Providential Recto This form of prolapse, while occurring frequently in children, is most common in the adult. The erect position of man in walking tends to throw the weight of the contents of the abdomen and pelvis on the elevators an, and, in weakened individuals, a loss of muscle power easily follows in the form of a prolapse of the rectal wall.

Causes. Among the causes of complete prolapse of the rectum are an enlarged prostate, enteritis, prolapse of theuterus, proctorial, fecal impaction, polyp, tumors of the sacrum and coccyx and chronic intestinal diseases. Age seems to be a factor in the very young and old, due to a lack of muscle tone, while in the middle-aged and thoroughly healthy individual, traumatize and irritation within the rectum or in the surrounding tissue, seem most commonly the cause. Paralysis of the sphincters from operations or from lesions of the spinal cord, rupture of the perineum, and loss of muscle tone in the elevators an, over distention of the rectum and persons who lose weight from some other disease or from overwork, are also included in the enumeration of causes.

Symptoms. There is a protrusion of a large mass, greater in most instances than could possibly occur in the incomplete prolapse; there is pain; a discharge of mucus, which may be tinged with blood; a dragging sensation; loss of sphincter control causing frequency of movements; loss of weight; more or less hemorrhage; and if ulceration takes place, in cases of the second or third degree, there is a constant desire to expel the mass from the rectum.

Diagnosis. The complete prolapse will present a gurgling sensation when an imagination exists, more marked in the second degree; there is a space between the anal canal and the mass, while in the prolapse of the mucous membrane in the first degree prolapse, the external surface is continuous with the skin. This condition means an involvement of all the coats of the rectum including the mucous membrane.

First Degree. The whole circumference of the bowel participates in the sliding down or protrusion, beginning at the much-cutaneous junction which carries with it from two to five inches of the rectal wall. This feature distinguishes it from a prolapse of the second degree.

Second Degree. The prolapse begins higher up, just above the internal sphincter muscle, and protrudes through the anal orifice.

Third Degree. The prolapse begins high up in the rectum or sigmoid flexible and extends down into the ampul la of the rectum, but may or may not protrude through the anal orifice.

In either of the complete varieties one must bear in mind that the mass consists of more than mucous membrane. The sense of feeling will distinguish a thoroughly firm mass of muscle tissue, representing two layers of muscle and two of mucous membrane. The size of the protruding mass, its structure, and the transverse furrows of the protrusion due to the contraction of the circular fibers of the rectum, are so pronounced as to make the diagnosis clear. One must bear in mind that a polyps is a firm, rounded tumor, which may present and resemble the prolapse of the second degree; that malignant growths may have some of the same characteristics, but are more apt to be eroded or broken down and bleed. Hemorrhoids are so superficial and limited in extent that it is almost impossible to confuse them in the diagnosis.

Complications. The dangerous complications are peritonitis due to a rupture of the rectal wall, or a rectal hernia induced by lifting or straining.

Prognosis. A spontaneous cure often occurs in children who are properly fed and restrained from producing the rectal prolapse. Surgical treatment in children is never successful without medical treatment and the above precautions.

Long standing cases in the adult are best treated by surgical means at the onset, and it will be dependent on the judgment and experience of the operator, as to the selection of the method of surgical procedure best suited to the particular case. The results will be found amazingly good as to an ultimate cure, and to the comfort of the patient in the majority of cases.

Palliative Treatment. Removal of the cause which may be in the form of hemorrhoids, neoplasm, stricture, ulceration or any of those previously mentioned. In children phosphorous, iron and strychnine, as suggested above. If the prolapse is held for several weeks in its former position and the general tone improved, a permanent cure occurs very often.

Treatment, in the form of cold water, astringent solution of alum and tannin, iron, zinc, silver, Kramer, and infusion of oak bark, often give good results, but are to be considered only palliative in their effect. The strength of any of these solutions should be made according to age, and extent of the prolapse. When any of them produce nausea, or colic, a weaker solution should be used or the remedy stopped altogether.

Hypodermic Injections of strychnine, ergo tine, nix vomit or carbolic acid, are variable in their,, success, and may be classified as uncertain on account of the complications which follow in the form of abscess or fistula

Compresses in the form of pessaries and trusses for the support of a prolapse cause dilatation and a relaxation of the sphincter muscles, and while their use may give temporary relief and comfort, in time an exaggeration of the trouble is more likely.

Massage for the sacrum and coccyx and internally to the rectum itself gives more of a sense of comfort than any curative value.

Electricity, either of the faradize or galvanic variety, administered through the specially constructed instruments for applications from the interior of the rectum, is of much benefit in weak and debilitated patients where more radical treatment cannot be instituted, and when a treatment can be given two or three times each week. The good results of the electrical treatment are probably due to its tonic effect upon the muscular and circulatory apparatus.