Chapter III: Part 3

If there be an overgrowth of the rectal valve and if it form an almost impassable barrier to the descent of the feces it may be in some measure overcome in infants by the dilatation which may be effected through the means of the gently introduced trained finger. In case the defective valves are present in the form of diaphragmatic strictures or membranous septa with circular aperture, the valve may be safely cut by a method described in another place.

As at birth the pelvic bones are not yet united and as the rami of the ischium and pubes are still quite cartilaginous it is obviously possible that a little energy intelligently directed upon the anus from without will spread the pelvic outlet, whereas the infant labors ineffectually with his own forces applied as they are from within. The nurse, therefore, may be directed to pare away her nail-ends, lubricate her fingers and gently introduce the smallest finger through the anus. Daily gradual dilatation of the infant’s pelvic outlet should be practised, graduating from finger to finger until the required degree of dilatation be reached. The introduction of the finger independent of its dilating uses incites the mechanism of defecation to action.

Rachitic subjects with abnormal contraction of the pelvic outlet demand forcible divulsion of the ischial tuberosities.

OBSTIPATION IN THE ADULT.

If it be the function of the normal rectal valve to beneficently retard the descent of the feces it is obviously true that it may be the especial property of the valve in certain other than normal conditions to maliciously obstruct the descent of the feces.

There are three forms of valvular obstruction:

1. _Anatomic coarctation of the valves_ may afford an exaggerated physiologic resistance to the descent of the feces (Fig. 54).

2. _Congenital hyperplasia of the rectal valve_ is a condition classically described as diaphragmatic stricture or membranous septum in the abdominal rectum.

3. _Hypertrophy of the rectal valve_ constitutes the classic annular stricture of the abdominal rectum.

THE SYMPTOMS.

The patient is the subject of more or less chronic obstipation, he sometimes makes frequent partially successful attempts daily at defecation, but may experience an unrequited desire for stool. The patient acquires the reprehensible physic-habit. In time the periods of obstipation are interrupted by diarrhea. There is an ineffectual straining at stool except for fluid feces. Later the diarrhea occurs with greater frequency, and ultimately long periods of diarrhea may ensue which are interrupted by a transitory constipation and obstipation. All these symptoms may be accompanied by increasing degrees of flatulence and borborygmus, and from time to time the patient is subjected to attacks of intestinal autointoxication, and finally he becomes neurasthenic. On account of the especial nonsensitiveness of the rectal valve the patient’s sufferings are not uniformly referred to this region by himself, but in many instances, however, the intelligent patient is prepared to present his physician with a ready-made diagnosis of rectal obstruction. Finally, the symptoms of intestinal obstruction become pronounced, and if the patient be unrelieved the disease proceeds to a fatal termination. Symptoms of pain, aching in the sacral and iliac regions, hemorrhage, proctorrhea, prolapse, hemorrhoids, fistulas, etc., are usually the signs of concomitant sequels of the hypertrophied valve, and these may embrace the entire proctica. For a classic graphic description of the symptoms of rectal stricture, which has never been excelled, the reader is referred to the paper by Dr. Sherwin published in the Transactions of the London County Medical Society in 1787.

PATHOGENESIS.

1. _Obstructive anatomic coarctation_ of the normal rectal valves is a fortuitous embryonic affair, and admits of no amplification in this section.

2. _Prenatal hyperplasia_: The fibrous and muscular laminas of the rectal valve are developed from the mesoblastic layer of the blastoderm and the mucous membrane is derived from the hypoblast; this latter layer consists of columnar epithelium, and epithelium of this character may be found covering both superior and inferior surfaces of congenital diaphragmatic strictures or membranous septums. When there exists an aperture in this character of stricture it is seldom or never situated centrally. Another distinguishing feature of this obstruction is that it constitutes a cephalad boundary to a rectal chamber. If the lowermost valve be deformed, and if it be situated unusually low down, the lower rectal chamber may be noninflatable. In such an instance the anal or fixed rectum may seem to be of an extraordinary length, but that such is not really the fact may be determined by digitally ascertaining the situation of the anal borders of the levatores ani muscles. Such a stricture has its origin, probably, in the embryonic hyperplasia of the rectal valve. Another form of diaphragmatic stricture is sometimes observed at the anus. It has its origin in an imperfect anorectal coalescence. The salient structures of this septum are hypoblastic enteron and epiblastic proctodeum, and a microscopic inspection of a portion of membrane taken from its inferior surface reveals its epiblastic origin. This anorectal septum is of variable thickness, if there be a perforation it is located centrally. This character of stricture is always situated caudal to the rectal chamber. It is due to an arrest of fetal development.

3. _Postnatal hypertrophy_: Inflammation of the normally formed rectal valve, infiltration of lymph through its structures and organization of the plastic exudate contract and fix in a state of contraction this normal projection across the lumen of the rectum and constitute the nonmalignant annular stricture of this organ. Abnormal increase of fibrous tissue from any cause may, without contracting the valve-strait, render the valve sufficiently inelastic as to constitute it an obstruction. Extension of the inflammatory processes to an adjacent valve or a general hypertrophic rectitis involving an area occupied by several valves, consequent contraction of the longitudinal muscular bands in the area involved, together with contraction of the circular muscular bands, the infolding of masses of the lax mucous membrane, and the infiltration of plastic lymph into all these tissues between the valves as well as into the valve structure itself, organization of the exudate, degeneration of the muscular elements and increase of fibrous tissue, is the probable sequence of morbid processes which establish the nonmalignant tubular stricture of the rectum. The great thickness of the gut-wall at the situation of the tubular stricture is ordinarily not a new product of the disease. It is the consequence of the infolding of the mucous membrane, fixed in longitudinal corrugations by the organization of the plastic exudate.

The causation of hypertrophy of the rectal valve may be direct infection; a rectitis, dysentery, chancre, chancroid, gonorrhea; or traumatism, irritation or injury by a foreign body; the irritation of scybalums; or, it may be the local expression of some constitutional dyscrasia; syphilis or tuberculosis. The influence of age or of emaciation, through atrophy of the cellular tissues and the hypertrophy of the fibrous, may contribute a relative increase to the tendinous feature of the rectal valve.

_Because of the absence of the rectal valve in the rabbit, cat, dog and monkey_ it was found impossible to do vivisection work for the production of an experimental stricture.

There are many specimens of hypertrophied rectal valves to be seen in the metropolitan museums in Europe, none of which, of course, are classified as such. The cases quoted below were copied by me from the catalog of the Pathological Museum of the Royal College of Surgeons, London, and the specimens which are pictured here may be found on their shelves. These cases are chosen for illustration because their accessibility affords the reader an opportunity for their verification. The pictures were drawn under my direction by Mr. Godart with the aim of illustrating this essay. The specimens immersed in preservative are sealed in cylindric glass jars of the usual laboratory type. Each of these we set into rectangular vessels of water to overcome refraction-errors and afford accurate appearances.

The first case quoted is one of traumatic injury to the rectal valve, and, I believe, affords a close imitation of what might have been expected from an effort at the production of an experimental stricture by simple inflammation of the rectal valve.

The method used for the preparation and preservation of these specimens accounts for the nonappearance of the normal valves. From the time of the preparation of Hunter’s first specimen to the present time more than a century and a quarter has about elapsed.

Fig. 55. “Specimen 2569. Presented by William Coulson, Esq. A rectum and part of a colon, the blood-vessels of which have been minutely injected. Six inches above the margin of the anus there is a very close and narrow annular stricture of the rectum, produced by thickening and contraction of its coats and of the tissues immediately surrounding them. The inner surface of the stricture is ulcerated, and a small thin piece of fish bone is sticking in it. Above the stricture the intestine is dilated to a diameter of nearly four inches, but its coats are not much thickened.” The following is the history of the case:

“‘I was requested to see a woman, aged 34, between four and five months advanced in pregnancy, who, three days before, had been seized with sickness, constipation, pain, and distention of the abdomen. These symptoms increased in severity, fecal matter was rejected from the stomach, the abdomen became more distended, no evacuation could be obtained from the bowels, and the injections which were attempted to be thrown up the rectum were immediately expelled. Her powers gradually sank, and on the third day from the commencement of the attack she died.

“‘On examination after death, the colon was seen to be exceedingly distended, especially its descending portion, and about six inches from the anus a foreign body, believed to be a small portion of fish bone, was found adherent to the lining membrane of the rectum.... Immediately below this body the bowel was completely closed, to the extent of half an inch, by the effusion of lymph caused by the presence of the foreign substance. There was no other morbid appearance.

“‘Prior to the attack which destroyed this patient, she was in her usual state of health and had no ailment whatever.’”

Fig. 56.--“Specimen 2568. Presented by Sir William Blizard: Portion of a rectum, of which the canal is at one part suddenly reduced to less than a quarter of an inch in diameter by the thickening, induration, and uniform contraction of its walls. The stricture is half an inch in length, and terminates as suddenly as it commences. The intestine above the stricture is very much distended, and its muscular coat is hypertrophied; the part below it is small and atrophied.”

Fig. 57.--“Specimen 2571a. Presented by Dr. David Lawson (see _Lancet_, Vol. I, p. 512, 1879): A portion of a rectum, the seat of a stricture, which was excised. The bowel is much narrowed, and its walls are thickened.

“From a woman, aged 34, who had suffered from symptoms of stricture of the rectum for 8 years. Dilatation by bougies proved of no permanent benefit. The stricture was hard, annular, admitted the tip of the finger, and was situated 2 inches above the anus. It was excised through an incision between the anus and coccyx, and the divided edges of the bowel above and below were united by sutures. The patient recovered from and was much relieved by the operation.”

The cases just quoted illustrate the typic advanced hypertrophy limited to the rectal valve. The 2 cases following next are cases of tubular stricture of the rectum. The definite boundary between the diseased and normal tissues suggests the idea that the rectal valves are both starting and limiting boundaries, and the tortuous course of the stricture’s canal in Case 2571 seems also to support this idea, as will be pointed out in the section on diagnosis.

Fig. 58.--“Specimen 2571. Presented by John Hunter, Hunterian MS., Cases and Dissections, No. 59. A rectum, with the urinary bladder and other adjacent parts. About 2 inches above the anus the canal of the rectum is gradually reduced to less than half its usual size by extensive thickening, induration, and contraction of the walls and of the tissues around them. They are all converted into a uniform pale, brawny, hard substance, like that of a cicatrix. This change, and the stricture due to it, extend for about 3 inches up the intestine. The mucous membrane lining the diseased part is superficially ulcerated; above it the intestine is greatly dilated, and its coats are thickened; below it is deeply wrinkled, but apparently not of unhealthy texture. The following is most probably the history of the case:

“‘About the spring, 1785, General G. consulted me. He complained of a sensation in the rectum, attended with a kind of difficulty in going to stool when costive, and often a desire to go when there was nothing to pass. I examined the rectum, and found, so far as I could reach with my finger, a hard contracted ring surrounding the gut. I then pronounced what the case was, and what would be the event.

“‘This hardness and thickening of the gut gradually increased, so as to make it difficult at times to pass the feces, especially when costive. At last, it occasionally became so difficult as to require the passing of bougies and hollow catheters, which one could always pass the lower stricture, but with difficulty passed the upper, which appeared to be 3 or 4 inches further up the gut.

“‘Clysters, purgatives, sedative and diluting, were occasionally thrown up, which sometimes had their intended uses. In this way he went on--sometimes better, other times worse--but upon the whole becoming worse. At last, it became difficult to pass a bougie, catheter, or even to throw up an injection, and which was attended with very disagreeable symptoms for the time, as acidity in the stomach, fulness, oppression, kind of hiccough, a vast rumbling in his bowels, and want of rest; but he got occasionally a passage which gave him relief for a time.

“‘He was, of course, put on a very low diet, and such as was thought best to answer the purposes of diet, while producing the least quantity of excrements, as also such as tended as little to acidity as possible. This was animal food in all the forms he liked best.

“‘All this art probably kept him alive for a twelve-month longer than he otherwise could have lived, for without this attention one or two costive days would have almost killed him, which I think I have often seen.

“‘What appeared to be very singular, the constitution did not, till the very last, seem to feel the disease or its consequences, for his pulse kept slow and regular, never in the least hard; and when signs of dissolution had taken place, the pulse was only weaker, but not irritable. At last nothing passed through the strictures, either downwards by stool, or upwards by way of clyster. The belly became gradually fuller and fuller, which was principally air, as towards the last he took but little food, and which was easily known by the sound in patting on the belly. He became in some degree insensible to his own situation, and in some degree less sensible of pain, which increasing, he died in that kind of easy and insensible manner.

“‘On opening the body the colon was found very much distended with air through its whole length; its transverse arch made a quick turn down to near the pelvis, then up upon itself to the left side, and then down the left, forming the sigmoid flexion; from all which turns, viz., making four, and being considerably distended, it appeared to fill almost the whole belly.

“‘There was a good deal of feces in the colon, but not in the least distending it.

“‘On putting the hand into the bottom of the pelvis was found a considerable tumor, which, with the bladder and rectum, was removed; but in this operation it was found that the tumor adhered closely to the hollow of the lower part of the sacrum, so as to be obliged to lay that bone bare in the removal of it.

“‘On slitting down the rectum, which was very large, it was found to be very much thickened in its coats, and of a hardish, gristly texture, a good deal like the turtle’s intestines. This increase of thickness was to give it power to expel its contents.

“‘At the tumor the intestine contracted almost at once; and at its entrance into the tumor its inner coats were thrown into loose folds, so as to obliterate almost any appearance of a passage there; however, I could readily pass the end of my finger into it, those folds easily giving way. The tumor was next slit through, which showed a firm increase of the gut, near an inch thick all round, and for three inches in length. At the lower part it terminated all at once into the sound gut, which we had often felt when alive. The inner surface had lost entirely its natural appearance; was slightly rugged so as to appear like villi.

“‘On introducing the pipe by the anus it was found to come butt against the side of the upper part of the cavity of the tumor, where there was a bend in the passage; but why a crooked pipe did not pass when attempted to be passed by turning it to all sides, I cannot conceive. Or why a bougie which was slightly bent, did not hit the hole, is not easily accounted for; but what is more extraordinary than either, why a clyster did not pass freely up; or why did not the wind or soft excrements, that did yet lay, pass pretty readily down, while I could pretty readily pass the end of my finger down from the gut above into the tumor. The folds of the contracted part did not appear after death to have been sufficient for an entire stoppage of this kind.”

The preceding case seems to illustrate that form of stricture which is built upon two or more rectal valves and in which the walls of the rectal chambers are involved and thickened. The mucous membrane is longitudinally folded upon itself and incorporated in the organized plastic exudate. The following case exhibits a tubercular tubular stricture and is characterized by a destruction of the mucous membrane:

Fig. 59.--“Specimen 2571c. Presented by Dr. H. Handford (see _Trans. Path. Soc._, London, 1888, page 117). From a lad, aged 17, who, four months before death, began to suffer from wasting, irregular attacks of diarrhea, and passed blood by the anus. Death resulted from purulent peritonitis, the result of perforation of a rectal stricture by a bougie. There were tubercle deposits in the upper lobes of both lungs and in the head of the pancreas.

“Microscopic sections of the lungs, the nodules in the pancreas, and all the lumbar and mesenteric glands showed masses of caseous material with a few giant cells.

“The rectum exhibits a tubercular stricture which commences 3½ inches above the anus. The stricture is 2 inches in length, moderately narrow, and the mucous membrane covering it is superficially ulcerated. The intestinal wall is somewhat thickened. Near the upper part of the stricture is a small perforation, produced in an attempt to pass a bougie through it.”

The following case is that of a stricture not builded on the rectal valve. It is situated at the levator ani level, it is probably a cicatricial product of disease which is not uncommon at this situation, but it may have had its origin in an imperfect anorectal coalescence.

Fig. 60.--“Specimen 2570. Presented by John Hunter: The lower part of a rectum, with the anus. On the margin of the anus are several large hemorrhoids, and the skin for a considerable distance around it is excoriated. At the right side of the anus is an appearance of a narrow granulating wound, as if a fistula had been there operated on. Immediately above the anus the canal of the rectum is suddenly and irregularly contracted to half an inch in diameter, but without any apparent change in the structure of its mucous membrane. Above the contraction it is unnaturally dilated, its coats are thickened, and the tissues around it appear rather indurated and confused.”

Case 2567 belongs to the same class as the preceding.

Fig. 61.--“Specimen 2567. From the Museum of Sir Astley Cooper: The lower part of a rectum, the canal of which, about an inch from the margin of the anus, is suddenly reduced to half an inch in diameter by the deep annular fold of its mucous membrane. Above the fold the mucous membrane appears healthy; below it is excoriated; and in one place there is a narrow bridge of it, as if there had been an abscess external to it, or as if a bougie had pierced it. The tissues around the contracted part of the rectum are not manifestly diseased. There are several external hemorrhoids at the margin of the anus.”

DIAGNOSIS.

_Fallacious Sounding._--Sounding the rectum with the patient in the horizontal posture, supinated or semipronated, has been a feature of the conventional method employed for the diagnosis of stricture of the rectum for more than a century, and as a great array of fatalities has not yet persuaded the profession to abandon the practice I feel that at this moment an analytic study of the procedure would not be unprofitable.

Sounding as a method of diagnosis requires three conditions: (1) that the tube to be sounded have a recognized limit of distensibility; (2) that its mobility in the direction of its axis be inappreciable, and (3) that there be not at irregular intervals normal anatomic obstructions in its channel sufficient to arrest the progress of a sound.

These conditions obtain in the urethra which is fixed from extremity to extremity within a mass of tissue which firmly supports it when the organ is in a situation for the practice of this diagnostic maneuver. The rectum on the contrary answers negatively to each of these three propositions.

Seven or eight inches (17.78 or 20.32 cm.) of the rectum’s length are not fixed; the lowermost inch (2.54 cm.) is the only portion muscle bound (Fig. 21) and as this part is easily accessible to digital exploration, to it, therefore, the method of diagnosis by sounding is not applied. A little way above the upper border of the prostate, or the pelvic floor in the female, the rectum is invested by a loop of peritoneum which does not yoke the gut fixedly but anchors it loosely in the abdominal cavity.

1. The distensibility of the abdominal rectum is governed by the elasticity of the gut’s inherent coats and is not limited by a comparatively unyielding musculofibrous wall supplied by the contiguity of other parts twentyfold its own strength and several times its own density and bulk, as is the case with the male urethra. The normal range of distensibility of the rectum then may be said to be from zero to three and a half inches (0 to 8.89 cm.) and consequently a definite calibration for sounding is impossible. (Fig. 21). The sound of a size which may enter the anus is not to be considered appropriate for sounding the rectum in accordance with the principle governing urethral catheterization which may be formulated in the aphorism; the sound which fits the mouth should discover contractions in the tube.

The average diameter of rectal sounds is about one inch (2.54 cm.). Two-thirds or three-fourths of the rectum’s expansibility, which may be greater than three inches (7.62 cm.), must then of necessity be sacrificed before rectal sounding will uniformly produce any definite evidence of stricture, provided all other things are equal and comparable to conditions obtaining in urethral catheterization.

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

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

3. There is, however, one other factor, which when fully recognized will effectually discountenance the practice of sounding according to customary rules. The rectal valves, which I have demonstrated to be typic anatomic valves and possessed, therefore, of a structure which qualifies them to offer both active and passive resistance, and which span one-half, two-thirds, and sometimes three-fourths the circumference of the rectum, and which have a depth from free border to that attached to the wall of the gut, varying from a quarter of an inch (.63) to an inch or more (2.54 cm.) according to the degree of distention of the rectum. These valves afford in many instances an effectual obstacle to the passage of the bougie; they supply evidence which simulates that of stricture when the sound is used, and a valve may constitute a very ready pocket to trip up and deflect the sound’s point out of the channel of the gut through its wall and into the peritoneal cavity.

Analytic survey of the anatomy of this part and study of the mechanics of surgical sounding compel the conclusion that (1) the enormous normal distensibility of the rectum (Fig. 31); (2) its great susceptibility to upward and downward displacement (Fig. 21), and (3) its normal valvular partitions (Fig. 22) are significant that the customary method of sounding the rectum for the diagnosis of stricture is unscientific, is unprofitable as a diagnostic measure, and is extremely hazardous to the life of the patient.

DIAGNOSTIC OBSERVATIONS.

The rectal obstructions under discussion may be readily diagnosed by ocular inspection. In the more exaggerated forms of the disease the method of visual examination, already mentioned in the first part of this monograph, is to be reinforced by certain instrumental means presently to be described. For a description of proctoscopy the reader is referred to the section on Instrumental Inspection.

_Anatomic coarctation_ of the rectal valves is visibly apparent, and the degree of obstruction which the coarcted valves afford may be estimated by requiring the patient to bear down, when it may be observed how the valves may crowd and overlap one another and erect at one point an almost insurmountable barrier to the descent of solid feces. _The symptoms_ of such a condition will be found in a history of labored defecation and chronic obstipation, with frequent and unsuccessful attempts at evacuation of the rectum.

The condition may be accompanied by a chronic catarrhal rectitis.

_Congenital hyperplasia_ of the rectal valve in the form of a diaphragmatic stricture does not restrain the atmospheric inflation of the rectum and the stricture may be observed as a membranous septum with a laterally placed aperture surrounded by the thin margin of the valve. The structure is not very elastic and tears readily on divulsion. _The symptoms_ are those of chronic obstipation with straining at stool; defecation may occur only at rare intervals and is accompanied by violent straining, much pain and consequent transitory prostration. There may be daily repeated unsuccessful attempts at evacuation of the rectum.

There may result rectitis, ulceration of the rectum, hemorrhoids, pruritus, prolapse, fissure, abscess, and fistulas, and this form of stricture may be the foundation and initial feature of any of the more formidable diseases of the rectum. Hypertrophy may ensue upon chronic inflammation provoked by the irritation or traumatism incident to the efforts at defecation. The appearance of the stricture may consequently become much changed and the adjacent rectum may become involved in a tubular stricture.

_Hypertrophy_ of the rectal valve when present as an individual lesion and if of minor degree, presents on proctoscopy the appearance of a much thickened state of the valve, which may be more marked near its free border and in the area occupied by the fibrous or tendinous structure. There may or may not be a noticeable narrowing of the valve-strait. The valve is not readily effaced under the pressure of the proctoscope. It offers great resistance to the hook shown in Fig. 17, and if the disease be long continued, and there be much hypertrophy of the fibrous tissue and infiltration of the muscular elements of the valve, the typic appearances of the classic annular stricture are presented. The valve-strait becomes circular in form and is contracted to greater or lesser degree according to the extent of the lesion. If the walls of the rectal chamber are involved to a degree which somewhat limits their expansion under atmospheric pressure, the annular stricture instead of presenting a smooth margin may be covered by corrugations of the mucous membrane. The mucous membrane will appear not smooth and close fitting as is the normal relation, but will appear loose fitting and in elevated folds, somewhat like the palmar skin when the hand is slightly flexed.

In those cases in which the pathologic processes are far advanced, the rectal inflation may be much compromised or entirely sacrificed.

The _symptoms_ of this lesion are usually those of an initial rectitis or dysentery followed by chronic obstipation, gradually increasing in degree as time elapses until the patient presents a picture of many of the symptoms described in the historic clinical reports quoted. Acute inflammation may attack the strictured part and produce an obstruction which may quickly terminate the life of the patient; ordinarily the case may proceed slowly to a fatal issue.

The _complications_ of this disease increase and multiply and may involve the entire proctica.

The _variable grades of hypertrophy_ of the rectal valves permit the lesion to be classified in three degrees: (1) The first may be said to be that in which there is evident thickening of the valve without corrugation of the mucous membrane; (2) the second degree may be described as that in which there is more or less intravalvular corrugation of the mucous membrane and in which rectal inflation is possible, and (3) the third degree may be described as that which constitutes a noninflatable rectal chamber. The extraneous causes of noninflatability of the rectum are described in the section on Inspection of the Rectum.

The second degree of this lesion may require, and the third degree essentially requires, the application of further instrumental means to determine the precise extent of the lesion. The instruments additional to those required for the proctoscopy described, are a set of curved cylindric sounds and of fenestrated speculums ten inches (25.40 cm.) in length and of a diameter which allows their ready passage through the proctoscope. These instruments are shown in Figs. 63, 64, 65.

THE POSITIVE DIAGNOSIS.

Proctoscopy is required to determine the presence of the obstructive lesions under discussion. It is also sometimes necessary to reenforce the proctoscopy by the use of additional instruments and by the exercise of a more elaborate technic. The proper use of these instruments requires that absolute familiarity with the anatomy of the part which is only to be acquired by numerous dissections of the human subject performed in some such manner as that described in the section on Topographic Anatomy, and it may be superfluous to add that the manipulations prove useful and safe in that degree which the skilled operator considers them difficult of execution and possibly dangerous to the continuity of the gut.

_Anatomic coarctation_ of the rectal valve is made apparent by a discriminating handling of the proctoscope, and the degree of their physiologic juxtaposition may be determined by requiring the patient to bear down while a view of the valvular area is kept under the command of the eye.

_The congenital errors in development_ of the valve are in most instances readily perceived. However, in some special cases, particularly those in which the lowermost rectal valve projects from the anterior wall, it may require some considerable degree of skill in the operator to find the valve-strait. Such skill may be acquired by much practice in the management of the patient, the proctoscope and the illuminating rays. In the instances under contemplation this valve-strait is usually found well back toward the hollow of the sacrum. The proctoscope being made to pass this valve it must be made to search for the next valve-strait in a direction somewhat behind the first valve, and so on, first on one side and then on the other till the whole of the rectum has been ocularly inspected.

In _cases of hypertrophied valve_ of (1) the first degree the amount of valve resistance may be determined by the use of the hook shown in Fig. 17. The normal and elastic valve may be effaced under its pressure. (2) Hypertrophied valve of the second degree, being that form which is usually called annular stricture of the rectum, presents on proctoscopy a valve-strait of an irregularly elliptic or circular form and a smooth-lying or corrugated folding of the mucous membrane according to the degree of contraction. It is sometimes impassable by the proctoscope and obstructs the inspection of the rectal chamber beyond and of the more distant valves and renders it impossible to determine without further means of inspection whether it is the only lesion of this character present or whether there is a multiple valvular hypertrophy. In such a case it is necessary that the fenestrated proctoscopes, which are shown in Figs. 64 and 65, be used in the following manner: The distal end of the cylindric proctoscope should be placed about the contracted valve-strait in such a way that the smaller fenestrated instrument may under the guidance of the eye be directed through the stricture. This having been accomplished, the instrument should be carried firmly but cautiously against the valve side of the contraction, that a tentative search may be made for the next valve-strait above. The instrument should never be pushed forward; it should be directed from side to side in search of the next valve-strait, through which, if it be safe for the instrument to pass, it may glide under the influence of gravity, for it is remembered that the patient is in a posture equivalent to the knee-chest posture. Never, under any circumstances, should greater pressure be given a proctoscopic instrument than that which may be given by the unaided flexor profundus digitorum. If there be encountered any difficulty in entering the third rectal chamber the first hypertrophied valve should be divulsed or cut after a method presently to be described, and a visual search made for the upper passage. Expansion of the lower valve-strait should render the one next above readily visible. (3) In rectal obstruction of the third degree, which consists in the tubular stricture already described and which essentially compromises or prevents atmospheric inflation of the rectal chamber involved, a search may be made for the channel of the stricture by means of the conjoint use of the proctoscopes and sounds. The largest sound which may enter should be tentatively introduced under the guidance of the eye, and its distal end directed in one direction or another for the strictured channel in accordance with our present knowledge of the natural deviations of the rectal course from side to side. If it be wise and safe that the sound should enter it will usually require little or no forward impulse from the proctologist’s fingers. Steadily and patiently the instrument should be held in the various positions given it till the muscular resistance yields to the sound’s gentle pressure. Systematically the field should thus be felt over. If the channel be found the traction of gravity will probably carry the instrument forward. Because of the nature of the anatomic features of the rectum, which have been already pointed out, tubular strictures, being those which involve the walls of the rectal chamber and the longitudinal area occupied by two or more rectal valves, are from 1 to several inches (2.54 + cm.) in length. The introduction through the cylindric proctoscope of the special instruments for channel searching is a procedure which places all resistance, if there be any, upon the pathologic obstruction itself and does not divide the responsibility for resistance with the sphincters or other muscles, which in the prevailing method of sounding is a decidedly confusing circumstance.

PRELIMINARY TREATMENT.

Preparatory for radical operative treatment it is often necessary to care for the one or more complications which are involved. If there be ulceration, hemorrhoids, abscess, fistulas, general rectitis or other disease, it is a matter for the consideration of the proctologist whether their treatment shall precede or follow the operation designed to remove the obstruction.

The following operation does not require general anesthesia. It may be painlessly performed without resort to local artificial anesthesia.

OPERATIVE TREATMENT.

_Divulsion._--Frequently-repeated massage of the hypertrophied valve by means of the coactor (Fig. 66) is often sufficient for the cure of minor valvular hypertrophy.

_Valvotomy._--The patient should be placed in the proper posture and the proctoscope introduced and given into the hand of an assistant. The valve to be divided should first be seized by the volsellum (Fig. 70) or by the long tenaculum, and steadied. The exercise of delicate judgment is required to determine how deep to grasp the valve without going into the circular muscular fibers at its middle part. The reader’s attention is directed to Fig. 33, which shows the arrangement of the structures of the valve. The hook should be made to transfix the mucous membrane and fibrous portions of the valve only.

Before transfixing the valve with the hook or volsellum, the depth to which the valve may safely be divided may be determined by the following procedure: A flexible uterine sound should be bent near its handle in a manner similar to that shown in the hook for valve-testing. At its distal extremity it should be bent in the form of a curved hook, which should complete three-quarters of a circle. This hook should now be introduced to a point above the valve and drawn toward the operator till the pressure of its end depresses the valve-floor which presents toward the operator in the form of a blanched eminence. Thus it may be estimated that the rectal wall behind and above the valve is at a safe distance from this point. The distance from the eminence to the free margin of the valve should be carefully noted, for in the subsequent operation of division the valve should be transfixed by means of the bistoury at a point considerably nearer the free margin than the estimated position of the eminence.

The valve should now be seized by tenaculums on either side of the point selected for section. The knife, shown in Fig. 71, should be made to transfix the fibrous border of the valve and to divide a few fibers of this tissue and the mucous membrane covering it, by cutting its way through the valve’s free border (Fig. 72). This should be transfixed with the bistoury at a moment when the valve is situated at a right angle to the gut-wall. Caution: If the valve be _pulled downwards_ by means of the tenaculums so that it presents an inclined plane toward the operator at the moment when the bistoury is made to transfix the conjoined tendon, the superior dense fibrous lamina will have a tendency to force the knife outward and through the gut-wall; hence the necessity of a proctoscope of different length for each valve, that the proctoscope’s end may be carried to the valve instead of the valve being pulled down to the proctoscope and probably to disaster. But a few fibers of the conjoined tendon are to be divided by the bistoury. After the incision is thus started, a scalpel-like knife, provided with a similarly bent handle, should be used to deepen the incision. In two places the valve should be cut. The instant the conjoined tendon is divided, a gaping wound will be presented to the eye. This wound is irregularly pyramidal and open at its apex; the two walls running away from the apex consist of the fibrous laminas of the valve; the base is made of the circular muscular fibers; external to the circular muscular fibers are the longitudinal muscular and the peritoneal coats of the rectum. Should hemorrhage occur it may be readily stopped by the temporary application of clamps (Fig. 74).

Hypertrophy of the rectal valve in the second degree, and which constitutes annular stricture of the rectum, usually requires the introduction of the smaller fenestrated proctoscope, according to the manner already described; or if this instrument does not fill the stricture and draw its border taut about the spokes, the larger fenestrated proctoscope should be placed on the smaller, that the smaller may serve as guide, and the two introduced through the cylindric proctoscope and carried into the stricture according to the directions given in the section on diagnosis. The smaller fenestrated proctoscope may now be withdrawn. On looking down through the vista the stricture or strictures may be discovered binding close about the instrument. The walls of the rectal chambers between the valves will be lifted away from the instrument by the atmospheric pressure, and may be seen only through the medium of the proctoscopic mirror. The valves may now be cut by transfixing and cutting through the free border as it is held taut about the fenestrated proctoscope. On the removal of the valvotome the coactor should be introduced and the stricture divulsed in several directions by opening the coactor, as shown in Fig. 76. The cervix divulsor shown in the illustrations 77 and 78 may be likewise used.

Hemorrhage is seldom of any consequence after operations on this variety of stricture. However, should it require treatment, the fenestrated proctoscope should be removed and the clamps temporarily applied. Should the operator fear secondary hemorrhage he should fix a serrefine on the bleeding point and leave it in place for twenty-four hours.

SUBSEQUENT TREATMENT.

Should there be any sign, constitutional or local, of hemorrhage, the patient should at once be subjected to a proctoscopic inspection and the bleeding point surgically cared for. Each day the wound may be inspected and dressed according to the nature of its requirements, and after the first two or three days the valve should be occasionally subjected to divulsion or massage by means of the coactor. Should there ensue a rectitis or a granulating wound, it may be treated by means of the atomizer, by the use of topic applications otherwise administered, or by lavage.

TREATMENT OF SIMPLE TUBULAR STRICTURE OF THE RECTUM.

The radical treatment of this stricture may possibly require a resection of that portion of the gut which it contracts, or in case of acute obstruction the establishment of an artificial anus may be imperative. The individual use of, or the alternate use of, the methods of gradual dilatation and immediate divulsion described in previous paragraphs may be efficacious. A continued course of treatment by instrumental massage has in my hands relieved such patients of their symptoms and restored contracted rectal chambers to normal inflatability and healthful mucous surfaces.

ACUTE RECTITIS.

_Salient Symptoms._--There is usually steady aching, or sensation of heat and weight in the sacral region and lumbar spine; the disease is initiated with a short period of obstipation or constipation which is sometimes followed by a somewhat longer period of diarrhea; finally there are discharges of mucus.

_Diagnosis._--Proctoscopy reveals the fact that the mucous membrane lining the rectal chambers is deeply infected. The arborescent arterioles may appear in clusters of bright red twigs. The club-shaped venous radicals, which are of a purple color, may be observed somewhat elevated above the surface of the mucous membrane at various points throughout the chambers, and there is a generally diffused redness throughout the entire area involved. Extensive rectitis sometimes prevents inflation of the rectum. This may be overcome by the use of the coactor.

_Treatment._--Acute inflammation of the rectal mucous membrane may be rapidly reduced by spraying the part with any of the familiar antiphlogistic solutions; silver nitrate solutions, 3 or 4 grains to the ounce, are also effective.

_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.