of septic infection of the peritoneal cavity, viz: distended and rigid abdominal muscles, face flushed and anxious, nausea, etc. It was determined to open the abdomen immediately. The bladder was first washed out and the incision which had been been made in the bladder at the first operation was closed with interrupted silk sutures a catheter was placed in the urethra to insure drainage and to prevent the urine from soiling the peritoneum and wound after it had been washed and dressed.

On opening the abdominal cavity, the visceral and parietal pelvic peritoneum was found inflamed and bathed in a dirty sero-purulent fluid, an evidence of fibrino purulent peritonitis. Near the bladder the peritoneum looked dark and very ugly, and in a few hours, without irrigation and drainage, would have been attended by diffuse suppuration or septic peritonitis. The cavity was irrigated for some time with hot sterilized water. The lower end of the peritoneal wound was closed with a continuous silk suture; the cavity well drained with iodoform gauze, and silk-worm sutures, placed in such a position as to close the abdominal wound after removal of the gauze. The patient was put to bed in a fairly good condition; pulse 120, temperature 101.2°. He rallied well with a steady decrease of temperature until May 26, at 2. 30 P. M. The drainage had ceased, the gauze was removed, and the abdominal wound closed; temperature 100.6°, pulse 88, respiration 26. By 7.30 P. M. temperature 102°, pulse 89, respiration 26. A dose of salts was given, and at 9 P. M. an enema was administered with good effect, reducing the temperature to 100. 8° by to P.M.

As he had been much nauseated, the patient was fed and stimulated by enemas. The bladder commenced to drain through the suprapubic wound on the sixth day after operation, showing that the sutures in the bladder had given way. The catheter was removed from the urethra. The abdominal wound soon became infected and sloughed somewhat. The abdominal

stitches were removed on June 2d, and the wound dressed with chloral solution. From this time, the temperature varied from 98.8° to 99.6 until June 17, when at 6 A. M., the condition was temperature 101°, pulse 102, respiration 24, at 5 P. M. temperature 103.6° pulse 116, respiration 26; delirious, and in a condition of profound sepsis. The origin was difficult of location.

When not delirious he would complain of great pain in the head, back and abdomen, and of nausea. Refusing all nourishment, he was fed by nutritive enemas; and also was given one grain of calomel every hour until six grains had been taken, then a full high enema was given which proved very effective.

June 18, 9:15 A. M., temperature 100°, pulse 105, respiration 24, complained of feeling chilly, still nauseated and suffering in his head and abdomen; 5 P. M., temperature 103°, pulse 100, respiration 26. This condition continued, with morning temperature about 100°, and afternoon temperature 103°, until June 21, at 3:30 P. M., when he became very restless and weak, suffered intense pain in his back in the region of the right kidney, aching in his limbs, head, and abdomen, pulse 120, temperature 104°, respiration 34. Sponge baths of iced water and alcohol were ordered to be given every two hours, and the nurse was told to push stimulants and nourishment. The next morning at 8:30, a great deal of pus escaped from the suprapubic wound and continued for several days. Whenever an enema was given to wash out the bowel, he would pass urine through the urethra, which would be filled with pus. Temperaturc remained up until June 23, 4 A. M., when his conditioned improved. He looked and felt better; temperature 100° pulse 84, respiration 22. June, 25, he again suffered from absorption of pus, temperature going up to 103.4°. The wound was washed out, as has been done before with peroxide of hydrogen, every six hours. By the 28th, the temperature was normal, but would vary during each day, going as high as 100°.

The poor little fellow's troubles had not yet ceased, for on July 7, he had another rise of temperature it being at 6 P. M., 108°, with all symptoms of sepsis. The wound was draining well and freely, so another form of infection had to be sought. Later in the evening he passed a large quantity of decomposed mucus from the rectum, and continued to do so three or four times daily for several days, the temperature varying during this from 101.5°, to 103.8°. The trouble in the rectum was due, no doubt, to the effect of the nutrient enemata he had been having so continuously during his illness. After washing out the bowel for several days, the temperature was again brought down to normal by the 10th., remaining so until July 14, when it again

rose to 102.6°, from the same cause in the bowel.

After washing out the latter for a few days, it fell to normal and remained so. To-day he was removed to his home in this city with the abdominal wound nearly healed, water being passed per via naturalis, and in an apparently good condition after nine weeks illness.

Several interesting points might be brought out in reviewing this, but, in concluding I will only refer to two: 1. Suppurative septic peritonitis may follow suprapubic cystotomy without me chanical injury to the peritoneum. 2. The early, prompt, and thorough flushing of the abdominal cavity followed by drainage for suppurative septic peritonitis will save life, where a few hours delay would only bring surgery into disrepute; and the patient's life would be doomed.

COMPLICATIONS OF INTERNAL HEMORRHOIDS. BY W. O. GREEN, M. D.

Fellow of the British Gynecological Society; Member of Societe Francaise d'Electrotherapie; Chief of Clinic for Diseases of the Rectum, Kentucky School of Medicine; Associate Editor New Albany Medical Herald; Member of the Asst. Visiting Staff, Kentucky School of Medicine Hospital; Member Visiting Staff to

A

the Masonic Widows and Orphans

Home Infirmary; Member Consul

ting Staff to the Louisville

City Hospital ect.

T the outset it may be presumed that pain is not a symptom of uncomplicated internal hemorrhoids, unless they become inflamed or strangulated.

While almost all rectal maladies may complicate internal hemorrhoids, the diseases which may usually be expected to co-exist are, fissures, ulceration, polypoid growths, and polypus, prolopse stricture, malignant disease, fistula and proctitis.

The most common of the diseases enumerated above is fissure, and its presence may generally be indicated by the characteristic pain. This is located at the anal orifice. It is of a burning. nature and appears either during defecation or shortly afterward. The pain may also radiate across the perineum, up the back or down the thighs. In some instances it is referred to the genitourinary organs. The fissure may be the cause of bleeding and give rise to a small quantity of discharge. If the lesion is located at the anal orifice, by carefully separating the adjacent folds of integument, the denuded surface will be exposed to view. If it is located inside the anus, its presence may be determined by the spastic condition of the sphincters and a superficial denudation of the mucous membrane, usually about the lower border of the internal sphincter, which sometimes can be outlined by digital exploration. In case the piles are inflamed the surgeon may first be made aware of the presence of the fissure after the dilatation of the sphincters.

This complication may be relieved by dilatation, which is now generally practiced preparatory to operative procedure for hemorrhoids, but it is not always best to rely solely upon such a course. If the clamp and cautery operation is employed, it is well to pass the cautery over the surface of the ulcer, or it may be included in the superfluous tissue which is incised. Unless the hemorrhoids are removed by Whitehead's operation, the most desirable procedure consists of drawing a straight bistoury across the base of the ulcer, carrying it down through the fibres of the underlying sphincter.

An uncommon complication of internal hemorrhoids is ulceration of the rectum. Its importance, however, is sufficiently great to demand attention here. It may be suspected by the morning diarrhea, heavy pains about the lower portion of the sacrum, inside the rectum, and sometimes, about the front of the abdomen, in the lumbar region and through the perineum. The pain is much, if not entirely, ameliorated by defecation. There is tenesmus and a discharge which, in the early history of the disease, resembles the white of an unboiled egg. Later in the development of the disease, the discharge has the appearance of coffee grounds. The diagnosis may be confirmed by digital exploration, and occasionally by the employment of the speculum.

In all except the simple cases, the ulceration is the disease of prime importance and will require, usually, a course of treatment based on rest, cleanliness, local applications and proper diet. This form of treatment may precede or follow operation upon the hemorrhoids. The operative form of treatment of ulceration will be modified only according to the character of procedure the surgeon may select for the hemorrhoids.

It is the fibrous variety of polypoid growth which generally complicates internal hemorrhoids. These growths are commonly small and may be deposited over the surface of the pile.

When large polyei are present and located high in the rectal pouch, their existance may be suspected by the presence of a glairy discharge, a tendency to looseness of the bowels and an intense desire to strain at stool. Sometimes the growth may be seen to protrude with the hemorrhoids, or it may notbe discovered until the finger is passed over the surface of the rectum and comes in contact with an oblong or rounded tumor attached to the mucous membrane and submucous coat by a cord-like pedicle.

When attached to the surface of the hemorrhoid, these growths are taken away with the superfluous tissue which is removed during the operation. Should a polypus be located high in the rectal pouch, it is a matter of great importance to be most careful in its removal. These growths contain a small vessel, and when of moderate size, if treated by torsion, as some writers recommend, disagreeable, if not dangerous, bleeding is likely to occur. They should be gently drawn down with a tenaculum, and after securely ligating the pedicle close to the base, cut away with the scissors outside the ligature.

A more common complication is prolapse. The term "prolapse" is here intended to signify a modified condition in the mucous and submucous coats of the anus and rectum, which gives rise to a protrusion of a portion of the mucous membrane, from the anal orifice. With a long standing or extensive case of protruding internal hemorrhoids, this condition almost always exists. sometimes becomes a source of annoyance to the surgeon, by reason of the difficulty to decide upon the character and amount of tissue to be removed by operative procedure.

It

The prolapse re sembles the hemorrhoids, which it may com