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.