to be careful to avoid swallowing plum-stones. A good deal of benefit may be obtained from the balsam of copaiba, in doses of twenty minims, taken in conjunction with fifteen minims of the liquor potassæ in a palatable mixture three times a day. This medicine allays the irritability of the mucous surface, and often proves sufficient to keep up a gentle action of the bowels. The accumulation in the distended bowel above the stricture may be prevented by the occasional passage of an elastic tube through the contraction, and the injection of half a pint of tepid water, or soap and water. It may be necessary to repeat the injection two or three times a week. When much pain has been experienced after stools, and the discharge is considerable and slimy, or tinged with blood, I have found the patient derive a good deal of relief from the application of a solution of nitrate of silver, in the proportion of five grains to the ounce of distilled water, to the diseased mucous surface included in the stricture. This can easily be made by means of a camel's hair brush passed through a small glass speculum open at the extremity, and introduced as far as the stricture. In a very bad case of strictured rectum, under my care in hospital, in which the consolidation was too great, and the mucous membrane too much diseased to admit of my attempting dilatation, the motions passed with much less suffering after a few applications of the nitrate of silver solution in this way. Anointing the mucous surface with the mild citrine ointment, applied by means of a thick camel's hair brush passed through a speculum, has also a good effect in correcting this morbid state of the membrane. Smearing the bougie with ointments, as commonly recommended, is not of much service, as the ointment gets rubbed off in the

first passage of the instrument, and does not reach the part affected. When stricture of the rectum is complicated with fistula in ano, no operation should be performed for the latter disease until the contraction in the rectum is removed.

The diseased mucous surface of the bowel above the stricture not only furnishes a copious discharge, which helps to exhaust the patient's powers, but is sometimes the seat of profuse bleeding. In the autumn of 1852, I attended, with Dr. Hess, a young married lady, who, after suffering for some years from a stricture in the lower part of the rectum, was attacked with alarming hæmorrhage from the bowels, which continued for several days. The bleeding evidently came from above the stricture, and it was suspected to proceed from a spot in the descending colon, which was very tender on pressure externally. The hæmorrhage was effectually stopped by repeated cold alum injections, carefully administered with the long tube passed through the stricture.

We often meet, especially in hospital practice, with old, inveterate, and neglected strictures, in which the disease is too far advanced to offer any prospect of being benefited by dilatation. In such cases, much may be done to mitigate the sufferings of this distressing complaint by the measures just described. This is all we can hope to effect; and in spite of all our care and palliative remedies, the disease will continue to make progress, wearing out the patient's strength, and ultimately proving fatal.

I have alluded to the circumstance, that in many cases of stricture of the rectum, the inconvenience is so slight, that no suspicion is excited, even of its existence, until the bowel becomes obstructed by the impaction, at the

contracted part, of hardened fæces, or some solid body, as a plum-stone. When the stricture is near the anus, the surgeon will be able to extract or dislodge any substance so blocking up the orifice, or, in case of extreme contraction, to afford relief by dilatation or incision, and injections through a flexible tube. But if the impediment should exist, as it more frequently does, at the termination of the sigmoid flexure, and out of reach of the finger, he will probably fail in his attempts to remove it, and the patient's life then becomes exposed to imminent danger from insuperable constipation. In these cases, the constitution not being impaired by disease, a long period elapses before the vital powers give way under the disturbance, patients having lived three weeks, and even longer, without passing stools. In this interval, the propriety of having recourse to an operation to provide an artificial vent for the fæces must necessarily come under the consideration of the surgeon. The first point to be cleared up is, all doubt in respect to the seat of obstruction. It may be found, that only a small quantity of fluid can be thrown into the bowel, and that it readily returns uncoloured; that the long flexible tube will not pass further than about eight inches; or, that if its progress be not arrested at that distance, the finger introduced into the rectum, by the side of it, will meet the end of the tube, which, on reaching the obstruction, has turned back. The distended colon may be traced down into the left iliac region. These signs, especially if accompanied with pain referred to, or felt on pressure at the upper part of the sacrum, towards the left side, would pretty clearly indicate the exact situation of the obstruction. And, as an impediment very seldom occurs at the point of termination of the colon in the rectum from any other

cause than stricture, the surgeon becomes apprised of the nature of the case with which he has to deal. His opinion will be strengthened, if he finds, upon inquiry, that the illness has been preceded by slight attacks of constipation, and difficulty in regulating the bowels. It is right to add, that notwithstanding these guides, the diagnosis may be difficult. In a case of stricture at the termination of the colon in the rectum, which came under my notice, some of the surgeons consulted hesitated pronouncing a positive opinion as to its seat. In another case of internal obstruction which was operated on without success, the surgeons were completely mistaken; the distended small intestines occupying the pelvis having so pressed on the rectum as to prevent the lodgement of injections, and to cause the doubling of the long tube, which led to the supposition that the obstruction was at the extremity of the colon, instead of in the ileum, as appeared after death.

The knowledge of the cause of the obstruction, and of its seat in the lower part of the alimentary canal, places these cases in a different category from those of internal obstruction, in which, with the utmost skill and care, and under the most favourable circumstances, the diagnosis of the situation and nature of the impediment must always be involved in considerable obscurity. Besides, there is not the same occasion for delay in the hope or chance of the impediment yielding, which tends so much to embarrass the practitioner in treating the more doubtful cases; for, when the ordinary means of giving relief have failed, it is clearly the duty of the

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Intus-susception occurs at this part; but in such a case the invaginated intestine would be felt in the rectum. Accumulations of hardened fæces above the same point would be dislodged by introducing the long tube, and throwing up injections.

surgeon to suggest the expediency of the operation for an artificial anus before inflammation is set up, or the intestines have become damaged by over-distension, or before the powers of life are too far exhausted to admit of the patient's recovery afterwards. That delay tends greatly to diminish the chances of a favourable result from such an operation is obvious enough. In a case which was operated on at the London Hospital on the fifteenth day of obstruction, and ended fatally, I found, on examination of the body, the peritoneal coat of the transverse colon ruptured to the extent of about six inches".

An operation for artificial anus may also be required in cases of old-standing stricture lower down in the rectum, in consequence of the contraction becoming so close as, in spite of surgical treatment, to prevent the passage of fæces, and to occlude the canal.

A contrac

tion near the anus very rarely, however, produces complete obliteration of the gut; for not only does the increasing contraction admit of being checked in most instances by proper management, but the ulceration of the mucous membrane, which so commonly ensues, slightly enlarges the passage, and counteracts the tendency to close. An opening into the intestine above the stricture may, however, be called for, in consequence of the extreme misery produced by a stricture in this situation, in addition to the difficulty experienced in evacuating the bowels. About two years ago I opened the colon in the left loin of a man, aged thirty-eight, who had a partial obstruction from a stricture at the commencement of the rectum. In this case, the

'This case is recorded in Mr. Phillips' paper on Intestinal Obstructions, in the Medico-Chirurgical Transactions, vol. xxxi.