Dr. John Wright read the following paper on "Diseases of the Rectum;"

SURGICAL DISEASES OF THE RECTUM.

Under the head of surgical diseases of the rectum, I propose to make a short report. I do not expect to present anything new, either on the pathology or treatment of this class of affections, or allude to all of them, but I will notice a few of them and only a few, more for the purpose of calling attention to some errors in diagnosis that are frequently met with in practice, rather than to attempt to present anything new or original. I will also try to show how the mistakes referred to are made, and how to avoid them.

In order to correctly diagnose rectal diseases, it is absolutely necessary to make ocular inspections of the rectum, aided in some cases by the use of the speculum.

Errors in diagnosis may happen and be unavoidable, with the most skillful physicians and surgeons, on account of the hidden locality or absence of manifestations of disease, as is the case in some affections of the brain, chest, abdominal and pelvic cavities. But diseases affecting the exterior of the body, as those of the eye, the ear, the mouth, the vagina and rectum, are not so difficult to diagnose, because, in addition to the history of the case, we can feel and touch the diseased structures. And in all such cases, errors in diagnosis should seldom, if ever, be seen in practice. This, however, is not the case in some of the diseases of the rectum. If we rely alone on the statements of our patients, and neglect to make ocular inspections, we will often make mistakes. Many of the leading symptons of hemorrhoids are also the symptons of fissure and fistula, and other affections of the rectum, and unless we are very careful in arriving at our conclusions we will be liable to mistake one of these affections for another. I have seen a few mistakes of this kind myself, two of which I will give a short account of, with the treatment and results.

A few years ago a lady, about thirty years of age, applied to me for treatment for hemorrhoids. She said she had been suffering for two or three years, and had been prescribed for by several physicians, but had received little, if any, benefit from

treatment, and that for some months had remained at home nearly all of the time, on account of the pain she suffered from, when her bowels were evacuated. She said the pain was so great that she had to go to bed and remain there nearly all day. I believe she aimed to have her bowels move about once in two days. She had adopted that rule because the pain was great, and she put it off as long as she could. She said the pain came on as soon as the bowels were moved, and continued to increase in severity for several hours; that at times blood and mucus passed by the bowels, and that the pain was a burning or smarting kind of pain almost unendurable, and lasted nearly all day, confining her to her bed nearly one-third of the time.

This was the history of her case as she gave it to me. On enquiring of her I could not learn that there were any tumors externally, or that any came down when the bowels moved. I asked if she had ever been examined to determine what was the matter with her, and she said there had never been any examination. I told her that it would be necessary for me to make an examination, in order to determine what the disease was and how to treat it.

I proceeded to make an examination, after placing the patient in a proper position. There were no tumors to be seen externally, and on attempting to pass the finger into the rectum, the sphincter contracted with such force as to render its passage impracticable. But by gently drawing the edge of the bowel down, and at the same time encouraging the patient to relax the sphincter as much as possible and bear down gently, I was enabled to find at the edge of the anus, posterior portion, an ulcer, or fissure. When the parts were relaxed and lay flat, it was an ulcer, a little larger than a ten cent piece, but as the anus closed it became a fissure, or slit, in appearance. I proposed to operate by cutting across the ulcer, and the patient consented to have the operation performed. A few days afterwards, I performed the operation by making an incision across the ulcer, and immediately introduced my thumbs into the anus, and strained the muscle so that the wound made by the knife was almost completely on the outside from the relaxed state of the parts. In a few weeks this patient was well, the ulcer having entirely healed.

Her general health was also much improved. In this case there had been no inspection of the rectum, and the diagnosis had evidently been made without due care, and based exclusively on the statements of the patient. Had there been an inspection of the parts, there would have been no mistake; for the diagnosis was readily made out without the use of the speculum or any other instrument. The mistake was the result of carelessness on the part of the physicians that diagnosed the case as one of piles.

Some time in June of last year, a gentleman called on me saying he wanted me to do something for him, said he was suffering from piles, that he had been a sufferer for several years; that he had been operated on several times, but not cured; was first operated on by a regular physician, a friend of mine who is a very good physician and surgeon, but from some cause the cure was not complete. In a few months after the first operation he visited a so-called regular pile doctor, a "specialist," a regular humbug, I suppose. The pile doctor pretended to remove a large number of tumors, but the patient did not see any of them. This operation also proved a failure, and the patient continued to suffer. For a year or two, he did nothing but use ointments, mostly patent nostrums. In May, a year ago, an infallible pile curer came to town, an itinerant, and the report went out that he cured piles without the use of the knife, ligature, or any other means known to the profession, a new treatment that was painless and never failed to cure. And by the persuasion of some of his friends, as he said, he was induced to report to the pile doctor for treatment. This was in May, and he continued to treat him until the fore-part of June, when he came into my hands. He had been getting worse from the time the pile doctor first prescribed for him. When he came to me he could not sit on a chair-had almost given up business. his bowels were evacuated in the morning, he would have to go to bed and remain there nearly all day, in consequence of the extremely painful condition of the rectum, which would last nearly all day. His general health was very poor, he was gloomy and despondent. The local symptoms were very much the same as those of the lady of whom I have spoken. examination revealed a similiar condition; viz., a fissure.

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operation was proposed and agreed to. On the 22d day of June, I operated in the presence of, and assisted by, Drs. T. K. Edmiston, Tyree and Waters. The patient being placed under the influence of sulphuric ether, and a Sims speculum introduced in to the rectum for the purpose of examining the condition of the bowel. No hemorrhoids were to be seen, but the mucous membrane was of a dark red color, as far up the bowel as could be seen. By means of the Sims speculum, which is the best speculum I ever used to examine the rectum, the ulcer was brought plainly into view. I made an incision across it, but not a very deep one. There was rather a free hemorrhage, on account of the congested condition of the mucous membrane. I introduced my thumbs and strained the muscle, as I did in the other case, so that the ulcer was partially external from the relaxation caused by straining the muscle with my thumbs. After the operation the patient remained in bed about a week, and then was permitted to get up. This operation did not prove a success, -the patient was benefited but not cured.

In about three weeks from that time, I examined the patient again, and found the ulcer had not entirely healed, but the mucous membrane was in a much more healthy condition. I repeated the operation, making a deeper incision, and strained the muscle as before with my thumbs. This double operation may appear to have been unnecessary, but it placed the parts completely at rest.

In a few days, this patient was up and well in a short time, though I never had an opportunity to examine the bowel again; but, judging from what he said and from his general appearance, I think the fissure was cured.

Shortly after I saw this case another patient applied to me for treatment for hemorrhoids. The symptoms in his case as given to me, were nearly the same as in the cases I have described; and I was almost ready to make up my mind that I had another case of fissure. But when I came to examine the rectum, I found a complete fistula, both openings being very low down, and giving rise to the burning or smarting pain that is so common in fis

sure.

This man too had been using all of the pile ointments that he could hear of, and of course without deriving any benefit from

them. Of course the remedy in this kind of a case is the knife. Hemorrhoids is the disease that is most frequently met with of all other diseases of the rectum. This affection is not confined to any one class of persons or occupations, but all are liable to be affected, and a great many do suffer more or less from piles. And I suppose that is the reason why fissure, fistula, and so many other affections are so often mistaken for hemorrhoids, and especially by those who neglect to carefully inspect the rectum before making out their diagnosis. To arrive at a conclusion that a patient has piles, without an inspection of the rectum, is arriving at a conclusion by guessing at it, a practice that is never justifiable.

I do not pretend to say that mistakes are made in the practice of all physicians or surgeons. Those who devote their time exclusively to surgery, and those connected with colleges and hospitals, seldom if ever make such mistakes. But they are apt to happen to the general practitioner, and especially to those in small towns and in the country, where surgery, as it is in some localities, is almost entirely neglected, or where all surgical cases are sent off to large cities to have operations performed, unless an intinerant comes that does all the work for them.

While it is a fact, that hemorrhoids is by far the most frequent of all affections of the rectum, and the symptoms so nearly the same in all cases that it would appear to be almost impossible to make mistakes, yet I am well satisfied that if we rely alone on the statements of our patients, who suppose they are suffering from piles, to make up our diagnosis, we will often arrive at erroneous conclusions. A few years ago, an intelligent old lady called on me for a prescription for what she said was piles. She said when her bowels were moved that she had pain, passed some blood and mucus, and suffered more or less all the time with her hips and back, and had a feeling of weight about the rectum. I learned that she had also a vaginal discharge, which made me suspect that her disease was not hemorrhoids. I made an examination and did not find piles, but I found cancer of the cervix uteri. Whether this case had ever been diagnosed hemorrhoids by a physician or not I do not know, but I do know her description of her case was very much the same as is ordinarily given by persons who are suffering from piles, with the excep