CHAPTER III. EXCRESCENCES OF THE ANAL REGION. THE fine skin surrounding the anal orifice and the mucous membrane at the verge of the anus are subject to various morbid growths, designated by authors of past ages by the fanciful appellations of scycoma, fici, mariscæ, cristæ, porrus, condylomata, verrucæ, &c. These growths differ much in appearance, consistency, and sensibility, some being acutely painful, whilst others occasion but little suffering. In one form they will be observed as distinct and separate tumours, with a smooth surface, sometimes slightly lobulated, having a constricted base, and usually flattened in form, owing to their compression between the nates; they vary in size from a pea to that of a chestnut or larger; and commence as small folds of skin, soft and pliable at first, like the healthy tissue, but, as they increase in size, become of firmer consistence by the development in their interior of a fibro-cellular tissue. Others will be met with partaking of the character of warts, and consisting of clusters of enlarged arborescent papillæ, rising to one or two inches above the surface of the skin, and in some cases entirely surrounding the anus, the aperture of which is hidden in the morbid growth. The most common cause of excrescences of the anal region is some local irritation; thus we frequently meet with them as a complication of several diseases of the rectum attended with discharge; in some individuals the secretion of the perspiratory glands is so copious, that the parts are constantly bedewed with moisture, and irritation ensues; those persons in whom the glutei muscles are largely developed are liable to these morbid productions, as a consequence of the irritation produced by the close apposition of the integumental surfaces. The smooth and lobulated form of excrescence not unfrequently has its origin in the prolongations of integument remaining after the collapsing of external piles, which, taking on a new and increased action, and by a species of abnormal nutrition, become transformed into tumours that may attain a considerable size. Excrescences of the anal region are more frequent in women than in men, probably owing to the circumstance that, in addition to the exciting causes the latter are subject to, in the female the parts are liable to be irritated by the contact of discharges-simple and specificfrom the uterus and vagina. They occur more often in the adolescent of either sex than in the adult, except that form of tumour which has its origin in an external hæmorrhoid. Besides those growths to which the term excrescence is applicable, tumours of various kinds occur in this locality; they are more prevalent among the inhabitants of hot countries than in Europe, and in them also attain a large size, but this may be owing to their not coming under surgical observation till an advanced period of their existence. Of the several forms of tumours, the fibrous is the most frequent. Mr. Curling* mentions having had a tumour of this kind sent to him by Mr. Howell, of Clapton, which had reached unusual dimensions; it had been excised from a gardener, fortyone years of age; it weighed upwards of half a pound, and was composed of fibrous tissue, arranged in several lobes; it had been pendulous, and attached to the margin of the anus by a narrow neck. There was an ulcer on its surface, produced, no doubt, by pressure in sitting and friction against the dress. This tumour had been seven years in forming. In addition to the pain experienced in the morbid growths themselves, their presence increases the irritation in which they had their origin, and the skin around becomes excoriated and fissured, producing great smarting; or, if the integument remains intact, the patient will be *Observations on Diseases of the Rectum,' by J. B. Curling, p. 122. tormented with intolerable itching, generally worse at night, and interfering seriously with his rest; neither are the effects always confined to the part, pains in the hips, thighs, and sacral regions being experienced, and also derangement of the bowels. Mr. Mayo* mentions the following case, and similar instances have come under my own observation : A woman, æt. forty-eight, was under Dr. Watson's care, in Middlesex Hospital. She had been suffering for several years with pain and uneasiness, extending from the anus to the loins, and round the lower part of the belly, aggravated when the bowels acted, which were generally in a disturbed state, being either relaxed or constipated. All these symptoms depended upon two large thick condylomata, one on each side of the anus. I removed these tumours with a scalpel; the surface healed very quickly, and the patient was free from all the distress she had previously experienced. When the anus is surrounded by warty growths, in addition to the symptoms already described, the patient will be subject to hæmorrhage, and an exceedingly fetid and copious secretion. In the treatment of these affections at their commencement no operation is necessary, as the excrescences, if small and not much indurated, will generally disappear by the application of a lotion of the bichloride of mer *Observations on Injuries and Diseases of the Rectum,' by Herbert Mayo, p. 98. cury, in proportion of a grain of the salt to an ounce of water; should they be attended with itching, a solution of the nitrate of silver, or a lotion of the bicyanide of mercury in bitter-almond mixture, will usually succeed in allaying it. But when the growths are large and dense, excision is the only effective and proper plan of treatment a probe-pointed bistoury or scalpel is much the more surgical instrument than the scissors, which are commonly recommended to be used; with the knife the incisions can be made more rapidly and with greater precision, and, what is of more consequence, with much less pain to the patient. The operation may be performed either with the patient lying on his side, or kneeling and leaning over the back of a chair. Each tumour is to be seized with a pair of dressing forceps, and removed close to its base, but none of the surrounding integument is to be taken away. In whatever position the patient is, the surgeon should remove the lower growths first, so that the bleeding may not interfere with his view of the others. If the anus is surrounded by warty excrescences, a composition-bougie may be introduced into the intestine, and then, with a circular sweep of the knife, the whole growth is at once removed. It is seldom that any vessels will require ligature; however, should any present, they are easily secured; a considerable oozing of blood will sometimes take place from the incised surface, which can always be readily suppressed by a well-arranged pad, pressed firmly |