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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one be permitted to pass after it has entered the contraction, it should be allowed to remain a few minutes, and then withdrawn.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instrument that was introduced on the first occasion should be used again: if it passes with greater ease, it may be withdrawn, and one a little larger passed, and thus the treatment is to be pursued till a full-sized bougie can be introduced with ease, and the patient ceases to suffer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

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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 hæmorrhage, 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 dilatation. 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,

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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.

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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 inwards, 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 stercoraceous fistulæ. The pelvic bones may also become affected by caries, or otherwise involved in the dis

ease.

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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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