ANUS, Prolapse of.
This is usually easily reduced when the protrusion is of recent origin by smearing the mass with vaseline and making firm pressure by the fingers so as to gently push it back within the grasp of the internal sphincter. if reduction does not speedily follow, owing to the struggling of the patient (who is generally a child), he may be placed in the lap of a nurse, with his head depressed as thoroughly as possible, when the greased right forefinger is inserted into the lumen of the bowel as if making a high rectal examination, when the prolapse will usually be easily reduced, Cripps after oiling the finger wraps a layer or two of dry lint round it before inserting it into the bowel. Atter reduction the finger is slipped through the lint, which is left behind as a support to the relaxed walls.
A conical piece of Ice enveloped by lodoform Gauze may be introduced instead of the forefinger into the opening, when gentle pressure causes the protruded mass to pass above the internal sphincter carrying the gauze and ice along with it, where they are then left in situ., the operation being repeated after each evacuation of the bowel contents.
In long-standing prolapses the blood must be gently and patiently expelled by the pressure of the fingers, after which the forefinger inserted into the opening and pressure applied by the adjoining portion of the metacarpal prominence will effect reduction alter some minutes. A firm pad of dry lint kept in its place over the anus by broad strips of adnesive plaster, securing the nates firmly together, or a I bandage, should then bd applied till next defecation.
l3rodie's plan was to wash out the rectum with warm water whilst the patient was lying upon his side, after which a small enema of cold water was left in the bowel. This treatment is better suited to adults than children.
The cause of the prolapse should be sought for after reduction; thread worms, polypi, a long or adherent prepuce, iixmorrhoids, uretnral stricture, vcsical calculus and prostatic troubles will demand rebel. Emaciation is a common cause, and, as insisted upon by Cripps, permanent cure may be expected when the absorbed fatty tissue is replaced in the pads in the ischio-rectal fossi.e. Constipation must be remedied by laxatives, purga tives often aggravating the condition. Irreducible prolapses, when small in extent, may be treated like a ring of hemorrhoidal growths by removal, but in larger masses excision must be very carefully performed in order to avoid injury to the peritoneum, and sometimes it may be necessary to allow the irreducible mass to slough.
Astringents may be applied locally to the relaxed mucous membrane with the view of permanently increasing its tone and preventing future prolapses. Tannin, solutions of Alum, Nitrate of Silver, Perchloride of Iron, and astringent decoctions such as those of Krameria, Logwood, Oak Bark, &c., may be used, or these drugs may be administered in sup
pository or ointment form. Occasionally the Continuous Current has produced good effects, and Ice is often useful.
Vidal has reported successes by injecting 1-3 grs. Ergotin in solution into the prolapsed mass, even when the rectum was involved in the pro lapse.
If the above measures fail to prevent recurrences, the prolapsed surface may be painted over with strong solution of Nitrate of Silver, or, if small in extent, Nitric Acid may be brushed on it at several spots. Passing lightly the actual or thermo-cautery over the surface of small anal pro lapses and at the same time causing it to destroy completely any pendulous folds of skin existing about the anus often effects a complete cure.
Cripps in chronic intractable cases puts the patient into the lithotomv position. and with the actual cautery sears the mucous membrane by drawing it in the direction of the axis of the gut. forming four lines, each inch in breadth, commencing at the highest portion of the prolapse and running down to the anal margin, one line being on the anterior surface, one behind and one on each side. The prolapsed mass is then reduced and the rectum packed with iodoform gauze, leaving a tube of rubber in the centre of the packing in order to relieve flatus. The rationale of the treatment is the production of such a degree of inflammation as will fuse together the mucous and muscular coats of the rectum so as to prevent slipping or invagination.
It will be necessary to remove one or more flaps of mucous membrane and bring the edges of the gaps together in order to diminish the calibre of the bowel where a considerable amount of rectum is included in the prolapse. This operation is sometimes attended by alarming hamor rhage, and some surgeons prefer to make a complete circular resection of the prolapsed portion of the rectum.
Curling's plan of narrowing the anal aperture by powerful caustics is less satisfactory than Kelsey's ingenious method of a curved threaded needle round the lower end of the bowel, through the suhmucous tissue, and tying a catgut ligature over the finger-tip inserted in the anus. Formalin catgut persists 2-3 weeks, and by this time the tendency to prolapse will have disappeared by general treatment.
McLeod performs recto- or procto-pexy through an abdominal incision to permit the rectum being drawn up and fastened permanenev to the inner aspect of the abdominal wall, and Peters advises that the sutures should be so inserted as to cause narrowing of the lumen of the gut in order to prevent the colon descending into the rectum.
In complete rectal prolapse the aim of surgical treatment should be to obliterate Douglas's pouch, and the operation of colopexv should be com bined with it; a subsequent should he performed if per manent cure is to be effected.