Chapter I: 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.

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.

Dr. Kelly’s article, however, was the first to catch the attention of the general profession, and to him is due the credit of pointing out to a multitude of physicians the possibility of rectal inflation for inspection by such means. Kelly’s technic and tubular speculums are far superior to those of Mr. Allingham, who first employed a similar method in 1882.

In 1896 I published in the July number of _Mathews’ Quarterly Journal of Rectal and Gastro-Intestinal Diseases_, under the title of “Proctocolonoscopy and Its Possibilities,” a description of a technic and new instruments which increased the areas exposed to view, and which facilitated access to the part for the treatment of disease.

In 1896 A. Ernest Maylard[12] briefly referred to the various methods.

Review of the literature on rectal inflation for rectal inspection establishes the fact that Van Buren is entitled to the credit for priority; that Marion Sims was the discoverer of the possibility of atmospheric inflation of the hollow pelvic viscera; that there is much similarity in the methods of the various operators quoted, some using similar instruments and dissimilar technic, and _vice versa_; and it is made obvious, also, that he who would most insist upon a credit for originality must sometimes discount with the erudite his reputation for literary research.

The time has arrived when the profession must recognize that the rectum need no longer be regarded a darkest continent. There remains, however, something further to be desired in the way of an easier and more convenient method of manipulation to secure inspection, but I am confident that ere long the profession will accept the newer mechanic means and contrivances which will render a proctoscopy of as practical simplicity as is laryngoscopy. But it behooves us to remember the words of Dr. Edmund Andrews: “The false method is that of the bungler and amateur, who is only right by haphazard; the true one is that of the professional expert, who can not be balked by petty obstacles, but who will reach success when others have failed, not less by his dogged persistence and thoroughness than by his superior knowledge.”

THE EXAMINATION OF THE RECTUM.

It has been complained that the best methods proposed for the inspection of the rectum require so expensive an armamentarium and such painstaking practice on the part of him who would see, that the general practician can not hope to invade with his keen glance this field which is generally regarded a terra incognita. On the contrary, as shall be seen, no artificial means whatsoever are required for a complete ocular inspection of the rectum.

The elevation of the hips which sets in operation that principle of physics which governs the methods of Marion Sims’ vaginal inspection (1845), Van Buren’s rectal inspection (1871), and the methods of the senior Allingham (1882), of Walter J. Otis (1887) and of Howard Kelly (1895), which controls my own proctocolonoscopy (1896), and which suggested Trendelenburg’s posture, is, also, the chief feature of the simplest proctoscopy.

NONINSTRUMENTAL INSPECTION OF THE RECTUM.

The essentials to this simplest method are a patient, an assistant and an operator having at least one finger on each hand. The patient is to be put into the knee-chest posture, the assistant is to put and to hold the patient, and the physician’s fingers are to be used to open the anus, all in the following manner, to wit:

1. The patient is to be completely anesthetized as he lies on his back, and then turned toward the assistant and into Sims’ posture.

2. The assistant is to station himself at the patient’s knees. In his left hand he is to grasp the patient’s feet. He is to lean himself against the patient’s knees. He is to pass his right arm under the patient’s hips. Now steadying the feet and bearing himself firmly against the subject’s knees, with his right arm he is to lift the hips and pull the patient into the knee-chest posture, where he is to be balanced on his perpendicular right thigh throughout the whole time of the physician’s manipulations.

3. The physician is to close his hands and to point each index-finger as shown in the accompanying illustration (Fig. 1). The wrists are to be crossed, the hands placed back against back, and the nails of the index-fingers placed one against the other, as shown in the accompanying illustration (Fig. 2). The physician is to lubricate these fingers and gently insinuate them through the anus and place their ends beyond the borders of the levatores ani. This accomplished, the anus is to be divulsed in the direction of the ischial tuberosities, by the physician forcibly parting his fingers as is shown in the accompanying illustration. Under this manipulation the rectum becomes atmospherically inflated.

Now, provided the physician lowers his head to the level of his fingers and then rises again, or stoops, or moves a little from side to side, he may command under his eye a view of the interior of the atmospherically inflated rectum to the depth of six or eight inches (15.24 or 20.32 cm.), and in some instances he may behold even a part of the sigmoid flexure.

It is possible for the operator to manipulate his patient and to finish his inspection within two and a half or three minutes, provided the patient be in a state of complete anesthesia.

If this method is practised, as I am persuaded it may be with facility by the general practician, I am convinced that the greater number of rectal diseases may be instantaneously diagnosed. But I must declare that here at diagnosis, the achievement of the simplest proctoscopy ends, for the reason that the operator’s hands are so full of his patient he can do nothing at all for the disease which he may have discovered.

Under some conditions and amid some circumstances the rectum will not inflate. If the bladder is much distended; if there is an inordinate hypertrophic rectitis; if there is a close tubular stricture of the rectum; if there is malignant growth or other disease of the rectum by means of which the gut’s coats have become extensively filled and fixed with an organized plastic exudate; if for some reason the extraabdominal pressure is abnormally increased, as it may be by the bearing down of the patient, or by enormous flatus, or by ascites; or if there is an impinging uterus, adrectal growth or extensive infiltrating disease of the contiguous textures, rectal inflation by this method or by any other which is governed by the same principle may be a physical impossibility--but this need not baffle the man bent on seeing by instrumental aid.

Practised as described, when not embarrassed by the exceptions specified, this method will achieve its purpose and reveal to the physician that the transverse diameter of the rectum is variable; that in some places it is not more than an inch (2.54 cm.), in others it is more than four times this diameter.

The rectum may present to the eye of the imaginative observer the appearance of a chain of urinary bladders, communicating one with another by means of irregularly elliptic openings set at varying axes, and bounded by the nonparallel borders of the rectal valves. In the normal rectum the air-pressure smooths the mucous membrane evenly over the entire surface of the gut, as may be observed in the photographic illustrations. The normal mucous membrane of the so-called ampulla appears at first wet and of a shining bluish gray. As it dries, under the influence of gravitation the blue venous tint fades out of the gray and the wall assumes a pink tint. Presently it acquires the appearance of parchment, and sometimes it appears painted at rare intervals with ramifying little arteries which may be crowded and overlapped by the larger companion veins; the latter are less arborescent and more suddenly dive and disappear in the bowel-wall. In time, over all there comes a sheen and the vascular pictures may fade away. These phenomena appear exactly as described only in the healthy rectum. In the diseased organ the color varies much.