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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 dimirish, 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 lax and voluminous.

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 226): 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 endeavour 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 :

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 Eng

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

land two years : he was sallow and somewbat 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 annount 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, 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 diarrhea. He had no appetite for plain food, but partook freely of highlyseasoned 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 the 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 tumour 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

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