any kind inadvisable. A proper rectum supporter will help to lessen the inconvenience; and should difficulty be experienced in returning the protrusion, and the patient be obliged to lie down in order to effect it, comfort will be derived from his establishing the habit of relieving his bowels the last thing at night, so that he may retire to rest at once, and remain in a position favourable for the reduction, and prevention of the prolapsus until the morning.

CHAPTER VI.

POLYPUS OF THE RECTUM.

WHEN considering the changes consequent upon hæmorrhoids, I described the hypertrophied folds developed in this disease as sometimes assuming an elongated form, and protruding at the anus. These processes rarely become pedunculated, but spring from the lower part of the rectum, just within the external sphincter, and are usually attached by a broad base. Growths, however, occasionally arise from the mucous membrane of the rectum higher up in the passage, being attached by a narrow and elongated pedicle. A tumour of this kind is called a polypus of the rectum. It is rather a rare disease, and occurs generally in early life.

In children the polypus usually makes its appearance external to the anus after a stool, resembling a small strawberry, being of a soft texture, granular on its surface, and of a red colour. It has a narrow pedicle about the size of a crow's quill, and two or three inches in length, by which it is attached to the interior of the

rectum. It produces no suffering, but requires to be replaced with the fingers when protruded, and causes a very slight bloody discharge, which, appearing after every motion, excites some alarm. The description of the complaint given by the mother or nurse is liable to mislead the practitioner, and to induce him to conclude that the case is one of a much more common affection, -viz. prolapsus. The nature of the complaint can be determined only by an examination of the tumour when protruded. I am not aware that a satisfactory examination has been made of the structure of one of these small polypi; but I presume that it will be found to consist of an hypertrophied growth from the mucous membrane, and that they are analogous, in their mode of formation, to the pendulous tumours occasionally developed from the skin.

The treatment of polypus in children is very simple, and always effectual. The tumour should be strangulated by a ligature secured around the pedicle, and then returned within the bowel. This gives no pain, and produces no suffering afterwards, and the polypus separates and comes away with the motions in the course of two or three days. A polypus should not be excised, as bleeding is liable to occur from the cut surface of the pedicle. This happened, in a case operated on by Sir A. Cooper, to such an extent as to occasion alarm. Nor should the ligature be tied so tight as to divide the soft neck, for hæmorrhage has been known to arise from this cause. Mr. Mayo mentions, that in tying a polypus of the rectum in a girl eleven years of age, he drew the ligature so tightly that it cut through the slender pedicle. There was no bleeding at the time, but the following night the child lost a profuse quantity of blood, and came to the hospital the following

day faint and pale, and reduced, from the bleeding”. In a case of soft polypus in a boy about five years of age, who was under my care three years ago, the growth being high up in the rectum, I found it impossible to get a noose round it. The child was under the influence of chloroform, but I could introduce only one finger into the rectum to manipulate with, and was unable to drag the polypus out of the gut. It got completely broken down and destroyed under the attempts made to tie it. There was, however, no bleeding of any account at the time or afterwards, and the growth did not return.

The following case will serve to illustrate some of the chief points of practical interest in these cases :— A little girl, of sickly appearance, was brought to me in consequence of a swelling protruding at the anus after stool. The nurse described it as resembling a cherry, and stated that it constantly presented after an evacuation, and often required to be pushed back into the passage. It caused no uneasiness, but was attended with a slight bloody discharge. I was unable to induce my little patient to make any straining effort to cause the body to project, and on introducing my finger into the rectum could feel no swelling of any kind. As the parents resided twelve miles out of town, there was difficulty in getting an opportunity of examining the part after a stool. Apprehending that the case might be prolapsus, I prescribed steel medicines, and directed the tumour to be returned with a piece of soft lint, wetted with a solution of sulphate of zinc. I subsequently ordered an injection of the muriated tincture of iron to be administered daily. After paying me two or three visits, the child was taken to the sea-side for

"Outlines of Human Pathology, p. 354.

the improvement of its general health, and brought to me again on her return. Finding that the projection and discharge were not diminished, I made another examination with the finger, but could find no tumour. I ordered a dose of castor oil to be given early in the morning, and the child to be brought to me afterwards. After she had remained in my house an hour or two, the bowels acted, and I then succeeded in getting sight of a dark red vascular tumour, the size of a small cherry, which protruded at the anus, and had a long narrow pedicle. I passed a ligature round this without difficulty, and returned the strangulated swelling into the rectum. No suffering was produced; and in three days the tumour came away at stool, and the child was cured.

Polypus also occurs in the adult, though less frequently than in children. I once examined a pedunculated tumour removed by operation, which was of an oval shape, and the size of a chestnut, and had a firm stem about the diameter of a goose's quill. It had the irregular nodular surface of a cauliflower excrescence, and was composed principally of fibrous tissue. I suspect that this tumour had been present in the rectum from childhood, and had since grown and acquired a firm consistence. A tumour of this kind does not bleed, but protrudes at stool, and occasions a slight mucous discharge. It may be safely removed by ligature.

Mr. Syme has described another form of polypus occurring in adults, which is soft, vascular, and prone to bleed. The profuse, frequent, and protracted bleeding which proceeds from this sort of growth renders its removal an object of great consequence. He states that he removed, from a hospital patient, a tumour not less than an orange, which had a most malignant aspect,

and had nearly exhausted the patient by hæmorrhage. In another case, in which the disease was detected from the great hæmorrhage which it occasioned, he could not accomplish protrusion of the tumour, but guided a ligature on the finger, and tied it on the neck within the rectum. I have not met with any case of this description, which, I presume, must be very rare.

CHAPTER VII.

FISTULA IN ANO.

THE loose areolar tissue around the lower part of the rectum is occasionally the seat of abscess, which bursts externally near the anus. But instead of the part healing afterwards, like abscesses in other situations, the walls contract and become fistulous, and the patient is annoyed by a discharge from the opening. Such is the complaint termed fistula in ano; and though a very common disease, and one, apparently, of very simple character, there are still some points connected with it respecting which a difference of opinion exists.

The abscess giving rise to fistula sometimes forms with all the characters and symptoms of acute phlegmon, suppuration taking place early, and the matter coming quickly to the surface. In other instances a thickening appears at a spot near the anus with scarcely any sign of inflammation, and but little local pain, and is gradually resolved into a fluctuating swelling, which being opened, discharges a fetid pus. On introducing a probe

" On Diseases of the Rectum, 2nd edit. p. 82.