after which the bowel protruded but very little, and before cicatrization was complete it had ceased to come down at all. During the time he was under treatment, his diet consisted of broths, arrowroot, and light puddings. When the ulcers produced by the ligatures were nearly healed, he used enemata of cold water night and morning, and in less than a month he had quite recovered.

Prolapsus, preceded by morbid irritability of the stomach and bowels; cured by operation.

A gentleman, æt. fifty-three, stout, and of relaxed muscular fibre, had for many years suffered from morbid irritability of the stomach, being much troubled with flatulence and frequent vomiting of a watery fluid; his bowels were generally constipated, and defecation was attended with violent straining; at times he had attacks of diarrhoea. He had no appetite for plain food, but partook freely of highly-seasoned dishes. At length protrusion of the bowel at stool was superadded to his other ailments: for a time it was retracted after the evacuations had passed, but ultimately it became necessary to replace it with the hand. He experienced much pain and misery from the disease, and his linen was constantly soiled with mucus and fæces. Being very nervous and timid, and thinking some operative proceeding would be necessary, he endured the disease without making it known to his medical attendants: he had tried a variety of remedies without any decided benefit. When he came under my care I prescribed laxatives, tonics, and astringent lotions, with the effect of improving his health: however, the bowel continuing to be prolapsed, he consented to the operation I proposed, and accordingly a fold of the protruded membrane on each side was included in ligatures, which were tied as tightly as possible; the parts were then returned within the anus, and an opiate administered. For the first two or three days he complained of pain: this was mitigated by the use of morphine and the application of hot poultices to the anus. The ligatures separated in less than a week: at this time the operation did not appear to have been successful, as the bowel still came down at stool, but as cicatrization progressed it protruded less, and shortly did not descend at all. The disordered condition of

the stomach was relieved by tonics and mineral acids, and the administration of the oxide of silver in combination with a mild aperient pill every night for some weeks.

Prolapsus relieved without operation.

W. C, æt. sixty-seven, of feeble constitution, had been for many years subject to falling down of the bowel, which he attributed to straining violently at stool, being of a constipated habit; he had long been necessitated to replace the bowel with his hand after defecation. I first saw him, in conjunction with my friend, Mr. Bennett, in consequence of his not being able to return the prolapsus, and its becoming excessively painful and occasioning great constitutional disturbance. The prolapsed intestine formed a tumor the size of a large orange; its surface was inflamed and very painful: some difficulty was at first experienced in returning the extruded bowel, but by firm and constant pressure it was at length accomplished: he was confined to his bed, hot fomentations used, and medicines prescribed to allay the constitutional symptoms. On the following morning a dose of castor oil was prescribed, and when it acted the bowel again descended, but was reduced with less difficulty than on the previous occasion. The state of his constitution rendered an operation unadvisable; but, by attending to keep the bowels open by gentle laxatives, and after their action using soap and water to the protruded part, by replacing it immediately, and retaining it by mechanical means, he was restored to a state of comparative comfort.

Prolapsus of the rectum, leucorrhoea, and irritability of the bladder.

Mrs., æt. forty-three, of very delicate constitution, the mother of one child, but has had many miscarriages; from the state of her health she has taken very little exercise, and has always had great difficulty in keeping the bowels open. In the spring of 1849 she began to be troubled by a protrusion of the bowel when she strained at stool, which gradually increased: under medical advice she went to Brighton in the autumn, and tried sea

bathing, but with little benefit. The disease increased, and at last the bowel fell down even when she walked; profuse leucorrhoeal discharge and irritability of the bladder were also induced. I first saw her in 1851: a circular fold of the bowel, between one and two inches in length, was prolapsed; after being returned it fell down again immediately on her walking about. Palliative means were tried for some time, but with no decided beneficial result further than improving the general health. It being evident that nothing but an operation would keep the intestine in its proper place, and the bowels having been thoroughly acted on, ligatures were applied on each side of the protrusion, in the manner described in the text: she progressed very favorably, the ligatures separated in the usual time, and she was no longer troubled by the descent of the bowel: by the use of alum-baths the leucorrhoeal discharge ceased, and by taking tonics and laxatives she was restored to a better state of health than she had had for many years.

CHAPTER XII.

ABSCESS NEAR THE RECTUM.

ABSCESS or abscesses forming in the vicinity of the rectum demand especial attention, and more prompt treatment than when occurring in most external parts of the body, in consequence of the evils immediately depending upon them, and the sequelæ arising from implication of the bowel.

Purulent formations in the neighborhood of the rectum are not of infrequent occurrence, from the nature of the tissue surrounding the terminal portion of the intestinal canal, which is especially prone to suppurative action; and in this locality the predisposition is increased by the looseness of the tissue itself, by its being unsupported by surrounding parts, by the numerous blood vessels that exist there, and their liability to congestion from position and other causes.

Abscesses near the rectum occur under various circumstances; they may be idiopathic, and either acute, subacute, or gangrenous; they occur after fevers and diseases of a debilitating character, and in these cases appear critical; they may be produced by cold and damp, as sitting on stone benches, on the wet ground, on a wet seat while driving: they also arise from various causes in connection with diseases of the rectum, as in stricture of that part; with the existence of internal and external piles; with ulceration of the lacunæ and perforation of the coats of the intestine, the result of inflammatory action arising from the entanglement of the fæces in the follicles, or other causes mentioned in the chapter on Inflammation of the Rectum. Constipation and accumulation of fæcal matter in the rectum and colon will induce the formation of abscess by causing congestion of the vessels, which is increased during defecation by the violent straining to

expel the hardened excrement. Foreign bodies penetrating through the tissues of the intestine and sphincter muscle into the cellular membrane, such as fragments of bone and other substances that have been swallowed: injuries from without, as blows or wounds, lead also to suppurative action.

Abscesses sometimes present near the rectum connected with disease in other parts, as with caries of the spine, ilium, or sacrum, with disease of the hip-joint, and with affections of the uterus, prostate gland, &c. They are also met with in patients laboring under various organic diseases, either of the liver, heart, or lungs : phthisical patients are often sufferers from abscesses near the rectum, which generally lead to the formation of fistula in ano.

The acute idiopathic abscess is generally preceded by thirst, dryness, and heat of skin, scanty and high-colored urine, and, in fact, by the usual symptoms of pyrexia. In the part itself there will be heat, pain, throbbing, tumefaction, and more or less redness of the integument. These symptoms continue for a few days, when at length pus is formed, rigors frequently marking its advent. When suppuration has been fairly and fully accomplished, the feverish symptoms subside, and the patient generally becomes cool and comparatively easy. Although the swelling may now be considerable, and the part exquisitely painful to the touch, the acute throbbing previously experienced diminishes, and is superseded by a dull, heavy sensation. If no surgical means be adopted to evacu ate the matter, nature will form an opening for its discharge either externally through the integument, or internally through the intestine.

The subacute abscesses generally form far from the surface, and frequently contain a considerable quantity of ill-conditioned pus: at first they do not occasion much pain or inconvenience: a sensation of bearing down of the rectum is experienced by the matter pressing upon it, but as it increases in quantity it gives rise to severe and distressing symptoms; there will be violent spasm attended with great pain; there will also be a constant desire to go to stool, although the bowels are free from fæcal accumulation. In other cases there will be no local symptoms of the existing mischief, and the constitutional ones may be obscure and perplexSir Benjamin Brodie1 mentions the case of a gentleman he

ing.

"Medical Gazette," vol. xvi, p. 26.