HEMORRHOIDS.

Hemorrhoids are tumors situated near or in the anus, and are distentions of hemorrhoidal veins, with inflammatory swelling, congestion and hypertrophy of the mucous or submucous tissue.

Piles are either external or internal; if situated within the rectum they are denominated internal; if they are seated on the verge of the anus they are called external.

If they are attended with discharge of blood they are called open or bleeding piles; when there is no discharge they are denominated blind piles.

The symptoms of external piles are pain when passing fæces, or tenesmus after discharge; at first there is a projection of a livid appearance, which in a few days becomes solid; the blood becomes coagulated in the hemorrhoidal veins. In a few days the pressure of the fæces brings down the pile, and it becomes external. When inflammation comes on the patient suffers greatly, and can only be tolerably comfortable in a recumbent position.

Treatment of External Piles.—If consulted early, while the pile is only a livid projection, an active purgative should be administered, avoiding such as have particular influence on the rectum, such as aloes. Leeches may be applied in addition. As a local application liquor plumbi acetatis is highly commended.

If the pile has continued until it has become solid, insert a lancet into it, and press out the clot; then apply a cooling lotion, administer a purgative, and the patient will be rid of the disease.

Internal Piles are frequently accompanied by a high degree of fever, with a sense of weight and pain in the sacrum; pressing at stool causes the disease to show itself by prolapsus ani.

Treatment. The irritation must be relieved by general and local treatment. Apply leeches and fomentations; if these measures do not cause relief, the pile must be removed by ligature.

FISTULA IN ANO.

This is a fistulous ulcer by the side of the rectum, through the fibres of the sphincter ani.

There are three kinds recognized in books: 1. The complete fistula, which has one external opening near the anus and another in the bowel above the sphincter. 2. The blind, or incomplete external fistula, which

has no opening in the bowel. 3. The blind, or incomplete internal fistula, which opens into the bowel, but not externally.

Treatment consists in the division of the sphincter ani, so as to prevent the contraction of that muscle for a time. Before operating, the digestive organs must be put in good order, and a purgative must be administered, so that the bowels may not be disturbed for two or three days.

PROLAPSUS ANI.

FIG. 86.

FISTULA IN ANO.

There is an eversion of the lower portion of the rectum, and its protrusion through the anus. The affection is most common in infancy and old age. It may come from straining or from natural laxity.

Treatment. The parts should be carefully washed, and then replaced by gentle pressure with the fingers. If there is any difficulty, the forefinger, well oiled, should be pushed into the anus, when it will carry the protruded part with it, after which a thick compress, saturated with some astringent lotion, should be bound to the part by means of a T bandage. The bowel is to be kept in its place by means of quietude and the recumbent posture, and, if necessary, tonics should be resorted to. Lotions of a solution of alum, sulphate of zinc, decoction of galls, and astringent injections are to be employed, if necessary.

FISSURE OF THE ANUS.

This is a small chap, crack, or ulcer, which gives intense pain during defecation, frequently continuing for some time after the evacuation. It may be the remains of an external pile, and is generally situated behind it, and leads to the fissure.

Purgatives frequently give relief, and lotions of sulphate of zinc, of tannin, nitrate of silver, or sulphate of copper, are often beneficial; an ointment of galls with lead may be tried. Should these remedies not answer, forcible dilatation may be resorted to, so as to temporarily paralyze the sphincter muscle. To accomplish this, the two thumbs, well oiled, must be introduced into the rectum, and then, by firmly grasping the nates with the fingers, the sphincter muscle is dilated, by drawing the thumbs apart.

Should this means fail, an incision into the part should be made, through

the fissure or ulcer, with a straight, narrow, blunt-ended bistoury, so as to divide the mucous membrane, and in severe cases, to divide the sphincter. A small piece of lint should be laid in the wound, so that it may heal by granulation.

FIG. 87.

FISSURE OF THE ANUS.

CARCINOMA OF THE RECTUM

May commence as a distinct tumor, or as an infiltration into the walls of the bowel, causing stricture. The earliest symptoms are uneasiness in the rectum, aching spasm in the back, hips and thighs, and irritation of the bladder. As the disease advances, the bowel becomes more or less obstructed; there is frequent discharge of a fetid, muco-purulent matter, streaked with blood, and obstinate constipation attended with swelling of the abdomen, and sometimes with the symptoms of acute obstruction. There may be profuse and exhausting diarrhoea. Peritonitis, or perforation of the distended bowels, with exhaustion, terminate the patient's suffering in death.

Treatment.-Keep up the action of the bowels by enemata of warm water and very mild laxatives; allay irritation by occasional leeching, by belladonna and opiate applications, suppositories or enemata. patient's strength is to be sustained by tonics, cod-liver oil, etc., etc.

VARICOSE VEINS.

The

Varix is an enlarged and tortuous state of the veins, which are usually thickened, rigid, and formed into irregular pouches.

It is most frequently seated on the lower extremities, scrotum and rectum.

Varicose veins of the leg are accompanied by pain, weight, fatigue on taking exercise; they cause ulcers and excoriations of the skin; they sometimes burst, causing profuse hemorrhage, and occasionally blood clots in the veins, which may terminate in an abscess.

Treatment. The palliative treatment consists in applying strips of leather over the part, a common roller, as Martin's roller, or an elastic stocking which should be applied in the morning, before the patient rises. Galvanism or faradization has been recommended.

For the radical cure many methods have been devised; Sir B. Brodie recommended division of the vein by subcutaneous section; Watson, of New York, advocates excision of a portion of the affected vein; again, potassa fusa and quicklime, to cause slight inflammation, has been suggested. Pressure and the twisted suture both have their advocates.

CLUB FOOT.

This is a deformity of the foot, produced by rigidity and contraction of various muscles of the leg.

Talipes Equinus is where the heel merely is raised, so that the patient walks on the ball of his foot.

Talipes Varus.-The heel is raised, the inner edge of the foot is drawn upward, and the anterior two-thirds twisted upward, so that the patient walks on the outer edge, and in extreme cases on the dorsum of the foot and outer ankle.

Talipes Valgus.-The outer edge of the foot is raised, the longitudinal or inner arch flattened by the sinking of the head of the astragalus, and the patient walks on the inner ankle.

Talipes Calcaneus.-The toes are raised and the heel is depressed, so that the patient walks entirely upon it. There are also compound varieties, which need not be enumerated in a work of this kind. These deformities may all be congenital, or they may appear after birth. Contraction and shortening of the muscles are the cause of club foot. In non-congenital cases they may be brought on by spasms affecting many muscles, which may be dependent on a rheumatic fever, or produced by irritation directly from the spinal cord, or they may be sequelæ of bruises, injuries or diseased joints.

Treatment. In recent cases remove all irritating causes, soothe spasms, stimulate palsied muscles. If the case comes under the surgeon's notice before the contracted muscles become fixed, use constitutional reme

dies, fomentations, etc. In slight cases light splints of gutta-percha or wood, with bandages, may be of service.

In severe cases it is better to resort to Stromeyer's operation of subcutaneous tenotomy. By this operation the mechanical shortening of the muscle is obviated; the tendon being divided, its separated extremities heal by a new connective tissue, which renders it longer, and may be readily stretched while recent.

To perform the operation, the tendon is put on the stretch, and a narrow, sharp-pointed tenotomy knife is thrust through the skin on one side of it, then its edge is turned against the tendon and made to divide it as it is being stretched. Some surgeons prefer to pass the knife under the tendon,

FIG. 88.

FIG. 89.

SNOWDEN

SNOWDEN

DR. ALLIS CLUB-FOOT APPARATUS

and then cut toward the skin, and others pass it between the tendon and the skin and cut toward the deeper parts.

In talipes equinus the tendo-Achillis is cut.

In talipes varus the tendo-Achillis, tibialis posticus, anticus and flexor longus digitorum.

In valgus the peronei and the extensor longus digitorum.

In some cases it may be necessary to cut a portion of the plantar fascia, or the muscles of the sole of the foot.

Dr. Oscar H. Allis has devised a "club-foot apparatus," which can be readily understood by reference to the accompanying figures.