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rectal polyp and prolapse is ])robably not as Irecpient as these Hgures indicate, for only when a polyp purchase aldactone was either felt or suspected were a number of the cases of prolapse referred from two of the pediatric de- partments of the Mt. Sinai Hospital Dispensary.' The polyp was removed in eight of the ten cases. Of these six could be traced ; all have been cured of prolapse by excision of buy aldactone online the polyp. It should be noted that in not a single instance could the buy cheap spironolactone l>olyp be drawn out beyond the anus either at the examina- tion or when the patients were operated upon. 1 have seen three cases in which polyps protruded from the anus, but rectal prolapse (beyond the anus j was not present in any of them. The histories given by all but one of the cases of polyp complicated by {prolapse were quite uniform — the passage of blood and mucus in the stool, occa- sional bleeding immediately after defecation, and prolapse of mucous membrane during or after defe- cation or enema. The exceptional instance was that of a boy four years old, who had had prolapse ac- companying bowel movements for about generic aldactone two. aldactone order years. Forcible reduction by the mother was occasionally necessary. There never v;as any blood or mucus in the stool. Treatment had consisted in strapping of the buttocks. Upon examination, August 6, 191 3, in the surgical clinic of the Alt. Sinai Hospital Dis- pensary a polyp was found attached high up on the lateral wall of the rectum. It was unusually firm and fibrous in aldactone buy consistence. Its removal was followed by permanent cure of the prolapse. The prolapse disappeared at a varying period after bowel move- ments ; in none of the patients was it permanently beyond the anus ; the length varied from one to three inches. In contrast to the symptoms of rectal polyp com- plicated by prolapse, are the symptoms of pro- lapse not associated with polypi. None of the patients in the latter group of twenty-three cases gave a history or presented evidence of blood and mucus in the stools, with two exceptions. These were patients sufl-'ering from persistent diarrhea, and an enterocolitis of tuberculous origin (])0sitive purchase aldactone online von Pinjuet test in one of them) was suspected in both instances. Several experiences have demonstrated that rectal polypi can be and are very readily overlooked ; a most thorough local examination of every suspected case cannot be too strongly urged. Therefore a de- scription of the technic of rectal examination when routine cheap aldactone palpation does not disclose a polyp, may be permitted. Proctoscopy with the ordinary speculum has not been of any great value in my hands. Of six cases of polyp in which it was em- ployed the lesion could be seen in only two. In none did rectal inspection reveal a polyp that could not be felt. My impression is that the chief value of proctoscopy for rectal polyp in children lies in deter- aldactone online mining the condition of the mucous membrane in the neighborhood of the lesion. Returning to the question of rectal palpation, I wish to repeat that the routine examination often will fail to discover a polyp. A method of palpation of considerable >The clinics of Dr. J. S. Leopold and Dr. M. H. Bass. I am greatly aldactone price indebted to both for their courtesy aldactone 25 mg in referring the cases in question. value, first described by AJoUiere (8j, has disclosed the lesion in several of the patients in my series. The examining finger is introduced to the highest possible level, and, slightly fiexed, should be swept toward the anus along the rectal walls. In this man- ner the pedicle of a polyp often can be aldactone 50 mg hooked and the tumor thereby found. When Molliere's method is order aldactone online unsuccessful an enema should be administered and the rectum palpated immediately thereafter. This procedure brought the polyp within reach of the finger in one of my cases. Should these methods fail it ai)pears logical to palpate the rectum when filled with water ; polypi not demonstrable other- wise may thereby be floated free and felt. When indicated this j^rocedure will be tried in future cases. Since the treatment of polypi consists simply in their removal, it would appear superfluous to add any remarks upon the little operation, were it not complicated occasionally by hemorrhage. The polyp should be neither twisted nor torn off. Troublesome arterial bleeding following these procedures has been described, and it may be no easy matter to clamp and tie a bleeding pedicle situated some distance aldactone tablets from the anus. Although most authors reserve liga- ture for polyps of large size, surely it is mtich safer, in all instances, to ligate the pedicle of a polyp by a suture passed through its buy spironolactone online base. The bowels should be confined for two or three days. Finally, mention should be made of rare cases of rectal polyp in which the lesion is attached high ujj and the buy spironolactone base of the pedicle is broader than usual. It has been found that a fold of peritoneum may be included in such a pedicle. Careful ligation must therefore be practised and the precaution taken to leave suf^cient pedicle to avoid slipping, in all doubtful cases. SUMMARY. The question of the relation of rectal polyp buy cheap aldactone to rectal prolapse in children has received very scant attention ; widely divergent opinions are held by dif- ferent observers. Rectal polypi were found in ten of thirty-three cases of prolapse ; this does not in- clude the transient prolapse of infancy. The re- moval of the polypi resulted in permanent cure of the prolapses. Visible prolapse does not result (in the three cases seen ) when polypi protrude from the aldactone mg anus. Rectal prolapse associated aldactone cost with blood and mucus in the stool indicates a rectal polyp almost invari- ably ; prolapse without blood and mucus in the stool negates a rectal polyp almost invariably. Rectal ])olypi are readily overlooked ; special methods of examination for their detection are therefore de- scribed. A rectal polyp should not be removed by avulsion, but invariably by ligation through the base of its pedicle.

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