5. No anus, but the rectum is continued pervious as far as the integuments, which in some cases are then prominent, and of a violet colour, from the meconium appearing through in the situation which the anal opening should occupy. In other cases the skin is thick and hard, and gives no indication of the situation of the rectum. In such circumstances the surgeon must divide the integuments, either by a crucial or by a transverse and longitudinal incision, and then proceed cautiously until he exposes the dis tended rectum. When the skin only inter venes, the prognosis as to the result of this operation may be favourable, as the sphincters are probably perfect ; but when the cul-de-sac of the rectum is deep-seated, then experience affords but little encouragement to hope for success. Death is inevitable in such cases, unless relief can be afforded, and but very few cases of successful operations are on record.* .6. The anus and the continuous portion of the rectum are so contracted as scarcely to admit of any fluid discharge ; we have even seen it scarcely pervious to air, so that on forcing in a grooved director, a considerable burst of flatus has escaped. This contraction may exist be low, and yet the rectum be perfectly natural above. This contraction is sometimes not sufficiently noticed for several days or perhaps weeks after birth, because occasionally there is a small discharge of fatal matter; it ultimately, however, excites attention from the great diffi culty, straining, pain, and crying manifested at each evacuation. This condition of the parts sometimes admits of relief, by simple dilatation, by introducing a soft Bougie, or some prepared sponge, which should be re placed after each evacuation, and secured, if possible, by adhesive plaster and a bandage. Should these means fail, an effectual cure may be obtained, as we have seen, by a division of the circumference. This may done by intro ducing into the rectum a button-pointed bis toury for about an inch on a director, and dividing the wall of the intestine transversely, towards the ischium, first on one side, and then on the other, to the depth of about one quarter of an inch. The part must be carefully dressed, and the edges of each wound kept separate by lint. The success of the operation greatly de pends on the care in the after treatment, par ticularly in renewing the dressing whenever it has been displaced.
The anus is occasionally found much con tracted in new-born children who are con taminated by syphilis, and may be mistaken for a congenital malformation, especially of the kind last noticed, though not one in the strict sense • of the expression ; yet as it generally occurs at birth, it deserves the consideration of the practitioner in midwifery, whose attention is often first called to it by the same symptoms that attend the congenital malformation of this opening, namely, pain, difficulty, and straining at each evacuation, and a peculiarly small aper ture. On examination, however, there are other appearances which will assist in explain.• ing the real nature of the case, such as brown or dark discolouration of the surrounding parts, also considerable moisture, frequently excoria tion, and even superficial ulceration in the adja cent structures. Small fissures in the anus, also, are observable, discharging tenacious matter. Similar appearances may exist about the corn missures of the lips ; some soft granulations or condylomata are also often present in the im mediate vicinity. of the anus ; these frequently extend into the canal for a very little way: Other constitutional symptoms also are usually present, such as copper-coloured blotches on the skin, a tendency to cracking and excoriation of the skin about the hands and feet, and but tocks, an imperfect development of; or a ten dency to a separation of the nails, general emaciation, suspicious appearances about the mouth and tongue, and a remarkable and peculiar hoarseness in crying. Many, if not
most of these symptoms, aided sometimes by the history of the parents, will lead the prac titioner to distinguish this contraction of the anus from the congenital malformation before described. The distinction is important, as the treatment in both is totally different; the syphi litic contraction invariably yields to gentle •courses of mercury, administered in such form and dose as the circumstance of the case shall denote to be necessary. The local complaint disappears as the constitution is restored to health. Soothing, emollient applications are the best topical remedies ; should there be any ulceration or excoriation about the part, the surface should be slightly stimulated daily, either by caustic or by the ordinary mercurial lotions.
Morbid conditions.—The anus is the seat of several morbid affections, some of which pro ceed from a specific cause ; others are merely local. The specific diseases are syphilis and cancer ; and the• most common local derange ments to which the anus is subject are, super ficial ulcerations, excoriations, fissures, with or without contraction of the orifice from exces sive irritability of the sphincter muscle, pro lapsus ani, haemorrhoids, fistula in ano, polypi, &c. Some of these last mentioned affections must, strictly speaking, be considered as ap pertaining to the rectum, under which head the reader will find them noticed. As, how ever, the anus is more or less engaged in these diseases, we shall make some observations on each. The anus is also subject to laceration in parturition, and from other causes. • Syphilis affects the anus at all ages ; its ap pearances in the infant have been already noticed. In the adult it may present the primary venereal ulcer, which will have the same cha racter here as elsewhere, only somewhat modi fied by the position and function of the part.' The primary ulcer may be produced either by the &rect. application of the virus, or by ex tension - of ulceration from the neighbouring organs,' as not unfrequently occurs in the female. When the chancre is confined to the anus, which is very seldom the case, it may he difficult to discriminate between it and ulcera trolls 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 fwcation, 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.