CHAPTER XIV. SPASM OF THE SPHINCTER, NEURALGIA, WOUNDS, RECTAL ALIMENTATION. (Part 9)

rectal examination which shall be at the same time thorough and as free from pain as possible? Two things are necessary above all others — a good bed or table and a good light. For a table, a strong, four-legged one, npholatered with hair and 52 DISEASES OF THE BECTUU AND AHUS. leather, answers every purpose. It should be hard, without springs, and ahout thirty inches in height. In place of this, any of the examining tables of the gynsBcologists may be used. In my own office, luseamodifica- tion of the combined table and lounge of Dr. J. L. Little, which is rep- resented, closed and open, in Fig. 14 and Fig, 15. Its great advantage is that, when not in use, it answers as an ordinary piece of furniture, and when raised it provides a firm, hard operating table of convenient height. Either natural or artificial light may be used, but the latter is on some accounts preferable, being always at command, and easily thrown up the bowel or concentrated upon a particular point. To do this, a forehead mirror is requisite. The lamp which I have found most convenient is a modification of ToboM's, as FiQ. IT.— Case for recul inatramenla, with sUdlng cover A A. repreaented in Pig. 16. The whole apparatus is easily moved to any part of the room, and is not cumbersome; and with the lens a very powerful illumination is always attainable. The inatruments necessary are specnla of various forms, bougies, a Davidson's syringe, ointment, cotton, sponge-holders, towels, basins, etc. ; and these should all be placed within easy reach of the hand. A con- venient case for these things and for other surgical instruments, which is intended to stand on the floor by the side of the table or bed, is repre- sented in Fig. 17. The position in which the patient should be placed is a matter of some importance. For mere inspection of the anus and surrounding parts, the dorsal decubitus answers every purpose, and a digital exam- ination of the rectum may he made either in this posture or with the patient on the side. For a speculum examination or the passage of a GENERAL BULES KEGABDING EXAMINATION, DIAGNOSIS, ETC. 53 bougie, the patient should be placed on the side, with the buttocks well elevated, the thigh which is uppermost strongly flexed on the abdomen, and the breast resting on the table. In this way, the weight of the abdominal contents falls upon the front wall of the abdomen, and not upon the pelvis, and the lumen of the bowel is not so firmly closed, nor is the mucous membrane so firmly forced into the end of the speculum. Before commencing an examination, the bowel should be emptied, either by the natural effort of the patient or by an enema, and for this reason a water-closet in connection with the examining room is indis- pensable to the practitioner in rectal disease. In this way, the patient may come directly from the closet to the table with the parts in the best condition for inspection; and great additional confidence is acquired, especially by women, that the examiner's frequent reiteration to " bear down " will not be followed by untoward consequences. The point may seem trivial, but the fear of an accident will frequently, in women, result in a firmly closed sphincter, which no word of the surgeon can overcome, and a thorough examination cannot be made while the recta- pouch is filled with fasces. This is not merely a thing to be observed for the cleanliness of the examiner, for the act of defecation will bring internal haemorrhoids and prolapse to the light, and may greatly assist in the diagnosis of other maladies. In examination with a speculum, it is indispensable to cleanliness. A simple inspection of the anus and adjacent skin and mucous mem- brane is often suflBcient for a diagnosis, though it should never be trusted to alone. External haBmorrhoids and internal ones when brought down by the use of the closet or enema, external fistulae, ulceration, skin dis- eases, many venereal affections, pin worms, abscess, and fissure, may all be recognized in this way. A glance at the anus, too, may indicate to the practised eye the existence of serious disease within the rectum proper, for a discharge may fiow from it which marks ulceration above, and it may be relaxed and patulous from over-distention or partial destruction of the sphincter. A sunken condition of the ischio-rectal fossae, and a retracted anus surrounded by a profusion of soft, fine hair, may also properly excite a suspicion either of grave rectal disease or of some constitutional affection which is causing emaciation. By using gentle force in pulling the anus open with the fingers, the mucous membrane may be everted to a considerable degree, especially if the patient can be brought to assist by an effort at bearing down. In this way a fissui'e may almost always be brought into view without the use of a speculum of any sort, and the internal opening of the great majority of fistulas may be reached, with a good view of the radiated folds and lacunae. Dr. Storer,* of Boston, has described a method of examining the ^ Lancet, May 31st, 1873. 54 DISBABBS OF THE BBCrnTM AND AJCnTB. mucous membrane just within the anus, which is applicable only in women who have a lax sphincter. It consists in everting the mucous membrane by pressing it out of the anus by the index finger in the vagina. In a case in which the manceuvre can be practised successfully and without too much pain, a small portion of the anterior wall of the rectum may be brought into view. The pessary of G-ariel has also been used for the same purpose. It consists of a rubber ball, which is intro- duced empty into the rectal pouch, then inflated by means of a tube attached to it, and withdrawn with some force, the mucous membrane being prolapsed in front of it. But neither of these two procedures is of any great value. After having examined the anus in this way, the surgeon next pro- ceeds to the more difficult task of examining the rectum, an operation which may be done skilfully and almost painlessly, or awkwardly and with great suffering. The rectum may be explored either by the touch alone, or by vision alone, or by both combined. The former is the simpler and more painless method, and with practice may be made to afford all the information which can be gained by the two combined. To practise the rectal touch, the nail of the index finger should be well trimmed, and the finger lubricated with some tenacious oil. Olive oil is much better than vaseline, the latter being too easily rubbed off by the sphincter. The condition of the spincter muscle is first to be noted. Its resistance should be overcome by a slow and steady pressure with the ball of the finger, and not by a sudden exertion of force, for such an attack is always met by increased contraction. The force of the muscle will be found to vary greatly in different people. In the aged or debilitated it is lax; in the strong and healthy it is the opposite, and the finger can scarcely be passed through it without great pain and sometimes a slight laceration of the tender mucous membrane. When inclined to spasmodic contraction, as it sometimes is in persons of nervous tendency, a satisfactory examination may be impossible without 'he use of ether, on account of the pain. Unless an obstruction is encountered, the finger may be carried up the bowel its full length, and pressed as far as possible beyond this point. Additional distance may be gained by passing the three remain- ing fingers backward along the inter-gluteal groove, instead of closing them in the palm, as is generally done, and pressing the knuckles against the soft parts; for the knuckles prevent the full passage of the index finger. In this way three or three and a half inches of the rectum may be carefully explored, together with the prostate, the neck of the bladder, the uterus, and the anterior surface of the coccyx and lower part of the sacrum. With an exceptionally long finger it may even be possible to feel the vesiculsB seminales and vasa def erentia. In other words, all that part of the bowel which is most subject to disease is brought within reach. aENERAX RULES BEGARDLNG EXAMINATION, DIAGNOSIS, ETO. 65 But after this is done the examiner may be no wiser than before, for to appreciate fully the condition of the rectum by the sense of touch alone requires a facility in this method of exploration which most practitioners never attain. In the majority of cases a digital examination will be made to discover whether or not the patient is suffering from internal haemor- rhoids, and in the majority of cases also the examiner will be no wiser on this point after than before, for a soft internal haemorrhoid is a difficult thing to detect by the finger alone, being readily mistaken for the natural mucous membrane of the part, especially when the latter is abundant and gathered into folds, as it is apt to be. Ulceration is another condition which it is sometimes difficult to detect, especially when superficial and not attended by much induration; and so is the opening of a blind internal fistula; and yet, so well educated may the finger become that other methods of examination may be almost completely discarded. To carry diagnosis to this point it is first neces- sary by oft repeated examinations, to become perfectly familiar with the feel of the normal bowel. After this knowledge has been gained, a gentle sweeping of the ball of the finger over the whole inner surface of the G. TIEMANN & CO . ^^^^^mm^^ Fio, 18. lower three inches of the rectum will detect any cnange in it, however slight. I wish it were possible to describe plainly the different sensations which are conveyed by the different pathological conditions, but this is a thing each practitioner must learn for himself by practice. A stricture of small calibre cannot easily be mistaken, though one which admits the finger without constricting it may easily be overlooked. A stricture small enough to engage the end of the index finger firmly, marks the limit of safe digital examination, and the finger should not be forced through it for the sake of feeling what is above, for an attempt to do this has been followed by a fatal rupture of the bowel. In case of a tumor of any kind, advantage may be taken of conjoined manipulation through the vagina in the female, but these are the troubles most rarely met with, and most easily diagnosticated when encountered. The cervix or fundus of the uterus, when pressing upon the bowel, may be distinctly felt with the finger in the rectum, and may deceive the unwary into a diagnosis of a new growth. The prostate may do the same. The differ- ent varieties of ulceration have each their peculiar and often diagnostic feel. For examination by the sense of touch above the reach of the finger, • recourse may be had to bougies. These are of all forms, sizes, and 56 DISEASES OF THE BBCTTDM &HD ANUS. materials, and, in general words, the softer the inatniment the better it is for examination. I much prefer the black rubber instrument, with the blnnt point (Fig. 18), which may readily be bent into a circle in the hand, to all others iu the market, and the same instrument comes with a sharp point (Fig. 19) which sometimes answers a good purpose. These Instruments are made in twelve different sizes, and for the purpose of diagnosis the medium^sized is the best. The old-fashibned red, hard- rubber bongie is unnecessarily stifC and dangerous, and should be dis- carded, haying no advantages over the softer ones either for the purpose of diagnosis or for that of treatment. The bougie & boule, made of hu-d- nibber with a flexible whalebone handle, is a favorite instrnment with many. (Fig. 20.) For my own use I have had a kind of bougie made by Messrs. Stohl- mann, Ff^rre & Co., which I prefer to all others, (or the simple reason that it is softer and more flexible than any in the market. It is made of the same material as the red soft-rubber catheters, and differs from them only in size and in the thickness of its walls. With such an instrument one is pretty certain not to perforate tlie bowel, and for diagnosis it answers every purpose as well as the harder instruments. The better fitted a bougie is for pushing its way through a stricture the worse it is for rectal exploration. These instruments are all used for the same purpose — that of feeling for a stricture located above the reach of the finger; and with any of them the unpractised hand will generally detect an obstruction in the perfectly GENERAL RULES REGARDING EXAMINATION, DIAGNOSIS, ETC. 57 healthy bowel at about four inches from the anus. I have had patients in whom I have never been able to pass any sort of a bougie without first injecting the rectum, no matter what manoeuvering I resorted to; and I have seldom told a student to pass a rectal bougie that he did not at once discover a stricture. To pass a bougie into the rectum is rather a more difficult operation than to pass one into the urethra, the triangular ligament in the latter being replaced by the curves, the folds of mucous membrane, and the promontory of the sacrum in the former. Indepen- dent of Houston's valves of mucous membrane, it is not improbable that a slight degree of invagination of the upper into the lower part of the rec- tum may often exist; and into the sulcus formed by this condition, the point of the bougie may easily pass. For the sake of overcoming these folds of membrane the most minute directions have been given as to how the bougie should be introduced and gently urged along each suc- cessive inch of the bowel* by changing its direction and manipulating the handle. But such rules are of little value, for the simple reason that the obstructioa is seldom of the same kind or in the same place in two different persons. Esmarch' gives the general rule that the patient should lie on the left side, as the chief and most constant fold of mem- brane, the plica transversalis recti of Kohlrausch, projects from the right wall. The instrument should be passed gently, for force is never allow- able here more than m the similar operation on the urethra; and when an obstruction is met with the handle should be gently rotated, with- drawn, and again passed onward till by frequent repetitions of this manoeuvre it is made to pass. If this does not suffice, a Davidson's syringe may be attached to the lower end of the bougie and a stream of warm water thrown into the bowel until it is moderately distended when the bougie will generally pass with ease. For measuring the extent of a stricture, an ingenious instrument has been devised by Laugier, which consists in attaching a thin rubber glove- finger to the end of a perforated bougie. This is passed up the bowel empty, and then inflated and withdrawn till it reaches the upper limit of the obstruction. It is safer than the bougie a boule, for it may be allowed to collapse before being withdrawn, and all straining of the diseased tis- sues may thus be avoided. In case disease actually exists high up in the bowel, the attempt to pass an instrument is full of danger. A patient may easily recover from a false passage made in the urethra, but such will seldom be the case with the rectum, for here when the instrument leaves the bowel it enters the peritoneum. To understand this danger it is only necessary to remem- ber that the bowel is generally ulcerated both above and below the seat * Houston: ** Dublin Hosp. Reports," vol. v., 1830. •Die Krankheiten des Mastdarmes und des Afters, Pitha und Billroth's Chirurgie. 58 DISEASES OF THE BECTUM AND ANUS. of the contraction^ and is sometimes weakened to such an extent that it will allow a bougie to pass through it without the use of any appreciable force on the part of the surgeon. The bowel may also be lacerated with- out being directly perforated by the bougie, for the stricture may be pushed upward or dragged downward on the point of the instrument till the bowel gives way. Supposing, now, that a rectal bougie cannot be passed eight or ten inches up the bowel, is it safe on this account alone to make a diagnosis of stric- ture high up ? I should hesitate long before doing so, and should make many careful attempts to pass the instrument at different times, resorting to injection if necessary, carefully exploring through the abdominal wall for induration, and watching for the usual signs of obstruction. There are one or two points worthy of remembrance in this connection. The first is that the obstruction due to a stricture will always be at the same point in the canal; and another is, that when a bougie has once become engaged in a stricture it is firmly grasped, and the resistance to its with- drawal is equal to that encountered in introducing it farther. The feel- ' Fig. 21.— (Van Buren). ing conveyed to the hand under these circumstances is diagnostic, and is like that which is felt when the effort is made to withdraw a sound from the grasp of a stricture in the urethra. Should it still be necessary for diagnosis,