243 DB. CHASE'S RECIPES. 



An examination with the finger carefully introduced into the rectum will, 

 as a ruk, at once reveal the true nature of the case, for about two inches up 

 the rectum the narrowing will be felt, with or without new tissue infiltrating 

 the part or ulceration. In exceptional cases the stricture is beyond the reach 

 of the finger; under these circumstances, however, it may, at times, be brought 

 within reach by pressing with the free hand upon the abdomen above the pelvis. 



The examination of a rectum, the subject of disease with a tube, flexible 

 or otherwise, requires the greatest care and gentleness. Fallacies may mis- 

 lead the surgeon in every way, the end of the instrument striking against the 

 sacrum, or being caught in a fold of mucous membrane, may lead him to sus- 

 pect obstruction where none exists. But if some warm fluid, as linseed tea, 

 be injected somewhat forcibly through the tube, a place is formed admitting 

 the easy transit of the instrument. In stricture pain is felt when an instru- 

 ment reaches the point of contraction, and a flexible one is arrested or passed 

 on with more or less difficulty. 



Treatment. — It is so rare for a surgeon to be consulted about a stricture 

 of the rectum till the ulcerative stage has set in, or nearly complete obstruc- 

 tion has taken place, that he has few opportunities of testing the value of 

 dilatation of the stricture, for, although this practice is clearly useless if not 

 injurious when ulceration exists, it is probably of great value before any 

 breach of the surface has taken place. In cicatricial or inflammatory stric- 

 tures, indeed, it is the only form of practice upon which reliance is to be 

 placed, but in the cancerous, whether in the ulcerating style or not, it is not 

 wise to make the attempt. 



The dilatation is to be effected by mechanical means, and many instru- 

 ments have been invented for the purpose. The elastic gum bougie, in the 

 hands of the surgeon is, however, the best; forcible dilatation is inadmissible. 

 They are made in many sizes, and the one just large enough to pass through 

 the stricture should be chosen. It should be warmed and well greased, and 

 guided by the finger passed gently through the stricture, and retained for ten or 

 fifteen minutes at a time. When it does not produce any irritation, a second 

 larger, may be passed in two days. But when irritation has set in, the repe- 

 tition of the operation should be suspended until it has subsided. By these 

 means a simple stricture may be checked in its progress, and even dilated, but 

 rarely cured ; this practice may prolong life for years. Mr. Curling has, how- 

 ever, given a case in his book in which he believes he cured an annular stric- 

 ture in a lady, age 24, by incisions and dilatation. 



This dilatation is, however, only a means to an end, and that end is to 

 secure a passage for the intestinal contents. Enemata are valuable aids 

 to effect this purpose, the daily washing out of the bowels with gruel and oil 

 giving great relief, or the daily dose of mist, olei with manna, confection of 

 senna with sulphur, or any other gentle laxative that the patient has found to 

 suit. Cod liver oil in full doses often acts as a laxative as well as a tonic. 

 Care must, however, be observed in the introduction of the tube, for in a can- 

 cerous bowel perforation is very apt to occur, and even in a healthy one the 

 same accident has taken place. 



