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 T 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

diately after the motion is passed, previously washing it with a little alum and water, or a solution of tannic acid. The bowels must be kept easy, for which purpose castor oil is the best agent: some advise calomel and jalap, but it is likely to produce tenesmus. Sir Benjamin Brodie1 recommends the following treatment: "Purge him with calomel and rhubarb occasionally; be very careful about his diet, that he does not eat a great quantity of vegetable substance, which tends to fill up the cavity of the bowel, while it affords but little nourishment; and every morning let some astringent injection be thrown up. The injection which I have generally used is a drachm of tinct. ferri muriatis in a pint of water; and two or three ounces or more of this, according to the age of the patient, may be injected into the rectum every morning, the child being made to retain it as long as possible.

When calculus vesica is the cause of the prolapsus, the stone must of course be extracted, and the effect will then probably subside without any special treatment; if the presence of ascarides cause the bowel to descend, they must be removed by the means recommended in the eighteenth chapter.

Prolapsus recti in the adult, if of long standing, will rarely admit of being remedied by medical treatment, and we must have recourse to surgical operation for the relief of the patient. Of the various operations that have been suggested, none are so simple, attended with so little pain, and so effectual as that proposed by the late Mr. Copeland. The patient, previously prepared by the bowels having been thoroughly unloaded by mild purgatives and enemata, is directed to lean over the back of a chair, or to rest on a bed with his legs drawn up; according to the extent of the disease, one, two, or more folds of the mucous membrane are to be pinched up with the forceps, figured at page 129, or, with a pair of common dressing forceps, and included in a firm, round, and smooth ligature: the knots must be drawn tight, that perfect strangulation may be effected. In order that the ligatures may not slip, and that they may come away sooner, I prefer transfixing the base of each fold with a needle carrying a double ligature,

1" Medical Gazette," vol. xv, pp. 845-6.

2 "Observations on the Principal Diseases of the Rectum and Anus,” Third Edition, 1824, pp. 79 to 83.

and tying it in two portions; the pain is by no means increased, and the cure is expedited, as the threads have a smaller amount of tissue to cut through. After the operation, the prolapsus and the ligatures, the ends of the latter having been cut off, are to be returned within the sphincter. The patient must be confined to bed, and a dose of opium or morphia administered. On the second or third day the bowels should be moved by an enema of flaxseed-tea, or thin gruel and oil, and this must be repeated every day, or every second day, as may be necessary. For some days the bowel will descend more or less, but as the ulcers caused by the ligatures cicatrize, this will diminish, and a perfect cure will be effected.

Since the publication of the first edition of this work, at the suggestion of Sir Benjamin Brodie, I have applied the concentrated nitric acid to the mucous membrane of the prolapsed bowel with the happiest result, and think it is the better plan of treatment, except in those cases in which the mucous membrane is very

and voluminous.

lax

When the descent of the bowel is caused by piles, the treatment recommended in the ninth chapter must be followed. If the protrusion is a result of relaxation of the anus, a marginal fold of the integument and mucous membrane must be excised from either side; but the surgeon must be careful that while seeking to remove one source of annoyance he does not produce another which will give much more trouble than the primary affection, namely, contraction of the anus, which is certain to take place if he removes the integument too freely: the patient is placed in the same position as for lithotomy, or in that just described (page 176): a pair of forceps, a scalpel, or a pair of curved scissors, are the instruments required.

In some cases, on account of age, debility, or other circumstances, an operation cannot be performed: an endeavor must then be made to support the intestine by pads and a T bandage, or by a truss similar to that recommended by Gooch. The best instruments of the kind that I have seen, are those made by Mr. Egg and Mr. Eagland.

The following cases illustrate this affection :

1 "Cases and Practical Remarks on Surgery," by Benjamin Gooch, Norwich, 1767, vol. ii, p. 158.

Prolapsus, caused by disease of the liver and dysentery, induced by a long residence in India.

Mr. A, æt. thirty-nine, had been nearly twenty years in India; the latter part of the time his health had failed, and his liver became affected; he had also had several dysenteric attacks. Shortly before leaving for England the rectum began to descend, and during the voyage occasioned him much suffering and inconvenience mercury was administered freely by the surgeon of the ship, but with no benefit to his health. He consulted me after he had been in England two years: he was sallow and somewhat emaciated; his pulse was weak, quick, and irregular; he had frequent palpitation of the heart, and he was much troubled with flatulence; the bowels were irregular, and when they acted he suffered great pain, which continued some hours afterwards; he also complained of being annoyed by a discharge of mucus, and bleeding from the part. The several regions of the body were carefully examined: no organic disease of the heart could be discovered; the liver could be felt extending an inch below the margin of the ribs, and pressure over it produced a dull pain. A fold of the bowel on each side of the anus was protruded, and could not be kept up except when he was in the horizontal position; the surfaces were slightly ulcerated, and somewhat altered from their natural appearance. The urine was examined on several occasions, and was observed either loaded with crystals of uric acid, or with those of oxalate of lime. This patient was seen also by the late Mr. Morton, of University College Hospital, who concurred in the plan of treatment adopted, which was mild purgatives, gray powder with extract of taraxacum, and tonics with the nitro-hydrochloric acid, and the use externally of ablutions and astringent lotions. When his health had improved, ligatures were applied to both sides of the prolapsed bowel, and portions of the mucous membrane completely strangulated; the prolapsus was then returned, and a dose of opium administered. The operation produced a slight amount of pain, but it subsided in an hour or two: he slept soundly during the night. On the morning of the third day he took a dose of castor oil, which moved the bowels several times, and caused a return of the prolapsus: the ligatures came away on the fifth day,