INTRODUCTION.

IN the whole range of surgical pathology, no class of diseases among civilized communities is so prevalent, causes more suffering, or induces so many varied and distressing sympathetic affections as those of the rectum; happily for the sufferers, none succumb more readily to judicious, and, in the majority of cases, to simple treatment, when it is put in force at an early period of the malady; but unfortunately it often happens, from a mistaken delicacy on the part of patients, or from some other cause, proper advice is not sought till the constitution has become seriously deranged, or the local affection no longer endurable; or it may be that, under preconceived and erroneous notions as to the nature of the affection, or from the prominence and severity of some one of the sympathetic effects, the sufferers are induced to adopt a variety of empirical remedies which fail to afford the desired relief and restoration of health, and which are often productive of the most pernicious results.

From the important functions of the rectum, from the constant or recurrent pain attending diseases affecting it, induced each time the bowels evacuate their contents, and the serious constitutional disturbance these diseases excite, they require the careful attention and deep consideration of the surgeon. In past ages and in the present time a popular idea has prevailed that a deeper knowledge of, and a more intimate acquaintance with, the diseases of any certain organ is obtained by an exclusive consideration of that particular part; but no greater fallacy can be conceived, it being only by a comprehensive view, and after due consideration of all the symptoms produced, and the various phases presented

by disordered function and organic change in the various parts of the animal economy, that a just conclusion as to the fons et origo mali can be arrived at. Perhaps few classes of disease exemplify the necessity of a wide and mature consideration more than those implicating the rectum, either primarily or secondarily; for the same symptoms will often be found existing under the opposite conditions of cause and effect. Thus, in the female, many instances have occurred of stricture of the rectum being supposed to exist, and a long and useless treatment had recourse to, when ultimately all the patient's sufferings were found to depend on a displaced uterus, or on some morbid enlargement or growth of that organ; and the converse is not unfrequently the case, of a patient being treated for leucorrhoea or uterine disease, whilst the real source of the symptoms has been in some affection of the rectum. In the male also will be observed stricture of the urethra, diseases of the prostate gland and bladder simulating those of the rectum; or, on the other hand, diseases of this portion of the alimentary canal producing irritability and other disturbance of the genitourinary organs. Nor is it in contiguous parts alone that the reaction of one organ on the other is met with; it is necessary therefore to bear in mind the more remote sympathies induced in the cephalic, thoracic, and abdominal viscera, as evinced by headache, vertigo, impaired vision, palpitation of the heart, gastric distension, pain, and sickness; and deranged secretion from the kidneys, as exhibited by the various urinary deposits.

Formerly some of the affections of the rectum, which in reality are very simple in themselves, and easily relieved, rendered the subjects of them the victims of the most painful and in many cases dangerous operations. But by the advance of surgical science generally, and the study and observation of these particular diseases, even the most painful of them may generally be remedied by medical treatment; and when an operation is necessary for the removal of morbid structure, or for the purpose of inducing a healthy reparative process, it is simple in character, quickly performed, occasioning but a slight amount of pain, and confining the patient for only a very limited period. Thus fistula in ano, which, at a comparatively recent period, was considered among the heaviest afflictions that flesh is heir to, from the barbarous treatment that was then practised and considered necessary, as a consequence of the false

notions and erroneous pathological principles that prevailed, and which led to the scooping out of the parts in the track of the fistula, or to the extensive destruction of the surrounding tissues by corrosive unguents, is now remedied by a slight incision, performed in a few seconds, and not occasioning the loss of more than a few drops of blood. It was only a few years since it was deemed essential for the cure of fissure of the anus to entirely divide the sphincter muscle; but it is now proved that when an incision is required it is not necessary to make it more than a few lines in length, and to extend it no deeper than through the mucous and submucous tissues. In all operations about the anus, the general rule in surgery, that of not removing more of the integument than is necessary, cannot be too forcibly insisted on; for if this is not observed the patient will be doomed to much inconvenience and misery by the contraction that ensues.

The constitutional origin of these local affections, and their reaction on the general system, when their cause has been extrinsic, must always be borne in mind, for if this be overlooked, our hopes of success in the treatment will often not be realized.

Besides prescribing proper remedies, and giving strict injunctions with regard to diet and exercise, it is advisable that the surgeon should apply the dressings with his own hands; for though there is no difficulty in the matter, and little skill required, yet it is essential to the comfort and recovery of the patient that they should be accurately and properly adjusted: nurses and attendants, from not thoroughly apprehending the object to be attained, are too apt either to cram and distend the parts with the dressings, or not to approximate them with sufficient nicety: the surgeon should also exhibit the enemata, unless he has some intelligent and trustworthy person on whom he can rely. These matters may appear comparatively trifling, but if they pass unattended to, we shall often be disappointed in the result of our treatment, let it in other respects be ever so skilfully and well directed.

In some morbid conditions of the rectum, great advantage is derived by the use of the speculum for the purpose of examination, and also in performing some operations. In most cases one of the form of the annexed figure will answer the purpose: it is an oldfashioned instrument, and may be made of polished metal, or of glass silvered, and covered with caoutchouc. Several specula, dif

fering but slightly, have been contrived; some are made with metallic or wooden plugs to fill up the side opening while the instru

ment is introduced, but the finger will be found a far better substitute; others are furnished with handles, fixed or movable, which are worse than useless, being only in the way. Mr. Blaise, of the firm of Philip, Whicker & Blaise, surgical instrument makers, of St. James's Street, has invented a three-bladed speculum, which in some instances will be found exceedingly useful, as by it a surgeon has the power of dilating the bowel, and more fully exposing to view the diseased part when extensive. The instrument which I use is a slight modification of his, being somewhat conical, trumpet-shaped at the mouth, and admitting the introduction of the

finger, so as to prevent the mucous membrane being pinched between the blades when they are closed previous to withdrawing it.