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"the erosions, and sometimes by fissures of the mucous membrane <v*

*>4<UL^^1the rectum- . . a

All the children are constipated, but they are not otherwise 31

'__< J.t£}t4 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

i This is a difficult and very painful exploration; it should only be

'. (iS^HtiM performed in cases of absolute necessity. At a later period, the polyp*,

pushed forwards by the efforts of defecation and perhaps also by tie

/ illlud fasces, appears externally at intervals. It is then only that the diagncss

. / acquires all the certainty desirable.

These polypi do not in general constitute a serious disease, and with

"■ *■ UlUU'l the exception of cases of considerable haemorrhage do not require *

precipitate treatment. We may wait, indeed we should wait, OTf

,,■>*'* 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

i^j the Revue Medico-Chirurgicale.

(./!'<"-' Case. A little girl, two years and a half old, very intelligent, dark, of a b2*>nervous temperament, and good general health, passed nearly four months beton the extraction of a polypus of the rectum which was performed on tbe 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 lb* 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 rf defalcation. The blood passed was not at all mixed with the habitually consistent fiecal matter, which it only tinged externally and very often only partially. The defiecation 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 haemorrhage did not always accompany the expulsion of the faces, '' !lij that the child was sometimes several consecutive days without losing blood in spit* • of the daily efforts of defiecation.

In this case, up to this period, apart from the anal haemorrhage and its mode of appearance, there is nothing in common with the two cases of fissure of the aims observed at the Necker Hospital, but the symptomatologic analogy will be presently / .■' •? J ft / 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 ■'*// i yC more intense, and when the fieeal matters acquired more consistence. Several times, and particularly in the case of painful defiecation, 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 ■•, y/jii 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 /J. 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 ■■■f- reason have suspected the probable existence of a fissure at the anus, if at the same '-Cy time I could have positively recognized the spasmodic contraction of the sphincler.

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But in my opinion, it is not easy in the child to appreciate the true degree of this /(fit A'[/ ft

contraction, especially when the child cries, and struggles like a little imp on its

mother's knees; as Boon as you would introduce the finger into its anus, it closes it £)jj.j/ ,/£

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 fy ~f~

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 ■

the four cases published by M. Bourgeois, and in which the symptoms which the //)6^^^^/'»

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 £fyfi_£/j // general health continued to be perfect, in spite of this slight hemorrhage which reappeared more or less regularly at the time of defalcation, 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 b -y-f of remark. It was only towards the end of the third month from the commencement "4*'/t ////'■' 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 */jjit \ /f /■ 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 J / did not always present itself after each defalcation; 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 reentered 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 haemorrhage 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 haemorrhage from the remaining portion of the pedicle. Since then the hsemorrhage has not reappeared. The cure dates now from more than two years.

When the haemorrhage caused by the polypus is very slight, and Sji Jj / 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 ■ / anaemia, we should decide on removing the source of the evil. '' '*' *'/'

M. Stoltz has recommended the destruction of polypi of the rectum ,•+- r in children by ligature and the immediate excision below the thread. **.*/', "/ This advice is very good, and does away with the dangers of •/

- A*~/~ //,/ ,/

t

fl /Usl* $~ n8emorrnage> Dut '* is vel7 difficult to practise, and on this account

// is not of so much value as the method of M. Bourgeois. This pracU~t~ t~4 titioner simply tears away the polypus by means of the fingers, as

fjjiAsi+Uf majr be 009ervea m tne case Just reported This method has been /f employed four times by the author, and once by M. Perrin; it ha* '■'iiaiuuj*- *lway9 succeeded without accidents, and without causing the slightest haemorrhage.

ft / S ii^A.

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 determine; the escape of several drops of blood, but there is never any extensive htemorrhage. •tf, 'i... 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 5 j; tannin, 5 grains to the g j; extract of rhatany, 4 grains to the 3 j. '' fiJii * 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

f from her birth to constipation, which has particularly increased during the last

.' r*- /-< / <iV..four raontlis. The child only goes to stool onco every three or four days, and

t, utters sharp cries at the time of each defcecation. The pain appears to commence

v //,'/'/{ y with the effort of defalcation, and to be very acute during the passage of the faecal

, • r- - matters through the anus.

•'' About a month since, the constipation becoming a little more obstinate, defecation

.''. . is still more painful, and at each stool the child passes several drops of blood, which are expelled either before or after the fieces, 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 I' >•• t'/Hone-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 - /_, /. Q'fjviolently, strained as if at stool. The constriction around the anus is such, that the extremity of the finger can scarcely be introduced. , //j / 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

"V It.&fi vi0'ent diarrhoea, immediately succeeded by a very obstinate constipation.

This state had lasted for eight days, when the child was seized during defiecation

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Book XI.] ON PERITONITIS. 529 £/j\j ///

with a most acute pain. The fiecal matters on that day were slightly tinged 43 <* 1 with blood. Wtyl TM*

From this period, at each stool, the child is seized with very acute pain during the efforts of defalcation, and each time a small portion of very pure blood tinges the CdCfat^i. /** faeces without mixing with them.

On examining the anus, a slight erythema is observed, mixed with eczema nearly X ff^ ^ well, and the existence between two folds of the anus of a fissure about one-eighth . ' , of an inch broad, and less than one-sixteenth of an inch in length, not very deep, *L£bLs^ cty of a reddish colour, and which becomes perfectly developed when the child makes Q r

an effort of defalcation. The anus is also the seat of a considerable constriction.<SnS£.&C4 4fr /

In these two little patients, M. Trousseau prescribed: 6-^5?/ /~~

Extract of rhatany 15 grains.

Water 3 iij.

For an enema every day. _

This treatment had wonderful success, and effected the cure in the A^\JLUL^U! little girl at the end of eight or nine days, and in the little boy, ^ . . ^^, at the end of three days only. i*

BOOK XI.

ON DISEASES OF THE PERITONAEUM. ON PERITONITIS.

Peritonitis, or inflammation of the peritonaeum, is a very common /£ ,'><','// disease amongst newly-born children. It has been described by Billard, , Duges, and more recently by M. Thore, in a work of which I have/^. 'jU-i * H a very high opinion. "'/i"i\ .

Causes. Iv^ u' ., „.

Peritonitis is sometimes developed in the foetus whilst still enclosed „'t /.[jj^ in the womb of the mother, and it constitutes congenital peritonitit. y /,•, Billard, Duges, and Simpson have related numerous examples of it.

Peritonitis most usually manifests itself after birth, and during the fiClHJJ"- e, first month of existence. It is more rare amongst children of a more ( advanced age. Its appearance often coincides with the existence of *" epidemics of puerperal fever. It is sometimes developed in a primary i.n£ji J Lj>. manner without any appreciable cause, and without any anatomical ^ lesion in the neighbourhood of the peritonaeum accounting for its ' '■ *■ _' * • presence. Most usually the peritonitis is teeondary, and results from kJ\T f/.' the erysipelas of infants, and from the umbilical phlebitis which follows

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1 '' kSA.Lt .

Ci. .<tl V"Hj ligature of the cord; from an obstacle to the progress of the fiscal

i.tinl±fv~ matters in the intestine by constipation, imperforation of the anus,

. _ £- intestinal invagination or inflammation of a hernial sac; from rupture

i *of the bladder, laceration of the liver, perforation of the stomach,

(ini general eczema, <fec. In all these cases we may admit that the inflam

/ ,~ . ^.mation has been communicated to the peritonaeum by the lesions of

the surrounding parts above alluded to.

'// ft Amy Peritonitis is nearly as frequent amongst boys as amongst girk,

and is developed in all seasons, especially in spring and summer, but

without any well-marked influence of the external temperature.

Anatomical Alterations.

. T1 , Under the influence of the various causes above enumerated, the

*'peritonaeum becomes at first the seat of a more or less decided capillary

ir jjCy;/injection, at the situation of the abdominal walk, and at the inferior

'surface of the liver, in the case of umbilical phlebitis, or in the

'( ^ (4, /W"«6ther parts of the peritonaeum near to the cause of its inflammation.

£ ± r Sometimes this redness is general, and exists alone without any other

lesion of the peritonaeum. False membranes, of a variable consistence

"and thickness, often accompany this tinting, and this effusion of plastic

i lymph serves to establish more or less numerous adhesions between

the different intestinal folds. The peritonaeum is, moreover, sticky and

C1.'. / £4C/L ,-glutinous. It encloses a viscous sanguinolent or purulent serosity,

, £ ,' / in a quantity varying from one to seven ounces. At a later period

, these adhesions are more compact, more resisting, and, after the cure

■■■.to ' of the peritonitis, have the same appearance as that of other old serous

inflammations, that of vascular filaments converted into cellular binds.

Billard has observed this in two newly-born infants who were attacked

/ # i ,' - with peritonitis in their mother's womb.

According to M. Thore, peritonitis often exists with pneumonia, , sometimes with pleurisy without effusion, and with pericarditis; but ''. these lesions are consecutive to the peritoneal inflammation.

'Symptoms.

The peritonitis of infants is usually observed in the acute, and

very rarely in the chronic form. In both cases its symptoms are

very obscure, and the diagnosis is often only established on the table

of the amphitheatre, that is to say, after death. This is readily under

\ I «,,, stood, for peritonitis is very often a secondary disease, and is developed

. / 'as a consequence in the course of other diseases which mask its

', ■' % "■* commencement by their proper symptoms.

r ., , huu t When, however, the patients are narrowly watched, and when, on

daily examination, the abdomen is felt, in order to appreciate its state

!•.♦'•< V1* • of suppleness, it is discovered to be the seat of a very acuta pain

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