can only say that I have achieved very partial success; the
patient may leave the hospital very well, and you may con-
gratulate yourself upon having effected a cure, but in a few
months the bowel will again protrude, in all probability, as
badly as ever.
PROCIDENTIA RECTI. 12 J
In the second edition of this work I said, " Dr. Van
Buren, of New York, has recommended in these intracta-
ble cases the application of the actual cautery to the gut,
in spots or lines, and also to the verge of the anns over ihe
external sphincter muscle, so as to get contraction and thus
support the bowel. This strikes me as a very good sugges-
tion, and I shall certainly try it on a case where other means
have failed." I have now used this method on many hos-
pital and private patients and effected permanent cures.
The procidentia in the adult is sometimes very large; I
have seen it in a woman, larger in circumference than the
foetal head, and seven or eight inches in length.
I have had, in my own practice, many cases of prociden-
tia, in which there was a hernial sac in the protrusion, and
in all it was situated anteriorly, as from the anatomy of the
part, of course, it must be; you could return the intestine
out of the sac, and it went back with a gurgling noise.
Directly the bowel is protruded you can tell that there is
a hernia also present by the fact that the opening of the gut
is turned toward the sacrum; when the hernia is reduced
the orifice is immediately restored to its normal position in
the axis of the bowel. I have seen several similar cases in
the practice of my colleagues at St. Mark's; the condition is
therefore not very uncommon, but I have never found it in
children.
In very old and bad cases of procidentia more or less
incontinence of faeces always exists. There may be two
reasons for this symptom. First, loss of tone in the sphinc-
ters; the frequent protrusion stretching these muscles so that
they lose a great deal of their contractile power; and sec-
ondly, the mucous membrane gets so altered in structure as
to lose, in a great degree, its natural sensitiveness; thus when
fecal matter comes into the ' lower part of the rectum, the
sphincters are not stimulated to action, nor is the patient
aware of its presence.
The operation by the hot iron or Paquelin cautery, sug-
gested by Dr. Van Buren, is thus performed by me: The
patient is put under the influence of ether, and if the part
be not down it can be readily drawn fully out of the anus by
the volsellum. I then, having the intestine held firmly out,
with the iron cautery at a dull red heat, make four or more
longitudinal stripes from the base to the apex of the pro-
truded intestine. I take care not to make cauterization so
deep toward the apex as at the base, because near the apex
128 PROCIDENTIA RECTI.
the peritoneum may be close beneath the intestine, while a
deep burn near the base is not dangerous. I take care to
avoid the large veins which can be seen on the surface of
the bowel. If the procidentia be very large I make even six
stripes. I then oil and return the intestine within the anus;
having done this I partially divide the sphincters on both
sides of the anus with a sawing motion of the hot iron, and
then insert a small portion of oiled wool. From the day of
operation I never let the patient get out of bed for anything;
the motions are all passed lying down, consequently the part
never comes outside. If the wounds have not all thor-
oughly healed in a month, I continue the recumbent posi-
tion for two weeks more, by which time it very rarely hap-
pens that all is not healed. The patient can then arise and
get about, but still for some time I enjoin that evacuation of
the motions should be accomplished lying down. The
reason for the success of the treatment is simple enough.
When the burns are all healed, the bowel, by contraction of
the longitudinal stripes, is drawn upward, and circumferen-
tial diminution also takes place. In these cases, before ope-
ration, the sphincter muscles have quite lost power, the anus
is large and patulous; by sawing through the anus with the
iron the muscles contract and regain their power, the patient
having strength to cause the anus to close at will, and even,
to some extent, to squeeze the finger when introduced.
With this method of treatment I have had great success,
many persons being quite cured, while others have been
greatly benefited, so as to be able to work, by only wearing
a pad of cotton wadding.
In a case I had with Dr. Way, of Eaton Square, a lady
who had for years suffered from a procidentia recti five
inches long and nearly three in diameter, a perfect cure was
effected. She wrote me on the anniversary of the operation,
to say the bowel had never come down, though she walked
very much and had to go up and down flights of stairs con-
stantly. I need not say how grateful she was. In another
case in the practice of Dr. Woodhouse, of FuUham, in which
several operations had been performed unsuccessfully before
I saw him, and the procidented intestine was very large, a
permanent cure was effected. In a very bad case attended
by the late Mr. E. Carr Jackson and myself, the vessels on
the bowel were so large that great bleeding took place when the
cautery was applied^^ and ligatures had to be used. Secondary
haemorrhage, to an extent requiring very careful plugging,
PROCIDENTIA RECTI. I29
also occurred when the sloughs separated. This patient
was very anaemic, through large losses of blood prior to the
operations, and he was blanched to a dirty white, yet he
thoroughly recovered, and the bowel has never again pro-
truded. This patient was seen quite recently and remains
perfectly well. Several hospital cases which I have had
during the last few years have done admirably, though some
have required care and watching for months after the
operation.
Sometimes, when a large portion of the bowel comes down,
there is much difficulty experienced in returning it. I have
found, on several occasions, that the passing up the bowel of
a large flexible bougie, so as to carry before it the upper
part of the descended gut, is of great service; gentle taxis
should at the same time be used, and in this manner the
mass can generally be returned. When the gut comes down,
and the patient cannot get it back and does not seek assist-
ance, it gets tightly girt about by the sphincter, great swell-
ing takes place, and sloughing may ensue. I have seen
many cases of this kind, but, as far as my experience goes,
the sloughing is partial, and only the mucous membrane
separates. After a few days' rest, with the buttocks well
raised, to favor the return of blood, the part can be replaced
and considerable benefit may result. The only case I ever
saw where anything like dangerous or deep sloughing took
place was in consultation with a medical man who had most
assiduously and constantly applied a bladder of ice to the
protruded part, and this had so much favored sphacelus
that nearly the whole mass came away, and there was free
secondary haemorrhage. In this case the sloughing was so
considerable that a very intractable stricture resulted. This
shows the necessity of care in the application of ice; if it be
too long continued, or if the patient be old or of feeble con-
stitution, dangerous results may ensue.
I am not aware of any internal remedy which is of much
use in cases of procidentia, but small and frequent doses of
opium, with confection of black pepper, benefited some of
my patients.
A nasty, teasing diarrhoea is very commonly present, and
there is often a discharge of mucus, which keeps the linen
always damp, and adds not a little to the general discomfort.
Powdered acorns I have used frequently with advantage, for
the diarrhoea. The acorns should be baked and grated to
powder, and the dose is one teaspoonful in half a tumbler of
130 POLYPUS RECTI.
milk every morning. I have found this answer better than
either gallic or tannic acid.
The frequent and bountiful application of cold water in
these cases is to be strongly recommended. It is as useful
as ordinary astringent lotions.
CHAPTER XIII.
POLYPUS RECTL
This disease was formerly looked upon as a very rare one;
recently, however, it has been considered rather more
common, and it is supposed that in times gone by, rectal
maladies not being so well understood, many cases of poly-
pus escaped diagnosis. At a meeting of the Pathological
Society, in February, 1873, a gentleman stated that he had
seen fifteen cases in twelve months. His, I think, must be
a somewhat singular experience. I find that I have noted
altogether 6;^ cases without complication, as having occurred
in my own practice. My statistics at St. Mark's Hospital
shows that in 4000 cases of rectal disease there were only
sixteen of polypus without fissure.
It has generally been believed that polypi are much more
frequently found in children than in adults; this has not
been the case in my experience, as ;^6 existed in children
under fourteen years of age, and 27 in older persons.
By the word " polypus " I must be understood to mean a
pedunculated growth attached to the mucous membrane of
the rectum, and generally situated not less than an inch
from the anus. I have seen them quite two inches up the
bowel, but only occasionally more than that distance. In
the majority of cases the polypus grows from the dorsal
portion of the rectum, but I have found it on the perineal
and lateral segments. I think some surgeons apply the
term " polypus " to those small muco-cutaneous polypoid
growths which are so often found at the upper end of a
fissure, and' thus swell their statistics.
My friend Dr. Daniel Molliere, of Lyons (whose work on
rectal surgery surpasses all others in its pathology), says,
*' There is no word in surgery that has been more abused in
POLYPUS RECTI. I3I
its use than the word polypus, especially when applied to
tumors of the rectum. As a matter of fact, the term ' poly-
pus of the rectum ' is used to describe any neoplasm, no
matter whether benign or malignant, hard or soft, provided
only that it adheres to the rectum by a stalk or relatively
limited base."
Polypi have been usually described as of two kinds; the
soft or follicular, and the hard or fibrous — the former being
found in children, and the latter in grown-up persons. I do
not concur in the statement that the soft polypus is always
the one found in young children, and I am of opinion that
the true fibrous variety is rare even in the adult. In fact,
this rough division is very far from the pathological truth,
for the true fibrous polypus, in its anatomy, is an almost
perfect counterpart of the fibroid tumor of the uterus. In
the Hunterian Museum is one specimen of rectal polypus
arising from the muscular fibres of the rectum, and it is in
reality a fibro-muscular tumor, or, in the nomenclature of
Virchow, a myoma. The few I have s^n myself have been
nearly as large as an English walnut; they creak when cut,
and the incised surface is of a pale color. The peduncle is
about an inch and a half long, and is always attached above
the sphincters; the tumors do not usually appear outside the
anus, they do not bleed, but when they do protrude they
cause pain, irritation, and spasm, and often set up an ulcer
in the bowel. The discharge from them is of a very icho-
rious and ill-smelling character. These polypi have been
observed and minutely described by both French and Ger-
man pathologists, and. are considered quite exceptional'
specimens of this form of tumor.
The polypi usually found in the adult are smaller than the
mucous polypi of children; they are multiple. I have often
found two growing from opposite sides of the rectum; there
may also be two stems with one head only. The pedicle
may be an inch or a little more in length, and is not uncom-
monly hollow; the polypi are neither very hard nor soft, and
are easily compressible; they are sometimes cystic; a large
vessel runs up the stem; in some cases you can feel it pul-
sate.
The soft follicular polypus of children is no doubt rarely
met with in adults, but even in these it is not so rare as my
colleague, Mr. Gowlland, believes, who once stated at the
Medical Society that there were only two kinds of polypi,
"the soft and the hard." He had evidently not consulted
132 POLYPUS RECTI.
the writings of foreign pathologists, or he would have found
that there are numbers of different forms. The soft polypus
is almost always found in women, and thus Dr. Routh is likely,
as he says, to have seen a considerable number. The stem is
remarkably long and rather slender.
The polypi of children are small, vascular tumors, with a
peduncle often two inches long. They are about the size of
a raspberry, and resemble a small, half-ripe mulberry more
than anything else; they bleed very freely at times, and
occasion in the young great debility. They are said to be
either hypertrophies of the glands of Lieberkiihn, or of the
mucous follicles of the rectum. They may be dangerous
when high up, by occasioning intussusception of the bowel,
with total obstruction and death. When the peduncle is
more than an inch in length they usually protrude at stool,
and require to be returned after the bowels are relieved.
They are sure to be described by the child's mother as piles,
or as " the body coming down."
The peduncle is ^something so slender that it breaks on
very slight traction, and I dare say many polypi become
detached when the child is straining or passing a hard
motion, and are thus spontaneously cured.
A most valuable and original account of polypi in children,
by the late Dr. Bathurst Woodman, and founded on his
experience at the Northeastern Hospital for Children, may
be found in the Medical Press and Circular^ May 5th, 1875.
He names five kinds of polypi — i, the soft and gelatinous;
2, the cystic; 3, the papillomatous; 4, the dermoid; 5, the
sarcomatous. Dr. Woodman states, that the most common
variety in children is the hard polypus (I must say that such
has not been my experience), and that " the children of
arthritic parents, and those suffering from the syphilitic,
tuberculous, and cancerous cachexiae are most liable to these
affections."
From the polypus of the adult I have often seen abscess,
ulcer or fissure, and fistula arise. A short time since a
patient was sent to me with a fistula, complete and dorsal;
the probe passed readily through it into the bowel. On
introducing my finger I found the internal opening very
large, a hard polypus as big as a marble projected into it;
the stem was quite half an inch long, and was attached near
the promontory of the sacrum. I have seen, on post-mortem
examination in both adults and children, full-sized polypi
attached as high as the sigmoid flexure of the colon, and
POLYPUS RECTI. I33
also in the colon itself ; they cause diarrhoea and may bring
on obstruction of the bowel by setting up inflammation,
which occasions paralysis of the muscular coat of the intes-
tine. When fissure exists with polypus, the removal of the
polypus and gentle dilatation will cure both maladies.
The diagnosis of polypus has been stated to be difficult. I
cannot myself see why any difficulty should arise. The his-
tory of the case and symptoms will usually lead you to sus-
pect what the disease is, and if you are careful to administer
an injection and thoroughly search the bowel you must feel
or see it. When a polypus has a long pedicle it is apt to
slip away from the finger, but even then the peduncle can be
readily felt at its point of attachment to the rectum.
The general symptoms in children are — frequent desire to
go to stool, accompanied by tenesmus, occasional bleeding,
with discharge of mucus, and a fleshy mass protruding from
or appearing at the anus when the bowels are acting.
It is possible to mistake this disease for internal piles, pro-
cidentia recti, or dysentery. An examination after an injec-
tion will clear up the doubt in the first two cases; in the last,
the presence of fever, the abdominal pain, and the appear-
ance of the motions are sufficiently distinctive indications.
In the adult the history, carefully inquired into, may be
found peculiar. The patient will tell you that without any
previous marked discomfort in the rectum, he all at once
discovered that a substance protruded on going to the closet.
1 his is characteristic of the malady; until the peduncle
becomes long enough to allow of the polypus being extruded
or grasped by the external sphincter, but little or no incon-
venience is felt, therefore the onset of the disease is consid-
ered by the patient as sudden; this is quite different from
the history of haemorrhoids.
I cannot at all say why these growths should arise; they
are not often connected with haemorrhoids or any other dis-
eases of the rectum save fissure and intussception. I have
not even observed that constipation, that potent factor of
bowel affections, obtains in these cases. I will relate a few
cases of polypus, and then say a word or two about treat-
ment.
Thos. B. — , set. 4, seen at the Farringdon Dispensary,
October 27th, 1862. For more than twelve months has had
what was supposed to be prolapsus of the bowel; he lost a
good deal of blood at times, and was very feeble and
anaemic. After an injection there came down to the anus
134 POLYPUS RECTI.
a spongy, irregular-shaped, bleeding mass, fully as large as a
medium-sized walnut ; it felt soft, but not gelatinous. A
tolerably long pedicle connected it with the anterior wall of
the rectum. I applied a ligature and cut the polypus off.
He was ordered an astringent draught to confine the bowels
for a few days. November ist. He took a dose of castor
oil and the ligature came away on the bowels acting. There
was no bleeding. Discharged cured.
Jane H — , aet. 7, brought to St. Mark's Hospital, October,
1864. Her mother said that something came down when the
bowels acted, and she lost much blood; she was obliged to
put the substance back again. After an injection two tumors
made their appearance, and I at first thought it was a case of
haemorrhoids; but on closer examination, passing my finger
into the rectum, I found that they were polypi, arising by two
peduncles from quite an inch and a half up the bowel. One
appeared to be attached dorsally, and the other laterally. I
applied two ligatures and snipped off the growths. In three
days the ligatures came away, and she was soon quite well.
Henry de C — , admitted into St. Mark's, March, 1866. He
was six years old, and looked a very feeble, delicate boy.
For two or three years he had lost blood at stool, and latterly
something had protruded after an evacuation; it had to be
returned by pressure. He had taken a quantity of medicine,
and been treated at several public institutions. After an
injection a dark-colored, very vascular polypus came into
view; it had a well-defined, rather thick neck. I applied a
ligature and cut through the pedicle; the tumor was about
the size of a raspberry. The thread separated in five days,
and there was no haemorrhage. I kept him under observation
some time, giving him tonics; he was ultimately discharged,
perfectly recovered.
Hugh L — , aet. 9, a weak and irritable boy, emaciated and
bloodless, suffers from cough. His mother says he has been
troubled for five years, at least, with his bowel coming down
whenever he went to the closet. He returned it himself by
pressure. He had been taken to medical men, and also to
hospitals, and she had been told that it was a weakness of
the bowel, and had used ointments and lotions for it. The
loss of blood he had sustained lately had been very severe.
He did not suffer any pain. When I first saw him his
mother said '' his body " would come down if he stooped and
strained a little, and on his doing so a round, vascular, bright-
red, villous body, bleeding freely, was seen outside the anus.
POLYPUS RECTI. I35
It was not at all painful to the touch. I found that it was
connected with the bowel just above the internal sphincter,
by a pedicle of pale color, at least two inches long. I applied
a silk ligature and ordered him a little aromatic confection,
to confine the bowels. In three days the ligature separated
on action taking place. I then prescribed for him some iron
and cod-liver oil. In a fortnight they brought him again,
saying that another substance had made its appearance, and
sure enough, on his straining, a tumor, almost precisely sim-
ilar to the former one, protruded from the anus. To this
also I applied a ligature. When I saw him at the end of the
week I administered an injection to see if there were any
more polypi, but I found none, so I discharged him as cured.
Duncan J — , set. i8, came to St. Mark's in 1867. His
health was generally good. For twelve months he had some-
thing protrude from the anus on visiting the water closet,
and he had lost a quantity of blood. It retracted spontane-
ously on his rising up after the action. He has been under
the care of many physcians and surgeons, and has always
been treated for bleeding piles. He has a pain of a dragging,
burning character in the rectum, but it is not severe. After
an injection a large (the size of a walnut), vascular, velvety-
looking polypus appeared at the verge of the anus. The
pedicle was rather thin, and not so long as usual. I held it
with a volsellum while the house-surgeon applied a ligature;
this was pulled so tight that it cut the peduncle at once. I
was apprehensive of bleeding, and so kept him lying down in
the out-patients' room for a couple of hours, when, finding
there was no haemorrhage, I sent him home. In a week he
came and said he was quite well.
Martha H — , aet. 25; married; no children; several mis-
carriages; admitted into St. Mark's, 1865. She had one
perineal hsemorrhoid and a dorsal fibrous polypus, the size of
hazel-nut. The polypus had a shortish broad pedicle; it
was situated above the internal sphincter, and I found some
difficulty in applying the ligature. She left the hospital well.
Mr. James B — , set. 37, was sent to me by a medical man
who thought he was suffering from piles After an injection
a polypus came down, resembling much that found in
children, but it was firm and not so vascular; it was about
the size of a raspberry. I placed a ligature on the stem and
cut it off. This gentleman did not rest, as I advised him to
do, for a few days, and he had an abscess form a week after
the separation of the ligature.
136 PRURITUS ANl.
A lady, set. 46, who had been supposed to be suffering
from some uterine affection, was sent to me by Dr. Priestley.
He had found on examination that the patient's symptoms
were due to a polypus of the rectum; this was easily felt
from the vaginia. I removed the polypus, and the patient
soon recovered.
• These cases of polypus forcibly illustrate the desirability
of always giving an enema before making an examination, as
it is only by seeing the patient just after the bowels have
acted that you can make certain of your diagnosis.
The only treatment to be recommended is the removal of
the growth. I do not think it safe either to cut or tear
polypi off, as troublesome arterial haemorrhage may ensue.
I have seen them bleed very freely indeed, and, as they are
attached at some distance from the anus, it would be by no
means easy to place a ligature upon the bleeding vessel.
I have used the clamp and actual cautery twice, and it
answered very well, but it is rather a formidable proceeding,
the idea of hot irons frightening the patient, although really
the operation is painless, as also is the ligature; the latter
has the advantage of being always at hand. The simplest
method, however, is to seize the peduncle close to its base,
with the German catch torsion forceps, and gently twist the
polypus around until it comes away. There is no danger of
haemorrhage, no pain, and scarcely any necessity for resting
more than one day.
If a ligature be used, I think it is very desirable that the
patient should rest until it separates, and I usually order a
mild astringent draught, to keep the bowels confined, for
three days, then I administer^an aperient, and on relief tak-
ing place the ligature comes away. In two cases I have seen
abscesses follow where much exercise had been taken.
CHAPTER XIV.
PRURITUS ANI.
Pruritus ani, or, as it may well be called, painful itching
of the anus, is a most distressing malady. I have often
heard a patient say that his or her life was rendered almost