strictures are the most favourable cases for treatment, and the most benefited by dilatation.

A common caution given by writers on this affection is, to avoid mistaking a fold in the mucous membrane of the bowel, or the prominency of the sacrum, for an impediment in the passage, as it appears that they have, in many instances, been taken and treated for stricture of the rectum. I need not repeat this caution, because I consider it a safe rule never to attempt the mechanical dilatation of a stricture unless the contraction be within reach of the finger. I have stated that the ordinary seat of stricture is about two inches from the anus, and that when situated as high up as the point at which the rectum begins, the strictured part is sometimes forced down low enough to admit of being felt by the surgeon. But in these cases the passage of a bougie through a contracted opening is by no means an easy matter; for the part being loose, the point of the instrument is very liable to catch in a fold of the mucous membrane, and to push the bowel before it, beyond the reach of the finger, without penetrating the stricture. In the case alluded to at page 87, this difficulty occurred, so that I could make no progress at all with bougies: I had recourse, therefore, to a two-bladed instrument contrived by Weiss, a modification of his dilator, and similar to what has sometimes been used in the dilatation of a phymosis. This being small, could be carried along my finger up to the stricture, and passed through it, and then, by turning a screw, and separating the blades, I managed to dilate the contraction. The patient derived temporary relief from this proceeding, being able to pass his motions afterwards with greater freedom; but the case was a very bad one, and so much difficulty was found in con

tinuing the treatment, that it was discontinued, and the man left the hospital without being permanently benefited. I describe the plan, because it may be found useful in other cases of stricture in a similar situation, but not so far advanced.

In cases of stricture at the junction of the colon with the rectum, without any descent or prolapsus, the seat of contraction may be indicated by the limited distance to which a flexible tube can be passed, and its reflexion on reaching that point. Still, when a stricture is out of the reach of the finger, there is no way of ascertaining its character, no guide for the selection of a propersized bougie, or for using it so as to dilate the contraction; no means, too, of determining positively whether the disease is simple stricture, or that form of disease— the carcinomatous—which is not likely to be benefited by mechanical interference, and in which the use of instruments is attended with risk of perforation. Such an accident has happened, indeed, without any disease at all, an instrument having been forced through the healthy coats of the intestine in the attempt to penetrate a supposed stricture. In the Museum of Guy's Hospital, there is a preparation of a colon in a perfectly sound state, perforated by a bougie at the distance of fourteen inches from the anus. It was taken from a gentleman who had long suffered from derangement of the digestive organs. This being at length attributed to stricture of the lower bowel, was treated by the passage of a bougie, which had been forced through the intestine into the peritoneum, and had destroyed the patient. The colon has even been perforated with O'Beirne's tube. I was present at the examination of the body of a man who had suffered from obstruction in the bowels. It appeared that a hard-handed prac

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titioner, in giving an injection, had forced an elastic tube through the upper part of the rectum, and injected the abdomen with turpentine and castor-oil. A prudent surgeon, therefore, would always be very careful in the introduction of instruments any distance along the gut, and especially cautious not to employ force to pass what he supposes may be a stricture. It should be borne in mind, that the intestine, unless diseased, is not a very sensitive part, and will bear a good deal of pressure and rough usage without the production of pain. This will account for the injury which patients have been known to inflict on themselves in the

passage of instruments into the rectum. Some years ago, a man, aged thirty-nine, was admitted into the London Hospital on account of a close stricture of the rectum. A bougie was passed two or three times, and, for convenience, left in charge of the patient. Being very anxious to make progress, he rashly ventured to pass the instrument himself. Shortly afterwards, he was seized with symptoms of peritonitis, and died the following day. On examination of the body, I found the usual appearances of active peritonitis, and, about an inch and a half from the anus, a firm, indurated stricture of the rectum, an inch in length. Just above the stricture there was a perforation in the bowel half an inch in extent; and two inches above this, another rent, somewhat larger, through which a portion of intestine was protruding. It is scarcely necessary to repeat the caution already given, not to trust a patient to pass a bougie for himself, however slight the contraction may be.

When the stricture is very close, with much induration of the submucous tissue, dilatation may be facilitated by previous incision of the thickened part. The

incision is usually directed to be made in the back of the rectum, towards the sacrum. Some surgeons recommend this to be done with the bistouri caché; but I prefer using a straight, probe-pointed bistoury, introduced flat upon the finger, and carried with it through the stricture. The blade can then be turned towards the contraction. More advantage is gained by two or three notches in different parts of the contracted ring, than from a single deeper division of the stricture. To stop bleeding, and to keep the wounded structures apart, a plug of lint or sponge should be passed into the strictured part immediately after the operation, and retained there for a few hours; and gentle dilatation should be attempted on the next or following day. I have never met with hæmorrhage to any extent after the operation. It is very rarely that a vessel of any size runs directly beneath the mucous membrane in indurated stricture. Mr. Mayo, however, divided a stricture seated within three inches of the anus, towards the sacrum. The operation was followed in a few hours. with very serious hæmorrhage, which was arrested by the introduction of a pledget of lint saturated with a strong styptic solution. A deep incision is not only liable to cause bleeding, which it may be difficult to stop, but also to lead to the formation of abscess and fistula, by allowing the passage of feculent matter into the areolar tissue about the rectum. Such an occurrence has happened several times after the operation, and, of course, has added to the difficulties of the case and distress of the patients. A case of stricture once came under my observation, where a surgeon was induced to make an incision into it at the back part. The patient, a female, died about a week afterwards; and on examination I found a long sinus, containing

a thin feculent fluid, extending from the wound upwards on the right side to the extent of six inches, and terminating under the peritoneum of the broad ligament of the uterus. There were marks of recent peritonitis in the pelvic cavity. On the whole, I am averse to having recourse to incisions. Though they facilitate the dilatation a good deal at first, the permanent gain is not considerable, and the operation is attended with risks.

In addition to these measures for dilatation of the stricture, means must be adopted to relieve the irritability of the part, and to ensure the regular passage of soft evacuations. A suppository of ten grains of soap and opium may be given at bed-time, and, if the motions are costive, some confection of senna with sulphur or castor-oil, in the morning, in doses just sufficient to obtain an action of the bowels without purging, which invariably adds to the patient's distress. Castor-oil is of great service in the treatment of this disease. In small doses it softens the feculent masses, and lubricates the passage, without weakening the patient. The chief objection to its use with many persons is the nausea to which it gives rise. But if the patient perseveres, the stomach gets accustomed to the remedy, which it tolerates as it does the cod-liver oil, so that we find patients with chronic disease of the rectum continuing to swallow it daily for weeks and months without any feeling of nausea, or impairment of the appetite. The diet should be nutritious, and consist principally of animal food, so as to afford a small amount of excrementitious matter. Cod-liver oil is an excellent remedy in these cases. It nourishes the patient, and softens the feculent discharges, often rendering aperients unnecessary. It is no needless caution to advise patients