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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 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, which well illustrates the distinctive characters of prolapsus recti, and the difference between

it and internal hæmorrhoids, 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 insufficiency 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; 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 hæmorrhoidal disease, polypi, 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 tumour 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 labouring 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

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