183 



ANUS. 



tumours are frequently developed; the mid- 

 dle hsemorrhoidal veins are uncertain as to 

 number, size, and situation, but the superior 

 are very large and numerous; their branches 

 form repeated anastomoses in the submucous 

 tissue around the intestine, and frequently 

 present all the appearance of erectile tissue, 

 particularly in front, communicating below 

 with the perinseal veins, before with a plexus 

 of vaginal or prostatic veins, and above with 

 the trunk of the inferior mesenteric which 

 leads to the vena portae. This latter communi- 

 cation, as also the absence of valves in the 

 portal system, has laid the foundation of the 

 practice of applying leeches to the anal region 

 in chronic inflammatory affections of the liver 

 and bowels. The same facts also have been 

 adduced to explain the frequency of haemor- 

 rhoids, varices, and vascular congestion about 

 the anus and rectum in cases of diseased and 

 hardened liver, which, under such circum- 

 stances, is supposed to obstruct the circulation 

 by impeding the returning blood through the 

 venae portae. 



ABNORMAL CONDITION OF THE ANUS AND 

 NEIGHBOURING PARTS. 



Congenital malformations. The lower ex- 

 tremity of the rectum and anus not unfre- 

 quently present in the new-born foetus con- 

 genital malformations, some of which are in- 

 compatible with continued existence, while 

 others admit of protracted suffering, with great 

 inconvenience and imminent danger to life; 

 while, again, some may be relieved by the in- 

 terference of art. Hence it is necessary to con- 

 sider these anomalous appearances with a view 

 to discriminate those which are curable from 

 those in which all remedial attempts are totally 

 useless. The following congenital malforma- 

 tions have been noticed by surgical writers, 

 some of which have come under our own ob- 

 servation. 



1. The anus has appeared at first view to be 

 natural, but on a more accurate examination 

 no canal has been found above it; and after 

 death it was discovered that the rectum was 

 absent, that the left colon ended in a cul de 

 sac, and that a dense fatty substance occupied 

 the situation of the rest of the canal. It is plain 

 that no operative interference could avail in 

 such a case. In some cases of this want of 

 rectum the anus has been absent also.* 



2. The anus and rectum have appeared 

 natural, but after death it has been found that 

 the latter was interrupted in one part of its 

 course, and that the intestine had ended above 

 that in a cul de sac. This state of parts must 

 lead to the same practical conclusion as that 

 last mentioned. In these and in such like cases 

 of unhappy malformation, some have suggested, 

 as a " dernier resort," the propriety of opening 

 the intestinal canal at some point in the abdo- 

 men, so as to evacuate its contents and establish 

 permanently an artificial anus. The proposal 

 was first made by Littre,f of opening the 



' See Diet, des Sciences Med. t. xxiv. p. 129. 

 t Mem. de I'Academ. des Sciences, 1720. 



sigmoid flexure of the colon in the left iliac 

 region. A successful case of this operation is 

 recorded as having been performed by Duset* 

 on a boy twenty-four hours after birth : the 

 child was reported, at twelve years of age, to 

 be in good health, with an artificial anus esta- 

 blished in the left iliac fossa.f 



3. No anus, but the rectum has opened into, 

 and its contents escaped either by the urethra 

 in the male, or by the vagina in the female. 

 This condition is an approximation to the 

 cloaca of birds, and of some fishes. Life may 

 continue under such an arrangement, particu- 

 larly in the female, when the intestine opens 

 into the vagina, with great inconvenience no 

 doubt ; but in the male the prognosis cannot 

 even be so favourable, as the urethra can 

 scarcely suffice to give exit to the faeces after 

 some time ; and as the bladder and organs in 

 its vicinity will be subject to constant irrita- 

 tion. Cases are, however, recorded of life 

 being protracted for several months; and in 

 one case, a boy, who lived for eight months, 

 on examination after death it was found that a 

 cherry-stone had blocked up the passage of 

 communication between the rectum and ure- 

 thra. In such a state of parts it has been ad- 

 vised to cut through the perinoeum in the situa- 

 tion of the anus, and endeavour to open the 

 extremity of the rectum. The bladder should 

 be previously emptied of urine, and a sound 

 or staff be retained in it, as a guide to the 

 operator to protect it from injury. In the 

 other somewhat parallel condition of these 

 parts in the female, the exit for the alvine mat- 

 ters is usually more free ; and several cases are 

 on record of life being continued for several 

 years. These cases offer more encouragement 

 for operative interference than the former. A 

 curved probe may be passed from the orifice 

 in the vagina into the rectum, and then directed 

 towards the perinaeum to the situation of the 

 anus. An incision is to be then made upon 

 it ; and when the canal of the rectum is thus 

 opened to the surface, the channel is to be kept 

 carefully dilated, in order to oppose the natural 

 tendency in the parts to close. 



4. The anus may be open, but the con- 

 tents of the intestine retained, in consequence 

 of a congenital contraction of the rectum at 

 some distance above, owing either to a mem- 

 branous septum extending across it, or to a 

 circular thickening and contraction. Such cases 

 may be overlooked, and their cause remain 

 unknown until after death : in cases, therefore, 

 of obstinate constipation at this early age, this 

 part should be particularly examined. Petit J 

 describes this condition, and mentions a case 

 in which he detected such an obstruction in the 

 rectum, about an inch above the anus. This 

 he divided by a pharyngotome, with success. 

 The division may be effected by a bistoury, if 

 situated low down ; or by a trochar, if at a 

 considerable distance from the anus. 



* Recueil Periodique de la Societe de Med. de 

 Paris, t. iv. p, 45. 



t Diet, des Sciences Med. t. xxiv. p. 126. 

 $ Mem. d.e 1'Acad. de Chirurg. t. i. p. 385. 



