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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 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 faeces 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 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 faeces. 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 fjeces, 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 faecal 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 saponin 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