rough at one point, it had produced considerable soreness in the part of the canal against which it had pressed. The absence of the ordinary sphinctermuscle had been of no inconvenience. The difficulty he had experienced had been in expelling, not in retaining the contents of the intestine. Even if he took aperient medicine, this difficulty was experienced; which, however, was obviated by the use of injections of warm water.

III. The third head under the subject of imperfections is the wrong termination of the rectum in other parts, or of other parts in the rectum.

The latter case is essentially irremediable; the former is not necessarily more than a complicated case of deficiency of the rectum. Suppose, for instance, the intestine to want an inch in length, and to open into the vagina or the bladder at the same part ;—there is here the deficiency explained, with its appropriate remedy, under the last head, and in addition, an opening into another cavity. There are then two malformations instead of one. But the additional one renders the first more tractable. If, for instance, the intestine open into the vagina, it is much more easy to make an artificial canal to the extremity of the intestine than without this means of directing the incision. The first step to be taken is to cut such a new canal, and to gain for it proper dimensions and permanency by metal cylinders kept constantly in it. When this

has been accomplished, it remains to close the original false aperture by sutures.

SECTION IX.-OF LACERATION OF THE INTESTINE. MECHANICAL laceration, or tearing of the bowel, may involve either its inner lining only, or its entire structure. The mucous membrane alone may be lacerated, or the bowel may be torn through.

The first case may arise from hard fæcal matter passing, or from the forcible introduction of a foreign body. If the patient is kept at rest a few days, and upon a restricted diet, and the bowel washed out by emollient clysters, the lesion is quickly repaired, and the part heals. If neglected, such a lesion becomes the troublesome complaint which has been already described as a fissure or superficial ulcer of the rectum.

Laceration of the entire structure of the intestine may take place either at the orifice, not involving a complete division of the sphincter, or it may include the whole breadth of the sphincter, or, leaving this muscle untouched, it may perforate the intestine above. These injuries are of more frequent occurrence in women than in men, and are in the former of much more consequence. In the latter, they are simple wounds, which heal more or less readily, being attended in different cases with more or less local inflammation, and the like. In

women, these injuries acquire their serious character from threatening to establish permanent communication between the intestine and the vagina.

The two first lesions are liable to take place in labour, when the descent of the child is more rapid than the dilatation of the external parts.

If the laceration, though complete, is superficial only, and does not include all the fibres of the sphincter, the lesion is of little consequence; the state of the patient ensures the observance of all the conditions necessary for its reparation. These are rest in the recumbent posture, and frequent ablution with warm water. The superficial rent quickly re-unites by granulation.

When the laceration extends through the sphincter-muscle, so as entirely to divide it, a serious evil naturally follows. The tone of the muscle draws asunder the edges of the rent, which thus are prevented re-uniting: in this state they cicatrize separately, leaving a communication of an inch to an inch and a half in depth; and the power of retaining the contents of the bowel is lost. Fortunately there are modes both of preventing this ill consequence of the accident, and of repairing it when established.

When the laceration is quite recent, that is to say, when two or three days only have elapsed from the confinement of the patient, the following

practice is to be adopted. The sphincter-muscle is to be divided in one or two places, that is to say, on one or both sides of the anus. By this means, the lateral strain or traction upon the rent of communication between the intestine and vagina is done away with, and there is no impediment to its re-union by granulation. But it is necessary to keep the edges of the rent in a wholesome state by frequent bathing with tepid water, to prevent their cicatrizing separately by daily touching the edges with lunar caustic, and to prevent the lateral sections of the sphincter from closing too soon by means of pledgets of lint introduced into, and retained in them constantly. A patient on whom I performed this operation eight days after laceration of the sphincter in labour, had entirely recovered in five weeks; the original rent first healing, and then the artificial divisions being allowed to close. By the same time the retaining power of the sphincter was perfect. This patient has subsequently borne two children, without again suffering rupture of the sphincter. This practice was originally used by Mr. Copeland in cases of recent laceration of the sphincter. It had previously been used by Dieffenbach as a part of the more elaborate operation requisite when the communication is of long standing. In recent cases, however, Dieffenbach himself does not employ it, but contents himself with sutures alone, which, in the relaxed state

of the parts following labour, are generally successful.

When the edges of a laceration through the sphincter have cicatrized without uniting, the means of remedying the defect consist in paring off the edges, and keeping the new surfaces in apposition by means of sutures. It is to

render their adhesion surer that Dieffenbach introduced the lateral section of the sphincter into the present operation. The necessity of using it here is, however, very doubtful, and many cases have done well in which it has not been employed. The secret of the success of the operation is the management of the patient before and after it. For several days consecutively aperient medicine should have been given, so as to leave an artificial costiveness for the period necessary for the adhesion to be completed. Or without this condition is rigorously maintained, the operation, however skilfully performed, will probably fail, the part being forced open when fæces pass.

The mechanical elements of the operation are, first, providing as large an extent of surface of adhesion as possible by making the sections oblique, and extending them through part of the skin immediately adjacent; secondly, the use of two sets of sutures, one for the mucous membrane of the rectum, the other for the mucous membrane of the vagina: : the former are of course to be first intro