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of the diaphragm being impeded, pains in the legs and cramps are complained of, the feet are cold, there is determination of blood to the head, producing giddiness and stupor, and, lastly, symptoms of internal strangulation supervene, which terminate fatally, unless relieved by operation.
The prognosis of stricture will be influenced by a number of circumstances depending on the degree of contraction, its condition, position, and the causes that led to its formation. If within reach of the finger, and the contraction and induration have not advanced far, we may entertain hopes of very favourable results from judicious treatment. But if the disease has progressed, the hardening being great, and the passage of the bowel much diminished, our opinions as to the prospect of a cure will be less favourable. Should ulceration have occurred. the patient is in a much worse condition, and will require very cautious treatment, or the disease may be aggravated instead of being benefited.
The object to be obtained in the treatment of this disease is, if possible, to restore the bowel to its natural dimensions, or, if that cannot be accomplished, to enlarge the constricted part sufficiently to permit the free passage of the fæces. Dilatation by the careful introduction of bougies is the means by which this is to be effected. In the majority of cases, it
will not be prudent to have recourse to the bougie immediately, either in consequence of the irritability of the bowel, or from its being immensely distended above the point of contraction by the accumulation of feculent matter, which, pressing against the stricture, is a source of constant irritation, and tends to aggravate the disease; therefore, the importance of unloading the bowel before adopting other means must be obvious. This is to be accomplished by the introduction of an elastic tube through the stricture into the superincumbent mass of fæces, and injecting tepid water, thin gruel, and olive oil, or tepid water and soap : this practice must be repeated every day, or every other day, till the whole of the fæcal accumulation is dissolved, and washed away; the size of the tube must be regulated by the tightness of the contraction ; in some cases we shall not be able to use one larger than a urethral catheter. If much local or general irritability or restlessness be present, an opiate enema, or a suppository of the pilula saponis composita at bedtime, will be of the utmost service, followed in the morning by a mild unirritating aperient, such as the confection of senna, tartrate of potash, manna, castor oil, &c. Sir Benjamin Brodie recommends the following draught to be taken two or three times a day: balsam of copaiba, half a drachm ; solution of potash, fifteen minims; mucilage, three drachms; and nine drachms of caraway-water. If inflammatory symptoms be present, blood may be taken locally, and a warm hip-bath used at night. It will be desirable during the treatment that the patient should observe the horizontal position as much as possible, and the diet restricted to that which is light and nutritious, and yields the smallest amount of excrementitious matter, such as good broths, jellies, eggs, arrowroot, sago, and the like.
Having freed the bowel from the accumulated fæces, and allayed the irritability of the part, we may endeavour to restore its calibre by the introduction of bougies. These are made of various substances, of metal, wood, cloth covered with plaster and elastic gum: only those formed of the last two materials should be used when the stricture is not close to the anus. I give the preference to the elastic gum bougie, and have them made more flexible than those usually sold in the shops, which obviates the objection urged against them by surgeons who advocate the use of those formed of plaster..
The surgeon, by previous examination having satisfied himself of the existence of stricture, and formed an idea of the extent to which the narrowing of the intestine has taken place, selects an instrument that will pass into it without much difficulty. The patient is placed on his side, with his knees drawn up,
and the bougie, lubricated with oil or lard, is passed upwards to the obstruction, and steady but gentle pressure is made against it; no force must be used, and if the resistance cannot be overcome without, a smaller instrument must be tried, till one be permitted to pass : after it has entered the contraction, it should be allowed to remain a few minutes, and then withdrawn. Some authors recommend the bougie to be left in for several hours ; but such a mode of treatment is more likely to produce irritation than to effect the object we have in view, namely that of stimulating the vessels to the absorption of the effused lymph forming the stricture. If much irritation follows the operation, the patient should have a hip-bath, and it may be necessary to inject soothing and opiate enemata. At an interval of three or four days, the operation is to be repeated ; the same instrument that was introduced on the first occasion should be used again: if it passes with greater ease, it may be withdrawn, and one a little larger passed, and thus the treatment is to be pursued till a full-sized bougie can be introduced with ease, and the patient ceases to suffer any inconvenience.
In some cases of close stricture of long standing, we shall gain time by incising its margin previous to using dilatation : the best instrument for the purpose
is a narrow blunt-pointed bistoury passed into the stricture, on the finger previously introduced; several slight notches are far preferable to one of greater extent, as there will then be no fear of hæmor. rhage, or of matter forming in the cellular tissue. In 1855 a gentleman came from Australia to place himself under my care, having stricture of the rectum arising from congenital malformation. The stricture was so dense and unyielding that, with the ordinary bougie, I was unable to make much progress in dila: tation. I then contrived an instrument which I could easily introduce into the stricture, and then distend it laterally, and was thus enabled to proceed rapidly and satisfactorily with the case. Subsequently I have improved on the instrument, and in the one I now use the pressure can be regulated to any degree with the greatest ease. It has been proposed to destroy the indurated structure by various escharotics; but such a proceeding must always be uncertain in its effects, from the difficulty of limiting the action of the caustic, and therefore unadvisable.
Those cases of stricture that have come under my. observation have been within reach of the finger, and have been treated on the principles advocated in the text.
Various instruments have been invented for dilating strictures of the rectum, by Weiss, Bushe, Arnott,