Fig. 30. Complete rectal prolapse, third degree.

Si One teaspoonful two or three times a day to a child over a year old.

General tonic treatment in the form of fresh air, exercise when the child is old enough, strychnine, arsenic, iron and improvement of environment complete the palliative treatment of these cases.

Surgical Treatment of this condition is limited and dependent, in any variety, upon the degree of prolapse.

In cases of incomplete prolapse the application of pure nitric acid, recommended by Appalling, is of great service and will prove successful in a majority of such cases. The application is made in longitudinal lines varying from one-eighth to one-fourth of an inch in width and about one-half of an inch apart. Care should be exercised to confine the action of the acid by immediately applying a blotter to the part so as to take up the excess, and further neutralize with bicarbonate of soda. Linear Cauterization (Van Burn's) with the actual cattery is also of much value in these cases, and is done with the cay trey at red heat, making three, four, or more longitudinal stripes. Be careful not to burn too deeply at the apex of the prolapse, as the peritoneum sometimes reaches a point within one and one-half inches of the normal anal opening in children. The modified clamp and cattery hemorrhoid operation has proved most satisfactory in the hands of many operators, when care is exercised to include only the mucous membrane within the grasp of the clamp. This operation accomplishes all that the above methods do and with a greater degree of certainty. After the prolapse is reduced, three or four sections are clamped and cauterized, as indicated by the amount of tissue prolapsed.

The success of either of these two methods is largely Dependent upon the retention of the prolapsed rectum long enough after the operation to allow union and caricaturization The tenements following treatment by either method is easily controlled by the injection of olive oil, bismuth sub nitrate and tine op ii, in the following combinations.

Fig. 31. Archdiocese or rectal hernia.

Fig. 32. Complete rectal prolapse, showing circular muscular contractions.

This injection should be given into the rectum twice daily for four or five days. The opium may be omitted sometimes on the third or fourth day. The bowels should be opened on the fourth day, by a simple water enema and the sweet oil and bismuth should be continued for a week after the discontinuance of the opium. An ounce of a solution of ten per cent. witch-hazel in water should be injected after the bowels have moved so as to ensure cleanliness. Constipation is best relieved with sweet oil internally or the cod liver oil as recommended above. Cascara gradate may be necessary.

These methods, however, are only applicable to the incomplete variety and possibly to some cases of the first and second degrees of complete prolapse.

The Ligature Operation for hemorrhoids used in various ways for prolapse has never appealed to me, on account of the liability to infection and hemorrhage, and therefore I have had no experience with that method.