184 



ANUS. 



l ions from other causes. Ulcers in this region 

 are very generally difficult and slow to heal, 

 owing to the irritation to which they are exposed 

 from the passage of the faeces, and from the 

 motion, pressure, and changes of form to which 

 the parts are necessarily subject. Syphilis 

 frequently appears here in the form of fissures, 

 clefts, rhagades : these are very distinct, and 

 different from the fissures attending the irri- 

 table anus. The syphilitic fissure is chiefly in 

 the integuments; it seldom extends to any 

 distance within the anus : the edges are some- 

 what elevated and thickened, and the surface 

 secretes an adhesive pus, which forms crusts 

 or scabs. Although in some instances these 

 fissures or rhagades are attended with pain in de- 

 faecation, yet we have met many cases in which 

 they caused very little uneasiness, and thus 

 contrasted remarkably with the simple or the 

 irritable fissure. Warts, condylomata, or ex- 

 crescences about the anus are also frequent 

 effects of syphilis in this region. These are 

 generally on the cutaneous side of the anus, 

 and very rarely, I believe, extend within it : 

 they are not, therefore, difficult to distinguish 

 from those vascular excrescences which are of 

 mucous origin, and which so commonly pro- 

 trude at the anus. Syphilitic warts and con- 

 dylomata have generally a broad base; their 

 surface is flattened by pressure against the op- 

 posite nates, soft and moistened with an offen- 

 sive sero-purulent fluid. In these cases the 

 surrounding skin is often excoriated, and clefts 

 and superficial ulcers frequently exist in the 

 vicinity of the anus. 



Cancer is a disease to which the rectum is 

 very liable, and may attack any part of the 

 intestine, but usually exists at some inches 

 above the anus. This opening, however, may 

 become implicated by the extension of the dis- 

 ease. We occasionally see that form of cutaneous 

 cancer called " cancer scroll" extend along the 

 pennaum and involve the circumference of the 

 anus. Its parietes may, however, be prima- 

 rily affected by cancer, in which case the 

 disease will commence by a chap or fissure, 

 or more frequently by a tubercle, which, gra- 

 dually increasing in size and in breadth, at 

 length ulcerates and shoots out a cauliflower 

 mass of granulations which protrude through the 

 opening, causing great uneasiness, pain, and dif- 

 ficulty in defaecation : the surrounding parts in 

 trine become involved, ulceration extends, and 

 a bleeding surface, very unhealthy, sloughy in 

 some parts, and fungoid in others, discharging 

 sanious and unhealthy matter, is an almost in- 

 cessant source of pain and irritation, which in 

 time wastes the health and strength of the 

 patient. As no local application or consti- 

 tutional treatment has yet been able to arrest 

 this disease, it has been proposed to extirpate 

 the anus and the lower end of the rectum when 

 in this condition. Unfavourable as this opera- 

 tion may appear, and rarely as it has been 

 undertaken in this country, it has been fre- 

 quently performed in France, and with some 

 success.* 



* See Velpeau, Med. Oper, t. iii. p. 1033. 



The anus is often affected with warty ex- 

 crescences, which by a superficial observer might 

 be condemned as cancerous, yet these are not 

 of a malignant character, and may be cured by 

 local remedies and due attention to the gene- 

 ral health. I have seen a warty tubercular 

 appearance about the anus, extending through 

 it, and even involving the mucous surface for 

 some height, and contracting the orifice so 

 much as to cause great pain and difficulty in 

 defalcation, and also materially impairing 

 the general health by continual irritation ; yet 

 this state of parts is not malignant, nor is it 

 prone to ulceration. Attention to the consti- 

 tution, to the functions of the bowels, with 

 local applications, will effect a cure. The anus 

 is also frequently affected, and even incon- 

 venienced by the growth of common warts ; 

 these, however, can be speedily removed either 

 by the scissors or by caustic. 



Excrescences frequently protrude through the 

 anal opening, which are not warty or cutaneous 

 growths, but elongations of the mucous mem- 

 brane from a little distance above the anus. 

 The anatomical disposition of these parts, before 

 alluded to, together with a very relaxed state 

 of the mucous membrane, accounts for the fre- 

 quency of this occurrence. In some these pro- 

 trusions only appear during defaecation, in others 

 they are permanent, but much increased in 

 volume during that act; and, indeed, in some 

 they are so large and fill up so much of the 

 canal, that they must be extruded before the 

 faces can escape. These excrescences are soft, 

 and very vascular; they often appear without 

 any assignable cause, though frequently they are 

 attributed to haemorrhoids, to constipation of 

 the bowels, to violent straining efforts in de- 

 facation, to fistula, or to long-continued irrita- 

 tion from any cause. 



Prolapsus ani, or procidentia ani, although 

 a term in somewhat common use, is rather an 

 incorrect one, as the anus itself is loo well 

 maintained in its situation to descend, at least to 

 any appreciable distance; the term rather implies 

 a protrusion of a considerable portion of the 

 relaxed mucous membrane of the rectum, or a 

 portion of the large intestine itself, which must 

 have become " invaginated or introsuscepted," 

 and then protruded through the anus ; in these 

 conditions the anus is rather dilated, the mu- 

 cous membrane sometimes remains protruded 

 after defalcation, but in others it returns after 

 this process, or it can be returned by the gentle 

 pressure of the hand : this is not uncommon 

 in children and in elderly persons. This disease 

 has been ascribed to a relaxation of the sphincter; 

 a circumstance which, however, does not seem 

 to be proved, for in paraplegia and in paralysis 

 of the sphincter, we do not find that the mem- 

 brane protrudes, although the anus is often in 

 these cases very dilatable; the condition referred 

 to ought perhaps rather to be considered as one 

 of the effects, than as the cause of the disease ; 

 moreover in some other instances the sphincter 

 appears rather irritable, and painfully and dan- 

 gerously constricts the protruded mass, which 

 must then, in order to save the intestine from 

 gangrene, be reduced by pressure properly 



