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 scrota" extend along the perinzeum 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 defkcation : the surrounding parts in time 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.''' 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 defkcation, 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 defkcation, 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 faeces 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 Skcation, 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 too 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 defaxation, 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 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 Jnembrane 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 he 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.