ANUS. 



185 



applied, and by attention to posture. In the 

 procidentia of old persons, Mr. Hey conceives 

 that the relaxed state of the lower part of the 

 intestine and of its surrounding cellular tissue, 

 are in fault, and that hence the folds or ex- 

 crescences about the anus remain, even when 

 the parts have been returned ; he therefore sug- 

 gests the removal of these flaps from the cir- 

 cumference of the opening, and relates some 

 well-marked cases in support of this practice, 

 in which the operation had been successfully 

 performed. 



The margin of the anus, like that of the 

 mouth, is subject to fissures, chaps, and super- 

 ficial excoriations, sometimes caused by lace- 

 ration induced by the passage of large and 

 hardened faeces, but sometimes arising spon- 

 taneously, and sometimes connected with a 

 peculiarly irritable and contractile condition of 

 the sphincter ani. This disease must not be 

 confounded with haemorrhoids; on examin- 

 ation it is not easily seen, but little is appa- 

 rent, the anus is much contracted, the orifice 

 somewhat redder than natural, slightly tender 

 on pressure, but exquisitely so on dilating it 

 by introducing the finger; this must be done 

 cautiously and slowly, a cleft will then be 

 observed just where the skin and mucous 

 membrane join, generally on one side extending 

 a little way, from half an inch to an inch and 

 a half, longitudinally up the intestine ; on di- 

 lating the part still more, the surface of the 

 fissure will be seen slightly ulcerated, and 

 when touched it is exquisitely painful ; the 

 surrounding muscle is in a state of rigid con- 

 traction. It is doubtful whether the contrac- 

 tion is the cause of the fissure, or whether the 

 latter is the cause of the irritable and con- 

 tracted condition of the muscle. Both expla- 

 nations may be occasionally correct; but it is 

 most probable that the irritable state of the 

 muscle induces the ulcerated fissure, inasmuch 

 as this muscular contraction occasionally exists 

 without any fissure, and is then equally pain- 

 ful ; and fissures frequently exist, as in syphilis, 

 without inducing any spasmodic constriction 

 of the muscle, and accordingly are attended 

 with little or no pain. 



Contraction of the anus also frequently ex- 

 ists without any fissure ; sometimes it is con- 

 genital, sometimes it appears in the adult ; the 

 pain and other symptoms are nearly analogous, 

 and as severe as in the case of fissure; the 

 examination by the finger however does not 

 detect one part to be more painful than another, 

 as is the case in that disease ; and this is almost 

 the only symptom distinguishing these two 

 affections. 



The term hamorrhoid has been applied by 

 writers, practitioners, and invalids to any con- 

 dition of the rectum and anus in which a 

 discharge of blood takes place. It is, how- 

 ever, more correctly applied to the small tu- 

 mours which are frequently seen at and very 

 close to the inner border of the anus or even 

 occupying the very aperture, also to somewhat 

 similar productions situated within the rectum, 

 at the distance of one, two, or even three 

 . inches above the anus. From such tumours 



occupying these different positions, they have 

 been arranged by all writers into external and 

 internal haemorrhoids; the latter are very im- 

 portant and demand the close attention of the 

 surgeon, both as to their pathology and sym- 

 ptoms, as being frequently obscure and liable 

 to be mistaken not merely for the ordinary 

 diseases of the anus, such as fissure, blind 

 internal fistula, &c., but also to be confounded 

 with a varicose condition of the veins of the 

 rectum, which is by no means an uncommon 

 condition, or with those vascular tumours 

 which are productions of the mucous mem- 

 brane occasionally protruding at the anus, 

 that have been already noticed, and are 

 of a wholly different character from -true hae- 

 morrhoidal tumours, or with the protrusions 

 of the mucous membrane itself, the effect of 

 the relaxation of its cellular connections. As 

 the full consideration of this important branch 

 of pathology belongs to the article on the mor- 

 bid anatomy of the rectum, we shall here con- 

 fine ourselves to a few observations on external 

 haemorrhoids and analogous tumours. 



External hemorrhoids appear at the border 

 of the anus as small bluish tumours, the 

 colour however varying according to the con- 

 dition of the tumours, being sometimes of a 

 dark and deep red or black, at others pale and 

 almost white ; in size they vary from a grain 

 of small shot to a large cherry ; they are some- 

 times full and almost bursting, at others they 

 are soft like a flaccid nipple, empty or with- 

 ered ; they are covered on the anal side by the 

 delicate cuticle which is smooth and glossy, 

 and on the outer side by the common integu- 

 ment; when small, they are moveable and can 

 be distinctly felt to be in the subcutaneous 

 cellular tissue ; when large and tense, they ap- 

 pear more connected with the skin itself; 

 an attentive examination can always distinguish 

 between these and the several excrescences, 

 vegetations, or condylomata, which have been 

 already mentioned as the effects of syphilis, 

 as also the folds or crests of integument and 

 mucous membrane which are found so fre- 

 quently prolonged from the border of the 

 anus. These tumours remain in many persons 

 for years free from pain, and productive of 

 little, if of any, inconvenience; occasionally, 

 however, and periodically in some, they en- 

 large, inflame, and interfere with the functions 

 of the anus, and by sympathy engage the ad- 

 jacent organs, and are relieved either by a 

 copious discharge of blood, or by suppuration, 

 or by the interference of art. 



The liability of the veins immediately about 

 the anus to varicose enlargement appears in 

 some measure founded in anatomical structure. 

 If we inject the intestinal veins in the adult 

 with wax injection, we shall often find a little 

 above the anus, just where the skin and mu- 

 cous membrane unite, a sort of constriction on 

 the vessels ; the veins appear larger imme- 

 diately above it, and again below it, and 

 many of the branches in the venous plexus 

 around the anus appear to be enlarged, while 

 in the very spot or circular line alluded to, 

 the vessels appear to be compressed. It may 



