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evacuations being fluid, and passing without much difficulty.
The symptoms in this affection are very similar to those of contraction of some portion of the canal above the anus : the pain will not be so severe as in stricture of the rectum, neither will there be the constant purulent discharge which attends the latter disease. The fæces will be passed with difficulty and pain ; · they will be compressed and figured, and, if they are solid, a sense of bulging out of the anus and perineum will be experienced during their passage. By the sufferings occasioned, the patient is often induced to postpone the calls of nature; but generally has reason to repent doing so, for the fæces, accumulating and becoming hard, considerably increase the pain and difficulty in defecating. In such a case it is no infrequent occurrence for the mucous membrane to be lacerated longitudinally by the passage of the stool, constituting fissure of the anus : spasmodic contraction of the sphincter will be superadded, attended with violent aching, for a longer or shorter interval, whenever the bowels act.
Those who suffer from this condition of the anus generally conceive they have stricture of the rectum ; however, we have the satisfaction of being able to assure the patient that the disease is of a much less
serious nature, and we shall further be able to promise not only a speedy but effectual cure.
Digital examination causes considerable pain, which will be greater if fissure coexists, but by it we can ascertain the nature and extent of the disease ; if the patient is very nervous, or very sensitive to pain, chloroform may be inhaled previously to the examination being made.
The treatment must be both medical and surgical. If inflammatory action be present, it must be subdued by topical bloodletting, hot fomentations, and cataplasms. The bowels must in all cases be kept loose by laxatives, as castor oil, confection of senna, &c.; great ease will be afforded by emollient enemata. The diet must be very moderate in quantity, and unstimulating in quality. The anus must be dilated by the introduction of bougies, and must be effected with much gentleness, for more pain will be experienced in this disease than in stricture of the rectum, in consequence of the greater sensibility of the integument than of the mucous membrane. When the instrument is used, the patient should rest on a couch or bed, with his knees drawn up. The better time for passing the bougie will be shortly before the usual period of the bowels acting. Ablutions with soap and water, twice or thrice a day, will add to the
patient's comfort, and lessen the local irritation. If much pain and nervous excitement be occasioned, anodynes may be required, which may be administered either by the mouth, or as suppositories, or enemata.
Congenital contraction of the anus cured by dilatation.
Some years since I saw, in conjunction with the late Mr. Morton, a child, about two years old, with congenital contraction of the anus, which would not admit a larger instrument than a number eleven bougie; the belly was tumid, and the general health impaired ; dilatation was had recourse to : in a short time the bowels could be entirely relieved, and, with the aid of tonics, the patient progressed favorably.
Contraction of the anus following the removal of external piles.
W. W., æt. thirty-nine, a clerk in a merchant's office, had suffered for some years from internal and external piles ; two years previously to my seeing him he had had the external ones removed; he described the wounds caused by the operation as being large, and that they were some time healing; after this he felt free from all his previous discomfort, but, at length, found a gradually increasing difficulty in passing his motions, and great straining was necessary to effect their expulsion : he also observed the stools were small and contracted when they were solid. To lessen the pain he suffered he had frequent recourse to castor oil.
On examination the anus presented several cicatrices, the radiating folds of the integument were effaced, and the anus would only admit the tip of the little finger. The general health had suffered by the pain and the anxiety the affection occasioned; the plan of treatment was that which has been described, and a rapid recovery ensued.
Contraction of the anus following an improperly performed
operation, complicated with fissure. J. T., à tailor, had suffered from piles, and had been operated on: he now complained of difficulty in defecating, attended with severe smarting, followed by aching. The history and the condition of the patient were similar to those described in the preceding case, except that there was fissure in conjunction with the contracted state of the anus. Bougies were used smeared with an ointment of gray powder and spermaceti, and extract of belladonna, applied on lint, to relieve the painful contraction of the sphincter. The fissure healed without the necessity of making any incision.
I have not met with a case of contraction of the anus and rectum as described by Mr. White. Dr. Bushe* relates the following case, which he considers syphilitic.
An officer, who had been engaged in many a well-contested field, and had endured great fatigue, and many privations while campaigning, became the subject in succession, of hepatitis, dysentery, ague, and dyspepsia. By proper medical treatment, and great attention on his own part, he improved
* • Treatise on the Rectum and Anus,' by George Bushe, M.D., New York, 1837, pp. 260, 261. .
much, but never regained his former state of health. In 1824 he contracted an ulcer on his penis, which healed with great difficulty, and was soon followed by secondary symptoms, under which his health rapidly deteriorated, and when I saw him, in the summer of 1826, he was greatly emaciated, with nodes on his bones, an eruption on his skin, chronic iritis, and induration, thickening and partial ulceration of the marginal integument and mucous membrane of the anus. He had suffered most annoyance from this last affection, having much purulent discharge, constant tenesmus, and excruciating torture both at and after stool. Leeches, fomentations, saturnine and opiate poultices, the introduction of meshes of lint besmeared with lard and extract of belladonna, as well as emollient and anodyne lavements, were tried in vain, at the same time that sarsaparilla and oxymuriate of mercury were administered.
This poor fellow sank in a few months, and on dissection, about an inch and a quarter of the extremity of the gut was found diseased.
Two cases have come under my observation of contraction of the anus by infiltration of lymph ; both had been preceded by dysenteric symptoms; and after their subsidence mild mercurials and iodide of potassium were prescribed, and dilatation had recourse to with the happiest effect.