Part 15

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.