Part 8
_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.
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.
_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.
_Salient Symptoms._--Constipation, obstipation or diarrhea may 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.
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 Royal College of Surgeons, London
56. Drawing of specimen No. 2568 in the Pathological Museum of the Royal College of Surgeons, London
57. Drawing of specimen No. 2571a in the Pathological Museum of the Royal College of Surgeons, London
58. Drawing of specimen No. 2571 in the Pathological Museum of the Royal College of Surgeons, London
59. Drawing of specimen No. 2571c in the Pathological Museum of the Royal College of Surgeons, London
60. Drawing of specimen No. 2570 in the Pathological Museum of the Royal College of Surgeons, London
61. Drawing of specimen No. 2567 in the Pathological Museum of the Royal College of Surgeons, London
62. Congenital diaphragmatic stricture of the rectum dependent on faulty development of third rectal valve. Composite view
63. Curved sounds
64. The fenestrated speculum No. 1
65. The fenestrated speculum No. 2
66. The coactor
67. The coactor
68. The coactor
69. Illustrating a method of seizing the free margin of the valve by means of the volsellum
70. A volsellum
71. A knife for valvotomy
72. Illustrating a stage preliminary to the division of the valve
73. The method of making the initial incision for valvotomy
74. Clamps
75. Telescoped proctoscope
76. Coactor within a proctoscope
77. A divulsor
78. A divulsor within the proctoscope
79. A method of spraying the rectum
80. A hooked probe
81. An atomizer
82. An insufflator
83. A curet
84. A composite proctoscopic view of a rectal polypus, papillomas, and of a hypertrophied rectal valve of the second degree
85. Portable operating table
86. The table and light-apparatus in position for examination and operations upon the anus
87. The table and light-apparatus in position for examination and operations within the rectum
88. The patient in the Sims’ posture
89. The patient in the new posture
FOOTNOTES: