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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 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. Southf 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.J "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

* • On Stricture of the Bectum,' by F. Salmon, Fourth Edition, p. 23.

t 'Chelius' System of Surgery,' translated from the German, and accompanied with additional notes and observations, by J. F. South, vol. ii., p. 336.

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

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 he 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 faeces 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 faeces, is the formation of abscess in the cellular tissue external to the bowel, which, bursting by one or several openings, degenerate into fistulas. 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 fiscal matter, if any, being small in quantity; as a consequence, a sensation of fulness 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 fiecal 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 faeces to pass, or from the lodgment of some body producing obstruction, which may be a nodule of indurated faeces, or the stone of a plum or cherry, the bone of a fish, or other substance that has been swallowed, becoming entangled, and occluding the opening. Obstinate constipation sets in, followed by vomiting: at first, the contents of the stomach only are thrown up, but shortly the vomiting becomes stercoraceous, and unless the natural passage be restored, or an artificial one formed, a fatal termination will be the consequence. In other cases, the patient may be carried off by peritonitis, which is generally induced by perforation of the coats of the intestine; ulceration taking place above the seat of stricture: while this process is going on, diarrhoea is often present.

Unless a stricture of the rectum is within reach of the finger, and fortunately it usually is, the diagnosis must be uncertain, and surrounded with doubt;

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