cicatrization and contraction would be more likely to arise, in cases of ulceration where the remaining coats of the bowel and parts around were healthy and yielding, than where there was much thickening and condensation of the subjacent tissues; and perhaps, this may partly account for the circumstance that, in such extensive disease as I have described in the foregoing chapter, there was so little attempt at repair, and scarcely any diminution in the calibre of the intestinal canal. Injuries of the rectum causing a breach in the mucous surface have in several instances produced contraction of the rectum. There is a preparation of much interest in the Museum of St. Bartholomew's Hospital, taken from a child five years old. Ten months before death, in the endeavour to administer an enema, a clyster-pipe was forced through the adjacent walls of the rectum and vagina. At the part thus injured there is a small depression in the wall of the vagina, and a long, pale, and irregular cicatrix in that of the rectum. Near this cicatrix, also, there are traces of small healed ulcers of the mucous membrane of the rectum. Just below the cicatrix, at a distance of about an inch from the anus, the canal of the rectum is reduced to an eighth of an inch in diameter, and the adjacent tissues are indurated. Above this stricture the intestine is greatly dilated.

Some difference of opinion exists respecting the seat of a stricture in the rectum. It varies, but is usually at the lower part of the gut, about two inches from the anus, and easily within reach of the finger. The point at which the sigmoid flexure terminates in the rectum, which naturally presents a slight contraction, is not

unfrequently the seat of stricture. If this part be loosely attached, the weight of the fæces accumulating above the stricture, and the violent straining of the patient, may force the contracted part low enough to be reached with the point of the finger introduced at the anus, the descent taking place in the form of a slight inversion of the bowel. A man with a stricture at this point was under my care in the London Hospital in 1850. The case was remarkable from the extraordinary dilatation which the bowel below the stricture had undergone. The finger seemed to pass into a capacious sac, at the fundus of which the contracted aperture of the intestine could be felt projecting.

Stricture of the rectum is a disease of middle life. It very seldom occurs in children, unless, as in the case related in the preceding page, where it was the consequence of injury. A few years ago, a girl, aged eleven, died in the London Hospital from stricture and ulceration of the rectum, the history of which I have not been able to trace. This is the earliest age at which I have met with the disease. It is rare, also, in old people. Most of the cases that have fallen under my notice have been between the ages of twenty and forty, and threefourths were women.

The earliest symptom of stricture is, generally, habitual constipation, with difficult defecation when the motions are solid. The difficulty being readily relieved by a solvent purgative, the nature of the case is not usually suspected at this early period. As the contraction increases, the constipation is with difficulty overcome, and the patient acquires the habit of straining to relieve the rectum. The stools are observed to be small in calibre, and are often voided in small

lumps. The mucous surface, irritated by the disturbance in the functions of the rectum, becomes inflamed and excoriated. This renders the actions of the bowels painful, a burning sensation lasting frequently for an hour or more after a stool. There is also a secretion of brown slimy mucus, which escapes with the motions, and soils the linen. The gases evolved in the intestines not escaping readily, give rise to flatulent distension of the abdomen, and disagreeable efforts for relief. The bowels often remain constipated for days together, and then a strong cathartic softens the motions, and enables the patient to void the accumulated mass, its passage being attended with pain. In other instances, the patient is teased with frequent evacuations, fluid, and small in quantity. As the disease makes progress, the mucous membrane ulcerates; the discharge becomes purulent and bloody, and the sufferings are much increased, the passage of motions being sometimes likened by the patient to a feeling as if boiling water were passing through the rectum. At this period, pain is often experienced in the sacrum. There is sometimes so copious a discharge as to mislead the practitioner, the stricture being overlooked, and the case treated as one of protracted diarrhoea. A slimy fluid perhaps escapes when the

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I give no account of the small, or flat tape-like, or figured fæces described by writers as characteristic of stricture, as I do not ascribe much importance to these appearances. When the bowels are irritable, and act frequently, persons with a healthy rectum will pass small and figured fæces; and an irritable sphincter likewise influences the size and shape of the motions. Besides there is no necessity to pay much attention to an uncertain symptom, when an examination with the finger can so readily determine the real condition of the part.

patient rises in the morning; and may, also, occur when he coughs or sneezes. The ulceration often leads to abscess and fistula, feculent matter being forced, or finding its way through the ulcer into the areolar tissue around, and exciting inflammation and suppuration. Fistula in ano, and sinuses in the buttocks or labia are, indeed, common complications of strictured rectum, especially in long-standing cases.

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The appetite often remains good, and even the ral health but little impaired, for a long time. The disease is very chronic in its progress; and so long as a passage for the motions can be obtained, though with difficulty, the patient continues following his avocations, suffering more or less at different periods. Indeed, it is surprising how great a length of time the general health will sometimes continue without being materially affected, even in cases of close contraction of the gut. The derangement of the digestive functions, and irritation kept up by the disease, in the course of time, however, undermine the constitution, and bring on hectic symptoms. The appetite at length fails; there is sometimes urgent thirst; the body emaciates; night sweats become profuse, and the stricture directly or indirectly becomes the cause of death. This is sometimes hastened by a lodgement of hardened fæces, or of some foreign body, just above the stricture, so as to block up the passage, and occasion all the ordinary symptoms of internal obstruction, with the death of the patient after many days' constipation. I know of several instances in which an occurrence of this kind first led to the detection of the complaint. In a patient whose motions are habitually soft, the stricture may make considerable progress without suspicion being excited of the existence of any important disease. He

may continue for months subject to occasional constipation and derangement of the bowels, and passing fæces of small size, but experiencing no further inconvenience until a sudden stoppage, and an examination of the rectum, reveal the presence of a serious stricture. The following case shows how slight may be the discomfort produced by a considerable contraction in the passage for the fæces:-A gentleman, of middle age, called on me one day in the autumn, complaining of inability to pass his stool, and of great pain from some obstruction at the anus. On examination I found a hard, rigidly-contracted anus, scarcely capable of admitting the point of the little finger, and a solid body impacted in the opening. Grasping this with a pair of forceps, and using some force, I extracted a plum-stone. On inquiry, I learnt that my patient had been operated on about two years before by a surgeon at the west end of town for some kind of growth at the anus, since which the orifice had remained contracted. His evacuations had been small in calibre, but he had experienced no difficulty in passing them, and previous to the obstruction described had not been troubled in any way. The suffering in stricture much depends upon the condition of the mucous membrane. When it becomes excoriated and ulcerated early, there is generally more distress in the after progress of the disease, and greater difficulty in conducting the treatment.

The symptoms of fully-formed stricture in the rectum are so clearly marked that the surgeon can generally predicate correctly the nature of the disease. He will desire, however, to have his opinion confirmed by a tactile examination. On exposing the part, small flattened excrescences are usually observed at the margin of the anus, especially when the stricture is