_Salient Symptoms._--Constipation, obstipation or diarrhea m_Obstipation

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