CHAPTER IV.

CONTRACTION OF THE ANUS.

CONTRACTION of the anus is productive of serious inconvenience and distress to the patient: it is not a common affection at the present day, but when it was the custom to treat fistula in ano by extensive incisions, to scoop out the sinus and surrounding indurated parts, or to destroy the tissues extensively with escharotics, it must have been a very general result of such surgical interference. Mr. Pott, deprecating De la Faye's treatment of fistula, as causing contraction of the anus, says, "If M. De la Faye had ever, in his own person, had the misfortune to experience the inconvenience arising from loss of the skin near to the fundament, or had he attended to that which it produces to those who, either from choice or necessity, ride or walk much, I am inclined to believe he would have been more sparing of it.'

M. De la Faye himself was not insensible of the evil resulting from his plan of treatment, and to guard against it advised the introduction of tents; the following are his words: “Lorsqu'on a coupé dans l'opération une portion considérable du bord de l'anus, et que les chairs commencent à remplir le vuide, il faut mettre dans l'ouverture de cette partie une tente, un peu courte, qui en empêchant le rétrécissement lui conserve son diamètre," but which it will often do, in spite of all the tents in the world.

The causes producing contraction of the anus are, loss of substance by ulceration, or by wounds, either accidental or caused by surgical operations. In the Chapter on Piles their excision is alluded to as a cause of this condition of the anus; and I may here repeat, that the surgeon, in removing external piles, cannot

"The Chirurgical Works of Percival Pott," edited by James Earle, 1790, vol. iii, p. 133.

be too careful not to take away more of the skin than is absolutely necessary; and he should also avoid an error I have several times seen committed, that of excising the oedematous ring of integument and cellular tissue around the anus, caused by irritation in the rectum, and very generally accompanying inflamed internal hemorrhoids. Dr. Colles' mentions a case where, for the purpose of extirpating warts, a ring of the skin at the verge of the anus had been cut away along with these excrescences, the condition of the patient was rendered truly miserable. Mr. McCoy adds another illustration of the evil effects of improperly removing the integument of the anus; he says: "I saw a gentleman who had been operated on four years before by an eminent surgeon, and so small and rigid had the opening of the anus become, that no solid larger than a pea could be passed from the bowels, and with the miserable prospect of its gradually becoming still smaller." Contraction also results from inflammatory action, inducing infiltration of lymph in the areolar tissue of the anus, or effusion of the same material on the surface of the mucous membrane, which becoming organized, forms false membranes, and filamentous bands, reducing the capacity of the opening, and interfering with its power of dilatation.

3

The matter of syphilis and gonorrhoea coming in contact with the anus, in those who are regardless of cleanliness, produces a form of contraction first described by Mr. White, as follows: "Not unfrequently a contracted state of the rectum occurs as a consequence of the venereal disease. When the disorder proceeds from this cause, it generally commences with an appearance either of ulceration or excrescence about the verge of the anus. The sphincter ani becomes gradually contracted, and the disease extending upwards within the rectum, a considerable thickening and induration of the coats of the intestine takes place, which produce great irregularity and contraction of the passage. Sometimes there is a continued line of contraction from the anus, as far as the finger can reach, then terminating in a kind of cartilaginous

1 "Dublin Hospital Reports," vol. v, p. 154.

2 "Lectures on the Theory and Practice of Surgery," by Abraham Colles, M.D., see note, vol. ii, p. 115.

2 "Observations on Strictures of the Rectum and other Affections," by W. White, Bath, 1820, p. 18.

border, the inner membrane having a thickened and condensed feel. There is a discharge indicating a diseased, if not ulcerated, state of the inner membrane, above the contracted portion of the intestine. All the cases which I have hitherto met with of this nature have occurred in females, and they have uniformly proved incurable when attended with the structural derangement just described.

Since the publication of the first edition of this book, I have met with two cases of induration and contraction of the anus arising from venereal disease: both patients were females. The affection differed from that described by Mr. White in not implicating the rectum : the disease yielded in both cases to a steady perseverance in the use of the iodide of mercury and the iodide of potassium.

Contraction of the anus is sometimes congenital: if the opening is not very small it may not attract attention in the early period of infancy, from the 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.

affection from which he had suffered for some years. This gentleman was stout, with the muscular system largely developed. He informed me he had for a long time experienced the most intolerable itching about the anus, and was also annoyed by a constant watery discharge: he had consulted several surgeons; various lotions had been prescribed, and the solid nitrate of silver applied twice, which caused him most severe pain, without any beneficial effect. Many years previously he had been the subject of hemorrhoids, and had had several large piles form at the verge of the anus; when these subsided, loose folds of skin remained, which occasioned him no inconvenience for some time, but at length he began to experience the symptoms which now caused him such severe annoyance. On making an examination, I observed the skin around the anus, and for about three inches posteriorly, inflamed and cracked, and bedewed with a serous secretion; three dense condylomata, the size of the shell of an almond, were connected with the anal margin, the whole of which was indurated, but not contracted. He was informed that excision of the tumors was the only means of freeing him of the disease, and he readily consented to the operation. Being somewhat affected with flatulence, and the bowels not acting freely, he was directed to take three grains of blue pill and a grain of ipecacuanha every night, and a draught, twice a day, composed of infusion of cinchona, infusion of senna, tartrate of potash, with some aromatic tinctures; by these means the bowels were freely acted on, and on the fourth day I removed the growths, cutting them off with a probe-pointed bistoury; Dr. Ashwell was present, and very kindly assisted me. No ligatures were required, a compress, retained firmly by a T bandage, restraining the little hemorrhage that ensued. On the following day the wounds were dressed with oxide of zinc and spermaceti ointment, and in a week were quite healed, as well as the cracks in the surrounding integument; a lotion of the bichloride of mercury in bitter-almond mixture was directed to be applied, and in a short time all induration of the anus had disappeared.

It is evident these growths had their origin in the folds of skin left by the collapsing of the external piles; and had the treatment hereinafter advocated been adopted, of excising external hemor

rhoidal tumors when large, this gentleman would have escaped the sufferings he subsequently experienced.

Condylomata of large size, attended by severe symptoms.

A gentleman, aged 54, residing in one of the principal squares at the West End, applied to me in May, 1856. He is very stout, and plethoric, rides much on horseback, and subject to attacks of gout. Three years before applying to me, and shortly after an attack of gout, he lost a considerable quantity of blood per anum; subsequently had a mucous discharge, and excrescences formed at the margin of the anus, which gradually increased in size. He experienced intolerable irritation in the part, aching down the thighs, and at stool had severe ulcerated and acutely painful to the touch; the integument around was of a purple color, and bedewed with a copious secretion; the margins of the anus were indurated. No internal hemorrhoids existed, but the mucous membrane of the rectum was congested, his tongue was coated, eyes dull, sclerotic conjunctivæ yellow.

& Pilulæ Hydrargyri, gr. iv; Pulveris Ipecacuanhæ, gr. j; Misce fiat pilula j. Hori somni sumenda.

R Pulveris Rhei, j; Potassæ Tartratis, 3j; Confectionis Aromaticæ, gr. xv; Tincturæ Rhei, 3j; Aquæ Cinnamomi, ad 3ij. Fiat haustus primo mane sumendus.

He was directed to use ablutions with soap and water locally night and morning, and afterwards to apply powdered starch. The medicines were repeated for four consecutive days, and on May 22d, with the assistance of Mr. Hulme, I excised the tumors with a bistoury. The hemorrhage was restrained by a pad of lint secured by a T bandage. He remained on the sofa two days, experiencing little inconvenience. In six days the wounds were healed, but the induration around the anus remained.

R Hydrargyri Bichloridi, gr. viij; Misturæ Amygdala Amaræ, Aquæ Sambuci, aa Ziv. Misce fiat lotio. To be applied to the part by means of cotton-wool.

R Infusi Gentianæ Comp., 3vij; Potassæ Iodidæ, ij; Potassæ Bicarbonatis 3iss; Tincturæ Aurantiæ, Syrupi Aurantiæ, aa 3iv. Fiat mistura. Capiat cochl. ij, magna bis in die.