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ULCERATION OP 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 faeces: 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 faecal 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 fieces 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 diarrhoea. Diseases of the urethra and prostate gland in the male, and of the uterus in the female, also give rise to ulceration of this bowel.
Ulcers in this region will assume different forms and phases, in like manner as when they occur in other and exposed parts of the body, being similarly influenced by the causes producing them, and the state of the constitution of the individual. They vary in size as well as number, and are either superficial or involve the whole thickness of the coats of the intestine. If produced by the lodgment of faeces in
* Page 73.
the lacunae, they will be moderate in size, deep, and if they have existed any length of time, the edges will be indurated and prominent.
The symptoms of ulceration of the rectum are a discharge of sanious, purulent, or muco-purulent matter oozing from the anus, soiling the patient's linen and producing great discomfort, and perhaps excoriation of the external parts; pain in the gut extending up the sacrum to the loins, or sense of weight in the bowel, aching down the inside of the thighs, smarting at stool, and, if the ulcer be situated near the verge of the anus, there will also be spasm of the sphincter, as in fissure of that part; the faeces will be besmeared with blood and pus, and the patient will be troubled with tenesmus, and irritation of the urinary organs. Mr. Colles,* speaking of the pain and discharge in this disease, says, "At times the quantity of discharge is much lessened, and then the sufferings of the patient are aggravated; but on the flowing off of a large quantity he experiences great relief;" this I presume must have been due to the acute and excessive inflammatory action, and not depending alone upon the quantity of matter secreted by the ulcer.
When the ulcer is situated just within the external sphincter, and spasm of that muscle does not exist, it * 'Dublin Journal,' vol. v., p. 156.
may be brought into view by devarication of the buttocks, and pressing aside the edges of the anus with the fingers; but if it exist higher up the intestine, and in the most usual position in which it is found, namely, immediately above the upper margin of the internal sphincter, the speculum must be used to dilate the anus, when we shall with ease be able to judge of the situation, form, extent, and 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 acu
* Op. cit
minated 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 phagedaena.
Many circumstances concur to interfere with a healthy reparative process in ulceration of the rectum. The constant contusion, and stretching of the ulcerated surface by the passage of the faeces, the irritation produced by contact of the excretions, the congestion that occurs in the capillary vessels by the whole weight of the column of blood reacting upon them, from the absence of valves in the portal venous system, and the depending situation of the haemorrhoidal veins, from which the return of blood may be still further impeded by accumulation of fasces, or the presence of pulvic tumours pressing upon them. Other impediments exist -to the healing process, such as the puckering and undue and unequal pressure the ulcerated surface is subject to, if situated within and embraced by the internal sphincter; and, lastly, the impossibility of keeping dressings accurately applied to the ulcer, and making that equal and constant pressure which proves so efficient in ulcers occurring in other parts, accompanied by retarded venous circulation.
From the liability of ulcers of the rectum to become