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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 phagedæna.

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 fæces, 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 hæmorrhoidal veins, from which the return of blood may be still further impeded by accumulation of fæces, 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

congested while the patient is allowed to be about, it will be necessary to confine him to the bed or sofa while under treatment; and during that time a strict regimen must be enforced, all stimulating food being prohibited, and only that allowed which will form the least amount of excrementitious matter.

In this disease we shall seldom be called upon to practise general bloodletting; but, if there be much throbbing and fulness about the part, the local abstraction of blood by cupping or leeches to the sacral region and perineum may be. necessary; emollient enemata will always be beneficial. Attention must be directed to the state of the general health, which we must endeavour to restore by appropriate means if it has been impaired by disease or irregularity of habits. Constipation must be remedied, the bowels are to be freed of fæcal accumulations by enemata, thrown up by O'Beirne's tube; the functions of the liver and pancreas are to be promoted by mild doses of mercurials, taraxacum, or nitro-hydrochloric acid, and irritability allayed by sedative and sudorific remedies.

Provided the ulceration is recent and not of great extent, it may generally be made to heal by the adoption of the constitutional treatment just mentioned, and by topical applications. The ulcer is to be brought into view as in making an examination, and the solid nitrate of silver applied more or less freely

according to its condition, or either of the following lotions may be used by means of a camel-hair pencil or swab of charpie.

R Argenti Nitratis, gr. xxx, ad xl; Aquæ Distillatæ, 3j. Misce fiat solutio.

R Acidi Nitrici Diluti, m viij; Aquæ Distillatæ, 3j. Misce fiat lotio.

It will be necessary, in some cases, to have recourse to these applications several times. Four or six ounces of water, with zinc, or lead, and two or three grains of extract of opium or belladonna rubbed up in it, and injected into the bowel once or twice in the twenty-four hours, will sometimes be found useful.

Under the foregoing plan of treatment, the ulceration, if not extensive, will generally take on the reparative process, and cicatrization rapidly follow. But it frequently happens the surgeon is not consulted till the disease has persisted some time, or is extensive, attended with great pain and violent spasmodic contraction of the anus; local applications will then be of no avail, and incision must be had recourse to it is to be performed in the same manner as described in Chapter V.,* on fissure, only that the sphincter muscle must be entirely divided. The incision is to be made through the centre of the ulcer, except when it is situated on the posterior or anterior * Page 44.

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aspect of the rectum, in which case it will be advisable to make an incision on either side of the median line, for the reasons elsewhere urged; light dressings must be applied to the wound, and a rapid cure usually ensues. The principle on which this is effected I conceive to be the following: the ulcer is freed from all undue pressure, the spasm of the muscle ceases, the blood-vessels are relieved from engorgement, the fæces pass without difficulty, and medicaments may be more easily applied to the part.

Previous to the operation the bowels should be unloaded by a dose of castor oil or laxative electuary, followed by an enema of thin gruel; and after it has been performed, a dose of opium should be given for the double object of tranquillizing the patient and producing temporary constipation.

Should ulceration attack many points of the intestine, and extend high up, the case will probably terminate fatally, in spite of the most judicious measures that we can employ.

Venereal ulceration may attack the rectum by the direct application of the poison from the genitals, or it may coexist with some form of secondary syphilis. In the first volume of the Pathological Transactions' is an account of the extensive ulceration of the rectum from syphilis: the specimen exhibited by * Pages 67, 68.

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