Constitutional Treatment is again emphasized for the good effects produced in all of these cases, both young and old.

Drastic Purgatives are contraindicated in all forms of rectal prolapse and care should be exercised to guard against the administration of such drugs, or the selection of them by the patient. Palliative treatment should not extend for more than two to three months.

Reduction. When there is much swelling or edema of the parts, which might interfere with reduction, the local applications of compresses, saturated with a twenty-five percent. solution of nitroglycerine, will be found efficacious in most instances. The same method should be followed in the treatment of the adult or child in attempts at reduction. Hot cloths should be applied in preference to cold. In these severe cases, the cold causes contraction of the blood vessels and interferes with the circulation in the protruding part, in many instances so poor as to be in a sloughing condition.

Vitus’s or the knee-chest position is best for attempts at reduction. The knee-chest position induces the aid of gravity in the reduction of the prolapse. The mucous membrane should not be bruised while introducing the finger into the lumen of the protruding mass. When gangrenous destruction of the prolapse has taken place no attempt at reduction should be made, as immediate amputation is the best treatment. In these cases, the prolapse may be so large as to have within it a portion of the peritoneum, and the attempt at reduction which has failed will expose the peritoneal cavity to infection before operative measures can be instituted. Should this occur, either suture or clamp the ends until adhesion have formed, in order to close over the peritoneal surface.

Operative Treatment. Operative treatment aims to produce sufficient adhesive inflammation between the various coats of the rectum to prevent slipping; it also aims to remove redundant tissue and reduce the caliber of the rectum and anus to normal size. These three objects must be constantly in the mind of the operator in order to produce good results.

The modern operations for the radical cure of prolapse are based upon the best surgical principles and are productive of good results, but space would hardly allow the technical description of all. In the selection of any operation for this condition, the surgeon is best guided by the particular case, than to select at random the technical of any particular operator.

Alliance' s Method of Nitric Acid. By this method nitric acid, or the acid nitrate of mercury, is used in the form of an application. A general anesthetic is given and the prolapse dragged down, washed off and dried. The acid must be applied all over it, care being taken not to touch the verge of the anus or the skin. The part is then to be oiled, and the rectum stuffed with wool. A pad must then be applied, outside the anus, and kept firmly in position by an adhesive plaster. The buttocks are, at the same time, brought close together. If this precaution be not adopted, when the patient recovers from the chloroform, the straining being urgent, the whole plug will be forced out and the bowel will again protrude. When the pad is properly applied, the straining soon ceases, and there is little or no pain. The bowel should be confined four days, the strapping is removed and castor oil administered.

Appalling states that this treatment is generally applicable to prolapse in children, and failure rarely follows if properly carried out, but sometimes the acid may have to be applied more than once. The virtue of this method is questioned by most American surgeons, as very few have the courage to employ it and safer methods are more generally known and used. Nitric acid when applied in its pure state is so strong an agent that it produces a slough and subsequent ulceration, very likely to result in stricture. There is absolutely no control of the acid thus used, unless neutralized, and then the decree of cauterization is very uncertain.

Linear Cauterization is far superior both in results and in the control of the cauterize The method used generally is to take a very small quantity of absorbent cotton, which is wrapped around a wooden applicator and dipped into the acid: this is laid upon the prolapsed gut. at points about one-half inch apart around the rectum, so as to produce cauterization with healthy strips of mucous membrane between them. These linear cauterization are carried over the margin of the anus to the highest portion of the prolapse. Small detractors should be used to hold the lumen open while the applications are being made. The after-treatment as suggested by Appalling is well employed in these cases, with the addition of a drainage tube extending above the packing to allow the escape of gas or blood, should hemorrhage occur. In the application of nitric acid, care should be exercised not to burn too deeply at the highest point, as in children the pertone um anterior reaches to within an inch and a half to two inches of the anal orifice.

Van Burn’s Linear Cauterization Method. The patient is anesthetized; the prolapse is dragged down as far as it will come, washed off and dried, and the cattery applied in lines about one-half inch apart all around the circumference of the gut, extending from the margin of the anus to the highest point of the prolapse. The Jacqueline cattery should be at red heat and only the mucous membrane should be cauterized. Care should be exercised not to perforate the muscle in order to avoid the involvement of the peritoneum while applying the cattery, should it have descended into the prolapse. A drainage tube should be introduced, with or without the ordinary gauze wound around the middle of it. Vaseline may be used on the gauze and tube to facilitate its introduction, and a safety pin put through the distal end of the tube in order to prevent its slipping into the rectum. A compress should he applied to the wound, best held in position with adhesive straps which draw the buttocks together. The bowel should be confined for four or five days, and the patient kept in bed in the recumbent position. At the end of this time, a small enema should be given through the drainage tube, about two hours after the administration of a dose of Epsom salts. The drainage tube and gauze is best removed at this time. The success of this operation will be the retention of the prolapse in its normal position and care should be taken to administer laxatives to regulate the bowels and to prevent a dragging down of the prolapse. The patient should be kept in bed. and the bowels moved while in the recumbent position, for a period of two to three weeks.