The human constitution and prolapse of the rectum
The role of the constitution in the development of pathological processes in the body has been known for a long time, and scientists have paid much attention to this issue since the early times.
Now no one will deny that there is a pathogenetic connection between the constitution and some diseases. At the same time, it must be emphasized that the constitution, perceived in the light of formalistic teaching in biology, as something autonomous, complete, unchangeable, independent of the environment, not only does not help, but, on the contrary, makes it difficult to ascertain the nature of a disease.
The constitution is an anatomical and physiological body of an organism that undergoes continuous change under the influence of the external environment. Only in this sense and in this sense should we take the concept of the constitution and especially about the constitutional factors. These factors affect not only the forms of the organism and its individual organs, but also the processes of assimilation and dissimilation that take place in them. Thus, they determine the functions of these organs. From this point of view, the organism can not be viewed in isolation from the external environment, which imposes its own imprint on it, changing its internal and external appearance, giving it some direction in the sense of its susceptibility to various diseases.
Just belonging to a constitutional type, predisposed to a particular disease, does not mean that this disease is bound to come. In addition to the constitution, we also need disease-inducing moments( factors that produce), or, as MI Lifshits calls them, Agents provocateurs. Thus, the content of the concept of "external environmental conditions" should include those social conditions in which the vital activity of the body. From this point of view, AI Strukov is right when he says that "in the understanding of the constitution and its variability, the role and social conditions must be taken into account."
The pathogenesis of many diseases is due to the constitutional features of the human body and should be studied when taking into account the conditions in which this particular human organism developed.
Disease is the result of the body's interaction with the external environment. In the pathogenesis of the disease, many causative factors take part, and all of them are important in their combination, but among all these factors there is always a basic, favorable for the development of the disease, the constitutional features of the organism "as a combination of its structural conditions, created under the influence of both hereditary deposits,and the environment. "
What are the most important features in the pathogenesis of rectal prolapse?
Recently, individual researchers began to pay attention to the structure of the skeleton, depending on sex, age, physical development of the organism and the diseases it has suffered, which can create an imbalance in the pelvic organs.
Still Ludloff noticed that in persons suffering from prolapse of the rectum, the coccyx is more steep and the curvature of it is less pronounced. Hofmann in 1905 also pointed to an inadequate deepening of the sacrococcygeal curvature in children, which, as is known, are more prone to the disease of prolapse of the rectum.
AG Hoffman, who has a large number of cases of prolapse of the rectum in children, indicates that the latter, in this suffering, in particular, have a steep descent of the coccyx and insufficient formation of the pelvic floor.
Malfetta cited 2 cases where a violation of the pelvic floor statics led to prolapse of the rectum. In one case, the case concerns a patient who, in connection with lupus, has been resected sacrum and coccyx. In the other case, the prolapse of the rectum appeared after a symphysiotomy produced for severe birth.
A number of authors in the development of prolapse of the rectum also sees a significant role in the changes concerning the length of the sigma and its mesentery.
The rectum, under the constant overhanging of the loops of the elongated sigma, eventually loses its elasticity and becomes excessively mobile in the pelvic part. As is known, the length of the mesentery of sigma averages 5-7 cm. Its maximum length does not exceed 9 cm.
In this respect, the reports of many authors are characteristic, which, in the case of a prolapse of the rectum, usually found an excessively long mesentery of the sigma.
YM Bune drew attention to the fact that when a rectum is absent, as a rule, there is a megasigma on a long mesentery. The size of megasigma in the pathogenesis of prolapse of the rectum gives importance and Corrasco.
VM Svyatukhin describes the case when a woman of 29 years old, who had a long mesentery of sigma, developed a prolapse of the rectum after the fall.
As if substantiating the above observations, A. Yu. Sozon-Yaroshevich, in accordance with his studies, concludes that with a long mesentery the position of sigma is sharply disrupted, which usually depends on the shape of the pelvis. For example, with a wide pelvis, the mesentery root is located more horizontally( in women), while with a narrow( in men) pelvis its position approaches the vertical one. Depending on the position of the mesentery root, there are also loops of the intestine or in the transverse direction to the axis of the body - for the wide pelvis, or parallel to it - for the narrow, when they descend down and lie at the bottom of the pelvic cavity, increasing pressure on the Douglas space. The formation of the loops of the large intestine and their movement, according to AV Melnikov, is "a compensatory adaptation to the spatial relationships of the magnitude of the change in the topography of neighboring organs."
We measured the length of the mesentery of sigma in all operations performed by the peripetuminal route for prolapse of the rectum. In 75 cases of rectal prolapse we found the mesentery length: from 15 to 20 cm in 7 cases, from 10 to 15 cm in 12, from 8 to 10 cm in 22, from 6 to 8 cm in 25 andup to 6 cm - in 9 cases.
Thus, it is seen that quite often in the prolapse of the rectum, there is an excessively long mesentery of the sigmoid colon.
A.V. Melnikov in his work "Classification of anatomical and mechanical causes of intestinal obstruction" is the last, in some cases, completely dependent on the external architecture of the colon, on its shape and size.
In 75 cases, tracked by me regarding the size of the mesentery of sigma, in 20 patients the rectum had a mesentery.
However, this does not exclude the possibility, as described by IV Georgievsky, of a prolapse of the rectum in the complete absence of a mesentery of sigma. I also observed when, in the prolapse of the rectum, the mesentery of the sigma did not exceed 2 cm in length, and the rectum did not have a mesentery.
It can be concluded that the constitutional features in the position of the mesentery root and the length of the latter cause changes in the location of the colon loops and lead to their placement in the abdominal cavity, in which the function of the sigmoid and rectum is disrupted and the intra-abdominal and intestinal pressure changes.
It is impossible to agree with the opinion of NI Napalkov, who believes that sexual differences in the pelvis are not important in the pathogenesis of prolapse of the rectum. This opinion must be considered outdated and incorrect, if only because the fact of the difference in the architecture of the pelvis of a man and a woman is fully established, and depending on this, the mutual arrangement of their organs will be different.
The high incidence of rectal cancer in men, compared with women, is explained, in particular, by the constitutional features of the structure of the male pelvis.
According to our summary statistics, 1877( 70.4%) fall on 2664 cases of rectal prolapse for men, and 787 cases( 29.6%) for women, ie the ratio of the number of male fallouts to their number in womenis approaching 3: 1.
However, as shown by the research of several authors, with the prolapse of the rectum there are certain deviations from the main type characteristic of the disease in the structure, shape and arrangement of individual organs and tissues that have some relation to the fixation of the rectum and its function.
DL Vaza, in her work on the problem of the ligament of the sigmoid colon, says that a wide basin corresponds to a longer sigma length, narrower to a smaller one. The shape of the pelvis determines the length of the sigma, the position of its root, the length of the mesentery and the position of the intestinal loops. VA Pavlenko, on the basis of a study of the dependence of the function of organs on their location, believes that in the pathogenesis of functional diseases of the intestinal tract, in some cases, due also to purely anatomical factors should be given.
The school of VN Shevkunenko now outlines the generally accepted position according to which the structure of the backbone often determines the pathological phenomena from the side of internal organs. Consequently, with the appropriate structure of the backbone and under favorable conditions, in this organism, one or another pathological condition may develop, in particular, prolapse of the rectum. LI Lorin-Epstein says that prolapse of the rectum consists of anatomical and biophysiological factors.
A. Yu. Sozon-Yaroshevich on the basis of his studies believes that the shape of the pelvis, influencing the position of the mesentery root, indirectly affects both the position and the shape of the intestine.
Thus, the topography of pelvic organs depends on the architecture of the latter and can often cause a violation of their physiological functions and lead to pathological processes.
As we see, here the authors put the pathophysiology of the rectum into close dependence on the anatomical conditions of the latter and its relationship with surrounding tissues and organs. This fully agrees with the modern concept of the relationship between the shape of the organ and its function, when the form is ultimately determined by the function of the organ and, conversely, when the function of the organ depends on its shape.
Naturally, the function of the atonic, descending and strained rectum will be different than that of the normal, unchanged gut.
MV Alferov studied the structure and shape of the rectum with the help of X-ray study, filling it with a barium suspension. In these studies, he everywhere found in patients with prolapse of the rectum an ampullar form of it. Hence the author concludes that one relaxation of the pelvic floor can not explain the prolapse of the rectum. In his opinion, the leading role is played by constitutional factors.
It was mentioned above that many authors, adhering to the theory of NI Napalkov, Ludloff, Valdeier, attach great importance to the pathogenesis of prolapse of the rectum to the low standing of the Douglas space. To substantiate this point of view, special studies were undertaken.
As we have already shown, the results obtained in this case are not the same, and therefore no conclusions can be drawn from them.
It follows that topographic anatomical studies are not entirely convincing for clinical conclusions, if their data is taken out of context with a variety of other conditions, both endogenous and exogenous.
As Jeannel's studies have shown, the standing of the Douglas space in one and the same person is subject to change and depends on the standing of adjacent organs, in particular the bladder. So, for example, with a filled bladder, the bottom of the Douglas sac rises to the top, and then the distance from it to the anus is 8 cm;with the empty bladder, the Douglas space, on the contrary, drops, and the indicated distance decreases to 5-6 cm.
Thus, from a purely physiological point of view, the standing of the Douglas space can not serve as an independent criterion so that it is given decisive importance in the pathogenesis of the proliferation of a straight lineguts.
There is reason to believe that the low standing of the Douglas space, usually observed in individuals with prolapse of the rectum, does not always precede prolapse, and often is a consequence of the latter. Cases observed in pathology are frequent, when functional disturbances of one or another organ ultimately lead to organic changes not only in the muscles of the latter, but also in the surrounding tissues. These changes in the secondary order are always observed when this or that organ is placed in not quite normal conditions for its functioning.
It must be assumed that secondary changes occur in the tissues of the pelvic floor, when the latter, being anatomically closely related to the precipitated rectum, falls into extremely unfavorable conditions and, in connection with regressive changes in the muscle fibers, gradually descends. Thus, the rectum that has changed its location causes the dislocation of neighboring organs and places them in conditions unfavorable for normal functioning. This is quite consistent with the normal balance of abdominal organs with respect to their block, when a change in one or another character in one of them causes changes in the entire system of this block and leads to its violation. In support of this, we can point to another fact observed in the pathology of the human body. It is known, for example, that for a long time the existing pilorospasm ultimately leads to atony of the stomach with all the accompanying last phenomena up to gastroptosis and bowel dysfunction. We see here how functional phenomena, often an expression of distorted connections of the stomach with the cortex of the brain, can underlie organic changes.
GM Novikov, referring to AL Polenov, says that the abnormal position of certain parts of the large intestines causes a violation in the position, shape and mobility of various parts of the large intestine and plays a significant role in its pathology. With the prolapse of the rectum a number of authors indicate a simultaneous displacement of the sigmoid colon, which, consisting of several loops and located on a long mesentery, fills the cavity of the small pelvis. NI Napalkov, in his patients with prolapse of the rectum, often found the omission of other organs. Just as mesenterium ileo-colicum or megasigma disposes to intestinal flaps, prolapse of the rectum;the latter causes a number of changes in the condition of the surrounding rectum formations, such as, for example, pelvic floor descent.
Investigating the level of standing of the Douglas space with appropriate laparotomy for this case, we found that: 1) a low standing of it in women is more common than in men;2) the low standing of the Douglas space is characteristic of persons who have a long mesentery and megacolon;3) the low standing of the Douglas space and the vertical position of the mesentery root are almost always combined;4) the low standing of the Douglas space is more often observed in old age.
So, in 200 cases of laparotomy, a deep pelvic floor was found in 78 cases: 47 women and 31 men.
In this case it turned out:
Low standing of the Douglas space plus an elongated mesentery of sigma - 51 times;
Low standing of Douglas space plus megasigma - 48 times;
Low standing of the Douglas space plus the vertical position of the mesentery root - 71 times.
Thus, in an overwhelming number of cases, the low standing of the peritoneal cavity is combined with the prolapse of the rectum, but does not determine the latter, being a consequence of it.
Lowering the peritoneal cavity often accompanies the process of prolapse of the rectum and is often caused by it. However, the possibility of an innate low standing of the Douglas space is not excluded. In these cases, the low peritoneal recess, assuming the main force of intra-abdominal pressure and the entire weight of the intestine normally located in it, can be a factor favorable for the development of pathological processes and play an important role in the pathogenesis of prolapse of the rectum.
VV Moskalenko considers prolapse of the rectum as a symptom of a congenital low standing of the pelvic floor, which is an expression of one or another type of structure of the skeleton and the location of the pelvic organs. In this sense, in his opinion, a pelvic hernia is the cause of prolapse of the rectum.
So, the pathogenesis of prolapse of the rectum is made up of the constitutional features of the organism in the broadest sense of the word, representing a combination of various factors - anatomical, biophysiological and functional - with the inevitable interaction of them with environmental factors. The presence of increased intra-abdominal pressure as an immediate factor that causes the intestine to come out to the outside is mandatory.
In the pathogenesis of rectal prolapse, either the rectum itself, the sigma, the elongated mesentery, and the low standing of the Douglas space, and the direction of the mesentery root, take an equal part in the same way, but certainly on the background of the features of the pelvis that are favorable to the prolapse of the rectum,which determines the interposition of organs included in its cavity.
The pathogenesis of prolapse of the rectum is so complex that it can not fit within the framework of any of the existing theories.
In the pathogenesis of prolapse of the rectum, one can also see a long mesentery of the sigmoid colon, motility of the caecum in the ileum, weakness of the musculature, pelvic floor, a decrease in the elasticity of the pelvic tissues, neoplasms, increased intestinal peristalsis, constipation, etc.
All these causes are oftenSimultaneously.
The constitutional features of an organism predisposed to prolapse of the rectum are:
1. The degree of expression of the sacrococcygeal curvature: the less it is expressed( children, men), the more favorable conditions for the appearance of prolapse of the rectum.
2. Relatively long sigma: in almost all cases of prolapse of the rectum we found a megasigma.
3. The presence of an elongated mesentery of the sigmoid colon: for 75 cases examined in this regard, a mesentery over 8 cm long was found 41 times.
4. The presence of a pronounced mesentery of the rectum causing excessive mobility of the pelvic part of it: in all cases of prolapse of the rectum, operated by the peritotuminal route, there was a mobile, with a long mesentery pelvic part of the rectum.
5. Distance from the posterior semicircle of the anal opening to the top of the coccyx, exceeding 3 cm.
6. Distance between the buttocks of the ischium bones, exceeding the average anatomical norm.
7. Congenital low standing of the Douglas space.
8. Changes in the architecture of the pelvis as a whole, causing violations in the interposition of organs in its cavity.
The latter circumstance can be caused by a corresponding trauma that changes the axis of the pelvic canal( fracture of the pelvis along the ring, fracture of the sacrum and coccyx), or chronic inflammatory processes in the pelvic bones that disrupt the statics of the latter and at the same time block the organs of the small pelvis.
If we take into account the known role of heredity in the onset of prolapse of the rectum, which often determines the anatomical and physiological body of the organism and its predisposition to prolapse of the rectum, the pathogenesis of the latter can be represented as the following chain:
N - K - C -B,
where H is a hereditary factor that determines K-constitutional features of the organism, which, under the influence of environmental conditions C( food, social conditions, occupation, those or other diseasesI, causing an increase in intra-abdominal pressure) can lead to B( disease) - prolapse of the rectum.
Rectal prolapse occurs as a result of the interaction of three factors - hereditary, constitutional and exogenous - in the sense;that inherited constitutional features in the structure of the pelvis and rectum create favorable conditions for the fall of it, which, however, can occur only in the presence of appropriate environmental factors affecting the body. It goes without saying that in the pathogenesis of prolapse of the rectum in humans, the role of the nervous system, especially with regard to interreceptive communication, is undeniable.
This alone determines the possibility of undertaking activities aimed at reducing the effect of heredity in this disease and preventing the development of severe forms of it.
Women's magazine www. BlackPantera.en: Sergey Avedisov