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instrument for the purpose is a narrow blunt-pointed bistoury passed into the stricture on the finger previously introduced; several slight notches are far preferable to one of greater extent, as there will then be no fear of hemorrhage, or of matter forming in the cellular tissue. In 1855 a gentleman came from Australia to place himself under my care, having stricture of the rectum arising from congenital malformation. The stricture was so dense and unyielding that, with the ordinary bougie, I was unable to make much progress in dilatation. I then contrived an instrument which I could easily introduce into the stricture, and then distend it laterally, and was thus enabled to proceed rapidly and satisfactorily with the case. Subsequently I have improved on the instrument, and in the one I now use the pressure can be regulated to any degree with the greatest ease. It has been proposed to destroy the indurated structure by various escharotics; but such a proceeding must always be uncertain in its effects, from the difficulty of limiting the action of the caustic, and therefore unadvisable.

Those cases of stricture that have come under my observation have been within reach of the finger, and have been treated on the principles advocated in the text.

Various instruments have been invented for dilating strictures of the rectum, by Weiss, Bushe, Arnott, Sir C. Bell, Charriere, Bermond, Costallat, Coxeter, and others; but though all of them are ingenious, they do not well answer the purpose.

When the stricture is in the sigmoid flexure of the colon, we cannot expect to obtain much benefit by bougies, from the uncertainty that attends their use in such cases. Should the contraction become so great that symptoms of permanent obstruction arise, the propriety of establishing an artificial anus, in order to save the patient's life, will be forced on our consideration. The bowel may be opened through the anterior walls, as suggested by Littre, or from the lumbar region, as proposed by Callisen, or by Amussat's modification of the latter. In the thirty-fourth volume of the "Medico-Chirurgical Transactions," Mr. Luke has considered the merits of the two operations, and in the thirty-fifth volume there is a very valuable paper by Mr. Cæsar Hawkins, in which all the recorded cases are arranged in a tabular form, and an elaborate analysis appended. Details of several of the cases are also published in the Society's Transactions.

CHAPTER XIV.

MALIGNANT DISEASES OF THE RECTUM.

THE rectum is one of the parts of the human frame in which is evidenced a disposition to those intractable heterologous growths and transformations of tissue, comprehended under the titles carcinoma or scirrhus; medullary or encephaloid cancer, and colloid cancer. Melanotic cancer of the rectum is not of rare occurrence in the horse; but I am not aware of its having been observed in the human subject, though I have seen, in the dissecting room, several instances of melanotic deposits in the ischio-rectal fossa.

Unlike simple stricture, malignant disease occurs most frequently in the upper part of the rectum, or in the sigmoid flexure of the colon: in a few cases the anus is the part first affected, the disease then assuming the form of epithelial cancer, and being of the like character to that we observe occurring in the lip and other parts.

Carcinoma or hard cancer commences either as tuberculous growths, of cartilaginous consistency, projecting from the surface of the mucous membrane, or originates in the intermuscular areolar tissue, and extends inwards, involving the other textures. In the progress of the disease, the muscular fibres become pale, degenerate, and lose their distinctive characters in that of the morbid growth; the calibre of the bowel is diminished by contraction, and by the projection of tubercles and nodules into it. Ulceration ensues, which may extend till perforation of the bowel takes place. Abscess is sometimes formed in the ischio-rectal fossa, leading to the formation of fistula: abscess may also occur in the cellular tissue of the pelvis, and the matter discharge itself by openings situated above the crest of the ilium, over the sacrum, and about the buttocks and upper part of the thighs: should an internal opening with the intestine coexist, these channels will constitute

stercoraceous fistula. The pelvic bones may also become affected by caries, or otherwise involved in the disease.

The rectum in some cases is involved in cancerous disease, which has its origin in adjoining structures: it is frequently implicated when the disease has commenced in the uterus, or in the upper part of the recto-vaginal septum, and then, by the process of ulceration, a communication may be formed between the rectum and vagina: in the male the bladder is liable to be involved, or the disease may originate in that viscus, and implicate the rectum secondarily. When the bladder is the primary seat of the disease, it usually appears in the form of medullary cancer. Mr. Busk1 exhibited a preparation at a meeting of the Pathological Society, in 1846, taken from a boy who died of acute peritonitis. He had a tight stricture of the rectum, three or four inches from the anus: it was accompanied by ulceration of the mucous membrane, and was produced by a large deposit of medullary sarcoma external to the muscular coat of the intestine. In the greater number of cases, unless they come under our observation from the commencement, we are unable to trace the disease to the tissue or organ in which it originated, in consequence of its extending, and so thoroughly pervading the whole of the surrounding structures.

The extent to which the intestine is affected varies with the character of the disease and its duration: carcinoma may occupy the whole or greater part of the circumference, and extend from one to six or eight inches in a longitudinal direction. Medullary and colloid cancer more generally implicate only a portion of the circumference of the bowel, but its cavity will be greatly reduced by the projection inwards of large masses of the morbid structure.

We meet with malignant disease of the rectum occurring concurrently with cancerous affections of the mamma, stomach, pylorus, and other organs, and it is very generally found as a secondary deposit in the lumbar and mesenteric glands, and in the liver.

Cruveilhier thinks cancer of the rectum, in whatever form it may appear, is mostly a local disease; but the majority of pathologists consider that malignant disease occurring in any part of the body, if ever local, is only so at a very early stage, that the constitution speedily becomes tainted, and a cachectic and malig

1 "Pathological Transactions," vol. i, p. 67.

nant diathesis established: in practice, we find, when a cancerous part has been removed by operation, in the greater number of instances, it returns either in the cicatrix or other parts of the body.

In April, 1855, I removed the right breast of a lady affected with cancer: the disease was circumscribed; the skin so slightly implicated that it escaped the observation of one surgeon who saw her; the glands of the axilla were not affected, and her general health apparently could not be better. But she died about four years after the operation, of cancer of the liver. I could recite many similar cases occurring in my own practice and that of other surgeons.

Malignant disease of the rectum is much more frequent than is generally supposed, and often escapes recognition till an advanced stage of its existence, the symptoms being attributed to one or other of the affections concurring with cancer. I have seen many cases where the patient was presumed to be suffering from fistula, hemorrhoids, dysentery, stricture, constipation, &c., and a useless plan of treatment pursued, whilst the vital powers had gradually declined under the insidious advances of a fatal disease. There is a greater tendency to cancer in females than in males, and in them is frequently developed about the time of the cessation of the menstrual function. The meridian of life, in both sexes, is the period most obnoxious to cancerous affections; but no age is exempt: encephaloid disease is more likely to attack the young than carcinoma. Bushe1 saw a case of the former in a boy of twelve years, and Mr. Busk's patient, previously referred to, was sixteen years

of age.

Whatever may be the character of the disease, whether carcinomatous, encephaloid, or colloid, it makes considerable progress, in the majority of cases, before giving rise to any severe or prominent symptoms. Constipation is one of the early effects, and often attributed to functional derangement only, but arises from the morbid growth projecting into and narrowing the capacity of the bowel, and also annihilating the function and power of contraction. Fistula in ano is often met with as a complication. Hemorrhoidal excrescences, internal and external, are frequent concomitants, resulting from obstruction to the circulation by the cancerous

1 Op. cit. p. 292.

mass in some cases a muco-sanguineous discharge, more or less profuse, may be all that engages the patient's attention; but sooner or later a dull aching and fixed pain in the sacral region, violent tenesmus, weight and bearing down, especially after defecation, severe shooting and lancinating pains extending to the loins, hips, and down the thighs, are experienced. The stools are passed with difficulty and pain, are scanty and frequent, and attended with bleeding or a puriform sanies, which is often excessively fetid in fungoid disease considerable hemorrhage occurs. from time to time. In most instances the stools are compressed and figured, or passed in small pellets, as in simple stricture, or diarrhoea may be present. From contiguity or implication severe vesical irritation is induced, and the patient is tormented by a constant desire to micturate in the female the uterus and vagina are frequently affected. Last year I saw, in consultation, a young lady, a patient of Dr. Barnes, who had cancer of the anterior and left walls of the rectum, which were extensively ulcerated: the cancer also affected the posterior wall of the vagina, the mucous membrane of which was not ulcerated, yet she complained of more pain in this part than in the rectum. I saw a similar case in consultation with Dr. Ridsdale. The whole of the digestive organs become deranged, causing flatulent distension of the stomach and intestines, and acute pains in the abdomen as the disease advances, hiccough, eructations, nausea, and vomiting are present; the appetite fails, emaciation and loss of strength ensue, the countenance assumes the peculiar leaden hue indicative of malignant disease, anasarca and hectic supervene, and under continuous suffering the vital powers succumb. Sometimes obstruction takes place, and the patient dies with all the symptoms of internal strangulation; or ulceration having extended up the bowel, rupture takes place during an expulsive effort, and fatal peritonitis occurs. This happened to Dr., an eminent physician residing in Lincolnshire, who sent for me in July, 1859, the day before he died. His bowels had not been moved for eight days previously to my seeing him: I passed a small O'Beirne's tube and injected some thin warm gruel, which had the effect of bringing away large quantities of fæcal matter; this was repeated several times. I left him on the following morning to return to town: subsequently he had several free evacuations: late in the after

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