will also accompany this disease. The tongue will be loaded, the countenance dull, and the functions of the liver and kidneys deranged. After the disease has existed for some time, the bloodvessels of the rectum and anus become engorged, and tumors are formed, most commonly by the extravasation of blood, which may become absorbed, and leave elongated folds of thickened integument around the anal orifice. Another consequence of vascular determination and impediment to the circulation, resulting from the condensation of the coats of the intestine and the pressure exerted by the accumulated fæces, is the formation of abscess in the cellular tissue external to the bowel, which, bursting by one or several openings, degenerate into fistula. As the disease advances, the patient will have sudden and frequent desire to evacuate the contents of the bowels, violent straining ensues; he passes chiefly mucus and a little blood, the fæcal matter, if any, being small in quantity; as a consequence, a sensation of fulness of the bowel remains, and is the reason why the attempts to defecate follow at short intervals. Sometimes temporary relief is experienced by the supervention of diarrhoea; the mucous membrane, from the irritation it is subject to, pours out a large quantity of mucus, which, rendering the fæcal mass fluid, permits of its passage through the contracted channel, and by this effort of nature the whole or the greater part of the accumulated matter is discharged, and serious consequences for the time averted.

When the disease has progressed, and the passage through the intestine becomes very narrow, the patient's condition is one of great peril, and symptoms of strangulated hernia or peritonitis may supervene at any moment: the former may occur from the aperture through the intestine being too small to permit the fæces to pass, or from the lodgment of some body producing obstruction, which may be a nodule of indurated fæces, or the stone of a plum or cherry, the bone of a fish, or other substance that has been swallowed, becoming entangled, and occluding the opening. Obstinate constipation sets in, followed by vomiting: at first the contents of the stomach only are thrown up, but shortly the vomiting becomes stercoraceous, and unless the natural passage be restored, or an artificial one formed, a fatal termination will be the consequence. In other cases, the patient may be carried off by peritonitis, which is generally induced by perforation of the coats

of the intestine; ulceration taking place above the seat of stricture while this process is going on, diarrhoea is often present.

Unless a stricture of the rectum is within reach of the finger, and fortunately it usually is, the diagnosis must be uncertain, and surrounded with doubt; exploration by a bougie can never be satisfactory, nor can it afford us positive information, from the liability of its progress being arrested by a fold of the mucous membrane, or the promontory of the sacrum, or by a flexure of the intestine, which in some individuals may be abrupt, and also liable to alteration of position at different periods. The instances are not few in which stricture has been supposed to exist, and numerous fruitless attempts have been made to pass a bougie, when, after death, no organic obstruction has been discovered. Mr. Syme1 mentions the case of an elderly lady who had been supposed, by two medical men of high respectability, under whose care she was, to suffer from stricture of the rectum between five or six inches from the anus; he goes on to say, "Finding that the coats of the rectum, though greatly dilated, were quite smooth, and apparently sound in their texture, so far as my finger could reach, and conceiving that the symptoms of the case denoted a want of tone or proper action, rather than mechanical obstruction of the bowels, I expressed a decided opinion that there was no stricture in existence. Not many months afterwards, the patient died; and when the body was opened, not the slightest trace of contraction could be discovered in the rectum, or any other part of the intestinal canal. One gentleman who had been formerly in attendance was present at this examination, and wishing to know what had caused the deception, which he said had led to more than three hundred hours being spent by himself and colleague in endeavors to dilate the stricture with bougies, he introduced one as he was wont to do, and found that, upon arriving at the depth it used to reach, its point rested on the promontory of the sacrum." But even supposing the instrument to enter a constricted portion of the gut, how are we to tell whether it is a simple stricture or a carcinomatous contraction?-a question of the utmost importance, for the treatment that would be beneficial in the former case would only aggravate the latter.

1 Op. cit. pp. 110, 111.

When a patient complains of a difficulty in defecating, and passes small and contorted stools, it by no means follows that stricture of the rectum exists: a variety of causes will produce these symptoms: they are very common in dyspeptic patients, caused by spasmodic and irregular contraction of some portion of the rectum or of the sphincter muscles: the latter is a condition of parts constantly attending ulceration of the lower part of the rectum; the pressure of a displaced and enlarged uterus, ovarian, uterine, and other pelvic tumors, abscess of the recto-vaginal septum, the impaction of alvine and biliary concretions, and in the male the enlargement of the prostate gland, may all produce the like effects.

One peculiar feature in stricture of the rectum is, that sometimes the patient's general health remains for a long period unaffected; he may have suffered from constipation or irregularity of the bowels, which he attributed only to functional disorder cases are on record where the disease has advanced till fatal obstruction has taken place, without the disease having been previously suspected, either by the patient or his medical attendant. Usually the appetite fails, the patient becomes pale, loses flesh, and ultimately hectic fever sets in, under which he sinks by the exhaustion of the vital powers. Previously, however, to the final termination of the case, a copious muco-purulent secretion takes place, and is sometimes so acrid as to produce excoriation of the anus, and may be in such quantity as to flow outward when the slightest exertion is made, or even on the erect position being assumed.

Sometimes sufferers from stricture die from the accumulation of fæces in the colon, before ulceration and hectic commence: they become melancholy and pallid, and are greatly distressed by flatulent distension, the circulation is disturbed, the pulse being weak and irregular, respiration is embarrassed by the free action of the diaphragm being impeded, pains in the legs, and cramps are complained of, the feet are cold, there is determination of blood to the head, producing giddiness and stupor, and, lastly, symptoms of internal strangulation supervene, which terminate fatally, unless relieved by operation.

The prognosis of stricture will be influenced by a number of circumstances depending on the degree of contraction, its condition, position, and the causes that led to its formation. If within

reach of the finger, and the contraction and induration have not advanced far, we may entertain hopes of very favorable results from judicious treatment. But if the disease has progressed, the hardening being great, and the passage of the bowel much diminished, our opinions as to the prospect of a cure will be less favorable. Should ulceration have occurred, the patient is in a much worse condition, and will require very cautious treatment, or the disease may be aggravated instead of being benefited.

The object to be attained in the treatment of this disease is, if possible, to restore the bowel to its natural dimensions, or if that cannot be accomplished, to enlarge the constricted part sufficiently to permit the free passage of the fæces. Dilatation by the careful introduction of bougies is the means by which this is to be effected. In the majority of cases, it will not be prudent to have recourse to the bougie immediately, either in consequence of the irritability of the bowel, or from its being immensely distended above the point of contraction by the accumulation of feculent matter, which, pressing against the stricture, is a source of constant irritation, and tends to aggravate the disease; therefore, the importance of unloading the bowel before adopting other means must be obvious. This is to be accomplished by the introduction of an elastic tube through the stricture into the superincumbent mass of fæces, and injecting tepid water, thin gruel, and olive oil, or tepid water and soap: this practice must be repeated every day, or every other day, till the whole of the fæcal accumulation is dissolved, and washed away; the size of the tube must be regulated by the tightness of the contraction; in some cases we shall not be able to use one larger than a urethral catheter. If much local or general irritability or restlessness be present, an opiate enema, or a suppository of the pilula saponis composita at bedtime, will be of the utmost service, followed in the morning by a mild unirritating aperient, such as the confection of senna, tartrate of potash, manna, castor oil, &c. Sir Benjamin Brodie recommends the following draught to be taken two or three times a day: balsam of copaiba, half a drachm; solution of potash, fifteen minims; mucilage, three drachms; and nine drachms of caraway-water. If inflammatory symptoms be present, blood may be taken locally, and a warm hip-bath used at night. It will be desirable during the treatment that the patient should observe the horizontal position

as much as possible, and the diet restricted to that which is light and nutritious, and yields the smallest amount of excrementitious matter, such as good broths, jellies, eggs, arrowroot, sago, and the like.

Having freed the bowel from the accumulated fæces, and allayed the irritability of the part, we may endeavor to restore its calibre by the introduction of bougies. These are made of various substances, of metal, wood, cloth covered with plaster, and elastic gum only those formed of the last two materials should be used when the stricture is not close to the anus. I give the preference to the elastic gum bougie, and have them made more flexible than those usually sold in the shops, which obviates the objection urged against them by surgeons who advocate the use of those formed of plaster.

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The surgeon, by previous examination, having satisfied himself of the existence of stricture, and formed an idea of the extent to which the narrowing of the intestine has taken place, selects an instrument that will pass into it without much difficulty. The patient is placed on his side, with his knees drawn up, and the bougie, lubricated with oil or lard, is passed upwards to the obstruction, and steady but gentle pressure is made against it; no force must be used, and if the resistance cannot be overcome without, a smaller instrument must be tried, till one be permitted to pass after it has entered the contraction, it should be allowed to remain a few minutes, and then withdrawn. Some authors recommend the bougie to be left in for several hours; but such a mode of treatment is more likely to produce irritation than to effect the object we have in view, namely that of stimulating the vessels to the absorption of the effused lymph forming the stricture. If much irritation follows the operation, the patient should have a hip-bath, and it may be necessary to inject soothing and opiate enemata. At an interval of three or four days the operation is to be repeated; the same instrument that was introduced on the first occasion should be used again: if it passes with greater ease it may be withdrawn, and one a little larger passed, and thus the treatment is to be pursued till a full-sized bougie can be introduced with ease, and the patient ceases to suffer any inconvenience. In some cases of close stricture of long standing, we shall gain time by incising its margin previous to using dilatation: the best