Such are the results of the investigation of this subject hitherto made. By comparing them together, it is easy to see how far they differ from one another. Unless we deceive ourselves respecting the justice of those results which we ourselves have obtained, it will be seen, by what follows, how far they all deviate from the truth. CRITICAL ANALYSIS OF RECENT PUBLICATIONS IN THE DIFFERENT BRANCHES OF PHYSIC, SURGERY, AND MEDICAL PHILOSOPHY. Appendix to Observations on the Contracted Intestinum Rectum: containing some additional Facts relative to that Complaint; with several Cases, and two Engravings. By W. WHITE, Member of the Royal College of Surgeons, London, and one of the Surgeons to the City Infirmary and Dispensary, Bath. 8vo. Bath, 1813. pp. 53. OME time ago we gave an analysis of Mr. White's treatise on Contracted Intestinum Rectum. The ingenuity and practical utility of that treatise, we endeavored to impress on our readers. The subject, always of importance, had been brought more under public observation than heretofore, by the publication of Mr. Copeland; the immediate inducement, as it then seemed, to Mr. White's pursuing the inquiry. Since that period many cases have fallen under the care of Mr. White, nine of which are here related. There are two points in this little volume principally to be looked to: one of these is a practical fact of some importance; the other assumes more the character of an hypothesis, though it is not directly hypothetical. A marked trait in the contracted rectum, and constituting a prominent feature in the diagnosis, is that of the faces being found to be lessened in their diameter. The occasional deviation from this, in advanced stages of the disease, when fæces of a natural size, at times, pass, Mr. White notices, with a view to prevent the practitioner mistaking the cases when this circumstance does arise; and as it appears mechanically contradictory, he enters into the following explanation of it. "If the stricture should happen to be low in the rectum as not to allow room for the accumulation of fæces, it must appear evident that 3 F 2 they they will be found uniformly small in diameter, in proportion to the degree of stricture, while they continue to be discharged in a figured state. And also, when the stricture happens to be high up the rectum, so long as the gut below the stricture retains its natural expulsive power, an accumulation will be prevented, and the diminished size of the fæces will continue. But as the disorder increases, the inferior portion of the intestine gradually loses that power; so that when the contraction becomes considerable, only a small quantity of fæces pass at a time through the stricture, and not being sufficient to stimulate the lower part of the rectum, an accumulation goes on from time to time, until at length it becomes difficult to remove; when on these occasions fæces of a natural size have sometimes been discharged." It has now some time been the fashion, or rather, perhaps, has now become an admitted fact, that strictures in the urethra, by some, yet unexplained, sympathy, produce morbid actions in distant parts of the system, of a character, à priori, not at all referable to such a cause. Mr. White does not doubt but strictures of the rectum may excite derangement in remote parts of the intestinal canal, or in organs that are associated with it in the performance of its natural functions. The liver is the organ to which our author looks as most likely to undergo this sympathetic derangement. In two patients a tuberculated state of the liver was believed to be the consequence of stricture in the intestine; and as the opinion is in a measure new, we shall lay before our readers the whole of the third case, which goes, in the author's opinion, particularly to this point. In this the biliary secretion was disturbed, and the alvine evacuations were always of a light clay color, except when the patient was taking calomel. "CASE 3.-Feb. 1812, E. Morgan, an unmarried woman, sixtythree years of age, complained of having been subject to pains about the os sacrum shooting down the hips, between four and five years. She had been always of a costive habit of body, seldom having any evacuation for four or five days, and not then without the aid of a strong purgative medicine, About a year ago she was attacked with a sudden hæmorrhage, which she supposed to have been a return of the catamenia in a most extraordinary and violent manner; but on the hæmorrhage recurring shortly after, she was convinced the discharge proceeded from the rectum; ever since which she has had frequent returns of the hæmorrhage; and upon that ceasing, a serous discharge supervened. Between five and six months ago she began to experience considerable pain and difficulty in passing her stools, attended with tenesmus, and almost constant pain in the gut her strength was much reduced, with frequent flushings of heat, but her pulse was regular. "On examination, I found great irregularity and induration in the rectum, about an inch from the anus, which extended some way up the the gut, when a considerable contraction was discovered, but yet a sufficient passage to admit the tip of the finger being introduced: the contracted part had an irregular and indurated feel. That I might have the patient more immediately under my care, she was admitted an in-patient at the Bath City Infirmary on the 25th of February. The next day a small tent was introduced, and the following pills were prescribed: R. Extr. conii, gifs. Pil. hydrarg. 3fs. M. f. pil. xxx æquales divid. "A clyster, with gruel and castor-oil, was also directed to be thrown up daily. Her diet-gruel, broth, arrow-root, and light puddings. "Feb. 27th.-Has had several motions without the injection, and less pain-tent again introduced. Capt. pil. extr. conii, et pil. hydrarg. j. mane et vespere, et quoque pil. opiat. gr. j. o. n. h. s. "28th.-Has a troublesome cough, breathing short, with wheezing. Omittr. pil. hydrarg, &c. R. Liquor ammon, acet. Aq. menth. pip. āā 3ils. puræ, 3iij. Syr. papav. alb, oxym. scillæ, aa 3ij. M. f. mist. Capt. coch, ij. ampl. 4ta. quaque hora. Repr. pil. opiat.-A tent introduced. 29th.-Breathing rather better, and less pain in the rectum. Repr. mixt. et pil. opiat.-A tent introduced. As the bowels had not been freely open, an injection was directed. "March 1st. Had a good night; the bowels have been moved in consequence of the injection, with scarcely any appearance of blood— A tent introduced. 66 2d.-Breathing much worse, and cough more troublesomepulse quick; has had two or three small loose motions without any blood. Repr. med. et enema laxativ. "3d. Her breathing better, and cough not so troublesome: had three motions from the injection, but no blood. 4th. Much the same: has frequent loose stools, (so as to prevent introducing the tent) but unattended with pain. "5th. She has still a frequent discharge of loose stools. Injecr. enema opiat. "6th.-Breathing much worse, with increase of wheezing, and the cough more troublesome; skin hot and pulse quicker; tongue white, and complains of thirst. A very large quantity of consistent fæces has passed. Applicr. emp. canth. sterno. Repr. mixtur.; add spt. æther vitriol comp. 3ij. "7th.-Breathing somewhat relieved, but the feverish symptoms continue. Has had two small loose motions. Repr. mist. et capt, haust, anodyn. h. s. "Sth. Both breathing and cough better; pulse not so quick, and tongue cleaner. Has had three small motions with a little blood. Repr. enema opiat. On introducing a tent, I perceived a fætid discharge from the rectum, which I had not before noticed. Repr. med. • 11th.- 11th.-Has very little uneasiness in the rectum, but general pains over the abdomen. Cough and breathing still troublesome," though in a slighter degree. Not so much heat on the skin, nor quickness of pulse. Repr. med. et enema opiat. 12th.- Less pain over the abdomen. Although there is less heat on the skin, she complains more of thirst. Has had some small loose motions. Repr. enema laxativ. 13th.-Has very little pain in the abdomen. The clyster occasioned several loose motions, which very much relieved her—a tent introduced. "14th.-Breathing more affected; has had several loose motions. Applicr. emp. canth. sterno, et repr. med. 66 15th.-Breathing somewhat relieved, but the cough still troublesome has had two loose motions, besides what is found to pass away involuntarily on returns of cough-a tent introduced. 66 "16th.-Had a restless night, from the difficulty of breathing and cough passed several sanious colored loose motions. Repr. med. 17th.-Breathing and cough much the same, but now attended with an expectoration free and copious-has had two small loose motions of the same appearance as last. Repr. med. et enema laxativ. "18th.-Breathing much the same; a little bloody mucus is brought up with the cough: has had more uneasiness in the bowels. Two injections have been given without producing any effect-the injec tion was ordered to be repeated with the addition of a little murias sodæ. "19th.-Had no evacuation until she took some castor-oil this morning, which procured several motions: cough and breathing much the same. Repr. med. "20th.-Had a better night: breathing not so difficult; skin cool; pulse regular; tongue clean. Passed three stools without any pain. Repr. med. 22d. Her breathing much better, and cough not so urgent: had a very good night; bowels open-a small tent introduced. 66 24th. Continues better: bowels still in an open state, and the evacuations of a more natural consistence-a tent introduced. "26th.-Bowels having been confined yesterday has taken castoroil, which procured three motions, one of them very copious-a tent introduced. "27th. Her breathing and cough better: bowels open-felt a soreness in the rectum after the tent yesterday. 28th.-Feels better; has had two motions without pain—a tent introduced. "30th.-Having had no evacuation yesterday took castor-oil, which operated two or three times. "31st. Complains of sickness, and the having brought up bile: had a motion this morning, followed by a little blood. The fœtid lischarge from the rectuni has ceased. Capt. mist. salin. card. 3i. 4tis, horis. Capt. haust. Anodyn. b. sa tent introduced, April " April 3d.-Sickness better: complains of pain over the abdomen. Took castor-oil yesterday, which procured several motions-a tent introduced. "5th.-Less pain in the abdomen: bowels open, and the fæces discharged without pain--a tent introduced. "11th.-Complains of having had a considerable soreness in the rectum since the last tent was introduced. Although, on examination with the finger, the contraction does not appear increased, yet there is a greater difficulty in passing the tent from the extreme irregularity on the internal surface of the gut-the tent was omitted. The bowels were kept open with castor-oil, and the evacuations continued to be discharged without pain or appearance of any blood. Her general health appeared also to be improving, and she was able to sit up a few hours daily, which she had not been able to do for a long time: her appetite was so much better as to render her very desirous of having a little animal food, which was complied with. "On the 23d a tent was introduced, but could not pass it until I had previously ascertained the direction of the contracted part by introducing the finger, the irregularity of the surface continuing the same. “25th.-The tent occasioned considerable pain in the rectum, and a little blood followed its removal. She took castor-oil this morning, not having had a motion since the last tent was introduced. "26th.-Had several motions yesterday, and her bowels very open to-day does not complain of any particular pain. “28th.—A small tent again introduced-the last time. t 30th.-Complains of having had much soreness in the rectum since the last tent was introduced, and has had no motion. Rep. enema laxativ. 66 May 1st.-Passed several motions. Had appeared to be rather weaker, her appetite having failed for the last day or two; but no material alteration was observable until the 5th, when, on entering the ward in the morning, I was surprised to find so great a change in her countenance; her breathing short; pulse extremely feeble; with She died the same every other appearance of a speedy dissolution. afternoon. in the night. The nurse informed me she had become suddenly worse "Appearances on dissection.-On dividing the parietes of the abdomen, there were evident marks of peritoneal inflammation, and the intestines also exhibited a similar appearance, but more particularly the ilium, and its folds were glued together in several places, the consequence of inflammatory exudation; and on its surface there were different patches of coagulable lymph: there was also some purulent matter in the pelvis. On separating the rectum from the sacrum, its posterior part gave way, appearing that only the peritoneal coat at this part of the intestine had remained; the other coats having been destroyed by ulceration. The internal surface of the gut was extremely irregular, and its inner membrane entirely destroyed by ulceration; which process had extended somewhat less than an inch from the anus, as far as the contracted portion of the rectum. The 1 muscular |