worthy of notice. Prior to operation I had paid too little attention to the patient's description of the mucoid material and her feeling of intermittent distention in the right pelvis. A diagnosis of tumor had been made by a former attendant. Whenever I examined the patient I found no evidence of a growth larger than that discovered at the operation, but I never examined her when her side was what she considered distended.

The operative findings are extremely interesting and account, in my judgment, for the opinion that the cystic condition of the right tube did intermittently increase in size by retention and decrease when the tension was sufficient to lift the cornual growth and relieve the pressure at the uterine end of the tube. The specimen of the tube and ovary shows little the condition found at the operation.

The tube collapsed on section. The material formalin and alcohol has further shrunk it. The drawing made by Dr. Carey, assisting at the operation, is very close to a life representation. The cornual fibroid must have acted not exactly as a ball valve, yet with the same effect. It obstructed the uterine end of the tube, the liquid contents of which gradually increased, giving the feeling of distention and in reality distending the tube until, with the increased distention due to menstruation, the tension became sufficient for the contents to break by the barrier and the mucoid discharge appeared with the menstrual flow and the feeling of distension and pain abated. The patient was left after the operation with a healthy left ovary, a uterus in its proper position, not sensitive and without discharge. Her kidney is fixed. She has no abdominal or renal symptoms.

PROCTORRHAPHY: THE SUSPENSION OF THE RECTUM FOR THE CURE OF INTRACTABLE PROLAPSE AND INVERSION OF THAT ORGAN.*

BY CHARLES P. NOBLE, M.D., PHILADELPHIA, PA.
Surgeon-in-Chief, Kensington Hospital for Women, Philadelphia.

Marked prolapse and inversion of the rectum in adults is a condition which is well known for its intractable nature and for the difficulty of effecting a cure. It is not my purpose to discuss the etiology of the condition nor the treatment of the recent and more simple cases, which can often be cured by the removal of the cause, and careful attention to the regulation of the bowel movements. I desire to advocate a simple method of operation which promises well in the treatment of intractable cases, and to report two cases in which this operation has been performed.

The good results which have been secured in the treatment of prolapse of the uterus by combining hysterorrhaphy with proper operations upon the pelvic floor, and the similar results which have been secured by fixation operations in prolapse of the kidneys and even in prolapse of the stomach, suggest that the same principle should apply to prolapse and inversion of the rectum. The operation which I would propose is to open the peritoneal cavity by an incision made through the left rectus muscle slightly below the promontory of the sacrum, to search for the sigmoid or for the rectum and to make traction upon it until it is inverted and until the slack" has been taken up. The point at which the lower portion of the rectum will come in contact with the abdominal wall on slight tension should be determined, and this point attached to the abdominal wall by three or more fine silk sutures. The sutures should be passed so as to include a portion of the rectus muscle, and should pass under the anterior longitudinal band of the rectum. In this way the bowel can be firmly attached to the abdominal wall with the least danger of penetrating its lumen and with the greatest prospect of permanent attachment. The abdominal wall should then be closed by the tier method.

* Read before the Philadelphia Obstetrical Society. December 6, 1900.

The accompanying illustration demonstrates very clearly the method of operation.

The history of the two cases is as follows:

Mrs. I., age thirty-five, primipara, consulted me March 21, 1899. She complained of backache and a feeling of discomfort about the rectum, which she attributed to piles. She stated that she had had

piles for about five years and that these came down and gave her a great deal of annoyance. The general examination threw no light upon the local trouble. Her health was otherwise good. Her bowels were obstinately constipated. On examination the supposed piles proved to be the inverted rectum. Because of the unsatisfactory results which are usually obtained from the various direct operations upon the protruded bowel, I determined to perform a proctorrhaphy, which was done two days later. She made a prompt recovery, and was

discharged from the hospital March 25th. Her physician has told me within a month that the operation has effected a permanent cure. She is perfectly well, with the exception that there is some tendency to constipation, for which it is necessary to administer a laxative.

Miss D., age nineteen, consulted me March 13, 1900, complaining of a sense of weight or bearing down about the rectum and intense backache. During each bowel movement there is an inversion of the rectum. For some time she has had but little control over her sphincter muscle. The present trouble began three years ago, after an attack of constipation, for which she took a powerful cathartic. Her bowels are constipated, but otherwise there is nothing in the history bearing upon the local trouble. Upon examination the sphincter was found in a paretic condition. In the Sims' position or in the knee-elbow position it dilated under atmospheric pressure, so that the rectum filled with air. Examination with the proctoscope showed a relaxed rectum, which was otherwise normal. On April 16th proctorrhaphy was performed. The patient made a good recovery and was discharged about five weeks after the operation. She consulted me in November, seven months after the operation, and reported that she had no trouble with her rectum until within a few weeks, since which time there has been some tendency to eversion of the bowel at stool. She is still constipated and has not taken her laxatives regularly. On examination the anus was found in normal condition, the bowel in situ, and, so far as an examination could show, the operation was entirely successful. As against this we have the statement of the patient that there is a tendency to recurrence of the old trouble. It is my judgment that reasonable care in the administration of laxatives and the use of enæmata, so as to avoid constipation and straining, will be sufficient to effect a permanent cure.

When I operated upon the first case, March 23, 1899, I was under the impression that the operation was original with myself. I have since learned that it has been done by Dr. W. Joseph Hearn of Philadelphia, in one case with a good result. Probably the first surgeon to perform this operation was McLeod of Calcutta (B. K. McLeod, F.R.C.S.E., “A New Operation for Prolapse of the Rectum," Lancet, Vol. II., p. 117. 1890). The technique which he employed, however, would not be likely to appeal to most surgeons. He introduced his hand into the rectum, reduced the inversion, put the rectum on the stretch from below upward, and pressed the rectum against the abdominal wall, endeavoring to press the small bowels to one side so that the rectall wall would come in contact with the abdominal wall.

Two acu-pressure pins were introduced through the abdominal wall and through the rectum, penetrating its lumen, so as to fasten the rectum to the abdominal wall. These pins were separated by an interval of three inches, and they were so introduced that the rectum was made to take the course of running from below upward and from within outward. Having fixed the rectum to the abdominal wall, an incision was made between the pins down to but not through the parietal peritonæum. The hand was again introduced into the bowel as a guide, and fine sutures were introduced through the abdominal wall and through the wall of the bowel, avoiding its mucous membrane, and then out through the opposite side of the wound. In this way the rectal wall was attached to the abdominal wall. The acu-pressure pins were removed after twenty-four hours. The patient made a fairly smooth recovery, the wound healing by first intention. The result.

was a cure.

The simplicity of the operation of proctorrhaphy and its comparative freedom from danger, together with the good results which have been secured so far as reported, commend it strongly, and I believe it well worthy of a trial in the treatment of this intractable condition. It is my own intention in future cases, should this operation fail, to cut down upon the rectum by a posterior incision from the border of the sphincter to the coccyx or to the sacrum, and then to dissect the rectum loose from its connective-tissue bed to a considerable extent laterally and pack the wound with gauze, allowing it to heal by granulation and cicatrization. It seems to me that with this procedure supplemental to proctorrhaphy, and the possible use of the cautery to make linear cauterization of the mucous membrane itself, we should be able to cure prolapse of the rectum without resorting to the more radical procedure of excising the prolapsed mass, as practiced by Treves and others.