posterior portions of the rectum, no incision should be extended beyond the mucous membrane in either direction, for the reason that wounds towards the coccyx split and separate the fibres of the external sphincter only, and are difficult to heal, while anatomical considerations will deter us from using the knife anteriorly; in the male, from the bulb of the urethra being in close proximity, and in the female the shortness of the perineum, and the knowledge that division of the anterior fibres of the sphincter in them is so frequently followed by incontinence of fæces.

The following cases illustrate the several phases of this affection:

Fissure of the anus from constipation.

G. C., æt. thirty-one, a saddler, became an out-patient under my care at University College Hospital, 1845. From the nature of his business he sat the whole day, and felt too tired on leaving work to take any exercise; he suffered from dyspepsia and constipation, the bowels not acting oftener than every second or third day; he was frequently attacked with giddiness and singing in the head; his tongue was coated and large; defecation was always attended with violent straining. Eight days previously to his applying at the hospital, while at stool, and making violent expulsive efforts, he felt something give way, and a smarting as the fæces passed; he also observed some blood; afterwards, each time the bowels were

moved, he experienced pain and aching, the latter being very severe. On examination of the anus a slight fissure was observed, florid, and very painful when touched. Ordered to apply a poultice at bed-time, and to take an ounce and a half of castor oil in the morning.

The next day the bowels were freely moved, attended with pain; the fissure was less inflamed; he was ordered to repeat the oil, in less quantity every morning, and to keep a small piece of lint, smeared with the following ointment, closely applied within the margin of the anus :—

R Unguenti Zinci, 3j; Extracti Belladonnæ, 3j. Ft. unguentum.

By continuing this plan, and using ablutions night and morning, in ten days he was quite well.

Fissure: intense suffering for four months cured by
incision.

Mrs. K, delicate, the mother of several children, had suffered from external hæmorrhoids during her pregnancies, and had always had great difficulty in keeping the bowels open. Soon after her last confinement she experienced smarting at the anus when at the closet, followed in a short time by intense agony various purgative medicines had been prescribed, but without affording the slightest relief. Occasionally her linen would be slightly stained with blood and pus, particularly after passing a hard stool. When I saw her -Nov. 1845-she had for some weeks been unable to leave the sofa, as the pain came on if she walked about, or even stood for a short time; sneezing, or any slight exertion also

produced it; her health was very much impaired and she was in a state of great nervousness and despondency. Making an examination, a small oval ulcer was perceived, extending half an inch upwards from the anal margin rather posteriorly on the left side: the sphincter was thrown into violent contraction by the examination: the colon could be felt through the abdominal parietes distended with fæces. To free the bowels of their accumulated contents, enemata were injected by O'Beirne's tube, and moderate doses of castor oil were prescribed.

My friend, Mr. Morton, saw this patient with me, and we agreed that an incision should be made through the ulcer, which I performed by passing a probe-pointed knife on the forefinger introduced into the bowel; a few meshes of lint spread with the following ointment were inserted into the wound:

R Unguenti Cetacei, 3vij; Extracti Belladonnæ, 3j. M. ft. unguentum.

The dressings were continued, the bowels kept easy, and the local affection was speedily cured. She afterwards took a combination of tonics and aperients, by which a regular state of the bowels was induced, and her health became perfectly restored.

Fissure of the anus cured by local applications.

Mr. æt. thirty-four, of nervous temperament, has suffered for some years from indigestion and irregularity of the bowels, being sometimes costive and at other times affected with, diarrhoea. Has consulted several medical men,

He

but never pursued any plan of treatment suggested. applied to me early in 1851, suffering from indigestion attended with pain at the epigastrium, flatulence, excessive nervousness, and inability to rest at night. On microscopic examination of the urine it was found to contain numerous crystals of oxalate of lime; he took mild aperients and bitter infusions with nitric and nitro-hydrochloric acids. He persevered in the remedies, and his health greatly improved. In the beginning of June in the same year he was slightly troubled with an external pile under ordinary treatment all inconvenience subsided in a few days, a small pendulous flap of skin on the anterior margin of the anus remaining. On the 24th of the same month I was sent for in great haste, and found him suffering intense pain at the anus, extending up the hollow of the sacrum; pulse quick and irritable, tongue slightly furred, skin somewhat hotter and drier than natural, countenance anxious: he had experienced slight pain for two or three days, and was in a state of great alarm about himself, imagining he had cancer of the rectum commencing, having a short time previously lost a sister by that disease. Examination revealed a fissure of the posterior part of the anus, about an eight of an inch broad, and half an inch in length. An enema of four ounces of decoction of barley and sixty minims of laudanum was administered at once, with the effect of relieving the pain: three grains of gray powder, and five grains of Dover's powder, were taken at bed-time, and an aperient draught in the morning. following day the bowels acted several times, the smarting and aching were less; the latter was relieved by an enema containing thirty minims of the tincture of opium.

The

A small strip of lint, impregnated with the following lotion, was applied within the margin of the anus, and renewed three times a day :

R Zinci Sulphatis, gr. vj; Tincturæ Opii, 3ss; Aquæ Sambuci, 3iij. M. ft. lotio.

The bowels were kept open by laxatives, and he took a mild tonic with alkalies. In nine days he had completely recovered.

Fissure and haemorrhoids inducing the idea of the existence

of stricture of the rectum.

Mrs. M—, æt. thirty-seven, married, the mother of four children, has suffered from hæmorrhoids for some years, particularly during pregnancy; she consulted me in consequence of fearing she had stricture of the rectum. She had for some time previously experienced considerable pain at the time of defecation, which she described as of a cutting character, resolving itself into severe aching, frequently so agonizing as to compel her to go to bed. She tried the local application of cold and hot water, experiencing slight relief from the latter. The symptoms which added greatly to her alarm, and which she had been told indicated stricture of the rectum, was a reduction in size, and contortion of the evacuations when they were at all solid. On making an examination, I found two external piles, and the buttocks being divaricated, a fissure was also perceived passing upwards between the piles; the sphincter ani was strongly contracted. The bowels having been freely acted on by castor oil and an enema, the piles were removed, and the