SPHINCTERISMUS.—This condition, though frequently attendant upon, may exist in the absence of, any fissure, crack, or ulcer of the anus. It is usually associated with constipation. In its treatment magnesia and rhubarb are to be used, and the diet must be simple, unstimulating, and taken at regular intervals. A hot hip-bath at night, with the use of a belladonna suppository, often proves effective. In more obstinate cases a bougie covered with ointment of belladonna should be used daily. In still more intractable cases the muscle must be forcibly stretched with the fingers. In the more obstinate cases which now and then occur it becomes necessary to completely divide the fibres of the sphincter muscle, followed by a thorough stretching of the parts.
PRURITUS ANI.—This distressing and vexatious complaint proceeds frequently from hemorrhoids. When caused by the presence of seat-worms, they must be dislodged by purgatives and enemata of quassia or of one composed of one part of carbolic acid to six parts of sweet oil, or of turpentine and flaxseed tea. An enema of milk of asafoetida answers a good purpose. If the pruritus is a result of the burrowing of the itch insect, any wash, ointment, or dressing that evolves sulphuretted hydrogen will rapidly bring relief. If caused by other parasites, an application of ung. hydrarg. or red precipitate ointment, followed by a warm bath, will be all that is necessary. In some it is a symptom of dyspepsia, in others of a disordered state of the nerves of the anus independent of local cause: in this case iron, quinia, and arsenic should be given, and the patient should live an outdoor life as much as possible. The remedies that have in turn been extolled and abandoned during the treatment of this distressing condition it would require too much space to even mention. The following are among the best: Sulphate of zinc and alum, equal parts, are to be placed in an earthen vessel and heated until a glassy mass is left, which is to be dissolved in a little water and thrown into the bowel; palm soap pressed into the anus, ointments of carbolic acid and morphia or of bromide of potassium and cosmoline, citrine and other mercurial ointments, and suppositories containing iodoform. Allingham uses a bone or a metallic plug of peculiar construction, so as to keep the anus upon the stretch at night without slipping into the bowel. The pressure which this exerts upon the nerves and vessels prevents the itching. Hot (not warm) water pressed against the anus with a sponge, or ten-drop doses internally of tincture of gelsemium, or washes of dilute hydrocyanic acid or of chloroform, or ointments of balsam of Peru or of veratria and aconitia, or the corrosive chloride of mercury in solution applied locally, are a few of the more reliable among this host.
STRICTURE OF THE RECTUM (NON-MALIGNANT).—The main modes of treatment of non-malignant stricture of the rectum are two—by dilatation or by linear incision (rectotomy). Dilatation may be practised by the finger alone or by the finger covered with hollow rubber covers of various sizes. These are open at the end, so that the guiding and recognizing sense of touch may be left to the end of the finger. When the stricture is out of reach of this method, either gum or metallic bougies must be used, beginning with the smaller sizes and deliberately and carefully adding sizes. When the lumen of a stricture is tortuous it is best to use a long rather flexible rubber bougie having an olive-shaped extremity. It is not necessary to leave these bougies standing for hours in a stricture, according to the practice of some; this merely excites inflammation. Should the stricture be irritable, every second or third day would be sufficiently often to attempt dilatation. In constrictions which are firm, but not sensitive, a good plan is to insert a Molesworth elastic tube and gradually distend it by hydrostatic pressure; Barnes's dilators have also been successfully used. When the stricture is elastic and re-forms itself at once after dilatation, incision should be practised. In those strictures which are low down, the constriction may be nicked in several places by a hernia knife, the blade of which is guided along a finger in the bowel; when high up, a long double-bladed knife must be employed. In syphilitic strictures, in addition to dilatation, proper alterative treatment is indispensable. As dilatation has often to be kept up for a long time, the patient may be taught to practise this for himself.
PERI-ANAL AND PERI-RECTAL ABSCESS.—When acute, and when the surgeon is called in time, the prompt application of leeches may abort the abscess, but usually, by the time the surgeon sees it, it is necessary to apply hot flaxseed poultices as fast as they become cool, keeping the patient in bed upon light diet. The rule is to open deeply and freely so soon as the least softening under the poultices indicates that pus is within reach. After lancing, the poultices should be continued for a few days: then the deep wound should be packed with a strip of oiled lint and allowed to granulate from the bottom. As the fetor of these abscesses is horrible, they should be injected with a solution of permanganate of potash or liq. sodii chlorinata. When the chronic variety of this abscess is discovered, it, with all its sinuses, diverticula, and pockets, should be laid freely open upon a director and packed with carbolized lint. It is often very necessary in these chronic cases to use tonic and alterative treatment, such as cod-liver oil and iodide of iron.
GONORRHOEA OF THE RECTUM.—Undoubted cases of gonorrhoea of the rectum in the persons of prostitutes have been observed. Burning heat and great pain are usually felt, with a free discharge of pure pus: the mucous membrane is always intensely inflamed. The treatment is simple; an injection of lead-water and laudanum or of sulphate of zinc answers a good purpose. Primary syphilitic disease of the anus and rectum is rarely seen, but of course the treatment indicated would be similar to that laid down for primary syphilis in its usual localities.
IMPACTION OF FECES.—This condition usually occurs among the aged and in women after parturition and in cases of paralysis. Those persons of sedentary habits who do not pay sufficient attention to the necessity of a daily alvine evacuation sometimes find themselves in this condition. Impaction occurs not infrequently among the insane, and more frequently among women than men. Allingham states that he has never seen a case of impaction in a young person; but Wetherill now has under his care a most obstinate case of this disorder in a young man whose system has been completely broken down by intemperance in drink.
In paralysis of the rectum of traumatic origin impaction is almost certain to take place unless great care is taken to prevent it. Diarrhoea is a very misleading element in these cases, and is a symptom which frequently deceives those who are not on their guard. The clayey mass of feculent matter forms a hard ball in the distended bowel, around which the small loose passages flow. Spasm of the sphincter ani is the usual accompaniment of impaction, and the muscle should be gently but thoroughly dilated before means can be used to free the canal. The finger or the handle of a tablespoon is best to use in the dislodgment of these masses, and should be oiled before introduction, the accumulation broken up, and then washed out by an enema of soap, turpentine, and warm water. Purgatives and hydragogue cathartics usually fail to give relief, and add much to the patient's discomfort. The bowel once freed, care must be taken to prevent a reaccumulation, which very readily takes place, as the bowel in these cases is distended and has lost tone. To this end frequent enemata of cold water should be used, and the patient should take a pill of dried sulphate of iron, sulphate of quinia, extract of nux vomica, extract of aloes, as recommended by Allingham. The diet should be restricted. An excellent adjunct to this treatment is the local use of the faradic galvanic current daily after breakfast. Let the patient lie upon a bed and apply one pole or electrode to the anus, while the other one is passed with pressure along the course of the large intestine. Not infrequently it happens after this has been continued for a few minutes that a very urgent desire is felt to go to stool. In the case mentioned of the young man affected with impaction this treatment answered admirably well, but before its use he had to take a small dose of croton oil daily to cause an action of the bowels, all milder measures having proved ineffectual. It is important in these cases to interdict a sedentary mode of life.
IRRITABLE RECTUM.—A rectum is said to be irritable when it shows an intolerance of the presence of feces or flatus, causing frequent desire to go to stool. From such abnormal activity of the part there arise a burning, uncomfortable impression of fulness and a soreness of the anus. If after examination it is found that there is no local exciting cause, a starch enema containing forty drops of laudanum should be given and retained. This plan of treatment will usually afford relief. Should the irritability prove to be obstinate, examine the rectum, and if a spot of redness or increased vascularity be found, touch the spot with strong nitric acid.
CONCRETIONS IN THE RECTUM.—These occur less frequently than do impactions, and differ from them in being cylindrical and nucleated, the nuclei being such bodies as balls or tangled masses of hair, or coins, buttons, biliary calculi, or the like. Covering these are matted animal or vegetable fibres or hardened fecal matter. They are not so readily dislodged as are impactions, and it is necessary to dilate the sphincter thoroughly and remove them with a scoop. Not infrequently these bodies are bathed in pus and are very fetid.
PROCTITIS, OR INFLAMMATION OF THE RECTUM.—This may be either acute or chronic, the latter being a disease of the aged. Allingham recommends in this variety small doses of Barbadoes aloes to stimulate the bowel, also such drugs as copaiba, turpentine, and black pepper. As an injection in the acute form starch and laudanum, or bismuth suspended in a mucilaginous vehicle, should be used. Probably the use of small, smooth fragments of ice in the rectum would allay the tenesmus and help to subdue the inflammation.