duction cone, placed on the finger, was introduced into the opening of the mucous swelling, and gently pushed upwards with continued pressure, and served to reduce the protruded portion of the rectum. The reduction once completed, the finger was withdrawn, then the cone of paper, without fear of drawing the intestine after it. Some persons place the child between their legs, head downwards, with a the buttocks elevated, and they press on the tumour, of which they Cose d Paper. thus cause the reduction. For my part, I employ the means recommended by Boyer, and which has always succeeded with me. It consists in putting a piece of thin linen covered with ointment on the swelling, then pushing with the finger internally, so as to cause the entrance of the mucous membrane; once reduced, it is supported by one hand, whilst the finger and the linen introduced into the anus are withdrawn. This is the method of Bell, modified by the substitution of linen for the cone of paper. Very young children, who have been for a long time subject to prolapsus of the rectum, should be seated on a hard and flat stool, or rather on a chair without arms and sufficiently high to prevent them touching the ground with their feet. They should, moreover, have a supporting bandage on the anus, and if they are large should use that which Boyer recommends. It is composed, 1st, of two brass elastic braces, which unite in front and behind by their extremities furnished with a buckle; 2nd, of an oval and rather soft pad, convex on the side of the anus, concave on the opposite side; 3rd, of two straps, one of which, single, is fixed to the posterior extremity of the pad, and the other, double, is attached to its anterior extremity; the posterior strap passes behind the pelvis and is fixed to the posterior extremity of the braces by means of the buckle placed there; the two portions of the anterior strap, after having passed on the internal side of the thighs, reunite anteriorly towards the middle of the abdomen in a single band which is attached to the buckle placed at the anterior extremity of the braces, which affords to the patient the facility, even in walking, of loosening and tightening the bandages at will. The straps should be elastic like the braces, so that they may lengthen and shorten to accommodate themselves to the different movements of the patient. When the prolapsus of the rectum cannot be kept up by this bandage, recourse can be had to another method also successfully employed by Boyer. It consists of pushing into the fundament a large tent of lint covered with ointment. When this tent is introduced, a large pad of lint is placed on the anus, over this pad a compress is applied, and the whole is sustained by a double T bandage. Invagination of the rectum has nothing in common with prolapsus & frompre. of the rectum, except the presence of a reddish soft tumour, which a It is not serious if the invagination is not considerable and can beer, reduced; on the contrary, it rapidly becomes fatal, when it is irreducible and complicated with symptoms of strangulation. a The tumour should be reduced as far back into the rectum as au mek possible, and by means of enemata or of ascending douches we should T attempt to render this reduction more complete and lasting. To this end we may make use of a gum-elastic bougie ending in a considerable enlargement destined to push before it the invaginated portion. In case of strangulation, incision of the sphincter of the anus has been recommended in order to facilitate the reduction, or the partial excision of the tumour, or its cauterization, &c.; but these operations are impracticable in young children, and should be reserved for the adult. CHAPTER III. ON POLYPI OF THE RECTUM. " Polypi of the rectum are very rare amongst young children, however MM. Stoltz, Bourgeois, and Perrin, have observed some cases of it. These polypi are generally fleshy and of a cellulo-vascular structure. They are of a rosy colour, homogeneous, although mamillated and very are al resisting under the finger. They sometimes exude a little blood under the influence of external pressure. Symptins They remain a considerable time without giving any symptoms of their presence, afterwards they are the cause of a slight hæmorrhage which comes on every six, eight, or ten days; sometimes, on the contrary, this hæmorrhage is much more frequent, and each time of insufficient quantity to throw the children in a state of anæmia, and to seriously compromise their existence. This flow of blood usually. appears with the stools, and seems to be brought on by the passage of hardened matters; it is accompanied by acute pains, produced by こ and 526 SPECIAL PATHOLOGY OF INFANCY. [Part III. the erosions, and sometimes by fissures of the mucous membrane of the rectum. All the children are constipated, but they are not otherwise ill. At first nothing is seen at the orifice of the anus, and in order to arrive at a diagnosis, the finger must be introduced into the rectum. This is a difficult and very painful exploration; it should only be He performed in cases of absolute necessity. At a later period, the polypus, pushed forwards by the efforts of defecation and perhaps also by the faces, appears externally at intervals. It is then only that the diagnosis acquires all the certainty desirable. Good. These polypi do not in general constitute a serious disease, and with the exception of cases of considerable hæmorrhage do not require a precipitate treatment. We may wait, indeed we should wait, save in particular cases, until the polypus appears at the orifice of the anus. Then the operation should be performed which Bourgeois has described, or the method used by M. Perrin in the following case reported by the Revue Médico-Chirurgicale. Case. A little girl, two years and a half old, very intelligent, dark, of a bilionervous temperament, and good general health, passed nearly four months before the extraction of a polypus of the rectum which was performed on the 26th of October, 1844, stools tinged with blood. Her mother, being uneasy, caused me to be immediately called in. The health of the child was perfect, and with the exception of a little habitual constipation, I could not, in the absence of all morbid symptoms, discover anything else than a slight flow of blood at the precise instant of defæcation. The blood passed was not at all mixed with the habitually consistent fæcal matter, which it only tinged externally and very often only partially. The defæcation accomplished, the mother examined the child, and the anus was observed smeared by the blood, which did not appear again except at the time of a fresh stool, and never under other circumstances. The flow of blood, of very small quantity, only consisted in an oozing, or a true stillicidium recti. It is even correct to add that the hæmorrhage did not always accompany the expulsion of the fæces, that the child was sometimes several consecutive days without losing blood in spite of the daily efforts of defecation. In this case, up to this period, apart from the anal hæmorrhage and its mode of appearance, there is nothing in common with the two cases of fissure of the anus observed at the Necker Hospital, but the symptomatologic analogy will be presently 74. apparent, if I add that, in my little patient, there was always pain on going to stool, of which she gave proof by her cries, and principally when the constipation became more intense, and when the faecal matters acquired more consistence. Several times, and particularly in the case of painful defæcation, on examination of the child, I was enabled to discover a little redness around the anus, with a marked sensibility of this region. The epithelium at the margin of the anus appeared moreover as if cracked, fissured, and like the lips of some persons roughened by the cold of winter, without however being able clearly to confirm the existence of a decided crack or a true fissure. Notwithstanding the absence of this, and taking other circumstances which I am about to specify into account, I should here with some reason have suspected the probable existence of a fissure at the anus, if at the same time I could have positively recognized the spasmodic contraction of the sphincter. But in my opinion, it is not easy in the child to appreciate the true degree of this contraction, especially when the child cries, and struggles like a little imp on its mother's knees; as soon as you would introduce the finger into its anus, it closes it and the with an unparalleled energy; this is at least what happened to me in the little child who was the subject of this case. Thus, instead of stopping short at the idea of a fissure, I did not hesitate to suppose the presence of a polypus in the rectum of this child. I hesitated the less, because at the same time I called to recollection Grenst the four cases published by M. Bourgeois, and in which the symptoms which theof. little patients presented were exactly those which I actually made out in mine. For nearly three months the state of the patient remained the same; and as the Guelik general health continued to be perfect, in spite of this slight hæmorrhage which reappeared more or less regularly at the time of defæcation, I thought I could completely tranquillize the parents on the consequences of this disease, and dispense with the necessity of seeking for the polypus by main force, and direct the mother always to examine the anus of her little daughter after each stool. This examination of the anal opening did not at first present anything worthy of remark. It was only towards the end of the third month from the commencement of the symptoms, that the mother rightly thought she recognized at the base of the half opened anus, immediately after the emission of a stool, the presence of a small swelling, which was only observed on a portion of its surface, the mammilated and deep red appearance of which much resembled that of a raspberry. This tumour did not always present itself after each defæcation; it was only in the last week which preceded its extraction that it showed itself in a more constant manner, and that it at last completely protruded, returning at the end of some minutes. After having been fruitlessly called ten times by the mother in order to perform the extraction of this polypus, which reëntered and disappeared during the time they came to seek me, I at last arrived at a favourable instant, immediately grasped the little tumour towards the base with the the thumb and the index finger, separating the anus as much as possible, seized the pedicle of the polypus which I ruptured with my nails. The pedicle was scarcely ruptured when the polypus escaped from my fingers like the stone from a cherry when compressed in a similar manner, and was projected to the ground. The polypus, of the size of a raspberry, was exactly applied on the anus, which, in its closed state, exercised a true constriction on the pedicle, so that I did not think it right, in consequence of the cries and struggles of the child, to introduce my finger into the rectum, in order to assure myself of the length of the polypus, and of the exact seat of its growth. The hæmorrhage which followed the extraction of the polypus was very slight indeed; some drops of blood only escaped, and that was all. However, the next day the expulsion of the stool was accompanied by a clot of black blood of the size of a small nut, which was a proof of hæmorrhage from the remaining portion of the pedicle. Since then the hæmorrhage has not reappeared. The cure dates now from more than two years. When the hæmorrhage caused by the polypus is very slight, and only appears every six, eight, or ten days, we may wait and defer the operation. If, on the contrary, the flow of blood is considerable, and sufficiently frequent to weaken the constitution and bring on anæmia, we should decide on removing the source of the evil. M. Stoltz has recommended the destruction of polypi of the rectum in children by ligature and the immediate excision below the thread. This advice is very good, and does away with the dangers of imarka When 14 A hæmorrhage, but it is very difficult to practise, and on this account is not of so much value as the method of M. Bourgeois. This praetitioner simply tears away the polypus by means of the fingers, as may be observed in the case just reported. This method has been (using employed four times by the author, and once by M. Perrin; it has i always succeeded without accidents, and without causing the slightest hæmorrhage. 着 CHAPTER IV. ON FISSURE OF THE ANUS. Fissure of the anus is sometimes observed in children at the breast. It is caused by the straining resulting from constipation, and by the superficial rent of the mucous membrane which lines the sphincter of the anus. It is the origin of the smarting and the burning pains which follow each stool. At this moment it sometimes determines the escape of several drops of blood, but there is never any extensive hæmorrhage. The fissure of the anus should be treated by laxatives internally, with the view of obviating constipation, or by opiated suppositories, or by astringent enemata, with the sulphate of zinc, 2 grains to the 3j; tannin, 5 grains to the 3j; extract of rhatany, 4 grains to the 3j. M. Trousseau has observed some instances of this disease, which he treated by rhatany, his usual practice. The first case was that of a girl, one year old, of good general health, subject from her birth to constipation, which has particularly increased during the last 14, four months. The child only goes to stool once every three or four days, and utters sharp cries at the time of each defecation. The pain appears to commence with the effort of defæcation, and to be very acute during the passage of the fæcal matters through the anus. About a month since, the constipation becoming a little more obstinate, defæcation is still more painful, and at each stool the child passes several drops of blood, which are expelled either before or after the fæces, but are never mixed with them. The circumference of the anus is perfectly healthy; but on widely separating the folds, there appears, at its anterior part and between two folds, a fissure of about Cone-sixteenth of an inch broad and about one quarter of an inch long, rather deep, of a red colour, and much more easily perceived when the child, crying Cyiolently, strained as if at stool. The constriction around the anus is such, that the extremity of the finger can scarcely be introduced. Some days after the cure of this child, M. Trousseau had under his care a little boy, eight months old, who, from being weaned too early, was seized with a very TG, violent diarrhoea, immediately succeeded by a very obstinate constipation. This state had lasted for eight days, when the child was seized during defecation |