alone, or combined with incisions, are the means by which this is to be effected. In the majority of cases, it will not be prudent to have recourse to surgical treatment 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 feces, and injecting tepid water, thin gruel, olive oil, or tepid water and soap; this practice must be repeated every day, or every other day, till the whole of the fecal 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 feces, 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.

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. 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.

By the foregoing plan most cases of stricture of the rectum in which the deposit of plastic material is limited, and the existing induration is not great, may be successfully treated. But the cases of stricture that most frequently come under the cognizance of the surgeon are those in which the adventitious tissue is considerable, is dense and unyielding, and in them bougies of all kinds are alike useless. This fact has long been recognized, and various instruments have been invented by Weiss, Bushe, Arnott, Sir C. Bell, Charrière, Bennoud, Castallat, Coxeter, and others; and though all of them indicate much mechanical ingenuity, yet in practice they have not been found to answer the purpose. Dr. Bushe, of New York, many years since invented an instrument for making pressure in cases of hemorrhage after lithotomy, and for which it is admirably adapted: it consists of a metal tube closed at one end, and the other furnished with a stopcock: near

the closed extremity are some lateral perforations, and over these a piece of intestine is tightly secured above and below by waxed thread. A syringe is fitted to the other end of the tube, by which the intestine is distended with water. This instrument has been lately introduced as an original invention for the dilatation of stricture of the rectum by a surgeon who ought to be well acquainted with Dr. Bushe's work. But there is one great objection to the instrument in its application to the treatment of stricture of the bowel, which is, that before any pressure can be exerted on the contraction the piece of gut at the end of the tube must be distended to its utmost limits, consequently it presses upon the rectum above and below the stricture, where there is always considerable irritation, even if ulceration does not exist. The requisites of a dilator for stricture of the rectum are, that the instrument shall readily pass into the stricture and then be capable of exerting lateral pressure in parallel lines, but without dilating the anus. I may here observe, that though there is an intimate pathological analogy between stricture of the urethra and that of the rectum, the difficulties in treatment are widely different. In close stricture of the urethra considerable knowledge and manipulative skill is required to get an instrument into the stricture, but that being effected all difficulty in the case is surmounted. Not so stricture of the rectum, in which the introduction of an instrument within the contracted part is readily effected; but the difficulty here is, that the instrument itself is incapable of exerting a sufficient amount of dilating power to stretch and expand the tissue of a rectal stricture, and which sometimes exceeds one or two inches in thickness. A very little experience in the treatment of the severer form of stricture impressed on me these very obvious facts, and in all such cases I have had recourse to various contrivances effecting lateral pressure only; but though with them I succeeded in accomplishing the object, they were all more or less defective and difficult of use. One of my earliest severe cases was that of a gentleman who came from Australia to place himself under my care. The stricture was the effect of a congenital occlusion of the rectum by a dense septum, which had been perforated by a trocar, and subsequently dilated to a limited extent. During his whole life he had daily used bougies, and by constant care, and with great

trouble, managed to keep the passage sufficiently free for the performance of the natural functions. While in Australia his instruments became worn out, and being unable to procure others, contraction rapidly ensued, occasioning him great misery and suffering, and necessitating his return to England. When I first saw him the stricture would only admit a number ten urethral bougie: I dilated it till I could pass a number twelve rectum bougie; and under the influence of chloroform, administered by Mr. Clover, I explored the bowel above the rectal stricture, for the purpose of satisfying my patient's mind of the non-existence of a second contraction higher up. I made various improvements in the instrument I employed in this case, and perfected the one I now use during the treatment of an eminent surgeon from Trinidad, who came to this country to be under my care. He had a close stricture, the result of cicatrization of an ulcerated surface caused by dysentery; and in his person he presented a living monument of surgical ignorance in the treatment of hæmorrhoids, from which he had suffered; they had been removed by a confrère in the West Indies, who not only removed the piles but the internal and external sphincters also, dooming this gentleman to the miserable condition of being unable to retain the feces except by the constant use of a tight perineal bandage. I have subsequently employed with great success the same instrument in several cases; among them, that of a gentleman holding a high official position in Ceylon, who came to England for the purpose of being treated for a very close annular stricture of the rectum. On his arrival here, his general health being much deranged, he placed himself under the care of Dr. Quain, from whose advice he derived much benefit. Afterwards I freely opened the stricture by dilatation and incisions, and in a few months he was able to return to Ceylon.

In some cases of close stricture of long standing, we shall gain time by incising its margin previous to using dilatation; the best instrument for the purpose is a narrow blunt-pointed bistoury passed into the stricture, on the finger previously introduced; several slight notches are far preferable to one of greater extent, as there will then be no fear of hemorrhage, or of matter forming in the cellular tissue.

It has been proposed to destroy the indurated structure by

NOTE.-The above woodcuts represent the dilator closed and distended, about one-third their size. The instruments were exhibited in the International Exhibition of 1862, in the case of an instrument-maker, but were not made by I him. The one that was distended was said to have burst and was removed from the case. I subsequently discovered, what appears to be a singular coincidence, that about the time of the accident the instrument-maker had received an order for one from my Trinidad patient, who had seen a notice of it in the Lancet.