LIBRARY OF CONGRESS. T\ Cv . Appearance of the anus where the sphincter was cut in three places in a girl who recovered perfect control of the bowel in six weeks, 107 44. Ideal anal dilators (half size), 126 45. insufflator, 140 4ti. A-llingham's ointment applicator, 140 47. Sims's irrigator and drainage-tube, 141 48. Diagrammatic drawing- of annular stricture, 146 -1'.). Diagrammatic drawing of tubular stricture, 146 50. Appearance of a cross-section of strictured rectum, 148 51. Bodenhamer's rectal explorer, ........... 162 52. Correct method of introducing a rectal bougie, 168 53. Whitehead's dilator, 169 54. Durham's dilator, 169 55. Set of " Aloes " bard-rubber bougies, 169 56. Wales's soft-rubber rectal bougies, 170 57. Appearance of gut before removal, 177 58. Artificial anus one year after operation, 178 59. Showing attachment of internal hemorrhoids, ....... 193 60. Hemorrhoidal truss, 194 61. Cross-section of internal hemorrhoids, 195 82. Pollock's hemorrhoidal crusher, 198 63. Herbert Allingbam's pile-crusher, 198 64. Cautery irons, 200 65. Cautery blow-pipe, 201 66. Thomas's curved tissue-forceps, 212 67. Correct method of applying the ligature, ........ 213 68. Clover's crutch, 214 69. Mathews's pile-forceps, 215 70. Paquelin cautery, 216 71. Smith's clamp. 217 72. Dilatation of the sphincter ani, 218 73. Severing the mucous membrane from the skin, 219 74. Cauterizing the stump, 220 75. Author's pile and polypus clamp, 222 70. Benton's India-rubber tampon. (Modified by Edwards), 233 77. Drainage-tube wrapped with gauze, 233 78. Hollow vulcanite drainage-tube, .......... 234 79. Herbert Allingbam's method of excision of rectum, ...... 301 80. Herbert Allingbam's method of excision of rectum, 302 81. Herbert Allingbam's method of excision of rectum, 303 82. Relations of peritoneum with mesentery, 320 83. Relations of peritoneum with mesenteiy, 321 8-1. Relations of peritoneum with mesentery 321 85. Longitudinal bands and appendices epiploic*, 322 86. State of gut with varying mesenteries 324 87. State of gut with varying mesenteries, 324 88. State of gut with varying mesenteries, 324 State of gut with varying mesenteries, 324 90. State of gut with varying mesenteries, 324 LIST OF ILLUSTRATIONS. Xlll FIG. l'AGK 91. State of gut with varying mesenteries, 324 92. Suturing gut, 328 93. Gut after operation, 329 94. Removal of gut, . 330 95. Double-barreled opening, 331 96. Showing double-barreled opening with directors passed into each orifice, . . 331 97. Mesentery as cause of procidentia, 333 98. Procidentia, .... 333 99. Mesentery made taut, ............ 334 100. Gut pulled out to full extent, 334 101. Herbert Allinghanrs colotomy clamp, 335 102. Removal of gut with above clamp, 335 103. Fecal fistula, 339 104. Artificial anus, 339 105. Procidentia from upper opening, 340 106. Procidentia from lower opening, .......... 341 107. Procidentia from both openings, 342 108. Position of peritoneum in condition 1, 348 109. Position of peritoneum in condition 2, 349 110. Position of peritoneum in condition 3, 350 111. Procidentia from both openings after lumbar colotomy, ..... 354 112. Procidentia from both openings after lumbar colotomy, ...... 355 113. Stick removed from rectum (half size), 363 114. Diagrammatic drawing showing deviation of coccyx anteriorly 367 115. Diagrammatic drawing showing deviatiou of coccyx posteriorly, . . . 367 LIST OF FULL-PAGE PLATES. PLATE PAGE I. Typical case of procidentia through artificial anus (frontispiece). II. Levatores ani as seen from above, .9 III. Levatores ani, side-view, 9 IV. Typical case of procidentia recti, 11 V. Syphilitic condylomata, 62 VI. Typical case of recto-vesical fistula, showing- result of extravasation of urine into scrotum and penis, 78 VII. Typical case of fistula in auo, with operation for same, 86 VIII. Painful ulcer (fissure) of the anus, 118 IX. Ulceration and polypoid-like sentinel teats, 130 X. Diagrammatic drawing of stricture of the rectum due to ulceration, . . . 156 XI. Artificial anus, showing one opening into rectum and the other into descending colon, 175 XII. Thrombotic hemorrhoid, 185 XIII. Pathology of internal hemorrhoids, 191 XIV. Protruded hemorrhoids, with prolapsed mucous membrane, .... 193 XV. Author's clamp adjusted and scissors in position for excision of hemorrhoids, . 217 XVI. Typical case of fibrosarcoma with multiple fistula, involving the rectum and anus, operated on by the author at his clinic, .... 307 and 308 (xiv) Diseases of the Rectum, Anus, and Contiguous Textures. CHAPTER I. INTRODUCTION. In the whole range of surgical pathology no other class of diseases among civilized communities is so prevalent, causes more suffering, and induces so many varied reflex and distress- ing sympathetic affections as the diseases occurring about the anus and rectum. This is because of the structure of the anus and rectum, their peculiar office in the economy of nature, and their relation to the important organs in their immediate vicinity. Happily for the sufferers, no other class of complaints succumbs more readily to judicious and, in the majority of cases, to simple treatment, when properly applied at the onset of the disease. Unfortunately, from mistaken delicacy or carelessness, patients often postpone seeking proper advice until the local symptoms have become unbearable or the constitution seriously deranged ; or, from the prominence and severity of some one of the reflex or sympathetic effects, they are induced to adopt a variety of empirical remedies which fail in the restoration of health and are often productive of pernicious results. Many of these dis- eases spring from irregularities in habit engendered by sedent- ary pursuits, or they result from indulgence in the luxuries of civilized life. They are, therefore, more prevalent in the middle and upper circles of society ; though they are not infrequently found in all classes. Diseases of the rectum have been mistaken for prostatic, uterine, and cystic affections. This renders a careful examina- a) 2 DISEASES OF THE RECTUM AND ANUS. tion, both visual and digital, absolutely necessary. Unless the surgeon understands the anatomy of the parts he cannot com- prehend the physiology of the rectum, much less the diseases to which it is liable. When well acquainted with it and the surrounding parts, he not only performs the operation with more deftness, but is enabled to understand the functions of the several organs and their mutual relations. Therefore, the sub- ject of the following pages cannot be introduced in a more use- ful manner than by briefly describing the anatomy of the rectum and its relation to the several organs contained in the pelvis. CHAPTER II. ANATOMY AND PHYSIOLOGY OF THE RECTUM AND ANUS. It is not our intention to go into the minute anatomy of the rectum and the anus, but to give such information that the operator may work with a degree of intelligence. The inferior portion of the colon and alimentary canal is called the rectum, — a misnomer in the human species ; the term originated prob- ably from the usual straight form that this organ presents in the lower animals. The length varies from six to eight inches (15 centimetres to 2 decimetres), the latter measurement being more common in advanced life, for as age increases the tortuosity of the bowel is more marked. Above it is continu- ous with the terminal portion of the sigmoid flexure of the colon, situated in the left iliac fossa, and terminating below at the anus. In rare instances the position of the abdominal vis- cera is reversed ; in such cases the rectum would necessarily commence on the right side. At its commencement it curves downward toward the right side of the pelvis three and one- half inches (8.8 centimetres), by which it is brought to the median line of the sacrum at a point opposite the third sacral vertebra ; it then descends obliquely forward and downward for about three inches (7.5 centimetres), at which point it is found opposite the apex of the coccyx ; from this point it turns upon itself, backward and downward, for about one and a half inches (3.8 centimetres), thus completing its course at the anus. It is obvious, in introducing the finger into the rectum, that it should be passed upward and forward. Like the hollow ab- dominal viscera, the rectum has three coats, — peritoneal, mus- cular, and mucous, — the first being only partial, w T hile the others are continuous throughout. Ordinarily it is that portion (3) 4 DISEASES OF THE RECTUM AND ANUS. which is not covered by peritoneum that is the seat of the disease. Peritoneal Coat. The upper portion of the rectum is in contact with the sacrum, internal pudic, and sacral plexus, in front with the pos- terior portion of the bladder in the male, and with the uterus in the female. Sometimes a convolution of the small intestine may intervene. At its commencement the rectum is generally surrounded by the peritoneum, which binds it to the sacrum ; but lower down it covers the anterior surface only, and is then reflected on to the bladder, forming the recto-vesical pouch. The uterus and vagina are interposed between it and the blad- der in the female. This pouch may extend down to within an inch (2.54 centimetres) of the prostate; the distance is liable to variations depending on the age and the distension of neighbor- ing organs. In the newborn it may extend to within an inch (2.54 centimetres) of the anus. The distance increases after the fifth year ; in old age with enlarged prostate the peritoneum goes still higher up. The distance from the anus to the lower portion of the fold has been a subject of much controversy both at home and abroad. We shall not enter the discussion, but will state that our observations lead us to believe that two and a half inches (6.35 centimetres) in the male and three and a half inches (9.9 centimetres) in the female, with an additional inch (2.54 centimetres) when both bladder and rectum are dis- tended, would be a fair average distance. Muscular Coat. This coat is thicker and stronger than other portions of the large intestine. It consists of two layers, — viz., circular or inner and longitudinal or outer. The fibres of the latter are partly prolongations of the colon, while some are peculiar to the rectum. They are more numerous in the anterior and posterior portions of the rectum, and by their action prevent the rectum's being thrown into folds as in the colon. They also seem to be ANATOMY AND PHYSIOLOGY OF THE RECTUM AND ANUS. 5 more abundant in the upper than in the lower portion. The circular fibres are neither particularly strong nor numerous in the upper portion, but become stronger and more abundant at the lower end of the rectum. There they form a muscular band, about an inch (2.5-1 centimetres) in width, constituting the internal sphincter muscle. Mucous Membrane. The mucous membrane is thicker and more vascular than any other portion of the large intestine. It contains many mucous follicles, which are distinct. It glides over the tissues beneath and is so abundant as to be gathered into folds, which diminish in proportion as the bowel becomes distended. Ex- tending from one fold to another, at times little arches may be seen forming small poc'kets, which are at the present writing the subject of much controversy. It is well to observe them closely, however, for it is an easy thing to mistake the mouth of one of these pockets for that of a blind internal fistula. The introduction of a probe will quickly settle the diagnosis and determine if it be a fistula or not. These follicles are very numerous and, under the microscope, present a honey-comb appearance. They prove of great value from their absorbing power, — a. fact demonstrated by the good results derived from rectal medication. Sometimes enlarged papillae are to be seen about the anal margin. Arterial Supply. The arteries of the rectum are derived from three distinct sources : — 1. The superior hemorrhoidal, from the inferior mesenteric. 2. The middle hemorrhoidal, from a branch of the internal iliac. 3. The inferior hemorrhoidal, from the internal pudic after it has re-entered the pelvis. 6 DISEASES OF THE RECTUM AND ANUS. The Superior Hemorrhoidal. — This artery divides into two branches, which course along the posterior wall of the rectum. They are at first superficial, but soon perforate the longitudinal fibres and give off a number of branches, which anastomose on the internal surface of the rectum, not only with each other, but with the middle and frequently with the inferior hemorrhoidal arteries. The main branches run parallel with the bowel. This accounts for the smallness of the hemorrhage from incisions made in the long axis and the profuseness of the same made at a right angle to the long axis of the bowel. Jfiddle Hemorrhoidal Arteries. — They vary in size and take an oblique course downward to supply the middle third of the rectum. Inferior Hemorrhoidal Arteries. — They send branches upward as well as downward to anastomose with the other hemorrhoidal arteries to supply the levator ani, sphincter muscles, and cellular, fatty, and tegumentary tissues in the anal region. Veins of the Rectum. The veins correspond in name with the arteries. The middle and inferior hemorrhoidal return the blood from the anal region to the internal iliac. The hemorrhoidal plexus of enlarged and anastomosing veins is situated in the lower part of the rectum and from it proceeds the " superior hemorrhoidal vein," which returns the blood from the rectum proper to the portal system. This vein and its branches pass upward under the mucous membrane for a distance of about three or four inches (7.62 or 10.16 centimetres), then perforate the muscular coat, and can be seen on the outside of the bowel. Verneuil has laid much stress on this anatomical fact, claiming that the veins pass through muscular button-holes, which have the power of contracting around them, closing their calibre and preventing a return of the blood to the liver. In this anatom- ical arrangement, he believes, is to be found the active cause of internal hemorrhoids. anatomy and physiology of the rectum and anus. 7 Nerves of the Rectum. They are derived from the two great classes which go to make up the nervous system, — the cerebro-spinal, from the sys- tem of animal life, and the sympathetic, or system of organic life. The former are from the sacral plexus and the latter from the mesenteric and hypogastric plexuses. The muscles of the anal region are supplied by branches of the sacral nerves, while the superficial perineal of the pudic supplies the levator ani and skin in front of the anus. The inferior hemorrhoidal (of the pudic) branch supplies the lower end of the rectum and anus. The pudic is controlled by the same part of the cord as the sciatic. Hence irritation from a fissure or ulcer located within the anus may be transferred down the limbs or to other distant parts. Mr. Hilton alludes to pain in the heel as a fre- quent symptom of fissure. The intimate relation of this nerve to the genito-urinary organs explains the frequency with which disorders of micturition are associated with rectal affections. The upper and middle portions of the rectum are much less sensitive than the lower, as has been proven by experiments made by Bodenhamer. The pain increases in proportion as the disease encroaches upon the anal margin ; hence disease, malignant or otherwise, situated high up may cause little pain. The sympathetic nerve is distributed to the rectum and anus and is derived from the hypogastric, which is formed by branches from the aortic plexus. It also receives branches from the lumbar and sacral plexuses. Lymphatics. The absorbents of the rectum and anus are much more numerous than is generally supposed. They consist of two systems, those of the anus being distinct from those of the rec- tum, the former going to the inguinal and the latter to the sacral and the lumbar glands. This accounts for the clinical fact of infiltrated inguinal glands from a similar condition in the rectum. Mr. Cripps, however, has recorded two cases of 8 DISEASES OF THE RECTUM AND ANUS. infiltrated inguinal glands when the seat of the disease was situated high up in the rectum. The x\nus. The anus is a small oval orifice, directed downward and backward, situated about an inch (2.54 centimetres) in front of the extremity of the coccyx, between the tuber ischii (but above them in the male), in the median line between the but- tocks. It is covered internally by integument, which is firm, soft, and provided with papillae, hair, and sebaceous follicles. The latter secrete an unctuous fluid with an unpleasant odor. The anus can be freely dilated, but, when closed, the surround- ing skin is thrown into numerous folds. Muscles of the Rectum and Anus. The muscles that especially interest us in the study of rectal diseases are three in number, — viz., the external and internal sphincters and the levator ani. External Sphincter. — This muscle is situated immediately beneath the integument. It arises from the tip of the coccyx. After surrounding the anus in the form of an ellipse, it is in- serted in front into the central tendon of the perineum. The action of the muscle is to close the anus and assist in the ex- pulsion of the feces in conjunction with the expiratory muscles. Its contracting power varies in different people and under cer- tain pathological conditions. For example, it will be found firmly contracted when a fissure is present. In most cases of malignant diseases it is loose and flabby. We always antici- pate serious rectal diseases when there is no sphincteric resist- ance to the introduction of the finger. Internal Sphincter. — This muscle is a flat, involuntary, muscular band lying immediately above the external sphincter. It is from three-fourths of an inch (1.9 centimetres) to one inch (2.54 centimetres) in breadth and one-sixth inch (4.2 PLATE II-LEVATORES AMI AS SEEN FROM ABOVE PLATE III.-LEVATORES ANI, SIDE VIEW ANATOMY AND PHYSIOLOGY OF THE RECTUM AND ANUS. 9 millimetres) in thickness. Its fibres are somewhat paler than those of the internal. United with this muscle are the un- striped bands, which arise from the anterior surface of the coccyx (recto-coccygeus muscle). The recto-coccygeus muscle embraces the lower end of the rectum in a fork, and it draws the rectum upward toward the apex of the coccyx, when it is forced down during the act of defecation. Levator Ani. — The origin and insertion of this muscle, as well as its action, have been the subject of much study and controversy. From the dissections which we have made we believe, with Mr. Cripps, that a large portion of the fibres arises from the inner surface of the symphysis and from half an inch (1.27 centimetres) of the anterior portion of the white line, and passes obliquely downward and backward to be in- serted on the sides of the coccyx. The fibres cross the rectum at right angles two and a half inches (6.35 centimetres) above the anus. (See Plates II and III.) The action of the levator ani is to compress the sides of the rectum and the neck of the bladder, and in the act of defe- cation, when the sphincter contracts to open the anus, it closes the urethra. This explains in part the well-known difficulty of discharging urine and feces at the same time. We have made two diagrammatic drawings (see plates) which show very nicely the relation of the levator ani to the rectum. This muscle also partly forms the floor of the pelvis to support the pelvic organs. In addition to this it has a volun- tary sphincteric action, which can be demonstrated by intro- ducing the finger into the bowel and requesting the patient to draw up the anus as much as possible, when a contraction may be felt from one and a half to two inches (3.8 to 5.08 centi- metres) above the anus. This Mr. Cripps attributes to the lev- ator ani. This action would, in part, account for the control of the bowel that is frequently seen after complete destruction of the sphincters. Again, after certain rectal operations where the sphincters have been thoroughly paralyzed, patients often 1 DISEASES OF THE RECTUM AND ANUS. complain of the anus's jerking. This we attribute to the action of this muscle. The Rectum. The rectum differs from other portions of the large intes- tine in that it has no longitudinal bands and it is non-saccu- lated in appearance. When distended to its fullest capacity it fills a large portion of the pelvic cavity. Internally it presents three or four transverse folds. According to Houston,* the largest one is situated three inches (7.62 centimetres) above the anus, opposite the base of the bladder ; the second, at the upper end of the rectum ; the third, midway between the two just named; while the fourth (rarely present) will be found one inch (2.54 centimetres) above the anus. They form, as it were, valves which occupy from one-third to one-half the circumfer- ence of the bowel, the margins of which are directed upward ; they are located on opposite sides, thus forming a kind of spiral tract, the object of which is to support the fecal mass and pre- vent a too rapid descent to the anus. The folds become almost obliterated when the bowel is distended. From the study of the anatomy we necessarily are led to the consideration of the physiology of the rectum and anus, to which attention is now invited. Physiology of the Rectum and Anus. It is a noticeable fact, to those accustomed to making rectal examinations, that the rectum is found to be empty, in a large percentage of cases, until just before defecation takes place. The prevailing opinion seems to be that the fecal mass is ar- rested and supported, in the upper part of the rectum, by the folds previously described, till just before expulsion of the same takes place. There has been and still is much contro- versy as to what produces the sensation which precedes the ex- pulsion. Some claim it to be due to contact. This is hardly probable, for we have seen large masses collect where no sensa- * Dublin Hospital Reports, vol. v, p. 158. ANATOMY AND PHYSIOLOGY OF THE RECTUM AND ANUS. 11 tion was felt whatever. Others ascribe it to some irritant pro- duced in the retained feces. This appears less reasonable than the other, for we know that the sensation is produced immedi- ately on the discharge of the fluid feces into the rectum in cases of diarrhea. While I am not positive as to what causes the sensation, I am inclined to believe it is of an organic nature, as a result of some intestinal change which takes place before the mass reaches the rectum. The peristaltic movements which precede defecation are increased by sphincteric resistance. At the proper time, however, the muscle relaxes and, by the aid of the abdominal muscles (especially the internal oblique and diaphragm), together with the levator ani, the fecal mass is ex- pelled. The frequency of the evacuations depends largely upon habit and diet. Actions occur more frequently in males than in females. Normally the bowel ought to act at least once in every twenty- four hours. It is not an uncommon occurrence, however, to see patients who do not have an action more than once in three or four days or even a week without the use of some medicine. This delay is often due to irregular habits in going to the stool. CHAPTER III. SYMPTOMATOLOGY. Before taking up for consideration the individual rectal diseases we desire, in a general way, to give the symptoms which one would be likely to meet in the treatment of this class of diseases, and to note their value as a guide to correct diagnosis. Among the more prominent ones we might men- tion are: pain, which may be confined to the neighborhood of the pelvis or reflected up the back or down the limbs ; dis- charges of blood, pus, or mucus ; protrusions, constipation, diarrhea, and itching about the anus. Pain. Pain may vary from a slight discomfort to intense pain. In getting the history it is well to inquire if it is constant, dull, or sharp in character ; if it is about the anal margin or high in the rectum, as well as its relation to defecation, to find out if it precede, accompany, or follow it ; also as to its duration, and accordingly some idea may be formed as to the nature of the disease. Pain may be expected when any of the following conditions are present : — 1. Fissure. 3. Ulceration. 2. Hemorrhoids. 4. Morbid growths. Fissure. — In fissure the pain is very severe and out of all proportion to the extent of the lesion. It usually comes on during the act of defecation, is most intense during the same, and lasts for some time afterward. It is described as being of a hot, smarting character, severe, and radiating toward the coccyx. Hemorrhoids, — Pain due to hemorrhoids depends on the size of the tumor, the location, and the amount of the inflam- (12) SYMPTOMATOLOGY. 1 3 mation present. External piles, unless inflamed, cause very little pain. The only inconvenience is a sensation of fullness and heat. If the pile chance to be of the thrombotic variety, there will be much pain and tenderness until the clot is turned out. Internal Hemorrhoids. — Like the external variety, they often produce a sensation of heat and fullness ; the pain will be more or less severe, depending upon the size, number, and location of the tumors. Should there be only one or two tumors situated above the grasp of the sphincter, they will cause very little annoyance; while if they are large and within the grasp of the sphincter to such an extent as to become strangulated, the pain will be intense and of a drawing and burning character, with a constant desire to strain down, which results in the tumors' swelling and acting as foreign bodies. They keep the sphincter in a state of spasmodic contraction in its endeavor to expel the same. Should the tumors continue to fill and the strangulation is not relieved, ulceration will prob- ably occur, inducing additional pain, which is likely to continue until the piles have been operated upon or taken nature's course and sloughed off. Ulceration. — In ulceration of the rectum the amount of pain depends upon the location and extent of the disease. If it is situated high up and is not too extensive, there will be a minimum amount of pain. On the other hand, when it is located near the anal margin, the pain is very great ; in fact, it increases in severity as the anal margin is encroached upon. Malignant Disease. — Pain in malignant disease, like that of ulceration, depends largely upon the extent and location of the disease, being much greater when situated low down. It increases as the disease becomes more fully developed. Much pain will be experienced every time the hardened feces pass over the diseased parts to be expelled, and after a time patients suffer from alternate attacks of constipation and diarrhea. During the latter the pain is of a smarting, burning character, 14 DISEASES OF THE RECTUM AND ANUS. and the straining almost unbearable. Strange to say, in some cases of malignant disease, even though it be extensive, little pain is experienced. This occurs only when the disease is located high up in the rectum. Because of the slight pain the surgeon, in all probability, will not be called until the disease has progressed to such an extent that little can be done. Protrusions. In getting the history it is desirable to find out if anything protrude from the anus. If so, ascertain if the protrusion oc- cur during defecation only or at irregular times, if it return of its own accord or if the patient return it himself, if it is con- stantly present, and if it is accompanied by hemorrhage. A protrusion, under such circumstances, might be the result of a variety of diseases, viz. : — 1. Prolapsus recti. 3. Polypi. 2. Internal hemorrhoids. 4. Villous growths. Prolapsus. — The tumor, in cases of prolapsus, is soft and smooth. The color of the mucous membrane and the whole circumference of the bowel is involved. Its size depends upon the extent of the prolapsed bowel. As a rule, it induces little suffering unless strangulation has taken place. Internal Hemorrhoids. — The protrusion of internal piles can be distinguished from that of prolapsus in that the tumor or tumors are distinct and do not involve the entire circum- ference of the bowel. There will be very little pain until strangulation takes place ; then the pain and the swelling- become exaggerated. At an early stage of the disease the tumors come down, but can be readily replaced ; while in cases of long standing they remain outside the anus nearly all the time. Polypi. — A polypus, like an hemorrhoidal tumor, usually comes out during defecation, the extent of which depends upon the length and size of the pedicle. It may return spontane- SYMPTOMATOLOGY. 15 ously or have to be returned by the patient himself. This sometimes becomes impossible, when strangulation occurs, and then it sloughs off. Villous Tumors. — These are vascular in character, but resemble the others just described, in that they are made to protrude during defecation. Hemorrhage. In the order of frequency as a symptom, hemorrhage comes next to pain. The blood may be voided pure or min- gled with feculent matter, or appear in streaks on the surface of hardened feces. Mucoid discharges tainted with blood are frequently to be seen. Hemorrhage of the rectum may be a symptom of any of the following diseases : — 1. Internal hemorrhoids. 7. Pol} T pi. 2. Prolapsus. 8. Villous growths. 3. Fissures. 9. Wounds and the presence of 4. Ulceration. foreign bodies in the rectum. 5. Stricture. 10. Hemorrhage from the stomach. 6. Malignant disease. Internal Hemorrhoids. — The amount of hemorrhage de- pends upon the case. It is usually started by straining during stool. In one case only a few drops will escape, while in an- other the flow may be very profuse ; in others there may be a continuous dropping for hours after stool. The hemorrhage is usually of a venous character. We have on several occa- sions, however, witnessed hemorrhages which were apparently arterial in character. It is not essential that the tumor pro- trude in order to have bleeding. Prolapsus. — Hemorrhage is of rare occurrence in cases of prolapsus unless ulceration is present. Fissures. — In fissures of the anus bleeding is usually scant. It follows defecation, is of short duration, and is more fre- quently to be seen in streaks on the hardened feces. 16 DISEASES OF THE RECTUM AND ANUS. Ulceration. — In this disease the bleeding depends some- what upon the extent of the ulceration and its location. The discharge rarely consists of pure blood, but of blood mixed with muco- purulent matter. Sometimes it can be seen in splotches on the feces. In the more severe cases it may become alarming, especially in cases of rapidly spreading, specific, or malignant ulceration. Stricture. — Stricture accompanied by bleeding is of fre- quent occurrence. When mixed with pus the discharge re- sembles coffee-grounds to a certain- extent, especially when it has been retained in the rectum for a considerable length of time. Malignant Disease. — In this disease bleeding almost inva- riably takes place. In the early stage the bleeding is due to congestion and is slight ; but when ulceration commences, it may be profuse and either venous or arterial in character or both. It may occur in the intervals of defecation. Several cases of death from the bleeding of these growths have been reported. Polypi. — Hemorrhage from polypi is rare and is seldom profuse. Villous Growths. — In these growths the bleeding may occur during, preceding, or following the act of defecation. It is usually slight, but at times becomes profuse. Wounds and Foreign Bodies. — Hemorrhage in these cases depends entirely upon the location and extent of the injury. Stomach. — In cases of hemorrhage of the stomach where the blood has not been vomited up, it may pass downward and be discharged from the rectum. Such discharges are of a blackish color, and may be mistaken for indications of some rectal disease. Constipation. The next symptom in point of frequency is constipation. There is nothing specially characteristic about this symptom, SYMPTOMATOLOGY. 17 for it may be a result of sluggish peristaltic action or of a great variety of other pathological conditions, such as : — 1. Fissures. 4. Impaction of feces. 2. Stricture. 5. Compression of the rectum. 3. Malignant growths. When caused by fissures it is owing to the patient's defer- ring defecation as long as he possibly can on account of the pain it induces. It is sometimes a symptom of impacted feces or compression of the rectum. Frequently it is a result of pressure from a misplaced uterus, enlarged prostate, or a tumor of some kind. Constipation is usually the first symptom to manifest itself in stricture of the rectum, due to the impedi- ment. It may be more or less severe, according to the tight- ness of the constriction. It very nearly always alternates with diarrhea in cases of malignant stricture, when fully developed. Diarrhea. Diarrhea and discharges from the bowel form a group of symptoms met with in many diseases occurring in the rectum. We think that in all cases of suspected rectal disease a careful examination should be made of the excreta to ascertain if it is natural in shape and consistence, for various unnatural dis- charges, such as blood, pus, mucoid secretions, and elements of tissue, will be found therein. Diarrhea may appear as a symp- tom of 1. Ulceration. 2. Stricture. Diarrhea may be a symptom of any form of rectal ulcera- tion which becomes extensive. It is worse on arising in the morning and after exercise or exposure to cold. The discharge, which resembles coffee-grounds, may be mixed with muco-pu- rulent matter and blood. In cases of stricture the diarrhea frequently alternates with constipation. The actions are more frequent, scanty, and fluid in character than in ulceration. IS DISEASES OF THE RECTUM AND ANUS. Diarrhea is almost invariably present in malignant disease, and it is not infrequently a symptom of impaction, from the fact that the watery portions may pass around the fecal mass and be dis- charged. Mucoid and purulent matters may be discharged at times in varying quantities. They can be recognized by their color and very peculiar odor. Feces. — A close examination of the feces will frequently be of service in making a diagnosis. Their shape may be altered when the calibre of the bowel is constricted from any cause, es- pecially when it occurs low down. In appearance, under such circumstances, the feces may resemble pipe-stems ; again they may be grooved or flattened and ribbon-like. When soft, the alteration may be due to a spasmodic contraction of the sphinc- ter ; hence, this change is not always indicative of organic dis- ease. iVgain, in cases where the constriction is located high up, the feces may accumulate below it and be discharged compara- tively normal in shape and size. Their shape may be altered from an enlarged prostate, which has been known to cause total obstruction, or from an impaired sphincter, because of their not being retained until well formed, for we know that fecal incontinence is not an infrequent complication of rectal cancer and sometimes occurs in cases of prolapsus of long standing. Pas. — Pus may be discharged from the bowel because of the bursting of an abscess, rectal inflammation, internal piles, ulceration, and in cases of stricture. The quantity may be large or small and the color light or dark, depending upon the extent of the lesion and the other discharges intermingled with it. In this connection we might add that mucoid discharges are present in cases of prolapsus, invagination, and villous growths, while tissue-elements and debris are found in the stool where extensive ulceration is present. CHAPTER IV. EXAMINATION OF THE RECTUM AND ANUS. Having considered the symptomatology of rectal diseases and their diagnostic import, it now remains for us to describe the best methods of examining the rectum which will give us the most information concerning cases coming to us for treat- ment. No patient should be prescribed for until both a visual and a digital examination has been made. Because a patient says he has piles or fistula and his family physician affirms the diagnosis, we should not be deterred from making: a careful © - © examination in each case to find out just what disease we have to combat. Those of us who treat a large number of these cases know what absurd mistakes both physicians and patients frequently make as regards a correct diagnosis. The blame in many instances should be placed upon the physicians, many of whom are only too glad to confirm the patient's diagnosis with- out the trouble of making an examination and proceed to pre- scribe some ointment or lotion when they are ignorant of the real disease. It is not an easy matter, in many cases, to get patients to submit to an examination, especially women. We have made a rule to have nothing to do with such persons unless they do consent, for treatment carried on in the dark will prove unsatis- factory, both to the patient and to the physician. If possible, the examination should be preceded by a thorough cleaning out of the bowel by some laxative followed by an enema. Unless this precaution is taken, when the speculum is introduced a view of the upper portion of the rectum may be obstructed by an accumulation of feces. Position. For an ordinary examination we much prefer the semi- prone of Marion Sims. The patient is placed on the left side (19) 20 DISEASES OF THE RECTUM AND ANUS. on a rather high table, the right shoulder turned away from the surgeon, the left arm brought backward from under the body, and the right thigh flexed upon the abdomen. The office-table used is so constructed that by pressing on a pedal the head can be lowered and the hips elevated. In addition to this, it can be rotated from side to side, thus enabling one to view the parts at a great advantage. It is the best all-round table we know of. It is manufactured by the W. D. Allison Company, of Indian- apolis. (See Figs. 1, 2, and 3.) Fig. 1.— Office-Table. We do not think the Marion Sims position the best one for making an examination high up in the rectum. For this we prefer the genu-pectoral, especially for men. Sometimes we have patients stand in the erect position and strain down. In this way the diseased parts will be brought nearer the anus, thus enabling us to reach an inch or two higher up. Gentle- ness should always be used when making a rectal examination. By so doing much pain and annoyance can be avoided. Before the finger is introduced into the rectum a careful examination EXAMINATION OF THE RECTUM AND ANUS. 21 of the external parts should be made. By separating the but- tocks a good view of the anus and surrounding parts can be had. Cracks, fissures, external hemorrhoids, excoriations, and discharges, when present, can be readily detected. The finger should then be slowly passed around the anal margin to detect any deep-seated or superficial hardness, which may be due to a fistula or abscess formation. Tenderness in Fig. 2.— Office-Table in Sims's Position. the neighborhood of the anus can be readily detected in the same way. Eruptions of any kind — eczematous, syphilitic, or otherwise — will also be noticeable. Next, a careful examination of the interior of the rectum should be made. The finger should be anointed with vaselin or some other stiff lubricant. The patient is then requested to bear down gently and by a boring motion the finger is passed forward and upward very slowly and gently. Much depends upon the tact used in making 22 DISEASES OF THE RECTUM AND ANUS. the examination, for, when it is exceedingly painful, we have known patients to defer an operation, laboring under the mis- taken idea that, if a simple examination caused so much pain, the operation would be unbearable. Much valuable information to the educated finger can now be obtained. First, notice the strength of the sphincter. A tight sphincter indicates a fissure, while a weak one is suggestive of malignant or other grave Fig. 3— Office-Table in Lithotomy Position. rectal disease. Then, by sweeping the finger around the rectal wall, internal hemorrhoids, internal fistulous orifices, fissures, ulceration, polypi, strictures, and morbid growths can be easily detected. Next, the prostate gland and the uterus must be examined, for when they press on the rectal wall they are liable to induce some pathological condition of the same at any time. If a tumor of any kind should be located, determine if it be EXAMINATION OF THE RECTUM AND ANUS. 23 hard or soft and, if possible, remove a small portion for micro- scopical examination to determine its character ; in more than one case a fecal impaction has been mistaken for a cancer of the rectum. On withdrawal, if there be any discharge on the finger, examine it and see whether it is blood, pus, or mucus. Speculums. The question of what speculum is best for rectal examina- tions is not of so much importance as one who does little work in this department of surgery would at first suppose. We use the speculum less and less every year in the preliminary exami- Fig. 4.— Hinged Speculum. nation, for. in cases where a diagnosis cannot be made after a thorough digital and visual examination of the outer parts when the buttocks have been separated and the anal margin pulled apart, it is difficult to make it with the aid of any of the specu- lums now in use unless an anesthetic is given. When we have a doubt as regards the diagnosis, we at once insist on a thorough examination under chloroform, that we may determine the exact condition of the parts. In cases where an anesthetic is not given, and it is desirable to use a speculum for the effect or other reasons, we prefer a small, cone-shaped, hinged one (Fig. 4). which we have used for several years with more satisfaction 24 DISEASES OF THE RECTUM AND ANUS. than any of the others, of which we have a great variety. Next to this we use Sims's wire or Mathews's speculum. (See Figs. 5 and 6.) Fig. 5.— Sims's Wire Speculum. Examination under Anesthesia. Examinations under an anesthetic are always satisfactory as far as the diagnosis of the local condition is concerned, for under chloroform or ether the irritable sphincter relaxes and a Fig. 6.— Mathews's Rectal Speculum. complete view can be had of the seat of the disease in cases where pain and spasm of the sphincter would otherwise offer almost insuperable obstacles to a complete exploration of the parts. The sphincter should be thoroughly divulsed ; then, EXAMINATION OF THE RECTUM AND ANUS. 25 by the aid of the improved speculums now in use and a good light, the lower four or five inches (10 or 12 centimetres) of the rectum can be seen easily, which makes the diagnosis of Fig. 7. — Bsmarch's Chloroform Inhaler. to-day easy in comparison with the difficulties which had to be overcome in former years. We use Pratt's bivalved speculum (large size) or Cook's trivalved speculum, to the exclusion of Fig. 8. — Piatt's Bivalved Operating Speculum. all others, for examinations conducted under chloroform, and for operations where a . speculum is indicated. (See Figs. 8 and 9.) In our office we use an artificial light which consists of an 26 DISEASES OF THE RECTUM AND ANUS. ordinary incandescent electric light fitted in a reflector similar to those used by throat specialists, attached to a dental bracket Fig. 9.— Cook's Trivalved Operating Speculum. in such a way that it can be raised, lowered, or turned at any angle. (See illustration.) I devised it some four years ago, Fig. 10.— Author's Artificial Light and Table Apparatus. and it has given perfect satisfaction and, in addition to this, does away with the use of an instrument- table. With this EXAMINATION OF THE RECTUM AND ANUS. 27 light and the aid of a pair of vulsellum forceps, with which to draw the gut down, a good view can be had of the entire cir- cumference for five inches (12.7 centimetres) or more. When a growth is suspected high up which cannot be diagnosed by other means, the hand and arm may be inserted into the rectum and, by so doing, the diagnosis may be made clear. This is accomplished more easily in the female than in the male. The hand should be small, and then introduced cone-shaped with the greatest caution, for cases have been reported where the rectum has been ruptured in this way, resulting in death. Mr. Allingham, Sr., says that in one case he diagnosed and com- pletely broke up a false membrane of peritoneum which was holding down the bowel as it crossed the brim of the pelvis, and the patient made a complete recovery. The danger from this method of diagnosis is that of rupturing the bowel, owing to the walls' being weak from ulceration. In concluding an examination it is always necessary to press deeply into the left iliac fossa to determine the presence of tenderness or a tumor of any kind. CHAPTEE V. CONGENITAL MALFORMATIONS OF THE RECTUM AND THE ANUS. Congenital malformations of the rectum and the anus are of comparatively rare occurrence ; still, it is essential that all medical men should be familiar with the different varieties and the treatment required. While some malformations can be re- lieved easily, others cannot be helped by the surgeon. Rectal malformations result from arrested fetal development of the rectum and anus in early fetal life. We shall not have the space to give in detail the development of the lower bowel in this volume, a full detail of which can be found in sys- tematic works on embryology. There are many varieties of malformations ; and nearly all authors vary some in their classification. We are of the opinion, however, that the most simple and practical classification is that of Holmes, with slight modifications, as given by Cooper and Edwards, which is as follows* : — Imperforate Anus. " Congenital narrowing of the anus without complete occlusion, but sometimes accompanied by a fecal fistula. " Closure of the anus by membranous tissue. " Entire absence of the anus, the rectum ending in a blind pouch at a varying distance from the perineum. " Imperforate anus with fecal fistula opening either into the vagina, male bladder, urethra, or upon the surface of the body." * Diseases "f Rectum and Amis, by Cooper and Edwards, page 44. (28) congenital malformations of rectum and anus. 29 Congenital Narrowing of the Anus without Complete Occlusion. Narrowing of the anus or rectum without complete occlu- sion comprises the least serious form of the preceding classifi- cation. The anal aperture is at times preternaturally small, either in consequence of a contraction of the lower end of the rectum or from the skin's extending over the border of the anal margin. The outlet may be sufficiently large to let the Fig. 11.— Narrowing of the Anus without Complete Occlusion. meconium drain away, or so small that an escape of the excre- mentitious matter is impossible. (See Fig. 11.) The symptoms, when pronounced, will be vomiting and abdominal distension ; when only slight, constipation and a dif- ficulty in voiding the feces only will be noticed. The diagnosis is usually easy, for the contraction is near the anus and can be readily detected with the finger, or it can be seen when due to a fold of skin extending, across the anus. Treatment. — The treatment consists in dividing the ring or skin with a bistoury on the dorsal surface, after which the parts 30 DISEASES OF THE RECTUM AND ANUS. should be thoroughly cleansed and antiseptic dressings applied. The ringer or a soft-rubber bougie should be inserted into the bowel daily, covered with balsam of Peru, to keep the opening- well dilated and the wound in a healthy condition. Any fistu- lous openings into the vagina generally close up after the outlet has been made sufficiently large to allow the excrementitious matters a free exit. Closure of Anus by Membranous Tissue. The second variety of imperforate anus also constitutes one of the simpler forms. The anus may be well formed and the Fig. 12.— Closure of the Anus by Membranous Tissue. bowel continuous, but the meconium is retained by a mem- branous partition (see Fig. 12) which stretches across the rectum above the anus. This membrane may vary in thickness, but is usually thin. The diagnosis is made by digital exami- nation or by the aid of a probe ; from the retention of the meconium and the bulging of the bowel, it is clearly visible when the child cries. Spontaneous rupture has been known to occur, thus affording an exit to retained matters. CONGENITAL MALFORMATIONS OF EECTUM AND ANUS. 31 Treatment. — Something' should be done at once or the oc- clusion may result in increasing abdominal distension, vomiting of the meconium, collapse, and death. A free incision should be made through the centre of the membrane, which will be followed by a discharge of the bowel-contents, affording relief at once. If the finger is inserted into the anus daily, tampons to separate the anal walls can be discarded. Sphmcteric power is usually well developed in these cases ; consequently patients have little difficulty in retaining the feces after the operation. In cases where the end of the rectum does not extend so far down as the anus, it should be drawn down and stitched to the anal mars-in. Fig. 13.— Imperforate Anus, the Rectum Terminating Far Above in a Blind Pouch. Entire Absence of Anus. In this class one may expect to find some of the most diffi- cult cases of congenital malformation, though some are com- paratively simple. Instead of a normal anus, the tissues extend across the anus from one side to the other, and the rectum may terminate quite a distance above the normal site of the anus. (See Fig. 13.) The intervening space may be made up of connective tissue, while a circular elevation or depression marks 32 DISEASES OF THE RECTUM AND ANUS. the natural site of the anus. In many of these cases the pelvic measurements will be considerably reduced. The diagnosis is made by pressing the abdominal contents down with one hand, while palpation is being made to the perineum with the other to ascertain if the distended pouch can be located or any impulse felt. If the perineum and the pouch are more than an inch (2.54 centi- metres) from each other, no impulse can be felt; while if it be less the impulse can usually be detected. In females an examination per vagina will at times be of material service in locating the pouch. If symptoms are not urgent, one is justified in delaying the operation, to see if the sac will not become so distended that its exact location can be determined. Treatment. — When the pouch has been located, an incision should be made in the median line from the centre of the perineum to the tip of the coccyx, and all tissues dissected down until the tense pouch is reached, opened, brought down, and the edges sutured to the walls of the incision somewhat similar to the operation for inguinal colotomy, being careful that the edges of the mucous membrane and skin are carefully united. Then cleanse the parts thoroughly with some antiseptic solution and put on dry antiseptic dressings, which should be removed daily and a bougie inserted and retained for some time, that too much contraction may not follow. If the pouch is situated high up, or if its location cannot be determined, the operator should so state the circumstances to the parents, and with their consent at once perform left inguinal colotomy, being careful to make a good spur and to see that the skin is well sutured to the mucous membrane so that a prolapsus will not occur. It is well to remember that, in children, the sigmoid may be located on the right side. This anatomical arrangement may be the cause of some difficulty in locating the gut. Imperforate Anus with Fecal Fistula. In this class the anus is absent, but a communication exists between the rectum and the vagina in the female (see CONGENITAL MALFORMATIONS OF RECTUM AND ANUS. 33 Fig. 14), the urethra or bladder in the male (see Fig. 15), or between the bowel and the surface of the body at some point near the anal region. FECAL FISTULA TERMINATING IN THE VAGINA. When the fecal fistula terminates in the vagina the open- ing will be larger than when it terminates in the urethra and will be found in the posterior or lateral wall ; the exit in such a case is frequently so large that the meconium and contents Fig. 11. — Imperforate Anus, the Rectum Opening into the Vagina. of the bowel can be discharged and distension is prevented. Women have been known to live to an advanced age with this malformation without being conscious of any abnormality. As a rule, however, they suffer very much from pain, ulceration, and excoriations of the parts. Treatment. — -The treatment is comparatively simple. A probe or groove director is passed through the recto-vaginal aperture to a point in the perineum where it is intended to make the anus ; it is then cut down upon. The rectum should 34 DISEASES OF THE RECTUM AND ANUS. then be brought down and sutured and the opening in the vagina closed. Some encourage the laying open of all the tissue from the fistula to the natural anal position and let heal- ing take place by granulation. Others pare and suture the edges of the opening in the pouch to those of the skin. It seems to us that, so long as the patient does not suffer from distension and can control the bowels satisfactorily, operative interference is uncalled for. Fig. 15.— Imperforate Anus, the Rectum Terminating in the Bladder. FECAL FISTULA TERMINATING IN THE URETHRA. Imperforate anus with the rectum opening into the bladder or urethra is a tar more serious condition. When it opens into the urethra, the opening is usually very small. (See Fig. 16.) Naturally, this occurs more frequently in the male than in the female, on account of the length and the narrowness of the urethra. The opening is always very small ; the meconium is unable to pass out, and at an early period distension is noticeable. The watery portion of the rectal contents oozes out at first, but as the feces acquire consistency obstruction will take place, and the life of the patient becomes endan- CONGENITAL MALFORMATIONS OF RECTUM AND ANUS. 35 gered. In an exceptional case, recorded by Mr. Page,* the patient, a man 54 years old, had throughout his life voided his feces and urine by the urethra. Soon after birth the imperforate anus was discovered, and an attempt was made to establish an opening in the natural position, which did not prove a success. At the age of 10 obstruction occurred, and temporary relief was afforded by incising the urethra in front of the scrotum. Through this opening he, with difficulty, dis- Fig. 16.— Imperforate Anus, the Rectum Terminating in the Urethra. charged his feces and urine with the assistance of aperient medi- cines for some time. Contraction of the fistula and the block- ing of the urethra finally led him to seek relief; but he refused assistance further than an enlargement of the fistula, although Mr. Page found that a probe could be passed through the anal aperture. The urethra was accordingly split up and the mucous membrane sutured to the skin, thus converting the fistula into an opening of fair size. Four months afterward the patient * British Medical Journal, vol. ii, pp. 875-SSS. 36 DISEASES OF THE RECTUM AND ANUS. reported that lie was comfortable and that his bowels acted regularly without medicine. Many other interesting cases have been reported where the bowel-contents have been discharged by the urethra for a greater or less period of time, causing little annoyance in some, while others suffered greatly, living for months until obstruction occurred and death ensued. Treatment. — When this form of malformation exists an operation for obtaining an exit at the natural site should not be delayed, owing to the serious symptoms which accompany dis- tension. The operation is performed by cutting down through Fig. 17.— Imperforate Anus, the Rectum Opening on the Surface by Means of a Fistulous Sinus through the Penis. the natural site of the anus until the pouch is reached, opened and sutured to the skin, and the fistula closed. In some cases the rectum opens into the bladder and, in such cases, the meconium and urine will be mixed and voided through the urethra. The child may survive for a short time, but a fatal termination is almost certain unless something is done, although cases are on record where adults have continued to discharge their feces through the urethra with comparatively little incon- venience. There is very little to be done from an operative stand-point, further than to keep the urethra dilated sufficiently that the contents may escape, unless we do a colotomy. CONGENITAL MALFORMATIONS OF RECTUM AND ANUS. 37 FECAL FISTULA OPENING UPON SURFACE OF BODY. Imperforate anus with fecal fistula opening upon the sur- face of the body presents a variety of forms, the openings being differently situated ;. there may be one or a number of them ; the most common site is some point in the perineum. If the opening is small and obstruction has taken place, make an incision with a probe-pointed bistoury, enlarging the opening in the median line or as near as possible. Then, if the edges of the rectum can be brought down to the margin of the wound and sutured, a fine result may be looked for. The opening at times may be located in the scrotum, the base of the penis, the gluteal, or lumbar, or sacral regions. Treatment. — The treatment differs according to location. The principal feature, however, is to establish the outlet at or as near to the natural seat of the anus as can be done. If pos- sible, unite the edges of the skin and mucous membrane. Not infrequently an operation is impossible ; then the only thing to be done is to enlarge the fistula to such a degree that the con- tents may be discharged with as little discomfort to the patient as possible. While operative interference does not meet with as much success as we could desire, yet much comfort can be rendered the patient and life made at least worth living. Imperforate Rectum. It now remains to consider the cases belonging to this class, — viz., those in which the rectum is imperforate, but the anus is in the natural position. These, according to the classi- fication adopted, may be divided into two classes. In the first of these the obstruction in the rectum is membranous in char- acter. (See Fig. 18.) In the second there is a total deficiency or an extensive obliteration of the rectum. The attention of the surgeon is not called to these cases, as a rule, until the symp- toms have become urgent, from the fact that the anus is in the normal position. The attendants naturally look elsewhere for a cause of the symptoms until distension occurs. I have myself 38 DISEASES OF THE RECTUM AND ANUS. seen a case of this kind in hospital practice, due to a mem- branous septum extending completely across the rectum about one inch (2.54 centimetres) above the anus, which was readily detected by the introduction of the ringer into the anus. I at once incised the membrane, washed out the bowel, and left a small rubber bougie to be passed daily for a few weeks. The child completely recoverd. When the obstruction is due to a membrane, this treatment should be carried out under antiseptic precaution and success will follow. In the second class, where Fig. 18. -Imperforate Rectum, the Anus Natural, but Rectum Separated from it by a Membranous Partition. the rectal pouch may be situated too high to get any impulse, the child's life is in great danger. Treatment. — The operative procedures at our command are two ; first, by dissecting up to the gut from the perineum ; second, performing colotomy at once, for the child must have immediate relief. If, after a thorough examination, the pouch seem to be within reach, the former may be tried; but if there is reason to believe that the pouch is so high up that it cannot be reached or that the rectum is abnormally developed, a CONGENITAL MALFORMATIONS OF RECTUM AND ANUS. 39 colotomy should be resorted to at once. When the artificial anus has been once established, if the indications should warrant it, an attempt can be made to restore the anus at the normal site. Dr. Byrd, of St. Louis, operated on a case of this kind by introducing a sound through the artificial anus and pushing the pouch downward in order to more easily reach it from below. He made an incision about two inches (5 centi- metres) deep upward from the anus and back to the coccyx large enough to permit the passage of the index finger. The sound was then carried downward until within one-eighth of an inch (3 millimetres) of the finger passed from below. When it could pass no farther with ease, it was forced through the intervening tissues and out the anus. In the after-treatment much ingenuity was displayed in trying to get the mucous membrane toward the opening, but the subsequent history was not given. It was thought that the artificial anus would close without further operative procedures than the wearing of a well-fitting pad. Cases have been reported where the opening in the groin was closed with success, while others were not so fortunate. In bringing this chapter to a close, we desire to mention that the death-rate in cases of malformation is high, even in simple cases where only a puncture has been made, though not so high as where, owing to the liability to constriction, an attempt has been made to establish an artificial anus at the natural site. The following table is taken from Cripps, and shows the mortality in one hundred cases operated on by him : — 1. Colon opened in the groin, . . . .16, died 11 o u U u u u 3 " 2 3. Puncture, IT, " 14 4. Cocc^yx resected, 8, " 5 5. Perineal incision or dissection, . . .39, " 14 6. Communication between rectum and vagina, 14, " 1 7. Miscellaneous, 3, " 3 Total, 100 " 50 40 DISEASES OF THE RECTUM AND ANUS. This report shows a death-rate of 50 per cent. This certainly is not encouraging, yet, on the other hand, probably all would have died if an operation had not been performed. In this chapter we have not attempted to treat of any varieties of malformations except those of the most frequent occurrence. Those desiring a more lengthy description of the varieties and treatment of malformation of the rectum and anus we respectfully refer to the excellent works of Bodenhamer, Curling, Cripps, and Ball. CHAPTER VI. PROLAPSE OF THE RECTUM. Prolapse of the rectum lias been very improperly denomi- nated prolapsus ani by many high in authority. Since the anus is merely an aperture with a fixed point, it cannot therefore be prolapsed. It may be everted to a certain extent, but it cannot be prolapsed. Prolapsus of the rectum signifies the descent of a portion of the bowel through the anus, which, in the normal Fig. 19. — Diagrammatic Drawing showing Prolapse of the Rectum. state, is within and above that aperture, the protrusion consisting of mucous membrane, either alone or combined with other coats of the rectum. Between these extremes there are many inter- mediate varieties. Again, we may have the upper portion of the rectum invaginated into the lower. From a practical stand- point we have three varieties of prolapsus of the rectum, viz. : — 1. Prolapse of the mucous membrane alone. 2. Prolapse of the rectal coats, and, when extensive, the peritoneum will be pulled down as well. 3. Prolapse of the upper portion of the rectum into the lower, called invagination or intussusception. (4i) 4*2 DISEASES OF THE RECTUM AND ANUS. Prolapsus of the Mucous Membrane. This we have found to be the most frequent variety. (See Fig. 20.) During normal defecation the narrow ring of mucous membrane protrudes from the anus, which returns when the act is completed. This is quite noticeable among some animals, as the horse. It occurs more frequently among children than adults. Causes. — The acute cases are found in children, and are usually produced by straining at stool, as a result of constipation Fig. 20.— Prolapse of the Mucous Membrane. or diarrhea, especially in those of a tubercular diathesis. Phi- mosis and stone in the bladder not infrequently cause this con- dition, as a result of the constant straining during micturition. In children, owing to tbe straightness of the sacrum, prolapsus is more liable to occur. Relaxation of muscles and of other structures may also bring about this condition. Prolonged or violent coughing or screaming may also produce prolapsus; paralysis and ulceration of the sphincter may cause it; polypi, internal hemorrhoids, or other foreign bodies in the rectum PROLAPSE OF THE RECTUM. 43 which produce straining may be classed as causes. The pro- lapsus may be immediate, as a result of coughing, vomiting, etc., or it may come on gradually. The more often the bowel comes down, the more the parts become stretched and relaxed, thus favoring a repetition of the prolapsus. Symptoms. — In recent and mild cases the protruded portion consists of a ring of mucous membrane, which comes down about one inch (2.54 centimetres) when the bowels move, and returns spontaneously, or by the patient's assistance, after the act is completed. At times there is much pain and the protruded mass is red and bloody. This is especially so if there be any ulceration. Otherwise there will be no pain, and the tumor will be of a deep-red color and marked by crescentic folds. When considerable time has elapsed after the protrusion first occurred, it may become congested and difficult to return. In cases of long standing the protruded mass is easily reducible on account of the weakened sphincter, but will not remain long at a time. Prolapse may be distinguished from a polypus by its softer feel- ing, uniform, smooth, appearance, and the absence of a pedicle; but it is not always so easy to differentiate between protruded in- ternal hemorrhoids and prolapsus. A careful examination with a practiced eye and touch will allay any doubt, however. In prolapse we have a tumor that involves the entire circumference of the bowel and has a soft, velvety feel. In other respects it resembles the normal mucous membrane and has a slit in the centre of the protruded portion ; while the hemorrhoidal tumors, hard or smooth and lubricated, are always separate and distinct, have a definite feel, and are more easily movable. Prolapse of the Rectal Coats. This form of prolapsus (see Fig. 21) does not occur nearly so frequently as the first variety. It differs from it in that the protruded mass is composed of all the coats of the rectum and the peritoneum as well, when it is extensive. When the prolapse extends down more than two and one-half inches (6.35 centi- 44 DISEASES OF THE RECTUM AND ANUS. metres) it is well to look out for folds of peritoneum ; for within there may be coils of the small intestine. This variety comes on more gradually than the other and occurs less frequently in children than in adults. The protrusion is pyriform in shape and at the lower extremity a slit-like opening may be seen, sur- rounded by folds of the mucous membrane and portions of the muscular coat. In this variety there is no invagination. This can be determined by following up the tumor (see Plate IV) with the finger and it will be found to be continuous with the rectal coat. When invagination is present a deep sulcus can be detected between the annular ring and the protruding mass. Fig. 21.— Partial Prolapse of Rectal Coats. This variety is the least likely to be confounded with hemor- rhoids or polypi. A complete examination will at once reveal the condition present. Complete prolapse may assume very great proportions, for in rare instances the greater portion or the entire colon may be protruded through the anus.* Symptoms. — The symptoms are similar to those of the first variety, but are of a more aggravated form ; the pain is not severe, as the lower portion of the mucous membrane has a low state of sensibility. Mucus is almost constantly discharged, and it is mixed with pus when ulceration is present. The most marked symptom, however, is the incontinence of feces, which is present, to a greater or less degree, in all severe cases. Compli- * Ball's Diseases of 1 tectum and Anus, p. 195. if PLATE IV.-TYPICAL CASE OF PROCIDENTIA RECTI. EurkS MTetridge Co.Lith Phila. PROLAPSE OF THE RECTUM. 45 cations of complete prolapse are to be watched, the chief danger being due to the envelopment of the peritoneal coat. When this coat comes down, it is liable to contain coils of the small intestine or one of the ovaries. They are to be looked for in the anterior half of the prolapse. As a rule, when a loop of the small intestine is included, it can be detected by feeling it slip on pressure. When present this condition can be properly designated hernia of the rectum, and noted as such. According to Allingham, when hernia is present, the opening of the gut is always directed toward the sacrum, and, when reduced, it im- mediately returns to its normal position. Another complication to be looked for is the spontaneous rupture of the rectal wall, for several such 'cases are on record. Prolapse op the Upper Portion of the Pectum into the Lower. In treating this variety Kelsey substitutes the term invag- ination for 2 )r °l a P se i which he thinks more aptly expresses the condition. We prefer, however, to speak of it as a prolapse and differentiate between it and the other varieties referred to. In the first and second varieties the lower portion of the rectum slips down through the anus, while in this form the lower portion of the rectum retains its normal position and the upper portion is telescoped through it. The lower portion of the bowel may come down in the upper part and remain there, or in extreme cases protrude from the anus a great distance. The diagnosis can be made by passing the finger around the invagi- nated mass within the bowel. When the protrusion is small and of recent date, it can be replaced easily, though it is likely to appear again when the bowel acts. In cases of extreme pro- trusion replacement becomes difficult and painful ; but after it has existed for a time the anus becomes patulent and the sphincter loses its elasticity so much that every time the bowels move or the patient makes the slightest exertion the mass pro- trudes, thus rendering life almost unbearable. 46 DISEASES OF THE RECTUM AND ANUS. Prognosis. — In giving a prognosis in any case of prolapse it is well to bear in mind that, when the mucous membrane alone is involved, a spontaneous cure is frequently effected. Simple remedies, however, often assist nature to a speedy cure. In severe cases no such happy results may be looked for, espe- cially in the aged. In old cases, where thickening has taken place, nothing short of a surgical procedure will effect a cure, and this may have to be repeated. So it is not well to commit one's self as to the time it will require to effect a cure. Treatment. — It matters not with which variety you are dealing; an effort must be made to return the mass. This usually can be accomplished without an anesthetic, in the fol- lowing manner : Place the patient, if a child, across the mother's knee, face down ; if an adult, he may be placed in a similar position on a table or bed with the head lowered. First clean all the protruded mass and place a soft, clean, well-oiled cloth over it ; then make gentle pressure over the whole mass of the tumor for several minutes, endeavoring to reduce the size of the mass by pressing out any fluid in the rectal coats. Next, en- deavor to return the more central part of the mass first, since it was the last part to come down. The reduction can be accom- plished in many cases with very little difficulty. To prevent the bowel's coming down immediately after the reduction, apply pressure for some time to the anus ; for this we prefer cotton- wool, a pad of gauze, or a soft sponge supported by a T-bandage. In case the mass has become swollen and painful, chloroform, which will materially assist in the reduction of the same, may be administered. After the reduction the patient should rest in bed with the nates drawn together tightly. We well remember seeing a number of cases treated by Dr. Seneca D. Powel, while we were house-surgeon in the New York Post-Graduate Medical School and Hospital. The following is his plan of treatment : After pulling the two buttocks together, he places strong straps of adhesive plaster, which are to be worn all the time, from one to the other. After defecation the parts are cleaned and new PROLAPSE OF THE RECTUM. 47 straps substituted. We have never seen this plan fail when used by him. In our own practice we have found this pro- cedure to be of great assistance in many cases. The piaster proves beneficial from the fact that it supports the sphincter during the intervals of defecation and diminishes lateral trac- tion while in the squatting position. In cases where it is not advisable to use the straps or other support, the patient should be required to defecate in the recumbent position, using a bed- pan, or else he should occupy the erect posture. The bowel should be trained to act just before bed-time, thus enabling the patient to lie down immediately thereafter. In all cases of pro- lapsus an examination should be made to ascertain if there is any other local pathological condition, such as hemorrhoids or polypi, that would be likely to keep up an irritation or produce straining. If there is it must be corrected, else the treatment inaugurated for the cure of the prolapse will prove to be of no avail. The treatment is : — 1. Palliative. 2. Radical. In children the palliative will usually prove satisfactory. The first thing to do is to look after the general health, and if a tonic is indicated it should be prescribed at once. Next, direct attention to the bowel and see that the child has at least one free action daily. This can be done by instructing the little one to go to the closet at the same hour every day, and to devote the whole time there to emptying the bowel. The pal- liative treatment is, to a certain extent, routine, and consists principally in the local application of astringents, or the injec- tion of the same into the prolapsed gut, which should be imme- diately returned. The daily injection of cold water into the bowel just previous to the patient's going to stool acts ad- mirably. The astringents recommended for the cure of pro- lapsus are many in number. Some of those that have stood the test of time are : tincture of iron, tannin, alum, sulphate of and chloride of zinc, etc. We have been in the habit of using a 48 DISEASES OF THE RECTUM AND ANUS. solution composed of pulverized alum, two drachms to the pint of water, with which the protruded mass was washed off before it was returned within the anus, and have been much pleased with the results. A decoction of black-oak bark acts equally well. When mild remedies fail to give relief, Allingham* rec- ommends the application of nitric acid. On the other hand, Mathews f deprecates its use in strong terms, and reports a case in which a bad result followed its use. In our experience the application of nitric acid has resulted in a cure in nearly every case where we have used it. It is never employed except in the treatment of prolapsus in children, when it is necessary to grease the surrounding parts with vaselin to protect them, and, Fig. 22.— Prolapsus Ani Truss. Fig. 23— Rectal Plug. further, to neutralize any excess of the acid with common soda. Kelsey % claims to be the first to cure prolapsus by the injection of carbolic acid into the protruded mass, and in the same manner as for the cure of hemorrhoids. The subcutaneous injection of ergotine into the perineum and immediate neighborhood of the anus has been highly recommended. We have had no experi- ence with the injection method ; consequently, we can neither decry nor commend it. In concluding these remarks on the palliative treatment, we desire to recommend rectal plugs (see figures), which are made in various sizes, to keep the bowel from protruding. The rectal plug consists of an oval knob of vulcanite with a slender shank, around which the sphincter COn- Diseases <>f the Rectum, p. 181. t Mathews, p. 480. X Kelsey, p. 218. PROLAPSE OF THE RECTUM. 49 tracts when it is introduced into the arms. We are indebted to Mr. Ball, of Dublin, for this ingenious device, which he has found to be of great service. It was invented by one of his patients. (See Fig. 23.) Operative Treatment. — When palliative measures have failed, it will be time to direct attention to operative procedure for the cure of this disease. It is pleasing to know that in this way relief can be given in nearly all cases. We shall not at- tempt to describe all the operations devised for the cure of prolapse, but will give briefly those that appear preferable. The cure of this condi- tion involves several objects, viz.: — 1. To cause adhesion of the coats of the rectum. 2. To remove redundant tissue. 3. To reduce the size of the anal orifice. We place at the head of opera- tive procedures the actual cautery, which has been brought prominently before the profession by one of our American surgeons, Van Buren.* It has been sanctioned by Cripps and many other authors on rectal diseases, and is used as follows : The bowel having been thoroughly opened on the previous day, place the patient on the table in the Sims position, anesthetize him, and reduce the pro- lapse ; introduce a speculum which will separate the parts amply, and with the Paquelin therm o-cautery (narrow point) make a number of parallel lines an inch apart, beginning three inches (7.62 centimetres) above and terminating at the outer margin of the anus. (See Case II.) These lines are to be made Fig. 24. — Kelley Pad used in Opera- tions about the Rectum. * Van Buren, Diseases of the Rectum and Anus, p. 81. D. Appleton & Co. 4 50 DISEASES OF THE RECTUM AND ANUS. deeper and nearer together, if the severity of the case demand it. In this way we get the full effect of the cautery in pro- ducing rectal cicatrices. We have followed this plan in treating many cases of prolapse, some of which were very severe, and we have found it eminently satisfactory ; though, in a few cases, we had to repeat it two or three times, but finally obtained a cure. In mild or severe forms of prolapse, elliptical portions of the mucous membrane may be removed with the Gant clamp, scissors, and cautery, or the edges sutured together with carbo- lized catgut before the clamp is removed, llemoval of the pro- truded mass may be done with the clamp and cautery and elastic ligature ecraseur, or by the knife, the last being preferable in the larger proportion of cases where removal of the entire cir- cumference of the bowel is desirable. Such men as Allingham* and Cripps do not look upon excision with much favor. Some objections which suggest themselves are the danger of strictures following the operation, as well as the danger of Avounding the small intestine during the operation, should a hernia be present. While we cannot commend the operation of excision as one to be resorted to in the majority of cases of prolapse, we must admit that it is certainly of great value in some cases, and deserves to be mentioned in this connection. Believing the prolapsed condition to be due to an abnormally lengthened mesentery in severe cases, Allingham, Jr., has devised an operation for its cure, which is done by incising the abdominal wall on the left side about the outer third of Poupart's ligament; the rectum is then seized and drawn up, the mesentery sutured to the abdominal wall, and the wound closed. The object to be hoped for is to produce a firm adhesion so that the upper part of the rectum will be prevented from being intussus- cepted into the lower. We had the pleasure of witnessing this operation by Dr. Allingham while in London, and desire to say that we were favorably impressed with it, though, as yet, we have not had an opportunity of performing it. Dr. F. Lang, of * Allingham on Diseases of the Rectum, p. 187. PROLAPSE OF THE RECTUM. 51 New York, devised an operation whereby he hopes to cure the prolapse by reduction in the calibre of the bowel as well as by the narrowing of the muscular ring. Yernenil. of Paris, en- deavors to overcome the prolapsed condition by raising the bowel and attaching it in the region of the coccyx. Both of these operations have their good points, but space forbids their further discussion in this work. ILLUSTRATIVE CASES. Case I. — Prolapsus due to Summer Diarrhea. A little girl. 2 years old. was brought to the dispensary to be treated for piles. Her mother said that the child had been suffering from summer complaint for three weeks and that the stools were frequent and caused much pain and straining : while on the chamber half an hour before, the piles came down. I placed the child across my knees, tlexed the limbs, and a tumor the size of a hen's egg (Fig. 20) presented itself just without the anus. The tumor was soft, smooth, and globular in shape, with a slit in the centre, and was of equal size on each side of the anus. The case proved to be a typical case of prolapse of the mucous membrane. The sphincter was relaxed, and every time the tumor was returned within the bowel it would immediately re-appear. Treatment. — Chloroform was administered and the tumor reduced; then the cautery-point was introduced up the bowel for two inches (5.08 centimetres) and then brought down and outward. This was done a number of times, until there were a number of parallel lines about half an inch (1.3 centimetres) apart. Apiece of gauze smeared over with vaselin was placed in the bowel to keep the rectal walls separated. The buttocks were then strapped tightly together with adhesive plaster to support the anus during straining. An opiate was given to tie up the bowels and the child sent home. Two days afterward the straps were removed and a good action followed ; then they were replaced and kept on for four weeks, when she was discharged. Three months later I saw her again. She had been perfectly well ever since the operation. Case II. — Extensive Prolapsus of all the Rectal Coats. Dr. Pollard, of Braymer. Mo., came to me to have an operation performed for prolapsus of the rectum and gave the following history : Age 38 ; country practitioner ; general health good except that he suffered more or less from constipation and headache. He seldom had actions more than twice a week, and then thev were attended with violent strain- 52 DISEASES OF THE RECTUM AND ANUS. ing and protrusion of the bowel. Sometimes only the mucous membrane would be everted ; at other Limes all of the rectal coats would come down for several inches, and, when not promptly returned, would swell up and were very difficult to reduce. Treatment. — He was anesthetized and the cautery applied deeply into the mucous membrane after Van Buren's method. It was then pressed deep down into the external sphincter in three different places, at equal distances apart, to insure contraction. The bowels were tied up for a week and the diet restricted to milk and soft-boiled eggs. On the seventh day, after taking a Seidlitz powder, he had a copious movement ; the bed-pan was used and he remained in a recumbent position. The rectum was irrigated and balsam of Peru applied to the mucous mem- brane. Ten days from the time he entered the hospital he returned home and, one week later, he was performing his usual duties. He called at my office a few months ago and said that the rectum had not troubled him in the least since the operation, more than two years ago. Case III. — Extensive Prolapsus. A lady came to be treated for extensive prolapsus. She had been operated on twice before by Van Buren's method. Operation. — It was decided to excise the redundant tissue, which was done after the following manner : An incision was made around the anus at the muco-cutaneous junction, and the mucous membrane dissected up for two inches (5.08 centimetres). It was then pulled down, cut off, and the upper portion brought down and attached to the skin by catgut sutures. Antiseptic dressings were applied, and union was complete within ten days without a drop of pus. At this time she was discharged with instructions to keep her bowels open and to report at mj^ office if the bowel came down again. One year afterward I met her and she in- formed me that she was well and that she had given birth to a fine boy since the operation. Case IV. — Dwarfed Child Suffering from Prolapsus. Eighteen months ago I was called to see a dwarfed child who had suffered from the time he was 6 weeks old with obstinate constipation and extensive prolapse of the rectal coats, which the father thought were the cause of the arrested development. He is 14 years old, weighs 38 pounds, and measures thirty-two inches (81.28 centimetres) in height. (See Fig. 25.) During the past eleven years he did not gain one ounce in weight nor one inch (2.54 centimetres) in height. Another interesting feature in this case is that he has an angioma between the thumb and forefinger of the right hand. This the family physician lanced for an PROLAPSE OF THE RECTUM. 53 abscess and came near losing the patient from hemorrhnge. This lad was treated by the cautery method and the prolapsus was cured. I cite this case merety because it is a unique one. Six months after the above notes were made I saw the child again, Fig. 25. — Dwarfed Child Suffering from Extensive Prolapse of the Rectum. and decided to give the desiccated thyroid gland a trial. The improve- ment in his general appearance since that time has been marked, indeed. His father tells me that he has grown five inches (12. T centimetres) in lieight. His countenance has changed entirely, his speech has improved, and he shows considerable mental development. I have, through the father's kindness, a late picture of the bo} T which I scarcely recognized at first sight. The dose given in this case was two grains every four to six hours. CHAPTER VII. POLYPI AND OTHER NON-MALIGNANT GROWTHS. Non-malignant growths found in the rectum will prove, in a large majority of cases, to he polypi of some variety. They may he single or multiple ; they are found more frequently in childhood than in adult life. Their usual site is at the upper portion of the internal sphincter. Polypi have been mistaken for hemorrhoidal tumors in not a few instances. This mistake will not occur, however, when a careful examina f ion is made ; the polypus can be distinguished by its pyriform shape, long pedicle, florid-red color, and soft, delicate, elastic feel. For a thorough and extensive classification of non-malignant growths we would respectfully refer the reader to Leichen stern's classifi- cation,* which we think an admirable one. It is not our pur- pose to enter deeply into this subject, but to refer to the more common varieties of polypi which one might be expected to treat in the practice of rectal surgery. Polypi differ much both in appearance and feeling. This is accounted for by the dif- ferent tissues entering into their formation. If they are com- posed of glandular substance they are soft; while, on the other hand, if they are composed of fibrous tissue they are firm. Again, they may vary in size from that of a pea to that of a small lemon. In nearly all cases they will prove to be either fibrous or adenoid in character, for these two varieties constitute by far the larger percentage of rectal polypi. The pedicle, of a polypus may vary in length from one to three inches (2.54 to 7.6 centimetres). We have seen one protrude two inches (5 centi- metres) below the anus. The pedicle is composed of mucous membrane ; and in some cases in the submucous tissues on the interior of the pedicle are to be found the vessels which give the blood-supply to the base of the tumor. * Ziemssen'e Cyclopedia, vol. vii, p. 634. (•54) POLYPI AND OTHER NON-MALIGNANT GROWTHS. 55 Adenoid, or Soft, Polypi. This variety is not uncommon. Soft polypi (Fig. 26) form generally in early life, and appear to be made up of an exag- gerated development of columnar epithelium ; in other words, the mass is made up of an enlargement of the follicles and the tissues of the normal mucous membrane. The pedicle is long and narrow and the base is small with a florid appearance, and when protruded from the anus after stool looks very much like a strawberry. In exceptional cases soft polypi may be due to dilatation of the glandular follicles. As a rule they are single, but occasionally they have been observed in great numbers. Symptoms. — The symptoms of non-malignant growths, Fig. 26.— Adenoid (Soft) Polypus, while not always characteristic, Avill often be of much assistance in making a diagnosis. Patients afflicted by polypus and other non-malignant growths seldom complain of pain. The first thing to attract their attention will be a slight bloody discharge after defecation. The bleeding may be slight, or, as we have seen, sufficient to weaken a child until he could scarcely stand alone. Hemorrhoids in the rectum of a child should at once lead us to suspect the presence of a polypus. Not infrequently the polypus acts as a foreign body and induces diarrhea or a discharge of mucus. The mother, in reciting the history of the case, will probably say, "Something comes down when the bowels move." This symptom is liable to lead one to suspect 56 DISEASES OF THE RECTUM AND ANUS. prolapsus. The differentiation, however, can be made by intro- ducing the finger into the rectum and passing it around the apex of the pedicle. The same holds good in reference to hem- orrhoids ; they have no pedicle, but are globular tumors. Treatment — The treatment of polypi in children is simple and always effectual. The proper treatment is to remove the polypus with the clamp and cautery (see Fig. 27) ; or, by placing a ligature around the pedicle at its attachment, that portion external to the ligature is cut off; or, after twisting it, it is Fig. 27. — Removal of Polypus High up with the Author's Clamp. snipped off with the scissors and some astringent is placed on the stump. The palliative treatment deserves slight mention in the treatment of polypi ; it consists in the application of astrin- gents as used for prolapsus. Astringents should never be resorted to except when consent to an operation cannot be obtained. Fibrous, or Hard, Polypi. The hard, or fibrous, polypi (see Fig. 28) occur in adults, and are more common in the rectum than those just described. POLYPI AND OTHER NON-MALIGNANT GROWTHS. 57 They appear to be formed from an increased growth in the fibro-cellular tissue beneath the mucous membrane, and covered by the normal membrane. The surface of the polypus may be smooth or irregular, being dependent on the shape of the sub- mucous enlargement, which protrudes farther and farther into the bowel, until a pedunculated tumor is produced, over which the mucous membrane forms a covering. This variety of polypus is pear-shaped, and the pedicle is more or less elon- gated and thickened at times. It may be soft and flabby, though it is more frequently tough, firm, and reddish when incised. Fibrous, or hard, polypi vary in size from that of a small hazel-nut to that of a walnut, and in exceptional cases fa