toi\'.;.».l'.' ■»r ■'*.■• yzM$z: V ■Mmm ;■ ■,ii' a'.' -K "- ■ a >%'•■•• ;-'' • ^-..' .='■; :-V;v% - '-.' ^ ''' ■• M*m ■. \£ ^v ;. n ■;■■■> ^r **-. • • "".'■•; '■•'•'■ u "-»■' yjL'*r'' '■ ^''i' Zi A / Surgeon General's Office < '^s,———aa.oa-.~aazooc>ciar>z- zyz^oi 9 OBSERVATIONS ON THE Diseases of the Rectum and Anus, £jc. OBSERVATIONS ON SOME OF THE PRINCIPAL DISEASES OF THE RECTUM AND ANUS; PARTICULARLY Stricture of tfte Eectum, THE HEMORRHOIDAL EXCRESCENCE, AND THE FISTULA IN ANO. — V BY THOMAS COPELAND, Fellow of the College of SurgeonsTand Assistant Surgeon to the Westminster General Dispensary. Alitur vitium, vivitque tegendo.—Vi>o-n.. *lH>i"* PHILADELPHIA:'^, 2,'i^t 5"^ PUBLISHED BY A. FINLEY"^/' '■-■'« ,\\°% Also, P. H. Nicklin, Baltimore; J. W. Campbell, Petersburg!!. Va.; D. W. Farrand and Green, Albany; and D. Malloiy and Co., Boston. Fry and Kammerer, Printers. 1811. CONTENTS. Preface....................... 7 Observations on the Stricture of the Rectum ... 13 Causes and different Kinds of Stricture of the Rectum...................... 27 Treatment of Stricture of the Rectum...... 40 Observations on the Hemorrhoidal Excrescence . 58 Observations on the Fistula in Ano........ 74 Cases of Stricture of the Rectum ........ 87 Cases of the Hemorrhoidal Excrescence.....105 Cases of Fistula in Ano ............. 104 Case of Indurated Faeces lodged in the Rectum 1 IS A2 PREFACE. IT is the misfortune of surgery, and conse- quently of society, that those diseases which are the produce of slow morbid aeration of parts, have met with less of the attention of surgeons, and the treatment of them has been less cultivated and improved than their im- portance demands; while the operative part of surgery has, by the industrious efforts of the most eminent of the profession, been carried to a perfection which, in the present state of anatomy and pathology, seems hardly to be increased. 8 PREFACE. The patient investigation of the origin and progress of disease is attended with more difficulty, but with more utility to society, and perhaps with more advancement to the progressive art of healing, than the most im- portant and successful operation. In the surgery of chronic diseases, much, very much, yet remains to be done; but wri- ters seem to have followed one another, par- ticularly in the complaint of which I am prin- cipally abtyt to treat, contented to have occa- sionally described a fatal disease, and its ap- pearances on dissection, without any efforts towards its cure, which that dissection might have suggested, as if the present limits of our knowledge were the boundary of the science. The functions of the rectum and anus are so important to the health and the enjoyment of life; their diseases and derangements so various, and such difficulty and disappoint- PREFACE. 9 ment are frequently felt by surgeons in their treatment, that I trust it requires no excuse for having brought before the public some of the most distressing and fatal, if not the most common of them. It is remarked by Mr. Pott, that he who thinks lie can produce any benefit to society, needs not to be anxious about an apology for the publication of his ideas. If it shall be found, when the attention of the profession is directed to the subject, that certain diseases, which we have not been in the habit of attributing to affections of the rectum, have their origin in morbid altera- tions of that organ, I hope I shall not have been uselessly employed. Similar complaints of the urethra give rise to disorders, which were never supposed to have any reference to that canal, until the subject was par- ticularly investigated; and now, some very 10 PREFACE. troublesome and hitherto unmanageable dis- eases are relieved simply by the introduction of a bougie. On the subject of the removal of the he- morrhoidal excrescence, the result of my ex- perience has been somewhat different from what I had been led to expect by the writers who have treated of this affection. I have not always found it a secure and safe operation. Other surgeons also have met with instances of great danger, and even death, produced by the free extirpation of these tumors. I have endeavoured to suggest some other modes of treating the disease, or so to modify the operation, as to render it less serious and less objectionable. It is not intended, however, by any means to comprehend all the diseases of the rec- tum, in these observations. The fistula in ano, for example, has been so ably treated of, and PREFACE. 11 the cure so simplified by Mr. Pott, that it is quite unnecessary to enter at large on this subject; although a few remarks on some of the most unusual and embarrassing circum- stances attending this complaint may not be uninteresting or superfluous. Golden Square, 1810. OBSERVATIONS, &c. SECTION I. Observations on the Stricture of the Rectum. I HE rectum, like every other part of the body, is subject to inflammation and its con- sequences. It is liable however, to other kinds of disease, arising from its particular structure, its uses, its relation to the blad- der in the male, and the vagina in the fe- male, and to other important parts; but es- pecially from the action which it is every day compelled to perform in the expulsion of the fasces. It is on this account that an attack of inflammation, which would not, perhaps, be an object of serious consldera- B 14 Observations on the tion in many other parts, here becomes often a distressing disease, to be relieved at last only by a surgical operation, and a tedious confinement. But among the morbid affections of this intestine, those which are attended with a diminution of the capacity of its canal, from whatever cause, are perhaps the most irk- some and the most fatal. I have been led particularly to a consi- deration of this subject, by a conviction that many of those cases of ileus,* and other * See Memoirs of the London Medical Society, vol. v. page 6: see also Memoires de l'Academie de Chirurgie, vol. iv. page 226. " Le canal intestinal, peut etre bouche par le retrecissement de ses tu- niques, ce que donneralieu aux memes accidens que le volvulus. Mons. de la Faye a rapporte qu'un offi- cier de la maison des Quinze-Vingt, fut attaque subitement d'une colique tres forte. Elle se niani- festa par une vive doleur dans le ventre, avec une tension considerable, la fievre, des vomissemens, enfin tous les accidens qui characterizent la passion Stricture of the Rectum. 15 more chronic disorders of the bowels, which resist every medical treatment, and are final- ly destructive, have their origin in organic obstruction of the canal of the large intes- tines. This obstruction is, very frequently, so near to the anus, as to be within the reach of surgical aid, if the cause of the complaint were known. Stricture of the rectum, though, I believe, by no means an uncom- mon disease, does not usually enter into the iliaque. II ne rendit pas la moindre partie des lave- mens qu'on lui donnoit: aussi le ventre devint-ilbien- tot d'une grosseur et d'une tension enormes: il mou- rut le seizieme jour de sa maladie. A l'ouverture du corps—a l'endroit ou l'intestin colon s'unit au rectum,, vers Tangle obtus que forme la demiere vertebre des lombes avec l'os sacrum, le retrecissement etoit si con- siderable qu'on peut a peine introduire l'extremite du petit doigt dans la cavite de l'intestin. En Texaminant a l'exterieur, il sembloit avoir ete etrangle par une li- gature avec un fil, si ce n'est qu'il n'y avoit ni pli ni froncement," &c. There are two or three other similar cases record- ed in Mons. Hevin's Memoire sur la Gastrotomie. j[(j Observations on the contemplation of a practitioner, who is con- sidering the cause of obstinately constipated bowels: violent cathartics are given; these only render the disease worse; at last the patient is destroyed, and the dissection proves that the sole cause of the complaint, and of death, was a partial or total obliteration of the canal of the rectum. These cases are not unfrequently met with in medical writers: there are many re- corded in Bonetus, Morgagni,* Ruysch,f * Epist. Anatom. Medica 32, art. 6, de Morbis Ventris. t Ruysch has taken very particular pains in the consideration of, and in relating one case: he seems to have been attached to his patient by private friendship, as well as the wish to relieve so dreadful a disease.; for it is written with an elegance of language, which is not very usual in a medical description, and a feel- ing for the sufferings of his patient which does him so great honour as a man, as a phy%ician, and as a writer, that I shall give the whole ease in his own words-. See Cases. Stricture of the Rectum. 17 Tulpius,* and others. Bonetus, indeed, was so satisfied with the impossibility of disco- vering the disease before death, that he makes the following observation on a case which was dissected. " Rectum fibris quasi tot " filis decussatim erat constrictum, ut neque " sursum, neque deorsum quicquam transire " potuit. Quis vero mali istius potuit esse " presagus? Lynceushic taceat, vis clandes- " tina peremit."f But the most perfect history of the dis- ease is to be met with in a paper, in the Memoirs of the London Medical Society,^: under the title of the Scirrho-Contracted Rectum, by Dr.-Sherwin. Indeed the seve- ral phenomena of this affection, uninfluenced by the only treatment which will relieve it, * Tulpii Observat. lib. Hi. caput 10. t Sepulcretum Anatomicum, vol. ii. page 269. ed. Genev. 1500. \ Vol. ii. page 9. B2 18 Observations on the are detailed by this author with a precision that renders any farther description almost unnecessary. But Dr. Sherwin also considers it as a disease totally beyond the powers of medicine or surgery to relieve, and that our utmost efforts can only palliate the most painful symptoms, and soften the road to inevitable death. Mons. Dessault,* in a paper published, I believe, by one of his pupils, in the Journal de Chirurgie, has the merit of pointing out some of the most com- mon causes of the disease, as well as the mode of relief; but I shall make some farther observations on Mons. Dessault's paper, when I come to the treatment of the com- plaint. A case of great importance, also, is re- lated by Dr. Mossman,f where a stricture of the rectum was found to have produced * Journal de Chirurgie, torn. 1. t Duncan's Annals, 1797, page 307. Stricture of the Rectum. 19 obstinate constipation, with the other symp- toms which characterize this affection, and finally death. It seems extraordinary, that the dissection and consequent elucidation of the disease, did not suggest to the doctor some ideas of detecting and relieving the complaint in future. But, although he has followed the authors I have mentioned, in describing an uncommon, and what they suppose, a neces- sarily fatal disease, he has furnished us with a very accurate history of the complaint to its final termination, and some important re- flections will present themselves on a care- ful perusal of the case. So true is the remark of Mons. Quesnay, that" sou vent les observa- " tions n'eclairent pas meme ceux qui les " communiquent, car les observateurs envi- " sagent rarement les faits par le cote qui " peut etre le plus instruitif."* * Memoires de l'Academie de Chirurgie, torn. i. page 235. 20 Observations on the But though those who are afflicted with this disease are sometimes quickly carried off with symptoms resembling those of ileus, this is not the most usual form of the com- plaint, for it commonly assumes a more chro- nic character. It attacks people of both sexes, and ©f almost all ages; but is most common about the middle age, and I think, as far as my experience goes, that women are more frequently affected than men.* The first symptom of the disease is an habitual costive - ness; but this is so frequent an occurrence, * The cases which Mons. Derrecagaix relates in Dessault's journal, are principally women, and the most aged is only forty-six years old. Mr. White, in a paper in the London Medical and Physical Journal, Oct. 1809, remarks, that this disease is most common at the decline of life; but his own experience does not bear him out in the assertion, for of eight cases which he gives, six are under fifty years of age. Mr. White considers the disease 3s necessarily fatal, but he does not seem to have heard of Mons. Dessault's paper. Stricture of the Rectum. 21 and produced in so many ways, that it is not likely that the cause should be sought for in an organic affection of the rectum; mild pur- gatives are resorted to, and the symptom be- ing relieved, the cause is no longer sought after. When this has subsisted for some time the patient complains of what is called piles, and what is often really so, as a consequence of obstructed circulation in the parts. The reme- dies usually given in such cases are applied, sometimes with relief, but more frequently otherwise; and then th© good old maxim of the inexpediency of curing piles, perhaps res- cues the practitioner from the discredit of failing to relieve his patient. The piles #re sometimes removed by ligature, or excision, and this gives a temporary abatement of the most painful symptoms, while the cause of the disease is still unknown. 22 Observations on the In a short time, as the gut continues to de- crease in diameter, the efforts to expel the faeces become more violent, and the conse- quent progress of the disease more rapid. The stools, which have been long evacuated with difficulty, become contracted in size, appearing like earth-worms in their form,, or small pellets. In this stage it is sometimes, in the male, mistaken for enlarged prostate gland, but if the finger be introduced into the rectum the gut will be found either obstruct- ed with small tubercles,* or intersected with membranous filaments;! or else the introduc- tion of the finger will be opposed by a hard ring of a cartilaginous feel, composed of the diseased inner membrane of the intestine^ * Dessault loc. chat. t Bonetus loc. citat. Case 5 in this book. \ Morgagni, annulo quasi quodam constringi vide- retur digitus, loc. citato. Adeo induratum ut anceps haererem an carnosum an cartilaginosum esset dicen- dum. Ruysch, t. iv. obs. 95. Stricture of the Rectum. 23 instead of that regular tumor on the anterior part of the rectum, which is formed by an enlargement of the prostate gland. As the disease advances, the faeces become more fluid, and there is a thin sanious discharge from the anus, accompanied with tenesmus; not however the painful tenesmus of dysen- tery,* but with less distress and less irritation of the parts than in that disease. During this time the constitution suffers so little, that the patient might be supposed, from appearance, to enjoy full health. But the ravages of the disease now begin to be felt in their effect on the general habit. Fre- quent eructations of air confined in the intes- tines, added to the other symptoms, torment the patient, and render his life miserable. This symptom is so constant, that if it did not occur also in affections of the kidneys * Sherwin. 24 Observations on the and other complaints, it might be regarded as pathognomonic; but I think it prevails to a greater degree in this than in any other disease. ' At this period abscesses very frequently form in the neighbourhood of the anus, and sometimes break into the vagina in the fe- male, and the faeces are discharged through the fistulous orifice. In the male, an adhesion takes place with the bladder and the abscess* discharges itself with the urine, and some- times fasces and wind are voided by the ure- thra. But more frequently the matter makes its way through the nates, as in cases of common fistula, for" which disease it is not unfrequent- ly treated. The patient often continues a long time * Petit CEuvres Posthum. torn. ii. p. 93, the con- trary also occasionally takes place, and urinary calculi are voided by the rectum. See Paulus ^Egineta, and Memoirs of the Medical Society, vol. iii. 496. 542. Stricture of the Rectum. 25 in this distressing situation, for none of the vital organs are affected, till, at last, worn out with the pain and the discharge, or per- haps the total obliteration of the rectum, he yields to his fate. This is usually the pro- gress and issue of the disease, when it is not early discovered, and I must confess also, sometimes the termination when it is; that is, when the parts are attacked with cancerous ulceration. But I believe that, when the cause of the complaint is ascertained in its early stage, the resources of the healing art are sufficient very materially to relieve, and often to cure it altogether; subject, however, like strictures in the urethra, to the necessity of now and then passing a bougie for a con- siderable time after the symptoms are re- moved. The rapid progress of disease,* from a * See some very important observations on this c 26 Observations, &c. very trivial origin, in parts subject to con- tinual motion, is very remarkable, in many instances, besides that one under considera- tion; for this reason, a simple wound near the organs of deglutition is so difficult to heal; for this reason perhaps it is that pulmonary consumption is so fatal a complaint; for the parts being necessarily in constant motion, have not the opportunity afforded them of recovering from an attack of disease. subject in Mons. David's Memoir on the Effects of Motion and Rest, translated by Justamond. Also Mons. Bazille sur les Effets des contre Coups en di- vers parties du Corps. Prix de l'Academie de Chirur- gie, torn. iv. quarto. [ 27 ] SECTION II. On the Causes and different Kinds of Stricture of the Rectum. STRICTURE of the rectum, like stric- ture of parts of similar structure, may be produced by whatever excites inflammation, or irritation of the inner membrane of the canal. It may therefore be simple thickening of the coats of the intestine, which will pro- duce all the same distress to the patient, as far as regards an impediment to the passage of the faeces, as if it depended on a specific disease: thus, it is sometimes the consequence of fistula in ano, or of the operation for it.* The extirpation of the hemorrhoidal excres- * Wiseman, page 237, London, 1676, folio 28 a Causes and different Kinds cence too, has been followed by stricture of the gut.* It may be cancerous, and certainly is now and then so; but, I believe, much less fre- quently than is generally imagined, for we must not be deceived by that hard scirrhous resistance to the introduction of the finger, which is so constantly met with in one species of the disease, and which is so justly descri- bed by Ruysch and Morgagni,f in the pas- * Dessault quotes an instance of this kind from Julius Caesar Claudinus, by Mangetus. Petit GLuvres Posthum. torn. ii. p. 156. t Besides the passage which I have cited, it may be remarked, that Morgagni was very well aware that diseases of the rectum have commonly a contracted orifice, dilating itself into a large ulcerated cavity. " Sic enim saepe recti intestini ac vaginae ulcera se " habere ut os angustum in capaciorem sinum se *' dilatet." But Morgagni does not seem to consider that the contracted gut is the cause of the ulceration beyond it, just in the same manner as the urethra ulcerates and gives way behind a stricture of that ca- nal. Morgagni Epist. Anat. Medic. 32. art. 13. Of Stricture of the Rectum. > 29 sages which I have before quoted. Whoever fully considers the hard cartilaginous feel of the tunica vaginalis testis, in ancient hydro- celes, or the extraordinary thickness to which the adherent sac of an old hernia will arrive, or the coats of the bladder, in diseases of the urinary passages, will not be readily disposed to pronounce, on this ground alone, that an indurated stricture of the rectum, is of that nature which terminates in cancer. When the disease is really cancer, it is usually attended with more severe pain, dart- ing through the pelvis to the bladder and the groins, the countenance is of that sallow leaden cast, which is so constantly met with in those who labour under a carcinomatous disease; but the dreadful havoc, which is soon made by the progress of the cancerous ulceration, does not leave us long in doubt on this point. I have, more than once, seen C2 30 Causes and different Kinds the whole of the sphincter ani muscle, and the cellular substance surrounding it, so en- tirely removed by the ravages of this disease, that the anus was continually open to an ex- tent, that would admit of the introduction of a full sized rectum bougie. A varicose state of the internal hemor- rhoidal vessels may be the cause of an im- pediment to the evacuation of the faeces, and when this is the case, the finger, if introduced into the rectum, comes in contact with several small tubercles, " (bourrelets)." "J'ai vue," says Mons. Petit, " tout l'interieurdu rectum " jusqu'a le S du colon variqueux, ce que " fait une maladie bien grave, de laquelle " j'ai vue peu des gens guerir excepte les " malades que j'ai soupconne d'avoir la ve- '•' role."* I am inclined to believe, that many • Petit CEuvres Posthum. torn. ii. p. 83. Of Stricture of the Rectum. 31 of those cases which are related by Dessault, are of this description. The rectum is also sometimes divided and intersected in its canal by small membranous filaments, which readily give way to the fin- ger, or the bougie, when introduced into the anus, and a discharge of blood follows the ex- amination. This species of stricture is more readily relieved by the bougie than any of the other kinds, but it is attended with more ir- ritation of the parts, so much as to render any examination extremely painful; and there is also commonly a more copious discharge of a thin fetid matter from the anus. I have twice seen the disease under this form, and it has each time been preceded or accompa- nied by the hemorrhoidal excrescence: it has also been described by Bonetus,* and noticed by Morgagni. * Loc. Citat. 32 Causes and different Kinds It seems probable that this kind of ob struction is produced by an actual adhe- sion, or union of the parietes of the gut to each other. The rectum is inflamed, from hemorrhoids, or from some other cause, and coagulable lymph is thrown out on its surface, instead of the natural mucous secre- tion. As the passage of the stool gives con- siderable pain, the effort is suppressed, per- haps, for many days, or for a period quite sufficient for the coalescence of two inflamed surfaces in contact with each other. The greater part of these adhesions will, of course, soon be destroyed by the passage of the fae- ces. But the very rupture of them is a cause of fresh inflammation, and of fresh adhesions, and thus the disease is reproduced. If the faeces are evacuated in a fluid form, many of these points of union are not broken through; but only elongated, precisely in the Of Stricture of the Rectum. 33 same manner as the adhesions between the two laminae of the pleura are elongated, by the action of the intercostal muscles, after an inflammation of that membrane. I will not, however, insist on this explana- tion of the mode by which the disease is produ- ced. It is much more important to know that, painful and distressing as it is, it admits of a more ready relief, than most other disorders of the rectum, when it is early discovered; and when the cause of the disease is over- looked, it goes on to produce very obstinate and very untractable affections of the intes- tine. Stricture of the rectum is sometimes said to be produced as a secondary symptom of the venereal disease, and this is a subject which merits very particular consideration. First, it may be remarked, that we meet with no description of the disease, in any 34 Causes and different Kinds author that I can find, before the time oi Wiseman; and the accuracy of the ancient writers of surgery, in their history of diseases, is universally allowed, whatever may be said of some of their modes of cure. It may there- fore, I think, be fairly inferred, that either the complaint did not occur so frequently formerly, or that it was overlooked by physi- cians and surgeons, who suffered scarce any thing which related to diseases altogether to escape them. The case in Wiseman, indeed, was the consequence of the operation for the fistula in ano, as it was then performed; but, I believe, he was the first who has described any species of the disease; and he treated it in a way that was well worthy of the imita- tion of his successors, if they had sufficiently considered it: but I shall say more of this when I come to the treatment of the disease. Soon after Wiseman, as I have related, Of Stricture of the Rectum. 35 many authors have described the disease, and they all concur in considering it as inevitably fatal, until Mons. Petit*gives a hint, that when it was a venereal symptom it was curable, by the usual remedies for that disease; but that in other cases he had never seen it relieved. Dessault saw it so frequently in combi- nation with other symptoms, decidedly vene- real, that he did not hesitate at once to put his patients under a course of mercury, and with a success that fully warrants us in consider- ing it as, very frequently, a symptom of the venereal disease. He did not, however, trust solely to the effects of this remedy for a cure, for he saw that the particular functions and morbid alteration of the part, required a par- ticular local treatment, independent of the medicine which was to cure the constitutional disease. He therefore, during the exhibition of mercury, every day introduced into the * Loco Citato. 36 Causes and different Kinds rectum, tents imbued with some ointment, of a greater or less size, and for longer or shorter, time, according to the circumstances of the case, and by this combined local and constitutional treatment generally cured his patient. Mons. Dessault does not seem, indeed, to consider the tent of so much importance in itself, but only as the vehicle of his me- dicaments. Be this as it will, however, he relieved his patients of a disease, which, till then, was generally considered as a fatal one. It should be remarked that he ascribes the complaint to many other causes, besides the venereal disease, as to rheumatism, to gout, to cutaneous complaints; but, notwith- standing this, he gave mercury, and mercury relieved them. Richerand* also in his Noso- * Le retrecissement de l'extremite inferieure du rectujn est quelquefois un vice de conformation; mais 6f Stricture of the Rectum. 37 graphie Chirurgicale, considers the stricture of the rectum as sometimes arising from the venereal disease. If the relief of a complaint by mercury (added to the use of the tent or bougie), which is often accompanied by less equi- vocal symptoms of the venereal disease, and which has been considered as constant- ly fatal, be not thought sufficient to esta- blish its syphilitic origin and nature, this opinion may, perhaps, derive some additional strength, when we reflect how often the neighbouring parts are attacked with com- plaints, of which no practitioner doubts the venereal origin. The condylomatous excrescences, which we see every day surrounding the anus; the plus souvent l'effet de l'epaississment venerienne de ses parois, de tous les symptoms de l'affection syphi- litique il n'en est point de plus grave.—Nosographie Chirurgicale, Paris, 1803, torn. iii. p. 418. D 38 Causes and different Kinds of large rhagades in these parts, though not so frequent a disease, are known to be venereal. And these, also, in addition to the constitu- tional remedy, require a local treatment adapted to their nature, as well as the stric- ture of the rectum. Even the fistula in ano is sometimes the consequence of the vene- real infection*, as has been remarked by Mr. Pott and Le Dran. After all, I do not by any means intend to assert, that it is always, or even most frequently, a symptom of the venereal dis- ease. If it is met with in combination with other syphilitic complaints, there can be no doubt of the propriety of using mercury. And if it is relieved, in such cases, by mer- cury, added to the use of the bougie or tent, I think it is reasonable to employ, and to ex- * Pott's Works, by Earle, vol. iii. p. 87, Le Dran, Observ. de Chirurg. torn. ii. obs. 84: Stricture of the Rectum. 39 pect benefit from, the same means in other cases, where it may be the solitary symptom, and where we are disappointed in our other methods of cure. [ 40 ] SECTION III. On the Treatment of Stricture of the Rectum. It has frequently been remarked, that he who knows a disease cannot be much at a loss how to treat it; and although this may not be true, perhaps, in its fullest extent, I be- lieve no one will dispute, that the art of curing diseases advances, in some sort of proportion, to the increase of our pathologi- cal knowledge. While the disease was generally consi- dered as a cancerous one, it is not surpris- ing that it was constantly fatal; for when left to itself, it is as necessarily, as certainly, and perhaps as quickly destructive as cancer itself. For, as I have before remarked, when Treatment, &fc. 41 the complaint is of the true carcinomatous kind, the ulcerative process often removes the impediment to the passage of the faeces, and death at last is produced in the same manner, as when cancerous ulceration takes place in other parts; namely, by gradually exhausting the constitution, with the pain, the discharge, the hemorrhage, and the ge- neral irritation it excites. Whereas the gra- dual, though certain, obliteration of the rec- tum in other kinds of the disease, points a shorter road to death, by a total obstruction of the alimentary canal. When, by a habitual costiveness, by the stools wanting their usual figure, the consti- tution being otherwise in tolerable health, an organic obstruction to the passage of the faeces is suspected; and this suspicion is con- firmed, by an examination of the rectum with the finger; the first object of the sur- D2 42 On the Treatment of geon should be an enlargement of the ob- structed part, by the introduction of a bougie. This bougie should be of such a size as to pass, when well lubricated with oil, without much difficulty or pain. Sometimes, when the disease has been of long continuance, it will be necessary to begin even with a large sized urethra bougie, or one of the same size as those which are made for a stricture of the oesophagus, and of a length that is like- ly to pass beyond the stricture, that is about six or seven, or eight inches: but, I think, it is of consequence to use a bougie at first, which is rather too small than too large. The benefit is derived much more from the con- tinuance of the bougie in the rectum, than from a sudden dilatation of the strictured part. And when it forcibly distends the stric- ture, the pain which is produced, renders it necessary to withdraw the bougie much soon- Stricture of the Rectum. 43 er, than if it had been of a size which would pass easily. When it has remained for half an hour or more, according to the feelings of the patient, it should be removed, and passed again the next day; and the same sized bou- gie should be continued for several days, be- fore any attempt be made to enlarge it. The bowels should be kept constantly lax by the use of castor oil, electuary of senna, or some such mild purgative medicines, whenever it is necessary, during the whole cure. I must here remark, that I am now con- sidering it as a simple stricture, unaccom- y panied by any specific disease. For when, from other concomitant symptoms, or from the history of the complaint, there is reason to suspect venereal mischief in the constitu- tion, it is in vain to expect relief from the local treatment alone, or from any other means 44 On the Treatment of than the exhibition of the specific remedy. But whatever be the nature of the stricture, whether it be that kind in which the rectum is obstructed by tubercles, by membranous filaments intersecting its canal (which two species are by far the most easily relieved), or whether it be the indurated stricture, from a thickening of the coats of the intestine, this local treatment is equally necessary. And it must be continued and the bougie gradually enlarged, until the rectum easily receives a full sized bougie. Even for some time after all the symptoms of the complaint have dis- appeared, it is necessary occasionally, that is every two or three days, to introduce the bougie and withdraw it again. For the dis- position of the disease to return, is much more prevalent in the stricture of the rectum, than in a similar affection of the urethra. In the indurated annular stricture, which Stricture of the Rectum. 45 has, for a.long time, resisted the introduction or the enlargement of the bougie, I have more than once introduced a probe-pointed curved bistoury, and divided the thickened parts, on that side of the rectum which is contiguous to the os sacrum; and I have fre- quently seen the late Mr. Ford perform the same operation. Wiseman divided a contract- ed gut three or four times in the same person; his case, however, was not one of idiopathic stricture, but was produced by the rude ope- ration for the fistula in ano, which was prac- tised at that time. The experience of Wise- man however, shows that the operation may be performed with safety and with benefit. The Greek* and Roman surgeons used much more freedom of operation in their * Hippocrates de haemorrhoidibus. Rectum enim intestinum et secans, et resecans, et consuens, et urens, et putrefaciens, etiamsi gravissima hsc esse videantur, nihil laeseris. 46 On the Treatment of treatment of the maladies of the rectum, than is at present found necessary to their cure. In the common operation for the fistula, the whole of the morbid parts were usually taken away, either by actual cautery, by excision, or by ligature; and the patients often recover- ed with the functions of the part perfect. There is no fear that any of these practices should be revived; but it may serve to show, that to introduce an instrument cautiously on the finger, even to a considerable extent up the rectum, and* to divide the stricture in its posterior part, is not so serious an operation as may be imagined. If it is done when the parts are in a quiet uninflamed state, considerable benefit will be derived; and much time will be * Palletta trovo talvolta vantaggioso il taglio della parte piu ristretta deir intestino, ch' egli dovette fare in occasione di congiunta fistola, ed il propone anche per le sole briglie piu strette, senza concomitanza di fistola.—Instituzione Chirurgiche di Monteggia, parte terza, sezione seconda, Milan, 1805, p. 549. Stricture of the Rectum. 47 saved in prosecuting the cure with the bougie. I have thought, in one instance, however, it is but fair to state, that it produced or accelerat- ed the formation of abscess and consequent fistula; but as the patient had several times before experienced similar impostumations in the part, excited only by the efforts to pass her stools through the stricture, it is not at all certain that this inconvenience was the con- sequence of the operation; and it is the only one I have seen, which could possibly'be attributed to it. In this operation, it is obvi- ous that the instrument should not be trusted beyond the reach and guidance of the finger; and it is most successful when, from the im- pression left on the bougie or other circum- stances, there is reason to believe that the stricture is not of considerable extent. The formation of abscess, in the vicinity of the rectum, is a very frequent occurrence in 48 On the Treatment of the advanced stages of the disease. I have not uncommonly seen patients, who have had the operation for fistula performed on them,— I need hardly say without success—for it is in vain to attempt the cure of the sinus, while the cause which produced it still remains, perhaps undiscovered, and is daily aug- mented. If in consequence of such abscess, a si- nus remains after the stricture is relieved, the complaint then becomes a simple fistula, and is, therefore, to be treated as such. Never- theless, it is not necessary, in all cases, to wait for the total removal of the stricture be- fore the fistula be divided. If the stricture be situated within reach of the operation, it may be divided at the same time as the sinus is laid open; and provided the use of the bougie be persisted in, the cure, both of the original disease, and of the fistula, will go on to- Stricture of the Rectum. 49 gether. The failure of the cure in the cases I have seen arises from the disease being con- sidered as a simple fistula, in consequence of an abscess of the part, without any reference to the morbid state of the intestine. The abscess, I have said, sometimes breaks into the vagina; and a communication being formed between this and the rectum, the faeces and wind, obstructed in their na- tural outlet, make their way through the fis- tulous orifice in the vagina; this is a dread- ful addition to the distress of the patient, and more particularly so, as the surgeon cannot promise that it will close again after the stric- ture is relieved. Dessault gives two cases of this commu- nication, in which the aperture was very much diminished in size, and seemed to be closing under the use of the bougie or tent. But, un- fortunately, neither of his cases is related to E 50 On the Treatment of its termination, for being so considerably relieved, they would not suffer confinement, but left the hospital before they were quite well; he introduced a tent into the vagina similar to the one in the rectum, and to this he attributes his success. Another manner of treating* this symp- tom has been, by passing a ligature from the rectum through the fistulous orifice, bring- ing it out at the vagina, and then tying it so as to include all the intermediate substance, but of this mode of relieving the complaint I have no experience. I have once seen the aperture between the rectum and vagina heal spontaneously after the stricture was relieved, but this event is too fortunate to be always expected. Mons. Petit relates a case of great importance, where a communication between the rectum and bladder in the male, which allowed of the passage of the faeces and of * C. Btll's System of Operatise Surgery. Stricture of the Rectum. 51 wind through the penis, was entirely cured by the constant use of the curved catheter.* Where the disease is in the male, al- though there is no actual communication with the bladder in most cases, this organ, as well as the kidneys, suffers very considerable de- rangement of its functions in the advanced stages of the disease, from its contiguity to the parts immediately affected. Retention, but more commonly suppression of urine, pro- perly so called, is not an unfrequent addition to the sufferings of the patient, but where the bladder is not actually distended, and appear- ing tumid above the pubis, I should warn the practitioner against the introduction of the catheter, although no urine has been passed for a very long period. In this case, the error is principally in the kidneys, whose function is suspended for the time. But in every case * La sonde en S. GLuvres Posthum. torn. 2. p. 93 52 On the Treatment of which I have seen,* these glands, after a short time, resume their office of separating the urine and the symptom disappears; where- as if the catheter be introduced, little or no irine will follow it, and much injury may be done, in such a state of the parts by the in- troduction of this instrument. To relieve the habitual costiveness, I have said that it is necessary to have recourse to mild purgatives, such as castor oil,, man- * When, in the year 1802, the operation of litho- tomy was performed on a late eminent accoucheur, there was very considerable hemorrhage at the time of the operation, and no secretion of urine took place lor six and thirty hours afterwards. I repeatedly pla- ced my hand above the pubis, and there was no ten- sion or tumor, nor in fact was there any untoward symptom; at last the urine burst from the wound, and flowed for a short time. The next day, the third after the operation, the whole of the urine passed by the pe- nis, and at no period afterwards was there any urine evacuated by the wound, so that the bladder healed by the first intention. Stricture of the Rectum. 53 na, or the like; but at this period we have frequently the opposite inconvenience to en- counter, for the stools now come away liquid, mixed with a sanious matter, and often in- voluntary, so that the patient complains of purging rather than of constipation. Dr. Sher- win* very justly remarks that, we should not be too hasty in checking this fluid dis- charge, lest the more serious complaint of obstinate costiveness should be the conse- quence, but I do not think it is commonly in our power to check it. I have seen the greatest benefit derived from the local application of opium, whether by clyster or by the introduction of a grain or two of opium into the anus, when the pain and irritation of the gut are violent, and under such circumstances the warm bath, or fomentations to the part, are so far beneficial * Loco Citato. E 2 54 On the Treatment of as to produce temporary relief. The extract of hemlock, either alone or mixed with small doses of calomel, is often employed in this and similar complaints. I have frequently used it, and I think with considerable ad- vantage; but when the symptoms point out the propriety of having recourse to mercurial medicines, a more decided mode of admi- nistering them should be adopted. If the disease is not cancerous, it is for the most part to be relieved by one or the other of these means, when recourse is had to them before the parts have suffered a very long time, and to a great extent in their struc- ture by the continuance of the disease; and if it be cancerous, I know of no mode what- ever that is capable of arresting its progress to a fatal termination. Before I quit this subject, it may not be unuseful shortly to recapitulate some of the Stricture of the Rectum. 55 most important circumstances of the disease and its treatment. First, That a stricture of the rectum is by no means so uncommon a disease as is usually imagined, and that it has been hither- to generally considered as necessarily fatal, because it has been discovered only in the last stages, or by dissection after death.* Secondly, That many of those obstinate cases of constipated bowels, which are of long duration, arise from an organic obstruction to the passage of the faeces, and that this ob- struction is most frequently so situated as to be within the reach of surgical aid. Thirdly, That it is requisite, in such cases, to examine the anus with the finger, or if the symptoms be strongly marked, and there be no obstruction within the reach of * See some observations on the diseased appear- ances of the rectum, by Dr. Baillie. Morbid Anatomy, page 111. 56 On the Treatment of the finger, to examine it with a rectum bougie. Fourthly, That the use of internal medi- cines alone will be unavailing in such cases, and that nothing without the use of the bou- gie affords any hope of relief to the patient. Fifthly, That the disease is much less frequently of a cancerous nature, than from the description of authors it may seem to be. Sixthly, That it is often combined with symptoms of the venereal disease, and, in such cases, is more readily relieved by mer- cury, added to the use of the bougie, than by any other means. Seventhly, That if the disease is often found in combination with syphilitic symp- toms, it is fair to infer that it may, in some cases, also, be the solitary symptom, and that if it resist the local treatment, and there be reason to suspect venereal mischief in the Stricture of the Rectum. 57 habit, it is right to try the effect of the mer- cury at the same time. Lastly, That whatever be the nature of the disease, provided it be not true cancer, it is necessary to continue the use cf the bougie, at intervals, for a considerable time after the free passage of the faeces has been established, and to return to it whenever there be any symptoms of a recurrence of the complaint. [ 58 ] SECTION IV. On the Hemorrhoidal Excrescence. 1 HE intestinal varicose tumor, or hemor- rhoidal excrescence has been so very accu- rately described, anddistinguished from other complaints which it somewhat resembles, by Sir James Earle and some others, and is a disease so well known to surgeons, that it be- comes unnecessary to enter into a minute detail of its nature and its appearances. But he who has no other opportunity of informing himself on this subject, than what is afforded him by the English writers, who have treated or touched on it, will be apt to conclude that the extirpation of such excres- cences, either by ligature or excision, is al- On the Hemorrhoidal Excrescence. 59 ways a safe and successful operation. The excision of these tumors has been strongly recommended by Mr. Ware,* under cer- tain and very prudent limitations however; and all the cases he has related, of this ope- ration, have terminated happily. The removal of them by ligature has been as powerfully urged by Sir James Earle in his edition of the works of Mr. Pott,f and each of the cases there recorded is also successful. These modes of relieving the disease are certainly preferable to the rude and elaborate operation which is proposed and practised by LeDranJ. * Remarks on the Fistula Lachrymalis, to which are added observations on Hemorrhoids. t Observations on the Hemorrhoidal Excrescence, by the editor.—Polt's Works, by Earle, Vol. 3. \ Pour parvenir a faire sortir les hemorrhoides, je fis mettre a la malade son corps, et je le fis serrer suffisamment. Je pris ensuite chacune d'elles l'une apres I'autre avec une herigne, et je les coupai. Pour me rendre maitre du sang et porter plus aisement le remede necessaire sur I'artere, qui en fournissoit gros comme le petit doigt, je fis une incision commen^ant 60 On the Hemorrhoidal Excrescence. But I am sorry to say that, although I have very repeatedly succeeded to the utmost of my wishes in curing the disease by the appli- cation of a ligature, this success has not been so uniform, as to establish it in my mind as an operation always to be recommended. In one instance the patient very narrowly es- caped death; in another, very serious symp- toms were produced by the operation; and in a third case, the operation was actually fatal. I have also heard of one or two other instan- ces where the life of the patient was destroyed by tying off the hemorrhoidal excrescence. a l'anus et tirant du cote de la fesse.—Obs. Chirurg. tom. 2. p. 226. Here then is an operation to cure the disease, and an operation still more painful which the former one has rendered necessary: surely the sur- geon, or rather the patient, will exclaim with the illus- trious Caius Marius, when he had, with great courage, suffered a very similar operation: " "Og» to tTrxiifiuptx r»; &Xy*idiv»s '«'f* u,%icv." Plutarchi Opera. Ed. Par. 1624 On the Hemorrhoidal Excrescence. 61 These circumstances naturally lead one to consider the reasons of such variety in the experience of surgeons, to seek for infor- mation on the subject, and, if possible, to remove the causes of these dangerous and fatal symptoms, or so to modify the operation as to render it less exceptionable and serious, without being less efficacious in the cure of the disease. The operation seems to have been very common in France, in the time of Mons. Petit, but it often gave rise to such serious symptoms, and even death, that this excellent surgeon thought it should be altogether abandoned, or resorted to only in a milder manner, after every other means had failed of giving relief. In one instance, where he per- formed the operation on a lady, under very favourable circumstances, (" on ne pouvoit " pas souhaiter une disposition plus favorable F 62 On the Hemorrhoidal Excrescence. a l'operation,") by tying three of these piles with ligatures, and the inflammation of the abdomen which followed, was so violent as to endanger her life, and resisted the most judicious treatment until the ligatures were removed; but it is an important part of this case, that the unfavourable symptoms subsi- ded when the threads were taken off from the tumors. In another operation, which, in justice to the character of Petit, I should ob- serve, was not performed by himself, five ligatures were applied at once, to as many of these tumors, and inflammation and swel- ling of the abdomen, vomiting and hiccough were very soon the consequence of the opera- tion. The ligatures were removed, but the event was not so fortunate—the patient died.* " Je compare," says this judicious surgeon, " ces accidens a ceux qui accom- * Giuvres Posthum. tom. 2. On the Hemorrhoidal Excrescence. 63 " pagnent les hernies, dans lesquels une pe- " tite portion de l'intestin est etranglee, si ces " sortes des hernies ne sont pas secourus " promptement, ils perissent quelquefois in " trente ou quarante heures, d'une inflam- " mation gangreneuse qui occupe tout le bas " ventre, mais particulierement les intestins. " C'est ainsi que mourut le malade avant le " deuxieme jour accompli." There is no fear that such a case can happen to a careful and prudent surgeon, for I think that no such surgeon would apply ligatures round five of these excrescences at once. But very serious accidents, and even death, sometimes happen when much less injury is offered to the parts than in the case which Mons. Petit has rela- ted. Locked jaw, suppression or retention of urine, and other bad symptoms, have occur- red when no more violence has been done to the rectum than in manv of those cases which 64 On the Hemorrhoidal Excrescence. have been published, and have terminated happily. In relating these cases, however, of death or imminent danger, produced by the appli- cation of ligature to the hemorrhoidal excres- cence, I must repeat that the instances of cure, without any untoward symptoms resul- ting from the operation, are far more numer- ous than such unfortunate occurrences. But it is right that such accidents should be known, and that the operation, when it be- comes absolutely necessary, should be under- taken with more caution than I think it usually is. Petit* proposes that the pile or excres- cence should be denuded of its external co- * I shall quote one more passage from the very excellent work of M. Petit (vol. 2. 156) because it proves that he was aware of the frequent combination or connexion of a stricture of the rectum, with the hemorrhoidal disease, though I do not quite agree with On the Hemorrhoidal Excrescence. 65 vering, which is the internal coat of the in- testine, before the ligature be applied, and that as little of the enveloppes or skin should be removed as possible. I have attempted this, but do not find it so easy a matter as I think he represents it. When other means fail, (for I believe that, if the disease be recent and the tumors not very large, it may admit of relief by other means,) and an operation for the removal of him that it was the removal of the pile which produced the stricture." On peut remarquer que, dans toutcs les operations que j'ai descrites, je recommande de me- nager la peau ou les enveloppes qui couvrent les he- morrhoides, et de les bien loin detacher pour qu'elles ne soient point comprises inutilcment clans l'amputa- tion. Quand on n'observe pas cette loi, on court risque tie causer un retrecissement de l'anus plus ou moins considerable scion que Ton a coupe plus ou moins de peau." He gives one very lamentable instance of this consequence of the operation. " Etant gueri, l'ouver- ture de l'anus. etoit si etroite qu'a peine y pouvoit on passer le canon de seringue.—Lorsque les matieres ctoient liees, elks sortoient comme d'une filiere." F2 66 On the Hemorrhoidal Excrescence. the excrescence becomes necessary; the safest and best way is to pass a ligature round one only of the tumors at a time, the most painful and troublesome of them, and to wait until the patient has quite recovered from this operation, before any thing more be attempted, if any thing more should still be necessary. Mr. Ware has judiciously re- marked, that there is usually one of these tumors more inflamed and tender than the rest, that this is the one that should be re- moved; and that it is not often necessary to extirpate the whole of them, to relieve the patient from the inconvenience he suffers. But I confess that I have hitherto been deterred by the fear of hemorrhage, from extirpating them by excision: for it is to be recollected that the veins of the abdominal viscera have no valves, and also that consi- derable difficulty has been felt by Mr. Hey,* •* Practical Observations on Surgerv. On the Hemorrhoidal Excrescence. 67 and by other surgeons in restraining the bleeding after such operation. It is better that this operation by ligature should be repeated two or three times, if it should become ne- cessary, than that the tumors should be all removed at once, at the imminent risk of the life of the patient, f t Among the various modes of extirpating these tumors, which are suggested or recommended by Hippocrates, who has described the diseaseand itscure almost as well as any of his successors, that of taking them off (I suppose pinching them off, cciptku*, aufer- rc,) with the fingers, deserves to be mentioned as a sort of medium between the ligature and the incision, comprehending, in cases where it is practicable, most of the advantages of each without the dangers of ei- ther. This rude operation of Hippocrates, (which he says may be done without telling the patient any thing of the matter,) or at least the essential principle of it, namely, of producing some kind of contusion at the time of removing the excrescence, is worthy of con- sideration. It is a well known fact that the instinct of animals directs them to bite off the umbilical cord, when they produce their young. The laceration which the parts suffer in this natural operation prevents all 68 On the Hemorrhoidal Excrescence. The case in Petit in which the symptoms of inflammation subsided on the removal of the ligature, and the recent important inves* tigations of Dr. Jones,* on the obliteration of bloodvessels, by the temporary application of a ligature, would lead one to suppose that the continuance of the ligature on the tu- mor was not necessary to its destruction, and that it would fall off eventually, if the thread were only very tightly applied, and removed again immediately; but this I have never tried. I have said that when the disease is re- cent, it may be relieved by other and more mild means than the operation I have been describing; and one of the most useful of hemorrhage from the cord. The life of the young is thus preserved, until the circulation is accommodated to that alteration which is necessary after birth, when the foetus becomes a perfect and respiring animal. * Jones on Hemorrhage, London, 1805. On the Hemorrhoidal Excrescence. 69 these means, from which I have often seen very beneficial effects derived, is the frequent injection of cold water* up the rectum, or water with the addition of a few grains of sulphate of zinc dissolved in it. This should be done after each evacuation, or twice a day, in the quantity of about half a pint at a time, which may easily be retained in the gut, whereas, if a larger quantity be used, it must generally be discharged immediately after its introduction. But, as far as my experience goes, above every other remedy, in the incipient stages of * There is a very remarkable observation from Schmucker in the 5th volume of Richter's Chirur- gische Bibliothek, on the use of injections of cold wa- ter in the prolapsus ani. " Ein alter vorfall des mastdarms der auf keine art k( zuruck gebracht werden konnte, ward gleichfals " durch kalt wasser glucklich gehoben. Man machte « kalte bahungen, gab kalte ktystiere, nach 24 stunden u ging er von sich selbst zuruck, und kam nie wieder " zum vorschein." Page 233. 70 On the Hemorrhoidal Excrescence. the hemorrhoidal excrescence as well as in the case of stricture of the rectum, the use of the bougie,* has been most serviceable. But in this case it js necessary that the bougie be of a larger size at first, than in the case of stricture of the gut. It must have been remarked by many practitioners, that the action of the sphincter ani is unusually strong in most of those per- sons who are the subjects of this disease; so strong as very powerfully to resist the ex- pulsion of the tumors when an examination of, or an operation for the complaint is desired, so strong as sometimes to require very con- siderable force to overcome its contraction, * Ma piu direttamente opereranno i locali remedii introdotti nell'ano; tra quali trovai prontamente cffi- cace una candeletta di cera spalmata di burro impas- tato con molta polvere di galla di querela.—Monteg- gia loc. chat. p. 521. On the Hemorrhoidal Excrescence. 71 and introduce the finger, with a view to in- vestigate the state of the inside of the gut. If I am right in my conjecture of the causes of the disease, this violent constric- tion of the sphincter ani muscle is among the most frequent of them. The internal membrane of the rectum, together with the vessels it contains, is protruded without the sphincter ani at each time of the expulsion of the faeces, and is caught, as it were, and its vessels strangulated by the contraction of the muscle. The constant recurrence of this circumstance, assisted, perhaps, by a costive condition of the bowels, sufficient to produce a varicose state of the hemorrhoidal vessels, without seeking for the cause in an obstruc- tion of the liver, or other viscera of the ab- domen. These* latter causes, indeed, cer- * Cette obstruction du foye est par rapport aux vcines hemorrhoidales, ce que la grossesse dans les 72 On the Hemorrhoidal Excrescence. tainly often produce the complaint; but in such cases, there is more constitutional indis- position, the visceral disease is marked by its proper symptoms, and the complaint in ques- tion, is a subordinate consideration. I will not, however, insist on this expla- nation of the usual origin of the affection; whatever be the mode by which the bougie produces its beneficial effects, whether it be by resisting the strong action of the sphinc- ter muscle, or whether its pressure on the tumors be the essential operation of it, the fact and the practice are still the same. The use of the large bougie does very considera- bly relieve the inconveniences produced by hemorrhoidal excrescences, when the opera- tion of its removal is not thought advisable, or there may be any other objection to its performance. femmes, et les jarretieres trop serrees, sont aux veines des jambes.—Petit Gluvres Post. tom. 2. On the Hemorrhoidal Excrescence. 73 It may not be superfluous to remark, that it is absolutely requisite that the bowels should be kept constantly in a relaxed condi- tion by the use of some mild purgative medi- cine, as castor oil, manna, senna, or the like, whenever the contrary tendency prevails. Aloes has been observed by Celsus, and afterwards by Mr. Pott, to be an unfavour- able medicine for hemorrhoidal complaints, so much so, that Fabricius* remarks, that when he suspected a suppression of the bleeding from piles, to be the cause of certain diseases, he endeavoured to reproduce the discharge of blood by the use of aloetic me- dicines. * Fabricius ab Aquapendente.- p. 618. G C 74 ] SECTION V. On the Fistula in Ano. 1 HE writings of the older surgeons, and the rude and even barbarous operation for the fistula in ano, which is described in them, have not yet ceased to operate on the minds of those who are afflicted with this disease. Although it is now, principally by the la- bour of Mr. Pott,* become a very simple * It is remarkable that a disease of so frequent oc- currence should have excited so little of the attention of the English surgical writers. Fewer cases of this disease have been published, and fewer remarks on the infortunia and the anomalous circumstances at- tending it during the progress of the cure, than al- most any other disease. Except the classical treatise of Mr. Pott, who has by no means exhausted the sub- ject, there has hardly any thing appeared on this sub- ject for the last century. On the Fistula in Ano. 75 operation, it occasions more dread and re- luctance to submit to it, than diseases of a much more serious nature, and operations of a much more dangerous tendency. Improved, however, as it is, and render- ed comparatively easy both to the surgeon and the sufferer, instances of great embarrass- ment at the time of the operation, and of the disappointment in the cure, are still not very uncommon circumstances. It would be superfluous to enter into a minute detail of the usual appearances of the complaint, which are familiar to every sur- geon, and would only be a repetition of what has been said by other writers; I shall there- fore only relate some of those embarrassing accidents which refer to the operation itself, and some of those circumstances which I conceive to be the causes of failure in the ultimatecure. 76 On the Fistula in Ano. In this operation, although there are no vessels of very considerable size in danger of being wounded; yet when the sinus ex- tends far up the side of the gut, a hemor- rhage now and then takes place either at the time of the operation, but more usually a few hours after it, which, if it be not important from the magnitude of the divided artery, becomes often so from the difficulty, perhaps impossibility, of securing it by a needle and ligature. It is surprising, that this circum- stance should have passed unobserved by Mr. Pott, in his Treatise on the Fistula in Ano; for I will venture to say, that it has occurred to almost every surgeon, who is in the habit of performing this operation. The usual method resorted to, when the vessel cannot be secured by ligature, is by filling up the gut and the divided sinus with lint, wet with some astringent and styptic On the Fistula in Ano. 77 fluid, so as by the combined effect of the stimulus and the pressure, to restrain the hemorrhage. A very operose method of ac- complishing this is described by Petit, and a more simple mode by Richerand; but al- though these may sometimes succeed, who- ever considers the nature of the contiguous parts, will be persuaded how inefficaciously any pressure can be applied where the bleed- ing vessel is surrounded with soft parts. The hemorrhage is apparently stopped indeed by this process, for the blood is, for some time, prevented from escaping externally by the dossils of lint; but the artery still pours its blood into the cavity of the gut, and then issues out through the compresses. This continues for a longer or shorter time, until perhaps, the patient faints from loss of blood, or stops and is again renewed, when the faeces are discharged. G2 78 On the Fistula in Ano. I have so frequently seen the hemorrhage kept up as long as this method of plugging the intestine was persevered in, and cease spon- taneously when every kind of application was omitted, and the parts left for a short time ex- posed to the open air, together with a cool room, and avoiding all drink that hurries on the circulation, that I cannot help thinking, that the irritation of the compresses keeps up the bleeding, and that the most eligible mode of treating it, when it is impossible to secure the vessel with ligature, is to take off every kind of dressing, and to suffer the part as much as possible to be exposed for a short time to the external air. To be a passive spectator, however, of an hemorrhage, though not a dangerous one, for an hour or two perhaps, after the surgeon has performed an operation, is a very irksome task, and a very painful state of suspense for On the Fistula in Ano. 79 the patient; but I am persuaded from repeat- ed experience that by being too busy with compresses and styptics, and astringents, and such like applications, we most frequently only hide the bleeding, and rather prolong its continuance, than otherwise. The consequences of a very small por- tion of the placenta, or even a coagulum of blood, left in the uterus, are well known to the professors of midwifery, and the ineffi- cacy of a partial compression, added to all the tribe of medicines usually employed, in hemorrhages from other parts of the body, is felt and acknowledged by surgeons. After many unsuccessful attempts to se- cure a bleeding vessel under such circum- stances, I once accomplished it by introdu- cing a blunt gorget into the rectum; and by keeping the gut thus dilated, I was enabled to see the orifice of the bleeding artery and 80 On the Fistula in Ano. to secure it; and I have been led from this to conjecture, that the old instrument, the spe- culum ani, is not altogether to be rejected from the apparatus of surgery, or rather that a more convenient instrument might be con- trived to assist us in similar difficulties. Among the causes of ill success, in the treatment of the fistula in ano, I have men- tioned in the observations on the stricture of the rectum, a morbid state of the inner mem- brane of the gut, is far from being the least frequent; and where this is the case, the fistula becomes only a symptom, or conse- quence of the original disease. It is evident that, in such cases, the common operation for the fistula in ano, and subsequent treat- ment must fail of success, if the cause which produced the fistula, that is, the disease in the gut itself, be not adverted to. When this disease is of a curable nature, On the Fistula in Ano. 81 when it is not cancer, the cure must de- pend on the state of the gut; and if by the means which are proper under such circum- stances, and which have been more fully ex- plained in another place, the condition of the gut be ameliorated or approaching to conva- lescence, the fistula will yield to the usual operation and treatment of fistula. I say approaching to convalescence; for it is not necessary, nor would it be right in a case of fistula dependent on stricture, to delay the operation until the stricture is subdued, for, as I have said, the operation itself will divide the stricture, in many instances, and the use of the bougie may be prosecuted with more advantage during the progress of the cure. It becomes necessary, then, to attend to the previous condition of the patient's bow- els, and the present state of the inside of the 82 On the Fistula in Ano. intestine, in cases of old or complicated fis- tula in ano. In such cases too there are other circum- stances, and other diseases to be adverted to before the operation be performed with a pro- mise of success, if the surgeon is anxious that his promise and prognostic should be accom- plished. The fistula in ano is very frequently met with, in those persons who are afflicted with symptoms of phthisis pulmonalis. The pro- priety of performing the operation under such circumstances must depend on the degree, or stage of this latter disease. These cases are not usually favourable in themselves, nor do they afford a favourable* prognostic of the * Alcuni riguardano come utile in tali casi l'asces- so e la fistola all'ano. Cio pud essere in qualche ca- so: ma io vidi morire ogni tisico, a cui sopravenne tal vizio, ed il Bordeu sull' autorita d'Ippocrate pre- disse la morte del delfino di Francia quando sentii On the Fistula in Ano. 8& issue, although the discharge 1 as been some- times supposed to be beneficial to the morbid state of the lungs. The degree of inconvenience therefore, which the fistula produces and the other cir- cumstances of the more important disease, are to be taken into consideration before the operation be resolved on, in cases of this de- scription. A carious state of the posterior bones of the pelvis, or of the lumbar vertebrae, or the common lumbar abscess, are sometimes the causes of fistula in ano; and when this is the case, the discharge is copious beyond all pro- portion to the apparent complaint; and he who promises to cure such a disease, by the common operation for fistula, will not be likely to fulfil the expectations of his patient. But the most usual cause of failure in the essergli venuta una suppurazione all'ano. Monteggiaj loc. cit. p. 335. 84 On the Fistula in Ano. cure of the simple fistula, which is the con- sequence of abscess in this part, is, that some one sinus, whether leading into the gut, above the part divided in the operation, or extend- ing laterally in the nates, is left unopened by the operator. When the fistula perforates the gut in more places than one, or which often happens, the perforation cannot be discovered with the probe or director, the operation must be finished by pushing the end of the bistoury through the side of the gut to the finger in - ano, but notwithstanding the facility which there seems to be in Mr. Pott's treatise, of doing this, it is not always so very easy a matter to execute; and the communication of the fistula with the gut, which is left un- touched in the operation, will not in every instance heal up; and there will still be a dis- charge from the anus after the external wound On the Fistula in Ano. 85 has healed, or else, the external wound does not entirely close. This part of the operation, therefore, is very important, and no pains should be spared in discovering the fistulous aperture in the gut with the director, at the time the operation is performed. It is not always possible to discover each of the sinuses, where there are many, at the time of the operation; the effusion of blood, perhaps, obscures the orifice, or it is so situat- ed, that it cannot be perceived; but if any one sinus be left undivded, the cure will most probably be incomplete, and the complaint will return. A very little attention, however, to the parts, after the suppuration is establish- ed, will discover the orifice of any latent sinus in the nates, that still exists. Sometimes, a little external hardness in the nates, will lead us to it; at other times, pressure with the fingers will cause the matter to issue from its H 86 On the Fistula in Ano. orifice, and when discovered, there will not be much difficulty or pain in laying it open with a director and sharp-pointed curved bistoury. [ 87 ] SECTION VI. Cases of Stricture of the Rectum. A LADY about forty years of age, who had been affected with an umbilical hernia for many years, was seized with violent pain in the abdomen and vomiting, and had not had any evacuation from the bowels for seven days. The rupture was painful to the touch, was of the size of a very large orange, and had been incapable of reduction for twenty- four hours. Her pulse was quick and weak, she been taking large doses of calomel and other strong purgative medicines without effect. In this state, Mr. Ford was called to her, and I saw her with him. The rupture could not be returned by any effort that was 88 Cases of Stricture thought prudent; and the vomiting, together with hiccough, was increasing in severity; she was bled, and directed to take some pills with calomel and extract: colocynth: and an injection of the tobacco fume was, with con- siderable difficulty, thrown up the rectum. It was proposed that, if these means failed of giving her relief, the operation to return the hernia should be performed without further delay. She now happened to tell us, that she had been for many years of so costive a habit of body, that she could never pass her stools without great pain and difficulty, and seldom without the assistance of clysters, and that they were always very small in size. These circumstances led to a suspicion that the seat of the disease was not in the her- nial sac, but in the rectum, and on passing the finger to examine the gut, a firm indu- rated stricture was discovered, about two of the Rectum. 89 inches up the intestine, which would not ad- mit the point of the finger to pass it. A rectum bougie of a small size was in- troduced high up the gut, and retained there about ten minutes. Soon after it was with- drawn, there was a copious evacuation of the faeces, the vomiting ceased, and the rupture soon returned spontaneously; in short all her complaints disappeared, and she was in the same state as before the attack. By persever- ing in the use of the bougie, the stricture was gradually enlarged, and in a fortnight she could pass her stools better than she had done for many years; she continued, how- ever, daily to pass the bougie for about a month, and then used it only occasionally. This is now seven years ago, and I saw her very lately, for another complaint, when she informed me, that she remained perfectly well of the stricture; but from fear of a return of H2 9Q Cases of Stricture her disease, rather than from necessity, she now and then passed the bougie, for a short time, and withdrew it again. of the Rectum. 91 CASE II. A poor woman, a patient of the West- minster General Dispensary in 1801, had complained of difficulty and pain in voiding her faeces for three years; and they were generally evacuated in small portions of the size of a quill, or large urethra bougie. For the last month there had been an ichorous, fetid discharge from the anus, and frequent- ly, an involuntary flow of liquid faeces from the gut, with almost constant tenesmus; and to add to her distress, a communication had taken place between the vagina and rectum, through which part the faeces passed. She had a fistulous orifice in the nates, near the anus, which had once been divided, but did not heal up; there was also a large condylo- 92 Cases of Stricture matous excrescence on the verge of the anus. She had been pregnant about three years before, and the child, when born, was cover- ed with spots, and died soon after its birth. She had the venereal disease nine years since, but, except her present complaint of the rectum, had been tolerably healthy since that time. On examining the rectum with the finger, which gave her great pain, a stricture was found near the extremity of it, of a hard scirrhus-like feel, which would only admit a very small bougie. She was directed to take a grain of calomel twice a day with three grains of extract of hemlock: and every day to introduce a bougie and retain it in the rec- tum, as long as she could bear it without much pain. In about a week the painful symptoms were considerably relieved, but as the stricture would not yet admit a larger of the Rectum. 93 bougie, a very small probe-pointed curved bistoury was introduced on the fore finger, and the stricture divided in that part which was contiguous to the os sacrum. This oper- ation gave but little pain, and there was hard- ly any bleeding after it. A bougie of a larger size was then introduced, and although the parts were more tender for many days, she was still able to continue the use of the bou- gie, first for a shorter time, but afterwards for many hours. In about three weeks, she was so much relieved, as to pass her stools better than she had done for two years, and there was scarcely any thing passed by the aperture into the vagina, unless when the effort to discharge the faeces was more violent than common. I saw her from time to time, for about four months, gradually getting better, the stools being evacuated without pain, the discharge from the anus having 94 Cases of Stricture ceased, and her mouth occasionally tender from the medicine which she continued for nearly three months. The rectum admitted a full-sized bougie, and the remains of the stricture had a softer feel; but neither the fistula in the nates, nor the orifice in the va- gina had quite closed up. She then removed from her residence, and I regret to say, I have not since seen her. of the Rectum. 95 CASE III. A lady about thirty-two years of age, who had always enjoyed good health, about four years ago, found her bowels so slow in their action, that it was seldom, and with great difficulty, that she could obtain an eva- cuation without the assistance of purgative medicines. This costiveness was generally more obstinate during the period of menstru- ation; she now has, and for these two years past, has had great pain about the anus, fre- quent inclination to void her faeces, but the efforts produce nothing but blood and mucus; at other times, there is a sanious, very offen- sive discharge from the rectum. On examin- ing the rectum, a considerable stricture was discovered about an inch from the anus, and 96 Cases of Stricture a fistulous orifice in the perineum, the re- mains of an abscess, which broke there about six months ago. A curved probe-pointed bistoury was in- troduced into the rectum on the finger, and the stricture freely divided in its posterior part, so that a bougie could be easily passed through it. The next day she took some pur- gative medicine, and had a more free evacua- tion than for a twelvemonth; but complained of pain and difficulty in passing the urine: for several days she voided her faeces involun- tarily, and was so uneasy, that the operation did not seem to have mended her condition. But by perseverance for six weeks, in the use of the bougie, which she sometimes re- tains in the rectum for twelve hours together, and the occasional use of purgative medi- cines, these symptoms went off, and she had regular stools without pain or difficulty. She of the Rectum 97 then went to the sea-side for some months, and returned to London quite well; the sani- ous discharge having stopped, and possessing the power of retaining and evacuating her fteces in the natural way. I 98 Cases of Stricture CASE IV. I was desired to see a woman at Lam- beth, who some days before had swallowed a plumb-stone, which had passed through the intestinal canal as far as the rectum, but there stopped, and had obstructed the pas- sage of the faeces for a considerable time. She had been of a costive habit, and had pass- ed her stools with difficulty for more than a year. On examination, a stricture was dis- covered about two inches from the anus; a small bougie was introduced, and she was di- rected to take some castor oil; in a day or two, the stone passed the stricture, and her present complaints were relieved; but whe- ther she continues the use of the bougie to effect a more perfect cure, I have no oppor- tunity of informing myself. of the Rectum. 99 CASE V. The servant of a nobleman applied to me for the removal of some hemorrhoidal ex- crescences. About a year before, some similar tumors had been taken away by the late Mr. Ford, by the application of a ligature round them. The patient was much relieved by this operation; but his complaints had been re- turning for the last six months. He had con- siderable pain in discharging his stools, which were small, generally liquid, and ac- companied with a quantity of blood, and a mucous discharge constantly flowed from the anus; he had frequent inclinations to pass his urine, which was evacuated with pain, and the uneasiness continued for some time after- wards. On examination, I found that the 100 Cases of Stricture cutis surrounding the verge of the anus was elongated into a pendulous flap, but there were none of the varicose tumors about the anus, like those which had been previously removed, nor could I learn that any were pro- truded when he went to stool. When I ex- amined the rectum, which gave him great pain, I found my finger obstructed by several filaments, some of which were broken by the force I used, and others extended as far as I could reach, and the whole surface of the rectum had a diseased and thickened feel, but was not particularly contracted in any one part, so as to form a distinct stricture. I then endeavoured to introduce a small bougie, which gave him such great pain, that I was obliged to withdraw it immediately, and a quantity of blood followed the instrument. I told him, that I thought nothing but the continued use of the bougie would relieve of the Rectum. 101 him, together with occasionally taking some mild purgative medicine, but I had no doubt, that these means, if persevered in, would do so; that there were no hemorrhoidal tumors, nor any complaint which an operation, such as had been previously performed, would cure. He went away somewhat discontented, but in a few days he returned again, so much relieved by the use of the bougie in the in- terval, that he was very willing to persist in the plan I had advised. To make the history short, in a month he was so well as to pass a bougie of a much larger size without any in- convenience, and to use it only occasionally; the discharge from the rectum ceased, and he passed his stools without pain. 12 102 Cases of Stricture Fatal Case of the Stricture of the Rectum, from Ruysch.—See note, page 16. Quid grandia molimur tenues et miseri mortales! qui tot lethalibus morbis sumus ob- noxii, ut nemo facile illos recensere posset. Nulibi tamen homines magis affligunt quam circa vias excretioni inservientes; ubi, si altio- res egerint radices, difficillime possunt era- dicari. Quotidie ad vitam sustentandam nobis edendum, bibendum, et quod superfluum est, evacuandum. Si vero viae, hisceo peribus de- stinatae male sint affectae, mors vitae saepius antiponitur ab afflictis. Amicus quidam flore aetatis, temperamento melancholico, ante triennium in Hyberniam ob negotia peragen- da profectus, de mingendi difficultate con- queri ccepit, quae brevi tantum sumpsit in- of the Rectum. 103 crementum, ut assidue ad urinam guttatim egerendam incitaretur, idque tanto cum cru- ciatu, et continuo conatu, ut perferre non potuerit. Quid fit? Brevi post, alterum non minoris momenti malum, caput quoque ex- erere ccepit; nimirum faeces alvinas liberaliter excernendi impotentia, dubio procul ab illis continuis conatibus urinam reddendi, unde intestinum rectum non solum fuit incrassa- tum, et scirrhosum factum, verum etiam in totum fere coaluit: vix enim, ac ne vix qui- dem stilum straminis crassitie in universum admittebat, unde miser nee urinam nee fae- ces alvinas excernere potuit, nisi guttatim et quidem continue ichorosa et purulenta materia remixtas, cum assiduis, tantisque cruciatibus, ut omnes homines ejuspraesen- tiam refugerent. Denique in patriam redux, contulit sese Amstelodamum et me aliosque consuluit, ast incassum, morbis factis insana- bilibus. Hisce malis perpetim incrementa 104 Cases of Stricture, &c. sumentibus, tandem animam Deo reddidit aeger, occasionem nobis relinquens malum penitius perscrutandi. Aperto igitur cadavere, in utraque renum pelvi calculum inveni hor- rendum, et praeter hosce in renis dextri me- dio adhuc alium ingentem. Ureteres et vesica bene erant constituta. Intestinum rectum in universum ita incrassatum deprehendi, ut pollicis crassitiem fere superaret, et ita in. duratum, ut anceps haererem an carnosum an verb cartilaginosum esset dicendum. Ca- vitas quoque dicti intestini, straminis latitu- dinem haud superabat, et quod notandum, tarn firmiter erat connatum ossi sacro, ut cultelli cuspis ad separationem minime suffi- ceret, sed cuneo ferreo malleoque ligneo ean- dem peragere coactus fuerim; imo, mirum dictu! cum summo labore ea disjunxi. Haec omnia Balsamo nostro praeparata a nobis re- servantur in dicti aegri memoriam, et historiae raritatem.—Tom. IV. Observ. 95, 4to. [ 105 ] SECTION VII. Cases of the Hemorrhoidal Excrescence. CASE I. A gentleman about thirty-five years of age, in good health, and subject to no other complaint, except now and then an eruption on the skin, had several hemorrhoidal excres- cences. He had been for a long time of a costive habit of body, and usually suppressed his efforts to evacuate the contents of the bowels, until the evening; for the pain and difficulty he experienced, in returning the tumors again into the rectum, interrupted his avocations. He suffered considerable loss of blood at each time of going to stool. When the excrescences were without the rectum. 106 Cases of the they discharged a great quantity of thin sani- ous matter. On examination, three of these tumors were discovered, and after he had emptied the bowels, and the tumors were protruded, a double ligature was passed through the centre one, and tied on each side of it: as he did not feel any great degree of pain in this part of the operation, the other two smaller ones were also included, each in a separate ligature. He took an opiate immediately after- wards, and went to bed, without much un- easiness. The first two days he passed toler- ably well, his bowels were open, he repeated his opiate each night, and lived very abste- miously. On the third day he became feverish, the pulse weak and quick, and in the evening nausea and hiccough came on, with pain in the abdomen and retention of urine. The ca- theter was introduced, and about a pint of Hemorrhoidal Excrescence. 107 urine evacuated, which gave him great ease; his bowels were emptied by a mild purgative. On the fourth day the nausea, hiccough and affection of the bladder were very, consider- ably increased, with great pain in the ab- domen, and a weak, quick, intermitting pulse. The only ligature which had not sepa- rated was cut out, but the symptoms aug- menting rapidly, he died on the morning of the fifth day. On opening the body, the stomach was found considerably inflamed, the small intes- tines slightly so, and on taking the bladder and rectum out to examine them more mi- nutely, the internal coat of the rectum, quite down to the anus, was free from inflammation, and the bladder apparently healthy. The pro- state gland was considerably enlarged, and several small calculi in its substance; these were the only diseased appearances on dis- section. 108 Cases of the CASE II. A professional gentleman had several hemorrhoidal tumors which gave him great pain, and occasioned considerable loss of falood when he went to stool. A double liga- ture was passed round the most prominent and painful of them, and he suffered but little pain at the time of the operation. The next day he complained of great pain in the back and loins, much irritation about the anus, and had some fever. He applied a common poultice to the anus, and his bowels were emptied by a saline purgative medicine. The third day the parts were much swelled, inflamed, and excoriated by the pendulous ends of the ligature, which were therefore removed. The fourth day he had still great Hemorrhoidal Excrescence. 109 pain in the vicinity of the rectum, together with fever, headach, and a diminished secre- tion of urine. On the fifth day he had less pain and fever, but the parts were swelled exter- nally, with slight ulceration in the perineum. He remained in bed, the poultice was con<- tinued to the anus, and his bowels were kept open by saline draughts with magnesia. The ligature came away on the seventh day, but for a considerable time afterwards he had great pain in the prostate gland and the ure- thra; the anus was also swelled and painful for many days; after which he gradually recover- ed, and experienced much relief from the removal of the excrescence. K 110 Cases of the CASE III. A tradesman in Long Acre, about 40 years of age, consulted me for a painful affec- tion of the rectum, and gave the following history of his complaint. He was habitually costive, and lost a great quantity of blood whenever he had an evacuation, which he was constantly obliged to solicit by the use of purgative medicines. At the time of pass- ing his stool there were several tumors pro- truded from the gut which could not usually be returned for many hours. During this time he was in great pain, which lasted until he was able to reduce them with his fingers. When I examined him, I found the sphincter ani muscle so rigid that it was with difficulty I introduced my finger into the gut, which Hemorrhoidal Excrescence. HI appeared very much obstructed by soft tu- mors. I requested him to expel them from the gut, as in the effort to evacuate his faeces, and there appeared two excrescences of the size, and nearly of the color of a large pur- ple grape, which were not very painful to the touch. He was recommended to use an injection of ten grains of sulphate of zinc dissolved in half a pint of water, twice or three times a day, to keep his bowels open with electuary of senna, to reduce the tu- mors as soon as he could after each evacua- tion, and to empty the gut in as short a time as he could. He continued this plan for about a fort- night, when I saw him again, somewhat better, but not very materially so. I told him, that I hoped, by perseverance in this plan he would be relieved; but that the removal of the tumors by ligature was the most ready 112 Cases of the way of obtaining a cure, if he would submit to the operation and subsequent confinement. He consented, and after evacuating his bow- els, I took hold of the largest and most pain- ful of these tumors with a double hook, and passed a ligature tight round it. I then tied the other in the same manner, and return- ed them with the ligatures into the gut. He took an opiate and went to bed. The next morning he complained of great pain in the abdomen, which was tense and swelled; he had had no sleep, and was hot and feverish. I directed him to live extremely low, and to take castor oil until a copious evacuation was procured. The pain and tension of the abdo- men continued for three days; after which it gradually subsided, the ligatures came away, and he was considerably relieved by the ope- ration. But, in a short time afterwards, he had the mortification to perceive some other simi- Hemorrhoidal Excrescence. H3 lar tumors protruding, and giving him all the same inconvenience which the former ones had done. As he had suffered so much, from the operation which had been perform- ed, I was not willing to propose the removal of them again by ligature. I therefore recom- mended him to introduce a large rectum bougie, and retain it in the gut for some time, every morning. This he did; and the hemorrhage, when he went to stool, no longer troubled him; the tumors ceased to appear; and in about a month or rather more, he told me he hardly suffered any inconvenience from his complaint, but that he still occasion- ally introduced a bougie, and withdrew it again, after it had been in the rectum a short time. K2 [ li4 1 SECTION VII. Cases of Fistula in Ano. CASE I. A carpenter, about thirty years of age, had the operation for fistula in ano, perform- ed on him in the year 1803. There were two extenisve sinuses in the nates divided; but the principal one. extended above three inches up the side of the gut, and then per- forated it; this also was laid open. There was considerable hemorrhage at the time of the operation; but the patient fainted, and the bleeding stopped; and when the wound was dressed he went to bed. After he had been in bed about an hour the hemorrhage return- Cases of Fistula in Ano. \\$ ed; and the bleeding artery was so high up the sinus, as to be entirely out of the reach of the needle and ligature. The gut, therefore, and the wound, were filled up with com- presses of lint, wet with spirit of turpentine; and for some time it was thought, that this mode of compression had succeeded in stop- ping the hemorrhage. But during our fancied security, his pulse became hardly perceptible, his lips pale; and the whole of the body was in a cold sweat. He was now supported by wine and other cordials; and in a short time the hemorrhage burst out again with as much violence as ever, and continued for more than an hour. All the compresses were now removed, the rectum cleared as much as pos- sible of coagulated blood, and the wound left without any dressings. The hemorrhage stopped, and did not return again; but very large quantities of coagulated blood were 116 Cases of Fistula in Ano. evacuated with the faeces for three days afterwards. He was, as may be supposed, extremely debilitated by this loss of blood, but finally recovered his strength; and his fistula was dressed and cured in the usual way« CASE II. A gentleman about fifty-six years of age, who had been subject to complaints of the liver, and frequent hemorrhage from the nose, had the operation for fistula in ano performed. A sinus leading into the rectum, about an inch from the anus, was first divided, and then another passing towards the os coccygis. The opening of this last discovered another sinus penetrating the gut, about an inch or rather more above the former one, which had been Cases of Fistula in Ano. 117 divided. This also was laid open, and the wound bled very freely; but the orifice of the bleeding vessel could not be discovered. In a short time the hemorrhage diminish- ed; and the wound was dressed in the usual way, by introducing a piece of lint from the gut into the divided sinus. There was some degree of hemorrhage nearly the whole night: and in the morning a small artery was dis- covered, and a ligature passed round it; but the bleeding continued and increased very considerably, when he had an evacuation in the middle of the day. The wound was clear- ed of all the dressings, together with the coagulated blood; and the hemorrhage ceased. During the succeeding night, there was no bleeding; but in the morning it returned, when he had a stool, and he lost about four ounces of florid fluid blood. The wound was now filled with lint, wet with Ruspini's styp. 118 Cases of Fistula in Ano. tic, which happened to be at hand. There was a little hemorrhage during the day and in the following night, which, however, he passed tolerably well; and the wound began to sup- purate plentifully. But when he had an eva- cuation of the faeces, the bleeding again re- turned, but in a less degree; and for many days he lost some ounces of fluid blood every time he passed his stool. At last it ceased alto- gether; the wound went on well, and in about six weeks was quite healed. C 119 ] SECTION VIII. Case of indurated Faces and biliary Calculus obstructing the Rectum. AN elderly lady had for many years complained of great pain in the anus when- ever she evacuated the faeces. She was con- stantly obliged to take purgative medicines; and even with this assistance, she had consi- derable difficulty in emptying the intestine. She had now been confined to her bed for se- veral weeks with pain about the rectum so violent, that she compared it to that of labour. She was not relieved by the use of purgative medicines, nor by opiates; and clysters could not be thrown up in consequence of some 120 Case of Indurated Faeces, bi'c. obstruction in the intestine. On examining the rectum with the finger, the gut was found to be loaded with* indurated faeces, which were with great difficulty removed by the scoop which is used in lithotomy, and the finger. When this was done, a hard round body was discovered higher up in the gut. After many attempts, a large biliary calculus was brought away with the same scoop, and more of the alvine concretion which was lodged above the stone. She took some pur- gative medicine, and was soon relieved of her complaints. * There a\ e many cases of this disease recorded in books, particularly by Mr. Hey, by Mr. White, and by Dr. Folhergill. 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