Observations on the diseases of the rectum

Front matter

22101331091

OBSERVATIONS

OJ>r THE

Preface

TO THE THIRD EDITION.

In this enlarged edition of my Observations on the Rectum, a great part of the work has been re-written or altered ; eight new Chapters have been added, and many improvements in treatment described. Besides the brief mention of a large number of cases, fuller details have been given of more than forty new cases, in treating of those affections which seemed to require such illustration. The subjects comprised in the new chapters are Nervous Affections of the Rectum; the Villous Tumour; Epithelial Cancer of the Anus and Rectum; Atony of the Rectum; Organic Contractions of the Anus ; Obstructions of the Rectum, and Operations required for their Relief; Congenital Imperfections of the Anus and Rectum; and Colotomy in cases of Imperforation. Special labour has been

VI PllEPACE.

bestowed on the somewhat intricate subject of Congenital Imperfections, and I have endeavoured to give as complete an account of them as the present state of our knowledge and experience, and the practical character of this work, admit of.

39, Grosvenor Street, December, 1862.

Chapter I

tNTEODTJCTOET OBSEBTATIONS ON DISEASES OF THE EECTUM.

PAGE

Persons most subject to these Diseases 1

Mode of examining, and making applications to the Eectum . 2

Description of improved Speculmns 3

Advantages of Chloroform in the Treatment of these Diseases 4

Operations on the Eectum . 5

CHAPTER II. IEEITA3LE TILCEE OP THE EECTtTM

Description of the Folds at the lower part of the Rectum . . 5

Seat and Characters of the Irritable Ulcer 6

Symptoms of the Disease ^

Occurrence after operations for Hsemon-hoids 8

Persons most subject to it 9

Liability to be overlooked ib.

Mode of inspecting the Sore ib.

Treatment of Irritable Ulcer 10

Division of the superficial fibres of the Sphincter Ani ... 11

Treatment after the operation 12

Sores and Ulcers at the margm of the Anus 13 viii

CONTENTS.

Chapter III

lEEITABLE SPHINCTEB MXTSCLE.

PAGE

Symptoms produced by an irritable Spbincter 15

DifSculty in Defecation ib.

CHAPTEE IV.

Irritable Rectum 18

Persons subject to it 19

Morbid sensibility of the Rectum 21

Characters of the complaint ib.

Neuralgia of the Rectum 23

Obscurity of the causes 26

Affections chiefly mental 27

CHAPTER V. HJSMOEEHOrDS

Arrangement of the Veins in the lower part of the Rectum . 28

Different Forms of Haemorrhoids ib.

StiTicture of External Piles ib.

Structm-e of Internal Piles 30

Appearances presented by Haemorrhoids 31

Causes of Haemorrhoids 33

Symptoms of External Piles 34

Symptoms of Internal Piles 35

Disorders of the Urinary Organs in connexion with this

Disease 36

Influence of affections of the Uterus f ... 37

Inflammation, Suppm-ation, and Sloughing of Htemorrhoids . 38 Bleeding from Piles, and periodical discharges of Blood from

the Rectum 39

CONTENTS. IX

PAGE

Case 40

The Sources of Haemori-liage ih.

Mode of examining Internal Hsemorrlioids 42

General Treatment of Hsemorrhcids 43

Treatment of External Hsemorrlioids 44

By Excision 45

Treatment of Internal Hsemorrhoids 46

Removal by Excision 49

Dangers of Hffimorrliage ^0

Removal by Cautei-ization i^-

Removal by Ligature 53

Improved mode of operating 54

Management of External Piles after operations on Internal . 55

Treatment after operation

Retention of Urine

Removal witb tbe Ecraseur i^-

Mode of arresting Hsemon-bage from Piles 59

Case of obstinate Bleeding Pile cured by operation .... 61

Use of Mechanical Aids

CHAPTER VI. PEOLAPStrS OP THE BECTTTM

Nature of Prolapsus

Pathological changes in Prolapsus 65

Causes of Prolapsus

Instances of immense Prolapsus in a veiy relaxed state of the

Sphincter Muscle ^'^

Symptoms of Prolapsus

Strangulation of Prolapsed Bowel

Case with sloughing of Mucous Membrane i^-

Troublesome bleeding in Prolapsus

Treatment in children

Treatment in adults

By Escharotics

By Operation

By Mechanical Support

X

CONTENTS.

Chapter VII. Poltptts Of The Bectum

Forms of Polypus 75

Polypus in childi-en 76

Treatment ib.

Polypus in adults 79

Strangulation of Polypus ib.

Case ib.

Chapter VIII. Villous Tttmoub Op The Eectitm

Structui-e of the Villous Tumour 80

Symptoms 81

CHAPTER IX. PISTTJLA m AKO

Description 82

Modes of origin 83

Situation of the inner opening 86

Fistula in phthisical subjects ib.

Comphcated Fistula 87

. Symptoms of Fistula 88

Treatment of Rectal Abscesses 89

Mode of examining a Fistula ib.

Treatment of Complete Fistula by Operation 90

Treatment after Operation 92

Treatment of Sinus passing high up 93

Treatment of Haemorrhage after Operation 95

Cure of Fistula by Ligature 96

Fistula Trocar described ib.

Case treated by Ligature 97

Operation with the Ecraseui- ib.

Treatment of Blind External Fistula 99

CONTENTS. xi

PAGE

Treatment of Blind Internal Fistula 99

Case 100

Treatment of complicated Fistula 101

Operations for Fistula in phthisical subjects ...... 102

Treatment of Fistula communicating with, the Vagina . . . 103

CHAPTER X. Description of the Morbid Changes in Ulceration of the

Eectum 104

Causes 105

Syphilitic Ulceration 106

Tuberculai" Ulceration 107

Symptoms of Chronic Ulceration ib.

Eodent Ulcer of the Anus and Rectum 114

Case ib.

Chapter XI. ' Stbicttjee Op The Eectum

Description of the Changes in the Coats of the Rectum

occuii-ing in Stricture 115

The Seat of Stricture 116

Double Stricture 117

Causes of Stricture ib.

Frequency of Stricture in Women ib.

Strictures produced by the Healing of Ulcers and Wounds . 119

Cases ib.

Period of life subject to Stricture 124

Local Symptoms of Strictm-e ib.

Con.stitutional Symptoms 126

Mode of examining a Stricture 127

Growths and Excrescences on the Mucous Membrane in

Stricture 128

Causes of these Growths 129 xii

CONTENTS.

PAGE

Examination of Strictures high up the Eectum . . . . . 130 Obstructions from Tumoui-s external to the Rectum . . . .131

Treatment by Dilatation ib. ■»

Mode in which Bougies operate in curing Stricture . '\ . . 133

Difficulty of curing Stricture of the Eectum 134

Cases of cure 135

Treatment by forcible Dilatation 138

Treatment by Incisions ib.

Dangers attending Incisions 139

Treatment of Strictures high up in the Rectum 140

Dangers incurred in the Use of Instruments in these cases . 142

General Treatment of Strictm-e 143

Local appKcations to the mucous surface 144

Haemorrhage from the Bowel in Stricture 145

CHAPTER XII. CAJfCEE OF THE EECTXJM

Morbid Changes in the Rectum produced by the different

Forms of Carcinoma 146

Seat of the Disease 147

Symptoms 148

Age at which Cancer occurs 150

Frequency in Men ib.

Excision of the Carcinomatous Rectum 152

Lumbar Colotomy for Relief of the Symptoms ib.

Successful Case 153

CHAPTER XIII. Liability of the Anus to Epithelial Cancer 154

Cases treated by Excision ib.

Dangers from Hiemorrhage after Excision 160

Epithehal Cancer of the Rectum 161

Case ib.

Effects of Epithehal Cancer, and Scirrhous, and MeduUary

Cancer on the Rectum, contrasted 163

MELAJrOTIC CANCEK OF THE ANUS.

PAGE

Case 164

CHAPTER XV. Obstructions at the termination of the Sigmoid Flexure from

Stricture or Cancer 165

Symptoms mdicating Obstnictions in this situation . . . . ib.

Mode of exploring the Eectum 166

Colotomy for the relief of the misery consequent on Strictui-e

and Cancerous disease 168

Eelative advantages of Inguinal and Lumbar Colotomy considered 169

Table of Operations for Lumbar Colotomy performed, or witnessed by the Author 170

Mode of performing Lumbar Colotomy ib.

Difiicidties of the Operation 172

Conditions of an Anus in the Loin • 181

PEUEIGO ANI.

Causes 189

CHAPTER XX: Classification 193

Case of Congenital Tecal Fistula 194.

Relative frequency of the Fornis of Imperforation . . . . ib.

Causes of these Imperfections 195

Relations of the Peritonemn to the Bowel in Imperforation . 196

Defects in the Pelvis 197

Imperforate Anus without deficiency of the Rectum . . . , ib.

Treatment by Operation 198

Imperforate Anus, the Rectrnn being partially or whoUy

deficient ib.

Treatment by Operation ib.

Anus opening into a Cul-de-sac, the Rectum being partially

or wholly deficient 199

Varieties of this Form . . . ib.

Treatment by Operation 200

Importance of securing the Bowel to the outer Woimd . . . 201

Case 202

Inconveniences of an Operation simply by Incision or Puncture ib.

Unique Case operated ou by Amussat 203

Imperforate Anus in the Male, the Rectum being partially or

wholly deficient, and communicating with the Urethra

or Neck of the Bladder 204

CONTENTS.

XV

FAGE

Inconveniences of this Malformation 204

Treatment by Operation 205

Imperforate Anus in the Female, the Rectmn being partially

deficient, and communicating with the Vagina 206

Inconveniences of this Malformation ib.

Operation for Enlargement of the Vaginal Outlet .... 207 Operation for estabUshing a new Passage at the natural site . 208

Operation for closm-e of the Vaginal Outlet 209

Imperforate Anus, the Rectum being partially deficient, and

opening externally in an Abnormal situation by a naiTOW

outlet 210

Varieties in the two Sexes ib.

Operation for Enlai'gement of the original Outlet . . . . ib.

Formation of an Anus at the natural site 212

Cases of Operation on the Male ib.

Cases of Operation on the Female 213

Narrowness of the Anus 216

Case ib.

Treatment ib.

Condition of the Anus estabhshed- by Operation at the natm'al

site 217

Causes of death in Imperforation - . . ib.

Causes of death after Operations 218

Changes in the Bowel consequent upon Partial Obstruction . 219 Troubles in Defecation resulting therefrom 220

CHAPTER XXI. COLOTOirr in congenital IMPEUPECTIOlfS OP THE AITCTS A20)

EECTUM.

The Lumbar and Inguinal Operations considered 221

The comparative difficulties in performing these Operations . ib. Author's Experiments and Observations on the Bodies of still-born Infants ' 222

The comparative dangers of these Operations 224

The comparative convenience of an Anus in the Loin, and

of one in the Groin 225 xvi

CONTENTS.

PAGE

Condition of the Anus in two successM Cases of Colotomy in

the Grrcan 225

Case of successful Colotomy in the Loin, and condition of the

Anus 226

Condition of the Anus in the Loin in a Boy operated on by

Amussat 229

Case of Inguinal Colotomy 230

Question of Operation in Eight or Left Grroin ib.

Author's Experiments on the dead Bodies of Infants . . . 231

Mode of performing Inguinal Colotomy on Infants .... 232

ON

DISEASES OE THE EECTUM.

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 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

B

INTRODUCTORY OBSERVATIONS.

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, in most cases it is 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 application of remedies, may, in many instances, be aided by the use of speculums. They are made of various kinds, some of them ill adapted for the object in view. Thus, many of them are of little use in consequence of the bulgings of the mucous coat of

INTRODUCTORY OBSERVATIONS. 3

the bowel between the narrow blades of the instrument; and, in others, the side opening is too narrow or small to admit of a sufficient exposure of the part diseased. It must be borne in mind that the parts requiring inspection are situated, with some rare exceptions, within an inch and a half of the orifice of the bowel, and generally within the circle of the sphincter. I sometimes 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 provided with 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 many of the ordinary speculums, they scrape the mucous membrane and produce bleeding and soreness. The handle 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, in a position where it can be most conveniently held by an assistant or the patient. The subjoined engraving shows the improved speculum reduced in size about one-half.

Fig. 1.

INTRODUCTOEY OBSERVATIONS.

There is, however, no speculum which I have found so generally useful, both in the examination of the lower part of the rectum and in the application of remedies to this part, as a glass reflecting speculum with a large side opening and a conical extremity.

Fig. 2, half-size.

A small glass speculum with an open end made oblique is often very serviceable, especially in the application of caustic solutions to ulcers and strictures, but it cannot well be introduced if the- sphincter be at all close or irritable. Before the use of any of these instruments the rectum should be emptied, and, if necessary, 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 ofifer 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.

It may seem superfluous to remark, that no opera-

IKRITABLE ULCER OF THE RECTUM. 5

tion, 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 haemorrhoids ; and although all operations are more or less liable to ill consequences, they very rarely happen after operations on the anus and rectum, except where the precaution alluded to is neglected. No prudei^t 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 after-treatment, 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 manv 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

6 IRRITABLE ULCER OF THE RECTUM.

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 fseces are liable to be caught or detained in the pouches just described. And it is in these little sinuses, thus exposed to irritation, abrasion, and rent, 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 Jissure^ — the term commonly given, but improperly, to this sore, which, though often originating in a rent, is obviously more than a mere cleft or fissure 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. The surface is of a brighter

IKRITABLE ULCER OF THE RECTUM.

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 faeces, 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. I have also known patients to deprive themselves of food in order to avoid an action. In a case which came under my care, the intensity of suffering 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 occasionally assume lEEITABLE ULCER OF THE RECTUM.

a neuralgic character, and are described as shooting up the back, down the limbs, or along the urethra. In the case of a man who suffered severely, the pain was referred to the spermatic cord and down the thigh on the same side, the pain in the cord especially being most distressing. The irritation may extend to the bladder, producing painful micturition. The stools are sometimes streaked with blood.

The sharp sufferings just described occur only when the sore is within the circle of the sphincter. I attended, with Dr. Arthur Farre, a lady who, after a hard evacuation, had a rent in the mucous membrane of the rectum just above the muscle. It could be felt with the finger, and plainly seen with a speculum. The ulcer which resulted caused much uneasiness after defecation, but it was much less persistent and distressing than the pain of the irritable ulcer, and the sore healed readily under local applications. In some cases a small pedunculated pile is found lodged in the depression of the ulcer, adding a good deal to the irritation produced by it.

In comparison with many other diseases of the rectum, the irritable ulcer is not a common affection. The removal of haemorrhoids, 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. I have also met

IRRITABLE ULCER OP THE RECTUM.

with one which occurred after the removal of an internal pile by the acid nitrate of mercury in a lady of irritable constitution.

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 even to introduce the finger, spasm, with an aggravation of pain, is, in most cases, immediately excited; and the orifice becomes strongly contracted and forcibly drawn in. When this is the case, it is better to desist, and to get an assistant to administer chloroform. As soon as the system is under its influence, the sphincter yields completely, and the surgeon is able to make a satisfactory exploration of the part, and to ascertain the exact seat, character, and extent of the ulcer. In those cases in which there is little or no spasm of the sphincter, or when the muscle is relaxed under chloroform, the surgeon may dilate the anus with his two fore-fingers, so as to get a tolerably good view of the sore. A better examination, however, may be made by the use of the speculum.

IRRITABLE ULCER OP THE RECTUM,

This ulcer seldom heals under the influence of local applications. The treatment necessary is a longitudinal incision through its centre, including the superficial fibres of the sphincter muscle. The object of the operation is to place this muscle at rest for a time, and to enlarge the passage and displace the sore ; thus removing those sources of irritation which prevent its healing. An incision, it is true, is not invariably required; but in all cases in which the pain is considerable, and in which there is much spasm of the sphincter, the attempt to procure the healing of the sore by local applications so often protracts the patient's sufierings, and so constantly ends in failure, that it is not desirable to make it.

The credit of originating the operation of incision for the cure of this painful complaint is due to the distinguished French surgeon Boyer, His operation was a free division of the sphincter muscle, a procedure unnecessarily severe '. Dupuytren practised a slighter incision than the operation performed by Boyer, and the late Mr, Copland was content to make a simple superficial incision of the part. In describing the operation to me, this excellent practical surgeon spoke of it as merely a division of the mucous membrane. I am convinced that on this point he is in error; at any rate this is not sufficient; and that however slight and superficial the incision may be, a few, at least, of the fibres of the sphincter must be divided. I had occasion to examine the rectum of a lady sufifering from this aflection, whilst she was under

^ A serious objection to the free division of the sphincter, an operation still practised by surgeons in this country, is a deficiency in the retentive power of the muscle, which sometimes distresses tbe patient after the part has healed.

IKKITABLE ULCER OP THE RECTUM.

the influence of chloroform, and the parts being very lax, and in a good light, I was able to bring the ulcer well into view, and could distinctly perceive the fibres of the sphincter forming the bottom of the sore. Now, it is clear, that in such a case, or in an ulcer which has destroyed the mucous surface, an incision throuo-h the base of the sore must reach and divide muscular fibres.

In the evening before the operation, an aperient should be given, in order that the bowels may remain at rest for two or three days after the incision. The patient should be placed on the left side, with the nates projecting a little over the edge of the bed, and the thighs bent, and opposite a good light. Chloroform can then be administered. The division of the ulcer may be performed in two ways ; by an incision from within, or from without the rectum. In the latter mode, a sharp-pointed bistoury is carried through the base of the ulcer, and the parts are divided by an incision from without inwards through the centre of the sore. A speculum must be previously introduced, to protect the opposite walls of the bowels from the point and edge of the bistoury. I prefer the operation from within outwards, which may be easily, and, indeed, more conveniently performed without the speculum. The cutting edge of a straight bluntpointed bistoury is to be applied to the centre of the ulcer, which is to be divided by a slight superficial incision. It is important to divide the fibres of the muscle at the extremity of the ulcer near the verge of the anus rather more freely than those above, so as to avoid any ridge or shelf on which the faeces would lodge. With this precaution the after-treatment

32 IRRITABLE ULCER OP THE RECTUM.

becomes very simple. A small piece of wet cotton wool may be lodged in the wound to check bleedinoand afterwards the parts may be left pretty well to themselves. I have never been troubled with hemorrhage, but if any vessel be seen pumping out blood, it may be seized and tied. I usually order a full dose of laudanum in chalk mixture and cinnamon water, to be taken shortly after the operation. In two or three days a mild aperient may be given, and repeated when necessary, to prevent costiveness and keep the motions somewhat soft.

The effect of the operation is remarkable. It at once relieves the severe symptoms, the pain experienced afterwards being merely the sore of the wound, and it rarely fails to secure the healing of the ulcer in the course of two or three weeks. The progress of the sore must, however, be watched until the surgeon is satisfied by an examination that the part is quite healed; for I have known of disappointment ensuing, and the painful symptoms returning, after the case had been given up under the supposition that the patient was cured. He should keep the recumbent posture. He need not remain in bed : rest on a couch is sufficient. If the healing of the ulcer proceed slowly, it may be touched with a camel's-hair pencil dipped in a solution of the nitrate of silver (gr. x. to or occasionally smeared over with

some mild stimulating ointment. In an examination to ascertain if the sore be healed, it is better not to employ the speculum, which is liable to stretch the parts too much and to break the frail cicatrix. If a piece of wool, after being lodged in the part for a few hours, has no yellow stain ; if no abrasion can be

I]niITABLE ULCER OF THE RECTUM.

detected in a tactile examination, and the patient is quite free from soreness after stool, we may be sure the part is quite sound.

In cases of irritable sore, complicated with a pedunculated pile, the growth should be excised or tied after the incision of the ulcer.

Patients will not always submit to the division of the sphincter without a previous trial of other means ; and where there is not much spasm, and but moderate suffering, the cure of the sore may often be obtained without it. The patient should remain at rest in the recumbent posture, and should take some mild aperient medicine to ensure soft evacuations. The ulcer may be brushed over occasionally with a strong solution of the nitrate of silver, or touched with the solid sulphate of copper, and a mild mercurial ointment smeared over its surface night and morning, — such as the Unguentum hydrargyri diluted with two parts of lard, or the Unguentum hydrargyri nitrafAs mitius. For sensitive ulcers, ointments containing the extract of belladonna are recommended; and this drug is sometimes added to mercurial applications. It may be used in the proportion of from 5j. — 5ij. to ^j. of lard. I have found marked relief derived from an ointment containing chloroform ^