patient. The subjoined engraving shows the improved speculum reduced in size about one-half'.

In the application of remedies to the interior of the rectum, the common glass reflecting speculum, coated with caoutchouc and an open end, will often be found useful. Leeches may be applied to the mucous membrane of the bowel by means of a glass speculum with a small side opening near the closed extremity. Before using any of these instruments, the rectum should be well cleansed by an injection of warm water.

In the treatment of diseases of the rectum chloroform is a valuable auxiliary. In making examinations I have derived the greatest assistance and advantage from it. Under its influence the irritable sphincter relaxes, and a complete view can be had of the seat of disease in cases where pain and spasm would otherwise offer almost insuperable obstacles to a satisfactory exploration. And, in operations more painful than serious, the use of this remedy has not only facilitated their performance, but saved the patient considerable suffering and distress.

1 This instrument is an improvement on the one described and figured in the first edition of this work. It can be had at Ferguson's, in Giltspur Street, and Weiss', in the Strand.

It may seem superfluous to remark, that no operation, even of a trivial character, should be performed on the anus or rectum without due inquiry into the state of the patient's general health. I have heard of diffuse inflammation of a fatal character arising after the removal of a small excrescence from the anus, and after the division of a fistula; and of phlebitis occurring from the removal of hæmorrhoids; and although all operations are more or less liable to ill consequences, they very rarely happen except where the precaution alluded to is neglected. No prudent surgeon would undertake an operation on these parts in a person with a broken-down constitution, or with organic disease of the lungs or liver, or with albuminous urine; but with ordinary caution in the selection of cases, and with common care in performing the operations necessary, and in conducting the aftertreatment, they are as successful and satisfactory as any belonging to surgery.

CHAPTER II.

IRRITABLE ULCER OF THE RECTUM.

THE mucous membrane of the lower part of the rectum is arranged in longitudinal folds, which disappear in the expanded state of the bowel. These folds terminate below at the external sphincter. Just within this structure, and between the folds, the mucous membrane is slightly dilated, variously in different subjects, but in many to such an extent as to form small sacs or pouches. Besides these folds, and in the spaces

between them, there is a series of short projecting columnar processes, about three-eighths of an inch in length, separated by furrows or sinuses, more or less deep, which are arranged around the lowest part of the rectum. These various folds, though no doubt well developed in the living state, are not always obvious after death, unless the vessels are congested. They are rendered distinct by injections with coloured size, both in the adult and in the foetus. Now in the evacuation of the rectum, foreign bodies or little masses of hardened fæces are liable to be caught or detained in the pouches just described. And it is in these little sinuses, thus exposed to irritation and abrasion, that a superficial circumscribed ulcer is occasionally formed. On examining the ulcer, without distending the rectum, the lateral edges only being presented to view, the breach of surface has the appearance of a fissure,the term commonly given, but improperly, to this sore, which is obviously more than a mere cleft or rent in the mucous membrane of the bowel. Such an ulcer may occur in any part of the lower circumference of the rectum, but it is very generally found at the back part, towards the coccyx. It is quite superficial, and, though sometimes circular, is more usually of an oval shape; its long axis being longitudinal, and its lower extremity extending within the circle of the internal sphincter. On tactile examination, the breach in the mucous surface and the extent of the ulcer can be easily distinguished by a practised finger, especially when the edges are, as is often the case, somewhat indurated. With the speculum the longitudinal folds being stretched out, the ulcer can be fully exposed, and it is then clearly seen not to be a mere fissure, but a superficial sore, which may extend beyond the edges

of the opening in a common-sized speculum. The surface is of a brighter red than the surrounding membrane, and has the usual indented appearance of an ulcer.

The amount of suffering produced by this superficial ulcer varies a good deal, but the sore is generally extremely sensitive, and occasions severe distress. It is so situated that the fæces, in their passage outwards, rub over its surface, and the painful contact excites spasm of the sphincter muscle, causing a sharp burning pain, and often a forcing sensation, which lasts for two or three hours, the distress being usually greater after defecation than during the act, and in some instances an interval varying from five minutes to ten or more elapses between the evacuation and the occurrence of pain. The pain is sometimes so acute that patients resist the desire to pass their motions, and allow the bowels to become costive, in dread of the sufferings brought on by evacuating them. In one case which came under my care, the intensity of suffering had led the patient, a young gentleman, to adopt the dangerous course of inhaling chloroform whilst sitting on the close stool, and he could not be persuaded to go to the closet without this remedy. The pain though much increased during, and for some time after defecation, is in many cases constant-the patient never being free from a sharp lancinating pain, which disturbs rest, depresses the spirits, and renders the sufferer truly miserable. The least pressure at the anus gives uneasiness, so that the patient is obliged to avoid sitting, and either to rest on one hip or to lie down. He will sometimes place his finger on a spot outside the anus which exactly corresponds with the seat of the ulcer internally. The pains occasion

ally assume a neuralgic character, and are described as shooting up the back, down the limbs, or along the urethra. The irritation may extend to the bladder, producing painful micturition. The stools are sometimes streaked with blood.

In comparison with many other diseases of the rectum, the irritable ulcer is not a common affection. The removal of hæmorrhoids, and the division of a fistula, may be performed with little risk of the sore consequent on the operation assuming the characters of the irritable ulcer. There are, however, exceptions. One of the most painful ulcers I have had to treat occurred, I was informed, after the excision of a small pile. In another case, in which I removed a large pile by ligature, the patient, a gentleman, neglected my injunction to keep at rest afterwards. He returned too soon to active business, and an irritable sore in the rectum was the consequence.

The irritable ulcer occurs usually in middle life, and is more frequent in women than in men. It is met with as often in single as in married women; and in persons of an hysterical temperament there are occasionally pains of so anomalous a character as sometimes to mislead the practitioner. Indeed, it is surprising how often this sore is overlooked even in common cases. Tactile examination is not always sufficient, for the sore is sometimes so superficial as not to be detected except by the most sensitive and practised finger. In all instances, therefore, of painful defecation for which the surgeon is unable to account, the rectum should be carefully examined with the speculum.

On the attempt to separate the margins of the anus, or to dilate the sphincter to get a view of the ulcer, or