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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.
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 whieh 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 Chirurgical Works of Percival Pott,' edited by James Earle, 1790, vol. iii., p. 133.
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 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 ædematous ring of integument and cellular tissue around the anus, caused by irritation in the rectum, and very generally accompanying inflamed internal hæmorrhoids. 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. M'Coy * 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, in. ducing 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, formś false membranes and filamentous bands, reducing the capacity of the opening, and interfering with its power of dilatation.
* · Dublin Hospital Reports,' vol. v., p. 154.
The matter of syphilis and gonorrhæa coming in contact with the anus, in those who are regardless of cleanliness, produces a form of contraction first described by Mr. White,f 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
* · Lectures on the Theory and Practice of Surgery,' by Abraham Colles, M.D., see note, vol. ii., p. 115.
† Observations on Strictures of the Rectum and other Affections,' by W. White, Bath, 1820, p. 18.
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 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