Part 1

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.