duced and tied, the latter afterwards. The former may be allowed to separate of themselves into the rectum; the latter may be easily removed on the fourth, fifth, or sixth day, according to the degree of adhesion, or otherwise. Thirdly, keeping the bowels undisturbed for five, six, or eight days after the operation. This may be accomplished by previous purging, by subsequent spare diet, and if fæces still accumulate, by breaking the accumulation down and washing it out, through an elastic catheter introduced through the sphincter.

One source of failure against which the surgeon cannot entirely guard is the supervention of inflammation. But some security on this score may be obtained by delaying the operation till the patient's health is in the best order, either through diet and medicine, or temporary change of air, and the like. Likewise by noting the present influence of the weather as it is observable in the wards of hospitals; for it is certain there are some seasons in which the state of the atmosphere strongly disposes to erysipelas. These times are commonly the setting-in of damp weather. It is desirable, for the same purpose, that the patient should not reside at the time in the middle of a large town, but live in purer air in the suburb.

These precautions are less essential in other operations in which the result is not commonly influenced to a serious extent by the supervention of

slight inflammation, which here is fatal to success. Nevertheless, there is still a hope; the operation which has failed once through these causes may be successful when repeated.

Laceration of all the coats of the intestine above the sphincter has sometimes been produced by the passage of hardened fæces. Dr. Langmore told me an instance (the patient afterwards was under our care for cancer of the breast,) in which such a communication had been so produced. A lady, aged 40, naturally of a constipated habit, and at the time being on a journey, on striving to relieve the bowels, which had not acted for many hours, felt something give way, and the following morning some fæces passed per raginam. On examination, a transverse rent was found within the sphincter, sufficiently large to admit the end of the finger. The only treatment adopted in this case consisted in frequently cleansing the part by injections of warm water, and regulating the state of the bowels by proper medicines. In five weeks, the fæces had ceased to pass through the communication, which had closed permanently.

When such an aperture appears losing its disposition to contract, its closure may be promoted by occasionally touching the edge with nitrate of silver. If these means fail, the suture may be resorted to, the precautions already explained being observed.

The most severe case of this kind of laceration which I have witnessed occurred in an elderly lady, who had been seriously injured some weeks before by the pipe of a syringe improperly used. The rectum had been torn about two inches from the orifice, and had partly sloughed into the vagina ; at the same time, there was a large foul cavity higher up between the uterus and the intestine, from which a discharge of matter, and blood, and the contents of the bowel, flowed per vaginam. This lady's health appeared to be giving way under the spread of this foul and confined abscess, for the relief of which it was necessary to divide the sphincter, and to lay the lower part of the bowel open into the vagina. She then recovered her health; but the communication remains, which will admit, however, of being closed by the suture.

SECTION X.-ABSCESS AND FISTULA.

ABSCESSES frequently form in the neighbourhood of the rectum. Some may be considered as accidental, and are out of the scope of my present remarks. These are, first, abscesses from foreign bodies, as a fish-bone, an apple-core, or the like, being impacted in the gut immediately above the sphincter. When the presence of such a substance has been ascertained by examination, it has of course to be extracted; when its removal either

is followed by the immediate healing of the abscess, or the latter takes one of the characters presently to be described. A second form of accidental abscess at this part is, suppuration taking place in piles; this occurrence has been already noticed as a favourable event. A third kind is the descent and pointing of psoas abscess by the side of the anus; this case, which it would be out of place to consider here, requires to be treated on those common principles which regulate surgical practice in all cases of chronic scrofulous abscess.

Independently of these accidental cases, however, there is a strong disposition to form abscess about the anus, attributable to the local causes already explained; namely, the dependent situation of the part, and the pressure of the column of venous blood, to which may be added the want of support to the vessels of the part resulting from the laxness of the surrounding tissue. Or, as it is certain that many abscesses are often critical; that a feverish condition of the habit, or a gross and overloaded state of the body, or an impoverished state of the blood, will rather lead to the formation of matter in one part or other; so the circumstances above pointed out render the rectum particularly liable to be their seat.

Abscesses about the rectum are of two sorts; one of which may be termed diffused; the other circumscribed. The former, deep-seated at their

commencement, gradually work their way downward, and end in completely isolating the rectum behind and laterally, which lies in a great bag of matter. The latter are small gatherings in a mass of hardened tissue, from the size of a pea to that of a chestnut, on one or other aspect of the bowel, and close to the anus. The former are often attended with great constitutional disturbance, which disappears as soon as they are opened; the latter unattended by serious symptoms at their origin, end by giving rise to a very troublesome local disease, which will be presently considered.

The formation of deep-seated abscess upon the intestine is usually preceded by shivering and fever, furred tongue, pain in the back and head, sometimes delirium. It often happens that there is very trifling uneasiness about the rectum, the only local symptom being irritation of the bladder; the real nature of the disease is thus liable to escape observation for several days, till being suspected, it is at length ascertained by examining the perinæum and rectum.

Part of the treatment of this complaint proceeds on common principles; rest in the recumbent posture, abstinence, and saline aperients, with leeches locally applied, will mitigate all the symptoms. But that from which the greatest relief is to be obtained is the early opening of the abscess, into which a lancet should be introduced as soon as the