introduced for a longer or shorter distance before meeting with the sphincter unless only the mucous membrane of the anal border be prolapsed.

Prolapse of the rectum may be partial, i. e., affect only the mucous membrane of the anal border, or involve a larger section. In the latter case it simulates an intussusception or invagination of the middle portion of the rectum into the lower portion, or into the anus itself.

Prophylaxis.-If prolapse has once occurred, guard against its return by prevention of diarrhoea, constipation or tenesmus (opium enemata). The chamber should be placed so high that the child's feet cannot reach the floor, for straining by abdominal muscles is thus kept within safe limits.

Ice water clysters are often valuable, and if all else fail we may use rectal tampons saturated with some such astringent as rhatany, tannin, alum or vinegar. Jacobi advises an ointment of ext.

nucis vomica (gr. x to 3j). Prognosis.-Good.

Treatment. In atrophic children, above all other things, care should be had for good nourishment, for this alone assures the success of any local treatment. A reposition of the prolapsed mucous membrane of the anal border should be made immediately after each passage. This should be performed on the child in the knee-elbow position, gently pushing back the prolapsed portion through the central opening by means of a bit of greased cloth until the finger have passed through the sphincter, whereupon the finger must be withdrawn by carefully rotating it as it is withdrawn. If there is intussusception of the middle portion of the rectum, we must try to set it free by the careful use of a cotton tampon, or the colpeurynter, but cauterization is only permissible when the rectal wall is extremely relaxed.

15. RECTAL POLYPI.

Definition.-Pedunculated, hypertrophic growths of rectal mucous membrane.

Occurrence. After third year, and not so rarely as generally believed, as they are often mistaken for partial prolapse of rectum.

Symptoms are like those of prolapse of the rectum, viz.: pain and hemorrhage with each passage, and sometimes persisting for a while after, if the feces have been hard. Deep-seated polypi make their appearance at the anus with each passage, at first, quickly slipping back to their places. Later, when they have grown larger, they remain longer at the anal opening and their reposition causes pain.

Prognosis.-Good. Spontaneous cures, by the rupture of the pedicle by a hard stool, seem to be frequent. The return of a polypus is not known, but the simultaneous presence of several sometimes occurs.

Treatment.-Application of a double silk thread about the pedicle immediately after a free passage is produced by means of a laxative, with subsequent reposition.

16. RHAGADES ET FISSURE ANI.

Definition.-Fissuræ Ani are small fissures of the mucous membrane of the anus in the vicinity of the sphincter ani externus. Etiology.-Hard stools, or anal syphilis.

Symptoms.-Acute pain with every passage from the bowels, sometimes sufficient to cause convulsions before the passage. The stool is generally hard and is either coated with a little blood, or a little hemorrhage follows it, or both may occur at the same time. By pulling apart the folds of the mucous membrane about the anus, a wound, or a deeply hidden ulcer with more or less redness, can be discovered.

Treatment.-(1) Removal of the constipation by means of clysters, etc. (2) Cauterization of the denuded spot of mucous membrane with nitric acid or nitrate of silver. (3) In obstinate cases only, the forcible dilatation of the anus while under the influence of chloroform is to be recommended, with powdered iodoform as a local application to the ulcer.

17. CONGENITAL MALFORMATIONS IN THE
INTESTINAL TRACT.

1. Stenosis et atresia, or narrowing or closure of the intestine, is not very infrequent in children, and may occur at various points, e. g.

2. Entero-stenosis-seu Atresia interna-is either congenital or acquired. Most frequently seen as a congenital deformity. 3. Stenosis ani.—See Imperforatio ani.

Etiology. These congenital cases of narrowing or closure of the intestines can only be referred to interuterine cicatrices resulting from interuterine ulcers, or from the formation of peritoneal bands or tumors of the intestine in utero. The stenosis is most frequently located in the duodenum at the point of junction between the ileum and colon, or at the sigmoid flexure or rectum, a few centimeters above the anus.

Symptoms consist in a failure to pass the meconium, because when the stenosis or atresia is situated high up none is formed, and when low down the meconium cannot pass off. Soon the abdomen distends and fluids taken are rejected; if the stenosis or atresia are located high up, the ingesta are rejected as they were swallowed, but if the trouble is low down, they are thrown up mixed with meconium. Death, sometimes with convulsions, soon takes place from atresia, but if it is a case of stenosis, it may be deferred up to the tenth to eleventh day.

The acquired forms may arise from these same causes or from closure of the intestinal tube by means of indigestible food, pips, accumulation of ascarides, etc. Stenosis ani frequently escapes detection until the soft, pap-like stools of the newborn are replaced by harder, when the symptoms of narrowing of the intestinal tube first make their appearance, though they can usually be obviated by means of enemata and laxatives. More rarely, however, the stenosis is so great that there is no passage at all of meconium, or only after a very great effort.

Treatment.-The rectum must be dilated, preferably by means of a couple of sounds, as in fissure of the anus, or by nicking the same with a bistoury and a grooved director.

Imperforation.—Under the name of atresia seu imperforatio

M

ani, seu recti, we understand various conditions, all of which have the same termination, viz.: occlusion of the rectum.

Etiology.-(a) Rectum ending as a blind pouch with the anus in same condition, their floors forming the membrane which occludes the rectum.

(b) The rectum may terminate at any point below the sigmoid flexure and above the internal sphincter without a blind anal pouch, the rectum being attached directly to the floor of the perinæum, which gives a roundish swelling when the blind end of the rectum dilates with meconium.

(c) A blind pouch may be (normally) formed, but fail entirely to coincide with that of the intestines, of which the entire lower colon may be wanting. There may be a narrow canal, large enough, perhaps, to admit a goose quill, extending upwards from the anus 1-3 inches, the intestinal canal terminating in a similar blind pouch a short distance above, leaving an intermediate, tolerably firm fibro-cellular diaphragm. The anus and lower rectum may be altogether absent and the gut end in a small fistulous orifice upon the inner side of bladder, urethra, vagina, anywhere in the perinæum, or in the side or upon the anterior or lateral walls of the abdomen, or lead into the ductus omphaloentericus. (Anus præternaturalis, ectopia ani.)

Prognosis. Only favorable in the first variety, bad as a rule in the others, even after a successful operation for artificial anus. Treatment. If the rectum is clearly not the seat of the stenosis or atresia-diagnosed by passing elastic catheter to sigmoid flexure-then help can only be obtained by making an artificial anus, according to the degree of distention of the abdomen. (For steps in operation, see Hamilton's Surgery.)