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Title: Obstipation
Author: Thomas Charles Martin
Release date: January 12, 2026 [eBook #77683]
Language: English
Original publication: Philadelphia: The Philadelphia Medical Publishing Co, 1899
Credits: deaurider and the Online Distributed Proofreading Team at https://www.pgdp.net (This file was produced from images generously made available by The Internet Archive)
*** START OF THE PROJECT GUTENBERG EBOOK OBSTIPATION ***
OBSTIPATION
A PRACTICAL MONOGRAPH ON THE
DISORDERS AND DISEASES
OF THE RECTAL VALVE
BY
THOMAS CHARLES MARTIN, PH. D., M.D.
OF CLEVELAND, OHIO
Fellow of the American Proctologic Society, Professor of Proctology
in the Cleveland College of Physicians and Surgeons,
Proctologist to the Cleveland General Hospital, etc.
THE PHILADELPHIA MEDICAL PUBLISHING CO
1899
TO MY
GENEROUS COLLEAGUES
I GRATEFULLY DEDICATE THIS LITTLE BOOK.
T. C. M.
“I deny their existence, and if they did exist I would deny
that their use was to support the fecal mass. For many years
I have searched for these folds and I have yet to encounter
them. In my opinion, they existed only in the author’s mind’s
eye.”--JOSEPH M. MATHEWS, M.D., _Diseases of the Rectum_, p. 37.
CONTENTS
Prefatory.
Introduction.
A Chronologic Review of the Literature of the Rectal Valve.
The Chronology of Atmospheric Inflation of the Rectum for its
Inspection.
The Examination of the Rectum.
Topographic Anatomy.
The Rectal Valve.
Defecation.
Obstipation in Infants.
Obstipation in the Adult.
Diagnostic Observations.
Cases of Obstipation Radically Treated.
List of Illustrations.
PREFATORY.
That man is guilty of a most reprehensible foolhardiness who undertakes
any of the operations herein recommended without first familiarizing
himself with the anatomy of the rectum under the conditions specified.
The benefit which accrues to the obstipated patient is measured by the
judgment and skill which the operator exercises in the selection of
his subject, in the application of the proposed methods, and in the
subsequent treatment of his patient.
Obstipation may be defined as that condition of obstructed defecation
which is due to the presence in the rectum of an organic obstacle to
the descent of the feces through it. Constipation, on the other hand,
is that condition of delayed defecation which results from a prolonged
retention of the feces in higher portions of the gut. Constipation may
exist independently of any obstruction and may be due to any of several
causes, such, for instance, as faulty habits and diet, imperfect
innervation or modified secretion--the consequence of disease or
accident. Obstipation and constipation may coexist.
INTRODUCTION.
The great diversity of opinion which characterizes the literature
on the anatomy of the rectum, our discouraging record of compromise
with the obstipated, paucity of definite knowledge of the etiology
and pathology of stricture of this organ, the lack of safe and sure
measures for acquiring this knowledge, the inefficacy of the methods
generally employed in the treatment of rectal stricture, and the too
heroic colostomy occasionally applied by the surgeon on the one hand,
or else the supine inertia of the physician on the other hand,--all
compel the search for a demonstrable conclusion to the matter.
That the rectal valve is the chief anatomic feature of the rectum is
capable of demonstration. That in certain diseases of this organ it
is to be reckoned with as the most important etiologic factor, or,
in other words, that the rectal valve provides a ready foundation on
which strictures may be quickly built, it shall be the attempt of this
treatise to prove. If it is proved that the rectal valve exists, it
will then be imperative that a method of diagnosis almost universally
practised be abandoned, and it will also be necessary that the methods
of treatment of certain obstructive lesions be modified; possibly, too,
a new point of view may be afforded from which to study congenital
malformation of the rectum.
A quarrel which is so archaic, so involved, and in which there is
such multiplicity of contradiction concerning a matter of scientific
interest, can not with proper understanding and with perfect fairness
be referred to without the free and exact quotation of the expressed
opinion of the distinguished workers in this field.
I ask no consideration for my ipse dixit, but on the contrary undertake
to present such evidence in support of my claims as reasonably may be
considered documentary, such as photographs of specimens, certified
drawings of historic specimens and of microscopic appearances of
valve-sections, together with the detailed descriptions of the
simple procedures by which my own findings may be readily verified.
Anticipating, however, that some may complain that the technic for the
anatomic research is too elaborate and the opportunity for its practice
by the ordinary student too rare, I would bespeak a general interest
in the subject by offering to the physician--after quoting sufficient
of the literature to exhibit the precise status of the subject--a
certain simple and practical method of inspection of the rectum, the
employment of which will discover a basis for the prosecution of this
investigation while at the same time it provides him with a ready
resource for the discovery of many of the diseases of the rectum.[1]
A CHRONOLOGIC REVIEW OF THE LITERATURE OF THE RECTAL VALVE.[2]
1723, MORGANNI, _Adversaria Anatomica III; Lungduni Batavorum_:
On page 10 observes that he found valves in two subjects situated about
a finger’s-breadth above the anus. “The form of the valves in one,” he
says, “was circular, and in the other transverse.”
1778, CHESELDEN, _Anatomy of the Human Body_; London:
On page 159 says: “As the gut approaches the anus, they (the valves)
become less remarkable and fewer in number.”
1803, PORTAL, _Cours d’Anatomie Médicale_; Paris:
“One notices at the inferior extremity near the anus, certain folds
of the internal membrane which form a sort of valves, arranged
more or less circularly. Glisson, who recognized them, called them
the semilunar valves. The inner membrane of which these folds are
constituted sometimes relaxes and prolongs itself to the extent of
forming an impediment to the passage of the feces.”
1810, THOMAS COPELAND, in _Diseases of the Rectum and Anus_;
Printed for J. Callow, No. 10, Crown Court, Princes Street,
Soho, London:
Omits mention of the rectal valve.
1815, M. BOYER, _Traité d’Anatomie_, tome IV; Paris:
The writer seems to verify the description of Portal. He says on page
377: “Sometimes, though rarely, in place of the semilunar folds of
which we have just spoken, veritable valves are found which in a manner
control the inferior extremity of the rectum.”
1821, JOHN HOWSHIP, in _Diseases of the Lower Intestines and
Anus_; Printed for Longman, Hurst, Rees, Orme, and Brown,
Paternoster-Row, London:
Omits mention of the rectal valve.
1824, THOMAS COPELAND, in _Diseases of the Rectum and Anus_;
Printed for Callow & Wilson, Medical Booksellers, Princes
Street, Soho, London:
Omits mention of the rectal valve.
1828, FREDERICK SALMON, _Strictures of the Rectum_; G. B.
Whittaker, Ave-Maria Lane, London:
Speaking of the rectum, says: “When empty, its mucous coat is thrown
into undulating folds, varying in number and size; near to the anus
these folds are larger than in the upper part of the bowel, and are
4 or 5 in number; to these Morganni has given the appellation of
the columns of the rectum. Between these, other processes are found
denominated _semilunar folds_.” Obviously, a reference to the anal
pockets and not to the semilunar valves.
1830, HOUSTON, _Dublin Hospital Reports_, Vol. V: Hodges and Smith,
College-Green, Dublin:
On page 158 writes: “In the natural state the tube of the gut does
not form, as is usually conceived, one smooth, uninterrupted passage,
devoid of any obstacles that might impede the entrance of bougies; it
is, on the contrary, made uneven in several places by certain valvular
projections of its internal membrane, which, standing across the
passage, must frequently render the introduction of such instruments
a matter of considerable difficulty. Cloquet and some other anatomic
writers have made a cursory allusion to this condition of the membrane;
but all the authors who have treated of diseases of the rectum appear
to have wholly overlooked it.
“The valves exist equally in the young and in the aged, in the male and
in the female; but in different individuals there will be found some
varieties as to their number and position. Three is the average number,
though sometimes four, and sometimes only two are present in a marked
degree. The fold of next most frequent existence is placed at the
upper end of the rectum. The third in order occupies a position midway
between these, and the fourth, or that most rarely present, is attached
to the side of the gut, about one inch above the anus.
“The form of the valves is semilunar; their convex borders are fixed
at the sides of the rectum, occupying in their attachments from
one-third to one-half of the circumference of the gut. Their surfaces
are sometimes horizontal, but more usually they have a slightly oblique
aspect, and their concave, floating margins, which are defined and
sharp, are generally directed a little upward. The breadth of the
valves about their middle varies from a half to three-quarters of an
inch and upward in the distended state of the gut. Their angles become
narrow, and disappear gradually in the neighboring membrane. _Their
structure consists in a duplicature of the mucous membrane, inclosing
between its laminae some cellular tissue, with a few circular muscular
fibers. The only method by which the condition of these valves in the
distended state of the rectum can be displayed, is that of filling and
hardening the gut with spirit previous to being disturbed from its
lateral connections._ By the ordinary procedure of distending it after
removal from the body the valves are made to disappear. Their presence
may likewise be ascertained in the empty state, if looked for soon
after death, _and before the tonic contraction of the gut has subsided_.
“They will be found to overlap each other so effectually as to require
considerable maneuver in conducting a bougie or the finger along the
cavity of the intestine.”
1830, ABRAHAM COLLES, A.B., M.D., P. of S. in the R.C. of S. in
Ireland, in _Practical Observations upon Certain Diseases of
the Anus and Rectum; Dublin Hospital Reports_, Vol. V:
Omits mention of the rectal valve.
1837, GEORGE BUSHE, _Treatise of the Malformations, Injuries and
Diseases of the Rectum_; French & Allard, New York:
Regard for brevity justifies quotation under Kelsey, 1893.
1840, ANDREW PAUL, A.B., M.B. Trin. Coll., L.R.C.S., in _Diseases
of the Rectum_; John Churchill, 16 Princes Street, Soho,
London:
Omits mention of the rectal valve.
1844, WILSON, _The Dissector_, page 52; P. B. Goddard, M.D.,
Philadelphia:
“In the cecum and colon the mucous membrane is smooth, but in the
rectum it forms three valvular folds, one of which is situated near the
commencement of the intestine; the second, extending from the side of
the tube, is placed opposite the middle of the sacrum; and the third,
proceeding from the front of the cylinder, is situated opposite the
prostate gland.”
1845, NELATON:
Regard for brevity justifies quotation under Kelsey, 1893.
1846, JAMES SYME, F.R.S.E., in _Diseases of the Rectum_, Second
Edition; Adam & Charles Black, Edinburgh; Longman, Brown,
Green & Longmans, London:
Omits mention of the rectal valve.
1848, E. D. SILVER, M.D., Reg. Coll., in _Diseases of the Rectum
and Anus_; Simpkin, Marshall & Co, London:
Omits mention of the rectal valve.
1851, HORNER, _Special Anatomy and Histology_, Vol. II, p. 47;
Philadelphia:
“At a corresponding part on each side of the gut, in its interior,
exists a transverse doubling of the mucous membrane, forming the
valvula conniventes alluded to. The result of this arrangement is a
semicircular valve on each side, one above the other, the margins and
diameters of which pass each other in the empty and contracted state
of the rectum, but touching at the same time, and they present an
additional barrier to the involuntary evacuation of feces.”
1853, HYRTL, _Topographic Anatomy_:
Regard for brevity justifies quotation under Chadwick, 1878.
1855, RICHARD QUAIN, F.R.S., in _Diseases of the Rectum_; Walton &
Maberly, London:
Omits mention of the rectal valve.
1860, T. J. ASHTON, in _Rectum and Anus_; Blanchard & Lea,
Philadelphia:
Omits mention of the rectal valve.
1865, HENRY SMITH, F.R.C.S., in _Surgery of the Rectum_, Fourth and
Fifth Editions; J. & A. Churchill, New Burlington Street,
London:
Omits mention of the rectal valve.
1866, HENRY LEE, F.R.C.S., in _Affections of the Rectum_; John
Churchill & Sons, New Burlington Street, London:
Omits mention of the rectal valve.
1870, WM. BODENHAMER, _Physical Exploration of the Rectum_; William
Wood & Company, New York:
“The idea of calling these small folds valves, and then of their
becoming relaxed and prolonged, except in a diseased state, so as to
form a barrier or an obstruction to the passage of the feces, is, to
say the least of it, hypothetic. If ever such cases occur, they must be
rare indeed.
“The first anatomist, however, who called especial attention to a
valvular arrangement of the rectum, was Mr. John Houston, of Dublin,
Curator of the Museum, and one of the administrators in the School of
the College of Surgery in Ireland. This he did in a very able practical
paper entitled, _Observations on the Mucous Membrane of the Rectum_,
inserted in the fifth volume (1830) of the Dublin Hospital Reports.”
After quoting from Houston the passages already quoted by me,
Bodenhamer continues:
“I have quoted quite sufficient from this ingenious author to present
him fairly, and I hesitate not to say at once that, in my opinion, he
has entirely failed to establish the verity of his statements, _that
the folds or projections of the rectum are genuine valves_; that they
are sufficiently strong to bear the whole weight of the fecal mass,
and to retard its downward movement and cause it to take a winding
direction; and that they exert great opposition to the introduction of
the finger, the bougie, or any other instrument not in the shape of a
corkscrew.
“The anatomic evidence against the existence of veritable valves in the
rectum is corroborated by numerous facts, a few of which I will now
adduce:
“I maintain that the irregular folds of the mucous membrane of the
rectum, supposed to be valves by the several authors I have named, are
not permanent but purely accidental, and are caused by the partial
contraction of the intestine. This can be verified by any one by
carefully examining this membrane _in the same subject on different
days, at such time when the rectum is not distended; and these folds
will be found each time to be more or less changed in appearance, and
to occupy different situations_. Not so with veritable valves anywhere
in the body.
“I further maintain that valves, such as described by Mr. Houston,
capable of supporting the whole weight of the fecal matter collected
in the rectum, and of resisting the introduction of the bougie or the
finger, would most certainly be easily distinguishable and demonstrable
in the living body; _and in the dead body the removal of the organ
ought not to obliterate them_, but, on the contrary, that they should
be capable of being demonstrated easily, and at any period previous to
decomposition.
“I deny most positively that these plicae, except in an indurated or
diseased state, are ever firm and unyielding; on the contrary, they are
soft, pliable and unresisting, being easily displaced by a proper-sized
bougie, or, if in reach, by the extremity of the index-finger, either
being well lubricated, and gradually introduced into the rectum. Should
there be resistance, it will be found not to be occasioned by valves,
but either by fecal accumulation, by the promontory of the sacrum, by
contraction of the rectum, by one or more tumors, by chronic irritation
or inflammation of the mucous lining, by spasm in nervous and irritable
subjects, etc. I have often found that a small-sized rectal bougie--say
a No. 2 English--will be apt to become hooked or entangled in these
folds or superabundant membrane, while one of a much larger size will
so dispose of them as to pass readily. A small sound, as a general
rule, the organ being in a normal and healthy state, will often
encounter much more resistance than a larger one, as any one must have
experienced who has frequently sounded the rectum or urethra.
“Veritable valves contain muscular fibers, and are capable of
firmly constricting the bowel, and can never be entirely effaced by
distention, I care not how far it is carried in length and in width;
_not so these irregular folds, for they may be completely defaced_”
(effaced) “_by this process_.
“_Veritable valves sufficiently large and strong to obstruct or dam
up this inferior extremity of the rectum is simply ridiculous; such
never have, and, in my opinion, never can be demonstrated_, the able
authorities I have quoted to the contrary notwithstanding. I admit that
these accidental folds of the rectum resemble the valvulae conniventes
of the small intestines; that they look like valves; _yet they lack the
essential attributes, and, consequently, are not valves_.
“The foundation of Mr. Houston’s error in relation to these folds
of the mucous membrane of the rectum, was his peculiar method of
investigation. He did not examine this membrane in its natural state,
indeed, his procedure was anything but natural, although he intimates
that it is the only method by which the condition of these valves, as
he calls them, can be displayed.”
1876, T. B. CURLING, F.R.S., in _Diseases of the Rectum_; J. & A.
Churchill, New Burlington Street, London:
Omits mention of the rectal valve.
1877, DANIEL MOLLIÈRE, in _Maladies du Rectum et de l’Anus_; G.
Masson, Éditeur, Libraire de l’Académie de Médecine, Paris:
Omits mention of the rectal valve.
1878, CHADWICK, _Transactions of the American Gynecological
Society_, Vol. II, page 43; Houghton, Osgood & Company,
Cambridge:
“Hyrtl (1853), in his treatise on Topographical Anatomy, devotes three
pages to the consideration of what he designates as the _sphincter ani
tertius_. From his description the only inference is that Hyrtl has
generally found a bundle of muscular fibers so encircling the rectum
as to exercise the function of a sphincter, at least when the other
sphincters are for some reason inoperative. On inflating rectums,
however, in accordance with the directions given by him, it is rather
surprising to discover that no such annular constrictions appear. At
the point of the rectum designated by him is, nevertheless, observable
a semicircular constriction of the rectum confined to the anterior
wall; corresponding to this, but an inch or more higher up, is always
seen a second semicircular constriction affecting the posterior
wall only. If, now, the rectum be cut open, and its mucous membrane
dissected off, as directed by Hyrtl, each of these two constrictions
may be demonstrated to consist, as he says the ‘third sphincter’ does,
of an agglomeration of the circular muscular fibers of the rectum. I
am able to show you seven rectums taken from dissecting-room subjects,
from which we dissected off the mucous membrane after cutting them open
longitudinally. In all of these you cannot fail to find corroboration
of my statements in the presence of two distinct masses of circular
fibers, each encircling about half the circumference of the canal.
“If, now, a mass of feces be supposed to advance through the rectum,
following the sinuosities, it is evident that _these bundles of fibers,
when not in active contraction, would present scarcely any obstacle to
its progress_. It is further noticeable these partial constrictions of
the canal differ only in degree from the constrictions visible in the
higher segments.
“At about 2½ inches from the anus the finger encounters a confused
mass of folds through which the continuance of the canal can only be
discovered by considerable burrowing. Here an annular constriction,
diminishing the lumen by about one-half, seems to be felt.
“If, now, the rectum be distended with water, the finger will almost
invariably detect, in place of the lax folds, what still seems to be an
annular constriction, but which a more careful examination will show
to be composed of two distinct semicircular bands slightly overlapping
each other, the posterior being somewhat higher than the anterior.”
Chadwick continues: “Being familiar with the views of Nelaton, Hyrtl,
and others, I at first sought to assign to this apparent constriction
of the rectum sphincteric functions, but soon had to relinquish that
idea, for the exploration of very many _rectums in the living failed to
reveal a single one in which the lumen of the supposed sphincter, when
quiescent, had a smaller diameter than three-quarters of an inch, while
in the majority it was over an inch_.
“These anatomical and clinical observations all tend to indicate that
the term _‘third sphincter ani,’ applied by Hyrtl to these constricting
bands, is a misnomer, and to show that they are simply a part of the
general circular layer of muscles_, whose function is to dilate before
and contract behind the scybala, thereby propelling them on their way
and not retarding them.”
Chadwick concludes, saying: “Having seemingly _elucidated the true
function of the ‘third sphincter ani,’ and proved by the above
observations that it should more properly be termed a detrusor faecium,
if deserving of any special appellation_, my attention was next
directed to the action of the internal sphincter.”
1879, W. H. VAN BUREN, M.D., on _Phantom Stricture and other
Obscure Forms of Rectal Disease; The American Journal of the
Medical Sciences_, October, 1879:
“The walls of the rectal pouch tend to fall into lose folds when empty,
and they present also certain slight permanent partial constrictions
or narrowings. The uppermost one of these corresponds with the level
at which the rectum gets its complete peritoneal investment. A normal
narrowing at this point has been already frequently recognized, and
the fact has been confirmed, by good observers, in the experiments in
manual exploration recently practised upon the rectum.
“Other writers have described slighter and more or less constant
permanent narrowings at and below this point of the rectum as a ‘third
sphincter,’ and, in fact, have cumbered the archives of surgery with
a good deal of _fruitless speculation concerning an organ to which
anatomy and physiology have been equally unsuccessful in assigning
either certainty of location or certainty of function_.”
1881, GEORG KOEHLER, prakt. Arzt, _Darmresection bei Carcinom des
Dickdarms_; A. Neumannische Buchdruckerei (C. Ducius) in
Breslau, Altbüsserstrasse 42:
Omits mention of the rectal valve.
1882, DR. VICTOR PATZELT, _Ueber die Entwicklung der
Dickdarmschleimhaut_; in Commission bei Carl Gerold’s Sohn,
Buchhändler der kaiserlichen Akademie der Wissenschaften:
Omits mention of the rectal valve.
1884, OSCAR JULIUSBERGER, prakt. Arzt, _Beiträge zur Kenntniss
von den Geschwüren und Stricturen des Mastdarms_; Druck von
Grass, Barth u. Comp. (W. Friedrich), Breslau:
Omits mention of the rectal valve.
1886, HERMANN KUMMELL, _Ueber hochgelegene Mastdarmstricturen_; Druck
und Verlag von Breitkopf und Härtel, Leipsic:
On page 2634 briefly refers to Hyrtl’s Sphincter ani tertius and to the
Falten des Rectums.
1886, SAMUEL BENTON, L.R.C.P. (London), M.R.C.S. and L.H.
(England), in _Diseases of the Rectum_; Henry Renshaw, 356
Strand, London:
Omits mention of the rectal valve.
1887, DR. FRIEDRICH ESMARCH, _Die Krankheiten des Mastdarmes und
des Afters_; Verlag von Ferdinand Enke, Stuttgart:
On pages 7 and 8 says: “Only one large transverse fold does not
usually disappear under complete dilatation because the longitudinal
muscular layer passes outside of this; this fold is situated about
.6 to .8 cm. above the anus at the junction of the middle and upper
division of the rectum, and does not include the whole circumference,
but arises for the most part somewhat obliquely as a sickle-formed
fold of mucous membrane projecting, at the most, 15 mm. from the right
and anterior walls of the rectum. Kohlrausch has called this fold the
plica transversalis recti. As it not seldom contains distinct circular
muscular fibers it has been described by several authors [Houston (?),
Hyrtl] as the sphincter ani tertius....
“Inflammatory and cancerous strictures often occur in this situation.
In addition, a similar fold is often found also in the region of the
sigmoid flexure.
“In rarer cases, also, transverse folds, which do not disappear on
inflation” (of the gut) “are found in other situations; these folds are
probably _due to a coalescence of the opposing walls of short lateral
curvatures_.”
1887, ALFRED COOPER, F.R.C.S., in _Diseases of the Rectum_; H. K.
Lewis, 136 Gower Street, W. C., London:
Omits mention of the rectal valve.
1887, WALTER J. OTIS, M.D., _Anatomische Untersuchungen am
menschlichen Rectum_; Veit & Company, Leipsic:
Elaborate investigation on the cadaver led him to say: “The rectum
consists of large sacular dilatations marked off from each other by
intermediate partitions or folds, projecting alternately from left
to right, one beyond the other.” And agreeing with Houston, he says:
“These partitions or folds are semilunar in shape, involve rather more
than one-half of the circumference of the internal surface, extend a
little farther on the anterior than on the posterior wall and project
at the center, where they are deepest, from one to two and a half
centimeters into the lumen of the bowel.” The number of visible folds
of this kind found by him was always two or three, two of which were
constant, the other variable. He locates these valves as did Houston,
and continues: “The folds described within the bowel are _composed
of mucous membrane and bands of circular muscular fiber in greater
or less proportions_. The longitudinal fibers do not enter into the
construction of the folds....
“_The physiologic action of this arrangement of the circular fibers I
believe to be as Chadwick has described, viz., that it is a part of
the expulsory apparatus of the intestine to propel the feces toward
the anal outlet, rather than to offer an obstacle to their descent._”
Continuing, Otis suggests: “That the divisions between the sacculi
which Houston described as the ‘Valves of the Rectum,’ Kohlrausch as
‘Plica Transversalis Recti,’ and Bauer as ‘Die Falten des Mastdarms,’
be called _plicae recti_, and as they are placed on the sides of the
rectum, that they be designated as _right_ and _left plicae_. That
the lowest plica on the right, which is the _plica transversalis_ of
Kohlrausch, be always known as such.”
1888, WM. ALLINGHAM, revised by Herbert Wm. Allingham, in _Diseases
of the Rectum_, Fifth Edition; J. & A. Churchill, 11 New
Burlington Street, London:
Omits mention of the rectal valve.
1889, MARTIN SIHLE, _Ein Beitrag zur Statistik der
Rectumcarcinome_; Schnakenburg’s Buchdruckerei, Dorpat:
Omits mention of the rectal valve.
1890, W. H. VAN BUREN, M.D., LL.D. (Yale), in _Diseases of the
Rectum_; D. Appleton & Company, New York:
Omits mention of the rectal valve.
1890, HARRISON CRIPPS, F.R.C.S., in _Diseases of the Rectum and
Anus_; J. & A. Churchill, London:
Omits mention of the rectal valve.
1890, LE D’ANDRE JACQUINOT, in _Rétrécissement Vénérien du Rectum_;
G. Steinhall, Éditeur, 2, Rue Casimer Delavigne, Paris:
Omits mention of the rectal valve.
1891, DR. JOSEPH SCHAFFER, _Beiträge zur Histologie menschlicher
Organe_; in Commission bei Carl Gerold’s Sohn, Buchhändler
der kaiserlichen Akademie der Wissenschaften:
Omits mention of the rectal valve.
1892, DR. RUDOLF FRANK, _Ueber die angeborene Verschliessung
des Mastdarmes und die begleitenden inneren und äusseren
angeborenen Fistelbildungen_; Verlag von Josef Safar, Wien:
Omits mention of the rectal valve.
1892, EDMUND ANDREWS, M.D., LL.D., and EDWARD WILLIS ANDREWS,
A.M., M.D., in _Rectal and Anal Surgery_; W. T. Keener, 96
Washington Street, Chicago, Ill.:
Omits mention of the rectal valve.
1893, KELSEY, _Diseases of the Rectum and Anus_, page 26; William
Wood & Company, New York:
“It is now about half a century since Nelaton, (1845) first described
the third sphincter muscle, and in spite of all that had been written
concerning it since that time, it is only a few years since Van Buren
(1878) characterized it as an organ to which anatomy and physiology had
been equally unsuccessful in assigning either certainty of location or
certainty of function. For the original description of the muscle by
Nelaton we are indebted to Valpeau, who writes that he has verified the
existence of a sort of sphincter of the rectum, lately discovered by
Nelaton, and goes on to say that it is a _muscular ring situated about
four inches above the anus_, just in the place where retractions of the
rectum are most often found. _If, after turning the rectum so that its
mucous surface is external_, it is moderately distended by inflation,
the muscles will be seen to be made up of fibers collected into bundles.
“Sappey admits its frequent existence, and locates it at the level of
the base of the prostate, in the middle portion of the rectum, six,
seven, eight or sometimes nine centimeters from the anus. It never
completely surrounds the rectum, but only one-half or two-thirds
its circumference; and it appears to him to be caused by a grouping
of the circular muscular fibers. Its breadth is one centimeter, and
its thickness two or three millimeters. Situated sometimes in front,
sometimes behind, and again laterally or antero-laterally, it is
constant in nothing except its direction, perpendicular to the axis of
the bowel. In place of one he has sometimes found two bands at opposite
points and different levels, and in one specimen there were three.
Henle adopts Sappey’s description in the main. Petrequin found the
muscle irregularly oblique, less marked in the front wall than in the
back, and consisting of a weak band of fibers.”
After these references Kelsey comments as follows: “_The third
sphincter muscle and the valves of mucous membrane in the rectum are
not, as might be supposed, one and the same thing, though it is true
that they have become almost hopelessly confounded in surgical and
anatomical literature_, and are often spoken of as identical. The
valves of the rectum, _we use the word simply as expressing the folds
of the mucous membrane_, were first described by Houston at about the
same time that Nelaton described the superior sphincter; and it is
worth remembering that the two authors _were writing about two entirely
different things, and two things which stood in no necessary relation
to each other, so far as we may judge from their descriptions_.
“According to this first and clearest of all descriptions--for the
whole article (Houston’s) is written with a force and clearness of
style which have perhaps had an undue weight in disarming criticism
as to the facts--the valves exist in all persons, but vary much in
different individuals as to location and number.”
Kelsey quotes Houston’s description, which has already been quoted by
me, and in contravention says: “The palpably weak points in Houston’s
article were very soon pointed out by O’Bierne (1833) in a work of
marked and almost amusing originality. O’Bierne seems rather to
regret that he is unable to accept Houston’s statements as to an
anatomic condition which would account so fully and so easily for
the physiologic emptiness of the rectum and fulness of the sigmoid
flexure on which his (O’Bierne’s) own views depend; but nevertheless
he sets himself to the task of demolishing them with great vigor
and considerable success. Although he believed the rectum to be
normally empty, except just at the time of defecation, he believes
that condition to depend upon the anatomic arrangement of the sigmoid
flexure joined with the narrowing of _the upper end of the rectum,
which is entirely independent of any folds of mucous membrane_. He not
only denies the existence of any such folds, but stated flatly that
Houston is altogether incorrect in his statement that Cloquet (1828)
or any other anatomist before his (Houston’s) time (1830) makes even
the slightest allusion to them. He (O’Bierne) believes _the folds to
have been produced by the method of making the preparations, distending
and hardening all the parts with spirit before making the incision_,
and asserts that this method is anything but natural, and nothing more
nor less than an attempt to exhibit natural appearances by placing the
parts in an unnatural situation--such a situation, indeed, as is not
known to be necessary for the exhibition of the valvulae conniventes
or any other valve of the body. _He_ (O’Bierne) _meets the statement
that by the ordinary procedure of distending the rectum after removal
from the body the valves are made to disappear, by the question, why,
if such valves really exist, and if muscular fibers enter into their
structure, they should not be discoverable at any time after death, or
in any state of the intestine--a question very difficult of solution._”
Kelsey, continuing, says: “Four years later (1837) the voice of a New
York surgeon was raised against these folds, and in almost the same
language as O’Bierne’s, though from an entirely different standpoint.
Bushe[3] (1837) declares that he has never in the living body, been
able to detect any valve of such firmness and capable of exerting any
such influence upon the descent of the feces as Houston describes,
though he has frequently met with accidental folds produced by the
partial contraction of the bowel. He (Bushe) points out that, by _the
method of hardening the rectum after distending it with spirit, the
accidental folds are rendered permanent by the induration resulting
from the action of the alcohol; and that, by the method of inflating
and drying, the projections resembling valves are produced by the
angles formed by the setting of the intestine during the process of
desiccation_.”
Referring to Otis’s investigations Kelsey says: “Except this
description of the arrangement of the muscular fibers and folds of
mucous membrane is more exact and definite than any previously given,
and as to this constancy of location my own observation does not lead
me to entirely agree, the author’s conclusions from his dissections are
_not different from those of other writers_.”
Kelsey, in his edition of 1898, repeats the substance of his discussion
just quoted.
Kohlrausch locates one important fold, the plica transversalis recti,
at the same point that Houston locates the most constant of the valves,
projecting well from the right side of the bowel, forming a little
more than a semicircle and running farther on the anterior than on
the posterior wall. Kohlrausch says that this fold is known as the
sphincter ani tertius, though he does not think that the anatomic
conditions justify the title, _as the circular muscular fibers do
not enter into the structure and are not developed more here than
elsewhere_.
Sappey describes the bowel in its empty state as presenting various
folds of mucous membrane, having no determinate direction, and but
slightly marked. Of 30 rectums examined, he found but three that answer
at all to Houston’s chief valve or Kohlrausch’s plica transversalis
recti. _He says that there is no proof that these folds persist when
the rectum is full, but that they probably are effaced by distention,
and that it is an abuse of language to apply the name valve to them._
Henle says that there is but one permanent valve, the “plica
transversalis recti,” which is present only in a minority of subjects.
Rosswinkler describes and locates two folds, but locates them
differently from several of the other authorities.
1893, MATHEWS, _Diseases of the Rectum, Anus and Sigmoid Flexure_,
page 37; D. Appleton & Company, New York:
Declares he has not been able to find the valve, and discussing this
subject, asks: “Is there a third sphincter muscle?” and answers that
Kelsey, in his work on the _Diseases of the Rectum and Anus_, page 39,
says: “From a study of the literature of this question, and from the
results of dissections and experiments which we have been able to make,
we are led to the following conclusions:
“1. What has been so often and so differently described as a third or
superior sphincter ani muscle is in reality _nothing more than a band
of areolar muscular fibers of the rectum_.
“2. This band is not constant in its situation or size, and may be
found anywhere over an area of 3 inches in the upper part of the
rectum.
“3. The folds of mucous membrane, _which have been associated with
these bands of muscular tissue stand in no necessary relation to them_,
being inconstant and varying much in size and position in different
persons.
“4. There is nothing in the physiology of the act of defecation as at
present understood, or in the fact of a certain amount of continence of
feces after extirpation of the anus, which necessitates the idea of the
existence of a superior sphincter.
“5. _When a fold of mucous membrane is found, which contains muscular
tissue, and is firm enough to act as a barrier to the descent of the
feces, the arrangement may fairly be considered an abnormality, and is
very apt to produce the usual signs of stricture._”
Mathews then adds: “The only exception I would make to any of these is
to note 2, which says, ‘This band is not constant in its situation or
size.’ I would beg to amend by saying that the band in many instances
is entirely absent. I quite agree with all these conclusions of Kelsey,
but would relegate the third or superior sphincter ani muscle to the
company of ‘Houston’s valves,’ and to the ‘pockets and papillae.’”
Mathews, in his edition of 1897, repeats these statements, and adds
that he believes “the rectal valve exists only in the author’s mind’s
eye.”
1894, CHARLES B. BALL, M. Ch. (Univ. Dub.), F.R.C.S.I., in _The
Rectum and Anus, their Diseases and Treatment_; Lea Brothers
& Company, Philadelphia:
Omits mention of the rectal valve.
1896, A. ERNEST MAYLARD, M.B., B.S. (Lond.), in _Surgery of the
Alimentary Canal_; P. Blakiston, Son & Company, 1012 Walnut
Street, Philadelphia:
Accepts Houston’s views without qualification.
1896, BERT B. STROUD, _Annals of Surgery_, July:
“_Anal Pockets._ The pectineal dentations are not usually equally
developed. But in rare instances two large ones adjoin, and the
depression between them is a large foliated sac or pocket. The walls
of this pocket contain numerous sacculi Horneri. The outer side of the
pocket is formed by a substantial fold of epithelium which unites the
two dentations. In the cases examined each terminated in a well-marked
papilla. _The fold has the appearance of a valve, which, if it were
sufficiently developed, might be of service in helping to retain the
feces under unfavorable conditions._ This, so far as I have been able
to determine, is a human peculiarity and not constant. It also, like
the papillae, has been described as pathologic.
“_Considering these facts, a question naturally arises, Is not
Nature in the process of evolving for man additional organs for his
convenience and safeguard? A careful compilation of statistics at
intervals, of say each generation, would throw light on this question._”
This interesting speculation was, however, preceded by the fact
itself, which is shown by the existence of a _rectal_ valve, as will
subsequently be incontrovertably demonstrated.
1896, GANT, _Diseases of the Rectum and Anus_, page 10; The F. A.
Davis Company, Philadelphia:
“Internally the rectum presents three or four transverse folds.
According to Houston the largest one is situated three inches above the
anus,” etc., quoting Houston; and in conclusion Gant says: “_The folds
become almost obliterated when the bowel is distended._”
* * * * *
This literature makes it obvious that there is an imperfectly
understood anatomic feature in the rectum.
It is not improper to assume that, if the judgment of trained observers
be equal, their description of the thing considered will vary in
the main, only as does the medium through which the view of each is
obtained. Our critic review of the literature on this subject has
revealed two important facts: that observers employing like means of
investigation adduce almost identic evidence, and that the more nearly
the method of one approaches that of the other the more in accord are
the conclusions reached. By the employment on both living and dead
subjects of the methods used by the various observers, I have secured
results similar to theirs, which, when considered collectively and in
comparison with the results of my recent researches, are practically
and logically as harmonious as they have heretofore appeared
contradictory, which proves that for about one and three-quarter
centuries these gentlemen have been discussing the same anatomic
feature, but have observed it from quite different points of view.
Houston distended and hardened the rectum in situ with spirit. On
mesial section of the subject the gut presented valve-like folds with
unvarying constancy but in varying number, and in different location
in different subjects. He declared their structure to be a duplicature
of mucous membrane and bundles of circular muscular fibers _only_.
Others recognizing that in moderate distention the mucous membrane is
loosely adherent in the lower rectum, insist that under the conditions
employed by Houston the membrane would assume the same appearance as
that described by him, and therefore conclude that these features are
accidental folds and not valves; and, as _Houston did not support
his statement by attributing to these valves the histologic element
which histologists recognize as the essential feature of a valve_, the
opinion of his opponents is seemingly reasonable, but is nevertheless
a mistake.
Hyrtl employed atmospheric distention after removal of the gut, and
observed an appreciable thickening of the wall of the rectum beneath
the mucous membrane, and with apparent reason assumed this thickening
to be muscle only. Under the same manipulations a valve may be made to
lose its valvular form and seem to support this view.
Velpeau supported Nelaton’s claim for the superior sphincter by
removing the rectum and _turning it inside out_, so that its mucous
membrane was external, and then by inflation demonstrated a marked
constriction on the now external surface, which was distinctly claimed
to be nothing other than a muscular band. It is not difficult to
understand how the true valve within the normally situated gut would
appear as a constricting band when the rectum is removed and turned in
the manner described.
Horner’s observations are put to the question.
Chadwick discovered by digital exploration the lowermost of the valves,
which he declared to be a detrusor fecium muscle _only_ instead of
a valve. I find that these valves, when not the seat of disease,
though often discoverable, frequently elude the finger of average
length, or if high up, are inaccessible to it. As the uppermost valve
is seldom less than nine inches (22.86 cm.) from the anus, this
means of determining their presence is not usually satisfactory.
This was proved by an instance: a subject was examined in which the
lowermost semilunar valve was malformed into a congenital annular or
diaphragmatic stricture with a circular aperture, which, although at
times within three inches (7.62 cm.) of the anal verge, escaped my
digital perception and that of a dozen other medical men in attendance
at my clinic and was not discovered until subsequently revealed by
proctoscopy.
Otis’s methods of inquiry were direct and to him must be accredited
the achievement of making the first positive ocular demonstration of
the existence of the valves. He, however, like Houston, attributes to
this band no especial structural element other than is found at any and
all parts of the intestinal tube. He agrees with Kohlrausch, and calls
the largest band the _plica transversalis recti of Kohlrausch_. And he
agrees with Chadwick that “its function is expulsory only.”
The photographic reproductions here published are documentary evidence
of the existence of the obstructions under discussion. The sketch, Fig.
33, which was drawn from the valve while under the microscopic lens,
exhibits the character of these obstructions and proves it that _of a
typic anatomic valve_, and the absence of permanent bands of any other
character in this organ is evidence that the semilunar valves and the
so-called plica transversalis recti, Falten des Rectums, sphincter
ani tertius, superior sphincter, and detrusor fecium muscles are one
and the same thing and this thing is essentially a valve. It is most
prominent when the gut is most distended.
THE CHRONOLOGY OF ATMOSPHERIC INFLATION OF THE RECTUM FOR ITS
INSPECTION.
Proctoscopy has proved an open sesame to a newer proctology.[4] As
there seems to be some confusion of opinion concerning the time of
its origin and the chronology of its evolution, the present time is
opportune for a brief historic review of the subject.
In 1845 Dr. J. Marion Sims[5] discovered by a chance that a hollow
or tubular pelvic viscus would inflate provided the orifice were
opened at a time when the patient’s hips were higher than the
chest. He elaborated the manner of this discovery to a method of
procedure. He first used the knee-chest posture, and subsequently the
semiprone-semiflexed position with elevated hips. This posture became
known as Sims’ posture, and the instrument which he designed as Sims’
speculum. The first published account of his method appeared in 1852,
in the January number of the _American Journal of the Medical Sciences_.
In 1871 Dr. Wm. H. Van Buren,[6] of New York, was the first to publish
an account of the use of the identical postures and Sims’ speculum for
atmospheric inflation and inspection of the rectum and sigmoid flexure.
In 1882 Dr. Wm. Allingham[7] employed elevation of the patient’s hips
and a tubular speculum, and achieved the same results. In subsequent
editions of his book in 1888 and 1896 he repeats a description of his
rather crude operation for inspection of the rectum through a cylindric
tube.
In 1887 Dr. Alfred Cooper[8] described a similar posture, and suggested
the use of two retractors for the purpose of opening the anus.
In 1887 Dr. Walter J. Otis,[9] of Boston, published in Leipsic a
monograph on the subject of rectal inspection, and described the use of
the knee-chest posture and of two retractors.
In 1887 Prof. Esmarch[10] described a method similar to that of Dr.
Otis.
In 1895 Dr. Howard A. Kelly[11] described a method of proctoscopy by
means of tubular speculums which are very similar in construction to
those of Dr. Edmund Andrews, which Dr. Andrews first described in 1887.
Dr. Kelly’s article, however, was the first to catch the attention of
the general profession, and to him is due the credit of pointing out
to a multitude of physicians the possibility of rectal inflation for
inspection by such means. Kelly’s technic and tubular speculums are far
superior to those of Mr. Allingham, who first employed a similar method
in 1882.
In 1896 I published in the July number of _Mathews’ Quarterly Journal
of Rectal and Gastro-Intestinal Diseases_, under the title of
“Proctocolonoscopy and Its Possibilities,” a description of a technic
and new instruments which increased the areas exposed to view, and
which facilitated access to the part for the treatment of disease.
In 1896 A. Ernest Maylard[12] briefly referred to the various methods.
Review of the literature on rectal inflation for rectal inspection
establishes the fact that Van Buren is entitled to the credit for
priority; that Marion Sims was the discoverer of the possibility of
atmospheric inflation of the hollow pelvic viscera; that there is much
similarity in the methods of the various operators quoted, some using
similar instruments and dissimilar technic, and _vice versa_; and it is
made obvious, also, that he who would most insist upon a credit for
originality must sometimes discount with the erudite his reputation for
literary research.
The time has arrived when the profession must recognize that the
rectum need no longer be regarded a darkest continent. There remains,
however, something further to be desired in the way of an easier and
more convenient method of manipulation to secure inspection, but I am
confident that ere long the profession will accept the newer mechanic
means and contrivances which will render a proctoscopy of as practical
simplicity as is laryngoscopy. But it behooves us to remember the words
of Dr. Edmund Andrews: “The false method is that of the bungler and
amateur, who is only right by haphazard; the true one is that of the
professional expert, who can not be balked by petty obstacles, but who
will reach success when others have failed, not less by his dogged
persistence and thoroughness than by his superior knowledge.”
THE EXAMINATION OF THE RECTUM.
It has been complained that the best methods proposed for the
inspection of the rectum require so expensive an armamentarium and such
painstaking practice on the part of him who would see, that the general
practician can not hope to invade with his keen glance this field which
is generally regarded a terra incognita. On the contrary, as shall be
seen, no artificial means whatsoever are required for a complete ocular
inspection of the rectum.
The elevation of the hips which sets in operation that principle of
physics which governs the methods of Marion Sims’ vaginal inspection
(1845), Van Buren’s rectal inspection (1871), and the methods of the
senior Allingham (1882), of Walter J. Otis (1887) and of Howard Kelly
(1895), which controls my own proctocolonoscopy (1896), and which
suggested Trendelenburg’s posture, is, also, the chief feature of the
simplest proctoscopy.
NONINSTRUMENTAL INSPECTION OF THE RECTUM.
The essentials to this simplest method are a patient, an assistant and
an operator having at least one finger on each hand. The patient is to
be put into the knee-chest posture, the assistant is to put and to hold
the patient, and the physician’s fingers are to be used to open the
anus, all in the following manner, to wit:
1. The patient is to be completely anesthetized as he lies on his back,
and then turned toward the assistant and into Sims’ posture.
2. The assistant is to station himself at the patient’s knees. In his
left hand he is to grasp the patient’s feet. He is to lean himself
against the patient’s knees. He is to pass his right arm under the
patient’s hips. Now steadying the feet and bearing himself firmly
against the subject’s knees, with his right arm he is to lift the hips
and pull the patient into the knee-chest posture, where he is to be
balanced on his perpendicular right thigh throughout the whole time of
the physician’s manipulations.
[Illustration: FIG. 1.--Positions of the hands for the practice of the
simplest method of proctoscopy.]
[Illustration: FIG. 2.--Positions of the fingers for the practice of
the simplest method of proctoscopy.]
3. The physician is to close his hands and to point each index-finger
as shown in the accompanying illustration (Fig. 1). The wrists are
to be crossed, the hands placed back against back, and the nails
of the index-fingers placed one against the other, as shown in the
accompanying illustration (Fig. 2). The physician is to lubricate these
fingers and gently insinuate them through the anus and place their
ends beyond the borders of the levatores ani. This accomplished, the
anus is to be divulsed in the direction of the ischial tuberosities,
by the physician forcibly parting his fingers as is shown in the
accompanying illustration. Under this manipulation the rectum becomes
atmospherically inflated.
Now, provided the physician lowers his head to the level of his
fingers and then rises again, or stoops, or moves a little from side
to side, he may command under his eye a view of the interior of the
atmospherically inflated rectum to the depth of six or eight inches
(15.24 or 20.32 cm.), and in some instances he may behold even a part
of the sigmoid flexure.
It is possible for the operator to manipulate his patient and to finish
his inspection within two and a half or three minutes, provided the
patient be in a state of complete anesthesia.
If this method is practised, as I am persuaded it may be with facility
by the general practician, I am convinced that the greater number of
rectal diseases may be instantaneously diagnosed. But I must declare
that here at diagnosis, the achievement of the simplest proctoscopy
ends, for the reason that the operator’s hands are so full of his
patient he can do nothing at all for the disease which he may have
discovered.
Under some conditions and amid some circumstances the rectum will not
inflate. If the bladder is much distended; if there is an inordinate
hypertrophic rectitis; if there is a close tubular stricture of the
rectum; if there is malignant growth or other disease of the rectum
by means of which the gut’s coats have become extensively filled
and fixed with an organized plastic exudate; if for some reason the
extraabdominal pressure is abnormally increased, as it may be by the
bearing down of the patient, or by enormous flatus, or by ascites;
or if there is an impinging uterus, adrectal growth or extensive
infiltrating disease of the contiguous textures, rectal inflation by
this method or by any other which is governed by the same principle may
be a physical impossibility--but this need not baffle the man bent on
seeing by instrumental aid.
Practised as described, when not embarrassed by the exceptions
specified, this method will achieve its purpose and reveal to the
physician that the transverse diameter of the rectum is variable; that
in some places it is not more than an inch (2.54 cm.), in others it is
more than four times this diameter.
The rectum may present to the eye of the imaginative observer the
appearance of a chain of urinary bladders, communicating one with
another by means of irregularly elliptic openings set at varying axes,
and bounded by the nonparallel borders of the rectal valves. In the
normal rectum the air-pressure smooths the mucous membrane evenly over
the entire surface of the gut, as may be observed in the photographic
illustrations. The normal mucous membrane of the so-called ampulla
appears at first wet and of a shining bluish gray. As it dries, under
the influence of gravitation the blue venous tint fades out of the gray
and the wall assumes a pink tint. Presently it acquires the appearance
of parchment, and sometimes it appears painted at rare intervals with
ramifying little arteries which may be crowded and overlapped by the
larger companion veins; the latter are less arborescent and more
suddenly dive and disappear in the bowel-wall. In time, over all there
comes a sheen and the vascular pictures may fade away. These phenomena
appear exactly as described only in the healthy rectum. In the diseased
organ the color varies much.
Should the operator deviate from the described directions for the
manipulation of his fingers and so twist his hands as to divulse the
anus in the anteroposterior direction instead of laterally, he invites
defeat upon himself, for in the male the fixation of the perineum and
the immobility of the coccyx interfere with the requisite dilatation;
while, in the female, the extreme mobility of the perineum and
particularly the backward displaceability of the coccyx will allow
such traction to be made upon the levatores ani as to pull their inner
fibers parallel and almost together, and, in consequence, the wider
the female’s anus be opened anteroposteriorly the closer is it made to
contract laterally to rob one of his view.
INSTRUMENTAL INSPECTION.
Certain paraphernalia and much practice in their use are necessary for
rapid, complete and painless inspection of the rectum.
The _chair_ which is shown in the illustrations was designed by me
to facilitate the placing of the patient in a new posture, which is
equivalent to the knee-chest posture.[13]
[Illustration: FIG. 3.--The chair, illumination-apparatus,
shoulder-suspender, and small pillow.]
[Illustration: FIG. 4.--The chair in the horizontal posture for
anoscopy.]
[Illustration: FIG. 5.--The position of the chair for the new posture
of the patient.]
Fig. 3 exhibits the chair and the attached illumination-apparatus in
the first position to receive the patient. Fig. 4 shows the chair and
illumination attachment in the second position, and Fig. 5 shows the
chair and illumination-apparatus in the position for the third step in
the procedure. Fig. 3 shows, also, hanging from the head of the chair,
a small pillow and the shoulder-suspender.
[Illustration: FIG. 6.--The anoscope.]
[Illustration: FIG. 7.--The obturator.]
[Illustration: FIG. 8.--The ointment applicator.]
The _anoscope_ (Fig. 6) consists of a short cylindric tube open at
the ends. It is two inches (5.08 cm.) in length and seven-eighths of
an inch (2.22 cm.) in diameter. The proximal end is provided with a
trumpet-shaped expansion and a strong handle. The distinctive feature
of the anoscope is the peculiar form of its obturator (Fig. 7), which
has a capacity for a multiplicity of uses.
The _obturator_ consists of a hard-rubber cylinder, in the middle
of which is fixed a brass tube for the purposes of irrigation. Its
surface is fluted in such a manner that it may be made to lock in any
of several positions upon a tubercle within the cylinder. These flutes
also provide for escape from the rectum of fluids and gases under
certain conditions. The contracted neck near the distal end of the
obturator provides a cup to facilitate the application of ointments to
certain rectal areas.
[Illustration: FIG. 9.--The two-way irrigator.]
The contracted neck is a feature which contributes to the instrument’s
usefulness as a means for irrigation, providing in the one case a
self-retaining direct-flow irrigator, and in the other case when locked
in the position shown in Fig. 9, an unobstructed two-way irrigator.
Platinum pins connect the centrally-placed brass tube with the surface
of the neck of the obturator, which makes the instrument an anal
electrode.
[Illustration: FIG. 10.--The proctoscope.]
The _proctoscope_ (Fig. 10) is of the same diameter as the anoscope,
and is four inches (10.16 cm.) in length, which, because of the
displaceability of the pelvic floor is usually of sufficient length to
reach as high as the promontory of the sacrum, except in some especial
instances, the management of which exceptions will be treated of in
another place.
_Special preliminary preparation_ of the patient is ordinarily not
required, as the usual condition of the rectum is that of emptiness.
In some cases, however, it facilitates the inspection if the patient
employs rectal lavage an hour before the examination. This injection
should not consist of more than one pint of fluid. The excess of this
might be accidentally dejected from the sigmoid and obscure the field
during examination. The bladder should be emptied, since its distention
would necessarily interfere with the accuracy of the examination.
[Illustration: FIG. 11.--The ointment applicator at the time of the
placing of the ointment in contact with a diseased area.]
[Illustration: FIG. 12.--The proctoscope ready for introduction.]
THE TECHNIC.
_Step 1._--The patient should be required to sit on the operating-chair
with his body turned to the left, facing the knee-board. The right knee
should be crossed over the left knee, the left arm should embrace the
right border of the chair-back, or it may be folded at the side as for
Sims’ posture. The small pillow should be held in the patient’s right
hand and against and upon his left shoulder (Fig. 13).
[Illustration: FIG. 13.--Sitting posture of the patient, the first step
toward proctoscopy.]
[Illustration: FIG. 14.--Horizontal posture of the patient for
anoscopy.]
_Step 2_ consists in shifting the chair to the horizontal position
shown in Figs. 14 and 4, and in adjusting the light-fixture. This
movement brings the patient into Sims’ semiprone-semiflexed posture,
without requiring any movement whatever on the part of the patient
after he is properly seated. In this posture, the external anus and
fixed rectum are to be examined.
(_a_) Digital examination and ocular inspection should now be made of
the anal verge, the external anus, and superficial ischiorectal space,
at a moment when the patient is relaxed, and, again, when he is bearing
down.
(_b_) Digital examination of the fixed or anal rectum, also, should be
made preliminary to the introduction of the anoscope.
(_c_) The anoscope should be gently pressed into the anus in the
direction of its axis till the sphincters relax to receive it. The
introduction of an instrument into the rectum may be much facilitated
by placing its lubricated end against the ectal sphincter and requiring
the patient to bear down; bearing down expands the ectal sphincters,
relaxes the levator ani, thins the pelvic floor, or shortens the fixed
rectum, and presses the ental sphincter over the instrument--in other
words, the patient’s anus is made to climb down upon the speculum.
After the introduction of the anoscope, its obturator should be
removed, and the inspection made. These observations should be made
coincident with the withdrawal of the anoscope. In cases of extremely
sensitive ani, a skillfully put hypodermic injection into the
sphincters of 10 or 20 minims of ⅒ of 1% solution of cocain may render
anoscopy painless.
A desire for precision requires that _lesions of the fixed or anal
rectum_ should be noted as occupying a given quadrant, and as situated
at a given zone, _e.g._, a circumscribed disease may be described as
situated at the ental sphincter zone, and in the left lateral quadrant.
[Illustration: FIG. 15.--Putting the patient into the new posture.]
[Illustration: FIG. 16.--The new posture.]
_Step 3_ (_a_) requires that the shoulder-suspender should be placed
and fixed to the chair, as shown in Figs. 5 and 16, that the knees be
drawn up, so that the thighs are at a right angle to the length of
the chair-top, and that the chair should be tilted to put the patient
in the new posture shown in Fig. 16. The leg foot-board should now be
lowered, and the operator’s stool placed in convenient position.
The illumination-apparatus should now be adjusted, as shown in the
illustrations. In this new posture, which is equivalent to the
knee-chest posture, the abdominal rectum is to be examined.
(_b_) Introduction of the proctoscope requires supported eversion
of the buttocks and steady gentle pressure of the well-lubricated
instrument upon the anus and in the direction of the umbilicus, until
the sphincters are felt to yield, or the patient may be required to
bear down to take the speculum; as the instrument enters the inflatable
movable rectum, it should be pointed toward the promontory of the
sacrum, and subsequently into the sacral hollow. The withdrawal of the
obturator is followed by atmospheric inflation of the rectum.
(_c_) The operator should observe the degree of rectal distention, the
situation and number of the rectal valves, their propinquity to one
another when passive, and the relation of one valve to another at the
time of the patient’s bearing down. Under pressure of the proctoscope
if possible, or the hook if necessary, each valve should be effaced or
displaced, and in regular order each of the rectal chambers should be
carefully inspected. A proctoscopic mirror may be necessary for viewing
the supravalvular surfaces (Fig. 18). The examination being finished:
[Illustration: FIG. 17.--The hook for testing the valves.]
[Illustration: FIG. 18.--The proctoscopic mirror.]
_Step 4._--The proctoscope should be withdrawn, the
illumination-apparatus fixed in the first position, the leg foot-board
lifted to its place, the lever extended, the crank turned and the chair
carried back to the horizontal and upright positions, and thus the
passive patient may be returned to his feet by the execution in the
reverse order of the several steps described.
This method of inspection does not subject the patient to struggle,
strain or embarrassment.
Observation by this method has taught me that in nearly all cases of
disease at the anus there is congestion or inflammation of the rectal
mucous membrane.
Those cases in which there is no apparent lesion at the anus, and which
are in a perfunctory way sometimes declared catarrh of the rectum,
will at once have the real condition, such as a high up rectal polypus,
congenital or organic stricture or ulceration, positively diagnosed,
and will be made accessible for intelligent treatment.
New growths and ulcerations may be seen and by means of a long-handled
curet scrapings made in order that the microscopist may determine their
exact character.
Stricture of the rectum need no longer be regarded as of only doubtful
presence, and this method proves positively, even to the casual
observer, how fallacious is the method of rectal sounding usually
employed for the diagnosis of stricture. I have repeatedly proved to
visitors how easy it is for an entering or returning bulb-sound to be
caught and held by the rectal valves,[14] and thereby yielding signs
generally considered diagnostic of organic stricture of the rectum.
Vesicorectal, vaginorectal and other deep fistulas are often apparent
at a glance, but in any case may be discovered by the use of the
proctoscopic mirror.
If this method of ocular examination be practised, I am convinced
there need be no longer any excuse for calling an undiagnosed disease
of the rectum obscure disease, and whatever the disease present this
method makes it susceptible of demonstration by the proctologist to the
attending physician. There is no necessity that a diagnosis be taken on
faith.
TOPOGRAPHIC ANATOMY.
A close study of the lesions of the rectum and their manifestations
and some experience in discussion of these subjects have convinced me
of the necessity of methods of greater accuracy than those generally
employed in designating the precise situation of a pathologic feature
in this organ. Mensural methods of designating the situation of
strictures in the rectum are of no surgical value.
The manner of the application of the details in a given method of
treatment for a disease situated in the fixed or anal portion of the
rectum should differ essentially from that employed in the application
of the same principles of treatment to a similar disease situated in
the movable abdominal rectum; and the application of the details of a
given kind of treatment should differ, too, according to the situation
of the disease at one point or another in the circumference of the
rectum. The prognosis as well as the treatment of rectal disease is
determined not only by the pathologic character of the lesion, but also
by its anatomic situation. “Two inches up,” or “one and a half inches
from the anus,”[15] if one were positively sure of the precise location
referred to as the anus, would point to very different anatomic parts,
whether the subject were male or female, and whether young or old, and
whether thin or stout.
The rectum, the terminal 8 or 10 inches (20.32 or 25.40 cm.)
approximately of the intestine, presents an upper abdominal and
essentially movable portion, which is about three-fourths the length of
the entire rectum, and a lower coccygeoischioperineal and essentially
fixed anal portion, which is about one-fourth the length of the rectum.
The upper half of the movable rectum is, in the majority of adult
persons, completely invested with peritoneum, which sometimes provides
this portion with a mesentery. The lower half of the movable rectum
begins at a point about the upper border of the second sacral bone,
and is not completely invested with peritoneum; the peritoneum is
reflected from the sides of the rectum toward the lateral masses of
the sacrum, so that the posterior wall of this part is not covered
by peritoneum. The movable rectum begins opposite the sacroiliac
synchondrosis. If a subject lies in the dorsal posture, and if the
abdomen be normal, the upper end of the rectum will lie opposite the
left sacroiliac synchondrosis. If the patient is inverted to the
knee-chest posture or its equivalent, and if the abdomen is normal,
the upper end of the rectum, if distended, is usually found nearer the
right sacroiliac synchondrosis. The movable abdominal rectum terminates
at the levator ani muscle.
[Illustration: FIG. 19.--Drawing of specimen No. 281 in the Anatomical
Museum of the Royal College of Surgeons, London. The dissection was
made by Mr. William Pearson. The drawing shows in the lower part of the
field the coccyx, in the upper part of the field the pubes.]
[Illustration: FIG. 20.--Drawing of specimen No. 284 in the Anatomical
Museum of the Royal College of Surgeons, London. The dissection was
made by Mr. William Pearson. The drawing shows in the lower part of the
field behind the rectum the coccyx, in the upper part of the field the
pubes.]
The fixed anal rectum begins at the levator ani and coccygeus muscles.
The levator ani has its origin at the sides of the bodies of the pubic
bones, the coccygeus at the spines of the ischii, and the levator ani
has additional origin from the fascia and bony parts on a line between
these two points. The fibers of these muscles are directed downward
and inward to the fixed anal rectum; many fibers are blended into the
contiguous structures of the pelvic floor. The coccygeolevator muscles
may be compared to an opened slat-fan, the apex having its place at
the anus, and its long border representing the line of origin of the
muscles, Fig. 19. The ental sphincter ani muscle, situated a few lines
below the levator ani, is made up of an aggregation of the fibers of
the circular non-striated muscular intestinal coat, Fig. 20. The ectal
sphincter ani striated muscle is situated immediately beneath the
external skin. It serves the present occasion to describe the ectal
sphincter of the male as a loop of muscle thrown about the terminal end
of the rectum and hitched to the terminal bone of the coccyx, and in
the female as a longer loop of muscle twisted upon itself so as to make
a tandem-loop, which, in the form of the figure eight (8), is thrown
about the vagina and terminal end of the rectum.
In the passive subject the finger discovers the ectal sphincter as a
broad, relaxed band of muscle situated beneath the external skin and
surrounding the infra-anal depression. In action the ectal sphincter is
contracted and is retracted from beneath the external skin to a point
beneath the mixed mucocutaneous integument. In such a state of ectal
sphincter contraction the fixed portion of the rectum is lengthened,
or in other words, the pelvic floor is deepened one-half inch (1.27
cm.), approximately. The finger progressing, it engages the tonicly
contracted ental sphincter muscle which the delicate touch discovers
as vibratory in its grasp of the finger, presenting to the touch the
sense of a sharp rigid ring, and again as a flat band snugly applied
about the finger. A few lines above the ental sphincter the finger
discovers the upper limits of the fixed or anal portion of the rectum
surrounded by the somewhat V- or U-shaped borders of the levator ani
muscle; the anterior quadrant is not encircled by the levator ani.
The fixed portion of the rectum presents, then, to the touch, three
landmarks: the usually relaxed ectal sphincter, the usually contracted
ental sphincter, and the levator ani muscles. The normal levator ani
muscle can not by the contraction of its fibers close the upper end of
the fixed rectum. It is possible, however, for the patient to contract
his levator upon the finger of the examiner to quite an appreciable
degree, a fact which led Mr. Harrison Cripps to state that the levator
ani can close the upper end of the fixed rectum. If a tubular speculum
of seven-eighths of an inch (2.22 cm.) diameter be introduced through
the fixed rectum and then withdrawn through the levator ani to a point
above the ental sphincter and the patient be directed to contract the
muscles of the pelvic floor, it may be observed that the axis of the
fixed rectum is directed more forward at its upper end, and that the
depression between the levatores ani is partially encroached upon by
the levator fibers but is in no sense effaced; hence, we must recognize
that the lower fixed portion of the rectum presents a canal of an
hour-glass form, expanded above as a concavity between the borders of
the levatores ani, narrowed at its middle part by the contracted ental
sphincter, and expanded below where it is surrounded by the relaxed
ectal sphincter muscle.
In the same subject the length of the fixed anal rectum is variable
with a state of activity or passivity, and in a state of activity there
are variations in its length of at least one inch (2.54 cm.) between a
contracted, uplifted pelvic floor and that of a depressed floor with
anal eversion; both of which conditions may rapidly follow one upon
the other while the examiner’s finger is engaged in diagnosis. Again,
variations in depth of the fixed anal rectum are quite noticeably
regulated by the size of the finger introduced. The thumb may find
a fixed anal rectum of two inches (5.08 cm.) in depth, while the
little finger discovers it but a little more than an inch (2.54 cm.).
Because of the bony confines to the tissues of the ischiorectal space,
displacement of its structures to open the anus must occur in the
vertical direction, the larger the finger the greater the displacement
upward.
Passing the finger beyond the borders of the levator ani, the distal
phalanx enters the movable or abdominal rectum, where it may be hooked
over the pelvic floor. In some instances, if the finger be directed
backward and crowded with a boring maneuver through the loose folds of
the movable rectum, and provided the folded knuckles displace upward
the pelvic floor, the finger may be made to engage the lowermost of the
rectal valves, which will contract about the finger with a rhythmic
action and mislead the uninformed, inexperienced and undiscriminating
explorer to think that he is but now encountering the ental sphincter
muscle, or, perhaps, that he has discovered a stricture--the phantom
stricture? In the passive rectum, this valve is usually about three
inches (7.62 cm.) above the lower border of the ental sphincter muscle.
The great range of mobility of the pelvic diaphragm permits a finger of
two inches (5.08 cm.) length to be hooked over a valve which under some
circumstances may be an inch and a half (3.81 cm.) beyond its reach.
The pelvic floor in the infant is often less than one-half inch (1.27
cm.) in depth. The depth of the pelvic floor in the adult, from the
lower border of the relaxed ectal sphincter ani muscle to the levator
ani muscle, is extremely variable. In the aged male, because of senile
enlargement of the prostate, the fixed rectum may seem to be three
inches (7.62 cm.) in depth. In the aged female, because of senile
atrophy of the generative organs and contiguous structures, the pelvic
floor may be much less than an inch (2.54 cm.) in depth. In the adipose
and in emaciated subjects because of the character of the tissues
occupying the ischiorectal space, there are the greatest variations in
the depth of the pelvic floor. Hence, it is obvious that the palpable
muscular landmarks of the fixed rectum are situated at variable
positions in the different sexes, and that the length of the fixed
rectum is changed in the same person at different periods of life and
in differing conditions of flesh.
The visible topographic features of the fixed rectum are several,
and under the influence of disease may become somewhat changed in
appearance and situation. In the male they are readily discoverable by
putting the subject in the dorsal posture, separating the nates with
the hands and placing the thumbs on bits of dry cotton to prevent their
slipping just exterior to the anus. Simultaneously to the patient’s
bearing-down impulse the thumbs may be used to evert the anal mucous
membrane. The anterior and posterior borders of the anus may in a
measure be everted by a somewhat similar manipulation. In the female
the visible landmarks of this region may be inspected by entering the
finger into the vagina and placing the thumb over the perineum; the
former is to push the rectum down while the thumb draws the external
skin forward over the perineum. The posterior segment may be exposed
by pushing the post anal skin toward the coccyx; the lateral segments
may be exposed with the finger and thumb of the left hand while the
right hand keeps up the initial pressure. Marked pigmentation of
the anal skin is observable in a circumscribed area about the anus;
beneath this area of darkened skin, intimately attached to the skin,
lies the surgically unappreciated corrugator cutis ani. Within the
borders of the everted anus the complexion fades to a light gray,
within which zone is sometimes noticeable the distinctly lighter zone
known as Hilton’s white line. Above, is noticeable an undulating
zone of deeply red mucous membrane the lower border of which has been
given the name of _linea dentata_ (Stroud). Between the linea dentata
and the white line is a zone occupied by several pyramidal elevations
about half an inch (1.27 cm.) in length, to which has been given the
names: columns of Morganni and pecten of Stroud. Their bases are of a
somewhat purple reddish color. Toward their apices they may pale and
terminate in projecting white eminences. The bases of these pyramids,
which, I believe, may without impropriety be called anal pilasters,
are extremely vascular and their structure partakes somewhat of the
character of erectile tissue. The apex contains a nerve end-bulb.
Under the influence of disease the color of these bodies is changed.
Their antemortem and postmortem appearance is quite different. There
are usually present in each anus from four to eight of these bodies.
Between these projections and at their lower borders, sometimes, there
is discoverable a thin fold of membrane. The saccule which it, together
with the anal wall and pilasters on either side, forms, has been known
as the saccule Horneri, pocket of Physic, and anal pocket, sometimes
inaptly called rectal pocket. Its cavity is about the size of a split
pea. The three typic visible topographic features of the fixed rectum,
then, are the white line of Hilton, the pecten of Stroud, or anal
pilasters, and the linea dentata.
The mucocutaneous membrane of which these visible landmarks are a part,
rests upon a quantity of loose connective tissue, which permits of a
great range of mobility of these features independent of movement of
the structures constituting the palpable landmarks of the fixed or anal
rectum.
[Illustration: FIG. 21.--From a photograph of an external view of the
paraffin cast-filled rectum. The rough surface shows the place of
attachment of the peritoneum.]
[Illustration: FIG. 22.--Interior view of the left half of the rectum
of an adult. Filled with melted paraffin, the subject being in the
proctocolonoscopic posture. The rectum is distended only to the degree
of normal atmospheric inflation. When the wax was hardened the rectum
was removed, varnished, dried and cut open longitudinally. The picture
is a reproduction of a photograph of the interior of the left half
of the rectum. The anus is at the picture’s left. The valves are
respectively two and one-half and seven inches (6.35 and 17.78 cm.)
from the anus.]
[Illustration: FIG. 23.--Knee-chest posture. Left lateral half-interior
view. Upper rectum and sigmoid out of focus.]
[Illustration: FIG. 24.--Posterior view of a specimen carefully
dissected to show the muscular supply to the valve-bases.]
[Illustration: FIG. 25.--Posterior half occupied by its cast.]
[Illustration: FIG. 26.--Anterior half of specimen shown in Fig. 25.]
[Illustration: FIG. 27.--Posterior view of a cast-filled rectum.]
[Illustration: FIG. 28.--Paraffin cast from a rectum.]
THE RECTAL VALVE.
That the rectal valve constitutes the most hypsometric of the
topographic features of the movable abdominal rectum, is conclusively
proven by the photographic pictures. The specimens from which the
photographs were taken were prepared by a method consisting in fixing
the cadaver in the knee-chest posture and pouring melted paraffin into
the atmospherically inflated rectum; when the wax had sufficiently
hardened the gut was carefully removed, for a few weeks immersed
in alcohol and subsequently dried, varnished, and finally dried
and cut into longitudinal, shell-like halves. A comparative study
of the photographs of the rectal interiors discovers the fact that
_the prominence of the rectal valve is increased with the degree of
distention of the rectum_.
The accompanying drawing was made from a microscopic section taken
from the middle of the lower valve of an adult specimen. In the
illustration, Fig. 33, it is shown magnified 5 diameters. Beneath the
mucosa is noticeable the heavy layer of fibrous tissue which gradually
diminishes till it is lost at the valve base. Bundles of circular
muscular fibers are seen in the middle of the valve. At its base are
seen arteries and veins for its special nutrition. This structural
arrangement makes this organ the typic anatomic valve. The evidence of
the fibrous tissue in the valve is an original contribution to our
knowledge of this subject.
The attached border of each valve spans a little more than half the
circumference of the rectum, and its free border projects half across
the diameter of the inflated rectum. Each valvular partition projects
at nearly a right angle to the wall of the compartment below it and
terminates in a sharply defined free border. The free margin of
the structure is slightly concave in form and is directed a little
obliquely. In life it is noticeable that the free border of the valve
is less elastic than the main wall of the valve. The latter will
yield to a modicum of traction without disturbing its free border,
while traction applied at the margin may at once disturb the entire
circumference of the gut at that point. The rectal wall opposite
the valve is usually concave. The aperture thus formed between two
rectal compartments is irregularly elliptic; it may be called the
valve-strait. Usually the greatest diameter of a rectal compartment is
directed laterally or else obliquely; it is almost never parallel to
the direction of the sacrum. Thus, what has been heretofore considered
a cavernous ampulla is seen to be divided into several chambers.
There are as many chambers in the rectum as there are rectal valves.
The number of rectal valves is variable. Some subjects have but two,
others have four, but 90% of persons possess three. The uppermost valve
is invariably situated at the juncture of the rectum and the sigmoid
flexure, which valve is invariably situated on the left, the next lower
is on the right wall, and the lowermost is on the left. The positions
of the lower two valves are sometimes anterior and posterior.
The specimen shown in Fig. 30 exhibits the rectum naturally distended
with feces. It was found in a deceased member of the demimonde who
had been habituated to opium indulgence. She was forty years of age
and of robust stature. On opening the abdomen the colon was discovered
loaded with a collection of scybalous feces, and the upper chamber of
the rectum was partially occupied with a similar deposit. The abdomen
was then opened through the pubes and perineum down to the coccyx.
The genitourinary organs and contiguous structures were removed, the
symphisis forcibly separated and the exposed sigmoid flexure and rectum
were photographed as shown in Fig. 29. The sigmoid and rectum were
carefully removed and immersed in alcohol. After a fortnight the gut
was divided into anterior and posterior halves, as shown in Fig. 30.
[Illustration: FIG. 29.--Photograph of a female cadaver showing, after
laparo-symphysiotomy and removal of bladder, uterus and adnexa, the
upper rectum and sigmoid packed with scybalums.]
[Illustration: FIG. 30.--The rectum, the same as is shown in Fig. 29,
divided into anterior and posterior halves.]
It must be readily seen that the new methods of rectal inflation
for rectal inspection and the cast method of dissection, which have
determined our newer ideas of the topography of this part, justify
that the lowermost chamber be considered the first rectal chamber;
the cavernous area beyond the first valve and below the second
should be called the second chamber; and the upper chamber the third
or perhaps fourth, according to the number of valves. The ancient
arbitrary division of the rectum by the anatomists into upper first,
middle second and lower third parts should be abandoned because such
a method is inaccurate and has no surgical significance. As the
arrangement of the fibers of the muscular coats of the abdominal rectum
and the attachments of the abdominal rectum provide for extension
and contraction of the gut on its axis, as well as expansion of the
diameter of the organ, it is obvious that there must be in the same
individual a great variation in the distance of any given valve from
the levator ani with the variable normal states of the organ. The
normal range of movement upward and downward of a given valve is from
two to three inches (5.08 to 7.62 cm.).
A discriminating study of the diseases of the rectum requires an
arbitrary division of the organ into several quadrants.
Regard for the conveniences of scientific description and
considerations of technic and of anatomy justify that the fixed anal
rectum be called _the anus_, and that the movable abdominal rectum be
called _the rectum_. The former is bounded above by the levator ani and
below by the ectal sphincter muscle.
From this survey of the topography of the anus and rectum and
consideration of the arrangement of the contiguous structures the
following salient aphorisms may be deduced:
1. In treating lesions on a level with the sphincter muscles the
operator should beware of dividing these structures through the
anterior quadrant. In the male the ectal sphincter terminates in the
tendinous raphe in common with the transversus perinei. Contraction
of the transversus perinei will separate the cut fibers of the ectal
sphincter and defeat the desired subsequent union of this muscle.
If an incision be carried forward or forward and laterally into the
transversus perinei the perineal fascia which doubles over this muscle
will be opened and the perineum and peri-urethral structures will be
made accessible to infection from the anus and ischiorectal regions. In
the female, to carry an incision forward through the anterior quadrant
would be unsurgical because the peculiar arrangement of the fibers of
the ectal sphincter ani and sphincter vaginae and their relation with
the transversus perinei would perhaps conspire to produce vulvoanal or
rectovaginal fistulas.
2. A stricture located at the upper end of the fixed rectum and
situated in the anal fascia, in the pelvic fascia, or in the fibers of
the levator ani muscle, should not be cut in the anterior quadrant nor
in the posterior quadrant, but in one or the other, or both, lateral
quadrants. An incision through the anterior quadrant on the plane of
the levator ani muscle would divide none of its fibers because there
are none there and would endanger the urinary organs and vagina in
the male and female respectively. An incision made into the posterior
quadrant on this plane would fail to increase the diameter of the
rectum for the reason that contraction of the fibers of the levator
ani would hold in coaptation the lips of the wound in such a manner as
to early reestablish the stricture. A skilfully made incision in the
lateral quadrants in this region will not endanger the peritoneum. A
possible hemorrhage may be readily avoided by digitally ascertaining
the situation of the middle hemorrhoidal arteries. And because of the
direction of the fibers of the levator muscle a short lateral incision
will effectually increase the diameter of the part.
3. The rectal valve must be reckoned with in studying the strictures of
the movable abdominal rectum. Linear posterior proctotomy, because of
the relation of the peritoneum to the posterior wall of the lower part
of the movable rectum, is eminently safe, but will be efficacious only
in some special instances--those instances in which the rectal valve
involved is posteriorly situated. Semilunar (annular) strictures may
be situated at any point in the circumference of the movable rectum,
for they are built on the foundations supplied by the rectal valves,
and may be safely cut through to the depth of a quarter of an inch (.63
cm.), provided the surgeon be equipped with the proper instruments and
provided the rectum be maintained in a state of atmospheric inflation
at the time of the operation.
The studies of the topography of the human rectum made in this research
employed more than 50 autopsies, on subjects of all ages, and physical
examinations of many hundred living persons, and the facts which are
set forth above justify the inference, I believe, that none but the
topographic designation of the precise situation of the rectal lesion
is of reliable surgical significance.
Dissection of many rectums of rabbits, cats, dogs and monkeys proved
that these animals are not provided with rectal valves.
DEFECATION.
“Defecation is partly a voluntary and partly a reflex act. But in
the infant the voluntary control has not yet been developed; in the
adult it may be lost by disease; in an animal it may be abolished
by operation; in each case the action becomes wholly reflex. In the
normal course of events, the rectum which is empty and quiescent in the
intervals of defecation, is excited to contraction as soon as feces
begin to enter it through the sigmoid flexure, and the sensations
caused by their presence give rise to the desire to empty the bowels.
This desire may for a time be resisted by the will, or it may be
yielded to. In the latter case the abdominal muscles are forcibly
contracted, and the glottis being closed, the whole effect of their
contraction is expended in raising the pressure within the abdomen and
pelvis.... The sphincter ani is now relaxed by the inhibition of a
center in the lumbar portion of the spinal cord, through the activity
of which the tonic contraction of the sphincter is normally maintained.
This relaxation is partially voluntary, the impulses that come from
the brain acting probably through the medium of the lumbar center; but
in the dog, after section of the cord in the dorsal region, the whole
act of defecation, including contraction of the abdominal muscles and
relaxation of the sphincter, still takes place, and here the process
must be purely reflex. The contraction of the levatores ani helps to
resist overdistention of the pelvic floor and to pull the anus up over
the feces as they escape.”[16]
The above paragraph concisely represents the accepted interpretation of
the act of defecation. The rectal valve, an individual anatomic organ
in itself, must, however, be reckoned with in studying the operations
of the integral mechanism of defecation.
DIGITAL OBSERVATION OF THE NONANESTHETIZED SUBJECT.
In the normal rectum, when the first rectal valve can be reached by
the finger, provided it be immediately discovered on the introduction
of the finger, a definite but not rigid band of tissue may be felt
buried behind the masses of lax mucosa. This band presents at one side
that which seems to be a circular aperture of variable diameter; a few
seconds’ application of the passive finger detects a gradual relaxation
of what first had seemed a ring-like constriction till the finger can
make out but an indefinite thickening on a side of the gut-wall. If
the finger be held passive, this constriction may again surround the
finger; but if so, it does so with a somewhat weaker grasp. Often the
presence of the finger within the rectum excites a peristalsis-like
contraction, during which the valve usually cannot be detected. When
the rectum is filled with water, the valve is sometimes more readily
discoverable by the finger, and when discovered, the diameter of the
valve-strait is greater than that before noticed, and the grasping
tendency of the valve is not so noticeable.
OCULAR OBSERVATION OF THE ANESTHETIZED SUBJECT.
If a somewhat emaciated male be selected, one whose rectum is
susceptible to atmospheric inflation while in the lithotomy posture,
and if the large intestine be freed of its contents, if such a subject
be anesthetized and his colon or sigmoid filled with water, and the
anus divulsed and held open with the speculum, the water confined to
the rectum may be bailed out, and the rectum will then be seen to
present the multichambered condition already described. If the inquirer
will now place a hand on the abdomen over the sigmoid flexure, and
give the part a quick, firm pressure, his watchful eye may observe a
downward rush of waters into the rectum, first striking the concave
wall formed by the juncture of the upper surface of the uppermost
visible valve and the adjoining rectal wall, bounding from this surface
to the opposite next lower valve, from which the stream is deflected
to a lower point on the opposite wall, by which time all may be
obscured by a wave of contracting peristalsis, rhythmically repeated,
which may project small quantities of water through the anus. In the
intervals of the contractions, the rectal chambers are observed to be
either submerged or else atmospherically inflated.
OCULAR OBSERVATION OF THE NONANESTHETIZED SUBJECT.
If a subject under proctoscopy be directed to bear down, it is
observable that the empty and atmospherically inflated rectum closes
under the compression of the voluntary forces by the concave anterior
wall becoming convex, and being carried backward toward the fixed
posterior wall, the transverse diameters remaining apparently but
little shortened. The compression may be noticed as being applied from
before and in a backward direction, and simultaneously from above
downwardly. In case firm fecal masses, or lubricated balls of cotton
experimentally placed, are dejected by these efforts, there will be
noticeable depression of the valve-floor under the pressure of the
descending mass. Presently the mass will appear at the valve-edge,
where it may seem suspended for a few seconds before it is plunged on
into the next lower chamber. Occasional rhythmic contractions of the
rectal muscular coats occur, which fill and transitorily obscure the
field under observation with masses of the reduplicated mucosa, and
it is always possible to note that such contractions have changed the
positions of the gut’s contents.
These anatomic findings and physiologic observations warrant the
conclusion that the rectal valve has a function. Its histologic
elements endow it with essentially passive and active properties. When
the muscular elements are relaxed and the gut is either greatly dilated
or else in a lesser measure distended, the valve is passively projected
across the channel to resist the hurried or uncontrolled descent of
the feces. The presence of the bands of fibrous tissue under the free
margin of the valve provides a guard or _control_ to receive and retain
the bolus, or, I may say, the valves receive a series of boluses, till
a sufficient pressure is made to stimulate the complex involuntary
mechanism of defecation to an expulsion of the feces or to a reversed
peristalsis. The presence of the feces or the involuntary movements
incident to their presence, signals the consciousness to cooperative
voluntary expulsory effort, or gives warning of the necessity of
voluntary resistance. In the event of the exercise of these forces in
the direction of resistance there seems to be some reason to believe
that an antiperistalsis returns the feces to the sigmoid flexure. The
same arrangement which sets in operation the involuntary factors of
defecation also provides for the minimum expenditure of energy on the
part of the voluntary forces for the reason that the gut’s contents are
collected on the surface of the unyielding sacrum and steadied there to
receive the pressure of the really expulsory voluntary effort. Such
an arrangement of the feces as is mentioned above further facilitates
defecation for the reason that the entire contents of the rectum are
not rushed upon the anus at once. The surgeon remembers that it is
usually impossible to reduce a hernia _en masse_.
The bundles of circular muscular fibers which constitute the muscular
element of the valve evidently belong to the same mechanism and have
the same function as those which form the ental sphincter. Their
usual state may be that of tonic contraction; they are relaxed by
inhibition; when the muscle is in a state of inaction the fibrous bands
are projected and support the valves across the channel of the rectum.
In health the valve is susceptible, under pressure, of a temporary
effacement.
If it be the function of the normal rectal valve to beneficently
retard the descent of the feces it is obviously true that it may be
the especial property of the valve, in certain other than normal
conditions, to maliciously obstruct the descent of the feces.
My experience convinces me that a perfect knowledge of the rectal
valve constitutes the key to an understanding of obstipation, rectal
stricture, and their sequels.
[Illustration: FIG. 31.--From a photograph of an anal end-view of a
cast-filled rectum; the average transverse diameter was 3½ inches (8.89
cm.), the vertical diameter was 3 inches (7.62 cm.).]
[Illustration: FIG. 32.--From a photograph of an external view of a
cast-filled rectum and its mesenteric attachment to the sacrum; taken
from an 18-months-old infant.]
OBSTIPATION IN INFANTS.
The infant strains at stool because of the imperfect development of the
anatomic features concerned in the mechanism of defecation. These are
as follows:
1. The infant’s lower gut is muscularly deficient.
2. Its great length and its mobility within the abdomen are obstructive
to defecation.
3. The rectal valves are obstructive.
4. The infant’s anus not being sufficiently expansible is also
obstructive to the descent of feces.
The specimens of infant rectums and sigmoids here pictured are all
fairly illustrative of the facts upon which the foregoing declarations
are based.
The dried specimens shown in the illustrations were prepared by
flushing the intestine and then fixing the subject in the genuacromial
posture; the anus was then fixed open and melted paraffin was injected
under about twelve ounces’ pressure. When the cast had hardened, that
portion of the gut which it occupied, was removed. Specimens shown in
Figs. 43 and 44 were prepared by placing the subject upon its back and
by opening the descending colon; the intestine below was then washed
out and the colon perforation fixed at the abdominal wound, which,
save for this point, was sewed up, the anus was tied up and as much
melted paraffin as would enter under two-pounds’ pressure was forced
into the gut; subsequently the sigmoid and rectum were removed as in
the other instances. After immersion in alcohol the specimens were
varnished.
[Illustration: FIG. 33.--A semilunar valve drawn as seen under a glass
magnifying five diameters. _A_, mucous membrane; _B_, fibrous tissue;
_C_, bundles of circular muscular fibres; _D_, vein; _E_, artery; _F_,
vein; _G_, artery; _H_, areolar and adipose tissue.]
[Illustration: FIG. 34.--The instrument case; the drawers opening on
three sides afford access to any drawer without disturbing the position
of the others.]
Following are the memoranda of a few of the autopsies made in this
study:
CASE 1.--Female, stillborn, height 16 inches (40.64 cm.);
circumference at anterior superior spinous process 7½ inches
(19.05 cm.); anterior superior spinous process diameter 3
inches (7.62 cm.); ensiform to pubes 4 inches (10.16 cm.);
transverse diameter pelvic outlet ¾ inch (1.90 cm.);
peritoneum at last vertebra of coccyx. (Fig. 35).
[Illustration: FIG. 35.--The rectum of an infant, stillborn; muscular
coat undeveloped. Filled from below.]
[Illustration: FIG. 36.--Side view of the specimen shown in Fig. 35.
Antero-posterior angulation at third sacral vertebra.]
CASE 2.--Female, aged 1 hour, height 17 inches (43.18 cm.);
circumference at anterior superior spinous process 7½ inches
(19.05 cm.); anterior superior spinous process diameter 2½
inches (6.35 cm.); ensiform to pubes 4 inches (10.16 cm.);
transverse diameter pelvic outlet ½ inch (1.27 cm.); peritoneum
at last vertebra of coccyx. (Fig. 37).
[Illustration: FIG. 37.--Front view of the rectum of an infant aged one
hour; autopsy while in a state of rigor mortis. The rectum being nearly
perpendicular and the sigmoid almost tied in a knot. Filled from below.]
[Illustration: FIG. 38.--Side view of the specimen shown in Fig. 37.]
CASE 3.--Male, aged 1 month, height 23 inches (58.42 cm.);
circumference at anterior superior spinous process 9 inches
(22.86 cm.); anterior superior spinous process diameter 3½
inches (8.89 cm.); ensiform to pubes 4 inches (10.16 cm.);
transverse diameter pelvic outlet ⅝ inch (1.59 cm.); peritoneum
at last vertebra of coccyx.
[Illustration: FIG. 39.--Front view of the rectum of an infant aged one
month; autopsy while in the state of rigor mortis. Filled from below.
Two-third life-size.]
[Illustration: FIG. 40.--Side view of the specimen shown in Fig. 39.]
CASE 4.--Female, aged 6 weeks, height 24 inches (60.96 cm.);
circumference at anterior superior spinous process 10½ inches
(26.67 cm.); anterior superior spinous process diameter 3
inches (7.62 cm.); ensiform to pubes 5½ inches (13.97 cm.);
transverse diameter pelvic outlet ⅝ inch (1.59 cm.); peritoneum
at last vertebra of coccyx. (Fig. 41).
[Illustration: FIG. 41.--Front view of the rectum of an infant aged six
weeks. Filled from below.]
[Illustration: FIG. 42.--Side view of the specimen shown in Fig. 41.]
CASE 5.--Female, aged 2 months, height 20 inches (50.80 cm.);
circumference at anterior superior spinous process 8 inches
(20.32 cm.); anterior superior spinous process diameter 3
inches (7.62 cm.); ensiform to pubes 3½ inches (8.89 cm.);
transverse diameter pelvic outlet ¾ inch (1.90 cm.); peritoneum
at last vertebra of coccyx. (Fig. 49).
CASE 6.--Male, aged 6 months, height 24 inches (60.96 cm.);
circumference at anterior superior spinous process 10 inches
(25.40 cm.); anterior superior spinous process diameter 4
inches (10.16 cm.); ensiform to pubes 5 inches (12.70 cm.);
transverse diameter pelvic outlet ¾ inch (1.90 cm.); peritoneum
at last sacral vertebra. (Fig. 43).
[Illustration: FIG. 43.--Front view of the rectum of an infant aged
six months. Filled from below after disappearance of rigor mortis.
Two-thirds life-size.]
CASE 7.--Male, aged 6 months, height 24 inches (60.96 cm.);
circumference at anterior superior spinous process 12 inches
(30.48 cm.); anterior superior spinous process diameter 4
inches (10.16 cm.); ensiform to pubes 5 inches (12.70 cm.);
transverse diameter pelvic outlet ¾ inch (1.90 cm); peritoneum
at first bone of coccyx. (Fig. 44).
[Illustration: FIG. 44.--Front view of the rectum of an infant aged six
months. Filled from above after disappearance of rigor mortis.]
[Illustration: FIG. 45.--Side view of the specimen shown in Fig. 44.
The mesentery from sacrum and coccyx to the rectum is fairly well
shown, but is shown shorter than in the fresh state, alcohol immersion,
varnishing and drying having shrunken it. Observe also how nearly the
peritoneum approaches to the anus.]
CASE 8.--Male, aged 17 months, height 25 inches (63.50 cm.);
circumference at anterior superior spinous process 12 inches
(30.48 cm.); anterior superior spinous process diameter 4
inches (10.16 cm.); ensiform to pubes 6 inches (15.24 cm.);
transverse diameter pelvic outlet 1 inch (2.54 cm.); peritoneum
at last sacral vertebra.
Examination of the pictures of _the dried specimens reveals that the
wall of the infant rectum and sigmoid flexure is thin_ compared to that
of the adult.
It is impossible to distinguish the longitudinal muscular bands which
are so apparent in the gut of the adult. The infant gut being very
deficient in muscular elements, therefore the intrinsic power of
peristalsis cannot be present in that degree necessary to it as a
component factor of defecation.
_The relations of the peritoneum to the rectum_ of the infant also
contribute to the difficulties of defecation, as also does the
relatively _great length of the descending colon and sigmoid flexure_.
In young children the length of sigmoidal mesentery from its attachment
to the parietes to its invagination of the lower loop of the sigmoid
is often greater than the distance from the promontory of the sacrum
to the distal bone of the coccyx. (See Figs. 44 and 45.) From the
sigmoidorectal juncture to the beginning of the middle third of the
rectum the mesentery rapidly shortens but apparently completely invests
the upper third of the rectum. The middle and lower thirds are not so
completely invested, and present upon their posterior parts a vertical
lane bare of peritoneum, from the borders of which the peritoneum
is reflected in lateral directions. This uncovered part of the gut
is not applied directly to the sacrum and coccyx. There is a space
between which is occupied by loose connective tissue. The distance from
the dorsal parietes to the gut is variable here, being from one-half
to one-fourth of an inch (1.27 to .63 cm.). At the beginning of the
middle third there is usually a gradual decrease in the length of the
peritoneal band as it descends, till it is one-eighth or possibly but
one-sixteenth of an inch (.32 or .16 cm.) in length at the last bone of
the coccyx; it rapidly shortens from this point to its termination.
The parietal peritoneum descends over the ischial tuberosities and
approaches nearly to the ental sphincter muscle. In the newly-born the
peritoneum is situated within one-fourth inch (.63 cm.) of the anal
skin.
The disproportionately great length of the descending colon and
mesentery of the infant obviously contributes to the possibility of
angulation of the gut.
We may see in the presence in the child of lax and long, or relatively
long, peritoneal ligaments, and in the great length of the descending
colon and the consequent probability of numerous acute angulations
in the infant sigmoid and rectum, and in the mobility of these parts
within the abdomen, the possibility of development of a perfect adult
mechanism for defecation. The essential features of this development
are two: (1) the growth of prostate or uterus and their supports which
relatively fix the lower rectum; and (2) the downgrowth and outgrowth
of the pelvic bones and the consequent conversion of mesenteric
peritoneum to parietal peritoneum, which shortens the adult mesentery
and in some measure fixes the upper rectum; thus the entire rectum is
steadied to facilitate discharge when the mechanism of defecation is
set in operation.
[Illustration: FIG. 46.--Diagrammatic of this gut in the empty
state, therefore its flexions are not the same as those shown in the
photographs. In the partly filled state, which is the condition about
the time of defecation, the flexions and positions of these parts would
be intermediate to those of the filled and empty conditions. (The
dotted lines indicate positions of valves.)]
The diagrammatic figures do not exaggerate these obstructive elements.
The collateral muscles which assist in the performance of the act of
defecation force the feces in the direction of the lower angle in each
flexion, and in that flexion whose onward, or, to be paradoxic, whose
downward direction for the time points upward (Fig. 46), the auxiliary
pressure is in the direction opposite to that of peristalsis.
[Illustration: FIG. 47.--Diagrammatic, showing direction of forces and
resistance in infant, in defecation.]
[Illustration: FIG. 48.--Diagrammatic, showing direction of forces and
resistance in adult, in defecation.]
Inspection of the pictures of the dried specimens reveals the
angulations referred to, which may be expected to be more numerous the
more segmentary the gut’s contents.
_The third feature obstructive to defecation in infants is the rectal
valve._ It is a feature and factor which not only is not recognized,
but is one whose very anatomic existence has been persistently disputed
by Matthews, Kelsey, and others. It was imperfectly described as an
anatomic feature of the rectum by Mr. Houston in the Dublin Hospital
Reports in 1830, and in 1887 Dr. Walter A. Otis more practically
demonstrated its presence; neither of these gentlemen, however,
attributed to it the characteristic element of an anatomic valve,
although happily and by chance bestowing upon it its proper name. A
number of investigators have discovered this organ and have miscalled
it by various names and given it widely varying descriptions; but a
greater number still deny its existence and critically strive to
dissolve away the imperfect evidence recorded in medical literature.[17]
The pictures here shown of the dried specimens prove that in the infant
the valve is such a matter of fact that its existence is no longer a
question for debate.
[Illustration: FIG. 49.--The rectum and sigmoid of an infant aged
two months. The photograph shows the interior of the anterior half.
Portions of two valves are noticed at the middle part.]
[Illustration: FIG. 50.--The interior view of the opposite posterior
half of the rectum shown in Fig. 49, the two valves shown in Fig. 49
being continued toward each extremity of the ampulla. The sigmoid is
out of focus.]
[Illustration: FIG. 51.--The paraffin cast removed from the gut shown
in Figs. 49 and 50.]
The fetal specimens pictured indicate that the valves are particularly
well developed early in embryonic life. The infant specimen shown in
Fig. 49 is marked by two valves, situated so close together that the
middle portion of the rectum presents its longest diameter at right
angles to the main direction of the gut. Another valve may be seen at
the juncture of the upper portion and the sigmoid flexure.
It must be readily seen that the presence in the rectum of such a
structure as an anatomic valve would be essentially obstructive to the
passage of feces.
In studying the physics of the rectum it is important that we recognize
that the posterior wall from which the mesentery is reflected is
less movable than other parts in the circumference, hence distention
of the rectum not only tends to carry a given point of its wall away
from the point opposite to it, but also carries it away from a given
point cephalad or caudad. So it may be assumed that if the two valves
situated at the middle of the cast-distended dried specimen (Fig. 49)
are three-eighths of an inch (.95 cm.) separated, and that the two
opposite walls of the rectum in the portion bounded by these valves are
one inch (2.54 cm.) apart, that in a state of the gut’s collapse or
systole the valves would be in contact, and thus afford a very definite
obstruction to the descent of semisolid feces.
The _bony pelvic outlet_ in the infant is so contracted that the limits
of anal expansion are such as to almost defeat the passage through it
of other than fluid feces. It should be remembered that the normal
average measurement from ischial tuberosity to ischial tuberosity
in the adult is about four inches (10.16 cm.), and it is a fact
proven by our observation that the average transverse diameter of the
newly-born infant’s pelvic outlet is but a little more than one-half
inch (1.27 cm.), the pubococcygeal measurement is even less. Those
who are familiar with instrumental divulsion of the adult anus may
have observed that two and a quarter inches (5.71 cm.) is the average
limit of lateral separation of the anus, the remaining portion of the
pelvic outlet being filled with the compressed soft tissues of the
ischiorectal space. Therefore it may be estimated that nine-sixteenths
at most, of the diameter of the pelvic outlet is the reasonable limit
of expansibility of the anus for the passage of feces. Applying this
calculation to the infant we find that if the ischial tuberosities are
one-half inch (1.27 cm.) separated, that the anal expansibility is but
five-sixteenth of an inch (.79 cm.), which is, as we know, the diameter
of a No. 22 sound (French scale). Reference to the paraffin cast of
the infant gut (Fig. 51) indicates that the average distensibility of
the sigmoid flexure and rectal chambers, in which the feces when firm
are formed, is four or five times that of the anal expansibility; thus
it is readily perceived that compared to the adult the juxtaposition
of the ischial tuberosities in the infant supplies a most obstinate
obstructive factor in defecation.
To collate in brief:
1. The muscular development of the adult rectum and lower sigmoid is
plainly apparent in the plates here exhibited of the fresh specimens. A
deficient muscularity is observed in the infant specimens.
2. The peritoneal band of these parts in the adult is observed to be,
relatively, very considerably shorter than that in the infant, and the
sigmoid flexure is relatively shorter.
3. The rectal valves appear to bear the same proportion to the gut in
both adult and infant, but when we remember the difference in muscular
development in the two the disproportionately greater resistance of the
valve in the infant rectum is obvious.
4. The anal expansibility is remembered as adequate in the adult, and
is seen to be deficient in the infant.
Correlative to the facts just stated we must recognize that the adult
rectum has resident within its own wall a powerful expulsive muscular
mechanism; that the shortening of the mesentery holds the upper rectum
steady under the applied auxiliary forces; that the angulations of the
normal sigmoid are not necessarily obstructive, though in a desirable
measure retardative; that the forward incline of the lower sacrum and
coccyx behind, and the development of the uterus and prostate and
their inherent supports in front, provide the lower adult rectum with
a firm funnel-like arrangement which guides the feces directly upon
the os internum of the anus; that the valves divide the feces into
portions to facilitate their separate successive discharge, and finally
in sequence, that the physiologic descent of the structures of the
ischiorectal space reduces this last resistance to the minimum in adult
defecation.
Straining, the ruptures and prolapses, obstipation, retention of feces,
and the multitudinous consequent ills demand our consideration, though
this study forces the conclusion, I believe, that the individual’s
escape is ultimately assured by process of development, and that for
the normally formed infant, the physician will find the solution of the
problem of difficult defecation in the solution of the stool.
TREATMENT.
Diet, hygroscopic suppositories, and fluid injections which may render
more fluid the intestinal contents will favor their descent through the
convoluted gut, the valvulated rectum, and the contracted anus.
Massage of the abdomen over the region of the colon aids in (1) the
development of the auxiliary abdominal muscles of defecation and of
the intrinsic expulsory muscles in the intestinal wall; and further,
such manipulations (2) directly propel the gut’s contents along the
tortuous course of the bowel and hence (3) reduce, inasmuch as they
may overcome the obstructive features of the valve.
If there be an overgrowth of the rectal valve and if it form an almost
impassable barrier to the descent of the feces it may be in some
measure overcome in infants by the dilatation which may be effected
through the means of the gently introduced trained finger. In case the
defective valves are present in the form of diaphragmatic strictures or
membranous septa with circular aperture, the valve may be safely cut by
a method described in another place.
As at birth the pelvic bones are not yet united and as the rami of
the ischium and pubes are still quite cartilaginous it is obviously
possible that a little energy intelligently directed upon the anus
from without will spread the pelvic outlet, whereas the infant labors
ineffectually with his own forces applied as they are from within. The
nurse, therefore, may be directed to pare away her nail-ends, lubricate
her fingers and gently introduce the smallest finger through the anus.
Daily gradual dilatation of the infant’s pelvic outlet should be
practised, graduating from finger to finger until the required degree
of dilatation be reached. The introduction of the finger independent of
its dilating uses incites the mechanism of defecation to action.
Rachitic subjects with abnormal contraction of the pelvic outlet demand
forcible divulsion of the ischial tuberosities.
[Illustration: FIG. 52.--A three-and-a-half-months fetus. A photograph
showing the posterior half of the rectum prepared by the paraffin-cast
process. The rectal valves are noticeably prominent at this stage of
fetal development.]
[Illustration: FIG. 53.--A five-months fetus. A photograph showing
a paraffin cast-filled rectum in situ; the other organs having been
dissected away.]
OBSTIPATION IN THE ADULT.
If it be the function of the normal rectal valve to beneficently retard
the descent of the feces it is obviously true that it may be the
especial property of the valve in certain other than normal conditions
to maliciously obstruct the descent of the feces.
There are three forms of valvular obstruction:
1. _Anatomic coarctation of the valves_ may afford an exaggerated
physiologic resistance to the descent of the feces (Fig. 54).
2. _Congenital hyperplasia of the rectal valve_ is a condition
classically described as diaphragmatic stricture or membranous septum
in the abdominal rectum.
3. _Hypertrophy of the rectal valve_ constitutes the classic annular
stricture of the abdominal rectum.
[Illustration: FIG. 54.--Anatomic coarctation of valves.]
THE SYMPTOMS.
The patient is the subject of more or less chronic obstipation, he
sometimes makes frequent partially successful attempts daily at
defecation, but may experience an unrequited desire for stool. The
patient acquires the reprehensible physic-habit. In time the periods
of obstipation are interrupted by diarrhea. There is an ineffectual
straining at stool except for fluid feces. Later the diarrhea occurs
with greater frequency, and ultimately long periods of diarrhea
may ensue which are interrupted by a transitory constipation and
obstipation. All these symptoms may be accompanied by increasing
degrees of flatulence and borborygmus, and from time to time the
patient is subjected to attacks of intestinal autointoxication,
and finally he becomes neurasthenic. On account of the especial
nonsensitiveness of the rectal valve the patient’s sufferings are not
uniformly referred to this region by himself, but in many instances,
however, the intelligent patient is prepared to present his physician
with a ready-made diagnosis of rectal obstruction. Finally, the
symptoms of intestinal obstruction become pronounced, and if the
patient be unrelieved the disease proceeds to a fatal termination.
Symptoms of pain, aching in the sacral and iliac regions, hemorrhage,
proctorrhea, prolapse, hemorrhoids, fistulas, etc., are usually the
signs of concomitant sequels of the hypertrophied valve, and these may
embrace the entire proctica. For a classic graphic description of the
symptoms of rectal stricture, which has never been excelled, the reader
is referred to the paper by Dr. Sherwin published in the Transactions
of the London County Medical Society in 1787.
PATHOGENESIS.
1. _Obstructive anatomic coarctation_ of the normal rectal valves is
a fortuitous embryonic affair, and admits of no amplification in this
section.
2. _Prenatal hyperplasia_: The fibrous and muscular laminas of the
rectal valve are developed from the mesoblastic layer of the blastoderm
and the mucous membrane is derived from the hypoblast; this latter
layer consists of columnar epithelium, and epithelium of this character
may be found covering both superior and inferior surfaces of congenital
diaphragmatic strictures or membranous septums. When there exists an
aperture in this character of stricture it is seldom or never situated
centrally. Another distinguishing feature of this obstruction is
that it constitutes a cephalad boundary to a rectal chamber. If the
lowermost valve be deformed, and if it be situated unusually low down,
the lower rectal chamber may be noninflatable. In such an instance
the anal or fixed rectum may seem to be of an extraordinary length,
but that such is not really the fact may be determined by digitally
ascertaining the situation of the anal borders of the levatores ani
muscles. Such a stricture has its origin, probably, in the embryonic
hyperplasia of the rectal valve. Another form of diaphragmatic
stricture is sometimes observed at the anus. It has its origin in an
imperfect anorectal coalescence. The salient structures of this septum
are hypoblastic enteron and epiblastic proctodeum, and a microscopic
inspection of a portion of membrane taken from its inferior surface
reveals its epiblastic origin. This anorectal septum is of variable
thickness, if there be a perforation it is located centrally. This
character of stricture is always situated caudal to the rectal
chamber. It is due to an arrest of fetal development.
3. _Postnatal hypertrophy_: Inflammation of the normally formed rectal
valve, infiltration of lymph through its structures and organization
of the plastic exudate contract and fix in a state of contraction
this normal projection across the lumen of the rectum and constitute
the nonmalignant annular stricture of this organ. Abnormal increase
of fibrous tissue from any cause may, without contracting the
valve-strait, render the valve sufficiently inelastic as to constitute
it an obstruction. Extension of the inflammatory processes to an
adjacent valve or a general hypertrophic rectitis involving an area
occupied by several valves, consequent contraction of the longitudinal
muscular bands in the area involved, together with contraction of
the circular muscular bands, the infolding of masses of the lax
mucous membrane, and the infiltration of plastic lymph into all these
tissues between the valves as well as into the valve structure itself,
organization of the exudate, degeneration of the muscular elements
and increase of fibrous tissue, is the probable sequence of morbid
processes which establish the nonmalignant tubular stricture of the
rectum. The great thickness of the gut-wall at the situation of the
tubular stricture is ordinarily not a new product of the disease. It
is the consequence of the infolding of the mucous membrane, fixed in
longitudinal corrugations by the organization of the plastic exudate.
The causation of hypertrophy of the rectal valve may be direct
infection; a rectitis, dysentery, chancre, chancroid, gonorrhea; or
traumatism, irritation or injury by a foreign body; the irritation of
scybalums; or, it may be the local expression of some constitutional
dyscrasia; syphilis or tuberculosis. The influence of age or of
emaciation, through atrophy of the cellular tissues and the hypertrophy
of the fibrous, may contribute a relative increase to the tendinous
feature of the rectal valve.
_Because of the absence of the rectal valve in the rabbit, cat, dog
and monkey_ it was found impossible to do vivisection work for the
production of an experimental stricture.
There are many specimens of hypertrophied rectal valves to be seen
in the metropolitan museums in Europe, none of which, of course, are
classified as such. The cases quoted below were copied by me from the
catalog of the Pathological Museum of the Royal College of Surgeons,
London, and the specimens which are pictured here may be found on
their shelves. These cases are chosen for illustration because their
accessibility affords the reader an opportunity for their verification.
The pictures were drawn under my direction by Mr. Godart with the aim
of illustrating this essay. The specimens immersed in preservative
are sealed in cylindric glass jars of the usual laboratory type.
Each of these we set into rectangular vessels of water to overcome
refraction-errors and afford accurate appearances.
The first case quoted is one of traumatic injury to the rectal valve,
and, I believe, affords a close imitation of what might have been
expected from an effort at the production of an experimental stricture
by simple inflammation of the rectal valve.
The method used for the preparation and preservation of these specimens
accounts for the nonappearance of the normal valves. From the time of
the preparation of Hunter’s first specimen to the present time more
than a century and a quarter has about elapsed.
[Illustration: FIG. 55.--Drawing of specimen No. 2569 in the
Pathological Museum of the Royal College of Surgeons, London.]
Fig. 55. “Specimen 2569. Presented by William Coulson, Esq. A rectum
and part of a colon, the blood-vessels of which have been minutely
injected. Six inches above the margin of the anus there is a very close
and narrow annular stricture of the rectum, produced by thickening and
contraction of its coats and of the tissues immediately surrounding
them. The inner surface of the stricture is ulcerated, and a small thin
piece of fish bone is sticking in it. Above the stricture the intestine
is dilated to a diameter of nearly four inches, but its coats are not
much thickened.” The following is the history of the case:
“‘I was requested to see a woman, aged 34, between four and five months
advanced in pregnancy, who, three days before, had been seized with
sickness, constipation, pain, and distention of the abdomen. These
symptoms increased in severity, fecal matter was rejected from the
stomach, the abdomen became more distended, no evacuation could be
obtained from the bowels, and the injections which were attempted to be
thrown up the rectum were immediately expelled. Her powers gradually
sank, and on the third day from the commencement of the attack she died.
“‘On examination after death, the colon was seen to be exceedingly
distended, especially its descending portion, and about six inches from
the anus a foreign body, believed to be a small portion of fish bone,
was found adherent to the lining membrane of the rectum.... Immediately
below this body the bowel was completely closed, to the extent of half
an inch, by the effusion of lymph caused by the presence of the foreign
substance. There was no other morbid appearance.
“‘Prior to the attack which destroyed this patient, she was in her
usual state of health and had no ailment whatever.’”
[Illustration: FIG. 56.--Drawing of specimen No. 2568 in the
Pathological Museum of the Royal College of Surgeons, London.]
Fig. 56.--“Specimen 2568. Presented by Sir William Blizard: Portion
of a rectum, of which the canal is at one part suddenly reduced to less
than a quarter of an inch in diameter by the thickening, induration,
and uniform contraction of its walls. The stricture is half an inch
in length, and terminates as suddenly as it commences. The intestine
above the stricture is very much distended, and its muscular coat is
hypertrophied; the part below it is small and atrophied.”
[Illustration: FIG. 57.--Drawing of specimen No. 2571a in the
Pathological Museum of the Royal College of Surgeons, London.]
Fig. 57.--“Specimen 2571a. Presented by Dr. David Lawson (see _Lancet_,
Vol. I, p. 512, 1879): A portion of a rectum, the seat of a stricture,
which was excised. The bowel is much narrowed, and its walls are
thickened.
“From a woman, aged 34, who had suffered from symptoms of stricture of
the rectum for 8 years. Dilatation by bougies proved of no permanent
benefit. The stricture was hard, annular, admitted the tip of the
finger, and was situated 2 inches above the anus. It was excised
through an incision between the anus and coccyx, and the divided edges
of the bowel above and below were united by sutures. The patient
recovered from and was much relieved by the operation.”
The cases just quoted illustrate the typic advanced hypertrophy limited
to the rectal valve. The 2 cases following next are cases of tubular
stricture of the rectum. The definite boundary between the diseased
and normal tissues suggests the idea that the rectal valves are both
starting and limiting boundaries, and the tortuous course of the
stricture’s canal in Case 2571 seems also to support this idea, as will
be pointed out in the section on diagnosis.
[Illustration: FIG. 58.--Drawing of specimen No. 2571 in the
Pathological Museum of the Royal College of Surgeons, London.]
Fig. 58.--“Specimen 2571. Presented by John Hunter, Hunterian MS.,
Cases and Dissections, No. 59. A rectum, with the urinary bladder and
other adjacent parts. About 2 inches above the anus the canal of
the rectum is gradually reduced to less than half its usual size by
extensive thickening, induration, and contraction of the walls and of
the tissues around them. They are all converted into a uniform pale,
brawny, hard substance, like that of a cicatrix. This change, and the
stricture due to it, extend for about 3 inches up the intestine. The
mucous membrane lining the diseased part is superficially ulcerated;
above it the intestine is greatly dilated, and its coats are thickened;
below it is deeply wrinkled, but apparently not of unhealthy texture.
The following is most probably the history of the case:
“‘About the spring, 1785, General G. consulted me. He complained of a
sensation in the rectum, attended with a kind of difficulty in going to
stool when costive, and often a desire to go when there was nothing to
pass. I examined the rectum, and found, so far as I could reach with my
finger, a hard contracted ring surrounding the gut. I then pronounced
what the case was, and what would be the event.
“‘This hardness and thickening of the gut gradually increased, so as to
make it difficult at times to pass the feces, especially when costive.
At last, it occasionally became so difficult as to require the passing
of bougies and hollow catheters, which one could always pass the lower
stricture, but with difficulty passed the upper, which appeared to be 3
or 4 inches further up the gut.
“‘Clysters, purgatives, sedative and diluting, were occasionally thrown
up, which sometimes had their intended uses. In this way he went
on--sometimes better, other times worse--but upon the whole becoming
worse. At last, it became difficult to pass a bougie, catheter, or even
to throw up an injection, and which was attended with very disagreeable
symptoms for the time, as acidity in the stomach, fulness, oppression,
kind of hiccough, a vast rumbling in his bowels, and want of rest; but
he got occasionally a passage which gave him relief for a time.
“‘He was, of course, put on a very low diet, and such as was thought
best to answer the purposes of diet, while producing the least quantity
of excrements, as also such as tended as little to acidity as possible.
This was animal food in all the forms he liked best.
“‘All this art probably kept him alive for a twelve-month longer than
he otherwise could have lived, for without this attention one or two
costive days would have almost killed him, which I think I have often
seen.
“‘What appeared to be very singular, the constitution did not, till
the very last, seem to feel the disease or its consequences, for his
pulse kept slow and regular, never in the least hard; and when signs
of dissolution had taken place, the pulse was only weaker, but not
irritable. At last nothing passed through the strictures, either
downwards by stool, or upwards by way of clyster. The belly became
gradually fuller and fuller, which was principally air, as towards the
last he took but little food, and which was easily known by the sound
in patting on the belly. He became in some degree insensible to his own
situation, and in some degree less sensible of pain, which increasing,
he died in that kind of easy and insensible manner.
“‘On opening the body the colon was found very much distended with air
through its whole length; its transverse arch made a quick turn down to
near the pelvis, then up upon itself to the left side, and then down
the left, forming the sigmoid flexion; from all which turns, viz.,
making four, and being considerably distended, it appeared to fill
almost the whole belly.
“‘There was a good deal of feces in the colon, but not in the least
distending it.
“‘On putting the hand into the bottom of the pelvis was found a
considerable tumor, which, with the bladder and rectum, was removed;
but in this operation it was found that the tumor adhered closely to
the hollow of the lower part of the sacrum, so as to be obliged to lay
that bone bare in the removal of it.
“‘On slitting down the rectum, which was very large, it was found to be
very much thickened in its coats, and of a hardish, gristly texture, a
good deal like the turtle’s intestines. This increase of thickness was
to give it power to expel its contents.
“‘At the tumor the intestine contracted almost at once; and at its
entrance into the tumor its inner coats were thrown into loose folds,
so as to obliterate almost any appearance of a passage there; however,
I could readily pass the end of my finger into it, those folds easily
giving way. The tumor was next slit through, which showed a firm
increase of the gut, near an inch thick all round, and for three inches
in length. At the lower part it terminated all at once into the sound
gut, which we had often felt when alive. The inner surface had lost
entirely its natural appearance; was slightly rugged so as to appear
like villi.
“‘On introducing the pipe by the anus it was found to come butt against
the side of the upper part of the cavity of the tumor, where there
was a bend in the passage; but why a crooked pipe did not pass when
attempted to be passed by turning it to all sides, I cannot conceive.
Or why a bougie which was slightly bent, did not hit the hole, is not
easily accounted for; but what is more extraordinary than either, why
a clyster did not pass freely up; or why did not the wind or soft
excrements, that did yet lay, pass pretty readily down, while I could
pretty readily pass the end of my finger down from the gut above into
the tumor. The folds of the contracted part did not appear after death
to have been sufficient for an entire stoppage of this kind.”
The preceding case seems to illustrate that form of stricture which
is built upon two or more rectal valves and in which the walls of the
rectal chambers are involved and thickened. The mucous membrane is
longitudinally folded upon itself and incorporated in the organized
plastic exudate. The following case exhibits a tubercular tubular
stricture and is characterized by a destruction of the mucous membrane:
[Illustration: FIG. 59.--Drawing of specimen No. 2571c in the
Pathological Museum of the Royal College of Surgeons, London.]
Fig. 59.--“Specimen 2571c. Presented by Dr. H. Handford (see _Trans.
Path. Soc._, London, 1888, page 117). From a lad, aged 17, who, four
months before death, began to suffer from wasting, irregular attacks of
diarrhea, and passed blood by the anus. Death resulted from purulent
peritonitis, the result of perforation of a rectal stricture by a
bougie. There were tubercle deposits in the upper lobes of both lungs
and in the head of the pancreas.
“Microscopic sections of the lungs, the nodules in the pancreas, and
all the lumbar and mesenteric glands showed masses of caseous material
with a few giant cells.
“The rectum exhibits a tubercular stricture which commences 3½ inches
above the anus. The stricture is 2 inches in length, moderately narrow,
and the mucous membrane covering it is superficially ulcerated. The
intestinal wall is somewhat thickened. Near the upper part of the
stricture is a small perforation, produced in an attempt to pass a
bougie through it.”
The following case is that of a stricture not builded on the rectal
valve. It is situated at the levator ani level, it is probably a
cicatricial product of disease which is not uncommon at this situation,
but it may have had its origin in an imperfect anorectal coalescence.
[Illustration: FIG. 60.--Drawing of specimen No. 2570 in the
Pathological Museum of the Royal College of Surgeons, London.]
Fig. 60.--“Specimen 2570. Presented by John Hunter: The lower part
of a rectum, with the anus. On the margin of the anus are several
large hemorrhoids, and the skin for a considerable distance around
it is excoriated. At the right side of the anus is an appearance of a
narrow granulating wound, as if a fistula had been there operated on.
Immediately above the anus the canal of the rectum is suddenly and
irregularly contracted to half an inch in diameter, but without any
apparent change in the structure of its mucous membrane. Above the
contraction it is unnaturally dilated, its coats are thickened, and the
tissues around it appear rather indurated and confused.”
Case 2567 belongs to the same class as the preceding.
[Illustration: FIG. 61.--Drawing of specimen No. 2567 in the
Pathological Museum of the Royal College of Surgeons, London.]
Fig. 61.--“Specimen 2567. From the Museum of Sir Astley Cooper: The
lower part of a rectum, the canal of which, about an inch from the
margin of the anus, is suddenly reduced to half an inch in diameter
by the deep annular fold of its mucous membrane. Above the fold the
mucous membrane appears healthy; below it is excoriated; and in one
place there is a narrow bridge of it, as if there had been an abscess
external to it, or as if a bougie had pierced it. The tissues around
the contracted part of the rectum are not manifestly diseased. There
are several external hemorrhoids at the margin of the anus.”
[Illustration: FIG. 62.--Congenital diaphragmatic stricture of the
rectum dependent on faulty development of third rectal valve. Composite
view.]
DIAGNOSIS.
_Fallacious Sounding._--Sounding the rectum with the patient in the
horizontal posture, supinated or semipronated, has been a feature of
the conventional method employed for the diagnosis of stricture of the
rectum for more than a century, and as a great array of fatalities
has not yet persuaded the profession to abandon the practice I feel
that at this moment an analytic study of the procedure would not be
unprofitable.
Sounding as a method of diagnosis requires three conditions: (1) that
the tube to be sounded have a recognized limit of distensibility;
(2) that its mobility in the direction of its axis be inappreciable,
and (3) that there be not at irregular intervals normal anatomic
obstructions in its channel sufficient to arrest the progress of a
sound.
These conditions obtain in the urethra which is fixed from extremity
to extremity within a mass of tissue which firmly supports it when the
organ is in a situation for the practice of this diagnostic maneuver.
The rectum on the contrary answers negatively to each of these three
propositions.
Seven or eight inches (17.78 or 20.32 cm.) of the rectum’s length are
not fixed; the lowermost inch (2.54 cm.) is the only portion muscle
bound (Fig. 21) and as this part is easily accessible to digital
exploration, to it, therefore, the method of diagnosis by sounding is
not applied. A little way above the upper border of the prostate, or
the pelvic floor in the female, the rectum is invested by a loop of
peritoneum which does not yoke the gut fixedly but anchors it loosely
in the abdominal cavity.
1. The distensibility of the abdominal rectum is governed by the
elasticity of the gut’s inherent coats and is not limited by a
comparatively unyielding musculofibrous wall supplied by the contiguity
of other parts twentyfold its own strength and several times its own
density and bulk, as is the case with the male urethra. The normal
range of distensibility of the rectum then may be said to be from
zero to three and a half inches (0 to 8.89 cm.) and consequently a
definite calibration for sounding is impossible. (Fig. 21). The sound
of a size which may enter the anus is not to be considered appropriate
for sounding the rectum in accordance with the principle governing
urethral catheterization which may be formulated in the aphorism; the
sound which fits the mouth should discover contractions in the tube.
The average diameter of rectal sounds is about one inch (2.54 cm.).
Two-thirds or three-fourths of the rectum’s expansibility, which may
be greater than three inches (7.62 cm.), must then of necessity be
sacrificed before rectal sounding will uniformly produce any definite
evidence of stricture, provided all other things are equal and
comparable to conditions obtaining in urethral catheterization.
2. Let us suppose, now, that there exist a considerable constriction
of this gut. In such a case the element of _mobility_ of a part of the
rectum in the direction of its axis enters into the problem. The range
of such movement of that part of the gut constricted is determined
by the length of its peritoneal attachment at that point, and of
neighboring portions of the gut, possibly by adhesions of the rectum
to other organs, and, also, depends upon whether the contraction be on
the side next the mesentery or opposite it. To discuss these special
points in detail would be to dwell upon the degrees of a fallacy. The
perplexing fact is this, and it is one that in itself should dethrone
the practice of sounding the rectum by the customary method for the
diagnosis of stricture. A bulb-tipped sound entering the rectum
and coming in contact with a contraction presenting an aperture of
lesser diameter than the sound’s end, will carry that part of the
gut above its normal situation to a point where the limits of length
and elasticity of its attachments arrest the movement, at which time
the sound will be stopped or else will enter, dilate and pass the
stricture, or, perhaps, puncture the gut.
When the sound encounters an obstruction it is the conventional
practice to observe how far the proximal border of the supposed
stricture is from the anus, which, let us say for purposes of
illustration, is in a given case exactly five inches (12.70 cm.). This
measurement having been determined it is now desired that knowledge of
the exact location of the stricture’s distal border be obtained, that
the length of the gut affected by the contraction may be estimated.
Having passed beyond the stricture the sound is tentatively withdrawn,
the shoulder of the bulb presently engaging the upper border of the
constriction will carry it downwards until arrested by the gut’s limit
of displaceability downwards; the exposed length of the shaft of the
sound is now measured and it is discovered that the most distant border
of the contraction instead of being more than five inches (12.70 cm.)
is but three inches (7.62 cm.) from the anus, or, paradoxically, it is
discovered that the farther border of the stricture is two inches (5.08
cm.) nearer the anus than the nearer border was!
3. There is, however, one other factor, which when fully recognized
will effectually discountenance the practice of sounding according
to customary rules. The rectal valves, which I have demonstrated to
be typic anatomic valves and possessed, therefore, of a structure
which qualifies them to offer both active and passive resistance,
and which span one-half, two-thirds, and sometimes three-fourths the
circumference of the rectum, and which have a depth from free border
to that attached to the wall of the gut, varying from a quarter of an
inch (.63) to an inch or more (2.54 cm.) according to the degree of
distention of the rectum. These valves afford in many instances an
effectual obstacle to the passage of the bougie; they supply evidence
which simulates that of stricture when the sound is used, and a valve
may constitute a very ready pocket to trip up and deflect the sound’s
point out of the channel of the gut through its wall and into the
peritoneal cavity.
Analytic survey of the anatomy of this part and study of the mechanics
of surgical sounding compel the conclusion that (1) the enormous normal
distensibility of the rectum (Fig. 31); (2) its great susceptibility to
upward and downward displacement (Fig. 21), and (3) its normal valvular
partitions (Fig. 22) are significant that the customary method of
sounding the rectum for the diagnosis of stricture is unscientific, is
unprofitable as a diagnostic measure, and is extremely hazardous to the
life of the patient.
DIAGNOSTIC OBSERVATIONS.
The rectal obstructions under discussion may be readily diagnosed by
ocular inspection. In the more exaggerated forms of the disease the
method of visual examination, already mentioned in the first part of
this monograph, is to be reinforced by certain instrumental means
presently to be described. For a description of proctoscopy the reader
is referred to the section on Instrumental Inspection.
_Anatomic coarctation_ of the rectal valves is visibly apparent,
and the degree of obstruction which the coarcted valves afford may
be estimated by requiring the patient to bear down, when it may be
observed how the valves may crowd and overlap one another and erect
at one point an almost insurmountable barrier to the descent of solid
feces. _The symptoms_ of such a condition will be found in a history
of labored defecation and chronic obstipation, with frequent and
unsuccessful attempts at evacuation of the rectum.
The condition may be accompanied by a chronic catarrhal rectitis.
_Congenital hyperplasia_ of the rectal valve in the form of a
diaphragmatic stricture does not restrain the atmospheric inflation
of the rectum and the stricture may be observed as a membranous
septum with a laterally placed aperture surrounded by the thin margin
of the valve. The structure is not very elastic and tears readily
on divulsion. _The symptoms_ are those of chronic obstipation with
straining at stool; defecation may occur only at rare intervals and is
accompanied by violent straining, much pain and consequent transitory
prostration. There may be daily repeated unsuccessful attempts at
evacuation of the rectum.
There may result rectitis, ulceration of the rectum, hemorrhoids,
pruritus, prolapse, fissure, abscess, and fistulas, and this form of
stricture may be the foundation and initial feature of any of the more
formidable diseases of the rectum. Hypertrophy may ensue upon chronic
inflammation provoked by the irritation or traumatism incident to the
efforts at defecation. The appearance of the stricture may consequently
become much changed and the adjacent rectum may become involved in a
tubular stricture.
_Hypertrophy_ of the rectal valve when present as an individual lesion
and if of minor degree, presents on proctoscopy the appearance of
a much thickened state of the valve, which may be more marked near
its free border and in the area occupied by the fibrous or tendinous
structure. There may or may not be a noticeable narrowing of the
valve-strait. The valve is not readily effaced under the pressure of
the proctoscope. It offers great resistance to the hook shown in Fig.
17, and if the disease be long continued, and there be much hypertrophy
of the fibrous tissue and infiltration of the muscular elements of
the valve, the typic appearances of the classic annular stricture are
presented. The valve-strait becomes circular in form and is contracted
to greater or lesser degree according to the extent of the lesion.
If the walls of the rectal chamber are involved to a degree which
somewhat limits their expansion under atmospheric pressure, the annular
stricture instead of presenting a smooth margin may be covered by
corrugations of the mucous membrane. The mucous membrane will appear
not smooth and close fitting as is the normal relation, but will appear
loose fitting and in elevated folds, somewhat like the palmar skin when
the hand is slightly flexed.
In those cases in which the pathologic processes are far advanced,
the rectal inflation may be much compromised or entirely sacrificed.
The _symptoms_ of this lesion are usually those of an initial rectitis
or dysentery followed by chronic obstipation, gradually increasing in
degree as time elapses until the patient presents a picture of many of
the symptoms described in the historic clinical reports quoted. Acute
inflammation may attack the strictured part and produce an obstruction
which may quickly terminate the life of the patient; ordinarily the
case may proceed slowly to a fatal issue.
The _complications_ of this disease increase and multiply and may
involve the entire proctica.
The _variable grades of hypertrophy_ of the rectal valves permit
the lesion to be classified in three degrees: (1) The first may be
said to be that in which there is evident thickening of the valve
without corrugation of the mucous membrane; (2) the second degree may
be described as that in which there is more or less intravalvular
corrugation of the mucous membrane and in which rectal inflation is
possible, and (3) the third degree may be described as that which
constitutes a noninflatable rectal chamber. The extraneous causes
of noninflatability of the rectum are described in the section on
Inspection of the Rectum.
The second degree of this lesion may require, and the third degree
essentially requires, the application of further instrumental means to
determine the precise extent of the lesion. The instruments additional
to those required for the proctoscopy described, are a set of curved
cylindric sounds and of fenestrated speculums ten inches (25.40 cm.) in
length and of a diameter which allows their ready passage through the
proctoscope. These instruments are shown in Figs. 63, 64, 65.
[Illustration: FIG. 63.--Curved sounds.]
[Illustration: FIG. 64.--The fenestrated speculum No. 1.]
[Illustration: FIG. 65.--The fenestrated speculum No. 2.]
THE POSITIVE DIAGNOSIS.
Proctoscopy is required to determine the presence of the obstructive
lesions under discussion. It is also sometimes necessary to reenforce
the proctoscopy by the use of additional instruments and by the
exercise of a more elaborate technic. The proper use of these
instruments requires that absolute familiarity with the anatomy of the
part which is only to be acquired by numerous dissections of the human
subject performed in some such manner as that described in the section
on Topographic Anatomy, and it may be superfluous to add that the
manipulations prove useful and safe in that degree which the skilled
operator considers them difficult of execution and possibly dangerous
to the continuity of the gut.
_Anatomic coarctation_ of the rectal valve is made apparent by a
discriminating handling of the proctoscope, and the degree of their
physiologic juxtaposition may be determined by requiring the patient to
bear down while a view of the valvular area is kept under the command
of the eye.
_The congenital errors in development_ of the valve are in most
instances readily perceived. However, in some special cases,
particularly those in which the lowermost rectal valve projects from
the anterior wall, it may require some considerable degree of skill
in the operator to find the valve-strait. Such skill may be acquired
by much practice in the management of the patient, the proctoscope
and the illuminating rays. In the instances under contemplation this
valve-strait is usually found well back toward the hollow of the
sacrum. The proctoscope being made to pass this valve it must be made
to search for the next valve-strait in a direction somewhat behind the
first valve, and so on, first on one side and then on the other till
the whole of the rectum has been ocularly inspected.
In _cases of hypertrophied valve_ of (1) the first degree the amount
of valve resistance may be determined by the use of the hook shown
in Fig. 17. The normal and elastic valve may be effaced under its
pressure. (2) Hypertrophied valve of the second degree, being that
form which is usually called annular stricture of the rectum,
presents on proctoscopy a valve-strait of an irregularly elliptic or
circular form and a smooth-lying or corrugated folding of the mucous
membrane according to the degree of contraction. It is sometimes
impassable by the proctoscope and obstructs the inspection of the
rectal chamber beyond and of the more distant valves and renders it
impossible to determine without further means of inspection whether
it is the only lesion of this character present or whether there is a
multiple valvular hypertrophy. In such a case it is necessary that the
fenestrated proctoscopes, which are shown in Figs. 64 and 65, be used
in the following manner: The distal end of the cylindric proctoscope
should be placed about the contracted valve-strait in such a way that
the smaller fenestrated instrument may under the guidance of the eye
be directed through the stricture. This having been accomplished, the
instrument should be carried firmly but cautiously against the valve
side of the contraction, that a tentative search may be made for
the next valve-strait above. The instrument should never be pushed
forward; it should be directed from side to side in search of the next
valve-strait, through which, if it be safe for the instrument to pass,
it may glide under the influence of gravity, for it is remembered that
the patient is in a posture equivalent to the knee-chest posture.
Never, under any circumstances, should greater pressure be given a
proctoscopic instrument than that which may be given by the unaided
flexor profundus digitorum. If there be encountered any difficulty
in entering the third rectal chamber the first hypertrophied valve
should be divulsed or cut after a method presently to be described,
and a visual search made for the upper passage. Expansion of the
lower valve-strait should render the one next above readily visible.
(3) In rectal obstruction of the third degree, which consists in the
tubular stricture already described and which essentially compromises
or prevents atmospheric inflation of the rectal chamber involved, a
search may be made for the channel of the stricture by means of the
conjoint use of the proctoscopes and sounds. The largest sound which
may enter should be tentatively introduced under the guidance of the
eye, and its distal end directed in one direction or another for the
strictured channel in accordance with our present knowledge of the
natural deviations of the rectal course from side to side. If it be
wise and safe that the sound should enter it will usually require
little or no forward impulse from the proctologist’s fingers. Steadily
and patiently the instrument should be held in the various positions
given it till the muscular resistance yields to the sound’s gentle
pressure. Systematically the field should thus be felt over. If the
channel be found the traction of gravity will probably carry the
instrument forward. Because of the nature of the anatomic features of
the rectum, which have been already pointed out, tubular strictures,
being those which involve the walls of the rectal chamber and the
longitudinal area occupied by two or more rectal valves, are from 1 to
several inches (2.54 + cm.) in length. The introduction through the
cylindric proctoscope of the special instruments for channel searching
is a procedure which places all resistance, if there be any, upon the
pathologic obstruction itself and does not divide the responsibility
for resistance with the sphincters or other muscles, which in the
prevailing method of sounding is a decidedly confusing circumstance.
PRELIMINARY TREATMENT.
Preparatory for radical operative treatment it is often necessary to
care for the one or more complications which are involved. If there
be ulceration, hemorrhoids, abscess, fistulas, general rectitis or
other disease, it is a matter for the consideration of the proctologist
whether their treatment shall precede or follow the operation designed
to remove the obstruction.
The following operation does not require general anesthesia. It may be
painlessly performed without resort to local artificial anesthesia.
OPERATIVE TREATMENT.
_Divulsion._--Frequently-repeated massage of the hypertrophied valve
by means of the coactor (Fig. 66) is often sufficient for the cure of
minor valvular hypertrophy.
[Illustration: FIGS. 66, 67, 68.--The coactor.]
[Illustration: FIG. 69.--Illustrating a method of seizing the free
margin of the valve by means of the volsellum.]
_Valvotomy._--The patient should be placed in the proper posture and
the proctoscope introduced and given into the hand of an assistant.
The valve to be divided should first be seized by the volsellum (Fig.
70) or by the long tenaculum, and steadied. The exercise of delicate
judgment is required to determine how deep to grasp the valve without
going into the circular muscular fibers at its middle part. The
reader’s attention is directed to Fig. 33, which shows the arrangement
of the structures of the valve. The hook should be made to transfix the
mucous membrane and fibrous portions of the valve only.
[Illustration: FIG. 70.--A volsellum.]
[Illustration: FIG. 71.--A knife for valvotomy.]
Before transfixing the valve with the hook or volsellum, the depth
to which the valve may safely be divided may be determined by the
following procedure: A flexible uterine sound should be bent near its
handle in a manner similar to that shown in the hook for valve-testing.
At its distal extremity it should be bent in the form of a curved hook,
which should complete three-quarters of a circle. This hook should now
be introduced to a point above the valve and drawn toward the operator
till the pressure of its end depresses the valve-floor which presents
toward the operator in the form of a blanched eminence. Thus it may be
estimated that the rectal wall behind and above the valve is at a safe
distance from this point. The distance from the eminence to the free
margin of the valve should be carefully noted, for in the subsequent
operation of division the valve should be transfixed by means of the
bistoury at a point considerably nearer the free margin than the
estimated position of the eminence.
[Illustration: FIG. 72.--Illustrating a stage preliminary to the
division of the valve. The most convex portion of the valve, which
is projected toward the operator’s eye by means of the three-quarter
circle-bent hook, indicates a point midway between the free and
attached borders of the valve, to which point it is perfectly safe to
cut the valve. By this means the invisible wall of the rectal chamber
immediately above the valve is fortified against accidental injury.]
[Illustration: FIG. 73.--The method of making the initial incision for
valvotomy.]
The valve should now be seized by tenaculums on either side of the
point selected for section. The knife, shown in Fig. 71, should be made
to transfix the fibrous border of the valve and to divide a few fibers
of this tissue and the mucous membrane covering it, by cutting its way
through the valve’s free border (Fig. 72). This should be transfixed
with the bistoury at a moment when the valve is situated at a right
angle to the gut-wall. Caution: If the valve be _pulled downwards_ by
means of the tenaculums so that it presents an inclined plane toward
the operator at the moment when the bistoury is made to transfix
the conjoined tendon, the superior dense fibrous lamina will have a
tendency to force the knife outward and through the gut-wall; hence the
necessity of a proctoscope of different length for each valve, that
the proctoscope’s end may be carried to the valve instead of the valve
being pulled down to the proctoscope and probably to disaster. But a
few fibers of the conjoined tendon are to be divided by the bistoury.
After the incision is thus started, a scalpel-like knife, provided with
a similarly bent handle, should be used to deepen the incision. In
two places the valve should be cut. The instant the conjoined tendon
is divided, a gaping wound will be presented to the eye. This wound
is irregularly pyramidal and open at its apex; the two walls running
away from the apex consist of the fibrous laminas of the valve; the
base is made of the circular muscular fibers; external to the circular
muscular fibers are the longitudinal muscular and the peritoneal coats
of the rectum. Should hemorrhage occur it may be readily stopped by the
temporary application of clamps (Fig. 74).
[Illustration: FIG. 74.--Clamps.]
[Illustration: FIG. 75.--Telescoped proctoscope.]
[Illustration: FIG. 76.--Coactor within a proctoscope.]
Hypertrophy of the rectal valve in the second degree, and which
constitutes annular stricture of the rectum, usually requires the
introduction of the smaller fenestrated proctoscope, according to
the manner already described; or if this instrument does not fill
the stricture and draw its border taut about the spokes, the larger
fenestrated proctoscope should be placed on the smaller, that the
smaller may serve as guide, and the two introduced through the
cylindric proctoscope and carried into the stricture according to the
directions given in the section on diagnosis. The smaller fenestrated
proctoscope may now be withdrawn. On looking down through the vista
the stricture or strictures may be discovered binding close about the
instrument. The walls of the rectal chambers between the valves will be
lifted away from the instrument by the atmospheric pressure, and may
be seen only through the medium of the proctoscopic mirror. The valves
may now be cut by transfixing and cutting through the free border as it
is held taut about the fenestrated proctoscope. On the removal of the
valvotome the coactor should be introduced and the stricture divulsed
in several directions by opening the coactor, as shown in Fig. 76. The
cervix divulsor shown in the illustrations 77 and 78 may be likewise
used.
[Illustration: FIG. 77.--A divulsor.]
[Illustration: FIG. 78.--A divulsor within the proctoscope.]
Hemorrhage is seldom of any consequence after operations on this
variety of stricture. However, should it require treatment, the
fenestrated proctoscope should be removed and the clamps temporarily
applied. Should the operator fear secondary hemorrhage he should fix a
serrefine on the bleeding point and leave it in place for twenty-four
hours.
SUBSEQUENT TREATMENT.
Should there be any sign, constitutional or local, of hemorrhage, the
patient should at once be subjected to a proctoscopic inspection and
the bleeding point surgically cared for. Each day the wound may be
inspected and dressed according to the nature of its requirements, and
after the first two or three days the valve should be occasionally
subjected to divulsion or massage by means of the coactor. Should there
ensue a rectitis or a granulating wound, it may be treated by means of
the atomizer, by the use of topic applications otherwise administered,
or by lavage.
TREATMENT OF SIMPLE TUBULAR STRICTURE OF THE RECTUM.
The radical treatment of this stricture may possibly require a
resection of that portion of the gut which it contracts, or in case
of acute obstruction the establishment of an artificial anus may
be imperative. The individual use of, or the alternate use of, the
methods of gradual dilatation and immediate divulsion described in
previous paragraphs may be efficacious. A continued course of treatment
by instrumental massage has in my hands relieved such patients of
their symptoms and restored contracted rectal chambers to normal
inflatability and healthful mucous surfaces.
ACUTE RECTITIS.
_Salient Symptoms._--There is usually steady aching, or sensation of
heat and weight in the sacral region and lumbar spine; the disease is
initiated with a short period of obstipation or constipation which is
sometimes followed by a somewhat longer period of diarrhea; finally
there are discharges of mucus.
_Diagnosis._--Proctoscopy reveals the fact that the mucous membrane
lining the rectal chambers is deeply infected. The arborescent
arterioles may appear in clusters of bright red twigs. The club-shaped
venous radicals, which are of a purple color, may be observed somewhat
elevated above the surface of the mucous membrane at various points
throughout the chambers, and there is a generally diffused redness
throughout the entire area involved. Extensive rectitis sometimes
prevents inflation of the rectum. This may be overcome by the use of
the coactor.
_Treatment._--Acute inflammation of the rectal mucous membrane may
be rapidly reduced by spraying the part with any of the familiar
antiphlogistic solutions; silver nitrate solutions, 3 or 4 grains to
the ounce, are also effective.
[Illustration: FIG. 79.--A method of spraying the rectum.]
_Technic._--With the patient under proctoscopy, the operator should
take in his left hand the proctoscope, and in his right hand the
atomizer (Fig. 79), which should be attached to a compressed-air
reservoir. By coordinate movement of the hands, each of the chambers
involved in the disease may be rapidly and systematically sprayed with
the solution. If the hand-bulb spray be used, an assistant will be
required to hold and to direct the proctoscope from chamber to chamber.
The method proposed is neat and susceptible to a rapid execution; the
other is awkward and fatigues the patient, while it but imperfectly
achieves its purpose. Autolavage of glycerin solutions are also helpful.
[Illustration: FIG. 80.--A hooked probe.]
[Illustration: FIG. 81.--An atomizer.]
[Illustration: FIG. 82.--An insufflator.]
CHRONIC HYPERTROPHIC RECTITIS.
_Salient Symptoms._--There are usually lumbar and sacral backache, and
obstipation if there be valvular hypertrophy. There may be diarrhea,
in some instances, if there be increased secretion of mucus. The
patient becomes much debilitated and suffers from recurring attacks of
flatulence and dyspepsia. The symptoms are not of reliable diagnostic
significance.
[Illustration: FIG. 83.--A curet.]
[Illustration: FIG. 84.--A composite proctoscopic view of a rectal
polypus, papillomas, and of a hypertrophied rectal valve of the second
degree.]
_Diagnosis._--Proctoscopy may reveal a somewhat magenta-colored mucous
membrane, the opacity of which often obscures the arterioles and
renders the engorged veins less clearly defined than in the acuter
forms of this disease. At various points small areas of the mucous
membrane will be observed superficially eroded; and here and there
will be seen inspissated masses of mucus burdened with exfoliated
epithelial cells, while elsewhere in many places about the chambers may
be seen larger collections of viscid mucus.
_Treatment._--This disease requires the application, by methods
described in a preceding paragraph, of sprayed solutions which are
essentially stimulating in their character. It is necessary that the
treatment be repeated after an interval of several days.
CHRONIC MEMBRANOUS RECTITIS.
_Salient Symptoms._--Constipation, obstipation or diarrhea may
alternate. Discharge of shred-, cord-like or tubular casts, which are
usually of a light gray color, is a common symptom. The patients are
the subjects of repeated attacks of intestinal autointoxication and are
usually neurasthenic.
_Diagnosis._--Proctoscopy reveals the mucous membrane of the rectal
chambers of much the same appearance as in the most aggravated forms of
chronic hypertrophic rectitis. The discharge will be characterized by
shred, rope, cord-like or tubular formations of mucus and epithelium,
and occasionally fibrin also may be detected incorporated in the
casts. If these casts are not observed at the time of the proctoscopic
inspection they will be reported in the patient’s anamnesis.
The _Treatment_ is essentially the same as described in the preceding
paragraph on treatment.
CASES OF OBSTIPATION RADICALLY TREATED.
CASE 1.--June 3, 1898, Miss R. T., 32 years of age, consulted
me for the relief of long-continued obstipation. She reported
that for many years defecation was possible and easy only
when the feces were rendered fluid by means of cathartics or
enemas, that when the feces were formed their evacuation was
accomplished only with the greatest of straining and by manual
assistance. The young woman was profoundly neurasthenic and
suffered from repeated attacks of intestinal autointoxication.
Proctoscopy discovered a general hypertrophic rectitis and such
a degree of hypertrophy of the rectal valves and contraction
of the valve-straits as is equivalent to multiple annular
stricture. Without the employment of general anesthesia the
fibrous bands beneath the valve-margins were divided by
means of the knives especially designed for the purpose.
The operation was painless and unaccompanied by hemorrhage.
Within three days the patient was able to take a journey of
several miles to visit me at my office. During the first two
or three days, without the aid of enemas or cathartics, there
was on each day a normal evacuation. On the third day, fearing
that there would be contraction of the valve at the seat of
the wound I practised instrumental massage. There ensued a
mild degree of rectitis, and for two weeks the defecation
was attended with some difficulty, but in lesser degree than
formerly. The rectitis presently subsided. Normal defecation
was restored.
CASE 2.--Mr. J. C., aged 24 years, was referred to me by Dr.
H. L. S. in August, 1898. The patient presented a history
of persistent obstipation, which began after an attack of
fever from which he suffered some six years ago. The patient
reported that except when the feces were rendered fluid by
means of cathartics or enemas it was impossible for him to
procure evacuation of the bowels. He reported that there was
progressive increasing difficulty in getting injected fluids
into the colon. He complained of tenderness and pain throughout
the region of the sigmoid, and reported that for several
years rectal irrigations had brought cord-like and membranous
deposits on their return. The patient was neurasthenic.
Proctoscopy discovered a general hypertrophic rectitis with
no apparent contraction of the valve-straits and hypertrophy
of the rectal valves, their borders being twice their normal
thickness, which on the employment of the hook were discovered
to be rigid and inelastic. The sigmoid was observed to be
enormously dilated and here and there were observable deposits
of gelatinous mucus. Without the employment of artificial
anesthesia the fibrous band beneath each valve-border was
painlessly divided. Subsequently the valves were subjected
to instrumental massage by means of the coactor, the rectal
and sigmoidal mucous membrane was sprayed daily with a weak
solution of silver nitrate. At the end of ten days defecation
was being daily normally performed and the pain and tenderness
had entirely subsided in the sigmoid.
CASE 3.--In October, 1898, Mrs. C., 34 years of age, the mother
of two children, consulted me for the relief of persistent
obstipation and annoying borborygmus. She was emaciated,
neurotic, and irascible to the last degree. She reported
that since childhood she had been the subject of difficult
defecation. The rectum was evacuated only occasionally, and,
within the last few years she had suffered recurrent attacks
of diarrhea. Proctoscopy discovered the two lowermost rectal
valves slightly hypertrophied and the presence of two much
hypertrophied rectal valves at the juncture of the rectum
and sigmoid flexure. The sigmoid was observed to be much
dilated. Because of her nervous symptoms and of her inability
to properly control herself she was placed in a condition of
general anesthesia and all the valves divided. During the next
four weeks, without the employment of cathartics or enemas,
defecation was normally performed at irregular intervals. At
the end of four weeks, because the patient would not submit to
instrumental massage of the valves, which I deemed necessary to
prevent their contraction and to make a perfect cure, the woman
discontinued her relation to me as a patient. Some two months
subsequently she called at my office and reported that during
the preceding six weeks defecation had been performed daily,
without difficulty and without the employment of artificial
aid; also, she had entirely recovered from neurasthenia.
CASE 4.--In June, 1898, Mrs. R. B., aged 36 years, the mother
of three children, was referred to me by Dr. G. W. C. for
the relief of obstipation and continued pain in the iliac
fossas. She reported that from childhood she had never had
an evacuation of the bowels except when the feces were fluid
and had been rendered so by cathartics. She was addicted
to the physic-habit, was neurasthenic, suffered repeated
attacks of intestinal autointoxication and recurrent attacks
of proctosigmoiditis. Proctoscopy discovered hypertrophic
rectitis of such a degree as to interfere with spontaneous
ballooning of the rectum, several applications of instrumental
massage and divulsion of the rectum by means of the coactor
and spraying the rectum with silver nitrate solutions soon
rendered rectal inflation possible and permitted the discovery
of four hypertrophied rectal valves. An operation for the
division of the valves was attempted without the employment of
general anesthesia, but because of the nervous movements of
the patient it was found necessary to completely anesthetize
her for the sake of continuing the focus of light upon the
field of operation. Without the aid of enemas or cathartics
normal defecation was almost immediately instituted and firmly
formed feces were evacuated with little or no straining once
in two or three days and finally daily with only an occasional
intermission. However, the patient was many months recovering
from the intestinal autointoxication incident to the dilated
sigmoid.
CASE 5.--Mr. F. D. N., of Red Lake Falls, Minn., aged 46
years, was for many years a subject of chronic obstipation.
His anamnesis detailed symptoms of backache, pain extending
down the thighs, tenderness throughout the sigmoid flexure
and colon, and straining at stool except when the feces were
rendered fluid by cathartics. He was neurasthenic. Examination
revealed internal varicose hemorrhoids, hypertrophy of the
rectal valves and a dilated sigmoid flexure. The hemorrhoids
were removed under cocain-infiltration anesthesia on March 6,
1898. A valvotomy was done on January 15, 1899. The patient
recovered normal defecation, was relieved of the symptoms
referred to and has gained 12 or 15 pounds in weight.
CASE 6.--Miss G. H., of Marion, Ohio, aged 19 years, was
referred by Dr. C. F. H. From infancy she had suffered more
or less chronic irregularity in defecation. This difficulty
increased to such a degree during the last two years that
cathartics and enemas were indispensable. She reported the
classic symptoms of intestinal autointoxication. An examination
by means of the proctoscope revealed the presence of four
rectal valves and the fact that the first two were anatomically
coarcted. On April 29 valvotomy of the two valves was done.
She was immediately relieved of the obstipation, the function
of defecation has since been perfectly normal, and her
neurasthenic symptoms have entirely subsided.
CASE 7.--Mrs. E. B. W., of Los Angeles, Cal., aged 48 years.
Her symptoms were chronic obstipation with straining at stool
except for the evacuation of fluid feces. Proctoscopy revealed
hypertrophic rectitis and much thickening of the rectal valves.
On May 6 valvotomy was performed and normal function restored.
CASE 8.--Mrs. A. B. P., of Conneaut, aged 44, was referred by
Dr. B. M. T. with a history of chronic obstipation, and of
an abscess in the right ovaroappendicular region at a time
prior to Dr. T.’s acquaintance with her. Her symptoms were
those of chronic obstipation, tenderness in the region of the
sigmoid and in the right iliac fossa. The pain was aggravated
by the presence of water or feces in the rectum. Even small
enemas caused such pain that cathartics had been relied upon.
Examination discovered a dilated sigmoid which was extremely
tender, the tenderness being greater in the right iliac fossa.
It also discovered the presence of hypertrophic rectitis with
hypertrophy and coarctation of the two lowermost rectal valves
and such a considerable degree of hypertrophic rectitis and
edema at the rectosigmoidal juncture as to prevent the entrance
into the sigmoid of even the smallest sound. On June 28 the
lower two valves were divided, a 4% solution of cocain was
sprayed upon the swollen rectosigmoidal mucosa, which becoming
ischemic permitted of an easy introduction of the coactor for
the divulsion of the highest stricture. During the ensuing
three weeks the lower intestine was daily irrigated with two
or three quarts of hydrastis solution, and the irrigation was
unaccompanied by pain or distress and normal defecation was
instituted and has continued. All of the symptoms have subsided
except a small degree of tenderness in the region of the
appendix.
CASE 9.--Mr. R. T. G., of Rochester, aged 24 years, was
referred by Dr. W. E. L. The patient was neurasthenic and
subject to chronic obstipation, backache, and extreme
tenderness in the sigmoid flexure, which was enormously
dilated. He suffered much from accumulation of gas, which
seemed to lodge, according to his own report, at a point just
below the navel. The dorsal posture was unendurable to him
because it seemed to increase the obstruction to the escape
of the gas. For this reason he had to cease frequenting the
barber’s chair and had to shave himself. This patient was
also the subject of excruciatingly painful sphincter spasm.
Proctoscopy discovered a small _fissure in ano_ and hypertrophy
of the third rectal valve with reducible invagination of the
sigmoid. Valvotomy, and silver nitrate application to the
fissure, soon relieved him of all his symptoms.
CASE 10.--Mr. F. C. S., of Cleveland, aged 52 years, consulted
me in July, 1898, for persistent obstipation and intestinal
autointoxication. Proctoscopy revealed a hypertrophic rectitis
with hypertrophy of the rectal valves. Instrumental massage of
the valves by means of the coactor was practised. The treatment
was administered half a dozen times with intervals of five or
ten days between the treatments. The patient made a perfect
recovery.
CASE 11.--A gentleman of Cleveland, aged 36, had suffered for
years from pyloric stenosis in an extreme degree, and from
chronic impairment of defecation. He had been operated for
gastroenterostomy some months previous to my seeing him and
had been completely restored to health in every way excepting
in that of defecation and tenderness in the lower abdominal
region. Proctoscopy revealed a general hypertrophic rectitis
with hypertrophy of the rectal valves. I twice performed
valve section upon this gentleman without improving his
defecation. He now finds it necessary to use a laxative to
secure evacuation of the bowels. This is undoubtedly a case
of obstipation _and_ constipation, illustrating the fact that
constipation and obstipation may coexist in one individual,
and that the division of the rectal valves, though removing
the strictured condition of the rectum and relieving him from
the dire consequences of such disease, will not cure the
constipation.
The subjects of hypertrophied rectal valves may present the symptom of
diarrhea; in such a case valvotomy may be performed at once or, on the
other hand, may be delayed until the catarrhal proctocolitis has been
brought under control by means of sprayed astringent solutions. The few
cases reported are typic. Up to the present time I have operated upon
forty-six patients whose cure has been established for sufficient time
to justify report. A few have been relieved by means of instrumental
massage of the valve and without resort to its section. The eleven
cases presented represent the average in severity of disease and in the
beneficence of the results achieved. Of all the operations performed
but three have been done under artificial anesthesia. The operation
is painless and if swiftly performed, as it may be by the skilled,
need not fatigue the patient. It is wise, however, to narcotize the
extremely neurotic. The operation should be performed in the hospital
or at the patient’s home.
The commoner complications of the hypertrophied valve, which may be
dilated sigmoid and colitis in varying degree, may contribute to the
establishment of constipation. In such a case, in addition to local
treatment by application of sprayed solutions, lavage and massage, such
measures as will improve the general condition of the patient must be
employed.
_In conclusion_, the reader is referred to the prefatory note.
[Illustration: FIG. 85.--Portable operating table made of bamboo and
light weight steel tubing, strapped in a package 42 inches in length
and 7 inches in diameter, and weighing about 29 pounds. The table
and its covering are susceptible of being rendered aseptic. This
table is capable of being made 6 feet in length. When set in shorter
length it affords a surface 42 inches in length for the lithotomy or
other dorsal, or Sims’ posture. It may be readily converted into the
Trendelenburg position without elevating the patient above the reach
of the standing operator; the table holds the patient securely in this
position without the aid of straps; the table may be turned to support
the patient in the new posture for operations high in the rectum; its
top may be made to serve as a stretcher by withdrawing the telescoped
end-pieces; and, finally, it may be used as a top piece for the
hospital wagon. The light-apparatus is susceptible of the adjustment to
an infinite number of positions and when not required for illumination
may be turned under the tabletop. This table has sustained a test of
over 500 pounds.]
[Illustration: FIG. 86.--The table and light-apparatus in position for
examination and operations upon the anus.]
[Illustration: FIG. 87.--The table and light-apparatus in position for
examination and operations within the rectum.]
[Illustration: FIG. 88.--The patient in the Sims’ posture with
the table and illumination-apparatus adjusted for examination and
operations upon the anus.]
[Illustration: FIG. 89.--The patient in the new posture with table and
illumination-apparatus adjusted for examination and operations within
the rectum. The passive patient is supported by the shoulder-suspender
and knee-piece.]
List of Illustrations.
1. Positions of the hands for the practice of the simplest method of
proctoscopy
2. Positions of the fingers for the practice of the simplest method
of proctoscopy
3. The chair, illumination-apparatus, shoulder-suspender, and small
pillow
4. The chair in the horizontal posture for anoscopy
5. The position of the chair for the new posture of the patient
6. The anoscope
7. The obturator
8. The ointment applicator
9. The two-way irrigator
10. The proctoscope
11. The ointment applicator at the time of the placing of the
ointment in contact with a diseased area
12. The proctoscope ready for introduction
13. Sitting posture of the patient, the first step toward proctoscopy
14. Horizontal posture of the patient for anoscopy
15. Putting the patient into the new posture
16. The new posture
17. The hook for testing the valves
18. The proctoscopic mirror
19. Drawing of specimen No. 281 in the Anatomical Museum of the Royal
College of Surgeons, London
20. Drawing of specimen No. 284 in the Anatomical Museum of the Royal
College of Surgeons, London
21. From a photograph of an external view of the paraffin cast-filled
rectum
22. Interior view of the left half of the rectum of an adult
23. Knee-chest posture. Left lateral half-interior view
24. Posterior view of a specimen carefully dissected to show the
muscular supply to the valve-bases
25. Posterior half occupied by its cast
26. Anterior half of specimen shown in Fig. 25
27. Posterior view of a cast-filled rectum
28. Paraffin cast from a rectum
29. Photograph of a female cadaver showing, after
laparo-symphysiotomy and removal of bladder, uterus and adnexa, the
upper rectum and sigmoid packed with scybalums
30. The rectum, the same as is shown in Fig. 29, divided into
anterior and posterior halves
31. From a photograph of an anal end-view of a cast-filled rectum
32. From a photograph of an external view of a cast-filled rectum and
its mesenteric attachment to the sacrum; taken from an 18-months-old
infant
33. A semilunar valve drawn as seen under a glass magnifying five
diameters
34. The instrument case
35. The rectum of an infant, stillborn
36. Side view of the specimen shown in Fig. 35
37. Front view of the rectum of an infant aged one hour
38. Side view of the specimen shown in Fig. 37
39. Front view of the rectum of an infant aged one month
40. Side view of the specimen shown in Fig. 39
41. Front view of the rectum of an infant aged six weeks
42. Side view of the specimen shown in Fig. 41
43. Front view of the rectum of an infant aged six months
44. Front view of the rectum of an infant aged six months
45. Side view of the specimen shown in Fig. 44
46. Diagrammatic of this gut in the empty state
47. Diagrammatic, showing direction of forces and resistance in
infant, in defecation
48. Diagrammatic, showing direction of forces and resistance in
adult, in defecation
49. The rectum and sigmoid of an infant aged two months
50. The interior view of the opposite posterior half of the rectum
shown in Fig. 49
51. The paraffin cast removed from the gut shown in Figs. 49 and 50
52. A three-and-a-half-months fetus. A photograph showing the
posterior half of the rectum prepared by the paraffin-cast process
53. A five-months fetus. A photograph showing a paraffin cast-filled
rectum in situ; the other organs having been dissected away
54. Anatomic coarctation of valves
55. Drawing of specimen No. 2569 in the Pathological Museum of the
Royal College of Surgeons, London
56. Drawing of specimen No. 2568 in the Pathological Museum of the
Royal College of Surgeons, London
57. Drawing of specimen No. 2571a in the Pathological Museum of the
Royal College of Surgeons, London
58. Drawing of specimen No. 2571 in the Pathological Museum of the
Royal College of Surgeons, London
59. Drawing of specimen No. 2571c in the Pathological Museum of the
Royal College of Surgeons, London
60. Drawing of specimen No. 2570 in the Pathological Museum of the
Royal College of Surgeons, London
61. Drawing of specimen No. 2567 in the Pathological Museum of the
Royal College of Surgeons, London
62. Congenital diaphragmatic stricture of the rectum dependent on
faulty development of third rectal valve. Composite view
63. Curved sounds
64. The fenestrated speculum No. 1
65. The fenestrated speculum No. 2
66. The coactor
67. The coactor
68. The coactor
69. Illustrating a method of seizing the free margin of the valve by
means of the volsellum
70. A volsellum
71. A knife for valvotomy
72. Illustrating a stage preliminary to the division of the valve
73. The method of making the initial incision for valvotomy
74. Clamps
75. Telescoped proctoscope
76. Coactor within a proctoscope
77. A divulsor
78. A divulsor within the proctoscope
79. A method of spraying the rectum
80. A hooked probe
81. An atomizer
82. An insufflator
83. A curet
84. A composite proctoscopic view of a rectal polypus, papillomas,
and of a hypertrophied rectal valve of the second degree
85. Portable operating table
86. The table and light-apparatus in position for examination and
operations upon the anus
87. The table and light-apparatus in position for examination and
operations within the rectum
88. The patient in the Sims’ posture
89. The patient in the new posture
FOOTNOTES:
[1] “Noninstrumental Inspection of the Rectum.”
[2] Italics in the quotations to follow are mine and are used to point
out statements to which I will make particular exceptions.
[3] “Treatise on the Malformations, Injuries and Diseases of the
Rectum,” French and Allard, New York.
[4] “The Chronology of the Methods of Atmospheric Inflation for
Inspection of the Rectum and Sigmoid Flexure;” Thos. Chas. Martin, _The
Louisville Journal of Surgery and Medicine_, December, 1898.
[5] “Clinical Notes on Uterine Surgery;” William Wood & Company, New
York, 1866.
[6] “Diseases of the Rectum;” D. Appleton & Co., New York, page 394.
[7] “Diseases of the Rectum;” P. Blakiston, Son & Company,
Philadelphia, page 12.
[8] “Diseases of the Rectum;” H. K. Lewis, London, 1887, page 16.
[9] “Anatomische Untersuchungen am menschlichen Rectum;” Veit and
Company, Leipsic, 1887.
[10] “Die Krankheiten des Mastdarmes und des Afters;” Ferdinand Enke,
Stuttgart, 1887.
[11] “A New Method of Examination and Treatment of Diseases of the
Rectum and Sigmoid Flexure;” _Annals of Surgery_, April, 1895.
[12] “Surgery of the Alimentary Canal;” P. Blakiston, Son & Company,
Philadelphia, 1896, page 566.
[13] My attachment consists of a superstructure and an additional
mechanism upon the Yale chair which adds the new movements without
interfering in any way with the other postures which the chair makes
possible.
[14] Section on Fallacious Sounding.
[15] Allingham, Diseases of the Rectum, page 261, Churchills, London.
[16] “Manual of Physiology,” 1895, G. M. Stewart, M.A., D.Sc., M.D.,
Edin., D.P.H. Camb., Professor of Physiology in the Western Reserve
University, Cleveland.
[17] See introduction.
Transcriber’s Notes.
Italic text is indicated with _underscores_, bold text with =equals=.
Small/mixed capitals have been replaced with ALL CAPITALS.
Evident typographical and punctuation errors have been corrected
silently. Inconsistent spelling/hyphenation has been normalised.
On page 15, “Mason” has been corrected to “Masson” (G. Masson, Éditeur).
On page 26 “Henly” has been corrected to “Henle” (Henle says that).
A reiteration of the book title has been discarded.
End of page footnotes have been sequentially numbered and relocated to
the end of the book.
To aid text flow, Illustrations have been placed between
paragraphs/chapters, and, where convenient to do so, close to their
mention in the text.
A Table of Contents and List of Illustrations have been compiled by the
transcriber.
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