of exciting the sphincter to healthy action. I generally introduce at the same time a suppository of opium.

"Now, it might appear to some that this operation would be very painful, but, singular to relate, if great care be taken not to include any of the integument within the blades, and not to allow the nitric acid or cautery to come into contact with it, the patient does not feel much pain, and really does not know when the heated iron is being applied. If, however, the cautery be kept in contact with the blades of the clamp for more than a few moments, the patient will suffer pain by the transmission of heat through the contact of the metallic surfaces, and therefore it has been suggested to me to have some non-conducting medium applied to the under part of the blades. It is possible that I may make some alteration in this presently; but a grave objection lies in the fact that by this means. the size and thickness of the blades would be materially increased."

Mr. Allingham (p. 89) describes the mode of treating hæmorrhoids by the ligature as applied at St. Mark's Hospital, after the manner devised by the late Mr. Salmon. Expressing his opinion that ligature is by far the best and most generally applicable method of operating upon hæmorrhoidal diseases, he guards against being understood as referring to "the usual method of applying the ligature by transfixion of the base of the pile and tying it in halves." The operation he recommends is as follows:

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'The hæmorrhoids are to be seized by the operator one after another with a vulsellum or pronged hook-fork, and drawn down; he then with a pair of strong sharp spring scissors separates the pile from its connection with the muscular and sub-mucous tissues upon which it rests; the cut is to be made in the sulcus or white mark which is seen where the skin meets the mucous membrane, and this incision is to be carried up the bowel, and parallel to it, to such a distance that the pile is left, connected by an isthmus of vessels and mucous membrane only.

"There is no danger in making this incision, because all the larger vessels come from above, running parallel with the bowel, just beneath the mucous membrane, and thus enter the upper part of the pile. A well-waxed, strong, silk ligature is now to be placed at the bottom of the deep groove you have made, and the assistant then drawing out the pile with some decision, the ligature is tied high up at the neck of the tumour as tightly as possible. If this be done, all the vessels must be included. The silk should be so strong that you cannot break it by fair pulling. A portion of the pile may now be cut off, taking care to leave sufficient stump between the ligature to guard against its slipping. When all the hæmorrhoids are thus tied, they should be returned thoroughly within the sphincter; after this is done, any superabundant skin which remains apparent may be cut off; but this should not be too freely excised for fear of contraction on the healing. An injection of Liq. Opii sedativus may be

administered. I always place a pad of wool over the anus, and a tight T-bandage, as it relieves pain most materially."

One very important practical point Mr. Allingham adds, a little further on (p. 95).

"I am quite convinced that the higher you carry your incision up the bowel the less does the patient suffer, because the ligatures are removed from the most sensitive part of the rectum and lie quietly above the sphincters."

In opposition to Dr. Bodenhamer as quoted, Mr. Allingham urges rest after the operation. He says (p. 92):

"I think it advisable, though not absolutely necessary, that the patient should keep lying down until the ligatures separate, which almost invariably takes place about the sixth or seventh day, occasionally a day sooner, very rarely a day later. If the ligatures are tied tightly and the incision has been free, this course of events is but very seldom departed from. Active exertion, even after the separation of the ligatures, is to be deprecated until the sores left in the rectum are quite healed; a fortnight or a little longer is generally about the time required to accomplish this. It is quite unnecessary that the patient should be kept in bed all this time, or even to his chamber-he may move about in moderation; but I am quite certain that a too speedy resumption of the erect position is likely to retard the cicatrization of the wounds."

Under five heads, advantages are claimed by Mr. Allingham for Mr. Salmon's operation as performed at St. Mark's Hospital:

"1st. The rapidity with which it may be executed. I have often operated upon four or five hæmorrhoids, returned them, and removed redundant skin in one minute and a half or two minutes.

"2nd. There is only a very small amount of tissue included in the ligature; in fact, little more than the vessels supplying the tumour.

"3rd. At least three quarters of the wound is a simple incised wound which heals rapidly, only the small portion included in the ligature having to slough away.

"4th. The ligatures are tied a considerable distance from the anus, so that, when returned into the bowel, they lie above the internal sphincter, where the sensibility of the mucous membrane is not acute, and consequently the pain and irritation after the operation is reduced to a minimum.

"5th. The operation is wonderfully free from danger to life, and its results generally are almost always satisfactory."

Mr. Allingham combats Mr. Smith's statements in praise of the clamp and cautery, which he stigmatises as "extravagant," and declares that he has seen a much greater proportion of un

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toward results from the clamp than from ligature, not only in his own practice, but in that of other surgeons; that the suffering after the operation is very considerable, the patient not being more free from spasm of the sphincter and retraction of the levator ani than after ligature; and that a good many times he had been annoyed after the clamp operation, to find that his patient had slight but recurring arterial hæmorrhage.

The clamp, then, would appear to be admissible in those cases of internal hæmorrhoids where the tumours are not numerous, and where especially there are no external piles or hypertrophic skin requiring removal. That the ligature is the safest and most effectual remedy, the opinion expressed by Mr. Curling in 1863, is thus supported by subsequent testi

mony.

The clamp has another antagonist in Mr. Ashton, who declines to admit its advantages; he further adds that there is "The impossibility of including between the two straight lines formed by the jaws of the instrument, so irregular a growth as that constituting the base of a hæmorrhoidal tumour, and which is also frequently attached as high as the upper margin of the internal sphincter." P. 121.

Mr. Ashton figures curved needles, having a cutting edge on the concave border, and furnished with two eyes, so that after the section of the anal attachment of the pile, the needle being driven throught its base from without inwards, both eyes may be threaded with "ligatures of gold thread made of longitudinal strands of silk bound round by a spiral band of fine gold." On the withdrawal of the needle, the two ligatures occupy its place, and can be tied, one on each half of the tumour transfixed. Mr Ashton strongly impresses the necessity of drawing the ligatures as tightly as possible and of including the whole of the tissues affected, differing from Mr. Curling, who states that the contraction of the cicatrix is sufficient to reduce any part that may have escaped the ligature. Mr. Ashton thus follows the practice of Mr. Quain at University College Hospital (op. cit., p. 44). Mr. Ashton's needles probably afford a convenient instrument for landing the double ligature.

If from this common affection of the rectum, which fortunately, proves so amenable to treatment, we turn to rarer diseases-obstructions of the rectum due to stricture and to cancerwe shall meet with questions of great interest in pathology and surgery. We have long had the conviction that strictures of the rectum, not cancerous, are for the most part syphilitic; and although it has not been possible for us in every case of stricture of the rectum in women to show signs of constitutional syphilis

on the surface, nevertheless the patient always has been a person likely to have suffered from syphilis, whenever palpable signs of syphilis did not exist. A patient, for example, to all outward appearance healthy, has stricture of the rectum: the history of her past life will show that she has run the risk of syphilis; and there will probably be that condition of the margin of the anus justifying the suspicion of mucous tubercles and of fissures at a former period. On the other hand, we have had in some patients syphilodermatous phenomena that have rendered denial of previous chancre superfluous-cases where we could point to palmar psoriasis, loss of hair, spots on the scalp, and cracks at the angles of the mouth. But constitutional syphilis presenting palmar psoriasis, &c. &c., is only too common, whereas stricture of the rectum is comparatively a rare disease; the missing link in the chain of causation, the initial symptom, is, we think, overlooked; it consists, we believe, in catarrh of the rectum. The following case fell under our own observation:-A lady during her first pregnancy by her husband, who was at that date of his marriage in the early stage of constitutional syphilis, had some symptoms of syphilitic infection; she miscarried at the seventh month; she afterwards suffered from catarrh of the rectum, with fissure of the anus and vaginitis.

Why should not catarrh of the rectum be followed by stricture of the rectum, just as urethritis is followed by stricture of the urethra? When a stricture of the rectum in a female exists, why need we search for the cicatrix of an ulcer, syphilitic or dysenteric, or for any extraordinary exciting cause to explain the fact? Is it not probable that the close relationship of the vagina and rectum has an important bearing upon stricture of the latter organ? But in how many cases would not catarrh of the rectum be considered by the patient as a mere irritation of the lower bowel, and be disregarded as one of the inevitable ills connected with child-bearing, or rather, with miscarriage!

It is not a little remarkable that the majority—a large majority of cases of non-cancerous stricture of the rectum consists of female patients. Mr. Curling says that out of twentyeight cases, twenty were women (op. cit., p. 117). Mr. Curling mentions "an instance of a girl, aged thirteen, who had suffered from stricture in the rectum quite four years, consequently since the age of nine." This is the earliest age at which he had met with the complaint (op. cit., p. 124). We have ourselves met with a female child under that age suffering from stricture of the rectum that was clearly the consequence of congenital syphilis.

Dr. van Buren (p. 109) thus declares his opinion, an opinion in direct contradiction to our own:

'I mean to say that stricture of the rectum is not one of the recognised manifestations of constitutional syphilis; and I make the statement in this form beeause the contrary opinion was at one time quite prevalent among the older surgeons. This doctrine culminated about the period of Desault and John Hunter, at which time mercurial treatment was pretty generally employed in the treatment of rectal contractions. Since clearer ideas have begun to prevail as to what syphilis really is, and the distinction between it and other contagious sores contracted in promiscuous intercourse, known as simple or soft chancres, is more generally recognised, it has become evident that true syphilis has little or nothing to do with the causes of stricture of the rectum."

After adducing the evidence of Gosselin, Després, F. Probst, Van Buren concludes, that

"In summing up what is certainly known on this subject we may conclude that there is no form of the disease to which the name of syphilitic stricture of the rectum can properly be given, and that, although gummy deposit may possibly occur in this locality as elsewhere, and fall into ulceration, it is probably of very rare occurrence as a cause of stricture; and that stricture, as such, is not amenable to anti-syphilitic medication."

Does one's clinical experience in this country justify anything such as suggested by Dr. van Buren? (p. 109):

"Thus phagedæna, which is so liable to complicate non-syphilitic or soft chancre, is a recognised cause of stricture of the rectum, but rarely encountered, except in women of a certain class, where chancrous pus, flowing from the vagina, has inoculated abrasions at the anus, and the ulcers then produced have assumed the phagedenic character, and extended within the bowe.."

We would much rather endorse Mr. Smith's opinion that

"It is extremely important to recognise the syphilitic poison as a cause of the disease; otherwise we shall be led into the error of limiting our treatment to local measures alone, whereas constitutional treatment for the specific affection originally causing the stricture must be employed at the same time" (p. 42).

But we entirely disagree with Mr. Smith when he attributes the origin of stricture to syphilitic ulceration of the parts in the neighbourhood of the lower portion of the gut; and, indeed, he admits that the stricture is occasionally found at the upper part of the rectum. However, when abscesses and fistulæ have formed by ulceration extending from the gut above the seat of stricture, what course is to be pursued? Every surgeon who has had any experience knows that the ordinary "cutting for fistula"