Diagnosis. Digital examination for the diagnosis of this condition is again emphasized as the only positive means of discovering a stricture within reach of the finger. When high up. the use of the pneumatic proctorial combined with the symptoms elicited from the patient will be sufficient. Sometimes it is necessary to place patients under a general anesthetic and by bi-manual examination through the vagina and the abdomen above, sesrch for the stricture during the period of general relaxation. In all of these examinations gentleness should be exercised in order to avoid the danger of rupturing the diseased bowel above or below the stricture, or around the diseased tissue.

The symptoms and diagnosis of stricture in the majority of cases is dependent upon the causation and the degree of obstruction of the bowel. Patients often imagine they have structure when in reality the sphincters are only in constant spasm as the result of a fissure or other painful affection at the anal margin. Stricture may be complicated by the presence of a fistula burrowing from an ulcerated surface in any direction.

Cancerous stricture, which has not undergone apparent ulcerations, may be differentiated as a firm, inelastic, epithelial growth; inflammatory stricture will be accompanied by temperature or other constitutional disturbances and will give a history of disease in or about the rectum prior to the formation of the stricture. Sarcoma is developed from the underlying connective tissue stoma and assumes the polypeptide or rounded ball-like shape, seldom annular in form. Syphilitic stricture is more widespread in its growth, being a proliferating process, and does not assume the band-like characteristics of cancer. In some instances however, cancer may involve the mucous membrane by metastasis at several points above or below the stricture, but never so extensively as syphilitic infection during the same period of growth. Cancer may push a portion of the healthy mucous membrane before it and give the impression of a connective tissue tumor (sarcoma), but at some place on its surface the epithelial nature of the growth will be discovered in the form of an ulceration with broken down tissue. A tubercular stricture breaks down almost as rapidly as it is formed and cannot constrict the rectum like the hard, firm, inelastic, cancerous tissue.

Treatment. Treatment of stricture in general is largely dependent upon the etiological cause which may be constitutional or local. When due to a specific disease, such as syphilis, treatment for that disease should be instituted in a vigorous manner with the hope of causing absorption. Medication, however, in cases of long standing is very disappointing. Gastric disturbances arise from the imperfect emptying of the bowel independent of the stricture. Where treatment by the various suggested methods is not indicated, liquid fecal movements are an absolute necessity to empty the intestine Electrolysis. This mode of treatment has been the subject of much discussion for many years without giving any very satisfactory results. It is claimed that electrolysis stimulates the absorption of fibrous tissue. Various forms of electrodes are used for this purpose, the olive form being the one most used. The positive electrode introduced into the mass itself has a tendency to harden the tissue while the negative pole has the reverse effect of dissolving it. My experience with this method of treatment has been so meager that in view of the adverse criticisms I have nothing to advise in this form of treatment.

Gradual dilatation is the only method of treatment that can be instituted in some of these cases, and is indicated only for those situated within five inches of the anal opening, below the level of the peritoneum anterior Above this point forcible dilatation might inadvertently rupture the rectum and cause peritonitis.

Stricture of the anal orifice may be dilated with the olive-shaped bogie which is made in four sizes and may, at this portion of the gut, be safely used by the patient. Dilatation between the anal opening and the reflection of the peritoneum is best done with the Wales soft rectal bogies which are made in various sizes and twelve inches in length.

Rapid dilatation of the rectum is best done with the knife as it is an instrument more definite in its lines of severance of the stricture.

Revulsion, by either gradual or forcible means, is resorted to more often than any of the other surgical procedures for stricture for the reason that the knife is not used. Forcible dilatation, as a rule, is done with the fingers under a general anesthetic, or bogies, uterine dilators, operating specular or any of the mechanical rectal dilators sold in the shop may be used. When it is possible, the fingers only should be used. They are the safest dilators, as a tearing of the mucous membrane or underlying tissue is readily detected. In using the bogie or dilators without general anesthesia it is seldom necessary to have the patient retain the instrument for more than five to ten minutes and this should be done every day for a week, if the dilatation is gradual. When the dilatation is done under anesthesia, the lumen of the bowel is increased to its greatest diameter without tearing and subsequently treated without an anesthetic with the idea of making the dilatation permanent.

Internal proctorial is described as a method which aims to incise a stricture within its lumen in various directions as the case demands, but owing to the liability to infection, ulceration and subsequent caricaturization, the method cannot be recommended.

Posterior proctorial consists in incising the stricture and all the tissue back to the coccyx. The knife is passed through the tissue and on withdrawal the stricture and intervening tissue is cut through, leaving a large triangular incision. Bleeding is arrested by ligatures and temporary packing with gauze. The wound should be irrigated with one to two thousand dichloride solutions and repacked again with chloroform or plain sterile gauze. A rectal suppository containing morphine or opium should be. inserted or hypodermic injections of morphine given to relieve pain.