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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 faeces, 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, <5f 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one be permitted to pass: after it has entered the contraction, it should be allowed to remain a few minutes, and then withdrawn.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instrument that was introduced on the first occasion should be used again: if it passes with greater ease, it may be withdrawn, and one a little larger passed, and thus the.treatment is to be pursued till a full-sized bougie can be introduced with ease, and the patient ceases to suffer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 sHght notches are far preferable to one of greater extent, as there will then be no fear of haemorrhage, 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, 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. Caesar 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.
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.
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 Up and other parts.
Carcinoma or hard cancer commences either as tuberculous growths, of cartilaginous consistency,