PROLAPSE OF THE RECTUM Prolapse of the anus or rectum is present when, in defecation, the mucosa of the anus, a larger portion of the rectul 11111COSft, or even all the layers of the wall of the rectum, are extruded from the anus. This condition can lead to a constant protrusion of the part. It is called a partial or complete prolapse according as to whether the mucosa alone or all the layers of the intestinal wall are involved in the prolapsus.
The latter condition may occur either when the lowest portion of the rectum is prolapsed, so that the skin of the anus passes without transitional folds into that of the rectum, or when only a higher seg ment of the rectum is prolapsed, and its lowest section, directly above the anus, remains in its normal situation so that a finger or sound intro duced along the side of the rectum, after a short space, conies upon the reduplication of the mucous membrane, at which point prolapse begins.
The condition is seen more often in childhood, particularly in the second and third years. The following are the usual causes: diarrhma with much tenesmus, especially in catarrhal colitis; constipation, which leads to a great increase of the abdominal pressure, hard fecal masses, the expulsion of o hich bulges the rectal MUCOUS membrane for ward; difficulty in micturition, which reacts upon the rectum; mechani cal conditions of local nature, such as rectal polypi; inflammation of its mucosa; and, finally, severe paroxysms of coughing which lead to strong pressure, particularly whooping-cough.
To these causes should be added the anatomical disposition pecu liar to childhood: namely, the narrowness of the infantile pelvis, its consistency, largely cartilaginous, the ahnost perpendicular course of the rectum, the greater play of its attachments with the neighboring organs, etc. Moreover, weak constitutions and chronic disorders of nutrition assist in the tendency', so that prolapse of the anus and rec tum are present, for the most part, in anamdc, badly-nourished children.
I found an inflammatory thickening of the rectal mucosa and a cellular infiltration of the submucosa, in a case examined at autopsy, o-hich produced a considerable loosening of the attachments between the single layers of the intestinal wall, and subjected the rectal mucosa to the action of the greatly hypertrophied rnuscularis mucosa. It
seemed as if the contraction of this muscle-layer pushed the rectal mucosa forward, and that the latter, aided by the strong vis a tergo pulled the other layers of the wall after.
The diagnosis of the condition presents no unusual difficulties. It is easy to avoid mistaking it for a polypus or other tumor. Hmniorrhoids of such size are scarcely ever seen in children. An intussusception of the rectum, projecting out from the anus, can be diagnosed apart from the severe general symptoms accompanying it, by means of a digital examination, which shows that the rectum is in normal position, and the above-mentioned reduplication of the mucosa is absent, or cannot be reached.
The symptomatology is also fairly clear. At first, after every defecation a dark red cylinder protrudes, having on its surfaces trans versely arranged folds, and with a round lumen at the free extremity. Later on, the cylinder, which becomes larger, remains on the outside, and, when the prolapse involves all the layers of the intestinal wall, it has a tendency to bend slightly forward. The mucosa becomes redder, bleeds spontaneously on touching, secretes purulent mucus, and shows superficial ulcerations which arc soon covered by yellowish deposits.
It is easy, at first, to reduce the prolapse, and to have it remain in place until again protruded by- another act of defecation, an attack of coughing, or similar cause. In the later stages, however, it prolapses again immediately and it is no longer possible to hold it back. There may be so much increase in the obstruction, that the bowel can no longer be replaced when as a rule, a constriction takes place at the base of the tumor, at which point the mucosa shows more or less extensive necrosis.