Handbook of diseases of the rectum

Front matter

Pass 7,

Book Jj

GopigM

Preface To Third Edition

The kind reception accorded the previous editions of this work necessitated a new edition several years ago. The author was at work on this task when this country entered the World War. His early departure on overseas duty with the American Expeditionary Forces disrupted his plans. Now that we are again at peace with the world, the revision has come to its completion.

So many of the methods described have been so satisfactorily employed by the members of the profession that the few changes in technic are merely refinements. A large number of new illustrations have been added to bring these out in more detail. The whole text has been made as free from technical terms as is possible in a work of this type. The scope of this volume has been kept within its original limitations while the field of local anesthesia continues to broaden. This, it would seem, is ample justification for the original publication of this work.

The author wishes to express his grateful appreciation to those members of the profession whose insistence is responsible for this edition and to the publishers and all others whose cooperation has always been loyally bestowed.

Louis J. Hirschman.

Preface To Second Edition

The very generous reception which was given this book when first published was the best evidence that the profession was in need of such a work.

The field of local anesthesia in anorectal surgery is well established, and in surgery generally is rapidly extending. The importance of a clear understanding of the diagnosis and treatment of anorectal diseases has forced itself upon the faculties of medical colleges and universities, with the result that an increasing number are giving regular courses in proctology.

With the endeavor to make this work more valuable to the general practitioner, and to the student, who is the general practitioner of the future, this work has been completely revised. Operative technic has been further simplified, new diagnostic methods added, the use of quinin and urea anesthesia described ; the value of radiography in proctology illustrated by many plates ; numerous new illustrations, including two new color plates, have been added to more clearly assist the reader to follow out the various procedures described in the text.

In the preparation of this edition the author wishes to extend his thanks to Dr. P. M. Hickey, Roentgenologist to Harper Hospital, who made all of the radiographs, and to the artists Tom Jones of St. Louis, and Norman Saxon Chamberlin of Detroit.

The author also wishes to express his renewed appreciation of the efforts of all those who assisted in no small degree in making the first edition possible.

Louis J. Hirschman.

Preface To First Edition

In presenting this book to the medical profession, the author does so with the feeling that it will be of some assistance to that great mass who were as unfortunate as he in their early college training in the special field of proctology. Diseases of the rectum and anus have been, and still are, in a great many colleges, dismissed with a single lecture or two, delivered as a part of the course on general surgery. The young graduate in medicine leaves his Alma Mater with a hazy idea that occasionally patients may suffer from "piles or fistula," and an operation under general anesthesia is their only hope of relief.

The fact that the profession as a whole has been so remiss in the treatment of patients suffering from rectal diseases has left the field in the past to the quack and the irregular.

A few earnest practitioners, however, in different parts of the country, gradually discovered that there was something more to rectal diseases than the treatment of "piles and fistula" and began the scientific study of the lower bowel with the result that today the special field of proctology is firmly established with conscientious workers in all parts of the world. The results of the work of some of these men have been given to the world in the shape of most complete textbooks on the subject. In many of these works, however, the subject has been treated from the standpoint of the specialist in rectal diseases, and written for those who wish to follow that line of practice.

With the introduction of local anesthesia into the treatment of diseases of the rectum and anus, a new field of work has been opened. Those patients suffering from many diseases of this region, who have sought the advice and care of the irregular and the advertising quack, have done so on account of their dread of hospitals, general anesthesia, and "the knife."

In order that the general practitioner may be qualified to diagnose and treat his patient who is suffering from anorectal diseases as scientifically and as successfully as he does affections of other organs and localities, the author presents the results of his experiences in the treatment of anorectal diseases.

10 PREFACE

The diagnosis of disease originating in this region has been dwelt upon to emphasize the importance of early examination. Illustrations, for the most part original, have been used wherever it has been thought necessary to supplement the text for the sake of clearness.

Non-surgical methods are described in those conditions where they have been found of value, and the technic of operative measures under local anesthesia has been made as simple as possible. Only those conditions which are amenable to treatment in office practice have been discussed, and the limitations of office treatment clearly set forth. For information regarding those operative measures that are only applicable under general anesthesia, and the consideration of those diseases whose treatment requires confinement in bed, the reader is referred to the several complete works on proctology that are now available.

Those physicians living and practicing in the Southern states, particularly, will appreciate the inclusion in this work of a chapter on Dysentery. The author has been exceedingly fortunate in securing the services of a man to prepare this chapter, than whom there is no one better posted on the subject: Dr. John L. Jelks, of Memphis, Tenn., President of the American Proctologic Society.

Inasmuch as a very important index to the condition of the entire digestive tract and its functions is found in the excretions; and the fact that the examination of the stools, which is fully as important as the urinary analysis, has been too long neglected, a chapter on the examination of the feces has also been included. Dr. George W. Wagner, of Detroit, Attending Physician to Harper Hospital, Gastroenterologist to the German Polyclinic, and Clinical Professor of Medicine in the Detroit College of Medicine, has kindly contributed this chapter, and the author considers himself extremely fortunate in securing the assistance of so well qualified a man.

To the above named gentlemen; to Dr. Robert C. Jamieson, of Detroit, Dermatologist to Harper Hospital Polyclinic, who made the excellent photographs under the author's direction; to Mr. James T. Nolan, the artist of Western Reserve University Medical Department, of Cleveland, 0., who made all of the drawings; to the J. F. Hartz Co., of Detroit, who furnished the illustrations of many of the surgical instruments ; to the publishers for their hearty and willing cooperation ; and lastly, to the many members of the medi-

PREFACE 11

cal profession through whose courtesy the author has been able to treat the large number of cases, the results of his experience with them having furnished the basis for the preparation of this work — the author extends his sincere and heartfelt thanks.

Besides the results of his own experience, the author has availed himself of the privilege of consulting many of the recent works and textbooks on the subject of proctology, among which may be mentioned those of Tuttle, Gant, Matthews, Martin, Ball, Cripps, Wallis, and Hertz, as well as many articles by other authors appearing in the current literature of the day.

If the author has succeeded in so simplifying the diagnosis and treatment of many of the more common diseases of the rectum and anus that this work will be of some assistance to the busy general practitioner in his everyday work, and has assisted in even a small degree in broadening the scope of the use of local anesthesia in this field, he will feel that he has accomplished all that he set out to do. This modest work does not pretend or aspire to take the place of a textbook on the whole subject of proctology, but if it will find a place on the physician's desk as a working handbook, the author feels that it will fill a long-felt want.

Louis J. Hirschman.

Chapter I ANATOMY Anus — Anal Canal — Rectum — Levator Ani — Ischiorectal Fossa — Sigmoid Colon — B'lood Supply — Lymphatics — Nerve Supply 21-33

ClIAPTZR II

SYMPTOMS WHICH SHOULD CALL ATTENTION TO THE RECTUM Pain — Tenderness — Spasm — Bleeding — Itching — Protrusions — Elevations — Discharge — Constipation — Diarrhea — Altered Stools — Sacral Backache — Shooting Pains down the Limbs — -Crampy, Painful, and Scanty Menstruation — Urinary Disturbances — General Disturbances — Anemia — Restlessness in Children — Foreign Body 31-39

Chapter VII Cause — Diagnosis — Treatment — Anal Ulcer . 127-113

Chapter VIII ABSCESS OF THE ANORECTAL REGION Tegumentary Abscess — Subtegumentary or Marginal Abscess — Submucous Abscess — Ischiorectal Abscess 141-156

14 CONTENTS

Chapter IX ANAL FISTULA— ANAL SINUS Varieties of Fistula — Simple Complete Fistula — External Sinus — Internal Sinus — Submucous Tract — Submucous or Mucocutaneous Fistula — Injection of Bismuth Paste — Anal Fistula in the Tuberculous Patient 157-182

Chapter X

Varieties — Causes — Symptoms — Diagnosis — Treatment 183-227

Chapter XI

RECTAL POLYPI— HYPERTROPHIED ANAL PAPILLAE— CRYPTITIS

Polypus— Hypertrophy of the Anal Papillse— Cryptitis 228-239

Chapter XII PROCTITIS AND SIGMOIDITIS

Acute Proctitis and Sigmoiditis— Chronic Proctitis and Sigmoiditis . . 240-252

Chapter XIII DYSENTERY

General Considerations — Acute Catarrhal Dysentery or Sporadic Bacillary Dysentery — Diphtheritic Dysentery — Secondary Diphtheritic Dysentery — Amebic Dysentery — Chronic or Secondary Amebic Dysentery 253-293

Chapter XIV PROLAPSE OF THE RECTUM IN CHILDREN

Etiology — Symptoms — Diagnosis — Treatment . , 294-301

Chapter XV TECHNIC OF THE USE OF LOCAL ANESTHESIA IN THE TREATMENT

OF ANORECTAL DISEASES Anesthetic Agents — Instruments — General Teclmic — Technic in Special

Chapter XVI LIMITATIONS OF LOCAL ANESTHESIA AND OFFICE TREATMENT

AND INDICATIONS FOR OTHER MEASURES General Contraindications to Local Anesthesia — Cancer of the Rectum — Ulceration of the Bowel — Stricture of the Rectum — Rectal Abcesses — Anal Fistula — Hemorrhoids — Prolapse of the Rectum — Removal of Concretions — Fistulas Communicating with other Organs .... 321-332

CONTENTS 15

Chapter XVII THE FECES AND THEIR CLINICAL EXAMINATION General Characteristics of Feces — Clinical Examination of the Stools — Microscopic Examination — Chemical Examination — Clinical Significance of Test — Animal Parasites — Character of Feces in Certain Intestinal Affections 333-360

Symptom Index „ 361-363

Index of Authorities . . 365-366

J 'late I. Cancer of the rectum complicating prolapsing hemorrhoids, Frontispiece

Plate II. Blood vessels of the rectum Facing page 32

Plate III. Giant sigmoid colon Facing page 78

Plate IV. Section of intestine below ulceration Facing page 272

FIG. PAGE

1. Rectum and anal canal in the male <• .... 22

2. Rectum hardened in formalin 24

3. Proctoscopic view of rectal valves 26

4. Muscles and nerves of the male pelvic outlet 28

5. Simple form of instrument sterilizer 41

6. Small instrument and dressing sterilizer 41

7. Operating-table 42

8. Electric magnifying headlight 43

9. External inspection 44

10. Method of applying lubricant from collapsible tube 45

11. Incorrect method of digital examination 4G

12. Correct method of digital examination . . 47

13. Vaginal eversion of the anus 48

14. Another method of everting anus .49

15. Amount of possible eversion of anal tissues 50

16. Method of examining the coccyx with one hand 51

17. Rectoabdominal bimanual examination 52

18. Rectoabdominal palpation , 53

19. Palpation of rectum through posterior vaginal wall 53

20. Ischiorectal abscess „ 54

21. Squatting position 55

22. Three-ounce, all-rubber bulb syringe 55

23. Knee-elbow position 56

24. Knee-shoulder position 56

25. Author's anoscope with oblique opening 57

26. Author's adjustable fenestrated anoscope 57

27. Silver wire probe 58

28. Long alligator forceps 58

29. Kelly anoscope 59

30. Method of using author's fenestrated anoscope 60

31. Author's modification of Martin proctoscope 61

32. Tuttle pneumatic proctoscope 61

33. Exaggerated lithotomy position 62

34. Kelly sigmoidoscope 63

35. Sigmoidoscope with author's tilting obturator 63

36. Adjustable proctoscopic mirror 64

37. Inverted or Hanes' position 64

PAGE

Imperforate anus in one-year-old child 66

Atresia ani vaginalis (complete) 67

Atresia ani vaginalis (incomplete) 68

Xormal segmentation of colon up to splenic flexure 71

Overdistention of ascending cecum and transverse colon 72

Megacolon 74

Megacolon, after removal 76

Coloptosis with angulation and adhesion of transverse colon 77

Bismuth meal passing from ileum to cecum 80

Whole colon injected with bismuth 81

Ptosis of cecum „ 82

Ptosis of cecum , 83

Hypertrophy of pelvic colon due to adhesions „ 88

Hypertrophy of transverse colon 89

Congenital dilatation of pelvic colon and rectum in five-year-old boy . . 91

Spastic descending and pelvic colon 92

Stricture at recto-sigmoidal juncture 93

Stricture near splenic flexure due to carcinoma 94

Author's dilating rectal massage bag 95

Author's dilating rectal massage bag (deflated and inflated) .... 95

Position for author's method of rectal massage 97

Author's four-inch operating proctoscope 101

Author's rubber ligature carrier 101

Author 's angular rectal scissors 101

Technic of author 's operation for rectal valvotomy 102

Author's rubber ligature operation 103

Pruritus ani _ Ill

Pruritus ani, showing excoriation 112

External hemorrhoids with pruritus ani 114

A simple and satisfactory rectal dressing 121

Sharp-pointed scissors curved on the flat 122

T-forceps 122

Ball 's operation for pruritus ani — lines of incision 123

Ball's operation for pruritus ani — dissecting the flap 124

Ball 's operation for pruritus ani — area of anesthesia 125

Krouse 's radiating incisions for Ball 's operation 126

Typical site of anal fissure 127

Traumatic fissure 12S

Anal fissure with sentinel pile , 129

Anal fissure, showing sentinel pile 130

Multiple anal fissure 131

Anal fissure from crypt of Morgagni 132

Applying ointment to anus from lead tube 133

Application of carbolic acid at point of puncture 134

Injection of anesthetic for fissurectomy at usual site 135

Injection of anal fissure 136

Anesthesia and sphincteric relaxation complete for fissurectomy . . . 137

FIG. PAGE

86. Fissure grasped ready for excision 138

87. Simple incision of fissure 139

88. Sharp-toothed or pronged forceps 140

89. Anal fissure complicating internal hemorrhoids 140

90. Author 's technic for incision of anal fissure 141

91. Posterior anal ulcer 142

92. Operation for excision of anal ulcer 143

93. Anorectal abscesses 145

94. Circumanal ulceration, infective 146

95. Characteristic sitting posture in anorectal disease 148

96. Proctoscopic view of submucous abscess 151

97. De Vilbiss rectal speculum 152

98. Line of incision for ischiorectal abscess 153

99. Anorectal fistula — anal sinus 157

100. Direct complete anal fistula 160

101. Angular fistulous tract 160

102. Glass syringe for injecting bismuth paste into fistulous openings . . 161

103. Injection of fistulous tracts with bismuth paste 162

104. Radiograph of simple direct complete fistula 163

105. Complicated complete fistula 164

106. Multiple fistula communicating with urethra 165

107. Soft silver probe passed through complete fistula 166

108. Grooved director 167

109. Principal instruments for anorectal surgery under local anesthesia . . 168

110. Fistula with three external openings 169

111. Incision for simple direct anal fistula 170

112. Soft silver probe passed through fistula 171

113. Author's technic for removing fistulous tract • 173

114. Multiple anorectal fistulse 174

115. Excision of fistulous tract 175

116. Fistulous area dissected clean 175

117. Wound lightly packed with dry gauze 176

118. Extent to which dissection must be carried in multiple fistuke . . . 178

119. Technic of ligature operation for fistula 179

120. Silver wire looped through fistula and fastened 180

121. Author's cryptotome with adjustable handle 181

122. Interno-external hemorrhoids 184

123. Section of interno-external pile 184

124. Acute external thrombotic hemorrhoid 185

125. Ulcerating acute thrombotic hemorrhoid 187

126. Acute thrombotic hemorrhoids of unusual size 188

127. External thrombotic hemorrhoids . . . 188

128. External cutaneous hemorrhoids 189

129. Granulomata (syphilitic) 190

130. Single prolapsing internal hemorrhoid 191

131. Prolapsing internal hemorrhoids 192

FIG. PAGE

132. Prolapsing internal hemorrhoids 193

133. Prolapsing internal hemorrhoids 194

134. Prolapsing internal hemorrhoids exposed ready for operation .... 195

135. Bivalve rectal speculum 196

136. Circumanal injection of anesthetic completed 196

137. Showing complete anesthesia and sphincteric relaxation 197

138. Injection of interno-external hemorrhoid 199

139. Injection of prolapsing hemorrhoid 200

140. Prolapsing interno-external hemorrhoids anesthetized 201

141. Distention completed, showing internal hemorrhoids presenting . . . 202

142. Injection of prolapsing pedunculated internal hemorrhoids .... 203

143. Perfect exposure of operative field 204

144. Grasping hemorrhoid with author 's hemorrhoid forceps 205

145. Author's hemorrhoidal forceps 206

146. Passing submucous ligature *..... 207

147. Ligature tied with a long and a short end 208

148. Rectal retractor modified from Sims' speculum 209

149. Author's blunt-pointed ligature carrier 209

150. All ligatures tied in situ 210

151. Internal hemorrhoid anesthetized 211

152. Excision of hemorrhoidal tissues, conserving mucosa 212

153. The blood supply controlled by four ligatures 213

154. Long end of ligature tied in needle . 214

155. All hemorrhoids ligated ready to be sutured . , 215

156. Long ends of ligatures tied to short ends 216

157. Edges in position for suturing 217

158. Teclmic of suturing 218

159. Completing the suturing 219

160. Skin closure 221

161. Operation completed 222

162. Distention of external hemorrhoids with sterile water 223

163. Anal polyp 229

164. Rectal polypus 230

165. Specimen of multiple colonic polyposis 232

166. Specimen from total colectomy for multiple polyposis ...... 233

167. Hypertrophy of anal papillae and crypts of Morgagni 234

168. Hypertrophy anal papillae 235

169. Proctoscopic view of hypertrophied anal papilla? 236

170. DeVilbiss spray tube 241

171. Author's rectal spray tube 242

172. Spraying rectum in knee-shoulder position . 243

173. Ulcer of the rectum 244

174. Amoeba histolytica 263

175. Amoeba coli mitis 264

176. Slough of mucous membrane 268

177. Edge of intestinal ulcer 269

FIG. PAGE

178. Dysenteric ulceration on the valves of Houston 270

179. Photograph of case 275

180. The Jelks' irrigating tube 286

181. Position for irrigation of colon with Jelks' tube 287

182. Position for introduction of colon tube 289

183. Method of application of solutions to rectum and sigmoid 291

184. Method of spraying rectum and sigmoid 292

185. Prolapse of the rectum, third degree 295

186. Prolapse of the rectum, first degree . . . 297

187. Aseptic all-glass hypodermic syringe 307

188. Aseptic all-metal syringe 307

189. First step — application of carbolic acid 309

190. Point of puncture for injecting local anesthetics .310

191. Quadrants of the anus 311

192. Amount of distention for anesthetizing sphincters 312

193. Point of puncture for anesthetizing sphincterian nerves 313

194. Producing dilatation of sphincters with vibrator 314

j 95. Amount of dilatation of sphincter 315

196. Anesthesia and relaxation produced by the technic outlined .... 316

197. Wales rectal bougie 319

198. Proctoscopic view of carcinoma 323

199. Carcinoma after removal by operation 324

200. Cancer of the rectum, with multiple fistula? 325

201. Cancer of the rectum 326

202. Cancer of the rectum, interior view , 327

203. Sulphid of bismuth crystals from the stools 335

204. Collective view of the feces 336

205. Muscle remnants in feces 339

206. Steele 's modification of Strassburger 's fermentation apparatus . . . 340

207. Mucus shreds 341

208. Mucus shreds after the addition of acetic acid 341

209. Hematoidin crystals from alcoholic stools ' . 343

210. Acholic stools 343

211. Gallstones 346

212 Amoeba coli 348

213. Balantidium coli 348

214. Ascaris lumbricoides 350

215. Oxyuris vermicularis 351

216. Oxyuris vermicularis 352

217. Ankylostomum duodenale 353

218. Trichocephalus dispar . . . . , 354

219. Trichinae 355

220. Anguillula stercoralis 355

221. Head of Taenia solium 356

222. Taenia saginata 357

223. Head of Bothriocephalus latus 358

Chapter I

It is not the intention in a work of this scope to go into minor anatomical details in the description of the aims and rectum. It is essential, however, that one who intends to treat even the most common and uncomplicated diseases of the aims and rectum should have a practical working knowledge of the gross anatomy of the anorectal region.

In reversing the usual order of describing these organs, the author starts with the anus first, because it is to the anal orifice that one's attention is first directed in proceeding to examine or operate for diseased conditions affecting these organs. It appears to the author, therefore, that the anatomy of these organs should be described in the order in which they are met: from without, inward.

ANUS

The anus is an oval aperture, longitudinal when in repose, situated at a point equidistant from the tuberosities of the ischii, and about one inch anterior to the tip of the coccyx. In the female it is situated a little more anteriorly than in the male. The anus is surrounded by integument which is slightly darker than the surrounding skin. The skin around the anus is arranged in radiating folds caused by the contraction of the corrugator cutis ani muscle. The circumanal integument contains sweat glands, sebaceous glands, and hair follicles. The circumference of the anal orifice varies from an inch to an inch and three quarters, but it may be dilated to a circumference five or six times greater.

Fig. 1. — Rectum and anal canal in the male — longitudinal section. (Section made by Professor A. F. Dixon of a formalin-hardened male pelvis.) — After Ball. B. C. Bulbocavernosus muscle.

B. Bladder.

P. Prostate gland.

R. U. Rectourethralis muscle.

S. V. Seminal vesicle with ejaculatory duct below. S. I. Internal sphincter muscle.

S. F. External sphincter muscle.

A. Anus.

P. R. Puborectalis muscle, around which the rectum bends sharply, to be continued into

the anal canal.

R. Rectum.

ANAL CANAL

The anal canal extends from the point at which the sides of the anal aperture first appose to the linea dentata or lower edges of the semilunar valves, which guard the openings of the crypts of Morgagni. Its depth varies frcni two thirds of an inch to an inch and a quarter. It is lined by a membrane composed of thin transitional epithelium, gradually changing in histological formation from the stratified cells of true skin at the anus to the goblet-cells of mucous membrane at its juncture with the rectum at the linea dentata, or anorectal line. Surrounding the lining membrane is one of cellular tissue, and beneath this the muscular layer composed of the external sphincter, a few fibers of the levator ani, and the lower portion of the internal sphincter. The dimensions of the anal canal, when in repose or dilated, are slightly smaller than those of the anus itself in like condition. The lining membrane presents to the eye a pinkish-red shining appearance, in some cases a more or less purplish hue (Fig. 1).

External Sphincter Muscle. — This is the most important muscle with which we have to deal from a surgical point of view. and is the principal muscular structure which goes to form the anal canal. It is composed of circular and longitudinal fibers. The longitudinal arise from the lower end and posterior aspect of the coccyx, and surrounding the anus in an elliptical manner, meet and are inserted into the central tendon of the perineum. The circular fibers are more superficial, entirely surrounding the anal canal. The muscle is normally in a state of contraction, keeping the anus closed, and it is of great importance in the voluntary control of the act of defecation. Its nerve supply is derived from the third and fourth sacral and superficial branch of the internal puelic and a filament of the fifth and sixth sacral, known as the lesser sphincterian nerve. This nerve is of extreme importance in the production of local anesthesia for the dilation of the anus. It enters the external sphincter on either side at a point at the juncture of the lower and middle third of the anus.

At the upper limit of the anal canal at its juncture with the lower portion of the rectum are situated the anal papilla 7 and crypts of Morgagni. The papilla? appear as a more or less distinct line of small saw-tooth-like triangular projections which en-

Fig. 2. — Rectum hardened in situ with formalin and then dissected out. — After Ball.

S. Sacral curve of rectum.

P. Peritoneum cut at reflexion from bowel.

R. Portion of rectum uncovered by peritoneum.

D. Pelvic diaphragm.

E. External sphincter.

circle the anal canal. This line is called the linea dentata, or anorectal line. Just behind these papillae are found the openings of the crypts of Morgagni. The anal papillae and crypts of Morgagni are of especial interest because they are often the seat of inflammatory conditions which present symptoms often out of all proportion to the size of the lesion causing them.

The blood and lymphatic supply will be taken up later.

RECTUM

The rectum is a hollow, tubular organ varying in length from five to seven inches, and extending upward from the anorectal line to the rectosigmoidal juncture (Fig. 2). When empty, its anterior and posterior walls appose, and a cross-section would show a transverse slit. The rectum is usually understood to be that portion of the lower end of the large intestine which extends from the left sacroiliac symphysis to the anorectal line. Instead of it being a straight canal, as its name indicates, it is curved backward from the anorectal line, following the hollow of the sacrum, curving forward at the promontory, where it joins the lower portion of the sigmoid flexure. Some authors describe the rectum as that portion which extends from the anorectal line to the third sacral vertebra, which includes that portion which is not covered by peritoneum, the part above this being called the loAver end of the pelvic colon, or sigmoid colon. Inasmuch as this latter division has not been accepted as yet, the author will consider the rectum as described in all of the standard textbooks on anatomy.

We will consider the rectum as divided in two portions : the upper or peritoneal portion; and the lower or that portion below the third sacral vertebra, the extraperitoneal. Thomas Charles Martin divides the rectal cavity into first, second, and third rectal chambers, each chamber corresponding to that portion below one of the rectal valves or folds of Houston.

The rectum is composed of four coats, being from within outward: the mucous, submucous, muscular, and serous. The muscular coat is composed of both circular and longitudinal fibers. At the lower portion of the rectum and extending down to the white line of Hilton in the anal canal, the circular muscular fibers are more numerous and thrown together into what is known as the internal sphincter muscle. The mucous membrane is gathered together in folds which converge at the anorectal line, ending at the crypts of Morgagni. These folds are known as the columns of Morgagni. With the patient in the knee-shoulder position and the rectum inflated, the circumference of the organ when dilated will vary from five to ten inches. With the rectum inflated certain definite crescentic folds will be seen standing out from the rectal wall, encircling it for from one third to two thirds of its circumference. They appear at definite points and are usually three in number. One extremity appears attached lower to the rectal wall than the other, and they are arranged in such a manner that on procto-

Fig. 3. — Proctoscopic view of the rectal valves — semidiagrammatic.

scopic view they give the effect of three projecting ledges arranged in the form of a spiral ; the second being attached an inch to an inch and a half above the middle of the first; and the third at a point about the same distance above the middle of the second (Fig. 3). The first rectal valve, or fold of Houston, as it is called, is situated more often on the left lateral wall of the rectum opposite the location of the prostate gland, while the third is at or below the rectosigmoidal juncture. These valves are not simple folds of mucous membrane, but contain muscular fibers and blood-vessels and present all the characteristics of a typical anatomical valve. They are of considerable interest and importance because of the fact that, when they are infiltrated, thickened, or enlarged, they offer more or less obstruction to the passage of the fecal current and ulcerations concealed on their upper surfaces are often overlooked, whose discovery would clear up the etiology of many cases of so-called diarrhea.

LEVATOR ANI MUSCLE

Except the external sphincter muscle this is the most important muscle with which we have to deal (Fig. 4). With the external sphincter, this muscle practically controls the act of defecation. During defecation the levator ani and external sphincter muscles are relaxed, and the feces are extruded by the involuntary action of the muscular coats of the bowel, assisted by the voluntary compression and contraction of the abdominal muscles. The internal sphincter, in all probability, does not act as a sphincter at all, but co-operates in the peristaltic movement of the internal muscular coat of the intestine. When the fecal mass is extruded, the anterior portion of the upper portion of the anal canal is fixed by the rectourethralis muscle, which is a definite muscular band by which the anterior surface of the bowel at the juncture of the rectum and the anus is connected with the urethra. The puborectalis portion of the levator ani then compresses the sides and draws the posterior portion of the opening toward the pubis.