Chapter IV: Part 4

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:

[1] “Noninstrumental Inspection of the Rectum.”

[2] Italics in the quotations to follow are mine and are used to point out statements to which I will make particular exceptions.

[3] “Treatise on the Malformations, Injuries and Diseases of the Rectum,” French and Allard, New York.

[4] “The Chronology of the Methods of Atmospheric Inflation for Inspection of the Rectum and Sigmoid Flexure;” Thos. Chas. Martin, _The Louisville Journal of Surgery and Medicine_, December, 1898.

[5] “Clinical Notes on Uterine Surgery;” William Wood & Company, New York, 1866.

[6] “Diseases of the Rectum;” D. Appleton & Co., New York, page 394.

[7] “Diseases of the Rectum;” P. Blakiston, Son & Company, Philadelphia, page 12.

[8] “Diseases of the Rectum;” H. K. Lewis, London, 1887, page 16.

[9] “Anatomische Untersuchungen am menschlichen Rectum;” Veit and Company, Leipsic, 1887.

[10] “Die Krankheiten des Mastdarmes und des Afters;” Ferdinand Enke, Stuttgart, 1887.

[11] “A New Method of Examination and Treatment of Diseases of the Rectum and Sigmoid Flexure;” _Annals of Surgery_, April, 1895.

[12] “Surgery of the Alimentary Canal;” P. Blakiston, Son & Company, Philadelphia, 1896, page 566.

[13] My attachment consists of a superstructure and an additional mechanism upon the Yale chair which adds the new movements without interfering in any way with the other postures which the chair makes possible.

[14] Section on Fallacious Sounding.

[15] Allingham, Diseases of the Rectum, page 261, Churchills, London.

[16] “Manual of Physiology,” 1895, G. M. Stewart, M.A., D.Sc., M.D., Edin., D.P.H. Camb., Professor of Physiology in the Western Reserve University, Cleveland.

[17] See introduction.

Transcriber’s Notes.

Italic text is indicated with _underscores_, bold text with =equals=. Small/mixed capitals have been replaced with ALL CAPITALS.

Evident typographical and punctuation errors have been corrected silently. Inconsistent spelling/hyphenation has been normalised.

On page 15, “Mason” has been corrected to “Masson” (G. Masson, Éditeur).

On page 26 “Henly” has been corrected to “Henle” (Henle says that).

A reiteration of the book title has been discarded.

End of page footnotes have been sequentially numbered and relocated to the end of the book.

To aid text flow, Illustrations have been placed between paragraphs/chapters, and, where convenient to do so, close to their mention in the text.

A Table of Contents and List of Illustrations have been compiled by the transcriber.