very mention of bedwetting made me disgusted with myself and modern medical practice. Nevertheless, I was surprised to hear myself say: "Sure, I can fix him up." The boy had been in a hospital some weeks and had been in the hands of "eminent specialists," all without any benefit. On my way home I said to my selm: "If is damn funny if I cannot cure him." The next day I went back, rigged up an ounce hard-rubber syringe to a child's size catheter, injected into the boy's bladder a syringeful of solution of silver nitrate a little less than 1% strong. The next three or four nights he did not wet the bed. After four treatments, together with 1 tablet of hexamethylenamin with a glass of water at night, bedwetting stopped for good. No doubt, bedwetting is a close relation to cystitis.

Since that time I am keen on these cases, and can promise a cure in a couple of weeks. I should like to hear from others on this subject through your columns.

Complete Prolapse of the Rectum

Definition. Different types. Anatomy. Hernia. Pathogenesis. Etiology. Symptoms. Complications. Diagnosis. Prolapse of the upper portion of the rectum into the lower (invagination). Symptoms. Treatment of prolapse of the third degree. Surgical treatment. 1. Operations which narrow the anal canal. Technic. Aftertreatment. 2. Resection (amputation of the prolapsed part). Operation. 3. Suspension (fixation) of the bowel. Restopexy. Sigmoidopexy.. Operation. Plastic repair of the sigmoid supports. Technic of operation. After-treatment. Conclusions.

By CHARLES J. DRUECK, M. D., Professor of Rectal Diseases, Post-Graduate Hospital and Medical School, Chicago, Ill.

C

OMPLETE prolapse of the rectum consists in the descent of all of the coats, and is far more serious a condition than the partial variety, because of the invalidism which it induces, as well as the complications which are ever present. In this variety the mucous mem brane is in its normal relation to the other coats of the bowel, but the entire rectum is protruded from the anus and has lost its normal relationship to the other pelvic viscera (Figure 1).

Two different types of pathological change contribute contribute to produce procidentia:

1. Extreme mobility of the rectum and the elongation of its supports may be the result of imperfect prenatal fixation or of traumatic conditions, either of which permit of constant dragging on the rectal attachments and supports. The intraabdominal pressure exerted at stool is applied to the recto-sacral ligaments.

The uterus and rectum have a common means of suspension; therefore any cause bringing about the fall of one endangers the fixity of the other. Hysterectomy deprives the rectum of the anterior sup port afforded it normally by the uterus. The weakening of the pelvic floor favors the prolapse of both of these organs.

The pelvic cavity is funnel shaped, and from its lower opening protrudes the rectum, held in place by the perirectal areolar tissue and fascia, the levator ani, the recto-coccygei, and the two sphincter muscles, which are interleaved or woven into the pelvic fascia.

The pelvic fascia is a continuation of the lumbar, iliac and transversalis fasciæ, and supports the abdominal contents from below. It is attached to the bony framework of the pelvis; in front to the inner surface of the pubic bone; on the sides, to the ilie-pectineal line; posteriorly, just above the attachment of the pyriformis, and to the anterior surface of the sacrum; and thus it binds the pelvic organs firmly together. From this level the fascia dips down between the pelvic organs, forming the obturator fascia and the recto-vesical fascia, covering the levator muscle and also forming the deep layer of the triangular ligament. These structures form the true pelvic floor, but from these are projected extensions between and about all the pelvic organs which become accessory ligaments of these organs. The true pelvic floor is a fixed structure, but the fascial branches between these organs are suspensory stays allowing considerable plav. these rectal stays which offer the resistance during the straining at stool which is necessary to prevent displacement of the rectum. When these stays become flabby from repeated or excessive stretching they lose their contractile power, and the organ they support drops away. A lacerated perineum destroys the fascia holding the rectum to the levator ani, and the powerful intrarectal pressure soon pushes the rectal wall into the vaginal outlet. The protrusion in turn tends to

further relax the musculo-fibrous structures.

2. In other cases a defect in the pelvic fascia permits a hernia of the pelvic bowel. This defect may sometimes be developmental.

In early embryonic life the peritoneal pouch reaches almost to the perineum. Later it recedes higher and if this process stops early the cul-de-sac of Douglass will be deeper than is normal. Thus we may have congenital malformation of the sac as one of the factors in the origin of the hernia. If there is also a developmental defect in the transversalis fascia it re

In every case presented, the condition of the sigmoid, the levator muscle and the depth of the cul-de-sac must be considered. An abnormally deep cul-de-sac acts as a pocket for the intestines, which by their pneumatic pressure pry apart the musculature. In this manner, whenever the protrusion is two inches or more in length, we may anticipate a fold of peritoneum, a coil of small intestine, an ovary or a part of the bladder wall to be included.

Several factors may contribute to the development of the prolapse, and in the case at hand a combination of these may

quires but little increased intra-abdominal pressure to drive the peritoneum as a wedge along the prolongation of the transversalis fascia. This is the incipient stage of prolapse.

The peritoneal covering of the anterior wall of the rectum is very adherent to the deeper coats. The levator ani muscle. and the very dense fascia on its lower surface also constitute a firm support to the perineal body and prevent a downward progression of the hernia. The line of least resistance seems to be through the muscular wall of the rectum, thus permitting the hernial development. The hernia now drives backward until it meets the resistance of the sacrum and Coccyx, when it is deflected downward through the rectal lumen, ultimately forcing the sphincters and appearing

externally.

be found. Complete prolapse usually comes on slowly through long-continued action of the primary cause, but in either children children or adults it may come on suddenly as a result of severe straining during heavy lifting or as a result of a crushing accident or fall.

It may arise from tumor or stricture high in the rectum which causes persistent peristalsis or straining at stool. Ordinarily about three to six inches may appear, although the whole colon and even part of the small intestine has been reported to protrude. reported to protrude. Tillman cites a prolapse as large as a child's head.

When protrusion has taken place suddenly it may be constricted by the sphincter muscle and its reduction be difficult.

Three types or degrees of complete prolapse are usually described. The first degree closely resembles the incomplete

prolapse beginning at the anal margin. Its external surface is continuous with the skin surrounding this aperture, and the prolapse involves the anal canal, together with a variable portion of the rectum.

In the second degree the prolapse begins at a point above the anus and the rectum is invaginated through the anal canal, which latter structure remains in position while the rectum protrudes externally. The walls of the anal canal are not here involved.

In the third degree some portion of the sigmoid or colon is invaginated into the rectum, although it may not appear at the anus.

Etiology.

First degree: This variety of prolapse results from the same class of causes as the procidentia mucosa, and it is frequently a sequence of the latter. The distinguishing feature of this degree of prolapse is that the mucous folds which run up and down in the incomplete variety extend in a circular direction in the complete types and surround the prolapse in irregular crescentic folds. (See Figure 1.)

The second and third degrees of prolapse represent the same character of pathology, although the third type occurs higher in the bowel. Many factors may contribute to bring about prolapse, such as elongation of the mesosigmoid, a relaxation of the sigmoid above the level of the prolapse; an abnormally deep cul-desac into which the small intestines drop may by continued pneumatic pressure, gradually work the levator ani and the pelvic floor away, thus allowing the rectum to appear at the anus.

In this type the rectum invaginates through the anal canal and protrudes from the anal orifice, thus leaving a sulcus between the protruding rectal mucosa and the anal margin into which can be introduced a probe or sometimes the tip of the finger.

Symptoms.

The symptoms of complete prolapse are much the same as those of the incomplete type. The complete prolapse begins within the rectum and protrudes through the anal orifice, thus leaving a sulcus between the prolapsing gut and the anal margin. The differentiating feature of complete prolapse of small extent from an

incomplete one of the same size is that the external surface of the protruding tumor is not continuous with the anal skin margin. There is a sulcus between the prolapsus and the anal margin which is not found in the incomplete prolapse.

The protrusion is thick, firm and pyriform in shape, and, when not more than three inches are present, the prolapse will extend straight out at right angle to the buttock with a slit-like orifice in the lower end. When more than this appears, traction upon the mesorectum draws the tumor backward toward the coccyx and the orifice will be on the posterior surface. In exaggerated cases, where the mesorectum and mesosigmoid are both dragged upon, the prolapse may make two or three corkscrew circuits. Some times in females the traction is forward because of vaginal attachments.

In old cases an hypertrophy of the exposed tissue occurs. All of the coats of the bowel are edematous and swollen and often ulcerated. The mucous membrane is thick, dense and leathery in structure in the frequently prolapsed parts.

The surface of the mucous membrane is marked with circular furrows. The submucous areolar tissues are infiltrated with a hyaline substance, and the mus cular layers are hypertrophied. The extruded part is therefore enlarged, not only by edema and congestion, but also by the development of new structures. Therefore, the prolapse does not recede to its normal size when replaced, it is often too large to be retained, and descends the next time the bowels move. In old or extreme cases replacement is difficult and painful, although gradually the anus becomes patulous and the sphincter so paralyzed that each time the sufferer defecates or even moves about, the mass protrudes and makes life a burden. The bowel is abnormally increased in size, and too large for its proper position within the pelvis, and although it may be reduced it will not remain so, because the tenesmus set up by its presence expels it promptly. In some instances the mucous membrane is eroded and granular and easily bleeds. In such cases the odor of the sloughing tissues may simulate malignant disease. A prolapse that has protruded for some time is often accompanied with an oozing hemorrhage which requires astringents to control. There is

a copious discharge of glairy mucus which is often blood stained.

In children the procidentia occurs only at stool, but in aged persons with relaxed sphincters it may be down all the time. Constipation is the rule, unless excoriation has occurred, when a teasing diarrhea may be present. In either instance bloody and mucous discharges are present, and later fecal incontinence comes on. Pain is complained of only when there is ulceration of the prolapse or when spasm of the sphincters occurs which constricts the prolapsed bowel. Strangulation is present only in young and robust persons and is rare in infants or the aged. When it does occur it may be only temporary, but if it continues, ulceration and gangrene will follow which may terminate fatally if the peritoneum is involved. When the lower part of the rectum alone is involved in the gangrene, a spontaneous cure may take place, but by the separation of the protrusion and the resulting cicatri a stricture is finally produced which leaves the patient in a more deplorable condition than before.

Complications.

Complications are prone to arise with the involvement of the peritoneal coat, for it is likely to carry down with it a loop of small intestine, an ovary or the bladder wall. When these organs are brought down, they are usually detected by touch and are generally found in the anterior part of the tumor. The intestine slips away from between the fingers with a gurgling sound due to the contained gas, or sometimes percussion demonstrates it by resonance. In the early stage the loops of the bowel are contained only in the anterior part, but if the protrusion is large the loops may wholly surround the prolapsed bowel, except at the mesenteric attachment. In practice, if In practice, if the buttocks are raised, the hernia usually recedes with a gurgling sound, and the prolapse may then be easily reduced. Adhesion between the loop of the small bowel and the prolapsed rectum may occur and strangulation result because the hernia cannot be reduced, or if the strangulation is not promptly relieved, death ensues from perforation of the bowel and peritonitis. If an ovary is in cluded in the prolapse, pressure on it causes a faint sickening feeling, if the

bladder is engaged it is demonstrated by introducing a sound through the urethra. Each condition constitutes a true hernia of the prolapse and must be immediately replaced, if possible, because spontaneous rupture of the rectal wall or of the peritoneal cul-de-sac and evisceration of the intestines has occurred and, of course, adds a most serious complication. Usually there is no sulcus or depressed line visible at the peritoneal or bladder junetion with the bowel, and so there is no way of determining by inspection the presence or absence of peritoneum or bladder in the prolapse.

Diagnosis.

The differential diagnosis between the partial and the complete prolapse is often important. Prolapse of the mucous membrance alone is usually recent, the tumor is small sized, thin and soft to the touch, and the folds radiate from the orifice, which is circular and patulous. When the deeper coats are involved the case is usually of long standing, the tumor is large and conical in shape, and its walls are thick and firm. The opening into the bowel is slit-like, and usually points backward, owing to the traction of the mesocolon, or points forward because of the vaginal attachments.

Hemorrhoids or neoplasms of the rectum which prolapse are differentiated by their irregular and lobulated shape and by finding other parts of the rectal cirExcoriacumference remaining in situ.

tion and hypertrophy resulting from the discharge may simulate epithelioma and may be differentiated only by a microscopical examination.

Prolapse of the Upper Portion of the Rectum into the Lower (Invagination).

By prolapse of the third degree is understood intussusception of the upper rectum, sigmoid or colon into the lower rectum or rectal ampulla. It is a true intussusception and may involve any part of the large bowel even to the cecum; the orifice of the appendix has been seen beside the included bowel. It differs from the ordinary type of intestinal intussusception in that it does not cause complete obstruction or strangulation. Also the, approximating peritoneal coats do not adhere as they do in the intestinal intussusception.

In the previous types of prolapse the dislodged tissues protrude from the anus; but in this form the upper part slips into (telescopes) the lower part, the whole mass remaining within the pelvis. The sphincters and anal orifice remain normal. Only in extreme instances does the bowel protrude from the anus. When it does, it appears as a cylindrical tumor covered with a dark-red, hyperemic mucous membrane. There is no pain or soreness at the anus nor any sensation of protrusion at the anus.

Symptoms.

The symptoms of intussusception of the rectum or sigmoid are ill defined, because the rectum is capable of great distention in its lower portion. The invagination does not cause complete obstruction as in ordinary invagination of other portions of the bowel, nor do the peritoneal coats of the invaginated portion become adherent and fixed as they do in the upper portion of the bowel.

There is usually a history of protracted constipation, and later an irregular diarrhea accompanied with tenesmus, straining and a feeling of incomplete defecation. Laxatives are not effective, but much relief is obtained with enemas.

The liquid of the clyster lifts up the bowel from below and stimulates reverse peristalsis, thus disengaging the invaginated portion.

The immediate effect of this intussusception is obstruction of the bowels; but this is seldom complete, because the feces are forced through by the increased contraction of the healthy bowel. The first symptoms of the constriction is a sharp pain developing suddenly. It may pass off in a few hours to return again or it may continue from the onset. Vomiting sometimes occurs, but not always, and if it does it is sometimes relieved by pressure. Abdominal tenderness may even be absent in some cases. The presence of fecal vomiting indicates complete obstruction regardless of the part of the bowel involved. A heavy dragging pain in the sacrum and radiating down the thighs or to the perineum is usual. Dysuria also occurs and the case may be mistaken for ovarian or bladder disease. A discharge of clear mucus, later becoming tinged with blood, is present, as the friction and irritation produces ulceration. If the constriction is severe enough, the pro

lapsed portion sloughs off and a circular cicatrix is left. Thus nature attempts to remedy the trouble, although the scar may produce an annular stricture. Sloughing frequently takes place after the first week and usually within three weeks, although it may occur much later.

Death results in about one-half of the cases where spontaneous separation occurs, and may be due to one of several causes. The local peritonitis which unites the bowel may become general or the ensheathing portion, through ulceration and perforation, may allow extravasation of feces. Perforation may occur at any weak point of union. On palpation, a tumor may be felt and may be characteristic, although sometimes obscured by thick abdominal walls or distention of gases. The tumor, when found, is cylindrical and moveable, even changing its position at times. Compared with obstruction of the upper bowels, intussusception of the colon or rectum is more chronic, less painful, diarrhea is more pronounced, or the evacuations are larger, and the vomiting is variable. Such a condition may continue for weeks, and death result from exhaustion or a general peritonitis.

Palpation or manipulation of the prolapse will often excite gurgling of the gas in the loops of small bowel which fill the anterior part of the prolapse. Percussion here will give a tympanitic note, while the posterior half is dull on percussion. This condition is not found in the incomplete variety of prolapses, where only the mucous membrane is detached.

When the prolapse has been reduced a careful digital examination will note a laxity of all the rectal muscles, and on palpation of the anterior rectal wall a distinct impulse will be observed on coughing, as may be demonstrated in any hernia.

The introduced finger may feel the sulcus between the invaginated and invaginating parts. If beyond the reach of the fingers a probe may be used through a speculum. The examination for this purpose should be conducted with the patient upon his side, and not in the knee-shoulder position, he being directed to strain down forcibly from time to time.

When the sulcus is not felt the case must be differentiated from volvulus, stricture, internal hernia, pressure on the