Sphincter

“ When a person is insensible, it is not always easy or convenient to ascertain whether the feces pass involuntarily from loss of power of the sphincter ani, or are discharged from the ordinary action of the bowels, of which the patient cannot give notice. It may be inferred when the urine flows in a stream, although apparently in an involuntary manner, that the power of the detrusor muscle of the bladder is only impaired. ”

“ But as they increase in quantity, and become more acrid by remaining and consequently more irritating, then the sensible organic contractility strongly brought into action, empties the intestine involuntarily. If the sphincter, which is voluntary, is paralyzed, there will be incontinence, because no resistance is opposed to the tendency of the rectum to contract, a tendency which though feeble as long as it is but partly filled, is however always real. ”

“ In some cases a few of these channels open into the rectum just above the internal sphincter muscles and become filled with water during the use of the enema taken to move and cleanse the bowels. As a rule, one end of the channel is under the mucous membrane of the terminal portion of the rectum, and the other somewhere under the skin of the anus or of the buttocks.
I presume that no disease of the human body has been assigned more reasons for its existence, with the exception of constipation, than that mere symptom of a disease, anal pruritus ”

“ It is at this time that the contractions of the stomach wall, which we recognize as hunger, begin to come on. There is a sphincter muscle between the esophagus and stomach which closes the opening tightly and so prevents the pressure within the stomach from forcing gas or liquid back up into the esophagus. This sphincter opens automatically only in connection with the act of swallowing. Every time we make a swallowing movement a sort of wave passes down the esophagus, and when this wave arrives at the stomach the sphincter relaxes, allowing whatever was moving down the esophagus to enter. ”

“ It is but natural that the lower portion of the rectal and anal structures should be affected more severely than any other portion of the intestines by the ulcerative, inflammatory process. The sphincter muscles are very strong, as a rule, and fill their office only too well when the anal and rectal canals are in a diseased state, for they effectually prevent the contents from escaping. ”

“ The muscle of the bowel is in a state of fatty degeneration, and atony and dilatation of the gut follow.
10. Painful affections about the rectum and anus deter persons from yielding to the desire for defecation. Fissure of the anus is the principal one of these, but fistula, hemorrhoids, and local eczema have a similar influence. A simple rigidity or spasmodic stricture of the anal sphincter creates constipation.4
4 Kunemann, De la Constipation compliqués de Contraction du Sphincter anal, et de son Traitement par la Dilatation de l'Anus, Paris, 1851. ”

“ Incontinence of feces is an unpleasant sequela to the operation for fistula. It is, happily, of rare occurrence, and follows only extensive operations, such as those in which the sphincter has been divided more than once, etc. When it exists to any extent it is productive of great annoyance to the patient, possibly more so than the original fistula. ”

“ The anus is a deeply pigmented, puckered opening situated an inch and a half or two inches behind the vagina. It is guarded by two bands of strong circular muscles, the internal and external sphincter ani. The skin covering the surface of the body extends upward into the anus where it becomes highly vascular and merges into the mucous lining of the rectum. Pressure exerted during pregnancy by the enlarged uterus is felt in both the rectum and bladder, frequently causing a good deal of discomfort and almost painful desire to evacuate their contents. ”

“ After the douche the labia should be separated and the vagina carefully dried by cotton held in dressing-forceps. Except in those cases in which the sphincter ani is involved, the bowels may be moved on the second or third day. The woman should stay in bed for two weeks, at the end of which time the sutures should be removed. 67 She should avoid heavy lifting, long standing, and bicycle- or horseback-riding for two months after the operation. Constipation should always be avoided. Coitus may be resumed six weeks after operation. ”

“ For by avoiding an operation, in addition they incur the inconvenience of a slow recovery. With regard to blind fistulæ, Leonides says: “When the fistula is deep, and penetrates the sphincter, whether beginning in the fundament, or arising from a distance and terminating in the sphincter, after the examination which has been described, we dilate the anus as we do the female vagina, with the instrument for that purpose, or the small specillum. ”

“ When these pockets are present, they always occasion a spasmodic contraction of the sphincter ani, a condition which is most frequently observed in those cases that are developing some deep seated constitutional disease. Their removal in this class of cases is invariably attended by more or less improvement of the patient’s general condition and circulation. ”

“ Before dealing with the pile the anus is vigorously dilated in order that the pile may be dealt with with greater precision, and also that the temporary paralysis of the sphincter muscle, which follows the stretching, may prevent the occurrence of painful and spasmodic contractions subsequently. ”

“ I am more and more convinced that all straining should be avoided. When the bowels do not move readily, wait a few moments passively for nature’s call, avoiding all anxiety in the matter. Should this method fail, then, by will power, press the sphincter muscles back by short, quick, and repeated movements. This will lubricate the rectum, force back the feces, and shortly after result in a satisfactory discharge of the bowels. A little practice will bring these muscles under complete control, and by this means a habit of constipation may be cured. ”

“ There are surgeons who recommend stretching and paralyzing the external sphincter muscle; and if they are correct in their diagnosis and treatment, those who prescribe bile-bouncers, and those who prescribe "nutrient suppositories," and those who prescribe the use of rubber bougies and candles, should call a convention (to meet in, say, New York City) to discuss the subject and see if they cannot agree to inform the people that constipation is a sign of, or a factor in, the evolution of the human race. ”

“ The actions of vomiting, and expulsion of the fæces, are very nearly related to one another in their automatic state. However, it seems to me, that an irritation in the stomach produces only a gentle contraction in the sphincter ani, viz. such a one as does not exhaust its power, and which therefore tends to confine the fæces. In like manner, an irritation in the rectum may gently contract the upper orifice of the stomach. ”

“ It should not pass through the rectal mucous membrane.
After the sutures in the recto-vaginal septum have been shotted, the operator may proceed to repair the perineum and the sphincter ani muscle (Figs. 41, 42) . 75
There is a variety of perineal laceration (between the first slight median laceration and the second complete laceration through the sphincter ani) in which only the outer fibers of the sphincter muscle are injured. In this injury partial incontinence results. The woman may be able to control feces when the movements are hard, but loses control over liquid feces and flatus. ”

“ In some cases of fissure the irritable condition of the sphincter will cause such contraction of the anus when an examination is attempted that it will be impossible for the surgeon to pass his finger into the rectum without etherization of the patient. ”

“ There is often oozing from the anal orifice a purulent-like fluid mixed with blood. The introduction of the finger into the rectum is very painful, causing contraction of the levator and sphincter muscles. It is only the employ- ment of considerable force with a large sexual member that can in these first few days cause relaxation of the sphincter by either inordi- nately expanding or actually tearing it. ”

“ A person suffering from constipation should make powerful movements of the sphincter ani, and of the levator ani, in as rapid succession as possible, continuing the exercise for three or four minutes or until the muscles are fatigued. The time chosen for this exercise should be either before breakfast or an hour after breakfast, according to the natural habit of the individual in respect to the evacuation of the large intestines. ”

“ By asking the patient to strain down moderately, its surface will be thrown up against the end of the finger and in this manner properly explored.
Fig. 11.—Lateral section of rectum; normal curve. R. Rectal pouch. C. cul-de-sac of the rectum. E. S. External sphincter. I. S. Internal sphincter. H. Hilton’s white line. P. Position of prostate gland.
A digital examination reveals, in the normal state, a soft, velvety, unbroken mucous membrane, the parts pliable and yielding, with no reflex excitability of the sphincters. ”

“ I have seen precisely similar conditions resulting from a sphincterismus being relieved by anal dilatation. I had one such case who had fallen into the hands of a quack, who made him believe that he was being affected with incipient softening of the brain; systematic dilatation or a rupture of the sphincter à la Van Buren is the appropriate remedy. ”

“ Now this weight, in a flexible organ like the colon, must cause a sagging down, exerting a serious strain upon its attachments to the abdominal wall, and by its pressure upon the sphincters will induce prolapse of the rectum. That is one reason why so many people find it almost impossible to receive enough water to make the treatment successful. When a physician, or trained nurse, is administering a high enema, it is a common practice to hold a folded towel against the rectum, to guard against this pressure and its possible results. ”

“ Retention of urine is not always present even in those cases in which the limbs are completely paralysed, as the fibres of one side of the cord are sufficient to maintain the functions of the bladder. The patient may be aware that the bladder is full, although he is unable to empty it. Similarly, sensation in the rectum and anus may be retained although the control of the sphincters is lost. ”

“ The lesion is exposed to continuous irritation from the urine and from the sphincteric action of the muscular fibers at the vesical neck—an action which is much increased by the tenesmus present. This constant muscular action impedes healing, as in the case of fissure of the anus. The internal urinary meatus should be dilated under anesthesia to the extent of 1⁄2 inch by means of the graduated bougies or the uterine dilator. After dilatation the woman should be kept in bed and the urine should be rendered as unirritating as possible by the use of diluent drinks and boracic acid. ”

“ This consists in a protrusion inward of the posterior vaginal wall and a pouch of the rectum, which is carried with it. The tendency to rectocele is seen in the natural bulging of the rectum caused by its expansion just above the sphincter ani. ”

“ The phenomenon of vicarious excretion may occur through the kidneys, lungs, skin, throat, nose, vagina, or uterus, thus keeping up chronic diseases and discharges that would not exist but for the chronic constipation or even for incomplete action of the bowels each day. Over-distention of the rectum, sigmoid and colon, due to the pressure of gases and the impaction of feces, results in inflammation, ulceration, stricture, appendicitis, abscess, strangulation, intussusception, and abnormal ballooning or roominess in certain portions of these intestines or conduits. ”

“ Too often such cases prove fatal, or at least a recovery is not attained, and urine or feces or both escape freely into the vagina. The simple laceration of the anus is easily sewed up, but the ends of the muscular fibers do not reunite and the control over the lower bowel is never fully reacquired. The successful stitching up of the wound communicating with the bladder or the rectum requires unusual skill and care, and though I have succeeded in a case of the latter kind, I can not advise the attempt by unprofessional persons. ”

“ If the oiled hand is introduced into the rectum or vagina in the early stages of the affection, the bladder may be felt beneath partially filled, but not overdistended with liquid, and its neck or mouth firm and rigid. In the more advanced stages of the affection the organ is felt as a great, tense, elastic bag, extending forward into the abdomen. In this condition the overdistended muscular coat of the bladder has lost its power of contraction, so that true paralysis has set in, the muscle closing the mouth of the sac alone retaining its contractile power. ”

“ In cases in which there is a fistula of the bladder the subject may live for some time, in some cases passing excrement through the urethra, in others, urine by the anus. These cases seem to have been of particular interest to the older writers, and we find the literature of the last century full of examples. Benivenius, Borellus, the Ephemerides, Tulpius, Zacutus Lusitanus, and others speak of excrement passing through the penis; and there are many cases of vaginal anus recorded. Langlet cites an instance in which the intestine terminated in the bladder. ”

“ Many females can urinate with tolerable comfort while lying on the back or abdomen, and others are much [402] relieved by constantly wearing a bandage. Constipation always makes this difficulty worse, and sometimes even causes it, by keeping the rectum full and thus increasing the pressure. In all such cases it will be readily seen, that forcing medicines are not only useless, but liable to cause injury. The change of position, rest, and supporting the abdomen are the means to be relied upon. If these fail, and the urine accumulates, the catheter must be used. ”