seated near the outlet.

These cutaneous growths

resemble collapsed piles, except that they are redder in colour, and are kept moist by the escape of a thin discharge from the bowel. They originate in the irritation kept up by this discharge. The finger, well greased, being passed carefully and gently into the rectum, will be arrested on reaching the stricture, so that the point only can enter. If the contraction be somewhat recent, and not very close, the surgeon may gradually dilate the part, and, with a gentle boring motion of the finger, penetrate the stricture, and thus examine its whole extent. If he encounters much resistance, or gives much pain, he must not venture to force the barrier, but must be content with ascertaining the seat and degree of contraction. In strictures high up in the gut, the rectum below will often be found quite healthy.

In examining for stricture, it must be recollected that the rectum is liable to be compressed and obstructed by disease of the neighbouring viscera,-by an enlarged or retroverted uterus, fibrous tumours of this organ, a distended ovary, an excessively hypertrophied prostate, or an hydatid tumour between the bladder and rectum. There is a preparation, in the Museum of the London Hospital, of considerable contraction of the rectum produced by a large fibrous and fatty tumour, of an oval shape, developed outside the intestine. I had recently a female under my care, whose rectum was so encroached upon by a large tumour, apparently a fibrous growth from the uterus, that she was unable to pass any solid motion. Her bowels were never relieved until the fæces were rendered liquid by medicine. Several cases are recorded in which bougies have been long used for the cure of a supposed stricture in the

rectum, when the obstruction has afterwards been found to arise from the pressure of tumours external to the coats of the bowel.

The main object in the treatment of a stricture in the rectum is to remove the chronic induration, and to dilate the contracted part sufficiently for the free passage of the motions. The surgeon is rarely consulted at a period when it would be right to adopt even mild antiphlogistic treatment. Yet my experience of the great advantage often derived from the local abstraction of blood, previous to the use of instruments, in stricture of the urethra, leads me to think, that a few applications of leeches to the mucous membrane of the rectum, near the seat of contraction, would prove of considerable service, in the early stage of the disease, in removing the chronic thickening, and facilitating the subsequent treatment. Leeches may be readily applied to this part by the aid of a glass speculum, with a side opening at its extremity. The dilatation of the stricture is to be effected by mechanical means,-by the passage of bougies. Rectum bougies are made of a slightly conical shape, and of various materials; usually of wax, elastic gum webbing, or caoutchouc. Wax bougies, being

soft, are adapted for very sensitive strictures; but as they can seldom be used more than once, and have little effect on a firm stricture, they are not found so convenient as the elastic gum and caoutchouc. The former, being smooth, glides readily through the opening, and offers considerable resistance to a firm stricture; the latter, being of a softer material, answers best in strictures which yield readily to dilatation. If caoutchouc bougies be used, they must be lubricated with soap and water, as oil and grease are injurious to them. But the bougies which I generally employ, and much prefer,

are the sponge-tent. They are made of forcibly-compressed dry sponge, coated with tallow, and are about three inches in length. When this kind of bougie is lodged in a strictured rectum, the tallow slowly melts away, and then the sponge, getting saturated with moisture, swells and dilates the stricture gradually, gently, and very effectively. Before the instrument is used, the bowels must be well relieved either by medicine or an injection. It may be passed with the patient kneeling; but the more convenient position is the recumbent, on the left side, with the limbs bent on the body. The character and closeness of the stricture being ascertained by a careful tactile examination, a bougie, of size sufficient to pass with ease, and without giving the least pain, should be selected. This should be passed gently through the stricture and fairly lodged within the sphincter, the loop attached to it being in the anus. The bougie should then be retained for about twenty-four hours. I have sometimes had occasion to withdraw it at the end of twelve hours, and at other times have left it for forty-eight hours. It is obvious, that with the sponge-tent bougie, dilatation can not only be kept up for a much longer period than with the ordinary bougie, but can be carried to a much greater extent, for the sponge swells to double or treble its size when compressed. The dilatation is, indeed, so effective, that in certain strictures care must be taken that the instrument introduced is not of too great a size; one that would fill the contracted passage often being, when fully distended, too large to be borne without producing pain. There is another inconvenience, too, which results from the use of too large a bougie. The portion of sponge in the dilated bowel above the stricture, as the bougie is removed,

has of course to be dragged through the stricture; but in a case of firm contraction, or irritable stricture, the withdrawal of this swollen part of the instrument requires some little force, which is attended with a painful, tearing sensation. When there is much discharge from the bowel above the stricture, the bougie can seldom be retained longer than eight or twelve hours. The operation may be repeated, as soon as the irritation produced by the instrument has quite passed off, about every third or fourth day, and the size of the bougie may be increased according to the effect produced by the dilating process. This should always be gradual, for forcible dilatation is very liable to excite inflammation in the coats of the rectum, and to aggravate the disease. Inflammation thus produced by a common bougie has been known to extend even to the peritoneum. The treatment by dilatation must be continued, not only until an ordinary bougie of full size can be passed with ease, and the motions are evacuated of proper size, but, even for some weeks or months afterwards, an instrument should be occasionally introduced to counteract any disposition in the contraction to return, and to insure, if possible, a permanent restoration of the canal.

The effect of a bougie introduced through a stricture of the rectum, as in stricture of other mucous canals, is at first to stretch, but afterwards to cause a gradual absorption and removal of the indurated tissue producing the contraction-the condensed areolar or fibrous submucous tissue. The operation of pressure thus applied is constantly witnessed in the treatment of strictures in the urethra. Formerly, when my experience was obtained principally from public practice, the frequent and early return of strictures which had,

apparently, been successfully treated, led me to join in opinion with those who doubted whether a firm, wellestablished stricture in the urethra is ever permanently cured by dilatation. More extended experience, and a longer observation of cases, have convinced me, that if the dilating treatment be sufficiently prolonged, the areolar tissue may regain its elasticity, and be restored to its healthy state, without retaining the disposition to contract and to indurate. It must be admitted, however, that the dilatation of strictures in the rectum is attended with much less success than the dilatation of strictures in the urethra. Whether this is owing to early neglect, by which the induration in the coats of the bowel becomes too great, before any treatment is resorted to, readily to yield to dilatation, and the mucous membrane too diseased to bear the necessary pressure, or to other causes, is hard to say. But all surgeons of experience will, I have no doubt, admit that fully-formed organic strictures in the rectum yield with difficulty to treatment, and, though often much relieved, are rarely permanently cured'. Annular

'An excellent practical surgeon, Dr. Colles, of Dublin, states: "I feel confident that a perfect cure of the organic stricture of the rectum has not been effected by any plan of treatment hitherto employed." He adds, "I have paid great attention to the use of bougies, and yet I must candidly declare, that, hitherto, I have not been so fortunate as to have effected a permanent cure in a single instance; nor have I had the good fortune to meet with any patient whom I knew to have been afflicted with this disease, who had been cured by another surgeon." (Dublin Hospital Reports, vol. v. p. 142.) I am more hopeful than Dr. Colles, who took, I think, too unfavourable a view of the results of treatment. He was evidently well aware of the reputed cures of irregular practitioners, who are so successful in convincing patients that they are the subjects of stricture, and in getting them to submit to the passage of bougies, when no obstruction exists.