Part 2

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.