Part 7

2. Let us suppose, now, that there exist a considerable constriction of this gut. In such a case the element of _mobility_ of a part of the rectum in the direction of its axis enters into the problem. The range of such movement of that part of the gut constricted is determined by the length of its peritoneal attachment at that point, and of neighboring portions of the gut, possibly by adhesions of the rectum to other organs, and, also, depends upon whether the contraction be on the side next the mesentery or opposite it. To discuss these special points in detail would be to dwell upon the degrees of a fallacy. The perplexing fact is this, and it is one that in itself should dethrone the practice of sounding the rectum by the customary method for the diagnosis of stricture. A bulb-tipped sound entering the rectum and coming in contact with a contraction presenting an aperture of lesser diameter than the sound’s end, will carry that part of the gut above its normal situation to a point where the limits of length and elasticity of its attachments arrest the movement, at which time the sound will be stopped or else will enter, dilate and pass the stricture, or, perhaps, puncture the gut.

When the sound encounters an obstruction it is the conventional practice to observe how far the proximal border of the supposed stricture is from the anus, which, let us say for purposes of illustration, is in a given case exactly five inches (12.70 cm.). This measurement having been determined it is now desired that knowledge of the exact location of the stricture’s distal border be obtained, that the length of the gut affected by the contraction may be estimated. Having passed beyond the stricture the sound is tentatively withdrawn, the shoulder of the bulb presently engaging the upper border of the constriction will carry it downwards until arrested by the gut’s limit of displaceability downwards; the exposed length of the shaft of the sound is now measured and it is discovered that the most distant border of the contraction instead of being more than five inches (12.70 cm.) is but three inches (7.62 cm.) from the anus, or, paradoxically, it is discovered that the farther border of the stricture is two inches (5.08 cm.) nearer the anus than the nearer border was!

3. There is, however, one other factor, which when fully recognized 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.

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.

_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.

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.

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).

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.

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.