By the 21st June the induration had disappeared, and his general health greatly improved. This gentleman has consulted me occasionally up to the present time: he has no symptom of return of the local disease, and by a little proper treatment he has had fewer attacks of gout, and now enjoys greatly improved health.

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.'

1

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.

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,3 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.

3 "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.

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