Part 14

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.