A few sufferers will object to the time required for an enema twice a day, although they find time to eat three, or even four times a day, without any objection whatever; there is plenty of time for filling up the digestive apparatus, but no time for its normal elimination. And these miserable, go-lucky, haphazard people are always sick and unfortunate. The internal Russian and Turkish bath is demanded only by those who truly desire to be free from their bowel troubles, and from the numerous symptoms resulting from mucus absorption, con­sti­pa­tion, and auto-intoxication.

A sufferer’s efforts to be well depend largely on how much he or she estimates the worth or value of mind and body. A noble purpose in life is priceless; are not one’s spirit and body worth the time required for two enemata each day and an hour for the internal bath, if needed? I think so, and you should likewise.

The author trusts the reader will not infer that all sufferers from piles, anal fissure, pruritus ani and vulvæ, mucus channels and reservoirs, abscess, fistula, and all similar troubles, require the enema and recurrent douche appliance; the character of the disease and its symptoms must determine the requirement of the treatment. Many of my patients receive office treatment only, omitting home attentions, although this is not always advisable. The reader might conclude that the recurrent douche treatment was simply for the cure of a chronic inflammatory invasion of the bowels and fecal auto-intoxication, and not be aware of another great source of auto-intoxication—that is, from the absorption of large quantities of serous, fibrinous, or albuminous exudation from a large area of tissues invaded by the very insidious inflammatory process, a condition which, in time, may reach the pus-forming stage. Thus we have three very grave pathological conditions to meet and remove before the pus-formation stage is made manifest through the development of abscesses. I have found five aids—perhaps more—to accomplish a cure in which I have been exceptionally successful, as my students and patients will verify; these are: local treatment, local medication, the proper use of the enema, the use of the recurrent douche, and the determination of the sufferer to get well.

CHAPTER XIX.
Hot Water in the Treatment of External Symptoms.

After proctitis has continued for many years it will give rise to painful inflammatory and ulcerative processes at the external anal vent and in the adjoining tissues. The anal mucous membrane and the integument about the anus become brittle, loosened, and detached from the areolar connective tissue by the retention of inflammatory serum. The engorged, indurated, and swollen mucous membrane and integument serve as reservoirs, especially when the chronic inflammation is excited to an acute stage, which stage is often accompanied by a fissure, abscess, or anal ulcer. Soreness and pain in the parts may then be so severe that the sufferer is compelled to stay indoors or in bed. Whatever the symptoms may be—piles, fissure, pruritus, abscess, or fistula—the sufferer desires to reduce the local fever and the acute inflammation, as well as to find relief from the pain. The customary treatment is to use poultices, which are troublesome and ineffective.

In the following illustration I give a good idea of a perfect device for relieving quickly the soreness, pain, acute inflammation, and induration, all of which are so very prostrating; and, situated as they are physiologically, they are exceedingly inconvenient to treat properly by the ordinary methods in use:

What has been said in a previous chapter on the therapeutic effects of hot water in the treatment of proctitis need not be repeated here.

The three indispensable appliances for combating and effectually overcoming the pathological conditions to which this book and my two previous books—Intestinal Ills and How to Become Strong—are devoted, are The Internal Fountain Bath, The Intestinal Recurrent Douche, and The Shallow Sitz-bath Pan. These appliances are well-nigh perfect for the uses to which they are adapted.

CHAPTER XX.
The Health of School Children.

“Cleanliness of body was ever esteemed to proceed from a due reverence to God, to society, and to ourselves.”—Bacon.

The International Congress on School Hygiene ended its fourth meeting at Buffalo recently to meet two years hence in Brussels. In the interim the Board of Education in this city, the Department of Health, and the New York School Luncheon Committee will continue their investigations as vigorously as in the past, and the information thus gained will be an important contribution to the next Congress.

Too much attention cannot be given to the question of hygiene, diet, and excretion to meet the psycho-physical requirements of the mind and body in normal health. As a rule, diet is prescribed for the purpose of relieving the various annoying and painful symptoms caused by chronic impairment of the functions of the stomach and bowels, but when we find the cause of these various symptoms arising from a disturbed gastro-intestinal tract, the question of diet will receive less attention. Why has not the subject of normal intestinal excretion received as much attention as diet in health or ill-health? As our knowledge of the human psycho-chemical laboratory increases, we are able definitely to locate a diseased organ and account for the symptoms caused by the pathological condition of that organ; and when the diagnosis is properly made these symptoms become a secondary matter of treatment.

The chief enemy of health among school children (and older persons as well) is the accumulation and retention of waste matter and gases in the intestinal canal, where are generated ptomaine, toxic, and other poisons which enter into the system, resulting in self-poisoning or auto-intoxication.

What do we mean by school hygiene? Is it only the school building, or the external appearance of the children, their eyes, teeth, mouth, nose, hands? What about the coated tongue, foul breath, fouler stomach, and putre­fac­tion of the contents of their intestines? A human being is only an extension of his gastro-intestinal apparatus, hence it is very essential that such apparatus should be in a hygienic state to ensure his physical and mental resistance and efficiency being at their normal strength. There is one symptom that causes more sickness and suffering from infancy to old age than all others combined—that is, con­sti­pa­tion with its attending putre­fac­tion and foulness of digestive organs. Only a small percentage of people escape its baneful effects or the secondary diseases induced by fecal and mucus auto-intoxication. Such a common primary symptom must have, necessarily, a common exciting cause or origin. Through many years of clinical experience as a gastro-enterologist and proctologist, we have found that inflammation of the anus, rectum, and sigmoid flexure is the frequent or common cause of con­sti­pa­tion. Observation has demonstrated that a soiled diaper is the exciting cause of Proctitis and Sigmoiditis in the beginning. Examination of one hundred children of the “defective class” would show most of them suffering from chronic Proctitis and Sigmoiditis, with some degree of con­sti­pa­tion and auto-intoxication, and even of those classed as “healthy school children” a large percentage would show the same conditions. The continuous invasion of the neighboring tissues by the disease, the increasing auto-intoxication and con­sti­pa­tion, the on-coming malnutrition, and anemia, the gradual emaciation, are all the while lessening the vitality and power of bodily resistance of their victims. The early inception of the malady and its insidious progress, with the symptoms and diseases resulting, easily deceives the victim as well as the parents and medical advisers, until the long-pent-up virulence breaks forth, showing itself in every part of the tabernacle of the spirit of man, when the removal of the primary cause does little or no good.

The Department of Health, in examining the sanitary or hygienic condition of a school building, would not devote all its attention to the top story to overcome unhygienic conditions; it would probably direct its attention to the trap and vent of the sewer of the building to see that there was no retention and filling up of the pipe to befoul the atmosphere of the structure. Why then so much attention to the head or top story of the human temple, and so little to the trap and vent of its sewer? Are modesty and ignorance to defeat the progress of hygienic measures dealing with the stomach and bowels of our school children? How long will those abdominal incubators of poisonous microbes and gases be allowed to infect not only a school building but all its occupants as well?

The absorption into the system of serous, fibrinous or albuminous mucus exudations from the invasion of chronic inflammation through all the layers of the tissues of the anus (Figure 1), rectum, and sigmoid flexure, as well as through the adjoining fatty tissue in the pelvic space around the organs (Figure 5), under the skin and between the muscles of the buttocks, goes on continuously, creating an extensive inflammable area and source of exudation of broken-down tissues. (See Chapter III.) It is a grave pathological condition and the source of mucus auto-intoxication, and its symptoms ought to be differentiated from those of fecal auto-intoxication. This mucus exudate has an intensely irritating effect on the nervous system, especially when an acute intestinal mucus storm has developed, torturing its victims and unfitting them mentally to attend to the ordinary duties of the day. Very often this is accompanied by more or less pain or muscular soreness. These annoying symptoms occur very early in the history of Proctitis and Sigmoiditis, and clinical experience has demonstrated to me and to my students the necessity for infants and children being examined in order to determine whether inflammation exists in the anus and rectum, and thus early cut short the progress of the disease and its numerous and familiar symptoms, which I may here enumerate, to wit: indigestion, flatulency, coated tongue, foul breath, bad taste in the mouth, capricious appetite, nausea, intestinal colic, cramps and pains, diarrhea, headache or band of pain encircling the head with sense of constriction, neuralgia, pain about the heart, cold hands and feet, malnutrition, anemia, emaciation, dry skin, seborrhea sicca, carbonic acid toxemia, sallow complexion, liver spots, jaundice, acute bilious attacks, drowsy states, mental torpor, bad temper, night terrors, irritability, melancholia, vertigo, dizziness, loss of memory, insomnia, drawn face, tired feeling, unrestful sleep, easily fatigued, subject to colds, catarrhal affections of the ears, eyes, nose, throat, etc., decay of teeth, dry cough, loss of hair, impaired vision, sterility, impotency, mucus and membranous cords and casts from the bowels, sediment in the urine, irritability of the bladder, premature age, reduced physical and mental efficiency, inability to concentrate the mind, morbidity, suicidal notions with a view to ending mental and physical suffering.

I am pleased to inform such sufferers that their ills can be properly diagnosed and treated; and the earlier in life they seek treatment, the sooner they will escape the accumulative ills that make existence so painful to endure.

We have mentioned Proctitis and Sigmoiditis as the primary cause of intestinal stasis in the majority of cases; later, other sections of the intestinal canal may be invaded by inflammatory process, causing a more serious intestinal stasis, not infrequently bringing about dislocation of the stomach, intestines, and other abdominal organs. We have enumerated the symptoms and maladies that are now, in the light of latest medical science, traceable directly or indirectly, to this primary cause; in short, it may be said that, with the exception of a few diseases caused by toxic agents, most of the illnesses that cause so much invalidism, cutting short our lives, can be traced to mucus and fecal auto-intoxication.

The purpose of this book and others I have published is to educate my fellow beings as to how to prevent or avoid the many diseases and symptoms that afflict them from the cradle to the grave; already I feel that I have accomplished something in helping humanity, and I trust others will do their part to lessen the ills that flesh is heir to through neglect and ignorance.

CHAPTER XXI.2
Internal Hemorrhoids or Piles versus Rectal Mucous Sac, Recto-Anal Mucous Sac.

Before the history of medicine and surgery began, man suffered at his hinder parts as well as at other parts of his organism. Bodily ills are as old as the human race, and the flowing of blood from the “terhinder” was a signal of distress or of physical anarchy, of which the references to “emeroids” in the Bible and in other ancient writings bear witness. The “emeroid” doctors of Egypt, in the time of Moses, unquestionably regarded the distress caused by the “emeroids” as a disease. And it came to pass that every subsequent Moses that has written on the subject of hemorrhoids up to the present time has regarded piles as a disease. And they likewise, all of them without exception, believe the “disease” to be hereditary, as is certainly their information on the subject. This mental obsequiousness of the proctologists of our day is indeed quite a long-drawn-out compliment to the pile doctors of Egypt, since our proctologists still continue to diagnose piles as a disease and “to smite the smitten of emeroids.”

I have always respected the idea of ancestral worship and of reverence for the dead past, but at the same time I have felt that one should not be wholly oblivious to their egregious mistakes.

If Moses, Samuel, Herodotus, Hippocrates, Galen, and other illustrious men had said that “emeroids” is a symptom of a disease, what a blessing they would have conferred upon suffering humanity. The simple use of that one word would have been illuminating, and would have set the tide of attention for the proper diagnosis and treatment in the right direction. Possibly some one more bold than the servile brotherhood did see and say that it was a mere symptom, but, if so, his temerity was treated by “the wise ones” of that day as similar innovations are treated to-day, with a “Tut, tut, tut; pugh, pugh, pugh. We know better, and we refer you to the following chapters in Holy Writ and to the classical work of the great Medi Cusus on ‘Pilus Diseasicus.’ And besides, have you no respect for the superior clinical advantages we enjoy?”

Notwithstanding the bad odor in which I shall be held, I will nerve myself to claim that, when the ancients considered and called piles or hemorrhoids a disease, they made a very grave and palpable mistake, and that, having made this mistake, it was inevitable that numerous errors should follow logically in its train when they attempted to account for the etiology, character, and means of cure of this “disease.”

Pruritus ani is also called a disease, and a similar bedlam of reasons is offered as causes and means of cure, all of which accounts for the many, many pages of a book filled to overflowing by a “classical” author, with compilations of the redeeming gospel truths on this subject from prehistoric times till the present day, including his own commentary, guesses, interpretations, and surmises. Ignorant as he is of the nature of this symptom, the conjectures of his perfervid imagination are “to laugh.” The errors of one or more authors, endorsed by the mistakes of others, seemingly make a truth to minds that are vassals to authority, which accounts for much of the useless medical literature of to-day and for the mistakes of those that are misguided by it.

Considering the pathological condition, it would be better if we were to give a more definitive characterization to it than “piles” or “hemorrhoids.” In accordance with the distinctive exhibit contemplated, we should describe it as a rectal mucous sac, an ano-rectal mucous sac, or an ano-muco-cutaneous sac. These are more distinctive and suitable designations for these symptoms of chronic proctitis, inasmuch, by such designations, we call attention to the fact that they are simply constricted mucus3 channels and sacs, with engorged arteries and veins, formed by the serous exudation that accompanies inflammation.

If a recto-anal mucus channel, under one or more layers of the mucous membrane, becomes constricted or obstructed (they usually do), its epithelial wall will become sacculated, and then we have a rectal mucous sac, or an ano-rectal mucous sac, or an ano-muco-cutaneous sac, all of which may be present in the same case. The inflammatory exudation called serum distends and destroys fatty tissue, which makes space for its lodgment under the tissue that imprisons it, and at the same time there occurs more or less proliferation of the cells of the tissue involved in the severe inflammation. The internal sphincter muscle, by its contraction, aids in the undue retention of the mucus and blood above it, hence the so-called pile-bearing region—that is, the sacculated mucosa region. The serous exudation meets with obstruction along the anal canal and the mucosa is sacculated. When the integument around the anus offers obstruction to the flow of serum and blood, we find that muco-cutaneous sacs are formed around the anus. If the exudation occurs in the areolar space under the ano-rectal mucosa, it readily passes down into the areolar space under the integument around the anus, and thence to parts deep, devious, and far away, as described in Chapter III.

Channels, reservoirs, sacs, that would hold from one to eight or more ounces of fluid, no longer excite my wonder and amazement at the extensive and serious pathological condition of which they are exhibits, a pathological condition that occasions symptoms often diagnosed as sciatica, rheumatism, myalgia, caries of the coccyx, coxitis, prostatitis, pruritus ani, scroti, and vulvæ, auto-intoxication, anemia, invalidism, etc.

Inasmuch as we have learned the cause of sacculated mucosa at the lower end of the rectum and over the anal canal and of the integument around it, we had better in future omit the following designations and distinctions, which are merely a ridiculous display of sciolism. Surely we can do without them, and ought to do so for the sake of truth and simplicity. With a sigh of relief let us in future ignore: Safety-valve piles, organized piles, itching piles, blind piles, bleeding piles, moon piles, cutaneous piles, thrombotic piles, external and internal pile tumors, venous piles, ulcerated piles, capillary piles, mixed hemorrhoids, arterial hemorrhoids, white hemorrhoids, acute hemorrhoids, chestnut hemorrhoids, chronic hemorrhoids, inflammatory hemorrhoids, hypertrophic hemorrhoids, atrophic hemorrhoids, Egyptian piles, Philistine itching hemorrhoids, etc.

Quite naturally such a variety of “diseases” called forth many sorts of surgical operations for their removal, of which the following are the ones most in vogue: Clamp and cautery, ligature, crushing electrolysis, excision, submucous ligation, the Whitehead operation, the Earle operation, the American operation, etc.

Forget them all, forget all of the senseless terms that are employed to describe a supposed variety of “disease” and all of the barbarous procedures for their banishment, and the banishment, alas! too frequently, of the wretched sufferer likewise.

Study carefully the varieties of chronic inflammation and the character and extent of the exudation in each case. By so doing you will ascertain the nature of the many varied symptoms of proctitis, of which the following are the most common: Sacculated mucosa and integument, submucous and sub­tegu­men­tary channels, reservoirs, pockets, fistula, pruritus ani, fissure- or ulcer-in-ano, con­sti­pa­tion, diarrhea, etc.

Proctitis may present a chronic, a subacute, or an acute stage, with an atrophic or hypertrophic condition, or a less marked structural change in the tissue. If proctitis were treated early in its inception, none of the above-mentioned symptoms would have occasion to develop. When mankind becomes properly enlightened on the subject of proctitis, due attention will be given to it long before so many annoying symptoms occur.

Ano-rectal mucous sacs, formed by the serous exudation into the connective tissue and stasis of the blood, are the slightest symptoms of proctitis, and by far the most easily removed.

Since we have found out what are the symptoms and what is the disease, it naturally follows that in treating a sacculated mucosa we should be governed by the character of the proctitis, whether it be in a chronic, subacute, or acute stage. If the inflammation be acute, no matter whether or not there is a general prolapse of the sacculated tissue, it may be well to delay the treatment for removal of one or more mucous sacs until we have in a degree overcome the acute inflammation by the use of a shallow sitz bath, Fig. 23, and by the use of a soothing ointment and liquid remedy, to meet the depurant requirements of the case.

The removal of the chronic inflammation, in whatever state it may be found, should be a paramount feature of the treatment from the time a case comes under one’s care. The cure of the disease ought to be of more importance than the removal of a symptom or symptoms. Should there be bleeding from a mucous sac, or should there be prolapse of it, or both, immediate treatment will give relief at once, and the sufferer will think you have performed a miracle, especially if the annoyance has existed for many years.

After the immediately annoying mucous sacs are removed by the hypodermic method, a physician can doubly guard his reputation in the painless treatment of mucous sacs by delaying further treatment of those remaining sacs, which, if treated, might occasion special annoyance, till such a time as the general inflammatory condition is much improved; but in the interim he may treat the mucous sacs that are located above the sphincter muscles, and the granular and ulcerated regions.

For the almost universal success in the painless removal of mucous sacs, the operator should be in possession of all of his normal wits and senses, so that his judgment will be at its best when the following points present themselves:

What to treat.

When to treat it.

Where to treat it.

How much to treat of it.

The quantity of remedy to be injected—all of which require discretion and good technique.

By the hypodermic method of treating mucous sacs some escharotic is employed with the object of causing the absorption of the sacculated mucosa. The object to be accomplished ought to determine the proper strength of any escharotic used. Whatever will absorb the mucous membrane involved in the sac in the slowest and mildest manner is the best remedy or the best way to employ any of the tissue absorbers you might select. And another fact: the lower the per cent. employed the larger the quantity that may be used at a time, and this is desirable if the area of a sac be large and you wish to absorb the greater portion of it. A skillful operator will make sure to have the escharotic used cover just the amount of the mucous sac desired, and no more. Physicians that are not aware of the channeled and sacculated character of the mucosa in the case of “piles” or “hemorrhoids” are liable to introduce the escharotic into the base or the center of the mucous sac with the hypodermic needle; and in such an event the remedy often enters a cavity or a channel, or both, and naturally it finds its way along the channel to the integument at the anus, whence, as a consequence, a deep, ugly fissure-in-ano is in a short time to be reckoned with by the patient and the physician, because of the destruction of the epithelial wall of the channel. The patient thereupon is far from being in a good humor, and the physician wonders how the thing happened, and he feels like quitting practice altogether, and doubtless many have done so; and certainly every one should do so if such an error were to occur a second time.

The object we wish to accomplish is to absorb the wall of the sacculated mucosa. Therefore the remedy should be injected at the apex of the sac, in the epithelial layer, or slightly deeper, if the occasion demands it. The area of the sac and the thickness of its walls must be taken into con­sid­er­ation, and will suggest the amount of the escharotic to be used.

A proper speculum is very essential to the successful treatment of sacculated mucosa, and I know of none equal to that devised some thirty years ago by Dr. A. W. Brinkerhoff. The speculum is easy to introduce, and by drawing a slide the tissue is properly exposed or shut out to a nicety, exhibiting just the amount you wish to treat. In some cases there is a rather lengthy sacculated mucosa on the side, or on the anterior wall of the anorectal tube, and it is advisable to treat only the upper third or half, and at a subsequent visit or visits to treat the remainder, thus avoiding annoyance to the patient.

The paramount concern should be to avoid causing pain both during the treatment of a sacculated mucosa or its possible occurrence a few hours or days later. I have often remarked that when pain or soreness follows the treatment of a mucous sac the fault is in the application of the remedy, and not in the remedy itself. Now and then there may be conditions in which you will expect pain or soreness to follow the treatment, and you will prepare your patient with the necessary appliances and remedies to overcome it promptly. Where there are no possible means for avoiding the pain consequent upon a treatment, leave nothing undone to make it as slight as possible. All mucous sacs ought to be treated without any after-annoyance to the patient, and they can be if we only wait for the proper time to treat them.

I have not thus far considered the muco-cutaneous sacs around the anus, which are neither useful nor ornamental, and which often indicate the volcanic action of inflammation and the amount of mucous lava thrown out around the vent.

CHAPTER XXII.
External and Thrombotic Piles versus Muco-Cutaneous Sacs and Thrombus.

The vent of a crater indicates the convulsive and destructive changes that have taken place within; and, very often, the vent of the gastro-enteric sewer gives like evidence of long, great, and severe destructive changes. The fire of inflammation has burned fiercely for many, many years, and serous lava has, from time to time, poured forth, leaving a searing, inflammatory path. As it was forced from the recto-anal crater, the acrid, burning mucus, that had been imprisoned, made subcutaneous streams, cavities, channels, sacs, etc. Its course is marked around the anus by peaks, crags, muco-skinny tabs, small and large bulging muco-cutaneous sacs, dilated anal veins in which clots of blood often form; light gray, brittle, shiny skin with small and large red and sore oases, thickly studded over the itching area, which the sufferer has scratched in the vain hope of appeasing the torture of pruritus ani, scroti, vulvæ; while cold drops of perspiration stand over his or her face and body, serving to indicate the physical and mental anguish inexpressible in words.

Muco-serous exudations under one or more layers of the recto-anal mucous membrane finds its way down to the integument around the anus, and being of a very irritating character, greatly increases the inflammatory process in the tissues it comes in contact with. Thus the increased inflammation and blood stasis and the augmented serum unite in hurrying the development of skinny tabs and the more or less capacious muco-cutaneous rugæ and sacs.

When the serous exudation takes place entirely under the recto-anal mucous membrane, there may be formed a large muco-cutaneous anal sac, especially on the right or left side of the anus, or the serum may pass under the integument about the anus with little or no anatomical change in the appearance of the skin at or about the anus. In the latter case, an experienced eye can detect sufficient evidence to diagnose the destructive changes wrought by the presence of serum in the connective tissue under the skin and ano-rectal mucous membrane.

The skin is not, as it should be, held fast by the connective tissue, but lies loose over the cavity; and a similar pathological condition exists under the mucous membrane of the anus, rectum, and sigmoid flexure, which circum­stance might lead one, in some instances, to conclude that there was almost an entire separation of the mucous membrane from the areolar tissue, by the ridges, folds, large, pouched, prolapsed, sacculated regions of mucous membrane that has the appearance of having been simply carelessly laid over the muscular structure of the organs. When we observe such destructive changes by the invasion of serous exudation under the mucous membrane, we have every reason to expect peri­proc­titis and peri­sig­moid­itis, with the possibility of the formation of pus occurring with the usual consequences. So remarkable and serious are the excursions of the mucous currents into healthy neighboring tissue that we find a symptom of a disease vastly more annoying and serious than the disease itself. Is it any wonder we find stenosis (narrowing of the passage) of eight, ten, or more inches of the lower portion of the large intestine, which is usually diagnosed atony of the bowels? Surely, you must by this time appreciate the reason I made so strong an appeal for the twice daily use of the enema as a means of relief. You need the combination of many aids over a long period of time to effect a cure of proctitis, etc., and its numerous symptoms. Proctitis and colitis is a serious affliction, and should have your undivided attention with the hearty co-operation of the patient in effecting a cure. How foolish is the practice of removing one or two annoying symptoms (piles and fistula) and leaving the sufferer untreated, the disease itself and the other symptoms not so apparent at the time of the operation, and then dismiss the case as cured! Shame on such practice, in which ignorance and cupidity dominate! Humanity cries for a correct diagnosis and a humane treatment!

The profuse serous exudation resulting from proctitis and sigmoiditis makes its way from the diseased area into the neighboring regions like lava from an active volcano, carrying with it an intense burning inflammation, destroying normal fatty tissue as it advances, owing to its extremely acrid character. Is it any wonder that we find dilated veins and arteries in the lower rectal and ano-rectal canal and around the anus where stasis of the blood has existed for a great many years? The real wonder is that thrombus in the veins around the anus does not occur more frequently than it does. What is the necessity of calling such a pathological change in the caliber of a vein and the weakening of its walls “thrombotic pile”? Thrombus is a clot of blood in a vein, and there is no use in adding the word “pile.” The aggravated character of the inflammation accounts for the hypertrophied and the cicatricial tissue so often found around the anal vent of proctitis cases. The Biblical suggestion that sacculated mucosa, commonly termed piles or hemorrhoids, is a disease, accounts for the numerous names used to designate the particular variety of the disease—whether it be an internal or an external pile tumor. It is very wrong to so mislead “scientific” medical men. Had they only known that the numerous sacs, bags, prolapsed pouches, longitudinal and transverse folds of the ano-rectal mucous membrane, and the ragged, jagged, prolapsed, pouched muco-cutaneous tissue around the anus, as well as the fissure-in-ano, pruritus ani, fistula, are only symptoms of a disease, all of the many abnormal changes and the other symptoms could have been prevented many generations ago by simply treating their exciting cause. But it is never too late to learn things that will benefit mankind.

Don’t for a moment think that all of the structural changes on the mucous membrane and about the anus mentioned above indicate an affliction only skin deep, or even the depth of the mucous membrane. They are far worse than that. You will find all the muscular structure of the anal organ and that of the rectum sigmoid flexure severely invaded by the inflammatory process and its fibrinous exudation, and also the external tissues that surround and support the organs.

We have circular and longitudinal muscular tissue entering into the structure of the anus and rectum. The sphincter muscles are two large and strong muscles that close the anal orifice and guard its vent very effectually if they are not destroyed by a surgeon’s knife.

The acrid burning serum coming in contact with the muscular tissue excites an aggravated inflammation in its structure as elsewhere. The constant irritation results in more or less permanent contraction of the sphincter muscles in which fibrinous exudation takes place, binding the contracted muscular fibers together. In time their expansibility is lost in many cases, and in other cases partially so, necessitating divulsion of the sphincters in order to break up the adhesions and establish a somewhat normal circulation of the blood in the diseased parts, also in order to relieve the irritation to the nerves distributed to the organs and their marked reflex excitement. In some cases an expansion of the sphincters for one and a half inches or two inches is quite sufficient; other cases may require a little more thorough divulsion; but never weaken or paralyze the sphincters, as your patient needs their normal use, and you need the reputation of never causing incontinence of feces. Guard the usefulness of the sphincters as you would a valuable treasure.

As a rule, I treat all of the ano-rectal sacculated mucosa in cases where divulsion is required before performing the dilatation to break up the adhesions, and very frequently the muco-cutaneous sacs and distended veins as well. It may be well to delay the divulsion—with which there is usually no hurry—until you determine how many U-shaped (or hairpin shaped) mucus channels and recto-anal mucus fistulas there may be present that have passed down under the recto-anal mucous membrane, down to the integument about the anus, and then pressed immediately upward again along the outer wall of the anus and rectum, to the extent of six inches or more. There may be three, four, six, or more of them quite prominent as to length and size.

For the treatment of the recto-anal sacculated mucosa the injection method is par excellent. For the removal of the muco-cutaneous sac a double V-shaped incision, the proper depth, length, and width, will remove the surplus or redundant tissue, after which the edges are brought together with a catgut suture,—or omit the suture if you think best,—followed by the home attention as prescribed for fissure-in-ano in a previous chapter. At the time of removing the sacculated tissue attention may also be given to the mucus channel; or you may, if you wish, leave it so that at some future treatment you can give it the desired attention. A one or two per cent. solution of alypin, cocain, or beta eucain will produce the necessary local anesthesia for a painless operation. I remove only one muco-cutaneous sac at a treatment, which permits the patient to go about as usual without much inconvenience.

If you have removed all of the ano-rectal sacculated mucosa in a case, and have omitted to remove the one or more ano-muco-cutaneous sacs or dilated veins that are so often present around the anus, and have also neglected to cure the chronic proctitis, then the sacculated mucosa may, by some hook or crook, become excited again into an acute inflammatory condition, the sphincter muscles may grip tighter than usual, and lo, thrombus has taken place in a vein, and the wrinkled, shriveled, skinny tab or sac looks like a miniature balloon, and your dismissed patient is in a troubled state of mind to have everything come back on him so soon!

The cure was all right so far as it went, but there was the disease and some of the old external symptoms to tell the tale of an incompleted treatment.

Those muco-cutaneous sacs at the enteric crater’s mouth are just so many thermometers at its vent to tell the temperature occasioned by the fire of inflammation within, and they will damage your reputation as a proctologist if they be not removed. By all means get rid of these symptoms and indicators of trouble within; and if there should by chance be a little of the old proctitis remaining that wants to assert itself by making trouble, in becoming acute, it will be surprisingly handicapped in its efforts, and the chances are all in your favor; and you will, moreover, from time to time, hear what So-and-So said about the very successful treatment of his or her case.

Sacculated mucosa, muco-cutaneous sacs, submucous channels, etc., having their source in the rectum and anus, are all of a similar origin, the result of serous exudation. These symptoms of proctitis vary in development and number according to the nature and progress of the disease. In those cases that are quite exempt from sacculated mucosa (piles) you may expect to find submucous channels largely developed, and vice versa.

Too much stress cannot be placed upon the serious results of auto-intoxication by the absorption of mucus from channels and cavities that will hold from three to eight or more ounces of fluid at one time. They are no doubt rapidly emptied by the process of absorption into the system.

I have not referred to the fatalities of the hypodermic treatment of sacculated mucosa (piles or hemorrhoids) because of the fact that none have ever occurred within my knowledge among those using either this or a similar method of treatment.

CHAPTER XXIII.
Abscess and Fistula Involving Anus, Rectum, and Neighboring Regions.

Hippocrates, the father of medicine, Celsus, Galen, and other writers in the early times, described fistula as a disease; and, naturally enough, through the influence of heredity, contagion, imitation, and auto-suggestion, every author on the subject to the present day has chimed in most complaisantly with his “Ditto! ditto! ditto!” “Me too! me too! me too!” I am sure that the rank and file of my medical brethren will agree with me that modern authors are hardly justified in this servility to the ideas of the fathers of medicine in this recreance to their duties toward suffering humanity. Is it that they do not know better, or that they are naturally servile and thus too lazy to do their own thinking?

Let me in connection with this point call your attention to a practice that many of us have been suspicious of for a long time, a suspicion that has been confirmed for me by one who speaks from positive knowledge; otherwise I should not refer to it here. The practice I am about to describe will make it plain why we have so many “Ditto and Me-too” authors on proctology and other medical subjects.

An eminent surgeon who mentally is as large as the human race, and has room for all that is good in medicine and surgery, narrated the following incident of his career to a learned doctor from Georgia and myself recently. Snatching occasionally a few moments from a busy practice, he has prepared sufficient material to make a book, and desired some competent person to edit it before publication. So he consulted an ethical co-worker concerning such a person. In a few days a gentleman called at the doctor’s house to inquire about the contemplated publication. The caller asked the title and size of the book, and when told volunteered the startling information that he could have the work ready in a few weeks’ time, but that in the meantime he would like to hear the doctor lecture once or twice that he might catch a few peculiar expressions to use in the work, so that the doctor’s friends, when reading the book, would say, “That sounds just like the doctor; that is his style of talking.” The would-be scribe never asked for the author’s manuscript, so accustomed was he to rely upon the medical literature to be found in the libraries of the city for all the information needed. It is hardly necessary to add that the professional bookmaker was summarily dismissed. The doctor’s manuscript is still unpublished.

There is a third reason for so many “Ditto and Me-too” authors. Publishers of medical books naturally desire to extend their business, and in order to do this they must issue new works of medicine in the same way that lay publishing houses compete for new works of fiction. Now, doctors usually obtain professorships in some institution by paying five thousand dollars or more for them, and in due time a publisher of medical books will tempt the professor to become an author. They place before him their great facilities for getting up a book, arguing that consequently but little or no labor on the professor’s part is required. They point out to him the fame and honor the publication will bring him, and at the same time estimate how much money they will make out of it. In due time a “Ditto and Me-too” medical brief, résumé, or treatise, is published covering the whole history of the subject, from Biblical mention of it to the present day. All of us have observed what a great amount of stuffing or padding it takes to make a book that is to sell for five or seven dollars. It occurs to me that it might be wise to get up a conference of enlightened physicians to take some practical steps or to devise some laws that will prevent such impositions on the too confiding medical brethren by unscrupulous publishers that rob them of their hard-earned income through delusive advertising. Still, before any action is taken that would result in effectively closing the door to this practice, it may be as well that the eyes of more of us should be opened that we may not continue to be duped and stung again and again by “Ditto and Me-too” scrapbooks with hundreds of pictures. When seeking for new and better information to help suffering humanity, let us be served for a little while longer with “rehashed rot.”

Pardon this digression. We will now consider, at first hand, the subject of fistula.

As a rule, pus in a fistula is a secondary symptom of chronic proctitis, except those fistulæ that occur from traumatic injury to the region of the rectum, anus, and buttocks. Early in my practice I entertained the idea that the formation of pus occurred at the point of dissolution of the tissue, and that, as the volume of pus increased it made its way in the direction of least resistance through it, if the abscess had not been opened by an incision. The idea was well founded when it was applied to the traumatic origin of an abscess and fistula, but not when their origin was traced to chronic proctitis.

It may seem incredible to all who read this that a mucus channel or a fistula can be formed for ten, twenty, forty, or more years before the formation of pus takes place in it; and that the pus exerts no part in producing the diameter or length of the fistula, which may have a capacity of six, eight, or more ounces of fluid. As soon as the chronic inflammatory process has penetrated one or more layers of the mucous membrane, mucus channel or fistula-formation must take place. If the sphincter muscles be rather weak or lax I would not expect sacculation of the rectal mucosa to occur to any extent. In these cases, however, the muco-cutaneous channels are usually found quite large and numerous. Of course the extent of the ano-rectal symptoms in each case depend upon how severe the chronic inflammatory process has been, and is, at the lower portion of the enteric canal. Often you will find that the seat of the most active chronic inflammation is in the middle and upper portion of the rectum, involving also the sigmoid colon. In these cases the ano-rectal symptoms are not numerous, if there be any at all, on the mucous membrane, but under it you may expect mucus channels that serve as outlets for the inflammatory product.

In every case of chronic proctitis and sigmoiditis submucous and sub­tegu­men­tary fistulæ can be found, and my experience in tracing them warrants me in stating that peri­proc­titis and peri­sig­moid­itis is present also; the latter pathological condition being due to the invasion of submucous and sub­tegu­men­tary channels or fistulæ around the outside of the structure of the anus and rectum, extending far up into the neighboring tissues of the pelvic space that support the rectum and sigmoid flexure.

The formation of pus in a submucous or sub­tegu­men­tary channel that has existed for many years does not make it a disease; it is only another incidental phase added to an already existing symptom of chronic proctitis.

Mucus fistulæ should be diagnosed and treated early in their formation, or at least before the tissues involved became so deteriorated as to form pus in quantity sufficient to occasion the usual period of suffering, fever, loss of rest and sleep before the pus is freed from its enclosure. The formation of pus in a mucous fistula is only incidental and marks a stage in the distinctive changes that have been going on for many, many years in the tissues involved in the inflammatory exudation.

The numerous small and large submucous and sub­tegu­men­tary fistulæ found in every case of chronic proctitis and sigmoiditis was the most grave and far-reaching of the numerous symptoms, but for three decades I have fully realized the baneful effects from mucus irritation, and the self-poisoning by the absorption of large quantities of serum and fibrinous septic material from the surface of the mucous membrane involved, as well as that from numerous long, cavernous mucus fistulæ: a fearful double source of auto-intoxication, for which it is useless to prescribe diet, tonics, and travel for building up the system and restoring the health.

Besides the numerous general symptoms, arising from self-poisoning by fecal and mucus absorption, we have more or less marked local symptoms in many cases; and if these be not present, the diagnosis can be made out from the general debility of the system and the character of the chronic proctitis and sigmoiditis.

The local symptoms of mucus fistulæ, peri­proc­titis, and peri­sig­moid­itis are, each of them, universally diagnosed as a disease: Such symptoms as pruritus ani, scroti, vulvæ, lumbago, sciatica, myalgia, rheumatism, prostatitis, coxitis, disease of the coccyx, chafing about the anus and along the thigh and scrotum, difficulty in getting up after sitting for a while, pain in the back of the neck, lame back, legs feel tired, and sometimes pain is very annoying, abnormal color of the skin, painful or sore spots at times, confinement in bed for many weeks from severe continuous pain in and about the rectum, etc.

Up to the present time proctologists have paid little or no attention to proctitis and sigmoiditis, which is a grave disease, with a far more serious symptom, that of mucus fistulæ of great length and diameter, extending in all directions in the pelvic cavity and tissues of the buttocks, the large area of tissue found so full of holes, might be likened to a sponge occupying the same space. They are very numerous in every case of chronic proctitis and sigmoiditis.

This will explain why an incidental symptom like pus in a fistula is commonly called a disease by the “Ditto and Me-too” authors, and why it is so frequently met with in practice. At some hospitals one-half of the cases treated suffer from fistula in which pus has formed. Why the per cent. is not much greater I am unable to explain, except to give credit to the defensive and restorative power of the human body. If the peri­proc­titis and peri­sig­moid­itis, brought on by the mucus fistulæ, is not treated at the same time as the cause, the treatment will be of no consequence in effecting a cure of the chronic inflammation of the lower bowels. Every mucus fistula should be located and healed at the time that the disease itself is treated; then the work will be well done. Every mucus fistula should be diagnosed and treated before the breaking down of the tissues reaches the pus-forming stage, and thus obviate all suffering, annoyance, and possible death. Attention to this course will ensure your treatment of the disease, and its symptoms, to be taken in time.

The only hindrance to the successful office treatment of a fistula in which pus has incidentally formed is the fear that you can not cure it, or that you will fail, or that at a hospital it could be cured quicker, better, and cheaper. These ideas are born of heredity, timidity, fear-habit, power of auto-suggestion, and too much caution on your part. They are all falsehoods and should not be heeded for a moment. During thirty years of practice in my specialty I have sent seven of my fistula patients to a hospital for treatment, and four of that number I afterwards very much regretted sending, as I could have accomplished the cure in a safer and better way by the usual office method of cure. In fact every fistula, pus or no pus,—I do not care how bad it may be,—can be cured by office treatment and at the same time aided by the home attentions of the patient. There may be periods of a year or more when your energies are overtaxed with numerous patients, and you feel like dividing the labor with some fellow-practitioner, and this in a measure accounts for those I induced to go, or was willing to have go, to the hospital.

Unless overwork is the excuse, you need never send a fistula patient to a hospital for treatment. I have everything to say in praise of the ambulant treatment of ano-rectal fistula and the mucus channels, since my practice thus far has been devoid of any unfavorable results,—a fact which should have much weight in favor of the ambulant office treatment of all of the many symptoms of chronic proctitis, sigmoiditis, and colitis.

Mucus fistula is very easily healed in all cases, and those cases in which pus has incidentally formed are likewise not difficult to cure. All you need to do is to instill intelligence in a stupid patient, if you haven’t an intelligent one, and induce him to utilize or improvise a few home conveniences for cleansing the fistula night and morning between office visits. During the treatment of the fistula patients will be able to attend to their imperative duties.

To properly explore a fistula and its branches, if any, as to whether pyogenesis (pus) has taken place or not, it is essential to have the external opening through the skin of sufficient depth and size to permit of the application of remedies over all its surface. For a mucus fistula antiseptic remedies can be applied after a thorough irrigation by hot water at a temperature of one hundred and twenty degrees, or more, for half an hour or less time, as the case may demand. Where pyogenesis (pus) has occurred in a mucus fistula there may be more or less necrotic tissue formed, which will require the use of an escharotic remedy as well as very hot water irrigation, followed by an antiseptic remedy, if not already incorporated in the hot water used.

As a rule I see a fistula case once or twice a week, as the case may require. There is no packing of the fistula after the morning and evening home treatment—I have never found it essential. A T-bandage is worn, with absorbent cotton, over the opening of the fistula, preventing soiling of the clothes while attending to daily duties.

Never mind what the “Ditto and Me-too” proctologists have copied or rehashed about the curing of a fistula, which they persist in calling a disease. Just be resourceful, safe, and sane in all you do, and every fistula will get well long before you have cured the chronic proctitis and sigmoiditis, of which the fistula, as a rule, is a symptom.

CHAPTER XXIV.
Nine Radiograph Illustrations of Mucus Channels and Cavities.

I am indebted to Dr. Caldwell, of New York, at whose laboratory my patients were radiographed for the very excellent illustrations; and also to Dr. Albright of Philadelphia, for his assistance in the radiograph work, while attending my clinic, and who, later, with rare skill and scholarly ability, presented my discoveries in a large volume, entitled; A Practical Treatise on Rectal Diseases, Their Diagnosis and Treatment.

The following illustrations can only give a hint of the pathological conditions that existed. Fig. 1 shows seven, and Fig. 2, eight probes inserted, which by no means indicate the number of channels or size of the cavities; twenty-five to fifty or more probes inserted would more accurately indicate the excursions of the inflammatory exudate.

The seven following illustrations, in which Bismuth Paste was injected, did not meet my expectations in showing the pathological conditions that existed. The disappointment was largely due to a desire not to cause annoyance to my patients, who so kindly consented, in the interest of science, to being radiographed. In all cases the paste extended over a much greater area than a casual glance at the illustrations would indicate. The probes and paste were not inserted with the idea of making a diagnosis, but simply to suggest research on the subject by proctologists. All the cases radiographed suffered from proctitis, sigmoiditis, peri­proc­titis, and peri­sig­moid­itis.