and by a copious or an offensive vaginal dis- | charge, this complication appearing most frequently and remarkably in married females.

care ought to be taken in administering an enema, lest the pipe of the instrument injure the swollen, softened, and tender parts along which it is passed. In every other respect the treatment should be identical with that advised for

tion has advanced to the colon and cæcum, or has continued any time. (See art. DYSENTERY, 88, et seq.).

41. D. Inflammations and excoriations of the anus and rectum in infants and young children (§ 34) should be treated with a strict reference to this cause. The diet of the infant, and even of the nurse, should be changed or corrected; the secretions and excretions improved and promoted; and, after the warm bath, emollients, &c., the zinc ointment, or lead ointment, or cooling lotions, or other means which the peculiarities of the case require, should be applied. In most of these cases, more or less constitutional disorder is associated with disease of the alimentary canal; and this latter is seldom confined to the rectum and anus, the colon or the digestive organs generally participating more especially in the existing derangement. these circumstances, the hydrargyrum cum cretà, conjoined with ipecacuanha, with small doses of rhubarb, and with absorbent powders or other antacids, will frequently prove most beneficial; and sometimes equal parts of precipitated sulphur and carbonate of magnesia, to which powdered liquorice root and cinnamon are added, in quantity sufficient to render the whole more pleasant, may be taken in milk or in water.

In

37. iii. TREATMENT should differ most remarkably with the activity and character of the inflammatory action, and the nature of the pre-asthenic dysentery, especially if the morbid acdisposing and exciting causes.-A. In sthenic acute proctitis, local depletions, especially cupping over the sacrum, leeches to the perinæum and around the anus; cooling and demulcent aperients; the warm bath, semicupium or hip bath, followed by cooling diaphoretics, and fomentations, with an antiphlogistic regimen, are the most efficacious, and generally remove the disorder in a few days. If much pain and tenesmus continue after depletion, the compound ipecacuanha powder, or simple ipecacuanha, with henbane, extract of hop or of poppy, ought to be given in the form of pill, the ipecacuanha in as large and frequent doses as the stomach will tolerate; and, having allayed the irritability, the bowels should be evacuated by fresh castor or olive oil, or by sulphur and magnesia, aided by confection of senna, or by a glass of lemonade taken soon after the magnesia, or by a demulcent, laxative, or oleaginous enema. 38. B. The sub-acute and chronic states of the complaint generally yield to the same means as just advised, local depletions to a less amount being usually sufficient; but these should vary with the habit of body and circumstances of the patient. Ipecacuanha, cooling diaphoretics, warm baths, and emollient laxatives, with demulcent and anodyne enemata, are generally beneficial. If external irritation, heat, or excoriations are experienced at the anus, a cooling and anodyne lotion, as a solution of the diacetate of lead, with vinum opii and acetic acid, will give much relief, and may be kept applied for a considerable time by means of pledgets of lint. The secretions and alvine excretions, especially the biliary, should be promoted by means of hydrargyrum cum creta, or PLUMMER'S pill, conjoined with ipecacuanha and soap, interposing a dose of castor or olive oil, or a demulcent and oleaginous enema.

39. C. Asthenic proctitis rarely admits even of local depletions, unless in plethoric persons. As the chief danger in this form of the complaint proceeds from the rapid extension of the disease along the rectum to the colon, the principal indication is to prevent or limit the extension by such means as experience has shown to be most efficient in this mode of operation. I have found the warm bath or hip bath followed by a warm terebinthinate embrocation applied over the sacrum or the hypogastrium, and the following pills, among the most efficacious means. As soon as the more painful symptoms, especially the spasm of the sphincter ani, were relieved, or even without waiting for such relief, the subjoined draught was also administered.

42. E. The specific-gonorrheal and venercal— forms of inflammation of the anus and rectum should be treated conformably with the principles which guide the treatment of these maladies in other situations and circumstances. The local affection will, however, require much of the soothing means already advised for other inflammations of these parts; the gonorrhoal especially, local depletions, saturnine or cooling and anodyne lotions, &c.; and, internally, the balsams, especially copaiba, powdered cubebs, or a decoction of the Achillea millefolium. Clysters are of doubtful advantage in the specific states of the disease, as they may favour the extension of the specific infection from the anus to the rectum and lower parts of the colon.

43. iv. ITCHING OF THE ANUS.-A. This is generally a symptom only of diseases of the digestive canal, or of the rectum and parts in the vicinity. It is often, however, so distressing as to form the most prominent disorder, and is then a most obstinate one to remove. It is most commonly caused, at all ages, by ascarides in the rectum, by other intestinal worms, and by chronic eruptions around the anus. It sometimes follows recovery from dysentery. It frequently precedes and accompanies hæmorrhoidal affections; and it often attends and folNo. 328. R Pulv. Ipecacuanha; Quinæ Disulph. Cam-lows the cessation of the menstrual discharge. phora, aa, gr. j. Extr. Humuli, vel Extr. Gentianae, gr. iij.; Confect. Aromat., gr. ij.; Mucilag. Acacias, q. 8. m. Fiant Pilulæ, ij., quarta vel quinta quaque horà sumende. No. 329. R Olei Terebinth., Olei Ricini, ää, 39s.; Aqua Mentha Virid., 3vjss.; Tinct. Capsici. m. iij. m. Fiat

Haustus.

40. Demulcent and anodyne enemata are always beneficial if early employed, or before ulceration or sphacelation of the internal coats of the bowel has commenced; but the utmost

It is often attended by more or less of mucous discharge from the rectum, or "medorrhaa ani." Pathologically, it may be viewed as an indication of either irritation of the intestinal canal, especially of the rectum, or congestion of blood in the rectum or anus, or cutaneous eruptions near the verge of the anus. It is often produced by the accumulation of fæces in the rectum and colon; by the abuse of calomel, or of

aloes, or of other purgatives which act chiefly | single. In cachectic habits it may be very large,

on the rectum; by various exciting emmenagogues; by irritation or enlargement of the prostate gland, and by self-pollution.

44. B. The treatment should be directed to the pathological and exciting causes, and to the complications of the case. Local bleedings are sometimes required, and these are often advantageously followed by cooling lotions, as the acetate of lead, with acetic acid, and the tincture or wine of opium. The yellow wash, or weak solutions of the nitrate of silver, and the other means advised for the chronic cutaneous eruptions affecting this part, should be employed when any one of these is the cause of the itching. In the more obstinate cases, clysters containing turpentine will be found most efficacious; and lotions, or a wash, with a saturated solution of the biborate of soda, will also prove most beneficial and appropriate to all the circumstances in which the symptom appears.

and spread to a dangerous extent.

48. Small abscesses, which form in the parietes of the rectum, or superficially near the anus, are generally consequent upon inflammatory irritation in the mucous membrane or its follicles; and in the more healthy subjects, and when the treatment is judicious, they generally terminate without producing any of the consequences to which the larger purulent formations often lead. When the mucous follicles of the rectum or anus are irritated, either by the nature of the excretions which pass over them, or by medicinal excitants, or by the morbid matters existing in the blood that they are partly concerned in eliminating, the irritation may, especially when occasioned by this last cause, rapidly pass into ulceration, which, if it extend to the connecting cellular tissue, may be followed either by purulent collections or by fistula, or, more commonly, by both these in succession.

45. v. MUCOUS DISCHARGE from the rectum -Medorrhea ani, J. P. FRANK-is often caused 49. (b) Abscesses seldom form externally to by the same pathological states as produce the coats of the rectum or to the sphincter ani, itching of the anus (§ 43). A. It may proceed independently of inflammatory irritation of the also from a chronic state of inflammation of rectum or anus, or of the urinary and sexual the lower portion of the rectum, and precede, passages. A small abscess or boil may, howaccompany, or follow hæmorrhoidal attacks, the ever, appear, independently of irritation of these hæmorrhoidal flux being very frequently follow- parts, external to the sphincter, or near the anus, ed by this discharge. When caused by inflam- owing to want of cleanliness or to some other matory irritation or congestion, it may prove a cause, and may, if opened early, and otherwise substitute for the sanguineous evacuations at- properly treated, in no way implicate the adtending hæmorrhoids. It is distinguished from joining canals or their outlets; but, if neglectgonorrhoea affecting the anus, or "venereal ed, or if suppressed externally, it may extend blennorrhoea," by its tenacious state and trans-upward or along the rectum, especially in caparent appearance, which it commonly retains. 46. B. The treatment of this discharge depends upon the cause. It is often produced by the abuse of calomel and aloes, and by resinous purgatives and emmenagogues, and is readily cured by relinquishing the use of these. It is a frequent consequence of the congestion or local determination of blood produced by masturbation; and hence it should excite suspicion of this vice, the existence of which will render treatment inefficacious, but the relinquishment of which will alone remove the disorder. When it follows proctitis or dysenteric attacks, or attends hæmorrhoidal tumours, or follows sanguineous evacuations from these tumours, the treatment advised for HÆMORRHOIDS will then be required; and when it is caused by intestinal worms, the treatment prescribed for these parasites is then necessary. In many cases, the means recommended for itching of the anus, or for chronic proctitis, will remove this affection.

47. vi. ABSCESS OF THE RECTUM AND ANUS.A. Abscesses may form in connexion with the rectum or anus, or with both, either consecutively of some form of inflammation of these parts, or from the extension of disease from adjoining parts, or, secondarily, from phlebitis or from purulent absorption.-(a) When either of the forms of inflammation terminate in abscess, the surrounding and connecting cellular tissue is the seat of the purulent formation. If the abscess form near the anus, it is formed in and confined by the surrounding adipose substance. The abscess may be between or external to the coats of the rectum : if the former, it is generally very small, or several may exist; if the latter, it is much larger, and is generally

chectic habits, and ultimately perforate the parietes of the bowel above the sphincter, and be followed by fistula. Although an abscess may occasionally thus originate, and with an apparent independence of any irritation or disease of the adjoining canals or of their outlets, I believe that instances are rare in which these affections, either of the mucous surfaces or of the follicles, are entirely absent, these affections proving the exciting cause of the inflammatory action and suppuration external to the rectum or anus.

50. (c) Irritation or inflammation passing into abscess in or near the rectum or anus, although commonly originating in those parts, and produced by the causes mentioned above (§ 35, 36), frequently proceeds from disease-from inordinate excitement, irritation, inflammation, or other lesions of adjoining parts. In females the abscess may be a consequence of irritation in the sexual passages, and be seated in the anterior parietes of the bowel, or in the rectovaginal partition, or in the perinæum, and may point or open into either canal or externally, according to its position. In males, inflammatory irritation or diseases of the urethra, of the prostate gland, or of the neck of the bladder, may extend to the adjoining cellular tissue, and endanger the integrity of the rectum by exciting inflammation of, and abscess in or extending to, this tissue. Even the means used to cure disease of the urinary and sexual organs, in both sexes, may excite inflammation or irritation, which will extend in this direction and terminate in purulent formation, which may open into the rectum. Abscess in the vicinity of the rectum or anus may, moreover, depend upon disease of some one of the pelvic viscera,

or upon disease or caries of a portion of bone | the patient. If the abscess be of a sthenic nain the vicinity; but these are comparatively rare occurrences, or causes of abscess in this situation. It should not, however, be overlooked that an abscess may appear near the anus, or may partially surround or open into the rectum, owing to the extension of disease, and to purulent extension and infiltration from the vertebræ, the abscess being, in such case, merely a variety of psoas abscess, proceeding from inflammation of the intervertebral spaces, or from caries or tubercular disease of the bodies of one or more of the vertebræ.

51. (d) Abscess, or abscesses, may form in the rectum or anus from inflammation of the veins of these parts, or of a hæmorrhoidal tumour, or of a dilated or varicose vein, the purulent collection being more frequently external to the vessel, or in the surrounding cellular and adipose tissues, than within, or involving the coats of the vein. It is not improbable that inflammation of the hæmorrhoidal veins, when commencing in their internal or serous membrane, may sometimes extend more or less along them, and contaminate the blood, or cause coagulation of the fluid in them, or other lesions fully described in the article on the pathology of the VEINS, and be associated with purulent collections in their course, either internal or external, as respects their parietes; but these results are certainly not so frequent as may be expected from the exposure of these vessels to the several causes of irritation and inflammation, which so often act upon the rectum and anus, and influence the circulation through the hæmorrhoidal veins, both in health and in disease. It still more rarely happens that secondary collections of matter form near the rectum or anus in consequence of purulent absorption, the few instances of abscess in these situations which have occurred in the puerperal state being those in which inflammation of the veins of the uterus or of the appendages has extended to the veins and cellular substance adjoining, and has implicated those parts in or

near the rectum or anus.

ture, the attendant fever is more or less inflammatory, and the tendency to point externally is manifest; but if it be asthenic, or the constitution cachectic, the local inflammation and the matter produced by it may be diffused, and isolate a portion of the parietes of the rectum or of the sphincter, and disconnect it from the adjoining parts. In these cases, the constitutional symptoms are always adynamic, and, however frequent the pulse, the vital powers are more or less depressed. In some of these the abscess will hardly point externally, or if it thus point, it will do so imperfectly, or assume the character of carbuncle. When the abscess forms near the side of the anus, and much redness or swelling and pain extend to the buttock, with considerable fever, then the more painful symptoms subside upon the formation of matter, especially in the sounder constitutions, and throbbing, chilliness, followed by a disposition to perspirations, with external pointing of the abscess, are chiefly experienced. If, however, the matter is more diffused, if the disease is more asthenic, if the constitutional powers are weak or exhausted, if the superficial appearance of the abscess is more carbuncular, and if more than one opening have appeared on the surface, both the local and general symptoms may be aggravated, or, at least, not abated, and, with the diffusion of the local lesion, the adynamic fever seriously, if not dangerously increased.

54. The severity of the symptoms and the consecutive evils are much increased when the abscess is consequent upon changes of the coats of the rectum, or upon ulceration of the mucous follicles of the rectum or anus, or upon inflammation of hæmorrhoidal tumours, or of the hæmorrhoidal veins; for, in these circumstances, not only are the local changes more complicated, but the constitutional affection is more severe, and the tendency to terminate in fistula, if not in still more serious changes, much greater. Much, however, in respect of severity of local and general symptoms, will depend upon the constitution and habit of body of the pa52. B. The symptoms of abscess near to or im- tient, and upon the exact seat of the local plicating the rectum or anus vary remarkably, change. Integrity of vital power will prevent in severity and character, with the causes of a dangerous extension of the mischief, while the inflammation of which this is the conse- depressed or exhausted energy, and an impure quence, with the severity of the inflammation state of the circulating fluids and their several and the extent of the abscess, in no small de- concomitants, will increase the evil. The exgree with the particular situation of the abscess, act situation of the abscess will also remarkaand with the constitution and habit of body of bly affect the symptoms. If the matter form the patient. The symptoms are often, at first, on one of the sides of the anus, the symptoms those of proctitis, especially when the disease will be much less severe than in any other sitcommences in the rectum or anus itself. But uation: they will be severer if it forms postewhen the abscess proceeds from inflammation riorly, and still more severe if it collects anof the adjoining parts, passages, or outlets, or teriorly; as in this last situation it implicates when it is so external to the rectum or anus as parts of greater sensibility than in the other at first not to implicate these parts, little incon- situations; and, in the male especially, it invenience is experienced there until the outlet volves parts concerned in very important funcis pressed upon, or consecutively inflamed by tions-whether extending merely to or originthe progress and distention of the purulent col- ating in these parts-and interrupts more or lection. less painfully, and even seriously, their offices. The abscess may in this situation involve the prostate gland, or neck of the bladder, or the urethra, or the vesiculæ seminales, either primarily or consecutively, and thus interrupt the excretion of urine, or cause retention of it, with various associated phenomena.

53. When the abscess is apparently, or even really unconnected with the bowel or sexual or urinary passages, and is at some distance from the anus (49), it generally appears in the form of an ordinary boil, and proceeds with central hardness, swelling, redness of a dusky tint, and throbbing, with symptomatic fever, varying in character and severity with the constitution of

55. In females the symptoms are seldom so severe as in the male, especially when the ab

dysentery and diarrhea; local irritants, and septic or contaminating vapours directed on the anus and rectum in foul privies; substances lodged in the rectum; operations and injuries implicating the rectum or its vicinity; certain kinds of ingesta, both medicinal and poisonous, taken too frequently or in too large doses, as calomel, arsenic, &c. ; scurvy and morbid states of the blood; and excessive sexual indulgences. (See ◊ 35, 36.)

59. D. The symptoms of ulcerations of the rectum are often those of chronic proctitis, especially tenesmus, the discharge of puriform, or a mixture of purulent, sanious, and mucous matters in the stools; more or less pain during the passage of the fæces, often with partial prolapsus of the inner coats of the rectum, and with more or less blood, sometimes a little only, following the fæculent evacuation. If the ulceration exist near to the anus, it may be associated with some degree of fissure, and a sanious or puriform discharge may either exude constantly or be discharged at intervals from the anus. When the ulcer is considerable, and

scess is anterior to the anus or points in the | hectic and other fevers; the several kinds of perinæum; and yet I have seen in two cases, of which strong females of a sanguine temperament were the subjects, both the local and the constitutional symptoms most acute, the abscess having been seated high in the recto-vaginal partition. In such cases, the abscess will not point in the perinæum, but either in the vagina or rectum, according as the parietes of either is primarily or chiefly affected, or as the irritation or cause existed in the one canal or in the other; but when pointing in either direction, perforation of the parietes is generally the consequence, and the risk of fistula being the result is great, especially if the rectum be perforated and the constitution be at all in fault. 56. vii. ULCERATION OF THE RECTUM.-A. Ulceration of the coats of the rectum is not infrequent, especially in the course or as a consequence of acute or chronic dysentery, of diarrhoea, especially of colliquative diarrhoea, and of tenesmus. It may take place as a termination of one of the forms of proctitis described above, and it may be either the consequence or the cause of abscess of the rectum or anus. It is frequent in the course of tubercular forma-low in the rectum, it may be felt upon the extions in the lungs, and less so in the advanced progress of organic diseases of the liver. In the former, it is often productive of fistula, having previously occasioned more or less suppuration, or distinct abscess in some cases, or a less obvious collection of matter in others; and it generally commences in the mucous follicles, and is often caused by the state of the blood consequent upon softening of tubercles in the lungs, and the absorption of tubercular matter. Ulceration may also follow the opening of an abscess into the rectum, when the matter proceeds from inflammation of adjoining parts, especially of those already enumerated (§ 49-51). It may possess asthenic or reparative character, in which case a favourable issue soon takes place; or it may present an asthenic or spreading form; or it may even assume a sloughing or rapidly disorganizing state. It may, moreover, be specific or venereal.

57. B. Ulceration of the rectum or anus is more frequently a complication of other maladies, as of those of the lungs, liver, &c., than a primary and simple lesion. It is often associated with other changes in the rectum-with inflammation of the rectum, or of the colon, or of both; with prolapsus ani, with fissure of the anus, with stricture and thickening of the parietes of the bowel, with hæmorrhages from the rectum, of which it is often the cause, and with hæmorrhoidal tumours, internal or external. It is often complicated with, or consequent upon, thrush and excoriations of the anus in children (34), chronic dysentery and diarrhea, at all ages and in all climates, and disease of the mesenteric glands. It is not infrequently associated with lesions of the urinary and genital organs in both sexes, and with tubercular formations in different parts of the body, but more particularly in the lungs.

58. C. The causes of ulceration of the rectum are the same as those which occasion proctitis or abscess of the rectum and anus; more particularly the several diseases just mentioned as often associating with them these lesions, as tubercular formations in the lungs or in other parts; disease of the liver and digestive canal;

amination, some degree of thickening, with slight induration of the edges and irregularity of the surface, serving to distinguish it. When it is beyond the reach of the finger, or above the sphincter, its existence may be inferred from the history of the case, especially from the appearance of purulent or sanious matter, or of blood, in the stools, but unmixed with the fæces; from the circumstance of these discharges having followed symptoms of proctitis or of abscess, or attacks of dysentery or chronic or colliquative diarrhoea; from the pain under the sacrum or pubis just before or during evacuation of the bowels; and from the partial prolapsus often attending fæcal evacuations. But it is rather from the association of several of these, than from either singly, that this change is to be inferred. (See art. HÆMORRHAGE—from the Intestines, &c., ◊ 197.)

60. E. Syphilitic ulceration of the, rectum or anus is a general attendant as well as consequence of syphilitic proctitis. It occurs most frequently in females, owing chiefly to the proximity of the infecting and infected surfaces. The specific characters of the syphilitic ulcer are often, but not always, present. When these are absent, as well as in other circumstances, the history of the case and the conduct of the patient, as far as that is known, will serve to guide the diagnosis. The existence of other syphilitic symptoms, primary and secondary, should also be ascertained.

61. viii. FISTULA IN ANO.-Rectal Fistula.Fistula is the consequence of abscess or ulceration of the rectum or anus, and hence it proceeds from the same remote causes-predisposing and exciting-as occasion either or both these lesions. It has usually been divided into three varieties, the last of which, however, is very doubtful. 1st. Complete fistula, which has two openings, one in the rectum and the other externally. 2d. Incomplete internal or external blind fistula, which has an opening in the bowel, but none externally. 3d. The incomplete external or internal blind fistula, which has an external opening, but no internal opening into the gut. The existence, however, of this third variety

has been disputed with much reason. More than one fistula may exist in the same person, and they may be of the same, or of the first and second varieties. They may present various differences; the fistulous canal may extend far up before opening into the gut, may have several external openings, may extend far beneath the external skin, may be attended by spasm of the sphincter, and by callosities, hardening, and disease of adjoining parts, as the vagina, bladder, urethra, prostate, or even of the pelvic bones.

the disease, and the habit of body of the patient.

65. A. When the abscess is of a sthenic character, is apparently only forming, then leeches and soothing applications may be employed; but in all cases, whether sthenic, asthenic, carbuncular, spreading, or burrowing, they ought to be opened as early as matter is formed, and a free external outlet to it be afforded. Afterward, as well as when ulceration of the internal coats of the rectum are ascertained upon examination, the treatment, both local and general, should depend entirely upon the features and pathological associations of the case. If the abscess or ulceration has not advanced to the formation of either an incomplete or complete fistula, such means as are most likely to promote the circulation through the portal vessels, and remove obstructions from the liver, ought to be adopted, aided by soothing, stimu

62. The constitutional and pathological relations of fistula in ano-the frequent dependence of this lesion upon important visceral diseasehave not sufficiently engaged the attention of surgeons in devising their intentions and means of cure. Hence the necessity of close investigation of the causes and complications of all cases of anal fistula which come under medical or surgical treatment. The causes of rectal fis-lating, or astringent and tonic means, locally or tulæ are those already mentioned in connexion with the diseases already discussed, but more especially injuries of the internal coats of the rectum by foreign bodies, or by retained matters in the bowel, and the suppuration or ulceration of bunches of hæmorrhoids perforating or destroying the inner coats of the gut. Fistula, from this latter cause, generally form slowly. The patient has itching at the anus, and a knobby swelling forms near the anus, which often merely empties itself by a small opening, or which has little disposition to break externally, but rather spreads upward, or it may be connected above, with a second opening into the rectum. In some cases the fistula is a consequence of injury, or of the burrowing of pus from some adjoining part, depriving the exterior parietes of the rectum more or less completely of their cellular connexions. These fistulæ are often critical, or, rather, the abscesses in which they originate. But more frequently the fistulæ accompanying constitutional disease, especially phthisis, originate in ulceration, frequently affecting the mucous follicles, in the manner already mentioned (ý 56).

constitutionally, according to the peculiarities of the case. With these views, I have given PLUMMER'S pill with soap and inspissated oxgall, or the precipitated sulphur, with the bitartrate of potash, the confection of senna, and confection of black pepper, or with capsicum, according to the state of the case. If the rectum continue irritable, or if the ulceration be attended by spasm of the sphincter, emollient injections, the local application of the extract of belladonna, with either of the ointments advised for anal fissure, and a recourse to the decoction of the yarrow or millefolium, which was recommended to my attention by Mr. PERKINS, of Mortimer Street, will afford relief. If the ulceration be obstinate, small injections of a solution of nitrate of silver, or of mucilaginous mixtures containing spirits of turpentine, or the balsams, especially the Peruvian balsam; or pills, with ipecacuanha, capsicum, ox-gall, and one of the balsams, will generally remove the disease, if the evacuations and the diet be duly regulated, and if the constitutional powers be duly preserved or increased.

66. B. If the ulceration present a foul, spread63. According to the researches of SABATIER, ing, asthenic, or gangrenous character, the treatLARREY, RIBES, and CHELIUS, the internal open-ment, both local and general, should be of an ing of rectal fistula is most commonly imme- antiseptic and tonic nature. Applications condiately above the part where the internal mem-taining one of the chlorides, or creasote, or brane of the rectum joins the external skin, and rarely higher than five or six lines above this part. Such appeared to have been the result in seventy-five cases examined by M. RIBES. The condition of the fistula is partly shown by the nature of its origin and history of the case, by the circumstances of the discharge being either purulent or fæcal, and by the passage of intestinal gas through it, especially after having been examined by the probe.

64. ix. TREATMENT OF ABSCESS, ULCERATION, AND FISTULE OF THE RECTUM AND ANUS.-The causes and the constitutional relations of these lesions should determine the indications and means of cure that ought to be adopted. If either lesion proceed from constitutional or general disease, the treatment should be chiefly constitutional and dietetic. If either have arisen from acute or sub-acute proctitis, the means already mentioned as appropriate for chronic proctitis (38) may be employed; but these should be varied with the diathesis, the complications, the duration or the obstinacy of

spirits of turpentine, or the Peruvian balsam, small injections with these, and the internal use of the decoction of cinchona, with alkaline carbonates, camphor, serpentaria, capsicum, aromatics, &c., are indicated in these cases. When the ulceration is considered syphilitic, then mercurials, especially the bichloride, in gradually increased doses, or calomel, blue-pill, hydrargyrum cum creta, &c., may be prescribed according to the peculiarities of the case.

67. C. Rectal or anal fistula require the adoption of similar principles and means to those espoused above. These fistula often require an operation for their cure; but such operations ought not to be undertaken inconsiderately for the following reasons: 1st. The fistula may be symptomatic of disease of the lungs or liver- of the lungs especially-and the discharge from it may have a beneficial influence on the pulmonary malady. No attempts, therefore, should be made to close this safety-valve of the frame in these circumstances until another has been established in some other quar