Br Med J: first published as 10.1136/bmj.4.5732.381 on 14 November 1970. Downloaded from BRITISH MED ICAL JOURNAL

LONDON SATURDAY 14 NOVEMBER 1970

Pointers Problems of Rectal Prolapse

Predicting Haemolytic Disease: Ratio of bile Prolapse of the rectum is no respecter of age, sex, or species. But most pigment to protein in amniotic fluid is a better cases do occur in either infants up to the age of about 3 or in middle- indication of severity of Rh-haemolytic disease aged and elderly people. Of adult patients females are affected about five than estimation of bile pigment alone (p. 387). or six times more often than males. Mankind may derive some satisfaction in that it shares this condition Clonidine in Hypertension: Clonidine had more effect on diastolic pressure than methyldopa in with horses, dogs, and pigs. The great majority of cases have no obvious an open, randomized, cross-over study; less cause. Though described as occurring in wasted children, it is usual to acceptable to patients because of side effects find that otherwise perfectly normal infants suffer from rectal prolapse. (p. 392). While it may complicate neurological conditions producing paraplegia, Fibrin Degradation Products in Embolism: such a precipitating factor is seen in only a small proportion of cases. Serum F.D.P. estimations may prove helpful Likewise it may complicate gross injuries to the pelvic floor after child- in diagnosing pulmonary embolism (p. 395). birth, but the majority of female patients are in fact nulliparous. Partial (mucosal) prolapse is often produced by some local condition such as Uraemic Acidosis: Sodium acetate found to prolapsing piles or a rectal polyp, but the more serious complete prolapse give comparable results to sodium bicarbonate in correcting uraemic acidosis (p. 399). usually has no such local cause. In 1912 A. V. Moschcowitz' suggested that complete rectal prolapse Spironolactone: An American study shows represented a sliding hernia of the pouch of Douglas, and much surgical spironolactone to be a safe and effective diuretic ingenuity was concentrated on operations intended to repair this defect. in patients with cirrhosis and ascites (p. 401). But recent observations have shown conclusively that rectal prolapse is an intussusception. 0. H. Beahrs and his colleagues at the Mayo Clinic

Fundal Height: Pelvic examination in the first http://www.bmj.com/ describe the prolapse as beginning at the recto-sigmoid junction.2 The trimester of pregnancy in 233 patients found to be more accurate in assessing gestational age intussusception then tugs the recto-sigmoid area away from its moorings, than abdominal palpation at a later time (p. 404). and, with repeated straining, the rectum pulls away more distally. As this Leader on page 382. happens, the fixed point anchoring the neck of the intussusception falls progressively from the recto-sigmoid junction until finally it reaches the Endocrine Function in Homosexuals: Abnor- malities shown in a small series of male and anal muco-cutaneous junction. These workers believe that the initiation female homosexuals (p. 406). of the prolapse is a chance occurrence precipitated by straining at stool. Though the diagnosis of prolapsed rectum is usually obvious, it is not on 1 October 2021 by guest. Protected copyright. Medical Memoranda: Symptomless carriage of always necessarily so. C. P. Sames3 has pointed out that complete pro- Australian antigen after renal transplant (p. 409); lapse may present as profuse rectal bleeding, severe anaemia, a solitary Combined rifampicin F and erythromycin for bacterial endocarditis (p. 410). rectal ulcer, or excessive mucus discharge. It may be necessary to examine the patient while he strains in the standing or squatting position in order Current Practice: Haemodialysis and renal trans- to observe the existence and the full extent of the protrusion. plantation (p. 412). A particularly distressing feature is the accompanying incontinence. N. Porter4 found that three-quarters of patients with complete prolapse Immunological Aspects of Cancer: Five papers suffered from it. In the great majority of these cases the incontinence presented at a symposium held recently in followed the prolapse, and it probably results from progressive stretching Edinburgh (pp. 418-426). Leader on page 386. of the anal sphincter by the prolapsing bowel. A feature of the surgical treatment of rectal prolapse is the extraordinary Personal View: A general practitioner on hypno- sis (p. 428). variety of operations which have been described for its cure, now amount- ing to about 50 different, often eponymous, procedures. In Britain the Correspondence: Letters on accident services, most popular operations employed today are the Roscoe Graham5 repair growth and cancer, myocardial infarction and of the pelvic floor, though this is a difficult (and maybe impossible) pro- the G.P., self-certification, hospital junior doc- cedure in the narrow male pelvis, especially in obese patients; anterior tors, cholera in Istanbul, and Seebohm sequel (pp. 429-436). resection of the rectum, which results in firm fixation of the rectum to the British Medical Journal, 1970. All reproduction rights reserved. No. 5732, page 381 382 14 November 1970 Leading Articles MEDITALISHUNAL sacral hollow, a procedure warmly advocated by Beahrs and after Roscoe Graham operations and two after Thiersch his group;2 the Ivalon wrap operation,6 7 again designed to wiring of operations). Seventy-five the patients who had had Br Med J: first published as 10.1136/bmj.4.5732.381 on 14 November 1970. Downloaded from fix the rectum by fibrous tissue against the sacral curve; and abdominal operations were available for assessment six the Thiersch wiring procedure, comprising simple narrowing months to 14 years after surgery, and five (6&6%) were found of the anal canal by means of a wire or a braided Nylon to have recurrent complete prolapses. Eleven more had suture, which is usually reserved for elderly and feeble mucosal recurrences of doubtful significance. Anal inconti- patients. Many other procedures, in particular recto-sig- nence had improved in about 60% of the cases. Of 19 moidectomy (perineal amputation of the prolapse), have been Thiersch operations performed only three or four gave abandoned because follow-up studies have shown an un- results that are at present satisfactory. Nine patients in this acceptably high rate of recurrence. group had developed faecal impaction, two infection around Surgeons can be helped in their choice of operative pro- the wire, two ulceration in the anal region, and four breakage cedure only by detailed studies of mortality, chance of recur- of the wire. KUpfer and Goligher consider the procedure very rence, and restoration of continence to be expected from a much a last resort. particular operation. C. A. Kiupfer and J. C. Goligher have Whereas modern surgery can offer patients with this dis- recently published a detailed account of 100 consecutive cases tressing condition a reasonable chance of cure of the prolapse of complete prolapse of the rectum personally treated by a with an acceptably low mortality rate, in many instances variety of operations at the General Infirmary, Leeds.8 In incontinence will not be improved. Its aetiology and treatment this series there were 17 male and 83 female patients, varying remain as important challenges. in age from infants to 97 years. One hundred and twelve Moschcowitz, A. V., Surgery, Gynecology and Obstetrics, 1912, 15, 7. operations were performed-91 by the abdominal route 2 Theuerkauf, F. J., jun., Beahrs, 0. H., and Hill, J. R., Annals of Surgery, 1970, 171, 819. (mostly Roscoe Graham repairs, Ivalon sponge implants, or Sames, C. P., Proceedings of the Royal Society of Medicine, 1969, 62, 717. a combination of the two). Nineteen patients had Thiersch Porter, N., Proceedings of the Royal Society of Medicine, 1962, 55, 1087. Graham, R. R., Annals of Surgery, 1942, 115, 1007. wiring and two recto-sigmoidectomy. There were two immedi- Wells, C., Proceedings of the Royal Society of Medicine, 1959, 52, 602. ate postoperative deaths. Twelve patients required further Ellis, H., British Journal of Surgery, 1966, 53, 675. Kupfer, C. A., and Goligher, J. C., British Journal of Surgery, 1970, 57, surgery because of recurrence or severe incontinence (10 481.

measurement of fundal height however it is made. In practice Length of Gestation experienced obstetricians have not paid much attention to the height of the fundus in the later weeks of pregnancy but have The length of a particular gestation is from the time of tried to make clinical estimates of the size of the baby in fertilization of the ovum. This has to be assumed to take utero. However crude, this is an attempt at a three-dimensional place about 14 days before the next period is due. In a measurement. It too is fallible. F. E. Loeffler' showed that 28-day cycle ovulation occurs about the fourteenth day of though fetal weight can be predicted within about 1 lb. that cycle, but in a 35-day cycle it will occur about the twenty- (450 g.) in 80% of cases, the error is greatest at the extremes http://www.bmj.com/ first day. Allowance may have to be made for this in assessing of weight-that is, around 5 lb. (2,300 g.) and 9 lb. (4,000 g.). gestational age. Clinically no allowance is made for women It is at these weights when interference with the pregnancy is who have shorter cycles than 28 days, even though it might be most likely to be needed. expected that they would ovulate earlier than the fourteenth The whole subject is bedevilled by biological variation. As day of the cycle. a rough check on dates it is usually assumed that fetal move- The regular growth of the uterus is an index that all is ments are subjectively felt at about 18 weeks of pregnancy, proceeding normally in the pregnancy, but there has perhaps

so that the addition of five calendar months to the date on on 1 October 2021 by guest. Protected copyright. been a too slavish adherence to the old methods of relating the which these movements occur should be about the time of height of the fundus to the landmarks of the symphysis pubis, delivery. But clinical experience shows that too much reliance the umbilicus, and the xiphisternum. In a paper at page 404 cannot be placed on this. of the B.M.J. this week Dr. J. M. Beazley and Miss Rosemary In the majority of pregnancies the time dimension is given A. Underhill show how fallible this method can be. The by the woman's dates. But there is an appreciable number of length of the abdomen is variable and so is the position of the women in whom the last period is not known, or who were umbilicus in different patients. The growth rates of fetuses amenorrhoeic at the time of fertilization, or whose periods vary, since at term the weight may be anything from 51 to were very irregular. If the pregnancy is normal all that is over 10 lb. (2,500 to over 4,500 g.) and still be considered required is patience. Delivery occurs in the end. But when normal, and yet both the smaller and the larger babies have pregnancy is complicated by hypertension, pre-eclampsia, taken the same length of time in which to grow. erythroblastosis fetalis, or poor fetal growth,. the obstetrician The problem is to decide whether growth matches the time has few things to guide him in management. S. Campbell2 which has elapsed from the first day of the last menstrual showed the value of ultrasound in estimating the biparietal period. In early pregnancy a fair measure of the size of the diameter of the fetal head, but repeated measurements uterus can be obtained by bimanual examination. This is a between 20 and 30 weeks of pregnancy are needed. A single rough measure of volume-that is, three-dimensional-and measurement at 30 weeks, for example, may vary by more than therefore more likely to be helpful than the unidimensional a centimetre, and a bipartietal diameter of 7-5 cm. may be I Loeffler, F. E., Journal of Obstetrics and Gynaecology of the British Com- found in a fetus of 26 to 29 weeks gestational age; the error monwealth, 1967, 74, 675. 2 Campbell, S., Journal of Obstetrics and Gynaecology of the British Com- may be greater at term. Examination of the liquor amnii monwealth, 1969, 76, 603. obtained by amniocentesis and stained with Nile blue shows 3 Barnett, H. R., and Nevin, M., Journal of Obstetrics and Gynaecology of the British Commonwealth, 1970, 77, 151. 10% or more of orange-stained cells after the thirty-sixth