character of the ulcer. Mr. Colles' recommends "a blunt polished gorget, with its concavity looking towards the seat of the disease, to be passed upon the finger into the rectum; then, by everting the anus as much as we can, we shall obtain a full view of the ulcer by the light reflected from the gorget." By the introduction of the finger, and making a careful and gentle exploration, we may arrive at a very correct knowledge of the extent, form, and situation of the ulcer by the pulpy feel of its surface, and by its edges being raised above the surrounding tissue; but as the introduction. of the speculum is not attended with more pain than digital examination, it is preferable and more satisfactory to have recourse to it, as we shall thereby acquire a better notion of the precise character of the sore.

Ulcers of the rectum assume every variety of form save that of the healthy ulcer, with small florid acuminated granulations rising to the level of the surrounding surface, and the process of cicatrization advancing from the margins. Ulcers in this region, in unhealthy and broken-down constitutions, are sometimes attacked with phagedæna.

Many circumstances concur to interfere with a healthy reparative process in on of the rectum. The constant contusion, and stretching cerated surface by the passage of the fæces, the irritation 1 by contact of the excretions, the congestion Mary vessels by the whole weight of the pon them, from the absence of valves. and the depending situation of the

the return of blood may be still
of
of fæces, or the presence of

Other impediments exist to
and undue and unequal
o, if situated within and
lastly, the impossibility
the ulcer, and making
es so efficient in ulcers
tarded venous circu-

tissues of the rectum and colon, and parts adjoining, such as ulceration, simple or fistulous, thickening, induration, and contraction of the coats of the intestine, stricture, spasmodic stricture, spasmodic contraction of the sphincter ani, fissure, &c.

Chronic proctitis may occur primarily as well as be the result of the acute or subacute form of the disease.

Asthenic acute proctitis occurs chiefly in cachectic and exhausted constitutions, or may be caused by the poisonous and depressing properties of the exciting cause, as when occurring from exposure to the emanations of foul privies.

In the treatment, the first thing to be considered is the nature of the predisposing and exciting causes, and the activity and character of the inflammatory action. If the inflammation has been produced by the lodgment of foreign bodies, by the accumulation and induration of fæcal excretions, or alvine concretions, they must be dislodged by mechanical means, all possible gentleness being observed in the operation. If the presence of ascarides is the cause, they must be expelled from their habitation by the administration of vermifuge medicines, and the use of oleaginous and terebinthinate enemata. Having attained these objects, the bowels should be kept free from irritation by the use of emollient enemata, and attention to the quality of the ingesta. In the sthenic form of the disease, and in plethoric individuals, it will be necessary to take blood locally by cupping over the sacrum and on the perineum, or by the application of leeches around the anus; the bleeding being promoted by the patient sitting over warm water after the leeches have fallen off, or by the use of hot linseedmeal poultices. The warm bath, semi-cupium, or hip-bath, will afterwards be serviceble.

The state of the excretions and secretions must be attended to. Hydrargyrum cum cretâ and the pulvis ipecacuanha compositus will be beneficial; if pain and tenesmus be complained of after depletion, the compound ipecacuanha powder, or simple ipecacuanha powder with henbane, extract of hop, or extract of poppy, may be administered: great relief will also be experienced by the administration of enemata, of four or six ounces of infusion of linseed, containing from thirty to sixty minims of laudanum. After the irritability of the rectum by these means has been somewhat allayed, the bowels should be moved by fresh castor oil or olive oil,

or by the confection of senna and sulphur, with or without the addition of copaiba, according to circumstances. Diluents should be taken freely, and all stimulating ingesta avoided.

The subacute and chronic forms will require the same treatment slightly modified. The abstraction of blood will be less necessary than in the acute form, but the warm bath or hip-bath, and soothing and emollient enemata, will be equally beneficial and necessary in the former states of the affection as in the latter. If excoriation, heat, and irritation are experienced, great relief will be afforded by the use of a cooling and anodyne lotion, such as a solution of the diacetate of lead, with acetic acid and wine of opium; pledgets of lint, saturated with it, being kept constantly applied to the parts. The asthenic form of inflammation of the rectum rarely admits of depletion, either general or topical. It has a greater tendency than the other varieties of inflammation to spread up the intestinal canal, therefore our endeavors must be directed to prevent and limit the extension of the diseased action, and to support the vital powers of the constitution. The first object is to be obtained by the use of the warm bath or hip-bath, followed by stimulating embrocations applied over the sacrum and to the hypogastrium; warm terebinthinate epithems, applied on flannel, will be of great service; demulcent and anodyne enemata should be employed early in the treatment, and are always beneficial. The constitutional treatment will consist of the administration of small doses of quinine with camphor, ipecacuanha, and the sedative extracts; castor oil, either alone or with turpentine, should be prescribed to move the bowels, or the confection of senna with the extract of taraxacum and bitartrate of potash.

Should ulceration or sphacelation occur, the treatment recommended in Chapter VIII,1 must be adopted.

In this, as in all other diseases of the rectum, great care is necessary in administering an enema not to injure the bowel with the pipe of the instrument, and there will be less probability of mischief occurring if the jet be made of elastic gum tube instead of metal or ivory.

The specific form of proctitis, arising from gonorrhoeal or syphilitic infection, must be treated in conformity with the principles of

1 Page 83.

treatment for the diseases occurring in other parts. Enemata should not be used in these cases, lest they should favor their extension, but strict cleanliness must be enjoined: the use of cooling and anodyne lotions, and such other means as are usually employed to allay local inflammation, must be put into requisition.

The occurrence of peritonitis will be a most serious complication, and demand active and prompt measures in the treatment. In plethoric individuals blood should be taken freely from the arm, and a large number of leeches applied to the abdomen, followed by hot anodyne fomentations, or by, what is much better, a flannel wrung out of hot water, and freely sprinkled with warm turpentine; calomel and opium must be administered more or less frequently, according to the urgency of the symptoms, and counter-irritation established on the lower extremities by stimulating pediluvia and sinapisms.

The hip-bath and anodyne enemata, and a strict observance of the horizontal position, will be most efficacious in relieving the bearing-down pains experienced by females suffering from proctitis.

When the urinary organs are affected, and dysuria and strangury induced, the warm hip-bath will be required, which if insufficient to afford relief, we shall be called upon to direct other measures, particularly if retention of urine should take place; then it would be advisable to prescribe a full dose of morphine in addition to the bath: tartar emetic, in frequent and nauseating doses, will generally relax the spasmodic condition of the muscles preventing micturition; but if these means fail, and the bladder is much distended, it must be relieved by the gentle introduction of the cathe

ter.

CHAPTER VIII.

ULCERATION OF THE RECTUM.

It is intended in this chapter to treat of ulcers resulting from simple or specific inflammation, or occurring as a complication or effect of other diseases and lesions. Those originating in fissure have already been considered.

Perhaps the most frequent cause of simple ulceration of the mucous membrane of the rectum arises either from bruising and subsequent inflammation, or from the surface being abraded, and a slight laceration produced by the passage of indurated fæces: it occurs in persons of constipated habit, in whom the mucous membrane of the rectal pouch is often relaxed, and in the act of defecation a small portion slipping down below the upper margin of the sphincter, becomes jammed between it and the fæcal mass, producing one of the lesions mentioned, and leading to ulceration.

It occurs not unfrequently as a consequence of dysentery, either acute or chronic, and of colliquative diarrhoea. It may be either the cause or consequence of abscess of the rectum and anus, or be the result of one of the forms of proctitis described in the previous chapter. Ulceration is often occasioned by the entanglement and lodgment of the fæces in the mucous follicles of the rectum; in which case several ulcers will generally exist.

Ulceration of the rectum is frequently found as a complication of disease existing in other organs, rather than as a primary and simple lesion. We meet with it associated with tubercular diseases of the lungs and liver, and tubercular deposits in other parts of the body. In children it is often a complication of thrush, of disease of the mesenteric glands, and a consequence of chronic