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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 faecal 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.
ty Argenti Nitratis, gr. xxx, ad xl; Aquae Distillate, 3J.
Misce fiat solutio. fy Acidi Nitrici Diluti, iri viij; Aquae Distillatae, Jj. Misce
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 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 faeces pass without difficulty, and medicaments may be more easily applied to the part.
* Page 44.
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, KK.
Mr. Avery was taken from the body of a girl who died in Charing Cross Hospital: the ulceration extended three inches up the intestine, and occupied the whole internal surface to that extent.
Venereal ulcers of the rectum are seldom met with except in those of the most depraved morals; and when they occur they often take on a phagedaenic action, from the constitution being worn out by vice and debauchery, death speedily terminating the sufferings of the unhappy victims: in this country this form of disease is rarely seen except in those prostitutes residing in the neighbourhood of the Docks or other low localities, and who, during their brief period of existence, are constantly under the influence of spirituous liquors.
Syphilitic ulceration not unfrequently leads to perforation of the recto-vaginal septum in the female, and recto-vesical walls when occurring in the male: records of such cases are more numerous in the writings of foreign authors than in those of this country.
The treatment must be varied according to circumstances. In phagedtena we must try to arrest the morbid action by the application of the concentrated nitric acid, taking care not to induce perforation of the bowel. The constitutional powers must be maintained by nutritious food, stimulants, quinine, &c.
Ulceration occurs in cases of stricture of the rectum
above the constricted part, as a consequence of pressure of accumulated faeces; the whole thickness of'the intestine may be perforated, giving rise to abscess, which may open externally by the side of the anus, or perforate the serous cavity of the abdomen, producing fatal peritonitis.
In the treatment of this last form of ulceration our attention must be directed to the cause, and if that cannot be remedied we shall be able to do but little to mitigate the effect.
Superficial ulceration treated with nitrate of silver.
Mrs. T , of middle age, delicate constitution, had been
subject to mucous diarrhoea. Three weeks previous to consulting me, she experienced great pain at stool and afterwards, of a smarting, burning character; she had purulent discharge, and complained of a sense of a weight in the rectum, pain up the sacrum and in the loins, and bearing down of the womb. By examination I discovered extensive superficial ulceration near the upper margin of the sphincter. I injected an enema of decoction of linseed, and afterwards passed the solid nitrate of silver over the ulcerated surface. L directed she should confine herself to the couch, and that her diet should consist of broths and farinaceous foods, and desired her to have a hot hip-bath each night before retiring to bed. Her bowels were kept easy, and enemata of four ounces of mucilage with liquor plumbi diacetatis and tinctura opii, were injected into the bowels twice a dayTwelve days sufficed to effect a cure.