Part 4

“The anatomic evidence against the existence of veritable valves in the rectum is corroborated by numerous facts, a few of which I will now adduce:

“I maintain that the irregular folds of the mucous membrane of the rectum, supposed to be valves by the several authors I have named, are not permanent but purely accidental, and are caused by the partial contraction of the intestine. This can be verified by any one by carefully examining this membrane in the same subject on different days, at such time when the rectum is not distended; and these folds will be found each time to be more or less changed in appearance, and to occupy different situations. Not so with veritable valves anywhere in the body.

“I further maintain that valves, such as described by Mr. Houston, capable of supporting the whole weight of the fecal matter collected in the rectum, and of resisting the introduction of the bougie or the finger, would most certainly be easily distinguishable and demonstrable in the living body; and in the dead body the removal of the organ ought not to obliterate them, but, on the contrary, that they should be capable of being demonstrated easily, and at any period previous to decomposition.

“I deny most positively that these plicae, except in an indurated or diseased state, are ever firm and unyielding; on the contrary, they are soft, pliable and unresisting, being easily displaced by a proper-sized bougie, or, if in reach, by the extremity of the index-finger, either being well lubricated, and gradually introduced into the rectum. Should there be resistance, it will be found not to be occasioned by valves, but either by fecal accumulation, by the promontory of the sacrum, by contraction of the rectum, by one or more tumors, by chronic irritation or inflammation of the mucous lining, by spasm in nervous and irritable subjects, etc. I have often found that a small-sized rectal bougie--say a No. 2 English--will be apt to become hooked or entangled in these folds or superabundant membrane, while one of a much larger size will so dispose of them as to pass readily. A small sound, as a general rule, the organ being in a normal and healthy state, will often encounter much more resistance than a larger one, as any one must have experienced who has frequently sounded the rectum or urethra.

“Veritable valves contain muscular fibers, and are capable of firmly constricting the bowel, and can never be entirely effaced by distention, I care not how far it is carried in length and in width; not so these irregular folds, for they may be completely defaced” (effaced) “by this process.

“Veritable valves sufficiently large and strong to obstruct or dam up this inferior extremity of the rectum is simply ridiculous; such never have, and, in my opinion, never can be demonstrated, the able authorities I have quoted to the contrary notwithstanding. I admit that these accidental folds of the rectum resemble the valvulae conniventes of the small intestines; that they look like valves; yet they lack the essential attributes, and, consequently, are not valves.

“The foundation of Mr. Houston’s error in relation to these folds of the mucous membrane of the rectum, was his peculiar method of investigation. He did not examine this membrane in its natural state, indeed, his procedure was anything but natural, although he intimates that it is the only method by which the condition of these valves, as he calls them, can be displayed.”

1876, T. B. CURLING, F.R.S., in Diseases of the Rectum; J. & A. Churchill, New Burlington Street, London:

Omits mention of the rectal valve.

1877, DANIEL MOLLIÈRE, in Maladies du Rectum et de l’Anus; G. Masson, Éditeur, Libraire de l’Académie de Médecine, Paris:

Omits mention of the rectal valve.

1878, CHADWICK, Transactions of the American Gynecological Society, Vol. II, page 43; Houghton, Osgood & Company, Cambridge:

“Hyrtl (1853), in his treatise on Topographical Anatomy, devotes three pages to the consideration of what he designates as the sphincter ani tertius. From his description the only inference is that Hyrtl has generally found a bundle of muscular fibers so encircling the rectum as to exercise the function of a sphincter, at least when the other sphincters are for some reason inoperative. On inflating rectums, however, in accordance with the directions given by him, it is rather surprising to discover that no such annular constrictions appear. At the point of the rectum designated by him is, nevertheless, observable a semicircular constriction of the rectum confined to the anterior wall; corresponding to this, but an inch or more higher up, is always seen a second semicircular constriction affecting the posterior wall only. If, now, the rectum be cut open, and its mucous membrane dissected off, as directed by Hyrtl, each of these two constrictions may be demonstrated to consist, as he says the ‘third sphincter’ does, of an agglomeration of the circular muscular fibers of the rectum. I am able to show you seven rectums taken from dissecting-room subjects, from which we dissected off the mucous membrane after cutting them open longitudinally. In all of these you cannot fail to find corroboration of my statements in the presence of two distinct masses of circular fibers, each encircling about half the circumference of the canal.

“If, now, a mass of feces be supposed to advance through the rectum, following the sinuosities, it is evident that these bundles of fibers, when not in active contraction, would present scarcely any obstacle to its progress. It is further noticeable these partial constrictions of the canal differ only in degree from the constrictions visible in the higher segments.

“At about 2½ inches from the anus the finger encounters a confused mass of folds through which the continuance of the canal can only be discovered by considerable burrowing. Here an annular constriction, diminishing the lumen by about one-half, seems to be felt.

“If, now, the rectum be distended with water, the finger will almost invariably detect, in place of the lax folds, what still seems to be an annular constriction, but which a more careful examination will show to be composed of two distinct semicircular bands slightly overlapping each other, the posterior being somewhat higher than the anterior.”

Chadwick continues: “Being familiar with the views of Nelaton, Hyrtl, and others, I at first sought to assign to this apparent constriction of the rectum sphincteric functions, but soon had to relinquish that idea, for the exploration of very many rectums in the living failed to reveal a single one in which the lumen of the supposed sphincter, when quiescent, had a smaller diameter than three-quarters of an inch, while in the majority it was over an inch.

“These anatomical and clinical observations all tend to indicate that the term ‘third sphincter ani,’ applied by Hyrtl to these constricting bands, is a misnomer, and to show that they are simply a part of the general circular layer of muscles, whose function is to dilate before and contract behind the scybala, thereby propelling them on their way and not retarding them.”

Chadwick concludes, saying: “Having seemingly elucidated the true function of the ‘third sphincter ani,’ and proved by the above observations that it should more properly be termed a detrusor faecium, if deserving of any special appellation, my attention was next directed to the action of the internal sphincter.”

1879, W. H. VAN BUREN, M.D., on Phantom Stricture and other Obscure Forms of Rectal Disease; The American Journal of the Medical Sciences, October, 1879:

“The walls of the rectal pouch tend to fall into lose folds when empty, and they present also certain slight permanent partial constrictions or narrowings. The uppermost one of these corresponds with the level at which the rectum gets its complete peritoneal investment. A normal narrowing at this point has been already frequently recognized, and the fact has been confirmed, by good observers, in the experiments in manual exploration recently practised upon the rectum.

“Other writers have described slighter and more or less constant permanent narrowings at and below this point of the rectum as a ‘third sphincter,’ and, in fact, have cumbered the archives of surgery with a good deal of fruitless speculation concerning an organ to which anatomy and physiology have been equally unsuccessful in assigning either certainty of location or certainty of function.”

1881, GEORG KOEHLER, prakt. Arzt, Darmresection bei Carcinom des Dickdarms; A. Neumannische Buchdruckerei (C. Ducius) in Breslau, Altbüsserstrasse 42:

Omits mention of the rectal valve.

1882, DR. VICTOR PATZELT, Ueber die Entwicklung der Dickdarmschleimhaut; in Commission bei Carl Gerold’s Sohn, Buchhändler der kaiserlichen Akademie der Wissenschaften:

Omits mention of the rectal valve.

1884, OSCAR JULIUSBERGER, prakt. Arzt, Beiträge zur Kenntniss von den Geschwüren und Stricturen des Mastdarms; Druck von Grass, Barth u. Comp. (W. Friedrich), Breslau:

Omits mention of the rectal valve.