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easily relieved, rendered the subjects of them the victims of the most painful and in many cases dangerous operations. But by the advance of surgical science generally, and the study and observation of these particular diseases, even the most painful of them may generally be remedied by medical treatment; and when an operation is necessary for the removal of morbid structure, or for the purpose of inducing a healthy reparative process, it is simple in character, quickly performed, occasioning but a slight amount of pain, and confining the patient for only a very limited period. Thus fistula in ano, which, at a comparatively recent period, was considered among the heaviest afflictions that flesh is heir to, from the barbarous treatment that was then practised and considered necessary, as a consequence of the false notions and erroneous pathological principles that prevailed, and which led to the scooping out of the parts in the track of the fistula, or to the extensive destruction of the surrounding tissues by corrosive unguents, is now remedied by a slight incision, performed in a few seconds, and not occasioning the loss of more than a few drops of blood. It was only a few years since it was deemed essential for the cure of fissure of the anus to entirely divide the sphincter muscle; but it is now proved that when an incision is required it is not necessary to make it more than a few lines in length, and to extend it no deeper than through the mucous and submucous tissues. In all operations about the anus, the general rule in surgery, that of not removing more of the integument than is necessary, cannot be too forcibly insisted on; for if this is not observed the patient will be doomed to much inconvenience and misery by the contraction that ensues.
The constitutional origin of these local affections, and their reaction on the general system, when their cause has been extrinsic, must always be borne in mind, for if this be overlooked, our hopes of success in the treatment will often not be realized.
Besides prescribing proper remedies, and giving strict injunctions with regard to diet and exercise, it is advisable that the surgeon should apply the dressings with his own hands; for though there is no difficulty in the matter, and little skill required, yet it is essential to the comfort and recovery of the patient that they should be accurately and properly adjusted: nurses and attendants, from not thoroughly apprehending the object to be attained, are too apt either to cram and distend the parts with the dressings, or not to approximate them with sufficient nicety: the surgeon should also exhibit the enemata, unless he has some intelligent and trustworthy person on whom he can rely. These matters may appear comparatively trifling; but if they pass unattended to, we shall often be disappointed in the result of our treatment, let it in other respects be ever so skilfully and well directed.
In some morbid conditions of the rectum, great advantage is derived by the use of the speculum for the purpose of examination, and also in performing some operations. In most cases one of the form of the annexed figure will answer the purpose: it
is an old-fashioned instrument, and may be made of polished metal, or of glass silvered, and covered with caoutchouc. Several specula, differing but slightly, have been contrived; some are made with metallic or wooden plugs to fill up the side opening while the instrument is introduced, but the finger will be found a far better substitute; others are furnished with handles fixed or movable, which are worse than useless, being only in the way.
Mr. Blaise, of the firm of Philp, Whicker, and Blaise, surgical instrument makers, of St. James's Street, has invented a three-bladed speculum, which in some instances will be found exceedingly useful, as by it a surgeon has the power of dilating the bowel, and more fully exposing to view the diseased part when extensive. The instrument which I use is a slight modification of his, being somewhat conical, trumpetshaped at the mouth, and admitting the introduction of the finger, so as to prevent the mucous membrane being pinched between the blades when they are closed previous to withdrawing it. The following engravings accurately represent the speculum as seen when closed and when partly open.
greatest benefit, more effectually accomplishing the object of the physician in removing accumulated excretions than any other means, and saving the stomach and commencement of the intestinal canal from the irritation and nausea which aperient medicines induce. Whatever the form of the instrument, it is important the jet should be elastic, and not—as usually supplied by instrument makers—made of ivory or metal, by which laceration or other injury of the bowel is very readily inflicted. Pumps are objectionable, for the reasons, that patients are apt to throw up either too large or too small a quantity of fluid, the necessity of a basin or other receptacle, and the inconvenience of employing both hands. From their simplicity and convenience, I recommend either a ten-ounce India-rubber bottle with a stopcock, or a cylindrical reservoir fitted with a piston: the jet is seven or eight inches in length, and being detached, affords* the important advantages of great facility of introduction into the bowel; and by means of a plug, its connection with the instrument is most readily effected. When it is intended by enemata to unload the colon of accumulated fiecal matter impacted in its sacculi and distending that intestine, a long elastic tube, known as "O'Beirne's tube," should be passed up the bowel, and the fluid injected by means