PROLAPSE OF THE UPPER PORTION OF THE RECTUM INTO THE LOWER.—This disorder is called "invagination" or "in tussusception" in other portions of the intestinal tract. It is described by J. M. Mathews as one "where the finger can be inserted into a groove alongside of the base of a tumor so that a distinct sulcus is recognized, of more or less depth, at the bottom of which, if not too deep, the lining membrane of the gut can be felt as it is reflected from the base of the pro truding mass." In such a case the rec tum has begun to fold upon itself; in other words, to become invaginated, or "telescoped," the upper part of the bowel always passing within the lower, at a point more or less distant from the anus, yet generally within the reach of the fin ger. This subject has been considered in the article on OBSTRUCTION, INTESTINAL, volume iv, and is mentioned here only for the sake of emphasizing the impor tance of recognizing the condition, espe cially as its treatment from a surgical stand-point differs materially from the operative procedures to be advised for the relief of the other two varieties of prolapse.
Diagnosis.—Though it is a compara tively simple matter to diagnosticate a prolapse, mistakes are frequently made. In children polypoid growths are more frequent than the literature would seem to indicate. In the adult hemorrhoids may be mistaken for prolapse. Mathews suggests, in doubtful cases, that the adult patient be instructed to take an enema and to strain. If it be a prolapse of the mucous membrane, it will occupy the most or all of the circumference of the bowel, with a certain degree of regu larity. The gut will be of a bright-red color, and if grasped between the fingers its folds can be easily pressed together, there being no well-formed tissue exist ing. In protruded Imnorrhoids the pro lapse is irregular and does not include the circumference of the bowel, and oftentimes exists only on one side; and if the parts are seized a well-organized tumor can be felt, which can be circum scribed; the color is usually a dark blue. Another point to which Mathews directs attention is the size of the protruding mass. Simple prolapse is never very large, and where any of the coats of the rectum or all of its coats are included, the protrusion is much larger. A simple prolapse of the bowel does not usually remain out for any length of time, and a prolapse containing the coats of the rec tum is very apt to remain out an in definite time, or until reduced.
Etiology.—Straining at stool is the most frequent exciting cause. Children are especially predisposed to prolapse, because the rectum is nearly vertical and the mesocolon is of considerable length. The unfortunate habit of placing a child upon a commode and leaving it there for a long time to establish regu larity of habit is a rather common cause of prolapse. Stone in the bladder and phimosis, by the straining efforts pro duced at urination, are factors not to be overlooked in searching for the cause of this disease. It is often due to ascarides, to rectal polypi, and to violent fits of coughing, as in whooping-cough.
In adult life the causes of prolapse may be traced to some cause which leads to unnecessary straining efforts, such as enlarged prostate.
Prognosis.—When the mucous mem brane alone is involved, a spontaneous cure is frequently effected; in children this result is more especially noticed. Mild measures of ten assist Nature. In the aged or in the young, where hyper trophy has occurred to any marked ex tent, operative measures are usually re quired to insure recovery. It is well not to promise too much to these patients as to the time necessary to effect a cure, as some cases respond but slowly to treat ment.
Treatment.—No matter what variety of prolapse we are dealing with, efforts should be made to return the mass as speedily as possible. In some cases con siderable difficulty may be experienced. Children should be laid across the knees and the entire mass should be subjected to gentle, but steady, pressure for some moments, so as to reduce the bulk of the tumor by the squeezing out of the fluid contents. The central portion should be returned first; this is best accomplished by inserting the finger into the lumen of the gut; then, by pressure of the fin gers of the other hand, the remaining portions of the bowel may be gradually pushed within the anus. Persistence in taxis will in nearly all cases suffice. In some cases artificial supports are needed. A belt may be placed around the waist and an elastic band, having a solid or in flated pad attached, is passed between the thighs in such a manner as to press the pad against the anus. The anterior part of the band is divided so as to come up to the belt in front of each side of the genitals. Another form consists of a belt, half steel and half leather, buckled about the hips just above the trochan ters, while a bent steel spring passes down behind and carries a pad to press against the anus. In temporary cases, it assists the stability of the pad to draw the nates together with a broad strip of adhesive plaster. (Andrews.) S. B. Powell recommends a plan which "consists in rolling in and strap ping the buttocks together with two strips of adhesive plaster, extending suf ficiently forward to secure a good hold. The child (or adult) defecates with these in position, is thoroughly cleansed after the act, and new strips are applied. This method, which, in the hands of the in ventor, has never failed, is based upon the fact that the relaxed sphincter is elevated and supported during the strains put upon it while the child is at play. and is protected from the lateral traction occurring in the squatting posi tion assumed in defecation. It and the parts above gradually regain their con tractile power, and ultimately become competent to fulfill their functions nor mally." (Andrews.) In all cases attention should be paid to regulating the actions of the bowels, and, instead of permitting the patient to sit in the usual position, defecation should only be permitted either in the recumbent posture, lying upon the back or side, or while the patient is standing. It is also of assistance for the patient to become accustomed to having the move ment of the bowels occur the last thing before retiring, so that rest may be ob tained immediately thereafter.