touch detects any evidence that suppuration is commencing, or a tolerable presumption can be arrived at that the inflammation is pointing. There is another rule respecting such abscesses; when they have matured, and, as then commonly happens, enclose and isolate the rectum in a bag of matter, it is necessary of course to give the freest escape to the matter; but this is to be obtained not by a large incision, but by two or three punctures of the breadth of a lancet-blade on different sides of the anus. So treated, they speedily contract and heal. Smaller circumscribed abscesses perpetually form in the neighbourhood of the anus. These are sometimes not felt, and their bursting externally, or inwards, makes them first known. Commonly, however, they are attended with local heat, pain, swelling, redness. Cooling medicine, moderation in diet, leeches, and cold applications, occasionally disperse such gatherings, but in most instances they suppurate; and it is important to open them, and that freely, as soon as fluid can be detected in them. By this means a very troublesome complaint may be avoided.

If these abscesses are not opened early, when opened, they do not heal, but contract to a certain extent only, leaving a tubular canal, just large enough to admit a probe, which has no disposition to close, and continues exuding purulent fluid.

Such a canal, or fistula, presents three varieties;

it may have one opening alone, and that by the side of the anus, or its one opening may be into the bowel; or it may open both externally and internally, and allow fæcal matter to escape by it.

There is one common plan of treatment, under which each of these kinds of fistula occasionally heal. That is, the use of medicine to prevent costiveness, and the application of local stimulants ;for the latter purpose, bathing with alum-water, and Ward's paste taken as already recommended.

But generally these means fail, and it becomes requisite to have recourse to a surgical operation. This is often of a very simple description.

If the fistula has two openings, a probe-pointed bistoury is passed from the outer opening into the intestine, and being there received upon the forefinger of the left hand, is drawn out, dividing the intervening thickness. The wound is made to heal by granulation from the bottom, through the introduction of a single layer of lint, replaced as often as it is necessary.

If the fistula has an external opening only, the same operation is requisite, the end of the bistoury being made to perforate the intestine opposite the end of the sinus.

If the fistula has an internal opening only (when it is often most difficult of detection, soreness only, and occasional pain and slight discharge of matter, indicating it,) a parallel, but slighter operation is to be performed, the bistoury being passed into the

sinus from within, and the lining of the bowel being thence divided to the sphincter.

Sometimes it happens that the wound thus made is slow to heal in that case stimulant applications are to be used locally, and tonic medicines, a liberal diet, and change of air, are to be resorted to, to recruit the patient's strength.

Sometimes it happens that fistulæ, which communicate at one or more points with the intestine, burrow further as blind sinuses in one or more directions. In general it is sufficient to lay these open as far as they run beneath the skin, or to their communications with the intestine. At all events, when they extend deep, this should be first tried, though it may afterwards prove requisite to lay them open to their extreme depth.

Fistula often occur in persons of undermined constitution, with disease of the lungs, or liver, and broken health. In such persons, an operation is not to be recommended; as it would only give gratuitous pain, with no reasonable chance of curing the malady.

SECTION XI.-CANCER OF THE RECTUM.

For this head, and to form the concluding section of this treatise, I have reserved the consideration of a variety of cases, which, differing among themselves in several pathological features, yet agree in their symptoms, in their fatal course, in the treatment which they require.

Anatomically, likewise, they so far agree, that they all consist in a local change of structure, in which the natural texture becomes more or less gristly, the lining membrane absorbed or ulcerated, and the passage through the intestine narrowed.

Anatomically they differ in this respect; the thickness of the coats of the intestine in one form remains

the same; the part is only a contracted gristly tube: in the other forms the diseased part displays increased growth with characters which are familiar to the scientific surgeon, under the names of carcinoma, medullary carcinoma, gelatiniform sarcoma, melanoma.

Diseases of the rectum are more frequent in women than in men,-a difference, the general causes of which are to be sought in the varying conditions of the uterus and in the shape of the female pelvis. The womb during its enlargement in pregnancy interrupts the free return of blood by the hemorrhoidal veins, and mechanically obstructs the action of the bowels. In the unimpregnated state, the periodical congestion of the same organ cannot fail of extending its influence to the vessels of the rectum. The straightness of the sacrum, again, in women, and the general expansion of the pelvic bones at the inferior outlet, deprive the lower part of the bowel of that pressure and support which appear to conduce to the healthy state of the viscera. Something, too

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is doubtless to be attributed to the less regular relief of the bowels and of the bladder, and their frequent over-distension, which result from the natural, but in this instance, prejudicial delicacy of women. But the comparative frequency of cancer of the rectum in women depends upon the cooperation of another and a more serious cause, which is the prevalence in women of the cancerous diathesis.

Of the different forms of the disease, that in which there is no thickening is again by far the most frequent kind in women. That, at least, is the result of my own experience of this complaint, which, owing to the cancer-wards established in the Middlesex Hospital, has not been inconsiderable.

The symptoms of cancer of the rectum, slow in their early progress, and hardly observed at first, are at length developed into local pain, sometimes of a dull aching character, at other times acute and lancinating, with a sense of weight and confinement in the part, numbness and uneasiness extending round the loins to the pubes, numbness in the hips and thighs. These sensations are aggravated upon walking, standing, or sitting, and are mitigated by the recumbent posture. The act of evacuating the bowels increases the pain and distress. The fæces are either liquid, or are passed in small fragments and by repeated efforts: blood, matter, mucus, are expelled with them. The patient, if a female,