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Fistula in ano; several external openings and extensive sinuses.

H. E , aet. forty-one, a butler, came under my care

suffering from fistula. He attributed its origin to injury of the bowel by a bone that he had swallowed, which he said lacerated his inside on its passage outward, and gave rise to an abscess by the side of the fundament; he applied poultices, and it burst in six or eight days from the time he first felt pain. He continued to poultice the part, and he was in hopes it had healed, but matter again formed, and then discharged itself. This process recurred several times, and other openings formed towards the buttock During this time he had taken various medicines, and used lotions and ointments: one gentleman whom he consulted proposed an operation, but his occupation prevented him lying up. At length, his general health failing, he was compelled to submit himself to proper treatment When I first saw him his countenance was sallow; the sclerotic conjunctivae yellow; his tongue was much furred and deeply notched transversely; his pulse was soft and weak; and he had been of constipated habit for years. The integument on the left side of the anus was of a purplish-red colour, and tho subcutaneous cellular tissue was infiltrated and indurated; four fistulous openings existed, one was within an inch of the anus, the furthest was five inches from it; a probe directed through the nearest opening to the anus passed a considerable distance up by the bowel; by a careful exploration an internal opening was found threequarters of an inch above the external sphincter. He was confined to his bed, and mild mercurials, taraxacum, and purgatives were prescribed: when the bowels had been thoroughly cleared out, and his countenance had assumed

.a brighter aspect, he took the iodide of potassium and sarsaparilla. Under this treatment the integument of the anal region became more healthy and the induration considerably diminished, but its vitality was too low to offer a hope of the healing process occurring without dividing the sinuses; I therefore laid them freely open, and also divided the tissues between the opening in the bowel and the external one. Two or three ounces of blood flowed, but no vessel required ligature. The wounds were dressed in the manner that has been directed; and, after the third day, the bowels were kept open by laxatives and enemata, and great attention to cleanliness observed. He continued the iodide of potassium and sarsaparilla for three or four weeks after the operation, when the iodide of iron was substituted for it.

In consequence of the condition of the tissues, and the length of time the disease had existed, it was nearly six weeks before the wounds had entirely healed.

CHAPTER XIV.

POLYPI OF THE RECTUM.

Like the mucous cavities of the nose, uterus, and vagina, the rectum is occasionally affected with growths of the nature of polypi. They vary in structure and form, and may partake of the character of the mucous polypus, the sarcomatous species, or the malignant. Sir Astley Cooper* describes those observed by him as resembling a worm or leech in form, vascular, and of a deep-red colour. Dr. Bushef thinks the mucous species the most common. Mr. SymeJ says the disease presents itself in three different forms; the first being similar to those described by Sir Astley Cooper; in the second the growth is soft, vascular, prone to bleed, lobulated, or shreddy and malignant looking, but possessing

* 'The Lectures of Sir A. Cooper, Bart., on the Principles and Practice of Surgery,' edited by J. Tyrrell, vol. ii., p. 357.

f 'A Treatise on the Reetum and Anus,' New York, 1837, p. 227.

J 'On Diseases of the Reetum,' by J. Syme, Third Edition, Edinburgh, 1854, pp. 103-105.

a peduncle of footstalk sometimes capable of sound cicatrization after being divided; in the third form which polypus of the rectum assumes, the tumour is of a firmer consistency, smoother surface, and more regularly spheroidal, or of oval form. In the 'Rev. Medico-Chirurgicale," M. Leclayse describes a fungous tumour of the rectum attended with bloody discharge occurring in children. He records three cases: the ages of the patients were respectively six months, five years, and eight years. The growths appear to be of the character of the second form of polypus described by Mr. Syme; and their removal was effected by the application of nitrate of silver.

The experience of Mr. Syme and Dr. Bushe, as well as the inference to be drawn from the majority of cases of this affection that have been recorded, lead to the conclusion that these growths most frequently occur in adults, though the greater number of cases observed by Sir Astley Cooper were in young subjects: only one case of a child with polypus of the rectum has at present come under my observation.

The symptoms of polypus of the rectum will at first be rather annoying than painful, the patient being troubled by mucous discharge from the anus soiling his linen; as the polypus increases, weight and fulness of the rectum, tenesmus and the sensation * Tome vii., p. 346.

of the presence of a foreign body will be complained of. If it be situated near the anus it will be protruded at stool, and will require to be replaced by the hand; if it has acquired any size, and is pyriform in shape, some difficulty may be experienced in returning it within the bowel; or if long and narrow, as in one case in which I operated, it will be always protruded. When the attachment of a polypus is near the anus, the irritation it produces will cause spasmodic contraction of the terminal portion of the intestinal canal. Dr. Bushe* had a patient in whom the bowel contracted with so much force as to detach the tumour. The polypus was of the mucous species. After the polypus has attained a certain development, diarrhoea and dysenteric symptoms will be present, consequent on the irritation to which the intestine is subject; flatulent distension of the stomach and bowels, and other sympathetic affections, will exist; and if it be of the character of the second species mentioned by Mr. Syme, the faeces will be besmeared with blood or pus; they will also be contorted and figured, leading to the supposition that stricture of the rectum exists.

In the benign polypi, the health will not usually be much affected, but in the malignant variety there is a sallow cachectic appearance of the countenance, the * Op. tit., i>. 228.

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