Obstipation

Part 1

OBSTIPATION

A PRACTICAL MONOGRAPH ON THE DISORDERS AND DISEASES OF THE RECTAL VALVE

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.

Part 2

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.

A CHRONOLOGIC REVIEW OF THE LITERATURE OF THE RECTAL VALVE.

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.

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