The Cure of Complete Prolapse of the 
Rechim by Posterior Proctectomy. 
BY 
JOHN B. ROBERTS, M.D., 
PHILADELPHTA, PA. 
FROM 
THE AMERICAN JOURNAL OF THE MEDICAL SCIENCES, 
May, 1893. Reprinted from The American Journal of the Medical Sciences, May, 1893. 
THE CURE OF COMPLETE PROLAPSE OF THE RECTUM 
BY POSTERIOR PROCTECTOMY.1 
By John B. Roberts, M.D., 
The means ordinarily advocated for the treatment of complete pro- 
lapse of the rectum seem to me either inefficient or too radical and dan- 
gerous. Searing the mucous membrane of the extruded intestine with 
nitric acid belongs to the first category; amputation of the prolapsed 
bowel to the second. It is possible that cauterization may be of service 
in mild cases of the affection; but it cannot be of much value when 
three or four inches of the everted bowel protrude through a widely 
dilated anus. The operation which I have designated posterior proctec- 
tomy is very efficient in such cases, and is, at the same time, more 
logical and probably very much less dangerous than amputation of the 
rectum. 
In the Annals of Surgery for April, 1890, I described what I believed 
to be a new method of operating for rectal prolapse, and reported a case 
so treated. Further observation of the patient has convinced me that 
my confidence in the value of the procedure was well founded. This 
opinion has been substantiated by the reports of two cases in the hands 
of other surgeons who operated by my method. A short account of 
these three cases will perhaps show that evidence is not wanting to war- 
rant my confidence in the utility of the operation. 
Case I. Dr. Roberts’s case. Prolapse of the rectum of fourteen years’ 
duration cured by posterior proctectomy.—A woman, aged thirty-four 
years, a weaver, had from the age of twenty suffered with prolapse of 
the rectum. The protrusion had originally occurred suddenly while she 
was at work and during menstruation. Her recollection is that the ex- 
truded portion was about three inches long; that she had looseness of 
the bowels, and was confined to bed about a week. Since that time the 
condition had continued. She always replaced the bowel after defeca- 
tion, and had control of the contents of the rectum except when diar- 
rhoea existed. About three years before she came under my observation 
she had been treated for what was considered to be membranous enteritis 
associated with the prolapsed rectum. 
During the many years that this woman had endured the annoyances 
of her disease she had been treated by various local and internal reme- 
dies. The prolapse had, however, continued to increase and the anal 
1 Read before the Philadelphia Academy of Surgery, November 7, 1892 2 
ROBERTS: CURE OF PROLAPSE OF THE RECTUM. 
aperture to become more and more dilated, until, when I saw her, a sau- 
sage-shaped mass about four inches long protruded through an anus 
into which I could readily insert the ends of my five fingers. The bowel 
was easily reduced, but soon slipped down between the buttocks, so that 
it was practically always prolapsed. The woman was dejected, nervous, 
emaciated and unable to work. 
My dissatisfaction with the operations ordinarily recommended and a 
study of the mechanical problems presented led me to the conclusion 
that to narrow the calibre of the lower part of the rectum and at the 
same time diminish the size of the anal opening were the indications. 
This, I thought, would give the weakened and dilated sphincter muscle 
an opportunity to prevent the exit of the lower part of the bowel. At 
the same time there would be less tendency to invagination of the rectal 
wall, because the lower portion of the gut would be narrower than that 
part which the downward thrust of the pelvic contents tended to ex- 
trude. Cicatricial influences, moreover, would make the coats of the 
bowel more rigid and less easily inverted and doubled upon themselves. 
The operation which I devised to meet these ends was carried out, and 
proved eminently satisfactory. 
The patient was put in the lithotomy position, and the protruded rec- 
tum fully reduced. I then made a small incision in the median line of 
the perineum, near the point of the coccyx; into this I inserted my fin- 
ger and broke up the cellular connections posterior to the rectum, in a 
manner similar to that adopted in excision of the lower end of the rec- 
tum for carcinoma. A knife was then introduced into the dilated anus 
at a point half an inch to the right of the median line, and a deep inci- 
sion carried obliquely backward, so that it divided the anal sphincter and 
skin from the aperture of the bowel to the original incision made at the 
end of the coccyx. The knife was then introduced into the anus upon 
the left side of the median line, and a similar incision carried back to 
the original wound in the perineum. These oblique incisions included 
between them a triangular portion of tissue consisting of skin, subcuta- 
neous cellular tissue and an inch of the sphincter muscle. The base of 
the triangle was at the margin of the anus; its apex was at the extrem- 
ity of the coccyx. About one inch of the sphincter muscle was thus 
excised by the two incisions. With scissors, I then cut out of the pos- 
terior wall of the rectum a long triangular piece embracing the entire 
thickness of the wall, which, in the first step of the operation, had been 
separated from its pelvic connections. The apex of this Y-shaped sec- 
tion of the wall of the rectum was situated about three inches up the 
gut, while its base corresponded with the inch of the sphincter muscle 
of the anus, which had been included between the incisions previously 
described. 
After hemorrhage had been controlled by catgut ligatures, chromi- 
cized catgut sutures were used to bring the divided wall of the rectum 
together. The first suture was introduced at the apex of the rectal 
wound; that is, three inches above the anus, and was tied with the knot 
within the bowel. Successive sutures were similarly inserted and tied 
at intervals of about one-third of an inch. The last intra-rectal suture 
was placed just inside the margin of the anus. The sutures were all tied 
with the knots upon the mucous surface of the bowel. It is possible that 
it would have been better to have used silk for these sutures, as they 
would probably have held the parts in apposition longer than catgut, ROBERTS: CURE OF PROLAPSE OF THE RECTUM. 
3 
even though it had been chromicized. As an aseptic condition of the 
wound in this situation is almost unattainable, I am inclined to think that 
hereafter I shall use silk instead of gut. This portion of the operation 
greatly reduced the lumen of the rectum, and was intended to make the 
lower part of the intestine funnel-shaped, with the small end of the 
funnel toward the anus. 
The ends of the divided anal sphincter, which were left by the exci- 
sion of one inch of that muscle, were then brought together by two cat- 
gut sutures and one wire suture, which was shotted. The anus was thus 
reduced in diameter so that it was barely possible for me to introduce 
the tip of one finger, whereas before the operation the ends of five fin- 
gers could readily be thrust into it. 
A rubber drainage-tube was then introduced into the space between 
the rectum and the sacrum, and the wound leading backward from the 
anus to the coccyx was closed by numerous shotted-wire sutures carried 
deeply through the structures by means of a strong curved perineum 
needle. This procedure made the rectum diminish gradually in calibre 
as it approached the anus, instead of being, as it was previously, a sort 
of funnel-shaped cavity with its widest end towards the external open- 
ing. The new condition was as inhibitory to the occurrence of prolapse 
as the previous one was favorable to it. Owing to diarrhoea, which oc- 
curred a day or two after the operation, fecal matter obtained access 
to the space behind the rectal wall; and, as a result, suppuration, slough- 
ing, and bleeding occurred. This interfered with the rapid healing of 
the divided structures, and destroyed what union had already taken 
place. On the fifth day I took out the wire stitches which had been 
inserted from the anus to the coccyx. It is possible that the diarrhoea 
which occurred was the result of the antiseptic washes, which, if I 
remember rightly, I employed through the drainage-tube. When I per- 
form this operation again I shall endeavor to keep the rectum aseptic 
by packing it with gauze after the operation, and at the same time have 
the bowels confined by the use of opiates, so as to allow union by first 
intention to take place. The suppuration, sloughing, and secondary 
hemorrhage, which took place because fecal matter obtained access to 
the wound by the giving way of the rectal stitches, greatly retarded 
convalescence. It is possible, however, that the cicatricial contraction 
due to this infiamation added to the permanency of the cure effected. 
For a long time after the operation, and even after the patient was 
discharged from constant supervision, there remained an opening pos- 4 
ROBERTS: CURE OF PROLAPSE OF THE RECTUM. 
terior to the anus leading into a small cavity back of, and communicating 
with, the rectum. This eventually entirely closed. The patient rapidly 
gained flesh after the operation, became strong and vigorous, and was 
able to go up and down stairs without any tendency to prolapse. She 
had control of the contents of her bowels, and was cured of the disgust- 
ing condition which had existed for so many years. 
An examination made by me in September, 1891, nearly two years 
after operation, revealed no evidence of prolapse, as far as could be de- 
termined by digital examination. The sinus had remained closed, the 
anus was small, and the mucous membrane was not protruding. The 
patient stated that sometimes there was a slight tendency for the lower 
portion of the bowel to appear at the anus, and that it was necessary for 
her to use enemas in order to empty the bowel completely and to get rid 
of the sensation of material in the lower end of the intestine. Inquiry 
repeatedly made did not convince me that this was anything more than 
a slight protrusion of the mucous membrane. There certainly was not 
enough anatomical change to give her much annoyance or prevent her 
attending to the ordinary duties of life. She was seen by me for other 
conditions a number of times, and I concluded that her anxiety about 
the state of the rectum was the result of her fear of a return of the trouble 
—a mental attitude not surprising, considering her years of rectal 
disease. 
I last saw her in April, 1892, when she was still well, though two 
and a quarter years had elapsed since the date of operation. The 
operation, therefore, was a satisfactory one, both to the patient and to 
me, and the cure effected has been permanent. 
Case II. Dr. Bell’s case. Posterior proctectomy for prolapse of the 
rectum existing for Jive years and associated with injury to the back; cure. 
—The case of Dr. James Bell, surgeon to the Montreal General Hos- 
pital, which he reported in the Annals of Surgery, 1891, vol. xiii. p. 
333, is as follows: A woman, aged twenty-two years, suffered from 
rectal prolapse to such an extent that simply standing in the erect posi- 
tion or walking a few steps caused a protrusion of the walls of the bowel 
of from four to six inches in length. According to her history, she, at 
the age of ten years, fell from a height of ten feet, receiving the force of 
the blow upon her back. This accident was followed by incontinence 
of urine, and after two years by diarrhoea, which persisted, more or less, 
for five or six years. About five years before she came under Dr. Bell’s 
observation the bowel began to prolapse, but was readily returned. The 
tendency to extrusion increased until the condition was as stated above. 
The incontinence of urine had persisted. She had only imperfect con- 
trol of the sphincter muscle ; when diarrhoea existed she had no control 
whatever over the contents of the rectum. There was loss of sensation 
over the buttocks and on the posterior surface of the thighs and calves, 
though there was no paralysis of the muscles of the lower extremities. 
No history of paraplegia could be obtained as having occurred after the 
injury, which she received when a child, and from which her present con- 
dition seemed to date. It is seen that the clinical history of the patient 
was somewhat obscure, as usually happens in cases of disease of long 
standing. The anus was so dilated that a man’s hand of ordinary size 
could be easily introduced into the rectum. It was the opinion of Dr. 
Bell that the prolapse was secondary to a paralysis of the sphincter ROBERTS: CURE OF PROLAPSE OF THE RECTUM. 
5 
muscle, which resulted from the injury received twelve years previously 
to the time of operation. 
On May 22, 1890, he removed, by my method, from an inch and a 
half to two inches of the sphincter muscle and a Y-shaped portion of 
the posterior wall of the rectum, the base of which corresponded to the 
section of the sphincter muscle. The apex of the triangular piece cut 
from the rectum was situated four inches up the bowel. Silk sutures 
were used to bring the edges of the rectal wall together and to unite the 
separated ends of the sphincter. The sutures used for the sphincter were 
stronger than those employed for uniting the rectal wall. A drainage- 
tube was then introduced at the coccyx, and carried up behind the line 
of sutures in the rectum. For eight days there was considerable 
inflammatory reaction. The temperature varied from 99° to 101° F., 
and on one occasion it reached 102° F. After the eighth day the tem- 
perature remained normal, and the patient was free from pain. The 
sutures were then removed from the sphincter and the drainage-tube 
withdrawn. A small sinus was discovered leading from the lumen of 
the bowel, just within the sphincter muscle, to the opening left by the 
drainage-tube. Through this some fecal matter passed during defeca- 
tion. The patient had an uneventful convalescence; was allowed to sit 
up after six weeks, and was discharged in a little less than twelve weeks, 
in better health than she had been for years. She had much more con- 
trol of the sphincter muscle than before. No fecal matter escaped by 
the small sinus still existing at the point of the coccyx, through which 
a fine probe could be passed into the rectum, and there was no tendency 
to prolapse of the wall of the intestine. 
The patient reported to the operator on October 28, 1890, who makes 
this note of the examination: “ The wound was then completely healed, 
the control of the sphincter was good—much better than before the op- 
eration—and the general health excellent. She stated that for two 
months she had been actively engaged in doing housework, going up 
and down stairs, etc., and that no sign of prolapse had ever been ob- 
served.” Dr. Bell, in his article, says further, that the operation recom- 
mended by Dr. Roberts is sound in principle as well as safe and simple 
in practice, and seems to leave little to be desired. He thinks that ven- 
tral fixation of the sigmoid flexure, as carried out by Dr. McLeod, of 
Calcutta, is theoretically objectionable. 
I have obtained a later account of this patient from the operator, 
who under date of October 13, 1892, says: “The after history of my 
case of prolapse of the rectum, on which I operated by the method de- 
scribed by you, has been perfectly satisfactory. The patient, who lives 
about sixty miles from Montreal, presented herself for examination, at 
my request, in November, 1891. There had been no return of the pro- 
lapse, and she had almost perfect control of the sphincter—better than 
she had had for years before the operation. Her general health was 
greatly improved, and she expressed herself as delighted with the result. 
I have not heard from her since. I am still of the opinion that this 
operation is the best and most rational that has yet been proposed for 
complete prolapse of the rectum.” 
Case III. Dr. Kammerer’s case. Posterior proctectomy in a man, fol- 
lowed by permanent cure.—At a meeting of the New York Surgical 
Society, October 28, 1891, Dr. F. Kammerer exhibited a man, aged 
forty-five years, upon whom he had operated by this method. The 6 
ROBERTS: CURE OF PROLAPSE OF THE RECTUM. 
patient, who had suffered with the condition from boyhood, had, at the 
time of the operation, a prolapse of the walls of the rectum measuring 
about three and one-half inches. When the bowel was replaced three 
fingers could readily be introduced into the rectum through the relaxed 
sphincter muscle of the anus. 
About one and one-half inches of the sphincter were removed, with a 
portion of the rectal wall extending upward about four inches. The 
walls of the rectum were united by a continuous catgut suture, which 
was also the method used for bringing the other parts of the wound 
together. The part of the cavity lying underneath the coccyx was 
packed with iodoform gauze, because it could not be entirely closed with 
sutures. The sutures through the sphincter muscle were reinforced by 
several deep sutures of silkworm-gut. After the parts united, a rectal 
fistule was left at the end of the wound near the coccyx. This closed, 
however, at the end of three months. 
The operation, which had been performed about six months before the 
exhibition of the patient, was, according to the statement of the oper- 
ator, a complete success. There was “ no recurrence of the prolapse, 
cessation of catarrh and ulceration of the rectum, and perfect control 
over feces and flatus.” 
I received a letter from Dr. Kammerer last month (October, 1892) 
in which he says, in reference to this case: “ I can only add that the 
patient has had no recurrence whatever of his former trouble, and has 
complete control over his sphincter.” 
The history of these cases has been presented, because I believe that 
there must be merit in an operation which has proved so successful in 
curing every case in which, as far as my knowledge goes, it has been 
employed. The method has now the indorsement of two surgeons, who 
previously were unacquainted with me, and who in each instance were 
as successful as I in obtaining a permanent cure. The evidence of the 
utility of the operation is greatly reinforced by this testimony and by 
the long time after operation at which all the patients were subjected to 
re-examination. Tfye Jotirrjal 
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