In either mode the patient must rest on his side, with his knees drawn up, and the buttocks projecting over the edge of a sofa or bed, or he may lean over a table or back of a chair. For the purpose of cutting from within outwards-the plan hitherto generally adopted—a straight probe-pointed knife, of the shape and size of the figure here given, will be most useful; it is made thicker at the back than an ordinary bistoury, by which a ridge or button on the end is rendered unnecessary. The forefinger, previously oiled, being introduced into the rectum, the knife must be pressed flat upon it till the point reaches the upper margin of the fissure or ulcer, when its edge must be turned, and an incision made through the mucous membrane, without extending it through the other structures. The other mode of making the incision is that advocated by Mr. Syme, and is performed by transfixing the ulcer beneath its base with a small, sharp-pointed curved bistoury, and cutting inwards through its centre; the opposite side of the bowel must be protected by the introduction of the finger, as previously directed. Having on several occasions wounded myself, I find that in dividing the ulcer inwards from without, the better plan is to introduce the speculum, and to cut into the open side. In operating in this affection, as well as in many others, the surgeon will experience great advantage if he is able to use the knife with either hand.

When the disease is situated in the anterior or 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 hemorrhoids 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

tissue, or even to the muscular fibres of the sphincter: the inferior extremity of the fissure is usually immediately within the margin of the external sphincter, or implicates the skin at the margin to a slight extent, but is not unfrequently situated higher up. A fissure may exist on either side, or perhaps on both sides of the bowel: it most frequently occurs posteriorly, and more rarely anteriorly. If an examination is made early in the disease, the fissure has the same appearance as the crack that occurs in the lip during the decline of catarrh; but it soon degenerates into an ulcer, in the same manner as wounds of other parts that do not heal readily, and will be most commonly observed to be about an eighth of an inch in width, and from a quarter to an inch in length. At first the edges are sharp, and the surface florid, but after the disease has existed for some time, the former become indurated and raised, and the surface pulpy and ash colored; the surrounding membrane may be inflamed, and its surface rendered friable, or the ulcerative process may extend, and an ulcer be formed, varying in size from a fourpenny piece to that of a shilling. The symptoms in the early stage of this disease are not generally severe, and are only experienced while at stool, when at some point or other, there will be smarting of greater or less severity, or perhaps only a slight stinging or pricking sensation may be felt; if the disease is allowed to progress, the smarting during the act of defecation will be greatly increased, or the pain may be burning or lancinating, followed by excruciating aching and throbbing, with violent spasmodic contraction of the sphincter muscle, continuing from half an hour to several hours.

The stools, when solid, will be streaked with purulent discharge, and slightly with blood, and when more soft will be figured and of small size, leading the inexperienced to imagine stricture of the rectum to be the cause of the sufferings endured; charlatans also have availed themselves of the latter symptoms to delude their victims into the belief of the existence of a more serious malady. The disease being fully established, the pain will be induced by sneezing, coughing, forced respiration, and by micturition; and so violent does the agony become, that individuals thus afflicted even avoid taking sufficiency of nourishment, in order to lessen the quantity of fæces: they also in their dread postpone the calls of nature, but only with the effect of aggravating their torments.

Sitting is painful, and in order to protect the anus from pressure, the patient rests on one hip or on a corner of a chair, or he may be compelled to remain recumbent. Partaking of highly-seasoned dishes and fermented liquors, will always involve the penalty of increase of pain: in females, the pain will also be increased during the menstrual period. From nervous irritation, pains are often felt in other parts, simulating sciatica, or rheumatism; the urinary organs are also liable to be sympathetically deranged, and thus the attention may be diverted from the real seat of disease.

It is stated women are more subject to this affection than men. I have observed it frequently in both sexes; and am unable to say that the one is more obnoxious to it than the other: want of proper exercise certainly predisposes to it. Women are sedentary, both from habit and the usages of society; in them, also, constipation, one of the exciting causes, is frequent, partly arising from their habitually neglecting to obey the calls of nature, which for a time they do with less inconvenience, in consequence of the greater capacity of the pelvic cavity than in the male, but thereby laying the foundation of protracted or permanent ailment: men are sedentary from the various occupations in the affairs of life; and among the working classes, many are compelled by the nature of their business to maintain the sitting posture for a number of hours consecutively, and in these all diseases of the rectum and anus are extremely prevalent.

The predisposing causes are constriction of the anal orifice, either from spasmodic action of the sphincter, occurring from intestinal irritation produced by the ingesta, or a vitiated and acrid condition of the secretions, or from the cicatrization of wounds after surgical operations, accidental or specific ulcers, or injuries to the part. Hemorrhoids are frequently the predisposing cause, and a complication of this affection: they narrow the outlet, and by the repeated attacks of inflammation to which they are subject, the surrounding tissue loses its elasticity, and is rendered friable and easily torn or broken. The exciting causes are constipation, induration of the fecal matter, and the violent action of the expulsive muscles requisite for its evacuation.

The examination necessary for ascertaining the nature and extent of the disease is almost always attended with much pain, and for this reason it will be often advisable to administer chloro

form previously: as before stated, the fibres of the superficial sphincter are strongly and spasmodically contracted, and the fundament, instead of presenting a hollow cone, has rather the appearance of a flat surface with a minute perforation in the centre, marking the anal orifice. If by the forcible separation of the buttocks, the fissure cannot be brought into view, the speculum ani must be used; or by the careful introduction of the finger, it may be detected as an elevated ridge, palpable to the touch, in proportion to the existing induration. If the fissure be situated deeply in the columnar folds of the bowel, and the examination be made at an early period of the disease, the surgeon may not be able readily to detect it by his finger, but he will become acquainted with its locality by the patient complaining of pain at some one particular point. Should the fissure have taken on the ulcerative process, the limit to which it has extended may also be detected by the finger; but it will be necessary to make an examination with the speculum ani, that the exact condition, as well as the dimensions, may be ascertained previously to determining the plan of treatment.

My experience fully justifies me in stating that in the majority of recent cases it is not necessary to have recourse to an operation, although some of high authority in the profession assert that incision is the only effectual remedy, and that all sorts of applications, soothing and irritating, are unavailing.

If the fissure exists at the verge of the anus, and is of recent origin, the patient must be directed to have recourse to ablution with soap and water, night and morning: after evacuating the contents of the bowels, half a pint of cold or tepid water should be thrown up; and when this has been ejected, a small piece of lint, saturated with the following lotion, or one of similar properties, must be kept applied to the part.

R Plumbi Acetatis, gr. x ; Liquoris Opii Sedativi, mxx ; Aquæ Sambuci, 3iv. Misce.

When there is much spasm of the sphincter, the extract of bel ladonna, in the proportion of a drachm of the extract to an ounce of spermaceti ointment, or ointment of acetate of lead, is commonly successful in relieving this distressing symptom. Belladonna has been employed in combating pain and spasm in diseases

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