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.