ON

DISEASES OF THE RECTUM.

CHAPTER I.

INTRODUCTORY OBSERVATIONS.

THE terminal portion of the alimentary canal—the rectum is subject to numerous and varied derangements, dependent upon its structure, its peculiar office in the economy, and its relation to the important parts in its vicinity. As a class of diseases, those of the rectum are as common as any to which the human body is liable; and they give rise to sufferings, in many instances, not only severe, but also often accompanied with depression of spirits, and an anxiety of mind, out of all proportion to the gravity of the disorders. Many of these diseases spring from habits prejudicial to health, engendered by sedentary pursuits, or consequent on indulgence in the luxuries of civilized life. They are, therefore, found to be most prevalent in the middle and upper classes of society. With a

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few exceptions, there are no diseases which yield more readily and effectually to careful management and surgical treatment, or which in their results afford greater satisfaction to the practitioner.

In the treatment of these diseases it is, in most cases, important that an early and careful examination should be made of the part affected. By neglect of this precaution, serious disorders, which, if detected in time, would yield easily to treatment, are allowed to make progress, and to become difficult of cure. In females, the delicacy of the sex too frequently leads to concealment of these complaints, and raises obstacles to an inspection of the seat of them. The chief information is to be gained by a tactile examination. We can discover in this way contractions in the passage, as well as tumours and excrescences; and by the practised finger ulcers may be detected, and their size and situation accurately ascertained. The examination should always be made with gentleness. This caution is especially required when the sphincter is irritable. Let the surgeon, in introducing his finger, well greased, proceed slowly, stopping at times until the sphincter becomes quiet and accustomed to its presence. The muscle will then yield, and allow the finger to pass on without pain. A rough attempt to penetrate excites resistance from the muscle and spasm, and the passage of the finger then occasions considerable suffering and after-distress.

The examination of the parts diseased, as well as the performance of certain operations, may in many instances be considerably aided by the use of a speculum. They are made of various kinds, some of them ill adapted for the object in view. Thus, many of the dilators are of little use in consequence of the bulgings

of the mucous coat of the bowel between the narrow blades of the instrument. There is an old-fashioned but serviceable instrument, consisting of a longitudinal section of a steel tube, with one extremity closed, which has long been employed at the London Hospital in examining these diseases, and which is well adapted for protecting the bowel, and finger of the surgeon, in operations for fistula. A blunt gorget has sometimes been used for the same purpose. Mr. Hilton contrived a plated speculum, with the end closed, and an aperture at the side into which a moveable piece slides. I have often used it, but have found the side opening too narrow to afford a complete view of an ulcer or pile of any size; and in consequence of the aperture not being carried to the extremity, fæces are liable to lodge there and prove troublesome to remove in protracted examinations, as in searching for the inner orifice of a fistula. I therefore employ a plated speculum of a conical form, so as readily to penetrate the sphincter, with the side opening of sufficient width, and carried to the blind extremity of the instrument: and instead, also, of a moveable piece, I have substituted a metal plug, which fits close into the aperture. The edges of the opening are made thick and rounded to prevent injury in the withdrawal of the speculum. The sphincter closely embraces the instrument, and when the edges of the opening are sharp, as in the ordinary speculum, they scrape the mucous membrane and produce bleeding and soreness. The handle of the speculum traverses the rim in a groove, but admits of being firmly fixed at any point by a screw. This is of advantage in enabling the surgeon to place the handle out of his way, and where it can be most conveniently held by the assistant or