tunics and intercellular membrane of the intestine, by which degeneration and alteration of the tissues are induced; the capacity of the bowel is diminished, and is still further decreased by the property of contraction inherent in the effused material.

Constipation, however induced, is one of the most frequent causes of irritation in the lower bowel, the fæces lodge in the sacculi of the colon, become hard, accumulate in the rectum, and set up a chronic state of low inflammation. Prolonged indigestion, depending on functional disorder of the stomach, duodenum, pancreas, or liver, may have the same effect, in consequence of the acridness and irritating properties of the excrementitious matter; and there are very few who have not themselves, when suffering from temporary derangement of the digestive organs, experienced, during defecation, the acute scalding and irritation so frequently attending that condition. Another frequent source of irritation is the very general habit, among many individuals, of having recourse improperly and too frequently to powerful and drastic purgatives. Dysentery and diarrhoea, particularly when neglected or improperly treated, will lead to the formation of stricture, and it may also result from the cicatrization of ulcers attending the former disease. Since the last edition of this work I have had two medical men under my care, with stricture resulting from dysentery. One was an army surgeon, who suffered severely while with the army in the Crimea; the other came from the West Indies, where he had long resided. Stricture of the rectum is also caused by a deposit of fat or fibrous tissue exterior to the bowel, but more frequently the coats of the intestine will be found infiltrated with the morbid growth. A case is recorded by Mr. Travers' of an excessive growth of fat external to the tunics of the rectum causing contraction. I have in my possession a specimen of stricture of the rectum, from a deposit of fibrous tissue external to its coats: it occurred in a woman, aged fifty-four, who had been ailing for twenty years, and for the last three years had been subject to relaxed bowels, occasionally passing blood. Ten days previous to death she was seized with severe pain in the abdomen, which subsided in a few hours. After this, constipation followed, and on the eighth day she took some castor

1 "Medico-Chirurgical Transactions," vol. xvii, p. 361.

oil; vomiting supervened, with great distension of the abdomen and considerable pain; no evacuation of the bowels was obtained. On the following day she was admitted into a public infirmary. She was much exhausted, and complained of great pain in the abdomen, which was large and tympanitic. The previous history of the case indicating disease of the rectum, an examination was made, and a contraction of the bowel found to exist at three inches from the anus, surrounded by a dense mass of morbid She died the day after her admission from exhaustion.

structure.

On post-mortem examination, the intestines were found greatly distended. No peritoneal inflammation existed. The rectum was contracted at the part already mentioned, and was surrounded by a large mass, having the appearance of fat, and very dense; but by the aid of the microscope, as well as subjecting the speci

men to the action of ether, it was found to be composed of fibrous tissue alone.

The specimen was brought before the Pathological Society,1 and is faithfully represented by the engraving.

Injuries by foreign bodies, or from attempts to extract them; lacerations of the mucous membrane, or of the whole thickness of the intestinal walls, also produce stricture: in the latter case it is usually very intractable, as is urethral stricture, the result of laceration by external violence; operations for fistula in ano, and the extirpation of hemorrhoids, when improperly performed, have given rise to this affection. Authors also mention syphilis, metastasis of cutaneous eruptions, and suppression of discharges that have existed for some time, and have become habitual, as causes of stricture of the rectum. Others are of opinion that there is frequently a predisposition to contraction of the rectum; and one recent author thinks this is not only the case, but asserts he has "repeatedly noticed several members of the same family afflicted with stricture."

It must not be supposed, as some writers would lead us to do, that stricture of the rectum is a very frequent disease: those who have had the greatest opportunities and the most extended fields for observation, whose acumen in the diagnosis of disease, and whose integrity is most to be relied on, have not met with this affection as a common occurrence. In the museums of our hospitals the pathological specimens are few, and those who are in the habit of seeing large numbers of post-mortem examinations meet with examples of it but seldom. In a large parochial infirmary in which I have had opportunities of examining many bodies, I have seldom discovered stricture of the rectum. In public and private practice I have met with not a few cases of dyspepsia, in which the symptoms simulated those of stricture, and, had I been induced to use bougies at the same time that internal remedies were prescribed, I might have deluded myself with the belief that I had cured a disease which, in reality, had never existed: however, I have the greater satisfaction in knowing I relieved all the symptoms and discomfort of the patients by very simple constitutional treatment. Dr. Bushe2 remarks: "Organic stricture is

1 See "Pathological Transactions," vol. vi, p. 201. 2 Op. cit. pp. 264-5.

supposed by many to be of very common occurrence, but I have not found it to be so; for the cases I have seen bore no proportion to the number I ought to have met with, were the statements made in books correct."

The most usual seat of stricture of the rectum is within two or three inches of the anus, and it can readily be detected by the finger: occasionally it is found higher up, even in the sigmoid flexure of the colon, but these cases are very few, and their absolute existence has not generally been known till after death; on the contrary, the cases in which stricture was supposed to have existed, and absence of all contraction has been demonstrated by post-mortem examinations, are by no means rare. Some writers

have expressed opinions that stricture is most common about the termination of the colon: Mr. White' says: "The situation in which we meet with strictures in the alimentary canal is most commonly about the termination of the colon." Mr. Salmon2 remarks: "In the majority of cases which have fallen under my observation, the stricture has been situated between five or six inches from the anus, about the situation of the angle formed by the first portion of the rectum. Next in frequency I have discovered the disease at the junction of the sigmoid flexure of the colon with the rectum." Mr. South observes: "These, however, must be very rare cases, for all the best authorities declare the stricture to be almost universally low down." Finally, I may quote the opinion of Sir Benjamin Brodie: "Strictures of the rectum are commonly situated in the lower part of the gut, within the reach of the finger. Are they ever situated higher up? I saw one case where stricture of the rectum was about six inches above the anus; and I saw another case where there was stricture in the sigmoid flexure of the colon, and manifestly the consequence of a contracted cicatrix of an ulcer, which had formerly existed at this part. Every now and then, also, I have heard, from medical practitioners of my acquaintance, of a stricture of the upper part

1 "Observations on Strictures of the Rectum and other Affections," by W. White, Third Edition, Bath, 1820, p. 47.

2 "On Stricture of the Rectum," by F. Salmon, Fourth Edition, p. 23.

3 "Chelius's System of Surgery," translated from the German, and accompanied with additional notes and observations, by J. F. South, vol. ii, p. 336. 4"Medical Gazette," vol. xvi, p. 30.

of the rectum, or of the sigmoid flexure of the colon, having been discovered after death. Such cases, however, you may be assured, are of very rare occurrence.”

Stricture varies considerably in extent: it may affect only one side of the bowel, or be confined to one of the folds of the mucous membrane which some anatomists term valves, or the whole circumference of the intestine may be involved, forming annular stricture : the same difference also exists with regard to the extent to which the bowel is affected longitudinally; the induration may be only a few lines in width, or may extend to several inches.

Stricture of the rectum attacks both sexes, and its comparative frequency in each is nearly equal; some writers having seen a majority of cases in females, whilst others have observed the reverse to obtain: however, they all agree that the difference in numbers is very slight; thus, out of fifteen cases of genuine stricture, which were all Dr. Bushe had seen, eight were females.

The period of life in which this affection usually develops itself is between twenty-five and sixty; but it has been observed as early as the ninth year, and from injury at five years of age. Dr. Bushe had a patient die of it in his seventy-second year.

Stricture of the rectum is very insidious in its progress, and the surgeon is seldom consulted till it has made considerable advances, and the symptoms become urgent. On inquiring into the history of such cases, we shall find the patient has for some time previously been subject to constipation, the bowels acting only at intervals of several days, the stools being scanty, passed in small lumps, or, attenuated and compressed; at other times diarrhoea supervenes, caused by the constant irritation to which the mucous membrane is exposed, the fluid fæces being ejected as if from a syringe. Itching and heat about the anus are early symptoms. The stomach and upper part of the alimentary canal are sympathetically affected, digestion is impaired, flatulent distension and spasmodic pains in the abdomen are complained of, and palpitation of the heart, and headache, will be other sources of suffering. After the disease has progressed to a certain extent, there arises a sense of obstruction and weight in the bowel; pain in the loins, extending down the hips and thighs, irritability of the urinary organs will be induced, and in the female, there will be a sensation of bearing down of the womb; nervous irritation and despondency