Prolapse of the rectum is a frequent complication of hemorrhoids, although it may also occur alone. The prolapse may involve either the mucous membrane alone or all the coats of the rectum. In the latter instance this condition is also called procidentia recti. Outside of the anus there is a protrusion of the mucous membrane in its entire circumference. An internal prolapse of the rectum may also occur, which consists in the descent of the upper part of the rectum through the lower part, but not appearing outside the anus. This corresponds rather to an intussusception. A relaxation of the ligaments which serve to keep the rectum in its place is often the cause of this malady. Weakness and paralysis of the sphincter ani muscles are also predisposing factors.

1 von Esmarch: "Die Krankheiten des Mastdarms und Afters," Stuttgart, 1887.

2 E. Graser: Penzoldt u. Stinzing, "Handhuch d. Therapie, " Bd. iv., p. 634.

Prolapse of the rectum is frequently found in debilitated children, especially if an intestinal catarrh is present, for these little patients go to stool too often and usually strain too much and for too long a time. These conditions weaken the muscular apparatus of the anus, and thus a prolapse of the rectum easily arises. In elderly people, in patients suffering from affections of the bladder or from severe constipation and internal hemorrhoids, and in women who have gone through many pregnancies in quick succession, prolapse of the rectum is also a frequent occurrence.

The symptoms are as follows: If the prolapse is only of a moderate degree, there appears in the act of defecation a protrusion of the rectum outside the anus, one or one and a half inches in length, the mucosa lookingquite red and puckered. In the more advanced stage the bulged out rectum resembles a large tumor with a star-like opening at its centre, while the color is pale or bluish-red. In children the mass generally protrudes only on going to stool, but in adults it is constantly down or comes down on the slightest exertion, and therefore may become ulcerated or inflamed. In old cases of prolapse incontinence of faeces is also frequently present.

The diagnosis of prolapse of the rectum is easily made from the above-mentioned appearances. Internal prolapse is not so easily diagnosed, as the mass never appears outside the anus. This condition can be recognized only by means of a digital examination of the rectum. The finger introduced into the bowel is first kept close to the anterior or posterior wall, and is passed up until it meets with an obstruction (i.e., it has passed into the cul-de-sac). Then the finger is slightly withdrawn and the centre of the gut examined until an orifice is found into which the finger or a bougie may be passed for some inches high up into the rectum. If the intussusception is rather far up in the rectum, the patient should bear down during the examination.

With regard to treatment it is of importance to eliminate all the conditions which were predisposing factors for the prolapse. Extreme cleanliness, especially after defecation, should be observed. The reposition of the prolapse should, be performed in the most careful manner. It is best done in the knee-elbow posture. If a considerable portion of the bowel has come down, a large flexible bougie may be passed into the bowel in such a manner as to carry before it the upper part of the descended gut. General taxis should at the same time be used, and in this way the mass can generally be returned. In cases in which the prolapse occurs quite frequently, even during a walk, a rectal supporter, as suggested by von Esmarch, should be worn by the patient. It consists of a soft-rubber ball .attached to the anus by means of a belt and a T bandage.

The palliative treatment which is especially successful in children is as follows: All sources of irritation should be removed and the general health strengthened. Straining at stool should be strongly forbidden and a mild laxative remedy given. After a movement of the bowels the protruded part should be well washed with cold water and pushed back into the anus by gentle pressure. After this procedure the patient should remain in a recumbent position for half an hour or so, best lying on the abdomen. If these means alone are not sufficient, the following more radical measures will have to be adopted: Cauterization of the prolapsed part with fuming nitric acid or with the therino-cau-tery under chloroform narcosis is often of great benefit. Care should be taken while cauterizing not to touch the verge of the anus or the skin. After this the prolapsed part should be well oiled and returned. Instead of nitric acid Allingham uses the acid nitrate of mercury.

These cauterizing methods have the disadvantage of often producing strictures of the rectum. For this reason a number of surgical operations have been devised. Thus excision of triangular or elliptical portions of the mucous membrane, bringing the edges together with sutures, has been practised. Extirpation of the entire prolapsed portion was first advocated by Treves.1 F. Lange,2 of New York, has described a new operation, serving the purpose of reducing the calibre of the rectum and at the same time producing a narrow muscular ring. The patient is placed in the genu-pectoral position, an incision is made from the lower part of the sacrum down to the anus, until the posterior wall of the rectum is reached; the coccyx is then removed. The object in view is to narrow the gut as high as possible and to lessen the impediments to the action of the levator ani. The calibre of the rectum is lessened by introducing buried etage sutures of iodoformed catgut, which do not perforate the entire thickness of the gut. The first rows are inserted near the middle line and form a fold in the posterior walls which protrudes into the bowel. In this manner the more lateral portions of the gut are brought into position without causing too much tension.

Similar sutures are applied to unite the cut surfaces of the levator ani and sphincter externus, which had been previously dissected in order to lay bare the posterior wall of the rectum. The cavity thus formed is filled up with iodoform gauze and the flaps of integument are united with sutures.

1 Treves: Lancet, 1890, vol. 1.

2 F. Lange: Annals of Surgery, vol. v., p. 497.

Another very efficient operation has been suggested by Allingham and consists in making a small incision through the anterior abdominal wall on the left side, just above the outer third of Poupart's ligament, then introducing the fingers into the abdomen, catching hold of the rectum and pulling it up. After it has been drawn as high up as possible, silk threads are passed through the mesentery and the latter is fastened to the abdominal wall.