Part 6

Omits mention of the rectal valve.

1893, KELSEY, Diseases of the Rectum and Anus, page 26; William Wood & Company, New York:

“It is now about half a century since Nelaton, (1845) first described the third sphincter muscle, and in spite of all that had been written concerning it since that time, it is only a few years since Van Buren (1878) characterized it as an organ to which anatomy and physiology had been equally unsuccessful in assigning either certainty of location or certainty of function. For the original description of the muscle by Nelaton we are indebted to Valpeau, who writes that he has verified the existence of a sort of sphincter of the rectum, lately discovered by Nelaton, and goes on to say that it is a muscular ring situated about four inches above the anus, just in the place where retractions of the rectum are most often found. If, after turning the rectum so that its mucous surface is external, it is moderately distended by inflation, the muscles will be seen to be made up of fibers collected into bundles.

“Sappey admits its frequent existence, and locates it at the level of the base of the prostate, in the middle portion of the rectum, six, seven, eight or sometimes nine centimeters from the anus. It never completely surrounds the rectum, but only one-half or two-thirds its circumference; and it appears to him to be caused by a grouping of the circular muscular fibers. Its breadth is one centimeter, and its thickness two or three millimeters. Situated sometimes in front, sometimes behind, and again laterally or antero-laterally, it is constant in nothing except its direction, perpendicular to the axis of the bowel. In place of one he has sometimes found two bands at opposite points and different levels, and in one specimen there were three. Henle adopts Sappey’s description in the main. Petrequin found the muscle irregularly oblique, less marked in the front wall than in the back, and consisting of a weak band of fibers.”

After these references Kelsey comments as follows: “The third sphincter muscle and the valves of mucous membrane in the rectum are not, as might be supposed, one and the same thing, though it is true that they have become almost hopelessly confounded in surgical and anatomical literature, and are often spoken of as identical. The valves of the rectum, we use the word simply as expressing the folds of the mucous membrane, were first described by Houston at about the same time that Nelaton described the superior sphincter; and it is worth remembering that the two authors were writing about two entirely different things, and two things which stood in no necessary relation to each other, so far as we may judge from their descriptions.

“According to this first and clearest of all descriptions--for the whole article (Houston’s) is written with a force and clearness of style which have perhaps had an undue weight in disarming criticism as to the facts--the valves exist in all persons, but vary much in different individuals as to location and number.”

Kelsey quotes Houston’s description, which has already been quoted by me, and in contravention says: “The palpably weak points in Houston’s article were very soon pointed out by O’Bierne (1833) in a work of marked and almost amusing originality. O’Bierne seems rather to regret that he is unable to accept Houston’s statements as to an anatomic condition which would account so fully and so easily for the physiologic emptiness of the rectum and fulness of the sigmoid flexure on which his (O’Bierne’s) own views depend; but nevertheless he sets himself to the task of demolishing them with great vigor and considerable success. Although he believed the rectum to be normally empty, except just at the time of defecation, he believes that condition to depend upon the anatomic arrangement of the sigmoid flexure joined with the narrowing of the upper end of the rectum, which is entirely independent of any folds of mucous membrane. He not only denies the existence of any such folds, but stated flatly that Houston is altogether incorrect in his statement that Cloquet (1828) or any other anatomist before his (Houston’s) time (1830) makes even the slightest allusion to them. He (O’Bierne) believes the folds to have been produced by the method of making the preparations, distending and hardening all the parts with spirit before making the incision, and asserts that this method is anything but natural, and nothing more nor less than an attempt to exhibit natural appearances by placing the parts in an unnatural situation--such a situation, indeed, as is not known to be necessary for the exhibition of the valvulae conniventes or any other valve of the body. He (O’Bierne) meets the statement that by the ordinary procedure of distending the rectum after removal from the body the valves are made to disappear, by the question, why, if such valves really exist, and if muscular fibers enter into their structure, they should not be discoverable at any time after death, or in any state of the intestine--a question very difficult of solution.”

Kelsey, continuing, says: “Four years later (1837) the voice of a New York surgeon was raised against these folds, and in almost the same language as O’Bierne’s, though from an entirely different standpoint. Bushe (1837) declares that he has never in the living body, been able to detect any valve of such firmness and capable of exerting any such influence upon the descent of the feces as Houston describes, though he has frequently met with accidental folds produced by the partial contraction of the bowel. He (Bushe) points out that, by the method of hardening the rectum after distending it with spirit, the accidental folds are rendered permanent by the induration resulting from the action of the alcohol; and that, by the method of inflating and drying, the projections resembling valves are produced by the angles formed by the setting of the intestine during the process of desiccation.”

Referring to Otis’s investigations Kelsey says: “Except this description of the arrangement of the muscular fibers and folds of mucous membrane is more exact and definite than any previously given, and as to this constancy of location my own observation does not lead me to entirely agree, the author’s conclusions from his dissections are not different from those of other writers.”

Kelsey, in his edition of 1898, repeats the substance of his discussion just quoted.

Kohlrausch locates one important fold, the plica transversalis recti, at the same point that Houston locates the most constant of the valves, projecting well from the right side of the bowel, forming a little more than a semicircle and running farther on the anterior than on the posterior wall. Kohlrausch says that this fold is known as the sphincter ani tertius, though he does not think that the anatomic conditions justify the title, as the circular muscular fibers do not enter into the structure and are not developed more here than elsewhere.

Sappey describes the bowel in its empty state as presenting various folds of mucous membrane, having no determinate direction, and but slightly marked. Of 30 rectums examined, he found but three that answer at all to Houston’s chief valve or Kohlrausch’s plica transversalis recti. He says that there is no proof that these folds persist when the rectum is full, but that they probably are effaced by distention, and that it is an abuse of language to apply the name valve to them.

Henle says that there is but one permanent valve, the “plica transversalis recti,” which is present only in a minority of subjects.

Rosswinkler describes and locates two folds, but locates them differently from several of the other authorities.

1893, MATHEWS, Diseases of the Rectum, Anus and Sigmoid Flexure, page 37; D. Appleton & Company, New York:

Declares he has not been able to find the valve, and discussing this subject, asks: “Is there a third sphincter muscle?” and answers that Kelsey, in his work on the Diseases of the Rectum and Anus, page 39, says: “From a study of the literature of this question, and from the results of dissections and experiments which we have been able to make, we are led to the following conclusions:

“1. What has been so often and so differently described as a third or superior sphincter ani muscle is in reality nothing more than a band of areolar muscular fibers of the rectum.

“2. This band is not constant in its situation or size, and may be found anywhere over an area of 3 inches in the upper part of the rectum.

“3. The folds of mucous membrane, which have been associated with these bands of muscular tissue stand in no necessary relation to them, being inconstant and varying much in size and position in different persons.

“4. There is nothing in the physiology of the act of defecation as at present understood, or in the fact of a certain amount of continence of feces after extirpation of the anus, which necessitates the idea of the existence of a superior sphincter.

“5. When a fold of mucous membrane is found, which contains muscular tissue, and is firm enough to act as a barrier to the descent of the feces, the arrangement may fairly be considered an abnormality, and is very apt to produce the usual signs of stricture.”

Mathews then adds: “The only exception I would make to any of these is to note 2, which says, ‘This band is not constant in its situation or size.’ I would beg to amend by saying that the band in many instances is entirely absent. I quite agree with all these conclusions of Kelsey, but would relegate the third or superior sphincter ani muscle to the company of ‘Houston’s valves,’ and to the ‘pockets and papillae.’”

Mathews, in his edition of 1897, repeats these statements, and adds that he believes “the rectal valve exists only in the author’s mind’s eye.”

1894, CHARLES B. BALL, M. Ch. (Univ. Dub.), F.R.C.S.I., in The Rectum and Anus, their Diseases and Treatment; Lea Brothers & Company, Philadelphia:

Omits mention of the rectal valve.

1896, A. ERNEST MAYLARD, M.B., B.S. (Lond.), in Surgery of the Alimentary Canal; P. Blakiston, Son & Company, 1012 Walnut Street, Philadelphia:

Accepts Houston’s views without qualification.

1896, BERT B. STROUD, Annals of Surgery, July: