Part 7

“Anal Pockets. The pectineal dentations are not usually equally developed. But in rare instances two large ones adjoin, and the depression between them is a large foliated sac or pocket. The walls of this pocket contain numerous sacculi Horneri. The outer side of the pocket is formed by a substantial fold of epithelium which unites the two dentations. In the cases examined each terminated in a well-marked papilla. The fold has the appearance of a valve, which, if it were sufficiently developed, might be of service in helping to retain the feces under unfavorable conditions. This, so far as I have been able to determine, is a human peculiarity and not constant. It also, like the papillae, has been described as pathologic.

“Considering these facts, a question naturally arises, Is not Nature in the process of evolving for man additional organs for his convenience and safeguard? A careful compilation of statistics at intervals, of say each generation, would throw light on this question.”

This interesting speculation was, however, preceded by the fact itself, which is shown by the existence of a rectal valve, as will subsequently be incontrovertably demonstrated.

1896, GANT, Diseases of the Rectum and Anus, page 10; The F. A. Davis Company, Philadelphia:

“Internally the rectum presents three or four transverse folds. According to Houston the largest one is situated three inches above the anus,” etc., quoting Houston; and in conclusion Gant says: “The folds become almost obliterated when the bowel is distended.”

* * * * *

This literature makes it obvious that there is an imperfectly understood anatomic feature in the rectum.

It is not improper to assume that, if the judgment of trained observers be equal, their description of the thing considered will vary in the main, only as does the medium through which the view of each is obtained. Our critic review of the literature on this subject has revealed two important facts: that observers employing like means of investigation adduce almost identic evidence, and that the more nearly the method of one approaches that of the other the more in accord are the conclusions reached. By the employment on both living and dead subjects of the methods used by the various observers, I have secured results similar to theirs, which, when considered collectively and in comparison with the results of my recent researches, are practically and logically as harmonious as they have heretofore appeared contradictory, which proves that for about one and three-quarter centuries these gentlemen have been discussing the same anatomic feature, but have observed it from quite different points of view.

Houston distended and hardened the rectum in situ with spirit. On mesial section of the subject the gut presented valve-like folds with unvarying constancy but in varying number, and in different location in different subjects. He declared their structure to be a duplicature of mucous membrane and bundles of circular muscular fibers only. Others recognizing that in moderate distention the mucous membrane is loosely adherent in the lower rectum, insist that under the conditions employed by Houston the membrane would assume the same appearance as that described by him, and therefore conclude that these features are accidental folds and not valves; and, as Houston did not support his statement by attributing to these valves the histologic element which histologists recognize as the essential feature of a valve, the opinion of his opponents is seemingly reasonable, but is nevertheless a mistake.

Hyrtl employed atmospheric distention after removal of the gut, and observed an appreciable thickening of the wall of the rectum beneath the mucous membrane, and with apparent reason assumed this thickening to be muscle only. Under the same manipulations a valve may be made to lose its valvular form and seem to support this view.

Velpeau supported Nelaton’s claim for the superior sphincter by removing the rectum and turning it inside out, so that its mucous membrane was external, and then by inflation demonstrated a marked constriction on the now external surface, which was distinctly claimed to be nothing other than a muscular band. It is not difficult to understand how the true valve within the normally situated gut would appear as a constricting band when the rectum is removed and turned in the manner described.

Horner’s observations are put to the question.

Chadwick discovered by digital exploration the lowermost of the valves, which he declared to be a detrusor fecium muscle only instead of a valve. I find that these valves, when not the seat of disease, though often discoverable, frequently elude the finger of average length, or if high up, are inaccessible to it. As the uppermost valve is seldom less than nine inches (22.86 cm.) from the anus, this means of determining their presence is not usually satisfactory. This was proved by an instance: a subject was examined in which the lowermost semilunar valve was malformed into a congenital annular or diaphragmatic stricture with a circular aperture, which, although at times within three inches (7.62 cm.) of the anal verge, escaped my digital perception and that of a dozen other medical men in attendance at my clinic and was not discovered until subsequently revealed by proctoscopy.

Otis’s methods of inquiry were direct and to him must be accredited the achievement of making the first positive ocular demonstration of the existence of the valves. He, however, like Houston, attributes to this band no especial structural element other than is found at any and all parts of the intestinal tube. He agrees with Kohlrausch, and calls the largest band the plica transversalis recti of Kohlrausch. And he agrees with Chadwick that “its function is expulsory only.”

The photographic reproductions here published are documentary evidence of the existence of the obstructions under discussion. The sketch, Fig. 33, which was drawn from the valve while under the microscopic lens, exhibits the character of these obstructions and proves it that of a typic anatomic valve, and the absence of permanent bands of any other character in this organ is evidence that the semilunar valves and the so-called plica transversalis recti, Falten des Rectums, sphincter ani tertius, superior sphincter, and detrusor fecium muscles are one and the same thing and this thing is essentially a valve. It is most prominent when the gut is most distended.

THE CHRONOLOGY OF ATMOSPHERIC INFLATION OF THE RECTUM FOR ITS INSPECTION.

Proctoscopy has proved an open sesame to a newer proctology. As there seems to be some confusion of opinion concerning the time of its origin and the chronology of its evolution, the present time is opportune for a brief historic review of the subject.

In 1845 Dr. J. Marion Sims discovered by a chance that a hollow or tubular pelvic viscus would inflate provided the orifice were opened at a time when the patient’s hips were higher than the chest. He elaborated the manner of this discovery to a method of procedure. He first used the knee-chest posture, and subsequently the semiprone-semiflexed position with elevated hips. This posture became known as Sims’ posture, and the instrument which he designed as Sims’ speculum. The first published account of his method appeared in 1852, in the January number of the American Journal of the Medical Sciences.

In 1871 Dr. Wm. H. Van Buren, of New York, was the first to publish an account of the use of the identical postures and Sims’ speculum for atmospheric inflation and inspection of the rectum and sigmoid flexure.

In 1882 Dr. Wm. Allingham employed elevation of the patient’s hips and a tubular speculum, and achieved the same results. In subsequent editions of his book in 1888 and 1896 he repeats a description of his rather crude operation for inspection of the rectum through a cylindric tube.

In 1887 Dr. Alfred Cooper described a similar posture, and suggested the use of two retractors for the purpose of opening the anus.

In 1887 Dr. Walter J. Otis, of Boston, published in Leipsic a monograph on the subject of rectal inspection, and described the use of the knee-chest posture and of two retractors.

In 1887 Prof. Esmarch described a method similar to that of Dr. Otis.

In 1895 Dr. Howard A. Kelly described a method of proctoscopy by means of tubular speculums which are very similar in construction to those of Dr. Edmund Andrews, which Dr. Andrews first described in 1887.

Dr. Kelly’s article, however, was the first to catch the attention of the general profession, and to him is due the credit of pointing out to a multitude of physicians the possibility of rectal inflation for inspection by such means. Kelly’s technic and tubular speculums are far superior to those of Mr. Allingham, who first employed a similar method in 1882.

In 1896 I published in the July number of Mathews’ Quarterly Journal of Rectal and Gastro-Intestinal Diseases, under the title of “Proctocolonoscopy and Its Possibilities,” a description of a technic and new instruments which increased the areas exposed to view, and which facilitated access to the part for the treatment of disease.

In 1896 A. Ernest Maylard briefly referred to the various methods.

Review of the literature on rectal inflation for rectal inspection establishes the fact that Van Buren is entitled to the credit for priority; that Marion Sims was the discoverer of the possibility of atmospheric inflation of the hollow pelvic viscera; that there is much similarity in the methods of the various operators quoted, some using similar instruments and dissimilar technic, and vice versa; and it is made obvious, also, that he who would most insist upon a credit for originality must sometimes discount with the erudite his reputation for literary research.