loaded 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 tranquillising the patient and producing temporary constipation.

Should ulceration attack many points of the intestine, and extend high up, there will probably be a fatal termination of the case, in spite of the most judicious measures 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 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 phagedenic 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 neighbour

* Pages 67, 68.

hood 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 phagedæna 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 fæces; 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 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. I directed she should confine herself to the couch, and that her diet should consist of broths and farinaceous food, 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 day. Twelve days sufficed to effect a

cure.

Superficial ulceration treated with nitric acid lotion.

Mr. H—— sought my advice on account of purulent disHcharge 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 sur

I

face covered with a tenacious muco-purulent matter. 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; incision of the

sphincter.

Mrs. L for several months had suffered pain 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 hæmorrhoids, 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.

æt.

Mr. William Bennett requested me to see F. Mforty-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 him, 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 anus the 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