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Superficial ulceration treated with nitric-acid lotion.

Mr. H sought my advice on account of purulent discharge from the anus, great pain in defecating, continuing for some hours afterwards; he also had irritability of the bladder. He was accustomed to high living, and attributed his indisposition to having swallowed a spicula of a bone of a partridge, which injured the bowel in its passage outwards. By examination I detected a superficial ulcer, somewhat less than a shilling in size, the edges were inflamed, and the surface covered with a tenacious muco-purulent matter. I applied the nitric-acid lotion on the occasion, put him on spare diet, enjoined the recumbent position, and directed the administration of an enema every day. He made a rapid recovery.

Ulceration of the mucous membrane; inoision of the sphincter.

Mrs. L for several months had suffered pains in the

rectum at and after defecating, accompanied by purulent discharge, which she attributed to internal piles: she took various empirical remedies recommended by friends, being unwilling to seek medical assistance; but, her sufferings increasing, she ultimately placed herself under my care. Her bowels had always been constipated, seldom acting without medicine. Some years previously she had haemorrhoids, which were removed by operation. I examined the bowel, and discovered above the sphincter an ulcer on the right side of the intestine of the size of a shilling; the edges were indurated, the surface pulpy. Being unwilling to submit to an operation, a variety of applications were used, the nitrate of silver, nitric acid, and others of a less active character; the recumbent position was adhered to, and a light diet observed; the bowels were kept easy by laxatives and emollient enemata, but the ulcer did not heal. Finding no benefit from the treatment, she consented to the operation proposed. I divided the sphincter, carrying the incision through the centre of the ulcer; an opiate was given after the operation. The wound was dressed in the usual manner; it granulated from the bottom, healed kindly, and in less than a month she had quite recovered.

Ulceration, its extension arrested by nitric acid, and division of the sphincter afterwards.

Mr. William Bennett requested me to see F. M , aet.

forty-one, of broken-down constitution. Somewhat less than a fortnight previously he began to experience pain in the rectum and anus; it increased in severity each day, and was excruciating when the bowels were moved: his linen was stained with pus and blood. When I saw hiin, febrile symptoms were strongly marked, the skin being hot, his face flushed, tongue dry and brown in the centre, and the margins and point preternaturally red; the pulse feeble and quick: he was much prostrated. By the finger, introduced into the bowel at its posterior part, a large ulcerated surface was felt, commencing a quarter of an inch from the anus. On dilating the auusthe edges of the ulcer were perceived to be irregular, abrupt, and highly inflamed; and the surface was covered with an ash-coloured slough: from the recent accession of the symptoms it must have extended rapidly. A large enema was at once administered, which unloaded the bowel. I then applied nitric acid to the surface and edges of the ulcer: a dose of opium was given immediately afterwards. On the following day, perceiving the ulcerative process to be arrested, I divided the sphincter on each side, cutting from within outward in the usual manner; lint was placed between the edges of the wounds, and three-fourths of a grain of morphine in solution was directed to be taken immediately, and six grains of Dover's powder and two of gray powder at bedtime; a poultice to be applied to the part, and renewed at night The powder was repeated twice a day for a short time: he remained in bed, and his diet was restricted to broth and arrowroot. The constitutional symptoms subsided; the third day he had some castor oil, and the dressings came away, when the bowels acted; after which a lotion of nitrate of silver was used to the ulcer, and simple lint to the incisions. The plan was continued till the parts were quite healed, which occupied little more than a month.

CHAPTER IX.

HEMORRHOIDAL AFFECTIONS.

Hemorrhoids is a term applied generally to certain tumours occurring at the verge of the anus, or within the rectum. The term, like many others, is not the most appropriate that could be chosen, as it conveys no adequate idea of the nature of the disease; yet by use it has become familiar both to the profession and the public, and its import generally understood: piles is the popular name under which these affections are known, indeed, by many, and by the working and poorer classes especially, almost every other disease about the rectum and anus receives the same designation.

It is not surprising that the ancients, from a. deficiency of knowledge of anatomy and pathology, were unacquainted with the true nature of the disease, that they should have had very erroneous opinions of the structure of the tumours forming haemorrhoids, and have entertained the notion that they performed the function of evacuating black bile and melancholic humours from the system. After the discovery of the circulation of the .blood by the illustrious Harvey, a new but equally erroneous theory was generally received; it being conceived that bleeding from external piles depleted the system generally, and that haemorrhage from internal piles depleted the portal system only.

Montegre * gives the following classification of haemorrhoidal complaints:—

1. Blind or dry Haemorrhoids (Caecw)

2. Haemorrhoids

with discharge
(Fluentes)

3. Haemorrhoids
with tumours
(Tumentes)

. Painful Haemorrhoids (Dolentes)

White discharge (Alboe), with catarrh of

the intestines Sanguineous discharge

(Sanguinolentae)

Varicose

(VariscaB)
Mariscous

(Mariscae)

Inflammatory

Nervous
Fissured
r Indolent

By Exhalation
By Bupture

I Dry

I Bleeding

rDry

] Bleeding from

( dilated pores

5. Haemorrhoids with constriction I of the anus . <

(Cum constric-l Painful tione ani) I

6. Haemorrhoids !Superficial with ulceration j

(Ulcerate) 'Fistulous

From induration
of the tissues

Spasmodic
Schirrhous

* 'Des Hemorrho'ides, ou Traite Analytique de toutes les Affections Hemorrho'idales,' par A. .T. de Montegre, Deuxieine Edition, Paris, 1830, p. 71.

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