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the chronic form, and induce various changes in the 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 faecal 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 linseed-meal poultices. The warm bath, semi-cupium, or hip-bath, will afterwards be serviceable.

The state of the excretions and secretions must be attended to. Hydrargyrum cum creta and the pub/is ipecacuanhae 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 endeavours 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.* 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 gonorrheal or syphilitic infection, must be treated in conformity with the principles of treatment for the diseases occurring in other parts. Enemata should not be used in these cases, lest they should favour 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

* Page 79.

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 counterirritation 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 wculd 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 catheter.

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