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editions of works on Rectal Surgery, and as strongly as the case is presented by these renowned authors, I believe there is not a physician but who could add to this extensiv array of symptoms still others presenting other manifestations of this most prevalent disease.

The Canadian Medical Record, November, 1892, in an editorial article says:

"We have on several occasions pointed out in these columns the importance of constipation as a cause of disease of the pelvic organs, prostate, uterus, ovaries and rectum." We feel equally certain also that constipation is also the cause of a great many milder forms of mental derangement, not mechanically as in the case of the pelvic contents, but chemically by the absorption into the blood of the ptomains given off by the germs of putrefaction." "In a recent

number of our excellent contemporary, the Alienist and Neurologist, several cases are reported which would seem to prove that extreme cases of constipation may result in insanity." "We think, therefore,

that in works on insanity, constipation should be removed from the list of symptoms, and placed near the head of the list of causes of this distressing malady."

In analyzing the consequences of constipation, as presented by these quotations, we see that aside from the purely mechanical results of the accumulation of the fecal mass in the intestins, and the physical results of the efforts necessary for expulsion of these masses, and the local diseases resulting therefrom, that the absorption by the system of the poisonous products of decomposition of the feces produces a state of auto-intoxication, causing a range of effects on the digestiv functions, from lack of appetite to markt indigestion and gaseous eructation; on the heart, by evidences of palpitation and dyspnea; on the brain, as evidenced by vertigo and dizziness even progressing to melancholia and insanity; affecting the eyes as shown by evidences of disturbed vision, the ears by tinnitus aurium, the blood as shown by evidences of chlorosis and anemia; also rheumatism; the nervous system by the numerous phases of hysteria. The hair, nails and skin also show unmistakable evidences of this condition; in fact, there is not an organ nor tissue of the body but that has been shown to exhibit the effects of the pollution resulting from the retention in the system of this "sewerage of the body." And yet we daily see people taking pepsin for their stomachs, alcoholic stimulants to overcome lassitude, iron, quinin and strychnin in poisonous doses for anemia. and chlorosis; various liniments and plasters for rheumatism, massiv doses of bromids and other powerful drugs for their nerves (so often resulting in the morphin and cocain habits).

The ladies, with their "beauty treatments,' facial steamings and massage, breath perfumes, skin foods, paints and powders to cover up the effects of constipation, if they would but stop to consider, would see the futility of their attempts to secure a clear complexion and a skin free from blotches when their systems are being

constantly poisoned by a fermenting mass of fecal matter; in fact, all the above drugs and treatments might well be compared to the old saying, "Squirting on the smoke and allowing the fire to take care of itself," as assuredly they are directed to the results and not the cause of the trouble.

I treated a case of ulcer of the stomach some years ago in which not a morsel of food passed the patient's lips for a period of over three months, nourishment being absorbed entirely by the rectum. This patient entirely recovered. Such cases as this, and they are not rare, show us that if the rectum has absorptiv power sufficient to maintain nourishment of the body for a quarter of a year, it must also have the power to absorb the noxious products of decomposing feces retained within it, the results of such auto-intoxication being that organs which without this poisonous effect would go on acting for years, are simply overwhelmed, and the life of the individual pays the penalty, as is frequently evidenced in cases of sudden death, in which the cause is given as "heart disease," "heart failure," "apoplexy," "paralysis" and other vague terms.

The Cause of Constipation.

Among the causes of constipation given in the books are hypertrophy of the rectal valves, stricture, polypus, tumors within or external to the bowel, intussusception, enlarged prostate, retroverted uterus, pelvic inflammation, irregular habits of living, lack of response to the calls of nature either from laziness, inopportune time or place, or false modesty, thus allowing the feces to accumulate in the rectum, thereby causing a lessening of the sensitivness of the nerve ends, improper diet, deficiency of the intestinal and hepatic secretions, diabetes, melancholia, old age, lead poisoning, the abuse of cathartics, lack of sufficient water, and down to the various local causes, such as hemorrhoids, anal fissure and ulceration, which by the pain induced from either of these affections, by the passage of the feces over the hypersensitiv dis eased areas, causes the patient to defer to the last the evacuation of the bowels.

This is but a partial list of the many causes to which this disease is attributed; in fact, one could go on multiplying the supposed causes almost indefinitly, but it is very remarkable that the most frequent, easily demonstrable, absolute cause of constipation, viz., an abnormally contracted sphincter ani muscle, should have gone practically unrecognized all these years, when by correcting this condition the other causes so numerous, and for which so many drugs, waters, foods, appliances, systems, exercises, etc., have been unsuccessfully used, disappear permanently.

When the fecal mass presents at the anal

outlet, and the person defers the evacuation of the bowel from any of the above mentioned reasons, the voluntary sphincter ani and the levator ani muscles are brought into action with sufficient power to overcome the peristaltic action of the bowels, and for the time being the desire is overcome. The continued action of these muscles (like the action of any other muscles of the body) results in development of their fibres, and hypertrophy soon follows; with the hypertrophy is often associated an irritability from the reflex nervous excitement, and we have an almost constant state of contraction of the hypertrophied muscle. The contraction of this sphincter muscle not only causes constipation; but (as may be demonstrated by placing a rubber band around a finger) by obstructing the return flow of blood in the hemorrhoidal veins, it is the principal cause of hemorrhoids. Before considering the method of cure of chronic constipation which I have found to be so universally satisfactory, I will ask your indulgence for a little more quoting (as using the language of other authors does away with any possible temptation on my part to exaggerate the importance of my subject).

Hare (Practical Therapeutics, eighth edition) aptly says:

The physician should bear in mind that defecation is a normal physiological act, which must be continued all thru life, and it is almost as foolish to stimulate the bowel continuously to peristalsis as to perpetually employ heart stimulants, or respiratory excitants.

Altho they are habitually employed by many persons in daily doses, the purgativ salts are exceedingly harmful in such instances, rapidly losing their power (necessitating increasing doses), and decreasing the patient's strength by the abstraction of liquids and salts from the blood; they often produce anemia when constantly used.

Mercury (calomel) is exceedingly harmful if used continuously as a purge, and is the cause of much ill health, of bad teeth, and of digestiv troubles. Castor oil is notorious for its tendency to cause ultimate constipation.

I wish to mention two other methods of treating constipation: what is known as ne Hall method, which consists of injecting increasing quantities of water until the ultimate quantity of one or more gallons can be retained, and the bran method, which consists of eating or swallowing various amounts of bran, which by its roughness stimulates peristaltic action in the intestins. Each of these methods has many followers, and they seem to work admirably for a time, but alas! the very worst cases of paralysis of the bowels result from the continued use of the increasing amounts of material required to so stimulate the peristaltic action of the bowel sufficient to overcome the strength of the contracted sphincter. (I am informed that Hall, the inventor of the so-called "method,' died from paralysis of the bowel, induced by the gradual distention of the bowel by the large quantities

of water that he was eventually compelled to use.)

I am often askt about the use of the rectal dilators or plugs to overcome "the power of the contracted muscle. While occasionally their use is attended by great good, yet as many of these patients experience much difficulty and pain from even the insertion of the nozzle of a syringe, we can readily appreciate the long drawn out and totally unnecessary suffering to which they subject themselves by the repeated insertion of the increasing sizes of plugs, over periods of weeks and months, with the certainty that the results attained will only be temporary, as it is impossible to dilate this muscle to the extent necessary to overcome permanently the irritability of the muscle without an anesthetic; and when we compare the suffering invariably induced by each insertion of the plug, and multiply it by the number of insertions necessary, the man who cut the dog's tail off an inch at a time because he didn't want to hurt the dog so much all at once, becomes a veritable Solomon in comparison with our poor deluded patient, who must needs suffer many insertions of the plug into this very sensitiv area before he can hope to increase the size of the plug by even a

half inch.

As a proposition in mechanics, let us compare the rectum to a pouch, and the sphincter ani muscle to a purse string holding the mouth of the pouch shut.

A reference to the accompanying illustration from Kelly's Operativ Gynecology will, I believe, make this comparison quite plain.

When it becomes necessary to empty the pouch, if the power of the purse string is many times greater than required for its normal action of simply holding the mouth of the pouch shut, and if at the same time it is irritated into a state of abnormal contraction, it surely will require many more times the force (peristalsis) to be used by the bowel to overcome this abnormal power and contraction of the muscle, than if the power of the "purse string" were normal.

The treatment generally advised and followed is to increase the power of the bowel, by the irritation of cathartics, liver pills, salts, various "medicated waters," injections, suppositories, etc. The reaction from this stimulation requires increasing amounts of these "peristaltic persuaders" to produce satisfactory results, until, as I have been assured by several patients, they had during the years of their suffering from constipation literally taken "pills by the thousand, salts by the bushel, and injections by the barrel."

The method which I use and advocate seems so much more reasonable, more pleasant to the patient, doing away with the necessity of dosing one's self, saving the time, annoyance and

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the index finger into the anus, and if there is a spasmodic grip of the sphincter ani, causing difficulty in inserting the finger, we may be assured that proper divulsion will invariably be attended with good results. Over 90 per cent of cases of chronic constipation will be per manently cured by proper divulsion of the sphincter ani muscle.

The method of reducing the power of the sphincter ani muscle is as follows: Patient is anesthetized by nitrous oxid gas, which by its perfect safety, rapidity of action, absence of the distressing suffocativ symptoms so often experienced in the use of the commoner anesthetics, the rapidity of recovery, and the retention of the sensitivness and resistance of the muscle, giving us this absolute guide to just the amount of divulsion necessary in each individual case, makes it truly the ideal anesthetic for this operation. When anesthesia is complete, the fingers are inserted within the anus, and by a massage combined with traction on the muscle in various directions until just the amount of divulsion necessary has been at

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[By courtesy of both Dr. Kelly, and his publishers, the Appletons, of N. Y.] tained, taking plenty of time to

in all cases of chronic constipation. It consists in merely reducing the power of the abnormally hypertrophied and contracted sphincter ani muscle to the normal standard required for its chief action, that of holding the lower end of the rectal pouch shut.

The Cure of Chronic Constipation. The most reasonable, certain, satisfactory cure for chronic constipation is the proper divulsion of the sphincter ani muscle. In view of the foregoing explanations I believe this assertion will be self-evident. I am sure that in the course of time doctors will more generally make rectal examinations instead of simply prescribing an ointment or suppository that they have read in some magazine is "good for piles," and allow the patient to suffer on for long periods of time without examination. I assure you that my experience is no different from that of other rectal surgeons, who have found almost every diseased state of the rectum and anus in patients for whom their physicians had for various periods been prescribing "something for piles," when careful examination revealed fissure, ulcer, fistula, pruritus, stricture, and even cancer to be the real cause of the suffering.

I here need be no difficulty in determining if a given case is one that would in all probability be cured by this method of treatment. Insert

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Overcome any spasmodic action of the muscle. This result is made known to the operator by a sensation of "giving" of the muscle. Great care is required to differentiate between this "giving" sensation and that "giving" which would indicate the tearing of the muscular fibres, as should this result, disastrous consequences might ensue. regret that words (at my command) cannot more plainly express this most important point, but I would urge on those performing this operation, until thoroly familiar with it, that it is very much better to do too little than too much, as the operation can readily be repeated if not enuf divulsion has been practised, when if tearing of the muscular fibres were to result, the condition would be worse than the original state of the patient. The power required varies greatly; in some cases the power of the muscle is overcome with ease; in others it requires the exertion of all the strength the operator can put forth.

A few moments after the completion of this operation the patient will show evidences of recovering, and in a few minutes will have completely recovered; and in a short while after, will be fully able to leave the office, it often being hard to convince them that the work has been completed. They do not feel as bad as they have many times felt after a simple evacuation of the bowels (as the tension of the muscle is overcome, allowing normal circulation).

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I could give you reports of cases that would Occupy many pages, but I will epitomize all that by saying that I have cured many cases of from five to thirty years' standing, varying in age from young infants (whose constipation yields readily to this divulsion) to their grandparents, many of whom were operated years ago, and so far as I am aware still continue free from their trouble.

I often hear that physicians not conversant with the details of this treatment, advise their patients that there is great danger of total loss of power of the sphincter muscle following this operation, and depict to them the horrible results if such an accident were to ensue. While of course it would be possible for such an accident to occur in unskilled or careless hands, or in persons having some defect of muscular structure, I am happy to state that after performing this operation on many patients, young and old, for years, I have never been so unfortunate as to have had such a lamentable experience; but rather, I find that the patients are enthusiastic in their praises of an operation to them so simple, quickly performed, and attended with so little suffering, curing them of a condition which had caused them so much suffering and ill health over long periods of time.

While this operation is more of a specific in constipation than quinin ever was in malaria, its good effects are by no means limited to this one field of work. it is the greatest single procedure in the whole domain of rectal surgery towards the cure of hemorrhoids, as it relaxes the tension on the circular muscle which enables the return flow of blood thru the hemorrhoidal veins to go on unobstructed; in fact, many severe cases of hemorrhoids are entirely cured by this operation alone, altho of course other measures are required in most cases. Professor Vernueil, of Paris, claims to cure 95 per cent of all cases of hemorrhoids by this operation alone. This operation should precede the injection treatment in all cases of hemorrhoids where there is a contraction of the muscle, as it is then possible to cure cases which, without this procedure, would positivly require the more radical "cutting operation."

In the treatment of fissure of the anus it is

about as nearly a specific as anything I know, relieving the tension on the muscle, securing rest, relieving pain, thus materially aiding the cure, while in ulceration it aids drainage, thus promoting cure. Aside from these results I have reports of many diverse reflex symptoms, such as insomnia, asthma, cold hands and feet, impotence, irritable bladder, pruritus, lumbago, hysteria, etc., which have been entirely cured by this procedure. When working on the anal sphincters, we are directly influencing the great sympathetic nervous system, which never sleeps until our final sleep, which controls our breathing, the action of our heart, and the peristaltic action of all the tubes of our body by which all the great involuntary functions of the body are carried on. The evidence of this is now so well establisht by the well-known effects of dilating the sphincter ani in cases of collapse under anesthesia, so many lives having been saved by this procedure alone, when without it the patient surely would have died, that one having repeatedly experienced these results soon learns that the merely local effects of this operation, while so very beneficial, are merely primary to the greater effects on the respiration, heart and circulation, the real life centres of the body.

In cases in which the condition has existed for so many years that a partial paralysis of the muscular fibres of the intestins has been induced either from unheeding the calls of Nature or from the abuse of purgativ medicins, enemas, suppositories, etc., it is at times necessary to use electricity, massage, and other adjuncts for a time, until the proper tonicity of the bowels can be establisht. I always advise patients to attend to the calls of Nature at regular times, correct errors of diet, drink plenty of water, eat fruit, avoid constipating articles, take sufficient exercise-in fact, to aid Nature in every way possible. W. G. STEELE, M.D., D.E.

1431 Girard Avenue, Philadelphia.

[Dr. Steele lays stress on this operation as a cure for constipation. Its great value as a cure for many reflex conditions and obscure symptoms has long been recognized, but it has been practised far too little. The necessity of general anesthesia is an obstacle to its general employment. As the Doctor says, nitrous oxid anesthesia is peculiarly adapted to this operation, because of the short time required. But few doctors have nitrous oxid, as it requires a rather expensiv apparatus, and the gas should be reasonably fresh. However, as no preparation of the patient is required for the operation. and no blood is spilled, and no dressings nor after treatment is required, a good plan is to take the patient to a dentist's office, and perform the operation there while the dentist administers the nitrous oxid, the patient re

clining on a suitable table or lounge, and not in the dentist's chair. This avoids the distressing nausea caused by chloroform or ether. The man who proves that local anesthesia can be safely and successfully adapted to this operation, and develops a plan for so doing, will render a great service.-ED.]

Some Remarks on the Treatment of the Severe Types of Scarlet Fever. Editor MEDICAL WORLD:-Twice within a short space of time this community has been afflicted with epidemics of scarlet fever. The number of children that contracted the disease was very great. Death occurred in several cases. The writer had an opportunity of treating many; some were of the light type, some moderately severe, and some quite malignant. None of the writer's cases ended fatally. The treatment employed by me is, I think, in some respects a little different from that by most general practicians. I will try to describe it as briefly as possible, and hope that it may be of some interest to the readers of this journal. I cordially invite the criticism of my professional brethren in this matter, and hope to hear opinions on the subject in a future edition of THE MEDICAL WORLD.

I will not waste time or space in speaking of the treatment of the mild forms of scarlatina, for they will recover, as we all know, without any, or with but very little medication. All that is required in such cases is the simple observance of the laws of hygiene and keeping the patient in bed and indoors for a sufficient length of time to protect him from cold, etc. The treatment which I shall briefly state refers to the severe and malignant type.

The writer believes that in the severe forms of scarlet fever (or in most any other severe disease) many a general practician is too apt to overdose his patient. Too much reliance is Too much reliance is placed in the use of drugs. It is too often forgotten that scarlet fever is self-limited; that the physician can only be the pilot, that should endeavor to guide his patient safely thru the storms of the disease by looking out for the points of danger, and not by trying to break up the fever, which, as we know, is impossible before it has run its natural course. Too often a stomach already weakened, intestins already in a state of toxic irritation, are still further interfered with in their function by the introduction of noxious medicins. The temperature is too often reduced at the expense of the heart and general vitality by giving the coal-tar products and other motor depressants. Attempts are made to whip up a weak heart by prescribing digitalis when the stomach is hardly able to take care of the lightest diet; and every physician knows that digitalis will not benefit a

stomach even under more favorable circumstances. In this way, while good is intended, harm is often done by interfering with the already debilitated functions of these organs. The writer believes strictly in as little internal medication as possible.

The patient is placed in a large airy room, free from all unnecessary furniture. Nothing but a light, long flannel night gown is worn, and wherever obtainable light woolen blankets serve as cover. The bowels are freely evacuated by castor oil or calomel, and occasional doses of castor oil are given throughout the attack. Cooling drinks, such as fresh water, lemonade, seltzer or vichy are freely given. In fact, the nurses are strictly ordered to give the patient drink at regular intervals, as he is usually too ill to ask for drink himself. I consider the introduction of large amounts of fluids into the stomach essential for the sake of the kidneys and temperature. Of course in this the strength and susceptibility of the stomach must serve as guide.

In the successful treatment of scarlet fever the three most important points to be considered are the strength of the heart, the functions and condition of the excretory organs, especially of the kidneys, and lastly the temperature and its accompanying delirium. The writer has combated, to a great extent, all three of these dangers by one remedy, namely, the high rectal injection of normal salt solution. The temperature of the solution used is 110° F. That the normal salt solution will and does stimulate the functions of the heart is an establisht fact. That it will increase diaphoresis and diuresis we also know, and that it will decrease temperature on account of the increast excretory functions seems fair and logical. The injections are given every three or four hours with a colon tube, the fluid being introduced slowly and as high up as possible, with the patient lying on his right side, the hips elevated higher than the head. The amount used varies from six ounces to a quart, according to the age of the patient. The solution is usually readily retained if introduced in this manner, but should there be trouble in the retention, a few drops of tr. opii deod. added to the injection will prove efficient. Within 20 minutes to an hour after this procedure the child will usually be found more restful, the skin moist and the temperature reduced one to three degrees. I would not hesitate here to use the normal salt solution subcutaneously or intravenously should the given method prove inadequate; but so far in all my severe cases of scarlet fever I have succeeded fully by its rectal use.

If the temperature requires more than the normal salt solution for its reduction, hydro

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