I have the greater satisfaction in knowing I relieved all the symptoms and discomfort of the patients by very simple constitutional treatment. Dr. Bushe* remarks,

66

Organic stricture is 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. Whitet says, "The situation in which we meet with strictures in the alimentary canal is most commonly about the termination of the colon." Mr. Salmon remarks, "In the majority of cases which have * Op. cit., pp. 264-5.

6

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

On Stricture of the Rectum,' by F. Salmon, Fourth Edition,

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 af 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 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 occur

Stricture varies considerably in extent; it may affect

'Chelius' System of Surgery,' translated from the German, and accompanied with additional notes and observations, by J. F. South, vol. ii, p. 336.

+ Medical Gazette,' vol. xvi, p. 30.

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 will also accompany this disease. The tongue will be loaded, the countenance dull, and the functions of the liver and kidneys deranged. After the disease has existed for some time, the blood-vessels of the rectum and anus become engorged, and tumours are formed, most commonly by the extravasation of blood, which may become absorbed, and leave elongated folds of thickened integument around the anal orifice. Another consequence of vascular determination and impediment to the circulation, resulting from the condensation of the coats of the intestine and the pressure exerted by the accumulated fæces, is the

formation of abscess in the cellular tissue external to the bowel, which, bursting by one or several openings, degenerate into fistula. As the disease advances, the patient will have sudden and frequent desire to evacuate the contents of the bowels, violent straining ensues, he passes chiefly mucus and a little blood, the faecal matter, if any, being small in quantity; as a consequence, a sensation of fullness of the bowel remains, and is the reason why the attempts to defecate follow at short intervals. Sometimes temporary relief is experienced by the supervention of diarrhoea; the mucous membrane, from the irritation it is subject to, pours out a large quantity of mucus, which, rendering the fæcal mass fluid, permits of its passage through the contracted channel, and by this effort of nature the whole or the greater part of the accumulated matter is discharged, and serious consequences for the time averted.

When the disease has progressed, and the passage through the intestine becomes very narrow, the patient's condition is one of great peril, and symptoms of strangulated hernia or peritonitis may supervene at any moment : the former may occur from the aperture through the intestine being too small to permit the fæces to pass, or from the lodgment of some body producing obstruction, which may be a nodule of indurated fæces, or the stone of a plum or cherry, the bone of a fish, or other substance that has been swallowed, becoming entangled