the surrounding parts, that it is almost impossible the whole should be protruded together; a separation or elongation of the union between the coats of the intestine must therefore precede the disease, and form its essential character; whether it be produced by the effusion of blood between them, or by the continued tenesmus, or efforts to pass the fæces, or peculiarity of structure, or any other cause.'

From anatomical causes, children are more subject to protrusion of the bowel than adults: thus in them the sacrum is less curved, the coccyx is not ossified, and remains movable on the sacrum, the intestine itself is straighter, and its connections are less extensive from the imperfect development of the prostate, urethra, and vesiculæ seminales.

The causes of prolapsus are constitutional, and depend upon some peculiarity of the general health, or of the habits or occupation of the individual; or they are local, either from disease or irritation existing in the rectum or in contiguous organs.

Of this affection, as well as of several others to which the rectum is liable, costiveness is one of the most general causes. When the bowels are not relieved every day the fæces accumulate and become hard; the watery portions being taken up by the absorbent vessels, the bowel becomes distended, local and general irritation is induced, and violent expulsatory efforts are necessary to dislodge the indurated mass; which, pressing on the bowel in descending, may not only drag down the mucous membrane, but cause the rectum itself to protrude.

Chronic diarrhoea and dysentery are likewise causes of this disease: they are accompanied by straining, irritation, and determination of blood to the lower part of the intestinal canal; and inflammatory action and various morbid alterations of structure are induced.

Disease of the liver is not unfrequently associated, as a cause, with prolapsus of the rectum: those who have resided in hot and miasmatous countries, and have suffered from hepatic affections, are very liable to experience the miseries of prolapsus, and we thus find it prevailing greatly in individuals returned from India. The engraving (p. 172), which well illustrates the distinctive characters of prolapsus recti, and the difference between it and internal hemorrhoids, is from a drawing of a case I was requested to see by

Mr. W. Bennett: the patient had malignant disease of the liver, consequently only palliative treatment could be adopted for the local disease.

Prolapsus may result from indigestion: the primary seat of the evil being in the stomach or duodenum, or some defects in the functions of the pancreas and liver, whereby the fæcal matter is rendered irritating and diarrhoea induced; or, on the contrary, the rectum and colon may not be sufficiently stimulated, and fæcal accumulations are consequently promoted.

Sedentary occupations act rather as a predisposing than as a direct cause of prolapsus. By insufficieney of exercise a torpid state of the alimentary canal is induced, the biliary secretion becomes diminished, and the skin does not properly perform its excretory functions.

Prolapsus may be attendant upon the violent straining and forcible muscular efforts during difficult parturition, or from the relaxation occurring by frequent child-bearing. It may also be produced by violent and immoderate horse exercise.

Constitutional weakness, hereditary or induced, is another cause. The children of the poor are the subjects of prolapsus, from being badly nourished, and living in close and unhealthy habitations, or by being suckled too long. In a public infirmary, a short time since, I had an infant under my care, which illustrated, in a marked degree, the effect of neglect and deficiency of proper nourishment: several inches of the bowel were prolapsed; and it was with great difficulty it could be reduced, and it was still more difficult to prevent its descent; but no treatment could be of any avail, the debility being so great and the assimilative functions so impaired, that death very shortly put an end to the little patient's sufferings.

The local causes in adults are hemorrhoidal disease, polypı, enlarged prostate, stricture of the urethra, stone in the bladder, inflammation of the bladder, inflammation of the rectum, loss of tone in the sphincter ani from some lesion of the spinal cord, or other circumstance; from debility of the intestine itself, produced by excessive fæcal accumulations, or the habitual use of large enemata, and the extraction of large foreign bodies from the rectum. In children, the most frequent causes are urinary calculi, intestinal irritation produced by acrid secretions, or the presence of entozoa, and the irritation that often exists during the period of dentition.

The symptoms produced by prolapsus recti are various, according to the duration of the disease, and the extent to which the bowel is protruded. The tumor in children is red, pyramidal, and coiled in form; in adults it is either globular, cylindrical, or appears as lateral folds on each side of the anus. The amount of intestine protruded varies from a mere fold of the mucous membrane to several inches of the whole of the tissues. In the case of a child who had stone in the bladder, which Mr. Liston removed, the intestine was prolapsed to the extent of six inches. At the commencement of the affection, the intestine is retracted spontaneously after the passage of the motion, but ultimately it becomes necessary to replace it with the hand. Sometimes the protrusion increases very rapidly, especially in children; but if the patient is an adult, and not advanced in life, or laboring under constitutional debility or weakness of the muscular apparatus of the anus, it takes place more gradually. A copious secretion of red glairy

mucus is poured out from the lining membrane of the rectum; pain is felt in the hips, down the thighs, and even extending to the legs and feet, and may be attributed to rheumatism or sciatica.

After prolapsus has existed some time, the mucous membrane becomes indurated, and loses its villous appearance. When the sphincter is relaxed, and the anus dilated from the repeated protrusion of the bowel, the latter descends on the slightest exertion: even assuming the upright position is sometimes sufficient to cause it to fall down; it is then very liable to become ulcerated from the friction to which it is exposed: in these cases the pain and distress are almost insupportable; defecation produces acute agony, and the patient is compelled to lie down for an hour or two afterwards.

In the treatment, we have to consider the removal of the cause, the replacement of the protruded intestine, and the retention of it in its natural position: if we fail in the latter, it will then be necessary to have recourse to operative surgery.

Our first efforts must be directed to the replacement of the protruded bowel: provided the prolapsed portion is free from engorgement, this may be effected at once, but if, on the contrary, inflammation and vascular turgescence exist, leeches must be applied to the surrounding parts, and subsequently hot fomentations of decoction of poppy-heads. Some have recommended scarifications and leeches to the bowel itself, but their use has been justly censured by most practical surgeons. If the engorgement is not sufficient to require the abstraction of blood, the application of cold lotions will prove beneficial. In order to replace the intestine, the patient must be placed on his side in the recumbent position, or be directed to kneel on the bed and rest on his elbows: the buttocks being separated by an assistant, the surgeon grasps the tumor in a piece of oiled linen, makes firm compression, and having reduced its volume, pushes it within the sphincter. During this proceeding the patient must be desired not to strain, otherwise our endeavors will be opposed. Should contraction of the sphincter prevent the return of the bowel, the patient may be put under the influence of chloroform, when the obstacle to the replacement will probably be removed; but muscular relaxation is not the constant effect of this anæsthetic agent, the converse being sometimes the case, and spasmodic contraction induced. Should the constriction

of the sphincter persist, the muscle must be divided by inserting under its margin the nail of the forefinger, on which the knife used in operating in fissure is to be carefully guided, and the necessary incision made. In children, especially if the prolapsus be large, great difficulty will be experienced in returning it to facilitate the operation, some recommend the introduction of the finger into the bowel, which is to be carried up with it; while the finger is being withdrawn, the intestine is to be supported with the left hand. Sir Charles Bell recommends the finger being covered with oiled paper, which will allow its withdrawal without bringing down the bowel.

Having returned the prolapsus, a pad of lint must be applied, and retained with a bandage. The attention must then be turned to the constitutional treatment, and to the removal of the cause. The digestive organs should be attended to, and any errors of diet corrected: the aliment allowed must be easy of digestion, nutritious, and such as will not cause bulky evacuations; highlyseasoned dishes and large quantities of vegetables and fruit are to be prohibited; the tone of the stomach, if impaired, is to be restored by bitter infusions and aromatics, with the addition of soda, potash, or ammonia: in some cases, the mineral acids will be found to agree better than alkalies.

Too great attention cannot be paid to prevent costiveness, which so generally accompanies this disease either as a cause or effect; but we must avoid having recourse to drastic purgatives. Emollient enemata, castor oil, lenitive electuary, Rochelle salts, and other similar remedies, will be the most desirable. It is very essential not to overlook the state of the liver; congestion of this organ will often be indicated by the lividity of the prolapsed bowel: alterative doses of mercury with ipecacuanha, taraxacum, and nitric acid, will be serviceable in hepatic derangement. After every evacuation the anus should be washed with soap and cold water, and four or six ounces of an astringent injection thrown up the rectum. the decoction of oak-bark with alum, or a solution of tannic acid, are better than solutions of the mineral salts.

In children, the treatment of prolapsus of the rectum is very troublesome and often tedious; the nurse must be directed not to allow the child to sit straining on its chair as is too commonly the practice, and she should be instructed to replace the gut imme