bowels in the morning, he was compelled to remain on his couch all day; and the only- time that he could be up and attend to business at all, was in the morning, an hour or two before stooling. This gentle- man's diseases were doubtless caused by obstinate constipation of the bowels. He was cured without dividing the sphincter muscles, in five or six weeks, by a method neither painful nor hazardous. Pie continues well to the present time. LETTER I. ----, Ky., September 10, 1841. Dear Sir—My wife is afflicted with a serious disease of the lower bowel, for which she has taken much medicine from several physicians, without any permanent good effect; indeed, they do not appear to understand her disease. Her physicians all have advised her to consult Dr. D----, believing that some surgical operation will be necessary. We have come to the conclusion before taking this step, to consult you, (in opposi- tion to all the physicians in this section,) and if you think you can cure her, we will visit you as soon as we get your answer to this. For several years, my wife labored under costive 74 A LADY CURED. bowels, for the relief of which she was compelled from time to time, to take purgative medicine. About seven months ago, one day after she had taken a large dose of Cook's pills, which operated severely, she was taken with such a burning pain, while at stool, that she nearly fainted. Ever since, whenever she stools, and for hours after, she suffers the most agonizing pain. These pains extend to her back, and down her lower extremities, and sometimes so affect her bladder, that she can- not urinate without great difficulty. Her discharges from her bowels are frequently mixed with mucus, blood, and matter, and when she has these discharges, the burning is just like hot lead passing down her bowels, as she describes it. She is nearly all the time confined to her bed, a mere skeleton, and so nervous, at times, that we can scarcely do any thing with her. Such is the dread she has of an operation on her bowels, that she frequently sheds tears for an hour or two previous. She has no cough, and her digestion is good, and if she was relieved of this horrid disease, she, I think, would be well. Some of her physicians call her disease fistula, others piles. She has had three children, the youngest two years old, and her age is thirty. [This lady was cured by me, six months after the date of the above letter, and she is now in the enjoy- ment of excellent health. I found, upon examination, a fissure on each side of the anus, one extending up the anal canal about one inch, the other was about half an inch long.] LETTER II. C----, O., June 5, 1844. Dear Sir—Having heard that you have been remarkably successful in treating diseases of the bowels, I have taken the liberty of writing you. I have been suffering almost mar- tyrdom, for the last year, from a most troublesome and dis- tressing affection of my lower bowel. I experience the great- est suffering while I am stooling, and then it is often so severe, that I am compelled to lie down for several hours. At these times, the burning and smarting are so severe, that it appears INEFFECTUAL OPERATION. 75 to me it could not be any worse if a red hot iron was run into the bowel. I have such a horror of stooling, that I only have a passage every other day, at night, so that I do not loose so much time in the day, by lying down. I use Blue Lick water to keep my bowels loose. The sore place is on the right side of the anus, communicating low down, and extending up about an inch. I can feel it quite distinctly with my finger, the introduction of which, however, causes the most intense pain. The only discharge I have noticed from the place, is a little matter streaked with blood. I have no doubt but this disease was caused by obstinate constipation of the bowels, under which I labored for years, and for which I have taken large quantities of purgative medicines. The disease did not come on suddenly, but gradually. I am thirty-one years of age, my health good in other respects, and I am by profession a law- yer. You will now doubtless wonder what I did for my dis- ease. I have done every thing. I have consulted the best medical men, and they all have disagreed with regard to my disease, some calling it piles, some ulceration, and some fistula in ano. About six months ago, I submitted to the operation of laying all the parts open with the knife, by Dr.----, of----, This operation afforded me partial relief for about six weeks, but I am now as bad as ever. I have lost all hope, and almost despair of ever being cured. I would much rather be dead than be compelled to live in this condition. Can you cure me? Can you give me any relief? [I am happy to say that I cured this gentleman about three months after the date of his intel- ligent letter. I found upon examination, a fissure about a quarter of an inch wide, extending up the canal nearly an inch. It could nearly all be brought to view, by causing him to strain. The division of the sphincter muscles, to which he had sub- mitted, was not through the fissure, but in the immediate vici- nity. The cut was but partially healed when he consulted me, and was laying the foundation of another excellent fissure /] 76 CAUSES AND SYMPTOMS CHAPTER IX. PROLAPSUS ANT. This is a very troublesome, very disagreeable, and often, a very serious accident. I shall distinguish it into two varieties, which are generally confounded. First, into that which is most common, in which there is a simple relaxation of the mucus membrane alone, of the anal canal, which passes through the sphincters, in consequence of either their too great relaxa- tion, or their parlaysis. Second, into that which is less com- mon, in which there is an inversion as well as a protrusion outwards, of the rectum, including both mucus membrane and muscular tunic; or in other words, in which the whole gut protrudes. This form of the disease is usually called prolapsus of the rectum; and many writers, by this term, include the first variety also. But to' avoid confusion, I have separated them, as they are each separate and distinct forms of the same acci- dent. In the first variety, the mucus membrane alone is everted in the form of a ring, and may project from one to two inches from the margin of the anus; in the second variety, it comes down in the shape of a globular or oblong mass, and mayT pro- ject from one to four inches. This disease occurs most frequently in children and persons advanced in life. The following are some of the principal causes of this affec- tion. Too much standing on the feet; long continued strain- ing efforts at stool in the sitting posture. This is a common cause, and all persons having a tendency to prolapsus ani should always have their stools either standing, lying, or sitting on a chair, so high as to prevent their feet from reach- ing the ground; their bowels should never be evacuated in any other posture, as either of these positions will keep the OF PROLAPSUS ANI. 77 trunk erect, and moderate the force of the expulsive efforts. The usual sitting posture renders the pressure of the diaphram most direct upon the contents of the pelvis, and thus favours the decent of the bowel. Constipation of the bowels, is a common cause, as it requires protracted straining to expel the hard faeces; all drastic purgatives, such as aloes &c.; colic; prolupsus uteri; parturition; stricture of the urethra; stone in the bladder; violent coughing; sneezing; enlargement of the prostate gland; haemorrhoidal tumours; ascarides (worms) which nestle in the rectum are a common cause, especially in children. When the disease depends upon a want of con- traction of the sphincter muscles, the causes generally are, diseases or injury of the brain or spinal chord; exhaustion attending weak health; sedentary habits; protracted diseases; operations performed for fistula ani; for fissure. When this disease takes place in aged persons, it is owing to a general relaxation of the tissues, and the imperfect tone of the sphincters. Children are more liable to this disease than adults, owing to the intestine being less curved, and to the imperfect development of some of the contiguous organs to the intestine, which, when perfect, give strength and support to it; and from the fact that they suffer much from irritation of the mucus membrane. When this affection first appears, it usually presents but a small tumour, surrounding the anus, like a ring. This gene- rally takes place by the efforts at stool, and it returns slowly of itself, when those efforts cease. Sometimes it comes down after a costive motion only, and either goes up of itself, or is easily pushed up, and when up, remains in its place until some accidental circumstance brings it down, such as consti- pation again; diarrhoea; and in children, severe fits of crying. But if it is not cured or checked in time, it increases in size, and appears at every stool, and no longer returns of itself, but has with difficulty to be replaced. When it arrives at this stage, in many cases, as soon as the protusion is returned, it comes down again on the slightest movement, such as 78 CONTINUED. standing, walking, riding, and sometimes the least excitement will cause it to fall down. Such persons are generally mise- rable, for they can neither cough, sneeze, nor laugh, without its coming down; neither are they by any means able to keep it up entirely, at any time, as a small portion always remains out. In cases of long standing, the protruded portion be- comes so fixed in its unnatural position, that it cannot be returned, and then it becomes inflamed from friction, ulcer- ated, sore, tender, painful, and finally covered with a kind of cuticle. In some cases, when the protrusion remains out any length of time, it becomes engorged with blood, from the pressure which the sphincter exercises on the veins, as manifested by its increase in size, and lived colour. If it is not soon redu- ced, inflamation takes place, attended with great local pain and fever; and in some instances, death ensues in consequence of extensive peritoneal inflamation. In some very rare cases, the protrusion sloughs off, and a natural cure follows. This disease should not be confounded with internal haemor- rhoids. This is a common error, and committed even by those who should know better; nothing however is more absurd or more unscientific. The distinction is important, and should never be lost sight of. The difference is this, when internal piles protrude, that portion only of the mucus membrane to which they are attached, or which covers them, comes down, or is pressed down, as indeed it necessarily must; whereas in real prolapsus of the second variety, the mucus membrane, as well as the muscular tunic, protudes for several inches. In the former, then, the mucus membrane descends, without the muscular tunic, and only that portion of it too, which covers the piles, and no more. It may also be confounded with intussusception. In pro- lapsus, neither the probe nor the finger can be introduced higher up than the border of the internal sphincter muscle, in LETTERS. 79 consequence of the doubling down of the mucus membrane ; while in intussusception no resistance is offered to the ascent of either one or the other. The popular method of treating this disease, when the case is very bad, is excission of the whole dependent flap; or in other words, the removal of the whole natural lining mem- brane of the middle and lower portions of the. anal canal. Sometimes only a few of- the folds of the prolapsed portion are dipt off with the scissors. Sometimes the actual cautery is used, as well as caustic of various kinds. I reject all of these, and my success in the treatment of this disease is the best commentary on the excellence of my method, and proves to a demonstration, that those violent and dangerous meas- ures are not by any means necessary, for I have treated successfully some as bad cases as are on record. LETTER A. E----, Ky., May 1, 1843. Dr. Bodenhamer:— Sm—I see from a card in the Louisville Journal, that you treat diseases of the rectum, anus, &c. I have been sorely afflicted with a falling down of the bowel, or as you Surgeons call it, prolapsus of the rectum, for fifteen years. For the last six years, I am confined most all the time to my couch, as I cannot take the least exercise without the parts coming down. I can neither stand nor walk; for sometimes, as soon as I stand up, down it comes; and on some occasions this even takes place in bed, by violent coughing, spells of which I sometimes have. The protruded parts are as large as my fist, or the largest size apple; it has become hard and rough, and at times a little yellow water runs from it. I am quite well in other respects. I am sixty-five years old. I had determined to visit Philadelphia about the middle of this month, in order to have my disease operated upon, and wish you to answer this immediately, as I shall be governed in this matter by your letter. Let me know whether you can cure 80 A MISERABLE OPERATION. me, or whether I can be cured at all by any method. I have already tried every thing I could hear of, after consulting numerous physicians. [This gentleman I cured sometime after the date of the above, as the following letter will show.] LETTER B. E----, Ky., November 3, 1843. Dear Doctor—I arrived home in safety on the first of October, and I am still free from my old disease. I have tried it effectually by riding, walking, and even by running. I believe I am entirely well. I follow strictly the rules you laid down to prevent a return of the disease. I consider them of the greatest importance, and I am well convinced that if they were closely followed by those who have the disease, that they alone would in nearly every instance effect a cure. LETTER C. N. 0., La., August 10, 1842. Dr. Bodenhamer: Dear Sir—I have just learned from a friend, that you are distinguished for curing a certain class of diseases. About one year ago, I was operated on by Dr.----, for what he said were the piles, but I always thought it was simply the falling down of the bowel, as it never gave me any pain as the piles do. The only trouble it was to me, was when I went to stool, I had afterwards to return it. When the doctor operated, he made me strain until the part came down well, and then he cut it off. It soon healed, but now I am ten times worse off than before. The bowel has contracted so much, that I can scarcely stool at all, unless the stool is quite thin. I cannot have a hard stool. There is always an uneasy feeling about the parts, as if something was pulling or drawing them, which makes me miserable. I have been trying bougies and every thing else that I could hear of, to no purpose; and I fear that CAUSES AND SYMPTOMS. 81 I have been by this operation rendered miserable for the BALANCE OF MY LIFE." [I cannot dismiss this case without remarking, that the treat- ment certainly was unnecessarily operative. The portion cut off was evidently not a pile tumor, but a section of mucus membrane, lining the rectum or anus. This is not a solitary case, I have met with several, and they should be a warning to the surgeon, how he operates about the anus, and to the patient, how he submits to such operations.] CHAPTER X. ULCERATION OF THE RECTUM. From whatever cause ulceration of the rectum may be induced, it not unfrequently produces severe suffering, and sometimes proves very unmanageable. The causes of this disease are various. It may be induced by the passage of hardened faeces, in obstinate constipation, which occasions great friction upon the mucus membrane, by the careless employment of surgical instruments, which may produce lacerations or abrasians; by surgical operations on the rectum; by the passage of foreign bodies taken into the stomach; by the entanglement of faeces in the mucus follicles, and their consequent enlargement; by the contact of venereal virus ; by unusual and rapid distension of the rectum by chronic inflammation of the mucus membrane, &c, &c. Ulcers of the rectum are sometimes found in irregular patches of a fungoid appearance, and of a livid, or dark red color, slightly elevated above the surrounding parts on the mucus membrane; again, they are small, well defined, and with quite elevated edges; and again, in old cases, they may be found excavated, with jagged and livid edges, devoid of granu- lations, covered with an ash colored tenacious matter, and 6 82 VENEREAL ULCERATIONS. surrounded by a deep inflammatory blush. When the ulcers are situated in the anal canal, within the limits of the sphinc- ters, they are exquisitely painful, like fissure of the anus. They sometimes spread rapidly, attacking many points of the rec- tum, and extend up high. Such cases usually terminate fatally, especially in bad constitutions. By the introduction of the finger, the ulcerated surface may very easily be detected, by its roughness; and when it is low down, nothing more will be necessary than to separate the buttocks, and evert the edges of the anus with the fingers. The best method, however, is to dilate the anus with a good speculum; then the situation, the extent, the form, and the character of the disease, can at once be easily determined. The lower portion of the colon and the rectum are more liable to ulceration, than any other portion of the alimentary canal, doubtless, in part owing to the accumulation and retention of faeces in this region. The feculent matter being detained here, becomes foetid and putrid, either from imperfect digestion or long retention, or from both; thus it becomes a source of irrita- tation, inflammation, and ultimately, ulceration. Not unfrequently, the coats of the rectum are thickened at the parts where these ulcers are situated, and in some instances, this thickening is so great as to diminish the area of the rectum considerably, and in this way finally produce stricture. With regard to venereal ulceration of the rectum, it may arise from the direct application of venereal virus, or it may be consecutive to disease in the genital organs, and then co- exist with other secondary symptoms. When it is caused by the direct application of the poison, it usually begins around the anus, passing up into the rectum, and extending up even to the colon. Where these ulcers heal, the whole circumfer- ence is occupied by chaps or clefts, indicative of the former existence of those ulcers, called "Rhagades," caused by vene- real virus. The whole surface of the rectum as high as the promontory of the sacrum, is often rough and hard, from the SYMPTOMS OF ULCERATION. 83 cicatrization of the ulcers. The muscular coat is thickened and indurated, and by this means, the diameter of the bowel, as in other kinds of ulceration, is considerably lessened. This kind of ulcerative process goes on progressively from the anus upwards, those healing below, while new ones are forming above. Their sensibility is not very great, except those around the anus. Sometimes in these cases, the mucus coat of the rectum, is the eighth of an inch thick, and so much indurated, as to resemble gristle. This chronic thickening and chronic ulceration, may last, in some cases, for a long time. The symptoms of this disease are, acute pain and smarting in the rectum; especially while at stool; pain in the back, extending to the loins; irritation of the bladder; flatulent colic in the umbilical region; a sense of weight in the rectum ; tenes- mus; a discharge of thin bloody fetid pus from the rectum, amounting from a teaspoonful to a half pint, at each evacuation. The discharge, in some cases, is going on all the time; in others, it ceases frequently for a few days, then comes on pro- fusely again. These discharges are sometimes veryr offensive; they either precede or follow the stool; and are scarcely ever mixed with it, unless the ulceration extends high up; when the faeces are hard they are all besmeared with it. When the ulce- ration is low down, the symptoms resemble those of fissure of the anus; such as spasm of the sphincters, &c. " Ulceration of the rectum," says Dr. Bushe, " is difficult to heal: firstly, because from the abscence of valves in the portal system, and the depending situation of the haemorrhoidal veins; they are loaded with blood, a condition which is still further increased, by the accumulation of faeces in the lower bowels, and the action of the sphincters: secondly, because the passage of the faeces contuses, and stretches the ulcerated surface: thirdly, because if the ulceration be within the limits of the sphincter, it. is not only unduly compressed, but puckered: fourthly, because the plicated condition of the mucus mem- brane, and the action of the sphincters, prevent the proper adjustment of suitable applications ; and fifthly, because we are 84 INTERESTING LETTERS. unable to- make pressure a most efficient remedy, in similar diseases of other parts." LETTER I. W----, Ky., Nov. 3, 1840. Dear Sir—My daughter, who is thirteen years old, has some serious disease of her bowels. About two years ago, she had measles, and soon after she was attacked with diarrhoea, which still continues, but not near as bad as it used to be. About six months since, she commenced discharging small quantities of matter and blood mixed; attended with pain in the bowel, especially when stooling. This continues gradually to increase in quantity, and she now passes about half a pint in twenty-four hours; sometimes it looks like pure matter, ui other times it appears like bloody water, and it now is very offensive to the smell. Her health has been good hitherto, but she appears now to be wearing away gradually, and her abdo- men is swelling, and quite hard. She has the most voracious appetite, and wishes to eat any thing. [This was a case of extensive ulceration of the rectum, as I found, upon examina- tion. I cured her.] LETTER II. G----, Miss., Aug. 25, 1841. Dr. Bodenhamer:— Dear Sir—Last winter I took a violent cold from exposure, crossing the mountains in the stage from Philadelphia; ever since I have been unwell. A short time after I came home, I frequently had considerable pain, whenever I had to stool; and I noticed that I discharged a little matter and mucus, mixed with blood, somewhat like the flux. I now suffer the most terrible pain sometimes, when I stool, especially when I take medicine. When my stools are moderately soft, I do not suf- fer so much pain. My bowels are very costive, and when I have a hard stool, the stool is completely covered with matter. I am fearful that I am about having a stricture of the bowel, as lately I cannot have a hard stool, as I formerly INFLAMMATION AND EXCORIATION. 85 had, and it appears to me the parts are growing up. I can feel the sore about two inches up the bowel; it feels hard and rough. I have found but little relief from my physician, and feel anxious to visit you, if you think my case comes under your practice. [This gentleman visited me a short time after the date of his letter, and upon examination, I found four or five ulcers on the mucus membrane of the rectum; they were each about the size of a picayune. Under my treatment he recovered rapidly.] LETTER III. La., September 1, 1845. Dear Doctor—1 am glad to hear that you are going to New Orleans this winter, as I will be saved the trouble of visiting you at Louisville. My physician tells me that I have ulcera- tion of the lower bowel. I pass a great deal of matter from my bowel daily, without much pain, however. He has done me no good so far. [This gentleman I cured at New Orleans.] CHAPTER XI. INFLAMMATION AND EXCORIATION OF THE ANUS. In consequence of the exquisite sensibility with which the skin about the margin and adjacent parts of the anus is en- dowed, it from various causes, is very liable to irritation, inflammation, or excoriation. These affections are generally associated, and maybe induced by the following causes; by the unavoidable attrition of the parts, in walking or riding long distances; by the passage of irritatino- secretions; by gross want of cleanliness of the parts; bv obesity and warm weather; by luxurious living; by an entanglement of the hairs by which the parts are clothed, or 86 DR. COATES--CORPULENT PERSONS. by the removal of the hair by the patient or surgeon. M. Velpeau mentions the case of a physician who removed the hair with scissors, and in whom such violent pain and fever followed, that he was compelled to keep his bed for three days. " The hair," says Dr. Coates, " in this, as in many other situa- tions, is intended to prevent the contact of the sides of the nates, and to act like a friction wheel in machinery, to diminish the attrition. For this reason, it is much more abundant in the male sex, because the anus is much more deeply situated in man. To remove it entirely, would therefore, produce no slight inconvenience; but when cut short, or when after being shaved, it has again grown to a certain length, it acts like a harsh brush upon the delicate skin, and may produce very severe inflammation." In bad cases of these affections, the cuticle is sometimes abraded, and a sero-purulent discharge oozes out from the naked cutis, which becomes indurated, and a circumscribed blush of inflammation surrounds it. These complaints will generally yield to habits of perfect cleanliness; aided with daily ablutions of cold water; to moderation in diet; to the avoidance of all stimulating applications; and to the use of raw cotton, dry lint or linen, so as to absorb all moisture and prevent attrition from the clothing. Corpulent persons are more liable to these affections than the lean; and gross livers, than temperate ones. They are quite common among a certain class of the poor, in large cities, caused by filthiness of the parts. In such persons, these affec- tions sometimes become serious, and then they will consult a physician, who will find that the injunction of cleanliness, is of all things, the most difficult to be enforced. I recollect about a year ago, of being called to see a case of this description, in this city. The patient was Mrs. C----, mother of several children. She complained of pain and soreness about the anus, greatly increased by walking, and accompanied by a slight acrid discharge. The parts were greatly excoriated. She said that she could scarcely walk at all, and the smarting and the burning almost set her distracted, and that she really did believe PRURITUS OF THE ANUS. 87 in her heart, that it must be "fistoolow!" and that was "wAy" she sent for me. I ordered her to maintain the horizontal posture for a week, to live on meagre diet, and to apply four or five warm poultices or fomentations to the parts during every twenty hours. By the cleansing effect of these, myr patient was cured of her "fistoolow" in a week; but I fear she was not cured of the cause of it! and she will probably be, again and again, subject to its recurrence. These affections should always be attended to in time, as they always, if not cured, result in ulceration, in abscess, or some other disease in this situation. CHAPTER XII. PRURITUS OF THE ANUS. This is a most distressing and rebellious affection, lasting for months, years, and even for life, and by some considered incurable; frequently reappearing after having been apparently cured. It is peculiar to no sex or occupation, though it appears more common in males than in females; and in old age, than in adult life. The causes of this troublesome disease are somewhat obscure. It seems, however, to be nearly always connected with a dis- ordered state of the mucus membrane of the alimentary canal. Sometimes, it appears to depend upon a morbid state of the alvine secretions, which is often connected with general debil- ity, especially in those who follow sedentary occupations. It most often occurs in weak constitutions, in old people, and in females who have ceased to menstruate. Ascarides in the rec- tum, and haemorrhoidal tumors often give rise to it. Strong mental emotions are also a frequent cause. The eruption is characterized by distinct papules, usually of the same color of 88 DR. LETTSOME. the skin, accompanied by itching. This itching is sometimes intolerable, and the patient, in his attempts to relieve himself by scratching, takes off the top of the papule, and causes abra- sions of the skin, which are followed by an oozing out of an irritating serous fluid, which produces excoriations of the parts. Patches of a similar eruption to those around the anus, are often developed upon the scrotum, upon the root of the penis, upon the inside of the thighs; these are sometimes continuous with that on the anus; upon the back; upon the neck; upon the groin; upon the labia pudendi, &c. From the repeated rubbing and scratching to relieve this intolerable pruritus, chronic inflammation is excited in the parts, and the skin around the anus becomes thickened and furrowed, and the elementary form of the disease is lost. The itching generally comes on towards evening, but it becomes intolerable when the skin is excited by the warmth of the bed, and not unfrequently prevents sleep for several hours. Stimulating drinks of all kinds, as well as all stimulating food, are the most exciting causes. This disease prevails to a great extent, in some of the South- ern States; indeed I believe in those States, every fifth or sixth person is annoyed with it to a greater or less degree. Many physicians, after exhausting the materia medica in endeavoring to cure this disease, have come to the conclusion, that it ought not to be cured, but kept as a kind of safety valve; that the cure would be attended with iminent danger, &c. "The late Dr. Lettsome," says Dr. Bushe, " thought that the pruriginous state of the anus, prevented the occurrence of more serious diseases. He formed this opinion from having seen persons, after various long indispositions, relieved by it. A gentleman, sixty years of age, who had been subject to pec- toral disease, was perfectly cured by the appearance of this pruriginous affection. A favorable termination of the same kind occurred in a case threatening apoplexy. Another patient was relieved from the gout, in a similar manner; he, however, GREEK, LATIN AND ARABIC AUTHORS. 89 imprudently endeavored to allay the itching by the application of a strong saturnine lotion, which produced the desired effect, but after a few dayrs, he suddenly expired." It is of the highest importance in the treatment of this obsti- nate, troublesome, and rebellious disease, in the first place, to detect, and well understand the cause which produces it. I have been remarkably successful in the treatment of this affection, and could here give the names of a large number of individuals, whom I have cured, some three, four, and six years ago, and who remain well to this day. CHAPTER XIII. EXCRESCENCES OF THE ANUS. The anus and its vicinity are very liable to a great variety of vegetations and excrescences, such as scirrhus, candyloma, steatoma varix, &c, none of which, however, are absolutely peculiar to this region. They usually sprout out from the fine skin and mucus membrane, about the verge of the anus. They are sometimes very numerous and varied in their form, in consequence of which, the Greek, Latin and Arabic authors have designated them by many fanciful appelations. They possess scarcely any vitality, and consequently endowed with but little sensibility. They generally are smooth, soft and fragile; they sometimes, however, are rough, hard and fur- rowed on their surface. They are usually the colour of the skin or mucous membrane, from which they sprout; they are however, sometimes of a dark, as well as of a pale red colour, and usually of small size. They sometimes exist alone, at other times they are associated with pile tumours; and there is constantly a purulent discharge from them. The cause of these singular productions is somewhat ob- scure. Some have attributed them entirely to venereal virus; 90 ALADYCURED. but this is an error. Dr. Bushe says that " Some authors look upon these excresences as arising, in every instance, from the syphilitic poison. This opinion, however, is not tenable; for the fact is, that they existed, as we have undoubted testimony, when syphilis was unknown. In the authors now alluded to, we discover the same perverseness, which led them to assert that almost all diseases of the genitals, were syphilitic. I have frequently seen them in persons, who never had the syphilis; and one of these was a fine child, two years old, who was placed under my care by Dr. Fanning of Brooklyn."— (Bushe on Diseases of the Rectum, &c, p. 224.) Inflamation of the fine skin and mucus membrane of these parts, is a cause of this affection; friction of the parts; compression, contusion, erasion, arising from filth and acrid secretions, or venereal poison. These excresences are liable to be confounded with carci- nomatous tubercules, polypi and haemorrhoidal tumours; but by examining carefully the description of each of these, this error will not be likely to be committed. About five years ago, I cured a lady who labored under this disease, who had previously been treated by an eminent Surgeon, who pronounced her case to be cancer. I found the anal canal almost completely filled up with moist fungus vege- tations, which greatly interfered with her faecal dejections. In 1841 I cured a Mr. Thompson of this disease. He had formerly driven the stage between Lexington and Cincinnati, and was the worst case I ever saw, or heard tell of. He could not sit at all. His excresences were exceedingly numerous, hard and warty; and they constantly discharged an acrid matter, which kept the adjacent parts so excoriated, that he could scarcely get about. He had them twice cut off before I saw him, but it only added new life to them, they grew much faster than before. I now have an excellent drawing which I had taken of this case. Mr. Thompson has been entirely well of his disease ever since, and I believe he resides at present, in Augusta, Georgia. SIR A. COOPER--MR. SYME. 91 CHAPTER XIV. POLYPI OF THE RECTUM. This is rather a rare disease, and Sir A. Cooper says that in the whole course of his experience, he met with only ten cases; he also says that it generally occurs in children, and very rarely in adults, and the most advanced age at which he met with it, was twenty-two. Mr. Syme says that the few cases which came under his observation, had attained or passed the middle period of life. Dr. Bushe observes, that if we may form any opinion from the cases of polypi of the rectum, that have been recorded, they appear to have gene- rally occurred in adults, and for the most part in females. With regard to the nature and forms of these tumors, no- thing very definite can be said. They are generally of the mucus, though they sometimes are of the sarcomatous species. They may be single or multiplied, and are smooth or lobulated on their surface; they are round or pea-shaped; varying in size from that of a pea, to that of a hen's egg. They usually have a narrow neck, which is generally attached to the mucus membrane some two or three inches above the verge of the anus, yet often still higher and out of reach of the finger. Sometimes these tumors are soft and feel like the mucus coat of the rectum, and indeed resemble it very much in appearance; at other times they are firm and un- yielding. The mucus species are developed very slowly, and never attain any great size; the sarcomatous species on the con- trary grow rapidly and attain to a great magnitude. Boyer mentions a case in which the tumor was as large as two fists. The causes of this disease appear to be involved in complete obscurity, I will therefore say nothing on the subject. The 92 A DANGEROUS DISEASE. symptoms are weight and fullness in the lower bowel, tenes- mus and considerable difficulty in evacuating the bowels. When the stools are soft, they are usually contracted, flat- tened, and generally covered with blood, mucus, or pus, so as to lead to the belief that a stricture existed. If the tumour is situated low down, it will protrude at each evacuation, and if large, it will be returned with great difficulty. This disease is always attended with danger, and if neg- lected will certainly degenerate, and sooner or later prove fatal. This is preeminently so, with regard to the sarco- matous species. In this species, as the tumour increases in size and malignancy, the patient will become sallow. His tongue will be coated; his thirst will be intense; and he will loose his appetite. He will be troubled with flatulence, and colic pains. He will emaciate; his extremities will swell and hectic fever will set in. His discharges from his bowels will be small in quantity, and voided with great difficulty. These symptoms will continue to increase, until death closes the scene. I have treated several cases of this disease successfully, and among the rest the following: LETTER A. N----T----, October 3, 1842. ------1 have not seen my mother-in-law, since I saw you, until to-day. She has just given me a full history of her case, and I believe as you do, that it is not simply piles, as we thought. She says that she first noticed the tumor about four years ago, it was thin and quite small; but it has been gradually growing ever since. It has never given her much pain or trouble until within the last year. At every stool, now, it comes down, and it is as large as a small pear and precisely the same shape. It feels very soft; just like a piece of liver; and pressing it, does not in the least hurt it. When it comes down, it cannot be returned sometimes for three or four hours; so that she has frequently thought of just cuttino- AN IMPORTANT CURE. 93 it off herself with a knife, but she was afraid. She has never had it examined by any physician; but she has consulted several, and they have called it the piles, and that it should be cut off with the knife. As it never pained her very much, she determined not to have it cui off, as long as she possibly could avoid it. She thinks it has grown more within the last six months, than during the whole four years, and there is now quite a discharge of bloody mucus, and a smarting pain when at stool, and until the tumour is returned. Her general health is gradually becoming impaired, which we have all noticed within the last six months. She is forty-five yrears of age, and the mother of five children. If from this discription you think you can cure her without her visiting you, which she would greatly prefer, please let us know as soon as you receive this. If you cannot, we will try and visit you by the first of December. Please say what length of time she will have to be under your treatment; what board can be obtained for, and what probable amount your fee will be, so that we can prepare accordingly. [I had the extreme pleasure of curing this ladyr, and she is now in excellent health.] CHAPTER XV. NEURALGIA OF THE ANUS. Tins is an extremely painful, but fortunately an extremely rare disease; yet occasionally cases do occur, and for this reason, I have noticed it in this work. It is doubted by some, whether the anus is in reality the primary seat of this affection, or whether it is really, essentially neuralgic in its character. But I can see no good reason, why real genuine neuralgia, may not just as well be primarily seated in the nerves of the anus and its immediate vicinity, as in any other 94 DR. BUSH E-- VEIPEAU, region; and why it may not be precisely similar in its cha- racter to that which occurs in other parts. Dr. Bushe is of opinion, that, in the majority of cases de- scribed by authors, in which both the anus and genito-urinary organs were said to be the seat of neuralgia, no such disease affected the anus; but that in consequence of irritation in the genito-urinary apparatus, the sphincter ani was thrown into a state of painful contraction. Dr. B. then goes on to relate the "only genuine" case of neuralgia commencing in the genito-urinary organs, and from thence extending to the ex- tremity of the rectum, which has come within his observation. —[Bushe on the Rectum, &c, p. 111.] Velpeau says that the caus'es of this disease are unknown. The anus, in this affection, is entirely free from redness, and from swelling; neither can the slightest alteration be percep- tible, but the patient soon becomes convinced that it is the seat of lancinating pains, which cause him to dread the least pressure of the parts. These pains frequently come on in paroxysms; sometimes suddenly, at other times more slowly; leaving the patient entirely free from pains during the inter- vals. In other cases however, the pains are constant, with but occasional exacerbations. In some persons, the anus appears to undergo momentary and forcible contractions, fol- lowed by speedy relaxations; in others, on the contrary, it is seen to expand to such an extent, that involuntary discharges take place. The pain frequently extends from the anus to the loins, to the back and to the urinary organs. Sometimes the evacuation of the bowels, as well as the bladder, is attended with difficulty and with the most excruciating pain. Persons of a nervous and irritable temperament, and who are subject to this disease in other parts, are most liable to this affection. Dr. Bushe describes a case in the following manner. " In 1829 I was called to see Mrs. H----, a nervous lady, about thirty years of age, who for several months had suffered from lancinating pain in the extremity of the rectum. For weeks A NERVOUS LADY. 95 this pain would be very severe, and then nearly, but not alto- gether subside. Her distress was greatest towards the close of the day, and then she was compelled to take black drop. Changes of temperature had a baneful influence on her, not only increasing the pain in the anus, but rendering her rest- less and melancholy. Her bowels were generally consti- pated, to remedy which, she generally took three doses of magnesia every week. During defecation, her distress was very much increased, especially when the excrement was hard. I examined the parts with great care, but could not detect any lesion. There was no spasm of the sphincter, and she bore pressure on every part of the rectum, that the finger could reach, without pain, save on a spot, about the size of a shilling, on the left side of the intestine, rather less than half an inch above the verge of the orifice, which was so exqui- sitely tender, that she screamed out when the finger was pressed against it."—[Bushe on the Rectum, p. 112.] This disease sometimes continues for life, rendering the patient miserable. I have in my practice, treated five marked cases, and with complete success. One, I recollect well, a Southern gentleman, who had labored under the disease about five years; he remarked that during that time he had taken at least five gallons of laudanum, and that he had been cupped and blistered along the spine, until the skin had become as rough and as thick as an alligator's! This gentleman had but one paroxysm of his disease after I commenced treating his case. My treatment generally gives immediate relief. 96 A PRIMARY DISEASE. CHAPTER XVI. SPASMODIC CONTRACTION OF THE SPHINCTER ANI. This painful and troublesome affection, according to many, is always considered as of secondary origin; depending entirely upon other diseases in the same vicinity, such as fissure, nural- gia, haemorrhoids, diseases of the genito-urinary organs, &c. Hence they do not view it in the light of a primary disease, nor make it the subject of special consideration. That these morbid affections do often co-exist, is a fact, which has already been shown in this work. This, however, they may do, or they may not do. Yet there is a species of painful spasmodic contractions of the sphincter muscle, which cannot be traced to any primary affection whatever, either in the anus or elsewhere. And it is especially this particular kind, which should be entitled to the consideration which I have given it in this work—a primary or substantive disease. Dr. Bushe, speaking on this subject, says, "The import of the word neuralgia, is too well understood, to need any expla- nation from me. That the cases I have described under this head, merited such a place, will scarcely be doubted; but whe- ther those described under the title spasmodic contraction of the sphincter ani, should not be placed under the same head, is the question. I would just remark, that I think they ought not be so arranged; because neuralgia of the anus can not only exist without contraction, but with relaxation of the sphincter; and it is no reason because contraction of this muscle is some- times combined, and in such cases, is in all probability the consequence of neuralgia, that spasm of the sphincter, because painful, merits the appelation of neuralgia. I am disposed to THE SYMPTOMS RESEMBLE FISSURE. 97 think, that it would be as reasonable to style fissure, neuralgia of the anus, or cramp of the gastrocnemius muscle, neuralgia of the leg, as to class all the cases I have narrated under the head neuralgia." (Bushe, on the Rectum, &c. p. 129.) In this disease the sphincter muscle will be found firmly and painfully contracted, and not the slightest perceptible altera- tion whatever in the structure of the parts, can be detected by the most careful examination. The origin and cause of this affec- tion are difficult to explain. Every thing that tends to irritate the anus, may be the cause of increasing the patient's suffering, such as introducing the finger, or a foreign body into the anus— forcibly expelling indurated matters—using stimulating articles of food or drink. Anxiety and distress of mind are said to have a powerful influence in confirming and aggravating its symptoms, and may not improbably also occasion its commencement. The symptoms of this disease resemble those of fissure of the anus very much; but if a minute examination is made, neither fissure, nor the slightest abrasion of the surface can be discovered, and the anus, instead of presenting its ordinary conical appearance, will look flat and scarcely present any trace of the orifice, owing to the powerful contraction of the external sphincter muscle; and every attempt at introducing the finger, will be attended with the greatest difficulty and the most violent agony. Sometimes persons are suddenly seized with violent contractions of the anus, attended with almost insuperable suffering, without being able to assign any cause whatever. Defecation is usually attended with difficulty and wTith severe pain. The urinary organs also greatly sym- pathize. The most popular treatment of this disease is the division of the sphincter muscles, as in fissure of the anus. This treatment I reject, for I have never seen a case that I could not, and did not relieve in twenty minutes, without resorting to it. Not long since, a gentleman in this city sent for me in great haste. I found him suffering the most agoniz- ing pain. He informed me that he was suffering the agonies 98 SIR C. BELL--CIIESELDEN. 0f the d----d, and had been for the last five hours. I relieved him in ten minutes, and in as many more he was laughing and talking. I have treated a considerable number of persons of this disease. CHAPTER XVII. ORGANIC STRICTURE OF THE ANUS. This contracted state of the anus, may be induced by what- ever tends to excite inflammation in its lining membrane. Sir C. Bell says, " that the cause of the inflammation for the most part is costiveness and straining, by which the fibres are strained and burst, and become inflamed. Sometimes it may come from the tenesmus, and frequent excitement of the orifice, by painful and ineffectual calls to evacuations." (Trea- tise on Diseases of the Rectum, &c, London, 1832, pp. 321-2.) The most common cause of this condition of the anus that has come under my observation, is from the contraction of cica- trices by operations on this organ, such as excission of haemor- rhoidal tumors, of prolapsed membrane, &c. Dr. Colles in one of his lectures says, " If you cut away any skin at the verge of the anus, you may depend on this—that although some time may elapse before the effect is produced (and it is generally slow in its progress) you subject the patient to a very serious inconvenience during his life, arising out of the contraction of the aperture of the anus that results from it." The editor of the London Lancet says, " I saw a gentleman who had been operated on four years before, by an eminent surgeon, and so small and rigid had the opening of the anus become, that no solid, larger than a garden pea, could be passed from the bowels, and with the miserable prospect of its gradually becoming still smaller." Cheselden says, "He saw BOLD UNTHINKING SURGEON. 99 a case where a bold unthinking surgeon cut off a part of a prolapsed ani, and the cicatrix afterwards, was so hard and contracted, that the patient could never go to stool without a clyster, and then, not without great misery." "In fine," says Delpech, " it happens that in cases of habitual engorgement and eversion of the internal membrane of the anus, in consequence of the presence of haemorrhoids, in attempting the excission of the scroll, (i. e. the latteral tumors, formed by this slight shade of prolapsus,) which sometimes occasion insupportable incon- venience, the surgeon has extended the operation to the whole circumference of the anus. In these cases, it has frequently resulted from this practice, that the circular cicatrix has con- tracted the natural passage, and rendered it almost incapable of performing its functions.''''* In many cases of contracted anus, there is merely a thick- ening and consolidation of the fine skin of the part, and of the adjacent cellular membrane. These often arise from sypelitic poison. I should have said that in all the forms of stricture of the anus, there is generally no disposition to spasm. The symptoms of this affection resemble very much those of stricture of the rectum, which will be treated of in the next chapter. At its commencement, it often does not occasion much inconvenience, except when the bowels are very much constipated; then there is pain and difficulty in passing har- dened faeces ; after a while, however, the anus becomes so con- tracted, that nothing but fluids can pass through it. I have seen several cases where it was impossible to get any thing into the anus larger than a common sized goose-quill. I have treated several cases of this affection with complete success. * Soe Letter C, pagp 80. 100 REGULAR AND IRREGULAR QUACKS. CHAPTER XVIII. STRICTURE OF THE RECTUM. This is a rare, but a very distressing malady, and one that has heretofore been but little benefitted by surgical measures. Therefore, a successful method, not of treating it, but of curing it, would be truly acknowledged a desideratum. If one might judge from what surgical writers say on the subject, the treatment of stricture of the rectum has hitherto been a mere matter of pecuniary speculation ; that this disease has been the "golden egg, both of the regular and irregular quacks." For the benefit of the reader, I will give the opinion of several on this subject. "It is in this disorder that quackery rejoices. Occuring out of sight, (if the quack may be trusted, out of reach also,) the charlatan lies with comparative impu- nity, and trusts to darkness to shroud his doings. Though stricture of the rectum is seldom seen after death, it is won- derfully common during life. A patient has constipated bow- els, he naturally applies to a rectum doctor; the doctor takes a long bougie, it hitches of course at the lateral turn of the rectum, or higher up than that, the case is one of confirmed stricture, the patient is doomed to be fleeced. Woe to him, or her, if he or she is rich; for it is rich people who have stricture of the rectum. Once in the hands of the cliarlatan and deliverance is far off. The doctor takes care to insist on the necessity of employing some one who understands the introduction of long instruments, and he naturally and pro- perly congratulates the patient on his fortunate application to him. The bait too often takes, and the stricture is a confirmed one, so long as it pays." (Medico-Chirurgical Review, vol. ix. p. 18,—1838.) " Before I finish this note, I may mention that the inexperienced are apt to refer the opposition offered to the passage of the bougie, by the folds of the mucus mem- SITUATION OF STRICTURE. 101 brane, or the projecting ridge of the sacrum, to stricture of the gut. I am mortified to add, that I have good reason for sup- posing there are a few who make a profitable trade of treating dyspeptic patients for stricture of the rectum; asserting that the obstruction is high up, when in truth, this intestine is per- fectly free from structural disease. Such practitioners, by passing bougies, apparently cure what in reality never existed, and thus obtain a character for skill, in the treatment of this disease, which, in truth they do not possess." (Bushe, on the Rectum, &c, p. 266.) "----the top of the sacrum naturally- projecting forwards on the commencement of the rectum, in some degree opposes the entrance of any large body, and this circumstance is laid hold of by the unprincipled or ignorant; the patient is very often declared to labor under stricture of the bowel, when none exists. Some practitioners discover stricture in almost every patient with disordered digestion." (Liston's Elements of Surgery, by S. D. Gross, M. D., p. 451.) But I will "turn from this disgusting exhibition, to the consi- deration of this disease, as it is, and not as cupidity would make it." Stricture of the rectum may be divided into functional or organic, or in other words, into spasmodic, or structural. The former is merely a contraction of the coats of the rectum, with- out either thickening or induration of the textures. Whilst the latter consists of a morbid growth, attended with the symp- toms, and prone to the changes which characterize malignant degenerations of structure. There is a considerable diversity of opinion with regard to the situation of stricture of the rectum, some contending that it is most always low down, not higher than three inches, and within reach of the finger, while others say that it is most always high up, from six to eight inches and higher. I will give the opinion of several eminent men on this point, which may not prove uninteresting to the reader. "----Not un- frequently, the inner edge of the deeper sphincter ani, being the scat of this stricture; and then the finger enters to the 102 CAUSES NOT WELL KNOWN. depth of the second joint, when it is obstructed by a sort of membrane, standing across the passage. Sometimes the stricture is more than two inches within the anus, and feels like a perforated septum."—(C. Bell on the Rectum, &c, p. 330, London, 1822.) "The ordinary seat of stricture of the rectum, is from two and a half to four inches, from the orifice of the anus. But sometimes it occurs at a greater distance, at from six to seven inches for example; and a contraction of the same nature is occasionally met with at different parts of the colon."—(Mayo on the Rectum, &c, p. 165, London, 1833.) "In a few instances, the stricture has been seated so high up in the rectum, that it could be but barely touched with the point of the finger, until the patient was desired to ' force down,' and then a satisfactory examination of it could be made."—(Colles Hospital Reports, vol. v., p. 139.) " Stric- ture of the rectum most commonly occurs near the termina- tion of the anus, a little within the sphincter, but it may take place in any part of the rectum ; sometimes the whole bowel is lessened in diameter, and on other occasions the stricture is situated in the sigmoid flexure of the colon."—(Allen's opera- tive Surgery, vol. iii, p. 488.) " Stricture in general, is readily ascertained by examination with the finger."—(Liston's Ele- ments of Surgery by S. D. Gross, M. D., p. 451.) " It is generally found about two inches and a half distant from the orifice, but may be situated much higher up."—(Syme's Prin- ciples of Surgery, p. 445, Edinburg, 1832.) "Independently of the malignant forms of disease hereafter to be described, I have very seldom seen a contraction of the rectum which was not within the reach of the finger."—(Bushe on the Rec- tum, &c, p. 265.) The causes of this disease are not well known. Some sup- pose it to be caused by spasmodic contraction of the muscular fibers; by inflamation ; by the venereal disease; by the result of cicatrization of ulcers, which have affected the muscular tunic of the rectum, by subacute chronic inflamation, which induces thickening of the tissues of the rectum, and contrac - DESCRIPTION OF STRICTURE. 103 tion of its natural capacity; thus impairing the organization and function of the bowel, so as to render its action irregular and difficult, and eventually to determine a complete and fatal obstruction. It is however very difficult to ascertain with any positive certainty, the circumstances which give rise to this affection. The analogy of what happens in other canals, would lead to the supposition that continued irritation of the intestine is probably the immediate exciting cause. One of the worst cases I ever saw of stricture of the rectum, was caused by an operation for fistula in ano. Wiseman relates a case which was also produced by the same cause.—(Chirur- gical Treatises, &c, p. 234-5.) Copeland says that stricture is sometimes the consequence of the operation for fistula in ano.—(Op. cit., p. 15.) This disease most always comes on slowly and insidiously, and even after it is perfectly estab- lished, the symptoms are well calculated to mislead the patient, as well as the surgeon, as to the real nature of the case. Dr. Bushe's description of the symptoms is so perfect, that I will transcribe it. " There is a sense of weight and obstruction in the lower bowels,—uneasiness, distention, and occasional spasmodic pain in the abdomen,—eructations,—precordial op- pression, pain in the site of the stricture, loins and sacral region, occasionally extending down the extremities,—vesical irritation,—bearing down in females,—itching and heat about the anus, head ache, nervous irritability, and dejection of spirits. The left colon is loaded with gas and feces, as may be ascertained by an examination of the corresponding iliac fossa. The urine is generally scanty, high colored and fetid, though I have seen a few cases, in which it was unusually abundant and limpid. The bile is also generally vitiated and scanty. When the disease has continued for some time, the haemorrhoidal vessels become engorged, and very commonly tumors form, which for the most part are produced by extra- visated blood, and hence it is, that in old cases the skin about the anus becomes thickened and elongated. In consequence of irritation, arising from the stricture, an increased quantity 104 CONTINUED. of blood is determined to this region, and its return is so much impeded by the condensation of the walls of the bowel, and the accumulation of indurated faeces, that abscesses form in the cellular tissue, near the anus, and degenerate into fistulae. The calls to stool are sudden, and amount to six or twelve in twenty-four hours: generally two, three, or more take place within a short time, and are accompanied with much straining, which in some instances, especially when the stricture is situ- ted high up, gives rise to protrusion of the mucus membrane. Much gas, and a small quantity of mucus, occasionally mixed with blood, is all that is commonly discharged; but every two or three days faecal matter, in small pellets, if hard, and in long, round, angular or flattened portions of small diame- ter, if soft, is expelled. After each attempt, though the pain is very moderate, a sensation continues as if the bowels had not been emptied, and this is the reason why, in these cases, several evacuations, such as they are, follow one another, at short intervals. When, however, a sufficient quantity of mu- cus or feculent matter has been discharged to give temporary relief, and from habit the amount is very trifling, the patient, who has been fatigued, desists from further attempts, until a sense of fulness indicates the necessity of making another effort. Occasionally, when the faeces accumulate above the stricture, which they often do in immense quantity, they are rendered fluid by an abundant secretion from the mucus membrane; in consequence of which, the patient is enabled to discharge nearly or perhaps all the accumulated matter; thus by an effort of nature, fatal consequences are warded off When the stricture is fully within the reach of the finger, the canal feels narrow, indurated and unyielding, for a greater or less extent, and in some instances we are able to pass the finger through the obstructed portion. Occasionally, it is rather higher than we can reach; but in such cases, if the patient bears down forcibly, the diseased portion of the intes- tine will so far descend as to admit of the requisite examina- tion."—(Bushe on the Rectum, p. 273-6.) FIVE CASES CURED. 105 Occasionally, persons labor under this distressing disease for months, and even for years, accompanied with but slight alvine difficulty and sympathetic disturbance. But sooner or later, the health declines, the body wastes away, and they die, worn down by sickness, inanition, and the dreadful spasmodic pains arising from the violent efforts of the bowel to overcome the obstruction. When emaciation has progressed to a great extent, the powerful peristaltic action may be felt and even seen, heaving the abdominal parietes in tracts, corresponding to the convolutions of the intestines. Purulent matter is also discharged in great abundance, and so acrid as to excoriate the anus; this frequently comes away when the patients cough, or assume the erect posture. Various diseases in the vicinity of the rectum may simulate stricture of the rectum; but the diagnosis is always easily determined by a careful and minute investigation of all the parts. I have treated eight cases of this distressing disease, three were females, and five were males. Three were complicated with fistula in ano. Five out of the eight, were perfectly cured; the remaining three, were very much benefited.— They are all, to the best of my knowledge, still living. One of the cases cured, was a lady who resides in this state, and who laboured under the disease for ten years. Several years ago she was treated in this city, in Cincinnati and in Lexing- ton, for her stricture. When 1 first examined her case, I could only pass a bougie through the stricture, about the size of a common goose-quill. She has been cured about five years. 106 CANCER OF THE RECTUM. CHAPTER XIX. MALIGNANT DEGENERATION OF THE RECTUM. This is the most formidable malady yet treated of, in this work, being the most rapid in its progress, and the most fatal in its termination. By the term malignant, I mean a disposition in the morbid tissue, to be destroyed, sooner or later, by ulceration, or by sloughing, and a tendency in the system to the formation of similar morbid tissues, whether the primary one is removed or not. But there are some growths and alterations of the rectum that appear to be between the malignant and non- malignant; they tend strongly to their own destruction by sloughing or by ulceration; and in this respect, they are ma- lignant. But the system shows no disposition to regenerate them, when they are removed, or to develope them in other parts, and in that respect they are not malignant. I mean, then, by the phrase, malignant degeneration of the rectum, simply, Cancer of the rectum, which designates gene- rically various organic alterations, whose inherent nature is unknown to us, but which, though of various forms and ap- pearances, constitute one and the same lesion, and have as common characters, the property of changing and disorgani- zing the texture of the rectum, and the tendency to spread both superficially and deeply, and are usually beyond the resources of surgical art. These -malignant alterations of the rectum, as just defined, have been distinguished into cartilaginous, lardaceous and encephaloid, by Dr. Bushe, whose description of them, though imperfect, is the best I have seen; indeed a good description of them, still continues a desideratum. Dr. Bushe observes, that " the cartilaginous disease may either commence in the form of hard tubercles on the mucus DESCRI PTION. 107 membrane, or in the muscular coat of the intestine, which is by far the most common,—the fibres become pale and firm, while the connecting cellular tissue undergoes a similar process of con- densation, without any alteration of color. As the deposition goes on, the cellular tissue frequently becomes lardaceous; but however this may be, the walls of the bowel increase in thick- ness, and the cellular and muscular tunics are sooner or later confounded and softened. Sometimes the mucus membrane becomes studded with lardaceous and encephaloid vegetations, while the serous coat presents cartilaginous tubercles. As I have just mentioned, the lardaceous transformations may be superadded to the cartilaginous; but I have seen two cases in which it was uncombined. In one of these, the mus- cular tunic and cellular tissue were thus transformed, while in the other, the mucus coat was studded with vegetations of this character. Finally, I have seen a case in which the muscular tunic and cellular tissue were lardaceous, while the mucus coat threw out encephaloid growths. The encephaloid transformation is sometimes primary, com- mencing in the cellular tissue or mucus membrane; but more commonly, it is the sequel of the cartilaginous or lardaceous degenerations. From the changes of structure above described, the cavity of the intestine is diminished, but this is not at all in propor- tion to the amount of disease, for the quantity of carcinoma- tous matter in any one part may not be great, though several inches of the intestine may be diseased. Indeed, it frequently happens, that though the bowel may have been considerably obstructed for some time, the softening down and separation of the projecting masses, again renders it pervious. Any portion of the rectum may be first attacked; it most commonly, however, commences at its junction with the sig- moid flexure of the colon; then immediately above the pouch, and lastly at the anus. The adjacent organs are most commonly involved in disease. I have seen a case in which the bladder was perforated, and 108 NO AGE EXEMPT FROM IT. two, where the recto-vaginal septum was extensively destroyed. When the finger is introduced, we may discover, firstly, that the intestine is firmer than usual, and a portion of its inner surface is covered with indurated tubercles; secondly, that it is hard and contracted for a considerable extent, and the mucus membrane studded with ulcers, more or less extensive, whose surface is unequal, granular or fungous, and surmounted with thick, hard, and everted edges; thirdly, that a firm cartilagi- nous ring, generally with an uneven surface and so extensive as barely to admit the extremity of the finger, occupies its circumference; fourthly, that a portion of its inner surface is rendered irregular, and its cavity lessened by soft fungous growths; and fifthly, that the disease is confined to its lower extremity, and a fungus is thrown out, either from a part, or all the circumference of the anus. The causes of this horrid malady are involved in great obscurity. Some authors have endeavored to trace it to injury, or to inflammation, acting perhaps on a constitution predis- posed to cancer; but such conjectures are more plausible than useful. Sometimes the cartilaginous transformation will last for years, while, on the contrary, the encephaloid runs a rapid course, destroying the patient in a few months. Those about or a little above the meridian of life, are most liable to this disease. No age, however, is exempt from it. I have seen the encephaloid transformation in a boy twelve years .old, and the lardaceous in a female of twenty-three. From an examination of published cases, I find that women are most commonly its victims, and especially those who have recently ceased to menstruate. May not this arise from engorge- ment of the rectum, produced by the more frequent retention of faeces, and the suppression of the uterine flux? When a patient is affected with this disease, he suffers a burning pain in the rectum, which shoots through the pelvis. He is also tormented with weight in the back, aching above the pubes, numbness of the thighs, and painful retraction of the anus. His stools are frequent, difficult, painful, scanty, slimy, dark A MONSTROUS OPERATION. 109 colored, and mixed with blood and matter of an ichorous quality. In some instances, however, they are figured or composed of small pellets, and occasionally they are liquid, abundant, and accompanied with dreadful tenesmus. He moreover, labors under abdominal pain and distension, enac- tions, hiccough, nausea, and severe vesical irritation. Fre- quently, he cannot sit, and in some instances, is unable to walk, only obtaining relief in the recumbent position. He looses his flesh and strength; the ichorous discharge increases, and runs out when he coughs, or even when he stands erect. There is occasionally considerable haemorrhage, and he becomes sallow or leaden colored, oedematous, and sinks under continued suffering. Sometimes, however, when the disease is of a fun- goid character, he may die from obstruction. The excessive shooting pain through the pelvis, the sallow or leaden color of the face, and the havoc made by the disease in the advanced state, enables us to distinguish it from stric- ture. It must be confessed, however, that unless it com- mences in the form of indurated tubercles or irregular fungoid growths, the diagnosis is not easy, in the commencement."' (Bushe, on Diseases of the Rectum, p. 290-3.) With regard to the treatment of this horrid disease, it is unfortunately useless to say much. I will however, call atten- tion to the operation recommended by surgeons for the re- moval of this disease; viz.: excission of the whole anal canal, or lower extremity of the bowel. This is a painful, cruel, unjustifiable, and unnecessary procedure; and one by which the disease is often fearfully and painfully accelerated; the knife only rousing it into fatal activity. Even if it ever could succeed, the patient would be rendered miserable for life, and it would be proof positive, that he might have been cured by other means. It is useless, however, to expend words on the reprobation of such a monstrous and extravagantly bad practice. There have also been a great variety of medicines recom- mended for the cure of cancer, not only cf this, but of other parts of the body. Many of these, together with all the acrid 110 MRS. R. OF TENNESSEE. and irritating external applications, are frequently worse than useless, being often exceedingly hurtful. The pretensions of empirics, in positively asserting that they have infallible reme- dies for the cure of cancer, &c, as well as the interference of kind friends and acquaintances, who ever have their particular infallible remedies for every thing, too often deceive the patient and prevent him from making application at the only time, perhaps, at which the disease might be arrested by proper treatment; or from using those means which, if they did not entirely cure the disease, would keep it in subjection for the time being. I have met with six cases of cancer of the rectum, in my practice, I did not cure them. Three of these were females, and three were males, they were all between the ages of forty- five and sixty, except one who was about twenty-eight. Al- though I did not cure one of these, I have every reason to be- lieve that I greatly relieved three of them, and thus prolonged their lives. One of these, Mrs. ----, of Tennessee, aged forty-seven, and mother of several children, consulted me in the fall of 1841, for a cancer of the rectum, which she had labored under for about nine months. Previous to the appearance of the cancer, she had submitted to two operations for a fistula in ano. From the chasm, caused by the last incission, which was extensive, an irregular fungus growth sprung up, and spread so rapidly, that in a short time the tumor encircled the entire anus, and was extending itself to the adjacent parts. This was her condition when I saw her. She died six months afterwards. These two operations were either the immediate cause of the morbid action in the rectum, or they gave great impulse to it, for immediately after the last was performed, the malignant growth commenced and rapidly advanced, whilst the general health in the same ratio declined. This is another evidence of the great danger attending this operation, and it is preeminentlyso, in all cases, but especially in such. A DISGUSTING DISEASE. Ill The great tendency to malignant alterations of the rectum in females, who have recently ceased to menstruate, and who appear to be the most common victims of this dreadful malady, should always deter surgeons from operating, even should there be no positive evidence of any malignant tendency at the time. CHAPTER XX, FISTULA IN PERINiEO- URINARY FISTULA. This is a very troublesome, inconvenient and disgusting disease, compelling the patient, whenever called to pass urine, either to place himself in the same position, required to have a faecal evacuation, or to be subjected to the necessity of hav- ing his clothes constantly wet; owing to the urine passing through a fistulous sinus, communicating with the urethra and the perineum. The disease is usually preceded by an abscess, situated in the perineum. The swelling commences slowly, generally assuming a chronic character, and its progress is marked by pain, hardness, shivering and febrile disturbance. The collec- tion, if suffered to do so, will sooner or later open spontane- ously', and frequently discharge at once, both matter and urine. The abscess does not close, but it partially contracts, and thus degenerates into a fistula in perinaeo. The discharge is usually thin and glairy, sometimes it is thin, dark colored and fetid, and often quite copious. Sometimes the abscess instead of opening in. the perineum, opens into the rectum. In such cases, urine passes out of the bowel, and air, and even faeces, mayr, and do pass through the urethra. At other times one branch of a sinus leads into the rectum, whilst another leads into the urethra, both having the same external opening in the perineum, through which urine and faeces pass. When the sinus enters near the neck of the bladder, there is a con- 112 A MISERABLE LIFE. stant dribling of urine, and the patient has to wear a sponge, or folds of cloth, to absorb it, and his life is thus rendered miserable. In other cases, the urine escapes only during the expulsive efforts at urinating. The surrounding parts are har- dened to a greater or less extent, become tender and excoria- ted, and the patient is in a constant state of discomfort, and his general health suffers severely. There may be but one fistulous opening, or there may be several. Dr. Colles saw a patient who had from twenty to thirty openings in the peri- neum and vicinity. I saw one who had fifteen, and urine passed through each one. Though there may be many exter- nal openings in the perineum, there is never more than one opening in the urethra, at one time. Sometimes a very large quantity of the urine passes through the fistulous canal. I once cured a case, where at least two-thirds of the urine passed through the artificial opening. In such cases, the con- sequence is, that the urethra beyond the opening contracts, and will ultimately become obliterated, unless the fistula is cured. The perineum abounds in cellular tissue, and the corpus spongiosum urethra traverses this region, it is therefore a matter of no surprise, that inflammation should frequently spread into this tissue, and occasion suppuration in it, espe- cially when the causes of inflammation are so numerous. Sup- puration in the perineum, as well as stricture of the urethra, are both very liable to follow acute gonorrhoea, particularly if it is badly treated, as is too common at the present day. Nothing is better calculated to lay a sure foundation for this disease, than the indiscriminate, stimulating, and empirical treatment of acute gonorrhoea, as now usually pursued. The most common cause, perhaps, of urinary fistula is stricture of the urethra. The urethra behind the stricture, is always dilated, and sometimes when the patient is obliged to use much force in expelling his urine, the dilated portion gives way, and the urine is extravasated into the cellular tissue, which gives rise to abscess, and finally' fistula. Liston ob- LISTON AND COLLES. 113 serves, " In the gradual escape of urine by ulceration, behind the constricted point—the urethra being either altogether ob- structed, or nearly so—abscess forms in the cellular tissue, exterior to the ulcerating part. The suppuration is often slow in its progress, and imparts to that part of the perineum a stony hardness. Repeated collections of matter may form, and if the cause be not removed, numerous openings will form in the scrotum and perineum, and through them faetid matter and urine will constantly and involuntarily distil. The patient is reduced to a miserable state; the neighboring parts are excoriated, and exhale a noisome odour; his body and bed-clothes are soaked and rotted by the discharge, and the atmosphere to a considerable distance around is very offensive. Fistula in Perinaeo is established."—[Liston's Ele- ments of Surgery, by L. D. Gross, M. D., p. 472. For the other causes of this disease, the reader is refered to the chapters on Fistula in Ano and on Abscess. This disease is very difficult to cure. The spongy body of the urethra does not very readily take on the adhesive inflam- mation, and the constant passage of the urine through the fistulous openings, even independent frequently of the con- stant use of the catheter, greatly retards, if not hinders the cure. The usual means resorted to at the present day for the removal of this disease, are the knife, the actual cautery, and various caustics. Dr. Colles recommends the operation by the knife, to be performed in the following manner: "When you cannot introduce the catheter, you are directed to cut down through the perineum and urethra on the point of the catheter, to find out the impervious part of the urethra, to cut through it, and pass on the instrument to the bladder, by the inferior opening. Now, the great difficulty is to find this opening, or to find the urethra at all. I assure you, one of the most ex- pert surgeons in the kingdom, was an hour and a half cutting here and there, looking for the urethra, and was at last obliged 8 114 A DIFFICULT OPERATION. to put the patient to bed, without finding it; the great diffi- culty is to find the urethra. The way I would advise you to proceed, so as to enable you to come on the urethra, is this : keep steadily in the middle line—take care that you do not let an assistant divaricate the parts as you cut, if he does, you will be thrown out of the proper line, and will be cutting in all directions, looking for what you will not find ; the parts will, indeed, separate but badly of themselves; they will even close on the knife—but do not mind; cut down in the middle line, until you come on the end of the catheter. In some cases the presence of the catheter in the urethra, hinders the wound in it from closing, and you must therefore take it out, notwithstanding the dread you may have, of the urethra being very narrow at the seat of the wound. The way I am accustomed to finish the operation,is this: having come down fairly on the urethra, and cut through it, I seek for the lower opening, and pass a small sized gumelastic catheter through it, into the bladder; I then seek the upper opening with a probe, and having found it, I just cut off the ivory top of the cathe- ter, and introduce the end into the upper perineal opening of the urethra, and push it up, or push the urethra down on it, until it appears out of the orifice at the glans. I then draw the integuments of the wound over it, and leave it so."— (Colle's Lectures on the Practice of Surgery, p. 248-9.) It should be recollected that the above are the deliberate conclusions of an able and experienced surgeon, one who for thirty-four years was Professor of Surgery in the Royal Col- lege of Surgeons of Ireland. Comment on such a difficult, dangerous, painful and very uncertain operation, is unnecessary. He who will submit to it, when he might be cured by me, by a mild, safe and most certain method, is beyond the bounds of reason and argument, and should be let alone, being joined to his idols. I have cured seven cases of this disease within the last ten years, one or two of them extremely bad cases; a few of their letters I will give below, for the benefit of the reader. My FIRST SAFE, THEN SUCCESSFUL. 115 motto in the treatment of this, as well as all other diseases, is, that any treatment, in order to be successful, must, first be safe. LETTER I . ------, La., April 3, 1843. Dr. Bodenhamer: Dear Sir—I have learned through Mr. T---, of your state, that you are very successful in the treatment of various dis- eases of the lower bowel. I am laboring under a very serious disease, it is not however of the bowel, and I do not know whether you treat such cases; it is what is called a fistula in perinaeo. It made its appearance on me just about two years ago, in the form of a small hard lump, at the root of the penis, or between the anus and the scrotum. This lump was slow in forming, sometimes, nearly disappearing, then becom- ing painful and rising again. I finally consulted my family physician, who advised me to poultice it, which I did for six or eight days, and then it was lanced, and about half a gill of whitish matter came out, and I thought that I was well; but the place would not heal, and I soon noticed whenever I uri- nated, six or seven drops of urine would pass out at the open- ing. 1 should have told you that I had what my physician said was inflamamtion of the neck of the bladder, about six months before the appearance of the lump. Sometimes I suffered with this very much, but since the other disease has appeared I am better of this. Last June I consulted Dr.---, of----. who operated on me with a knife. I remained under his care about six months, when he sent me home much worse than when I placed myself under his care. He advised me to spend the winter in the south, and return in the spring, and he would operate again. The cut has but partially healed, and instead of the few drops that used to ooze out, the urine now comes out in a stream. Indeed, about one half of the urine now passes out through this opening. The parts all around have become hard, very sore and excoriated, and my 116 TWO IMPORTANT CURES. general health is suffering very much. Of late, whenever I pass water, I have the most severe pain, and shivering spells, like the ague, so that I dread very much to urinate. [This gentleman called upon me in about two months after the date of his letter, and in about nine weeks he was per- fectly cured. I saw him last winter in New Orleans, in excellent health.] LETTER II. N. O., La., Feb. 16, 1844. ----I have now no less than three openings running up into the urethra, and the urine comes down through each one of them. My fistula was caused by a stricture of the urethra, which I have had for five years, and still have as bad as ever. I have had the best surgeons in New York and Philadelphia to attend me. I have had the stricture cut and burnt with caustic a dozen times, but resulting in no good, and I must have had one hundred bougies pushed up. But this fistula alarms me more than any thing else, and I long since deter- mined to die, rather than be cut for it with the knife. I reside in the state of N. York, but I am on business in this city, which will detain me here a few weeks. I will wait here for your letter, and if you think you can cure me without the knife, I will visit you forthwith. [This gentleman was cured in about three months. I cured his stricture first, without either caustic or cutting, and his urinary fistula afterwards.] LETTER III. C----, O., December 24, 1843. Dr. B.—Dear Sir—There is another case of fistula in perinceo in this city, one of my friends, a young man about twenty-one years old. He is of a scrofulous temperament. There is a tumour at the root of the penis, considerable sore- ness and swelling in the whole region. He will find it diffi- cult to leave home, as he can scarcely be moved. What shall be done? I suppose that the hope of a cure, would stimulate A DREADFUL DISEASE. 117 him so much, that he would bear the pain and privation of a removal from his father's house. Please write on the recep- tion of this, to Mr.----, C----, Ohio. [This young man was brought to this city in a few days after the date of the above, he was so feeble that he was scarcely able to walk. I cured him in a short time. He had previously been attended by two eminent physicians of C—.] Were the causes of this disease well understood, and at an early stage well treated, but few cases of fistula in perinaeo would occur. Great and manifold are the miseries which result from the diseases of the urinary organs, and a much more dilligent enquiry do they deserve, than they have yet met with; but as they do not immediately belong to my present subject, I must omit, or at least defer to another opportunity, entering upon them. This I shall do at some future day, in a work about the size of the present. In the successful treatment of fistula in perinaeo, the stricture in the urethra, the induration of the whole neck of the blad- der, the enlarged and ulcerated state of the prostate gland, the disease of the veru montanum, vesiculae seminales and the vasa deferentia, are the great and the principal objects of consideration. CHAPTER XXI. VAGINAL FISTULA. There are but few infirmities incidental to the female sex, more distressing in their nature, and which render the condi- tion of their victims more truly miserable, than this unfor- tunate and painful accident. The vagina may have a communication by means of one or more openings, with the bladder or urethra, by its anterior parietis, and with the rectum by its posterior parietis, or at 118 KILLAN AND JOBERT. the same time, in front and behind, with each of these cavities. Vaginal fistula, then, may be distinguished into three forms: vesico-vaginal, urethro-vaginal and recto-vaginal. Vesico-vaginal fistula, is that form of the accident in which an irregular communication exists between the vagina and the bladder, through which the urine enters into the vagina, and constantly flows out, involuntarily. This form, which is decidedly the worst, is usually occasioned by the detachment of a slough, the consequence of long continued pressure of the faetal head in the excavation of the pelvis, during difficult and laborious labors; by the unskilful use of obstetrical in- struments ; by the ulceration from the lodgment of foreign bodies in the bladder; by abscesses; by venereal ulcerations ; by cancerous ulcers, situated on the neck of the womb, &c. " The situation of vesico-vaginal fistulae is very various: in some cases I found the orifice about one inch behind the mouth of the urethra; sometimes further back; at other times, finally, as high up as the os uteri. They are seldom situate at any great distance from the middle line of the vaginal pari- etes. Killan, Jobert, and several other writers remark, that the accidents are more or less severe, according to the situa- tion of the fistulae; for example, when high up, the urine comes awayr only at times, and when the bladder is very full. However, I have always found the patient wet, no matter whether the opening was situate low down, in the middle, or very high in the vagina. Even the greater or less extent of the orifice seems to make little difference; the women were as constantly wet when the opening into the bladder was not larger than the point of a sound, as when it would admit the index finger. It is evident, however, the accidents must be greater in extensive destruction of the vagina and bladder. The inconveniences resulting from vesico-vaginal fistulae are of the most deplorable kind. Those connected with the married state do not require explanation. The constant passage of the urine into the vagina must necessarily produce considerable irritation, and even inflamation; the external genital organs, IT BREAKS THROUGH FAMILY TIES. 119 the perineum, insides of the thighs, and the legs, are exposed to the same injurious actions; the skin assumes a bright-red colour, and is partially covered with a furuncular eruption. The patients complain of a most disagreeable burning and itch- ing sensation, which often compels them to scratch themselves until the blood comes forth, and thus aggravate their sufferings. Others are obliged to shave off the hair from the external or- gans, which are sometimes covered with a calcareous deposite from the urine. Frequent washing with cold water is of little avail, since the linen is quickly saturated with the fluid which escapes. Position also avails little, and the bed, even when consisting of a hair mattress, is quickly soaked through, and emits a most disagreeable odor; the wretched patients them- selves are compelled to pass their lives on a straw bed, the materials of which are changed every day. The air in the chambers of such patients acts injuriously on their lungs, and wherever they go they taint the atmosphere. Washing and inunction are attended with no advantage. Perfumes only increase the disgusting effect of the smell. This unhappy ac- cident breaks through all family ties; the most tender hearted mother is driven from the society of such an afflicted child; she is confined to a solitary chamber, or sits on a perforated stool of naked wood, or a plank, with an open window to the apartment, unable to cover the seat with any cloth. Some of these unhappy patients fall into a state of indolence; othete present a stupid resignation; while others would willingljF resign their lives to get rid of the misery which surrounds them. It is impossible to find any alleviation of the accidents by mechanical contrivances. The introduction of a sponge, saturated with cold water, prevents the discharge of urine for a few hours, in cases where the fistulous opening is small. However, the sponge soon becomes saturated with urine, and produces disagreeable sensations, which render it insupportable to many females. All attempts at filling the vagina, and thus preventing the influx of urine, have failed. The different con- trivances for receiving the urine which flows into the vagina 120 DESAULT, DUPUYTREN. are also equally useless, and I have seen many cases in which they aggravated the evil instead of relieving it."—(Physiologi- cal views relative to Vesico-Vaginal Fistula &c. By Profes- sor Dieffenbach, London Lancet, August 27, 1836. From Berlin med. Zeit., June, 1836. A most savage operation for vesico-vaginal fistula is now performed and advocated by some of the French surgeons—it is nothing more nor less than an attempt at the complete ob- literation of the vaginal canal. If this operation could ever succeed in curing the disease, and if there was no other method less objectionable, then perhaps the adoption of it might be countenanced. The following extract from Rank- ing's Medical Abstract for July—December, 1845, pages 196-7 gives the modus operandi. "J. L. Petit shrank before the difficulties of any attempt to cure this disease when there was considerable loss of substance; but since the publication of a memoir by Lallemand, in 1825, the first surgeons in France have made efforts to cure it. Among these may be cited Desault, Dupuytren, Mallagodi, Roux, Velpeau, and Vidal, but with very little success. Many have denied that a cure has ever been obtained; nevertheless M. Jobert is said to have performed seven operations of an autoplastic nature, to which he has applied the term elyteplasty, with more or less success. We have given a very interesting case of this disease (Abstract, Art, 67,) in which the last men- tioned surgeon, having failed by his usual method, adopted a new one with complete success. " In a report by M. Vidal, * of a discussion at the Royal College of Medicine, we obtain the particulars of a case oper- ated on by M. Berand, by the method of infibulation or oblit- eration of the vagina. The principle of this method, is to abandon the perforation in the bladder, and to unite the vulva, so as to obliterate the vagina, and to form, with its posterior parietes, a new fundus to the bladder. The case was an enor- mous fistula, in which not only the vesico-vaginal partition, * Annates de la Chirurgie, May, 1845. A FATAL OPERATION. 121 but the posterior part of the urethra, was destroyed. M. Berand made an elliptical incision round the vagina, behind the nymphae, from the meatus above to the commissure below. The posterior edge of the incision was taken up with forceps, and the mucus membrane dissected off, two centimetres above and three below. It then formed a diaphragm, adherent by its large circumference, and pierced with an oval opening, presenting an external bleeding surface, and an epithelial sur- face towards the vagina. A suture (a point passe,) was pass- ed round the small circumference, the two ends of the thread being left pendent in the vulva. Then a catheter (sonde de Bel- loc,) introduced by the urethra, was passed through the fistula, and brought out by the small circumference. The two ends of the liguture were fixed upon this, and drawn back by it through the urethra. The catheter was then replaced by an elastic gum bougie, intended to facilitate the flow of urine, and to give attachmennt to the thread. This was fixed firmly. On drawing the threads the circumference of the diaphragm was drawn, like the mouth of a purse, backwards, presenting the aspect of a hollow cone, which could be tightened so as to close the aperture. The surfaces of the mucous membrane, from which the circular diaphragm was detached, were drawn together and maintained in contact by suture. The oblitera- tion of the vagina was not complete, and the patient died of peritonitis about six weeks after the operation. Numerous objections to this operation were brought for- ward. Among the rest, the impossibility of obtaining a com- plete occlusion of the vagina—the difficulty of the operation —the retention of the menses in early life—the prevention of the performance of the sexual functions—and the danger of peritonitis and purulent absorption. M. Berand remarked, in reply, that a woman with a large and deep vesico-vaginal fis- tula, the urine flowing without cessation, and irritating the vagina and vulva; the buttocks and thighs irritated; the pa- tient exhaling an insupportable odor; the sexual relations pre- vented; the disgust inspired; her sufferings casting her into 122 FABRICIUS HILDANUS' CURE. despair; urging her to suicide, or leading to inevitable death —the case incurable by all known means,—under these cir- cumstances he retains his favorable opinion of the operation for the obliteration of the vagina. In the case in question, the patient was doing well to the twenty-third day, when an in- flamatory attack occurred from cold, and she died seventeen days afterwards. On disseetion, the vulva was found nearly obliterated, two small openings only existed, superiorly and inferiorly, the latter communicating with the vagina and the former with the bladder." The following goes to prove that vesico-vaginal fistula may sometimes be cured by very simple means. " During the time not yet very remote, when it was suppo- sed that the cure of vesico-vaginal fistula, was always beyond the resources of art, and especially that it was useless to attempt the radical cure, by means of a surgical operation, the palliative method, which was generally employed with the sole view of diminishing the inconveniences of a disgust- ing infirmity, was sometimes found to be successful in the cure of the patient. Fabricius Hildanus, who died at Berne, in 1634, relates a complete cure obtained in this way, in a lady affected with a vagino-vesical fistula, following a labori- ous labor. According to this celebrated author, the cure was obtained by a treatment of eight months duration, which con- sisted simply in the use of some purgative doses, and of fric- tions upon the loins, but especially in the frequent employ- ment of injections, composed of a decoction of barley, of quince-seeds, and the seeds of the fenugreek, (trigonella, fe- num grcecum,) to which he added oil of sweet, almonds and honey of roses. We subjoin, moreover, the most important passages from this curious case: " Ilia autem continuo usa medicamentis (ut dixi) conglutinantibus, et per intervalla etiam purgantibus, intra menses octo, non sine admira- tione omnium eorum quibus res cognita plane curata fuit, adeo ut nunc Dei optimi maxima gratia ne guttula quidem urinae involuntariae affluat, sed a vesica colligatur, retineatur MONS. DUCHATELET OF PARIS. 123 et excernatur non aliter ac si antea nunquam male affecta fuisset."—(Colombat on Diseases, of Females, p. 244-5.) Urethro-vaginal fistula is that form of the accident in which a preturnatural communication exists between the vagina and the urethra. This form is not so bad as the preceeding, be- cause the urine does not flow usually except during the volun- tary expulsion of this fluid, which escapes partly by the mea- tus urinarious, and partly by the accidental perforation. It may be produced by the same causes, which produce the former. Recto-vaginal fistula is that form of the accident in which a fistulous passage communicates between the vagina and the rectum. This accident is usually the result of laceration of the septum, between the vagina and the rectum, by the rash use of instruments, or by tearing in the natural efforts of par- turition ; in the latter case, the perineum usually suffers lace- ration also; or by the opening of abscesses in the direction of the two passages, &c. In such cases the faeces when solid are expelled, in part, through the vagina, and in part, through the anus, but only during defecation; when the faeces are fluid however, they and the intestinal gasses, escape involuntarily through the fistula, and pass out by the vulva. This form of the disease appears to be common among pros- titutes, in consequence, it is believed by some of the recto-va- ginal wall being exceedingly thin in such characters. In about four thousand prostitutes in Paris, says Mons. Duchatelet, there occur annually about thirty cases of recto-vaginal fistula; and strange to say that they sometimes heal of their own accord, while these patients are persuing their ordinary avocations. These fistulae were generally found to co-exist with phthisis. (De La Prostitution Dans La Ville De Paris. By Mons. Pa- rent Duchatelet, M. D.) This accident must have existed at all periods, yet strange to say, that no good history of it can be found, and it has only been since the commencement of the present century, that it has, at all attracted the attention of surgeons. It is to be hoped, therefore, that the importance of 124 "HEAVEN'S BEST GIFT." the subject will not fail to excite the sympathies of all who un- derstand its nature in causing them to use every exertion in their power to alleviate the condition of those who are its vic- tims ; always remembering that they are Heaven's Best Gift to man. It is admitted by all that the treatment, especially of vesico- vaginal fistula, is attended with the greatest difficulty, in fact it is seldom ever cured. This, on account of the unfortunate sufferer, has always been a matter of the most profound re- gret. My success in the treatment of this sad accident, so far, has been complete, having had but four cases, and having perfect- ly cured each one. One was a case of vesico-vaginal fistula, and three were cases of recto-vaginal fistula. Two were married ladies, and mothers. They both have had children since they have been cured, and are now, both doing well. In one of these, the accident was caused by a laceration during a difficult labour, in the other it was caused by an abscess in that particular vicinity. The following letters will be explanatory of the case of vesico-vaginal fistula alluded to. LETTER IV. ----, Ky., May 21, 1841. Doctor Bodenhamer:— Dear Sir.—From what I know of your success in the treatment of a certain class of diseases, I have for the last six months been using my utmost endeavors to induce my sister- in-law, Miss----, who resides with me, to consult you for a most loathesome complaint which she has been laboring under for the last eighteen months. Such has been her reluctance to undergo an examination and treatment, that she had deter- mined to linger out a miserable existence rather than submit. This morning, however, she consented, for the first time, to let me give a statement of her case, and at least get your opinion of it. She has taken a great deal of medicine, but she VESICO-VAGINAL FISTULA CURED. 125 has never been examined by any physician. About one year before this disease came on, she labored under some disease of the bladder, at least such was the opinion of her physician. She almost always felt a dull heavy pain about the bladder, extending to the back, hips, and down the thighs, attended by a difficulty in urinating, and a constant desire to do so. All this time, every thing was done, that could be, to relieve her, but without doing any good. Her general health continued to decline, until she was scarcely able to walk across the room. One day as she was coming down the stairs, she felt some- thing break loose near the bladder, and immediately there was a discharge of about half a pint of a thin dark colored and very offensive matter. This she always believes came from her bladder. Since this has taken place, she suffers scarcely any of her old pains; but what is much worse, there is a con- stant dropping of urine both day and night, so much so that she has constantly to keep fresh cloths applied. The smell is also so very offensive, that she now has a room to herself, and scarcely sees any one. There is no discharge of matter now, as far as she knows. Her general health is better than it was previous to the appearance of the disease, but I discover lately that she is getting worse again. She appears quite melan- cholly and desponding, indeed she has entirely changed in every respect. Her age is twenty-four and she has never been married. LETTER V. ---, Ky., December 23, 1S41. Dear Doctor :- According to promise I now write you again. Miss--- still continues well; indeed I consider her entirely cured. She can scarcely realize it herself, and has until a few weeks always been imagining that she might not be entirely well or anticipating that the disease might return. However within the last two weeks she has changed very much in this respect, and she is now as cheerful as she ever was, and in as fine 126 THE YOUNG LADY'S ZEAL. spirits. To give you some idea of her zeal in your behalf, a few days ago, she made me take her in the carriage some twelve miles to see a lady, a stranger to us, who she heard had a disease like her own, in order to prevail on the lady to visit you immediately. It proved however to be a different disease. [This young lady continued well up to the fall of 1843, when she married, and left this State. She wrote me in the spring of 1845 that she was in perfect health.] A full report of these cases of vaginal fistulae together with the treatment, will be given in my forth-coming work on the genito-urinary organs. I would remark here, that I am well prepaied for the medi- cal and surgical treatment of all chronic affections of females, such as, diseases of the womb, of the bladder, of the kidneys, of the vagina, &c. CHAPTER XXII. TESTIMONIALS. Read not to contradict, nor to take For granted ; but to weigh—to consider.—Lord Bacon. I would most respectfully call the attention of the reader to the following, a few of the numerous testimonials I have in my possession, relative to the success which has attended my peculiar practice in the treatment of the diseases named in this work. Many of the testimonials and names are of gentlemen, who stand high in public estimation. From the Louisville Journal, May 2-1, 1S43. In publishing Dr. Bodenhamer's card, we feel that we are doing a public service by calling attention to it. Dr. B. called upon us a few days ago and exhibited to us his case of instru- ments, which greatly surprised us by their variety and singu- lar ingenuity. We can venture to say from the facts and EUERGETES, OR BENEFACTOR. 127 testimonials before us, that there are few cases of the diseases which he professes to treat, that he does not cure perfectly, speedily, and without the infliction of pain. The following is from Doctor Thomas, of Richmond, Vir- ginia, editor of " The Herald of the Future Age." The man, who by any discovery in the treatment of dis- ease, especially of surgical diseases, can diminish the intensity of human suffering, richly deserves the title of Euergetes, or Benefactor of his race. In the treatment of fistula in ano et perineo recourse is generally had to the knife, which is always painful, often hazardous, and frequently unsuccessful. These results are the invariable concomitants of the popular prac- tice. We feel pleasure, however, in announcing to the public, that those afflicted with the diseases mentioned in Dr. Boden- hamer's card, may if they will embrace the opportunity, confer upon themselves much happiness, \ y placing themselves under his treatment, which consists not only in treating but curing these diseases. We have seen many drawings of cases which have been cured by Dr. B. Several of these had been pre- viously operated upon twice or more times with the knife, but without a curative effect; thus superadding to the misery of the disease, intense suffering from useless incisions. Dr. Bodenhamer's principle of cure is a strictly scientific one; it is a principle adopted by all educated practitioners in the treatment of numerous surgical cases; and one, in brief, without which they could do nothing. From frequent con- versation with the Doctor, we have been enabled fully to comprehend his treatment, and have no hesitation in saying, that were it submitted to the judgment of the Royal College of Surgeons in London, Dublin, or Edinburg, they would pro- nounce it perfectly scientific, and the apponent of it to prac- tice as worthy of all praise. For ourselves there is nothing we despise so cordially as quackery in any department of human knowledge or inge- nuity. We can assure the public, there is none in the pre- 128 TESTIMONIALS. tensions of Dr. Bodenhamer. The cases he has cured, as the Editor of the Louisville Journal says truly " without the in- fliction of pain" will speak for themselves. The Doctor has cases from the remotest parts of the Union, who come to him, and board in Louisville, for the sole purpose of being under his care, upon the recommendation of others, who have been made whole by his instrumentality. For one thing wre cannot but blame him, namely, that he is too diffident—a fault, how- ever, if indeed it be one, the almost invariable accompaniment of true merit. We think he ought to advertise his card in the principal Journals of the Atlantic Cities, inasmuch as he is fully competent to confer substantial benefit upon the afflicted as well as upon himself. Hitherto, we believe, he has depen- ded chiefly on the recommendation of the individuals he has cured. JOHN THOMAS, M. D. Louisville, Ky., June, 1844. From the Western Citizen, Extra, of January 15, 1841. DR. BODENH AMER'S CARD. We issue a small extra sheet, this day, containing the Card of Dr. Bodenhamer, and the testimonials of a number of gen- tlemen, who have been cured by him. We take pleasure in adding our testimony to the success which has attended Dr. B's. practice in those diseases. Several of the gentlemen, whose certificates accompany his card, are our personal ac- quaintances, and others are known to us from character, and from a partial acquaintance, while here under Dr. B's care, and we take great pleasure in stating that the utmost reliance can be placed upon these statements. Dr. B. has been eminently successful in his treatment of those diseases as our whole community could testify, and is excited by a laudable spirit, in endeavoring to place the facts before all, who may labor under their sufferings. We send forth this " little extra," with the hope that it will CONTINUED. 129 prove "glad tidings of great joy" to many who are laboring under those the most painful and loathsome diseases "which flesh is heir to." We may add, that ours is a pleasant little town, in a rich and beautiful country, and its health, locality, accommoda- tions, and all combine to render it just such a place, as a stranger would like to tarry at for a while. We notice in the Louisville Journal, of August 31, 1840, the following paragraph: " On Friday we noticed the arrival of Dr. Bodenhamer, distinguished for his novel treatment of a certain painful dis- ease without the use of the knife. Dr. B. has since exhibited to us the most satisfactory testimonials of his success from persons well known to the public." Also the following from the same, of March 22, 1842: " [f~P Meessrs. Editors : Feeling well assured that you are disposed to publish any thing calculated to benefit the afflicted, and subserve the interests of science, I would re- spectfully ask a brief space in your extensively circulated paper, in order to call the attention of all those afflicted with diseases of the rectum and anus to the card of Dr. Boden- hamer. He is now at the Gait House, and intends remaining there for a few days, as I am informed. The class of diseases to which he has given his most particular attention, and in which he has had a most extensive practice, embraces some which are perhaps as distressing in their nature, and which render the condition of their victims more truly miserable, than perhaps any other to which human nature is liable. The unparalleled success of the Doctor's peculiar method of treat- ing these diseases has attracted to his residence (at Paris, Ky.) patients from different sections of the Union, and also secured to him a very enviable reputation. We would advise all per- sons laboring under any of these diseases to avail themselves of the present opportunity of seeing and consulting the Doctor whilst he remains in the city. D. F*' **." 130 TESTIMONIALS. From the Louisville Tribune, July 5, 1844. OCT3 We would direct especial attention to the documents contained in Dr. W. Bodenhamer's advertisement on our first page. He has been prompted to the publication of them by his friends, who consider him as pre-eminently entitled to pub- lic consideration and confidence not only in the treatment of perineal, anal and rectal lesions, but also as a physician in general. The following is from " The Protestant Unionist," Pitts- burg, Pa, Medical.—Perhaps from no other class of diseases, is more suffering experienced, than from those affecting the rectum. None are perhaps more difficult to treat successfully, and cer- tainly there are none in which a rational treatment is more necessary. Of the practioners who have directed their skill and genius to the cure of these diseases, no one has attained to greater celebrity than Dr. W. Bodenhamer, of Louisville, Ky. In the Louisville Tribune, Extra, Dr. B. says:—" Too many- patients are said to have been cured by operations that have ultimately failed. Those bloody beacons, like the false lights of wreckers, have blazed but to betray, and the surgeon and the patient have often been lured on by their lying lustre to perform and to submit to barbarous repetitions of equally un- successful butchery. It should, therefore, be the great object of surgeons to discountenance these barbarous practices. To this point mainly our humble efforts have been directed." The following is from " The New Orleans Picayune" of January 24, 1846. □OP Dr. Bodenhamer, whose advertisement will be found in another column, comes recommended by letters from the most respectable gentlemen, professional and otherwise, of the West. They speak of him as eminently successful in the branch of his profession to which he has given particular attention. CONTINUED. 131 From the Western Citizen. Mr. Lyle :—Feeling myself under obligations to Dr. Boden- hamer, of this place, and believing it to be my duty to publish any thing that might be of service to the afflicted, is my apol- ogy for troubling you with the following short notice, to which I feel assured you will cheerfully give a place in your useful paper. In the year 1836, I was attacked with that terrible and ob- stinate disease, called fistula in ano, under which I labored for some months, suffering great pain. I was told by physi- cians that there was no cure but by an operation with the knife, and was preparing myself for it. In the spring of 1837, I was advised by a friend to go and see Dr. Bodenhamer, and, although a little faithless, I went and submitted to his treat- ment about seven or eight weeks, in which time I was entirely cured, and have remained so ever since, which has been near nine months. Myr reason for not making this publication sooner, was for the purpose of letting time test the cure. NOAH SPEARS. Paris, February 26, 183S. [ Nine years have elapsed since I discharged my friend, Mr. Spears, cured. He is still free from his old disease, and in the enjoyment of good health.] [ The following letter is from W. Huston, Esq., of the late firm of January, Huston & Co., Maysville, Ky. Upwards of seven years ago I cured this gentlemen, and it affords me great pleasure to announce that he is still in excellent health.] To the Editor of the Paris Citizen. Dear Sir:—Aware as I am, of the prejudice existing in the minds of many against Dr. Bodenhamer's mode of treatment of the disease called fistula in ano, and that the use of the knife has been, and is still by many regarded as the only effec- tual method of cure, I would here bear testimony to the fact that I, with many others, have been cured—effectually 132 TESTIMONIALS. cured of this disease, by Dr. Bodenhamer, and would now re- quest you to publish in your paper, the following statement of facts in relation to my case: " In the spring of 1837, I had a tumor formed near the rec- tum, resulting in a fistulous ulcer, which I regarded as a mere ulcer and treated it accordingly. It, however, did not get well under the usual treatment, but continued until September of the same year, when I had it probed and examined by my physician; when we ascertained that a sinus had formed in the direction of the rectum, and terminating, as we supposed, just without the sphincter muscle. I was advised by my phy- sician to have the sinus laid open with a knife, which was done to the extent that the sinus could be traced with a probe. After the expiration of some eight or ten weeks, the wound was healed, but it did not result in a cure of the disease. The disease returned again much in the same form as at first, and continued so until the following spring, when I went to see Dr. Bodenhamer, of Paris, Ky. I remained with him or under his care about six months, and had the delightful satisfaction of being cured of this very loathsome disease. The case with me was protracted unusually long, in consequence of the pecu- liar seat of the disease and difficulty of treating it. In many other cases that have come under the care of Dr. Bodenhamer, the cure was effected to my own knowledge, in les^s than half the time. In my case the deranged state of my general health operated, among other causes, to retard the cure. I cannot close this communication without adding the ex- pression of my unfeigned gratitude to Dr. Bodenhamer for his kind, gentlemanly, and unremitted attention to me while under his care. Very respectfully, yours, WILLIAM HUSTON. Maysville, Aug. 6, 1840. The following is an extract of a letter written by Mr. Payne, a gentleman of Woodford county, Kentucky, whom I cured of a fistula in ano, to Mr. Evans, of Versailles, Kentucky, who CONTINUED. 133 had a brother laboring under the same disease, whom I have since also cured, and who had been operated on three times with the knife: Woodford County, Ky. April 10, 1840. Mr. Evans—Dear Sir:—I received your letter late yester- day evening, and hasten to comply with your request. I was attacked with a fistula in ano about two years before I applied to Dr. Bodenhamer. It commenced by a small tumor forming about one inch from the end of the rectum, causing but little pain at first more than an itching: it at last broke out and discharged a quantity of matter, and became so painful that I could scarcely sit at all. I became alarmed and applied to Dr. Dudley, who told me what it was, and said I could not be cured in any other way than by an operation with the knife, and gave me medicine to prepare for it. While preparing for an operation, I made extensive enquiries, and learned to my satisfaction that it was dangerous and uncertain. I deter- mined to let the disease take its course, and did so for a long time ; but it continued to grow worse: so much so that I was confined in the house nearly all the time, and a great portion of the time to my bed. I heard by mere chance that Dr. Bo- denhamer, of Paris, Kentucky, was curing the disease without the knife. I applied to him one year ago last January, and he cured me in a short time. His treatment was quite mild indeed, and I was not confined to my room a single day. My o-eneral health is now as good as ever it was. I would advise your brother to go to Dr. Bodenhamer immediately, by all means, if he has to be hauled in a bed, the sooner he goes the better, as he has no time to loose. Dr. Bodenhamer has cured cases so far gone that they were mere skeletons, and in a man- ner entirely helpless, and he has restored them to perfect health. He has cured a number who had been operated on, some as often as four or five times, with the knife, and given out to die by other physicians. Tell your brother I will war- rant him to be cured ; and that in a short time, if his lungs are not materially affected. Boarding in Paris can be had for three 134 T ESTIMONI ALS. dollars per week, and Dr. B's charges are not by any means extravagant. The poor who are unable to pay, he cures for nothing. Respectfully, your friend, LEWIS T. PAYNE. [ About eight years ago I cured my friend, Mr. Payne, and quite a recent letter from him announces that he is in excel- lent health.] From the Western Citizen. Mr. Lyle—Dear Sir:—Having been cured of an invete- rate fistula in ano, by Dr. Bodenhamer of this place, I feel it a duty I owe to him, as well as others who may be afflicted in the same way, to make it known to the public. Will you be so kind, therefore, as to publish this in your paper? I was attacked with this disease in October, 1837. It commenced by a tumor forming near the rectum, which finally broke in- ternally, and was lanced externally, from which continued to issue a most acrid matter. This discharge continued to grow worse, which affected my general health very much. Hearing of the success of Dr. Bodenhamer in curing this disease with- out an operation with the knife, I determined to apply to him, and done so last April. Since about the first of October last, I have been entirely well, and my general health nearly as good as it ever was. I would recommend to any person afflicted with this disease, to apply to him, being firmly of the belief that his skill and method of cure cannot be surpassed. I might have added that I was not confined to the house during the time I was under Dr. B's. treatment, and might have attended to ordinary business. J. D. COOK. Bourbon County, Jan. 17, 1839. [Mr. Cook was entirely well when I saw him a few years ago.] From the Western Citizen. Mr. Lyle.—Permit me, through the medium of your paper, to add my humble testimony in favor of the successful treat- CONTIN UED. 135 ment of fistula in ano pursued by Dr. Bodenhamer, of this place. In performing this duty, I feel no ordinary degree of pleasure, I assure you. About two years and a half ago I was attacked with this most obstinate and loathsome disease. It commenced by a tumor forming about an inch from the termination of the rectum. This tumor was lanced, from which issued a large quantity of matter. It could not be healed, and upon examination there were found four or five sinuses (or openings) running in different directions. One of these penetrated the rectum very high up. These sinuses were lined with a hard, callous flesh, and- they continued through one external opening, to discharge a thin and acrid matter. I applied to several eminent surgeons, who all in- formed me that there was no other method of curing the dis- ease at all but by an operation with the knife, and that in my case it would require quite an extensive and formidable opera- tion, and that I must submit to this or die. I concluded at that time at least to run the risk of dying rather than run the risk of perhaps being killed by an operation with the knife; believing it to be, from extensive testimony, a very inefficient method at any rate of curing the disease. As soon, however, as I knew to a certainty that Mr. Noah Spears, of this place, .was effectually cured of this disease, by Dr. Bodenhamer, without the knife, I immediately submitted to his treatment; and although I did not, as I should by all means have done, follow his directions with respect to diet and exercise, yet he has perfectly cured me. It is now about three months since, during which time I have enjoyed as good health, and con- tinued, as I ever did in my life. The number of cases that Dr. Bodenhamer has cured within the last year, renders it no longer a matter of controversy whether the disease can be cured without the operation of the knife. FRANKLIN HUTCHISON. Paris, July 4, 1838. [My friend Frank Hutchison has been cured about eight years, and is still in the enjoyment of perfect health.] 136 TESTIMONIALS. To the Editor of the Western Citizen : Dear Sir :—I feel a peculiar pleasure in giving my testimo- ny in favor of the method pursued by Dr. Bodenhamer, of Paris, Ky., in treating fistula in ano, having been effectually cured of that disease by him. Sometime after the disease made its appearance on me, I applied to an eminent physician of Maysville, who informed me that I must submit to an ope- ration with the knife in order to be cured; but when the time arrived, I declined, fearing the result. I then put myself under the care of a physician who proposed to cure me with- out operating with the knife. He treated my case about four months; but owing to the severity of the treatment, and the fact that I was getting no better, I determined to apply to Dr. Bodenhamer; I accordingly came to Paris and put myself under Dr. B's. care, and remained about five weeks, during which time he cured me. His treatment was so mild that I scarcely suffered any pain whatever. My general health, too, commenced improving immediately, and is now as good as it has been for a long time. I would recommend all persons laboring under diseases of the rectum and anus, to apply to him, being assured that they will never regret it. Respectfully, &c, JOSHUA BURGESS. Mason County, Ky., Aug. 23, 1840. [Six years ago I cured my friend Mr. Burgess, and he re- mains well to the 'present. Previous to my curing him, he had employed a physician who treated him according to Dr. Beach's method, caustic, potash, &c] To the Editors of the Louisville Journal: Gentlemen :—I feel that I would be guilty of a dereliction of duty in omitting to add my testimony to that of so many others in confirmation of the skill of Dr. Bodenhamer, of Paris, Ky., in the treatment of that most obstinate disease, called by surgeons, fistula in ano. Permit me therefore, although a stranger, to request you to publish my cure in your extensively circulated paper; not only for the benefit of Dr. CON T IN UED. 137 B., but for the benefit of those who may be afflicted in the same manner. All such I do earnestly request to make imme- diate application to him. He has cured a large number, some of whom have been operated on with the knife several times without being at all benefitted. About five years ago I sustained an injury near the rectum (or bowel) by riding a wild horse. A tumor formed and broke, and left a large abscess, from which three sinuses (or openings) ran in different directions; one of which penetrated the bowel high up. These were hard and callous and from them there was a constant discharge of thin and acrid matter. My gen- eral health suffered very much. I had a constant pain in mv back and hips. All the physicians I consulted, advised me to be operated on with the knife, as the only method of cure. This I determined never to submit to, on account of its un- certainty, painfullness, and danger. I happened by mere acci- dent to hear that Dr. Bodenhamer had cured Mr. William Huston, commission merchant, Maysville, Ky., who had been previously operated on; and that he had cured many others without the use of the knife. I immediately left my home (near Greencastle, Indiana,) and applied to him, and continued under his treatment about eight weeks, and a per- fect cure was the consequence. His treatment was mild and I was not confined to my room. AMBROSE DAY. Greencastle, Putnam County, la., Feb. 2, 1840. [1 have just heard from Mr. Day. He is in excellent health. It is six years since he was cured.] From the Frankfort, Ky. Commonwealth, May 21, 1844. Owen County, Kv.,.May 10, 1844. Mr. Editor—Dear Sir:—I may do the public some good, at least those who may be afflicted, as I once was, by calling their attention to the fact that in January, 1839, I made application to Dr. Bodenhamer, then of Paris, Ky., but now a resident of the city of Louisville, to be treated for the disease now quite 138 TESTIMONIALS. common, called fistula in ano—this disease made its appear- ance on me in the spring of 1838, during which time I had submitted to an operation with the knife for its cure. This operation (as is too common in those cases) instead of curing me, greatly tended to aggravate the disease. I was strongly urged to submit to another operation, by being told that noth- ing else would cure me; in the mean time I had heard of Dr. Bodenhamer, to whom I applied, as stated above, and the con- sequence was a perfect cure. This was done by no hazardous operation, with but little pain, and scarcely any confinement. It now astounds me when I hear of persons submitting to such uncertain, unnecessary, often dangerous, painful, and always cruel operations for those diseases, when they might be cured by a much more scientific, rational and effectual method by Dr. Bodenhamer, whose experience in such cases is not sur- passed by any physician in this country. Dr. Bodenhamer is a gentleman and a man of science, and justly deserves encour- agement. Your friend, JOEL HERNDON. [ In a letter from my friend Mr. Herndon, received a few weeks since, he announces that he remains entirely well.] From the Louisville Tribune. Dear Sir :—Having been afflicted with what is called a fis- tula in ano, for some four years, occasionally suffering very much, and feeling assured that unless the disease is cured, I must necessarily linger out my days with little profit to myself and fellow man; I came to the conclusion to make an effort to be healed, and dreading the operation with a knife, I con- cluded to place myself under Dr. Bodenhamer of Louisville, Ky., who advertises to cure without the use of the knife. I was under the doctor between five and six weeks, and am now per- fectly well and healthy, and can say that I suffered but very little under the treatment. I would advise all those afflicted with the above disease to call immediately on Dr. B.,in whom they will find all the traits which characterize the gentlemen, phi- lanthropist, and man of science. A. HATCHITT, Jr. Hebardsville, Ky, July 19, 1844. CON TINUED. 139 From the Louisville Tribune. Mr. Editor :—It is with great satisfaction I acknowledge my indebtedness to Dr. Bodenhamer, of your city, for the excellent health which I now enjoy, being in as perfect health as I ever was. I was first operated on for fistula in ano, by the late Dr. H. G. D. of Brandenburg, Ky, without any bene- fit. I then placed myself under the care of Dr. G., of Louis- ville, who also operated on me with the knife. I remained under his care about a fortnight without being benefitted. I then placed myself under the care of Dr. B., and without the use of the knife, or any painful remedy I find myself relieved from any symptoms of the complaint. I have been working hard, and using as much exercise on horseback and otherwise, as I ever did, without any inconvenience or annoyance from the disagreable disease. Yours with respect, EDWARD R. HARDISTY. Brandenburg, Ky., July 25, 1844. [ I have just heard from both Mr. Hatchitt and Mr. Hardis- ty. They are both in perfect health, and have been since I cured them.] From the Scioto Gazette. Mr. Ely:—You will please give the annexed one or two insertions and charge to our account. I feel it due to Dr. Bo- denhamer, to make this statement to the public. His moral character is unimpeachable; he has never failed of curing those who come to him in time. Feeling assured that you would publish any thing calculated to subserve the interests of humanity or science, I would res- pectfully request you to publish the following facts: I have been laboring under haemorrhoids, or piles, for four- teen years past, the last four of which in their most aggra- vating forms. They finally terminated in what is called a fis- tula in ano, an abscess formed at the side of the anus or bowel, which broke internally, and externally, and discharged matter from both openings, thus making a complete fistula in ano. 140 TESTIMONIALS. The sinus or opening in the rectum or bowel, was almost half an inch up the same. For about six months before I was cured of this most distressing disease, I suffered the most ex- cruciating pain, and a considerable portion of that time was confined to my bed. I was advised by my friends to submit to an operation with the knife as the only remedy. To this I could not consent, until I had at least tried other remedies. I accidently heard of the successful treatment of Dr. W. Bo- denhamer, of Paris, Ky. I wrote to a gentleman of that place, who kindly forwarded me the certificates of several res- pectable men, who had been entirety cured by Dr. B. I deter- mined at once to go to Paris, and put myself under his care. I arrived in Paris on the 21st of January last, and remained there just five weeks, and returned home, I am happy to say, " a sound man." My general health has improved very much. Dr. Bodenhamer's mode of treatment is very mild. I was not confined to my room a single day, was able to attend to ordinary business. During my stay at Paris, I became ac- qainted with several gentlemen who had been entirely cured of this disease, by Dr. B. Some of them had been operated on with the knife two or three times, without success. I would earnestly recommend those who are laboring under this distressing disease, to avail themselves of the services of Dr. B. without delay. Respectfully, yours, GEORGE PORTER. Piketon, Ohio, March 16, 1S42. [About three weeks since I received a letter from my friend Mr. Porter, in which he says his health is excellent.] From the Quincy (111.) Whig, April 24, 1844. Mr. Editor—Dear Sir:—I take great pleasure in calling the attention of the afflicted to the card of Dr. Bodenhamer, which you publish in your paper. His acknowledged skill and suc- cess in the treatment of the diseases named in his card, need not my testimony to establish. I cannot however, on the pre- sent occasion avoid expressing my decided approbation of both. CONTINUED. 141 Nearly two years since, I was attacked by what is called fis- tula in ano. A large abscess formed at the side of the lower bowel, and continued to discharge matter until I was cured last fall by Dr. B. I was under his immediate care about six weeks ; was not confined to my room, and suffered but little pain. I was induced to apply to Dr. B. by my friend Captain Gliem, of St. Louis, who was cured by him of the same dis- ease, having previously submitted to two operations with the knife. My advice to all afflicted with anyT of those diseases, is to make immediate application to him, and I am certain that they will never regret it. By publishing this in your paper, you will confer no small favor on me, and subserve the cause of science and humanity. Respectfully, JOHN FIELD. Quincy, 111., April, 1844. [ I received a letter from Mr. Field about one year ago. He was then in the enjoyment of excellent health.] Glasgow, Ky., Sept. 18, 1845. Dr. Bodenhamer: Dear Sir—Yours of the 7th inst. was duly received; in reply to which I am happy to say to you that I am entirely restored to health, which no man can enjoy while laboring under that dreadful disease called fistula; which disease I was greatly afflicted with ; but by your superior skill as a physician, I am now clear of it, and feel no symptoms of its return. I am convinced that if all who are so unfortunate as to be afflicted in that way, were to call on you, that they would be entirely cured. Please accept my best wishes for your future prosperity, and success in healing the afflicted. Your friend, CHAS. R. CROUCH. [I cured my friend Mr. Crouch about one year previous to the date of his letter. He had labored under an obstinate fistula in ano, for several years.] ----, Mi—, December 1, 1844. Dear Doctor—I am happy to inform you, that my wife has not had the slightest return of piles, since she left you 142 TESTIMON IALS. last spring. Her general health has improved so much that you would scarcely know her; and what is best of all, her bowels keep entirely regular, without her resorting to medi- cine. She still follows your directions with regard to purga- tive medicines, to diet, &c. In fact, her general health is better than it has been for ten years, for during that time, scarcely a day passed without her taking more or less med- icine. ------------. [The following was received from the Hon. Richard M. Johnson, whilst he was Vice President of the United States:] My Dear Sir:—This will be handed you by Dr. Boden- hamer, who wishes to make some publication in the Globe, relative to a certain class of diseases which he treats with the most astonishing success. Permit me therefore to recom- mend him to you as a gentleman of real merit, and in every respect worthy of confidence. I solicit for him your kindness and friendship. I am very respectfully yours, R. M. JOHNSON. F. P. Blair, Esq., Editor of the Globe, Washington, D. C. [The gentleman alluded to in the following communication, is Norman T. Cherry, Esq., of Cherryville, Tennessee. In 1841 I treated him for a desperate fistula in ano; and the fol- lowing letter from his brother, announces the gratifying intel- ligence that he is perfectly cured.] Cherryville, June 25, 1845. Doctor Bodenhamer: Dear Sir—Yours of the 30th ult. is at hand. You wish to know whether my brother's old disease is permanently cured. I am happy to inform you that it is. He says, how- ever, at times he experiences some effects, not perhaps of his old disease, but a kind of itching humor, nothing more. He CONTIN UED. 143 is entirely satisfied that his fistula is cured, and that it will not return. He would like however, to know of you whether this itching humor partakes any thing of the nature of fistula. He most cordially wishes you much success at your new place of location. I am most respectfully yours, C. W. CHERRY. [The following is from Samuel P. Weisiger, Esq., of this city. His case is alluded to, in another part of this work.] Louisville, January 1, 1846, Gentlemen—This will be handed you by my friend Doctor Bodenhamer, of this city. He visits New Orleans for the purpose of spending a few months, and practising his profes- sion. The Doctor treats the piles and fistula with great success; he having treated my case, (after having suffered greatly for more than eight months,) and giving me relief in a few weeks. I can, therefore, recommend the Doctor to any of your friends who may be laboring under a similar affection. Any aid rendered, or attention shown the Dr., will be grate- fully acknowledged. Respectfully yours, &c, SAMUEL P. WEISIGER. Messrs. Worsley, Foreman & Keneday, Commission Merchants, New Orleans, La. [The following is from W. Bishop, Esq., of this city, pro- prietor of the Louisville Hotel.] Louisville, Sth January, 1S46. Dear Sir—Permit me to introduce to your acquaintance and friendly attention, my friend Doctor Bodenhamer, of Louisville. It is the Doctor's intention to practice his pro- fession in your city for a short time. Here he stands very 144 TESTIMONIALS. high in a particular branch of his profession. Any attentions or civilities extended to him in aiding the object of his visit, will be thankfully acknowledged by Your friend and humble servant, W. BISHOP. P. N. Wood, Esq., New Orleans, La. [The following is from my friend L. H. Mosby, M. D., late Post Master of this city.] Louisville, Ky., January 3, 1846. Dear Sir—Although I have not the pleasure of a personal acquaintance with you, it has been my good fortune to have corresponded and co-operated with you in the Post-office ser- vice. I hope you will then excuse the liberty I am taking in introducing to your acquaintance Dr. Bodenhamer, a practi- tioner of medicine in this place. Dr. B. has for many years given his particular attention to the treatment of the diseases of the rectum; and I certainly regard him as decidedly the most successful practitioner, in that department of the profession, that I have ever known. I therefore do most cordially recommend him to any of your friends or acquaintances, who may need his aid. I suppose you may have heard that I have had to " walk the plank"—and have to return to the practice of my pro- fession—and which, by the bye, I had better never have left. I am truly and respectfully, Your unknown friend, L. II. MOSBY. Gen. W. De Buys, New Orleans, La. [For the success attending my peculiar method of treat- ing the diseases named in this work, I would most respectfully refer the reader to all, or any of the following gentlemen. Those marked with a star, have been cured by me offistula in REFERE NCES. 145 ano; those without this mark, have kindly permitted me to refer to them, being well acquainted with me, and the success attending my practice in those diseases.] *Mr. John C. Evans, Louisville, Ky. *Samuel P. Weisiger, Esq " " Abraham Hite, Esq. " " John P. Bull, Esq. Rev. M. J. Spaulding, D. D. " " L. M. Mosby, M. D. I. Everett, Esq., Gait House, " " W. Bishop, Louisville Hotel, " " *Mr. Noah Spears, Paris, " *Mr. B. F.Wigginton, " " *Mr. F. Hutchison, " " Messrs. Spears cVfalbott, " " Charles Talbott, Esq. " " E. Thurston, Esq. " " Thomas Y. Brent, Esq. " " Elder A. Raines. " " *Joshua Burgess, Esq. Mayslick, " *M Walker, Esq. West Port, " *Col. P. C. S. Barbour, Oldham Co. « *C. R. Crouch, Esq. Glasgow, " *Rev. James Elliott, Fairfield, " *Mr. David Fort, Smithland, " Hon. W. Reid, Esq. Washington, " * William Huston, Esq. Maysville," A. M. January, Esq. " " Mr. F. M. Cockrell, Lee House," « J. Montmullen, Esq. Lexington, " *Joel Herndon, Esq. Osventon, " •Hon. A. G. Hawes, Owensboro, " *A. L. Peay, Esq. Jefferson Co., " *Maj. Jacob Hikes, " " " *L. T. Payne, Esq. Midway, " S. M. Wallace, Esq. " " *Mr. A. Rouner, Mt. Hope, « *Hon. M. V. Thompson, Georgetown " Thomas S. Page, Esq. Frankfort, '< 0. G. Cates, Esq. " " John C. Herndon, Esq. W. W. Hall, M. D. Cincinnati, Ohio Richard Conkling, Esq. Rev. N. L. Rice, D. D. Daniel Gano, Esq. " " Elder James Challen, Elder David S. Burnett, " " L. Ludwick, Esq. " " *Capt. H. G. McComas, " *B. Montgomery, Esq. Decatur, " *G. Porter, Esq. Piketon, Ohio. J. Miller, Esq. Columbus, T. W. H. Moseley, Esq. " " D. Raffensparger, Esq. Canton, " Mr. J. Bodenhamer, Millersburg, " *E. E. Bass, Esq. Columbia, Missouri. Elder T. M. Allen, *Capt. J.H. Gliem, St. Louis, " *A. S. Swearingen, Esq. " " R. Henderson, Esq. Lexington, " *Gen. S. A. Burnett, N. Albany, Ind. C. Nunemacher, Esq. " D. G. Stewart, M. D. " " *Mr. Ambrose Day, Greencastle, " *James Sidener, New Washington, " Nathaniel Field, M. D. Jeffersonville," *N. T. Cherry, Esq. Cherryville, Tenn. W. J. Barbee, M. D., Franklin, " W. L. Vance, Esq., Memphis, « Rev. A. H. Kerr, Clarksville, _ " James Cage, Esq. Houma, Louisiana. *Hon. L. Saunders, Clinton, " S. Slaughter, M. D. Cheneyville, " Col. Y. N. Oliver, New Orleans, " Col. Miller, Mudge & Wilson, St. C. Hotel, " " *C. M. Rutherford, Esq, " " Capt. J. Hart, *B. B. Ellis, Esq. Rodney, Miss. *T. J. Lickens, Esq. Princeton, " *J. Crizer, Esq. Natchez, " Benj. Ricks, Esq. Canton, " *Lewis Beard, Esq., Aldie, Virginia. *I. H. Jones, Triadelphia, " John Thomas, M. D., Richmond, " * W. V. Barkalow, Esq. Philadelp'a, Pa. *Capt. Charles Stone, Alleghany, " *Thomas Wynne, Esq. Pittsburgh, " Elder Walter Scott, " " James Wright, Esq. Chambersburg, " Wm. Hildebrand, Esq. East Berlin, " Col. R. B. Servant, Esq. Chester, Ills. *John Field, Esq. Quincy, R. J. Thomas, Esq., St. Charles, " Elder D. P. Henderson, Jacksonville, " * Col. P. M.Butler, Columbia, S. C. Hon. J. Chambers, Burlington, Iowa. Rev. A. Cleaver, Jackson, Miss. 10 146 invalid's bill of fare. CHAPTER XXIII. CONCLUDING OBSERVATIONS. Under this head I wish to make a few brief and desultory remarks. Constipation of the bowels is a most fruitful source, and a most frequent accompaniment of the diseases treated of in this work. Its removal therefore is of the greatest importance; and this should be accomplished by the most simple means pos- sible, such as diet, enemata, exercise, and the invariable custom of visiting the privy once in the twenty-four hours, and solicit- ing an evacuation, whether there is a natural inclination or not. Much depends upon diet in obviating constipation, but it is impossible to lay down any general rules in this respect, or to furnish any one certain or exclusive plan of regimen, in consequence of the various and conflicting idiosyncrasies. Would the patient however, but pay strict attention to what really agrees or benefits him, and what disagrees or injures him, he would doubtless be enabled by the information thus obtained, to prevent constipation so far at least as diet is concerned. My patients are usually presented at the commencement of their treatment, and to be strictly observed during the same, with the following bill of fare. ARTICLES PRESCRIBED. Old Wheat, or Rye Bread, Bread made of coarse and unbolted wheat flour, Rye Mush, with either milk or molasses, Indian meal Mush, with either milk or molasses, plain Puddings, boiled Rice, Potatoes roasted in hot embers, Arrow Root, Tapioca, Sago, Indian meal Gruel, oatmeal Porridge, a little fresh Butter stewed Fruits, fresh Fish, fresh Oysters, Eggs cooked quite rare, Onions thoroughly boiled, animal Jellies, a small quantity of BEST PREVENTIVE MEASURE. 147 cold tender Meat or Poultry, such as Lamb, Deer, Veal, Chicken, Squirrel, &c; either Milk or Molasses when they agree, Coffee made of cocoa shell, weak black Tea. ARTICLES PROSCRIBED. Coffee, Green Teas, Gravies, Soups, Spices, warm Meats of all kinds, salt Fish, Bacon, fresh Bread, Pastry of all kinds, Cakes, mince Pies, Cheese, Pickles, unripe Fruits, Tobacco in every form, Nuts of all kinds, Ardent Spirits, Mait Liquors, &c. No late suppers should be indulged in. The great object is to keep the digestive organs in a good state, by the quantity and plainness of the food. In a word, there should be universal temperance, regularity and exercise. When purgative medicine is absolutely necessary in addition to regimen, to obviate constipation or to correct vitiated and irritating secretions, the most mild and least drastic of this class of remedies should be used; and the medicine should be immediately discontinued on the alvine discharges becoming healthy. As it regards enemata, cold water, or cold flaxseed tea makes the best lavement or enema, that can be used. All warm, relaxing or stimulating injections should be avoided. The method which I have found best in the employment of this kind of lavement, is to direct the patient to throw up into the rectum a pint and a half of cold water, or cold flax-seed tea, after breakfast, and about five minutes before a stool is sought for. When this has been voided, the patient should then throw up from two to four ounces, and retain it. The Pump Syringe, or Gum-Elastic Bag, is the best instrument for this purpose. Either of them renders the administration of this excellent means so very easy and simple, that no difficulty need be experienced in their frequent use. The gum-elastic bag is the most convenient for those-who are travelling, as it can be filled and carried in the pocket to the privy. Of all the preventive measures against those diseases, none are perhaps to be compared to the use of cold water, applied 148 DR. REYNELL COATES. to the anus and surrounding parts by means of a soft sponge, after each evacuation, or oftener. This is a great security against the diseases of this region, and should by all means be followed up, both in summer and in winter. Several important subjects have been omitted in this work, which will be treated of at large in the work named in the preface. They will appear in that work under the following heads : Anatomy of the Rectum and Anus; Physiology of the Rectum and Anus; Pathology of the Rectum and Anus; Mal- formations or Vices of Conformation of the Rectum and Anus ; Foreign Bodies in the Rectum; Injuries of the Rectum and Anus ; Atony of the Anus ; Preternatural Pouches of the Anus, or enlargement of the small semi-lunar sacs, formed at the ter- mination of the mucous membrane of the rectum. This last named disease has usually been confounded with occult fistulae, but it is essentially different from such fistulas, and should have a seperate and distinct consideration. It was first made known to the profession by the late and lamented Doctor Physic, the father of American surgery, in 1792. For a full description of this peculiar disease, the reader is referred to the American Cyclopedia of Practical Medicine and Surgery, Vol. 11, Article Anus, page 123. He will find the whole of the article Anus, to be one of the most able and interesting productions extant on this subject. It was written by Dr. Reynell Coates, of Philadelphia. Some may censure me for not giving in this work my pecu- lear method of treating those diseases. My answer is, that I am decidedly opposed to "publishing cures for the multitude." Too many works of this class already exist for the good of the community. The instruction they need, is how to pre- serve their health. Books giving such instruction, are real acquisitions. When, however, they do become sick, it is then especially the province of the physician to restore them to health. The object of the work has already been stated, it is simply to instruct all who will be instructed in relation to the nature, causes, symptoms, consequences and prevention of PREVENTIVE BETTER THAN CURE. 149 those affections. This is of the greatest importance, for the reader should never forget that " an ounce of preventive is worth more than a pound of cure." Another reason for not publishing the treatment in this work is, that these diseases are difficult to treat; and it is presumed that none would attempt to treat them, who have not the indispensable pre-requisite, a complete knowledge of their pathology, as well as a complete knowledge of the anat- omy and physiology of the parts concerned. Without this none can treat them with discrimination and success, and this kind of knowledge is not to be obtained from books; it is only by dissections, and by attending patients laboring under those diseases, that the medical man can ever acquire that quick- ness, that peculiar tact and that experience which alone can render him able and skillful in their treatment. It would be useless to dwell on the necessity of the surgeon being thoroughly acquainted with these painful maladies. Their distressing nature weighs heavily on a patient's comfort and repose of mind, and he anxiously seeks for relief at the hands of science; but too often he does not receive it. "How then can a physician practice with a clear conscience, who does not keep himself on a par with the knowledge of the age. In other professions, ignorance maybe folly; in ours, it is crime!" If patients would consult none but those who are really qualified to treat disease, quackery would at once cease, and "Messrs. Humbug, that large and flourishing Firm," would soon have to close doors. Were I disposed to make an apology for the many imper- fections of this work, I would remark that it was written at verv short intervals, "snatched" from professional engage- ments, during a few weeks in the months of July and August. I have now concluded my remarks on this important sub- ject, and hope that they will not prove altogether useless. They are imperfect it is true, but as far as they go, they are exclusively the result of observation and experiment. Should 10* 150 ADDENDA. they in the least tend to bring the diseases of the rectum and anus more within the range of science, (which have heretofore been too much the prey of the ignorant and the designing quack,) my object in a great measure will have been attained. ADDENDA. □CpAll persons who intend visiting me for the purpose of submitting to treatment, or who may wish to consult me by letter or otherwise, must remember that I spend the months of December, January, February, and March, of each year, in New Orleans, La.; and the remaining months I spend in Louis- ville, Ky., where I have my residence. I leave Louisville for New Orleans about the 20th of November, and New Orleans for Louisville about the 1st of April, of each year. By no- ticing and attending strictly to this arrangement, no disappoint- ment whatever need take place. [Xj3 All letters addressed to me, or to any of the gentlemen named in this work, as references, must be post-paid. OCf All persons writing to me for medical advice, for the first time, must invariably accompany their letters with at least five dollars, free of postage. INDEX. Page. The cause of the increase of Anal and Rectal affections - - 9 The southern gentleman and Brandeth's pills - - - - 9 Tight lacing and its evil consequences - - - - 10 Dr. Flint on the abuse of purgative medicine - - - 10 Interesting statistics relative to Fistula in Ano - - - 11 Hsemorrhoids or Piles—their antiquity, &c. ... 12 The "Emerods" of scripture, considered to be Piles - 12 The division of Piles—their symptoms—their structure - 13 The diagnosis of Piles - - 15 Most frequent and familiar agents in producing Piles - - 16 The opinion of the ancients with regard to their cure - - 17 Danger of delaying their cure 17 Their great frequency among the Turks - - - - 18 Baron Larry's treatment by horse exercise 18 Montegre's two cases cured by the "douche ascendante" - - 19 The kind of Piles'that should not be suppressed - - 20 Their common treatment generally empirical - . - 21 Various superstitious notions with regard to their treatment - 21 Excision of Piles, a most dangerous operation - - - 22 The natural cure of Piles ..... 23 Sir B. Brodie's account of Home Tooke's illness - - - 23 Novelty and ingenious speculations not admitted into this work 24 Interesting letters from persons laboring under Piles - 24 Physicians pay too little attention to Piles—the reasons - 32 Fistula in ano—its early history—Hypocrates, Celsus, Galen - 32 Louis XIV. labored under fistula ani—his experiments - 33 M. Felix received $30,000, for operating on the grand Monarque 33 Henry VIII. is said to have died of fistula in ano - 34 Definition of the term Fistula—clasification of Fistula - - 34 Description of Fistulae - - . - 35 The disease found among all clagses in society—the causes 37 INDEX. Page. 38 39 40 Various foreign substances extracled from fistulous abscesses Symptoms of fistula in ano - - - - The treatment of fistula in ano, by incision, by extirpation by the actual and the potential cautery, &c. The error that led to the adoption of these methods - 40 The method by incision the most popular 41 Dr. Bush's mode of performing the operation - - 41 A gentleman cut twenty-two times before cured - - 42 Objections to the knife operation - - - - - 42 Eminent danger of the knife operation—from hemorrhage, &c. 43 Dr. Colle's method of operating - - - - 44 No necessity whatever for the operation - - - 45 Spontaneous cures of Fistula in Ano - - - - 46 The object in publishing letters detailing symptoms, &c. 46 Very interesting letters from persons who had Fistula in Ano 47 A cure without either medical or surgical treatment - 53 Bodenhamer does not pursue Dr. Beach's method in treating Fistula in Ano - - - - 56 The Water doctor (not the cold water doctor) - - 57 Butler's description of Sidrophel - - - - 57 Abscess near the rectum and anus—various kinds - - 58 Spinal abscess cured, of 15 years standing - - 61 M. Velpeau and transpiration - 61 Numerous foreign bodies removed from abscesses - - 62 Letters from persons labouring under abscess - - 63 Two desperate cases cured ... . - 64 Complication of fistulous abscess with consumption - 65 The opinion of Laennec and Bordeu on this subject - 65 Andral's opinion - - ... 66 A fatal error to abandon such cases - - - 66 No harm can result from my treatment - - - 67 An important case cured - - - . - 67 Interesting letters on this subject 68 The worst kind of advice - - - . - 69 Death from procrastination ..... 69 Fissure of the Anus—its description, &c. - - - 70 The opinions of Merat, Velpeau and Boyer - - 71 The symptoms of fissure of the anus - - - - 71 Popular method of treating this disease - - - 72 The mode of operating as persued by Dr. Bushe - - 72 No necessity whatever for this operation - - 73 IN DEX. Page. An interesting case cured - - - - - 73 Letters from persons laboring under fissure - - 73 A Lady cured of this disease - - - - - 74 Prolapsus Ani—its varieties 76 The causes—the position to be observed in stooling - - 76 The popular method of treating this disease - - 79 Letters from persons laboring under Prolapsus Ani - - 79 A gentleman cured sixty years of age ... 79 A gentleman rendered miserable for life - - - 80 Ulceration of the Rectum—the causes, &c. 81 Veneral ulceration of the Rectum - - - - 82 The symptoms—it is difficult to cure 83 Letters from persons labouring under ulceration - - 84 A case cured at New Orleans _ ... 85 Inflamation and excoriation of the anus—the causes - - 85 Velpeau's case—the use or object of the hair about the anus 86 The treatment when caused by filthiness of the parts - 87 Pruritus of the Anus—a rebellious affection - - 87 Dr. Lettsome's opinion of this disease - - - 88 To treat it with success, the cause must be well understood 89 Excrescences of the anus—their description, &c. - - 89 Fanciful appellations of the Greek, Latin and Arabic authors 89 A Lady and Gentleman cured - - - - 90 Rectal polypi—Sir A. Cooper's experiance in - - 91 The symptoms—always considered dangerous - - - 92 A very bad case cured - - - - . - 9« Anal neuralgia ----- 9d 94 - 95 96 - 96 Symptoms—Dr. Bushe describes a case A humorous description of the common treatment Spasmodic contraction of the sphincter ani Not considered a primary disease by some Thesymp'.oms resemble fissure - - 97 The common treatment is division of the sphincters 97 A most violent case relieved in ten minutes Organic stricture of the anus—its causes, &c. A bold unthinking surgeon The danger of knife operations in this region Stricture of the Rectum—the golden egg of quacks Diversity of opinion, regarding the situation of stricture 101 The opinions of Bell, Mayo, Colles, Allen, Liston, Syme, and Bushe 98 98 99 99 100 INDEX. Page. Sometimes caused by the operation for fistula ani - 103 Dr. Bushe's description of the symptoms - - 103 Five cases of this distressing disease cured - - 105 Malignant degeneration of the rectum - - 106 Definition of the term malignant - - - 106 A description of this dreadful malady - - 107 A painful, cruel and unjustifiable operation - - 109 The pretentions of empirics regarding the cure for cancer 110 The case of Mrs. R. of Tennessee ... no Females who have just ceased to menstruate, the most com- mon victims - 111 Fistula in perinaeo—a disgusting disease—its description - 111 A patient who had thirty openings in the perineum and vicinity 112 Empirical treatment of acute gonorrhoea - - 112 Urinary fistula difficult to cure - - 113 Dr. Colle's method of operating in this disease - - 113 Seven cases successfully treated - - - 114 Any treatment to be successful, must first be safe - 115 Letters from persons who labored under Urinary Fistula - 115 The great and principal objects of consideration in treating Urinary Fistula ------ H7 Vaginal fistula, a most distressing disease - - 117 The division and discription of vaginal fistula- - - 118 M. Berand's operation for vesico-vaginal fistula - 120 Hildanus relates a cure, obtained by simple means - - 122 Recto-vaginal fistula common among prostitutes - 123 The successful treatment of four cases of vaginal fistula - 124 Two letters relative to a case and cure of vesico-vagina fistula 124 Testimonials—remarks of the Louisville Journal - - 126 Remarks of Dr. Thomas of Richmond, Virginia - 127 Remarks of the Western Citizen, January 1841 - - 128 The remarks of D. F---- in the Louisville Journal - 129 The remarks of the Louisville Tribune and Protestant Unionist 130 The remarks of the New Orleans Picayune - - 130 The Letters of Mr. Spear and Mr. Huston - - 131 Mr, L. T. Payne's Letter - - 133 The letters of Mr. Cook and Mr. Hutchison - - 134 The letters of Mr. Burgess and Mr. Day - - 136 Mr. Herndon's letter to the Frankfort Commonwealth - 237 Mr. Hatchitt's letter to the Louisville Tribune - J38 The letters of Mr. Hardisty and Mr. Porter - . 139 INDEX. Mr. Field's letter to the Quincy Whig - - 140 The letter of Mr. Crouch - - - - 141 A Lady cured of Piles - - - - 141 The Hon. Richard M. Johnson's letter to F. P. Blair, Esq. 142 Letter of Mr. Cherry - - - - 142 The letters of Mr. Weisiger and Mr. Bishop - 143 Dr. Mosby's letter to Gen. De Buys - - - 144 References ... - - 145 Concluding observations—constipation of the bowels - 146 Invalids' bill of fare - - - - *46 Purgative medicine—enemata of cold water, &c. - - 147 Several important subjects omitted in this work - 148 The reasons for not publishing cures for the multitude - 148 An apology for the imperfections of this work - 149 Addenda - 150 ERRATA. The author regrets that some oversights have occurred in correcting the proofs of this work, owing to the great haste, caused by their rapiS transit, to prevent de- lay ;■.—his residence being distant from the place of publication. The following are the chief typographical errors noticed. Page 32 line 17 from top, for Celcus, read Celsus. " " " 18 " " for Medicena, read Medicina. " 36 " 9 " " for mucus, read mucous. This error occurs frequently throughout the work. Page 38 line 14 from top, for speculae, read spiculse. " 40 " 11 " " for incission, read incision. This error also occurs frequently. Page 63 line 11 from top, for Feburier, read Febvrier. " 70 " 10 » " for with, read within. " 81 " 13 from bottom, for abrasians, read abrasion.s « 99 « 17 « « for sypilitic, read syphilitic. " 113 " 15 from top, for L. D. Gross, read S. D. Gross. » 118 " 10 « " for fatal, read fetal. " 120 « 13 from bottom, for elytoplasty, read elytroplasty. " 124 « 13 « « for Letter IV, read Letter I. 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