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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 fistulæ. 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 fæcal matter, if any, being small in quantity; as a consequence, à 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 diarrhæa; 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, 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, diarrhea 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 ; exploration by a bougie can never be satisfactory, nor can it afford us positive information, from the liability of its progress being arrested by a fold of the mucous membrane, or the promontory of the sacrum, or by a flexure of the intestine, which in some individuals may be abrupt, and also liable to alteration of position at different periods. The instances are not few in which stricture has been supposed to exist, and numerous fruitless attempts have been made to pass a bougie, when, after death, no organic obstruction has been discovered. Mr. Syme* mentions the case of an elderly. lady who had been supposed, by two medical men of high respectability, under whose care she was, to suffer from stricture of the rectum between five or six inches from the anus; he goes on to say, “Finding that the coats of the rectum, though greatly dilated, were quite smooth, and apparently sound in their texture, so far as my finger could reach, and conceiving that the symptoms of the case denoted a want of tone or proper action, rather than mechanical obstruction of the. bowels, I expressed a decided opinion that there was no stricture in existence. Not many months afterwards, the patient died; and when the body was opened, not the slightest trace of contraction could be discovered in the rectum, or any other part of the intestinal canal.

* Op. cit., pp. 110, 111.

One gentleman who had been formerly in attendance, was present at this examination, and wishing to know what had caused the deception, which he said had led to more than three hundred hours being spent by himself and colleague in endeavours to dilate the stricture with bougies, he introduced one as he was wont to do, and found that, upon arriving at the depth it used to reach, its point rested on the promontory of the sacrum.” But even supposing the instrument to enter a constricted portion of the gut, how are we to tell whether it is a simple stricture or a carcinomatous contraction ?—a question of the utmost importance, for the treatment that would be beneficial in the former case, would only aggravate the latter.

When a patient complains of a difficulty in defecating, and passes small and contorted stools, it by no means follows that stricture of the rectum exists: a variety of causes will produce these symptoms : they are very common in dyspeptic patients, caused by spasmodic and irregular contraction of some portion of the rectum or of the sphincter muscles : the latter is a condition of parts constantly attending ulceration of the lower part of the rectum ; the pressure of a displaced and enlarged uterus, ovarian, uterine, and other pelvic tumours, abscess of the recto-vaginal septum, the impaction of alvine

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and biliary concretions, and in the male the enlargement of the prostate gland, may all produce the like effects.

One peculiar feature in stricture of the rectum is, that sometimes the patient's general health remains for a long period unaffected; he may have suffered from constipation or irregularity of the bowels, which he attributed only to functional disorder : cases are on record where the disease has advanced till fatal obstruction has taken place, without the disease having been previously suspected, either by the patient or his medical attendant. Usually the appetite fails, the patient becomes pale, loses flesh, and ultimately hectic fever sets in, under which he sinks by the exhaustion of the vital powers. Previously, however, to the final termination of the case, a copious mucopurulent secretion takes place, and is sometimes so acrid as to produce excoriation of the anus, and may be in such quantity as to flow outward when the slightest exertion is made, or even on the erect position being assumed.

Sometimes sufferers from stricture die from the accumulation of fæces in the colon, before ulceration and hectic commence: they become melancholy and pallid, are greatly distressed by flatulent distension, the circulation is disturbed, the pulse being weak and irregular, respiration is embarrassed by the free action


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