holes the sky and all bright objects in the field of view will appear to be covered with black dots or lines, which are the shadows of the retinal capillary vessels, as the slightest oscillation of the eyes is sufficient to produce this appearance. An artist might avail himself of this fact to excite sympathy in behalf of a Galileo, or any other unworthily treated prisoner. The phenomenon would vary with the shape and size of the perforations. Whenever a pencil of light moves over the excentrical portions of the retina, rays radiating from its successively illuminated points (as mentioned in the early portion of this review) towards other parts of the retina will throw thereon the shadow of any retinal vessel they encounter. Thus, if we walk along by a quickset fence through which the sun shines, the shadows of these vessels incessantly flit before the eyes. In a similar way, a light in movement at the side of the face, a flickering flame, or rays of the sun reflected at the side by machinery in motion, or an oscillating tremor, as of a wave or something swimming on such wave, might develop a like effect. Hence, an artist might intimate in this fashion either that he was in movement himself with respect to objects near him, which were not embraced by his picture, or might intimate thus that there was a general whirl and unsteadiness of all things about him.

A traveller by rail who keeps his eyes fixed upon a single object sees all others in the landscape circulating round it, because luminous retinal impressions have a transitory life. Might any painter dare to import this effect into a kind of picture we have already described as conceivable?

We could give other illustrations of the use to which subjective phenomena of vision might be turned by a speculative artist, but we will let this suffice, lest any artist should prove weak enough to be tempted by us, for the sake of novelty, to enter upon what he would undoubtedly find to be a thorny career.

II.-The Surgery of the Rectum.1

THE anatomical peculiarities of the rectum afford the key to 11. The Physical Exploration of the Rectum: with an Appendix on the Ligation of the Hæmorrhoidal Tumours. By WILLIAM BODENHAMER, A.M., M.D. Illustrated by numerous drawings. New York, 1870.

2. Lectures upon Diseases of the Rectum, delivered at the Bellevue Hospital; Session 1869-70. By W. H. VAN BUREN, A.M., M.D. New York, 1870.

3. Prolapsus Fistula in Ano, and other Diseases of the Rectum: their pathology and treatment. By T. J. ASHTON. Third Edition. London, 1870.

4. The Surgery of the Rectum, being the Lettsomian Lectures on Surgery delivered before the Medical Society of London. By H. SMITH. Third Edition. London, 1871.

5. Fistula, Hæmorrhoids, Painful Ulcer, Stricture, Prolapsus and other Diseases of the Rectum. By WILLIAM ALLINGHAM. London, 1871.

At what point the

its pathology and to its special surgery. pathology of the intestinal canal passes from the province of the physician to that of the surgeon is a question very difficult to logically answer; if it can be answered. Professor Quain nearly twenty years since by his exposition of the anatomy of the terminal portion of that canal laid the foundation of a scientific treatment of its diseases. Mr. Quain said (p. 32, 'Diseases of the Rectum,' 2nd edition):

"The rectum is largely supplied with blood. The vessels as they are seen on its outer side are large, and they send branches at intervals through the muscular coat, which ramify between it and the mucous membrane. Independently of their position as regards the coats of the bowel, the arrangement is not the same throughout the rectum. Over the greater part the arteries and veins, taking both systems of vessels as following the same course, penetrate the muscular coat at short intervals, and transverse directions, and form a network by their communications with subdivisions of other similar vessels. Towards the lower end of the bowel, for the length of about five inches, the arrangement is very different; here the vessels have considerable length, and their direction is longitudinal; penetrating at different heights, they are directed in parallel lines towards the end of the gut. In their progress downwards they communicate with one another at intervals, and they are still more freely connected near the orifice of the bowel. In this place the arteries all join by transverse branches of good size. The veins form loops, and inosculate with equal freedom."

Now in respect of the most common of all the diseases of the rectum, the anatomy of the vessels is the most important element in the problem. In the treatment of hæmorrhoids it is the system of the vertical parallel arteries of Quain that constitutes the danger, and its management the means of success. Hæmorrhoids, nothing more nor less than hypertrophied, and often inflamed portions of the mucous membrane of the lowest part of the rectum, are fed by these vertical parallel arteries; no wonder, then, that simple clipping off of the protuberances thus formed with the subsequent retraction of the stumps within the sphincter, should have been followed by fatal hæmorrhage. Mr. Quain quotes from Sir Astley Cooper a warning example (p. 47, op. cit.):

"Sir A. Cooper says, respecting one of the cases (a nobleman æt. 74), 'As I was anxious about this patient, I did not immediately quit the room after the operation, but stood chatting with him for a short time, when he said, 'I believe you must quit the room, for I must have a motion.' I went out of the room, and upon returning shortly after, I found him trying to get into bed; and upon looking in the vessel, I perceived a considerable quantity of blood in it. In a few minutes after he said he must have another motion, got out of bed, and

again discharged a considerable quantity of blood. This he did four dif ferent times; one of the hæmorrhoidal arteries in the centre of one of the piles which had been removed was divided; and as I was determined he should not die of hæmorrhage, I said I must secure the vessel which bled, and with a speculum ani I opened the rectum sufficiently to see the blood-vessel, took it up with a tenaculum, and put a ligature around it.' The patient, however, became gradually worse, and died in four days."-Lectures,' &c., 12mo, 3rd Edit., p.422.

While we had Mr. Quain's description of the vascular system of the rectum fresh in our mind it happened that we had the opportunity of examining in the dissecting room the vessels of the rectum in a case of aggravated internal hæmorrhoids; we compared the sizes of the arteries of the rectum with the sizes of different arteries in other subjects; the comparison showed that the size of the superior hæmorrhoidal artery of the subject under dissection equalled that of the brachial of a neighbouring female subject. Where then is the ground for surprise at the persistence or the profuseness of bleeding from the rectum in long standing disease? The superior hæmorrhoidal is the direct feeder of the vertical arteries, and is in quite as close relation to the vertical arteries as the brachial is to the palmar arches; and the trouble a wound of one of the palmar arches often entails is too well known.

But the hæmorrhoidal veins present certain peculiar features; Mr. Curling thus describes them in his work on Diseases of the Rectum,' p. 28:

"The hæmorrhoidal veins distributed in the submucous tissue at the lower part of the rectum communicate in loops, and form a plexus which surrounds the bowel just within the internal sphincter. The veins are best seen when somewhat congested, their deep purple hue being very apparent through the thin mucous membrane with which they are in close contact. The plexus is then seen to be about three quarters of an inch in length, and composed of veins of various sizes, arranged the most part lengthwise and in clusters, being especially collected in the longitudinal folds of the rectum. The plexus does not extend lower than the external sphincter, but branches from it, passing between the fibres of the internal sphincter, descend along the outer edge of the former muscle, close to the integument surrounding the anus.''

Plate IV of Mr. Quain's illustrations affords a view of these veins, and of their relation to the sphincter, while Plate II gives the terminal disposition of the arterioles in their relations with the veins.

The sphincter ani also plays a prominent role in many forms of rectal disease, thus in internal hæmorrhoids, the thickened and sensitive mucous membrane extruded during the act of defæcation is straightway strangulated by the spasmodic

5

contraction of this circular or almost circular muscle. The nerve supply of the sphincter is by no means to be ignored, for in operations for the cure of hæmorrhoids, the claims of the hæmorrhoidal nerve to consideration cannot be overlooked. There is the nervous sympathy of the perineal surface to be consulted as well as the nervous endowment of the actual muscle itself.

Although Mr. Allingham's hospital statistics apparently show fistula to be the most common disease of the rectum, there can be little doubt that some form of hæmorrhoids is really far more frequent; there are, we suspect, scores of persons who suffer, and suffer severely, from hæmorrhoids, and allow their troubles to drag on, for one that may not think it worth the while to apply for medical relief for a fistula. We will accordingly examine our different authors on the treatment of hæmorrhoids. In the treatment of hæmorrhoids we have to deal, firstly, with the thickened and inflamed portion of the mucous membrane of the rectum and with the enclosed venous plexus; secondly, with the large arterial supply from Quain's parallel arteries from above; thirdly, with the muco-cutaneous membrane of the anus liberally endowed by branches of the pudic nerve, continuous below with the skin of the perinæum. What line of action can be clearer; we must remove the excrescence, prevent hæmorrhage, and obviate nervous irritation and preventible pain; and avoid risk of phlebitis and of pyæmia.

Dr. van Buren says (p. 35, et seq.):

"The means which have been employed to destroy the tumours are various; I have tried them all except excision, and can confidently recommend to you strangulation by the ligature as the safest, surest, and most manageable procedure.

"The use of the knife or scissors was fully demonstrated by Dupuytren's experience to be dangerous; he lost several cases from hæmorrhage, which comes on insidiously after the operation-the blood not escaping externally, but accumulating gradually in the cavity of the bowel. The actual cautery is a repulsive procedure, and not easily applicable under all circumstances. Galvano-cautery promises well, when proper apparatus is at hand. Of the potential caustics, nitric acid acts too slowly; and the others, in addition to this objection, are unmanageable. Chassaignac's écraseur, and its modifications, in which iron or copper-wire is substituted for the chain, require more time in their application, and bleeding does sometimes follow their use in this operation. The various clamps recommended by the instrument makers are, to say the least of them, unnecessary; and injection of the tumours with solution of persulphate of iron is painful and ineflicient. On the other hand, a stout ligature of silk, or gut, or hempen thread, is always to be readily obtained; its application requires no great amount of anatomical or surgical skill; and the result you will find certain and satisfactory-if you follow the rules I am about to give you.

"The patient being in good condition for operation, with bowels acting regularly and well, let him delay his daily stool until your visit, and present himself to you immediately afterward, with his piles thoroughly protruded; let him stand, bending forward over a bed or chair, with the parts exposed to a good light. Having provided yourself with a tenaculum, a double hook-such as is found in every operating-case, forceps, scissors, and several stout needles. armed with long double ligatures, seize the largest of the tumours with your hook-which you transfer to an assistant, telling him to draw gently upon it; then pass a curved needle pretty deeply through the base of the tumour, draw it through to the middle of the double ligature, cut the needle free, and proceed to tie one of the ligatures as deeply as possible, at either side of the base of the tumour, drawing your first knot tightly, so as to strangulate the included tissues thoroughly. Repeat this procedure upon each of the remaining tumours-there are rarely more than three or four at the most, sometimes only one or two-cut off your ligatures short, and then carefully replace the strangulated tumours within the cavity of the bowel. This is the outline of the operation; now for the details. If your patient cannot get his bowels to act at the time of your visit, or if the tumours do not come down satisfactorily, let him have an emena of tepid water, and try again. If they tend to retract during the operation, let him sit over warm water and strain; and it is well to have a curved spatula, or Sims's speculum at hand; also, to transfix and thus secure all the tumours you propose to ligate, before you begin to tie. Introduce your curved needle from without inward, protecting the gut from its point by your finger; strive to get well up into the bowel, and, if possible, avoid including any of the delicate semi-mucous integument of the anus in your ligatures, as this increases greatly the pain of the operation at the moment, and afterwards. If you are successful in this, the pain of the operation is really trifling. If you cannot succeed to your satisfaction, it is better to divide the integument on the anal side of the tumours' base by the knife or scissors, and, in tying, lodge your ligature in the groove thus made. This is a practical point of importance, for the delicate semi-mucous membrane of that portion of the rectum habitually grasped by the sphincter is far more sensitive to violence than the gut within; and, when included in a ligature, it is painfully pinched by the irritated muscle, becomes oedematous and rolls ont at the anus, giving the patient the unpleasant idea that his piles have come down again. Moreover, like one of the varieties of external hæmorrhoid, this sort of swelling is very slow to disappear, and then leaves behind it a tab of loose skin.

"In the majority of cases requiring this operation your patient will claim the benefit of anesthesia, or, if of the other sex, it will become you to recommend it, so as to spare her modesty, as well as to prevent possible pain. Here, not having the voluntary assistance of the patient in forcing down the hæmorrhoids and presenting them for operation, you will be obliged to vary your mode of procedure very materially, or you will operate at a disadvantage.