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., a 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

"Treatise on the Rectum and Anus," by George Bushe, M.D., New York, 1837, pp. 260, 261.

attention on his own part, he improved 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.

CHAPTER V.

FISSURE OF THE ANUS AND THE LOWER PART OF THE RECTUM.

THIS disease, of frequent occurrence, and giving rise to more uneasiness and suffering, in proportion to the pathological condition of the structures involved, than perhaps any other disease to which the human frame is liable, has met with very little consideration from the majority of surgical writers, and is even unnoticed in most systematic works on surgery: although the distinguished surgeon, M. Boyer, in the tenth volume of his "Traité des Maladies Chirurgicales," published in 1825, well described this malady, in this country it has not received that attention which the subject demands; and there is strong reason to believe the diagnosis and treatment are not so familiarly known as might be desired,—a fact to be regretted the more, as little difficulty presents itself in either. Fissure of the anus usually occurs during the middle period of life. Dr. Bushe1 has not observed this affection before the age of eighteen, or later than sixty-nine years of age. Professor Miller2 says, "they" (fissures) "have been observed in children at the breast;" but this must be of rare occurrence, the predisposing and exciting causes seldom existing till after puberty. One of the latest writers on diseases of the rectum objects to the term fissure, and speaks of the affection as "irritable ulcer of the rectum :" although, in many instances, when the surgeon is first consulted, it may present the form of an oblong ulcer, yet I have no hesitation in saying the primary condition was essentially a fissure or crack of the mucous membrane.

In the majority of cases, the lesion is confined to the mucous membrane only, but occasionally extends to the submucous cellular

2" Practice of Surgery," by James Miller, F.R.S.E., Edinburgh, 1852, p. 380.

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.

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.