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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 thirtyfourth 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 inter-muscular areolar tissue, and extends in wards, 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 ster. coraceous fistulæ. 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

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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. Busk * 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.

*Pathological Transactions,' vol. i., p. 67.

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 malignant 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

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