Treatment.—It is therefore necessary to remove this condition as soon as possible. In accordance with the tendency of this affection to heal spontaneously, we may succeed in a large number of eases by remov ing the etiological factors. The digestive disturbances should be over come. The child should be properly cared for and brought into clean and hygienic surroundings. The forcible straining at stool must be avoided and the children should not let their legs hang free. The ten dency to prolapse will disappear if the above precautions arc taken. Should the anal opening be relaxed, then we will usually succeed with simple strapping with adhesive plaster.
Although this is simple, it will be better to describe minutely }pow it is done. ?? e place the child on its abdomen and lift it up by the legs. Traction of the mesentery will tend to pull the prolapse back and it then be easier to replace it. Then the buttocks are pressed together to • invaginate the anus to some extent. This position is retained by apply ing overlapping strips of adhesive plaster transversely, below and in front we leave a small opening for the defecation (liasewi, Fischl).
Though a large number of these cases can be cured by this strap ping if long continued, there will still be left a considerable number in which we will have to operate.
The most. frequently employed methods of operative treatment consist mainly in the narrowing of the anal opening, in diminishing the mucous surface and in removing the prolapse.
According to Thiersch, we replace the prolapse and then carry a silver wire subcutaneously around the anus, and then twist the two ends together until the anal opening is of normal size. The wire remains, as a rule, without causing any reaction and is removed after one year. Rotter reports twenty-seven cures in thirty-one cases.
Hoffmann's method is also to be recommended. He makes a cres cent-shaped incision in the posterior raphe around the anus and tightens the sphincter and the pelvic floor with transverse sutures and closes the skin over these.
Reim removes a circular cuff of mucous membrane from the pro lapse and gathers up the muscular coat by longitudinal sutures, thus forming a muscular ring over which the mucosa is again united.
These operations give good results in adults and would also be appli cable in children if we did not usually have to deal with badly nourished children whose weakened bodies cannot stand these severe measures.
We have therefore adopted a simpler method, namely, the longi tudinal stiffening of the rectum with bars of paraffin.
This method is easily carried out and under the proper precau tions it is without any danger and may easily be endured even by the weakest child. At our hospital we proceed as follows: We first try the internal and bloodless measures; when we find that we cannot keep back the prolapse and that external circumstances do not permit a long-eontinued treatment, we admit the child into the hospital. Here we replace the prolapse, wash out the rectum and treat the child with retentive dressings until the mucous membrane shows no more excoriations and is entirely normal. We now wash out carefully and then proceed in light narcosis, after carefully disinfecting the anal region, to inject the paraffin. We take hard paraffin of a melting point of 50° C., place it in a water-bath, and prepare a 5 c.c. hypodermic with a canula of S to 10 em. in length.' We fill this syringe with the paraffin, insert it 1 cm. from the anal opening posteriorly and externally and push it in for about 6 or S cm., to the pararectal tissues, under control of the finger in the rectum and taking good care that we do not get too near the mucous membrane. We now begin to inject, withdrawing the needle at the same time, and we stop injecting about 1 em. from the skin and quickly withdraw the needle entirely. We thus form a continuous, more or less bar-shaped longitudinal stiffening which hardens rapidly; the same is repeated on the other side. After the injection, we apply the overlapping adhesive plaster straps for two days. After the first normal stool, the child goes home.
In 1006 we made an inquiry among our patients and found only one relapse in thirty-two cases (in this particular case only one bar was formed). Even the above-deseribed tremendous prolapse caused by a free mesentery was permanently cured by the formation of two paraffin-bars.
Owing to its great merits, we now use this method exclusively in our hospital service.
Accidents may happen when the surface is ulcerated, but in these cases all other methods will be subject to the same difficulties. We can never find out how deep these ulcerations really are, and the suppuration may therefore reach the bars and cause infection. This happened in one case in which we were obliged to remove the paraffin.