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appetite fails, the tongue is furred, and lancinating pains in the rectum, extending up the sacrum and down the thighs, and flatulent distension of the stomach and bowels will be experienced. As the disease advances, ulceration attacks the morbid growth and extends to the coats of the intestine, a copious fetid, purulent discharge, and haemorrhage to a considerable extent occur, by which the strength is greatly reduced; defecation is performed with difficulty, and attended with great agony; emaciation takes place, and the patient at last sinks, worn out by pain, irritation, and hectic.
Polypi of the rectum are usually solitary, but occasionally there may be more than one.
Mucous polypi are not very sensible; but they should be removed as soon as discovered, there being a possibility of their degenerating in structure, and proving fatal. Ligature presents the best means for their removal, and is that which I have hitherto adopted. Bushe recommends excision of polypi, and thinks there is no cause for the apprehension of haemorrhage. Sir Astley Cooper experienced considerable bleeding in one case, in which he excised a polypus: he usually removed them by ligature. Mr. Syme has always had recourse to that method. If the peduncle is near the anus, its connection with the intestine may be brought into view by injecting some warm water into the bowel, and at its expulsion the tumour will be prolapsed, when it must be seized with a pair of forceps and pulled down, and its point of attachment to the bowel will be seen; a ligature should then be applied around its origin, after which it may be cut off by a pair of scissors, taking care not to cut it so close that the ligature may be in danger of slipping off. If the polypus be sessile, or its stalk broad, the base should be transfixed by a needle carrying a double ligature, and tied in two portions. When situated higher up the gut, and the base not easily accessible to the fingers, a canula, similar to those employed in ligaturing polypi of the uterus, must be employed, or the ligature may be passed through a portion of gum elastic catheter. A medical gentleman engaged in extensive practice in one of the chief seaport towns brought his mother to me, requesting my advice: for several years she had experienced great discomfort and annoyance from a polypoid growth, about six inches in length and one inch and three-quarters in diameter, connected with the posterior part of the rectum, about five inches from the orifice: it was attended with a copious muco-sanguineous discharge. I recommended its removal, and Sir BenjamiD Brodie, who also saw the lady, concurred in my opinion. The patient was put under the influence of chloroform by Mr. Potter, and Mr. Knaggs making traction on the growth with a pair of strong forceps, I was able to carry a double ligature through the base, and effectually strangulate it; I then cut it off near its connection. The ligatures came away in a few days, and the lady experienced not the slightest inconvenience from the day of the operation.
Previously to operating, the bowels should be freely acted on, that they may not require to be relieved for several days afterwards. Subsequent treatment is seldom necessary with respect to the local affection, which is the only subject of consideration now before us.
STRICTURE OF TJrlK RECTUM.
When we consider the many points of analogy in structure and function of the rectum and those of the oesophagus and urethra, and of the numerous sources of irritation to which the terminal portion of the intestinal tube is exposed, it is not surprising that, like the last-named two mucous canals, it also should be liable to the formation of stricture.
Contraction of the rectum is met with under two very different forms. The one consists of a contraction and induration of its coats, and deposit of lymph in the connecting cellular tissue, which, when occurring within certain limits of the anus, and coming under our observation before it has proceeded to too great an extent, is very amenable to judicious surgical treatment. But in the other form, unfortunately, we are able to do but little more than palliate the sufferings of the patient, and perhaps retard the onward progress of the disease to a fatal end. This second kind of contraction consists of those heterologous growths and degeneration of structure denominated malignant, appearing as carcinomo, encephaloid, or colloid disease. It is obviously highly essential we should consider the two forms separately, and not confound them together; for, as Mr. Syme* remarks, . " Want of attention to this very obvious and necessary distinction has led to great misapprehension in regard to the nature of the disease, and serious errors of practice in its treatment." In this chapter it is intended to consider only the simple or benign stricture. Stricture of the rectum results from inflammation and prolonged irritation produced by a variety of causes, and, as a consequence, the deposit of plastic matter interstitially in the proper 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 faeces 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 con* Op. cit., Third Edition, p. 107.