Displacements of the Rectum.

These are-Rectocele ;

Prolapsus Recti (a) of mucous membrane,

(b) of whole thickness of bowel.

For Prolapsus Recti, which is properly surgical, see Van Buren or Allingham.

Rectocele is a protrusion of the lower part of the anterior wall of the rectum covered by the posterior vaginal wall, into the lumen of the vagina or even through the vaginal orifice. Etiology.-There are two factorstear of perineal body and pressure of scybala in rectum. Diagnosis.--The posterior vaginal wall is seen protruding into the vagina or out at the

pro

vaginal orifice. The diagnosis is made by noting the relations of the truded vaginal wall and by passing the finger through the anus into the pouch (Fig. 396). Treatment. The patient should wear in the vagina a Hodge or Albert Smith pessary with cross bars; explain the necessity of a regular daily evacuation of the bowels.

Fissure of the Anus.

This is a crack, or ulceration, of the anal skin or of the mucous membrane covering the internal sphincter. In the edges of the crack there is usually a nerve filament, and below the crack lies the powerful sphincter ani.

This apparently insignificant lesion gives rise in most cases to an un

bearable and even incredible amount of pain, lasting for hours after the bowels have moved. Hilton's explanation of this is so good that we give

it entire.

"The reason for this anal ulcer being so very painful is the number of nerves associated with it; and the cause of the continued painful contraction which accompanies it lies in the enduring strength of the sphincter muscle. Thus it happens that exposure of those nervous sensory filaments upon the ulcer causes excito-motory or involuntary and spasmodic con

Anus with a anal speculum in situ; it is turned so as to expose in the fenestra a fissure b, beneath which a tenotomy knife has been passed (Hilton).

The

traction of the sphincter, through the medium of the spinal marrow. sphincter muscle contracts towards its own centre, and, as long as the muscle is in a state of contraction, it brings the sensitive edges of the ulcer into forced contact; this excites more muscular contraction, and thus, by time and exercise, the muscle becomes hypertrophied, massive, and increased in dimensions."

bowels are being moved as of an unbearable pain coming on after the evacuation and continuing for some hours. The pain is described as unendurable, causing the patient to dread and postpone natural motions. There are often iliac pains and vaginismus; this last symptom is not infrequent. Physical Signs.-By speculum or eversion, the crack is seen.

Treatment.-Chloroform the patient, pass a tenotomy knife beneath the base of the ulcer (Fig. 397) and cut upwards. This divides the muscular fibre so that the irritated edges can no longer be brought together. The fissure gets rest and heals readily; a cure is thus effected.

Another and very good plan is to chloroform the patient, and introducing the thumbs (with the dorsal surfaces in contact) to stretch the anus by forcibly separating them; this ruptures the muscular fibre and acts just as the knife does, and is especially good when the fissures are multiple.

The bowels are not to be moved for a day or two; the patient has then some pain when the motion is passing, but none after it.

Piles.

Hilton has pointed out that at the anus the line of demarcation between skin and mucous membrane is marked out distinctly by "the white line," as he terms it. This line is of great practical importance, as we shall

see.

Piles are small tumours at the anus, on either side of this white line. They consist of dilated veins embedded in connective tissue and covered by skin or mucous membrane. We speak of external piles, i.e., those outside of the white line and covered by skin, and internal piles, i.e., those inside of the white line and covered by mucous membrane. Occasionally we have, as a special form of external pile, a dilated vein outside of the white line and usually containing a clot (venous pile).

Symptoms.-Venous piles cause great pain; while external piles, unless inflamed, occasion little inconvenience; from external piles, there is bleeding when the bowels are moved.

Physical Signs.-The venous pile is a purplish tumour outside of the white line; external piles are like tags of skin, or are more or less distended; internal piles are cherry-red and easily bleed.

clot.

Treatment.-1. When venous piles contain a clot, incise and turn out

VOL. II.-21

2. For internal piles, employ the following palliative treatment. Give sulphur confections when necessary.

B. Confectionis Sulphuris....

Sig.-Dessertspoonful at night.

Order gall and opium ointment to be applied.

B. Unguenti Gallæ c. Opio........

Sig.-As directed.

....

3 ij.

3 ij.

For any abrasions, order iodoform ointment (p. 204) or bismuth suppositories.

The radical operative treatment belongs more to the surgeon.

Recto-vaginal Fistula.

The situation of such a fistula is shown in Fig. 357. It may be due to carcinomatous or syphilitic ulceration, or to injury received during parturition. The last is alone amenable to operative treatment, which is the same as for a vesico-vaginal fistula.

Functional Disturbance of Rectum-Constipation.

Women are usually exceedingly careless in the matter of regulation of the bowels; very often, evacuation is practised once a week or even at longer intervals. This is in many respects not their fault, but is due to the insufficient water-closet accommodation, to modesty, and to the fact that evacuation is for evident reasons postponed during menstruation.

When consulted for constipation, the medical man should insist on the value of a daily evacuation at a fixed hour; this educates the bowels to demand it regularly. All quack pills should be tabooed as dangerous. The diet should be regulated; bran-bread, porridge and milk, stewed fruit, figs, etc., taken as part of food. The following pill is good.

R. Extracti Nucis Vomicæ,

Extracti Belladonnæ

Pilula Colocynthidis et Hyoscyami

Fiat Pilula ...

Sig. One occasionally.

..ãå gr. t.

gr. iij.

..mitte tales vj.

The nux vomica and belladonna strengthen the peristalsis of the bowel: the colocynth and hyoscyamus pill is purgative; aloes and iron pill may be substituted for it.

The purgative mineral waters are very useful. The best are the Friedrichshall, Hunyadi Janos, and Aesculap. The patient should take in the morning a wineglassful or half-tumblerful with an equal amount of hot water; the taste may be masked by the juice of a lemon with sugar. The Carlsbad salts are good and may be used as already directed (p. 13). Very often an enema of cold water is helpful. The medical man should deprecate the habitual use of purgatives, and insist on natural and daily evacuation.

The aloes and iron pill is good in sluggishness of the lower bowel. Rhubarb is bad as a habitual purgative, owing to its tendency to constipate after purging; the well-known "Gregory's Mixture" should not be used as a habitual purgative, but is good in diarrhoea inasmuch as it first purges and then binds. Fluid magnesia, castor oil, and some of the - milder salines (e.g., the easily taken Seidlitz powder) may be employed. Blue pill should be avoided; Euonymium or Iridin are better hepatic stimulants (v. p. 248).

COCCYGODYNIA.

LITERATURE.-Hildebrandt-Die Krankheiten der äusseren weiblichen Genitalien : Stutt., 1877, S. 127. Nott-N. O. Med. Jour., May, 1844. Simpson, Sir J. Y.— Dis. of Women: Edin., 1872, p. 202. Thomas-Dis. of Women: Lond., 1880, p. 151. By this we understand a painful condition in the region of the coccyx induced by sitting, walking, and the various muscular contractions associated with defecation and coitus. When we consider the anatomy of the coccyx, its muscular attachments (to the levator ani, coccygeus, external sphincter ani, and gluteal muscles), as well as the strain put on it when driven back during parturition, we are not astonished that in some cases there should be inflammatory changes around and in it causing pain in its movement. Symptoms. The chief symptom is pain on sitting, walking, and defe

cation.

Physical Signs.-By digital pressure on the coccyx and examination per rectum, the seat and nature of the pains are made out.

Treatment.-(1) Pass a tenotomy knife beneath the skin on the posterior aspect of the back, and free its lateral and apical muscular attachments; or (2) amputate the coccyx. To do the latter, make a vertical mesial incision over the posterior aspect of the coccyx; seize its tip and pull it well back; then free its muscular attachments with the knife, keeping close to the bone; finally separate it at the sacro-coccygeal joint.