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 othert imes affected with diarrhoea. Has consulted several medical men, but never pursued any plan of treatment suggested. He 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 begin

ning 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 eighth 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. The 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.

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 completly recovered.

Fissure and hemorrhoids 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 hemorrhoids 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 fissure touched with nitrate of silver: the operation was performed while she was under the influence of chloroform. After the third day the fissure was dressed with the following: spermaceti ointment one ounce, acetate of lead six grains, extract of belladonna a drachm; the bowels were kept easy by taking a teaspoonful of the following electuary every night :

R Confectionis Sennæ, Potassæ Bitartratis, Extracti Taraxaci, ana partes equales. M.

When the spasmodic action of the sphincter had subsided the ointment was discontinued, and four ounces of water, containing eight grains of sulphate of zinc and a drachm of tincture of lavender, were injected into the bowel night and morning. She recovered in less than a month, and all symptoms of stricture of the rectum entirely disappeared.

Fissure on the posterior part of the rectum, and external pile.

Mrs. H, æt. twenty-nine, married, a patient at the Blenheim Dispensary, in the autumn of 1851, suffering from ulceration of the lips, fissures of the tongue, and general ailment: in the early part of February, 1852, she was prematurely confined of a dead child. On the 2d of March, she again placed herself under my care, complaining of smarting of the anus on defecation, followed by extreme aching, which continued for one or two hours. Examination revealed an external pile, the sphincter was strongly contracted, and within the margin of the anus, at the posterior

part, a fissure existed. The pile was excised, and an ointment containing opium directed to be applied to the fissure; a laxative confection was also prescribed. The confection not acting on the bowels sufficiently, she took, on alternate nights for a few times, five grains of blue pill and one drop of croton oil, which unloaded the bowels thoroughly. She then resumed the electuary, and injected into the bowel twice daily six ounces of infusion of linseed. Before the end of the month she had quite recovered.

Fissure leading to the formation of an ulcer; sympathetic affection of the urinary organs.

In 1851, I was consulted by Mr., æt. forty-five. He had suffered, for about eight weeks previously, severe pain at the anus, extending up the sacrum to the loins, each time his bowels were moved: it first commenced after a very costive motion. He was much troubled by a frequent desire to micturate; and had noticed his linen slightly stained with blood and matter. Leading a sedentary life, and being of costive habit, he had for several years taken large quantities of Morrison's pills.

On examination, finding the sphincter ani strongly contracted, and taking into consideration the other symptoms, I suspected the existence of an ulcer, the result of fissure. An attempt to introduce the speculum inducing intolerable pain, chloroform was administered, and the instrument then used: an ulcer was exposed on the left side, of oval form, and nearly an inch in its vertical diameter; the edges were sharp and indurated, and the surface an ash color. Mercury with chalk and Dover's powder were prescribed to be taken at bed-time, and a teaspoonful of confection of senna and sulphur in the morning, to be followed by an emollient enema. He was directed to observe the recumbent position. From the appearance of the ulcer I deemed incision necessary, but it was objected to, and a wish expressed that other means should first be tried: nitrate of silver was applied on three separate occasions, and other applications were had recourse to during a period of six weeks, but without advantage. I then insisted on the necessity of the operation, to which the patient gave his consent. Having administered chloroform, I introduced into the rec

tum the forefinger of the right hand, and passed upon it a probepointed straight bistoury, and made an incision through the ulcer, dividing the mucous membrane, submucous cellular tissue, and possibly a few muscular fibres. From the time of the operation the ulcer rapidly improved, and in less than three weeks he was restored to health and comfort.

Fissure degenerating into an ulcer; sympathetic affection of the urinary organs; incision.

Mr. S, æt. thirty-nine, a gentleman residing in the country, had suffered for some time pain in the rectum, and frequent desire to micturate. His usual medical attendant, considering the symptoms depended on irritation of the urinary organs, prescribed appropriate medicines to allay that condition, and catheters were also introduced into the urethra, but without benefit. On his arrival in town he applied to me. In stating his case he complained of great pain at the anus during the act of defecation, increasing to intense agony, and continuing for about two hours afterwards. The bowels were constipated, and from the pain he suffered he put off the calls of nature as much as possible: his bladder was very irritable, having frequent desire to pass his urine. By digital examination of the bowel, an ulcer, with indurated edges, was felt on the left side. Having ordered means by which the bowels were fully relieved, the following day I incised the ulcer, by transfixing its base with a small curved knife, and cutting into the open side of a speculum previously passed into the bowel. The ulcer presented a foul, indolent surface, with defined raised margin. The after treatment was the same as has been advised, and a rapid recovery ensued.