The muscles and tissues constituting the anal vent should be as flexible and responsive to the will or desire of the rectum for relief of its contents as the lips are in permitting the saliva to escape. In like manner the upper portion of the rectum (Figs. [6] and [8]) should respond with instant readiness to the effort of the sigmoid flexure to expel its contents. But an abnormal condition like inflammation rooted in the anus and lower part of the rectum (Fig. [1], 4–4) will inhibit the passage of the pressing burden above them, which inhibition will cause the inflammation to extend to the sigmoid flexure, and thence on to the colon proper; and sooner or later the inflammation will penetrate the submucous coat (Fig. [1], 3–3), which is composed of fatty or areolar connective tissue in which trunks of nerves and blood-vessels are imbedded.
The first symptom of inflammation is undue redness, followed by slight puffiness of the anal and rectal mucous membrane (Fig. [1], 4–4), with more or less sensitiveness of the tissues involved; and as its irritability increases there is more or less contraction of the muscular tissue forming the anus and rectum, which lessens the diameter of their bore. And the consequence of this contraction is of physiological concern to the victim, for in proportion to the contraction the normal demand of the victim for relief of the impending feces and gas is modified and lessened.
In health, the anal canal is from two to three inches in length, and it will distend about two inches—an elasticity quite equal to that of any other orifice of the body. As the anal tissues are usually the first to be invaded by disease, it is but natural that the obstipation or constipation should occur right above it—namely, in the rectum. The average length of the rectum is about six inches, and when the disease invades its whole length the constipation occurs in the sigmoid flexure and may thence extend to the colon.
The filling of the intestine with feces and gases usually occurs just above the diseased portion of the gut; but at the same time the walls of the affected part of the canal are more or less coated with feces, and its abnormal pouches here and there contain more or less liquefied or dried feces. A diseased canal cannot expel all of its contents, since its normal expulsive power is gone. Some of the feces somehow or other gets down and out, but a larger portion inevitably remains. It is for this reason that a diseased intestine always reminds one of the Augean stable. It is simply marvelous that the human body continues as a living organism with so much filth and bacterial poison stored in its alimentary canal, and the vaults that result from abnormal pressure during periods of fecal impaction (Fig. [4]).
When the inflammatory process extends up the rectum and at the same time into the spongy, fatty, or areolar tissue under the mucous membrane (Fig. [1], 3–3), thence to the muscular and serous layers (Fig. [1], 2–1), or through the four layers of tissue comprising its wall, we have a more marked and serious occlusion (closing) of the organ than when only the mucous membrane was affected. When muscular tissue is inflamed, its tendency is to contract and become solidified by an adhesive inflammatory product secreted between the circular and longitudinal muscular fibres (Fig. [1], 7, and Fig. [7]). Often the circular or sphincter muscles forming the anal canal have to be distended to bring about a more normal vent. The same pathological conditions that occasion contraction of the anal bore or caliber occur, more or less, as far up the gut as the disease has advanced.
In a normal state of the lower bowel the sigmoid flexure passes its contents into the rectum, and the desire to defecate is reported—that is, the impulse to stool becomes more or less urgent until it is performed. But when all four coats of the anus and rectum are diseased, with perhaps a portion of the sigmoid flexure also, it is very difficult for the healthy portion of the sigmoid flexure and the colon to discharge their contents into the rectum; consequently no call, impulse, or desire reaches the mind. Constipation will then ensue, for the stool, not being called for, is not performed. Every demand of a healthy portion of the intestine is answered by increased contraction of the muscles of the diseased portion of the rectum. While the war between the healthy and the diseased sections of the bowels goes on, the victim naturally concludes that there is no occasion or demand for defecation, and he attends to other affairs, ignorant of the fact that he is thus making a fatal mistake.
The first condition that ensues is the tendency of the rectum to fill unduly with feces and gases, impelling the victim to “strain” in order to force the feces through the constricted anal canal. After a while the sigmoid flexure and colon will fill unduly, and then the victim will form the habit of waiting for the feces to descend, and of straining to expel what little manages to escape through the diseased gut.
A portion of the imprisoned feces in the healthy section of the intestine sometimes, at an unguarded moment, manages to distribute itself along the length of the diseased and constricted canal, where it is retained indefinitely, increasing the local irritation. And when the fecal mass accumulates sufficiently in both the healthy and the diseased portions of the intestines to set up a vigorous excitement, the victim may, by the aid of his waiting and straining habit (which habit, by the way, only torments and bruises the chronically diseased organs), bring on some sort of evacuation. In the early history of the disease this habit may serve for a time; but, as the disease progresses, the “laxative” habit is formed, which, in turn, settles into a chronic “drug” habit for all sorts and conditions of gastro-intestinal and other ills, which inevitably ensue. As the ravages of chronic inflammation of the anus and rectum increase, the symptoms rapidly multiply, till finally the victim, in desperation, feels that he must find additional sources of relief—and, among other habits, he forms the “diet” habit.
The order of abnormal habits brought into existence by ulcerative inflammation of the anus, rectum, and colon is about as follows: (1) the habit of unduly retaining the feces in the rectum; (2) the habit of straining at stool; (3) the habit of unduly retaining the feces in the sigmoid flexure; (4) the habit of resorting to the use of purgatives, pepsin, and other drugs; (5) the chronic “physic” habit; (6) the foolish “diet” habit; (7) the gastro-intestinal neurasthenic habit; (8) the health-resort habit; (9) the habit of trying desperately to appear agreeable while feeling really ill; (10) the habit of blaming the liver for all direful feelings, physical and mental.
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. Often their contraction or stricture is so great that their expansion is limited to from one-fourth to one-half an inch. This virtually permanent closure of the anal vent naturally results in an accumulation of feces just above it, or in the lower portion of the rectum, which accounts for the dilatation, stretching, or ballooning of the anal and rectal tissues immediately above these muscles, as shown in Fig. 4.