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CHAPTER VII.

INFLAMMATION OF THE RECTUM.

Inflammation of the rectum is either sthenic or asthenic, acute, subacute, or chronic; it may be the primary disease, or secondary, resulting from disease existing in the neighbouring parts, and will be either simple or specific in its nature.

The predisposing causes of proctitis are a sanguine and irritable temperament, sedentary occupation, particularly if conjoined with the indulgences of the table, a full habit of body, haemorrhoidal affections, venereal' excesses, and voluntary and involuntary pollutions; disease of the bladder, prostate gland, and urethra in the male, and of the womb and vagina in the female. The exciting causes act either through the medium of the intestinal canal, or from without.

Of those which act from within, the most frequent and important are the ingesta—dietetic or medicinal— substances swallowed with the food, either intentionally or accidentally, which lodge and irritate the intestine or penetrate its coats, such as fish-bones, spicuLe of other bones, the stones and seeds of fruits, &c.; the prolonged and improper use of aloetic and resinous purgatives, frequent and large doses of calomel and other mercurial preparations, the long-continued or excessive use of arsenic, emmenagogues similarly prescribed; the presence of entozoa, accumulation of faeces, morbid secretions and excretions, concretions formed in the bowels, and haemorrhoidal affections. To these, Bushe * adds rheumatism and gout, and relates two cases that came under his observation. The external agents in inducing inflammation of the rectum are accidental injuries, surgical operations, and wounds involving the anus and rectum; foreign bodies introduced from without, and the operation for their extraction; acrid enemata and suppositories, injuries inflicted by clumsy attempts to administer enemata; the contact of syphilitic and gonorrhceal virus and other infecting agents; the exhalation from foul privies—where the accumulation of night-soil is great—rising against the anus during the act of defecation: from this cause, soldiers, when encamped, are often affected with inflammation of the rectum, particularly if dysenteric diseases prevail, with which proctitis may be confounded; the abstraction of animal heat by sitting on the wet and cold ground or stones, or on a wet seat while driving in an open vehicle; the latter cause, besides inflammation, often * Op. cit., p. 87.

inducing abscess and fistula in ano in coachmen and others: inflammation may occur in the parturient female from protracted labour, from injury from the use of obstetric instruments, rendered necessary by the emergency of the case, or by the improper and unskilful application of them; and other contingencies of the puerperal state.

The symptoms will be modified by various circumstances, depending upon the constitutional powers of the patient and the nature of the exciting cause. The acute sthenic proctitis is manifested by a feeling of fulness, weight, throbbing, and heat at the anus, extending up the sacrum; frequent desire to go to stool, attended with great straining, but by scanty evacuations, and with mucous, membranous, or muco-sanguineous discharge, the pain and suffering at the time being greatly increased. The sphincter ani will be contracted, the mucous membrane of the bowel will be red and highly sensitive, its temperature exalted, which will be evident to the finger if introduced into the bowel, but great torture to the patient will thereby be occasioned.

The sympathetic constitutional disturbance varies with the attack and nature of the cause. If it arises from cold, rigors and chills may precede the local symptoms; the concomitants of pyrexia will be present, namely, loss of appetite, heat and dryness of skin, and thirst; the tongue is white, loaded, and enlarged, with the impressions of the teeth indented into its margins; the functions of secretion and excretion are impaired and disordered, the urine is scanty and high coloured, and is passed frequently and with difficulty if the urinary organs are implicated by the extension of inflammation to them: should the disease have been neglected, and large faecal accumulations have taken place, vomiting may occur, but this is not often the case.

The complications of inflammation of the rectum are often of a serious character, and require careful consideration and treatment. The urinary organs in the male are frequently affected, the prostate gland, the neck of the bladder and urethra becoming involved in the inflammatory action, causing dysuria, strangury, or even retention of urine, the latter depending upon spasm of the muscular structure acting on the urethra. In the female the inflammation is more prone to extend to neighbouring parts, the vagina, the os and cervix uteri becoming implicated, accompanied by distressing bearing-down pains. Occasionally, cases will be met with where the inflammation has extended to the peritoneum, rendering the patient's sufferings much greater, and seriously increasing the danger: to the other symptoms we shall then have superadded abdominal tenderness, more or less extensive and severe in proportion to the activity of the inflammatory action; tympanitis will also be present.

Like inflammation attacking other parts, proctitis may terminate in resolution, or subside by haemorrhage taking place from the mucous surface of the intestine; relief of all the symptoms immediately following. Should the patient have previously suffered from internal haemorrhoids, the same termination may occur by the accession of the haemorrhoidal flux. But if neither of these favourable results be arrived at, the inflammation may lead to ulceration of the inner coats of the bowel, an ulcer of greater or less extent being formed, or the ulcerative process may attack the follicles, and produce a number of distinct ulcers. Suppuration, external to the intestine, is liable to ensue from extension of the inflammation, or by perforation of an ulcer or ulcers, causing abscess between the rectum and vagina in the female, or between the bowel and neck of the bladder in the male, or in either sex in the loose cellular tissue around the bowel, and, as a result, the formation of fistula in ano. The haemorrhoidal veins and peritoneum may be involved in the inflammation, and in either case the complication is of a very serious character, and is fraught with much peril to the patient. Lastly, acute proctitis may subside into

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