CHAPTER XIV. SPASM OF THE SPHINCTER, NEURALGIA, WOUNDS, RECTAL ALIMENTATION. (Part 10)

the speculum may be used and the inside of the rectum illuminated. I have postponed any refer- ence to this means of examination till the present, because it will gener- ally be found useful only after the others have been tried. The thorough use of the speculum involves, almost of necessity, the administration of ether and the stretching of the sphincter muscles; to try to use it with- out these adjuncts is almost to infiict useless pain upon the patient. I flhall not attempt any description of the infinite number of instruments which have been invented for this purpose, or any judgment upon their relative advantages, but will merely say that the best vaginal speculum is still the best for the rectum — that of Sims, with a groove where the blade joins the handle for the sphincter to rest in as suggested by Van Buren, Fig. 21. The fenestrated instrument. Fig. 22, is sometimes useful for inspecting the parts just within the anus; and a long vaginal cylindrical QENEBAL BULKS BEOABDIKO EXAMIKATION, DIAGNOSIS, ETC. S9 epecnliiDi, with the end cat at such an angle as will beat expose the mucous membrane, may sometimes be of service in bringing into view a small portion of the inner surface of the bowel high up. But, after all have been tried, none will be found better for any purpose than a small- bladed Sima's, and without ether all will be found eminently unsatisfac- tory. Almost the only other speoulam besides Sims's which I have found of any practical value is the bivalve shown in Fig. 33, but the same objec- tion apidiea to this as to all the others, that the redundant n brane prolapses between the blades to such an extent as to render it almost useless, and that when the attempt is made to dilate the blades sufficiently to overcome this, the sphincter is immediately stretched to a painful extent. With any speculum the wooden depressor, shown in Fig. SI, may be found a useful addition. Fio. SM Rectal Depressor (Vui Biueu). The idea of the endoscope has been applied to the rectum in- the nse of the instmment shown in Fig. 35. It is of little, if any, practical value, 60 DISEASES OF THE RECTUM AND ANUS. however; its introduction beyond the point which can be reached by a long vaginal speculum being exceedingly diflScult, and, in case of the dis- eases which it is supposed to enable the surgeon to see, not devoid of danger; and the mirror quite useless. It is almost useless to attempt to see within the rectum with any kind of a speculum without first overcoming the sphincter muscle, and the only effectual way of doing this is by stretching it. It is, therefore, my own practice to resort to this procedure in every case of doubtful character, nor was I led to this practice without many trials of the various speculae in the market, all ending in disappointment. The stretching of the sphincter is in itself an entirely harmless proceeding, but one which neces- sitates the previous administration of ether. It should not, however, be done, as was at one time the usual method, and as it is often done at present, by introducing the thumbs back to back, and forcibly and sud- denly separating them till they touched the tuberosities on each side. In this way. the mucous membrane is often lacerated at one or more points. Ha t Fig. 25.— Colono6Cope of Bodenhamer. and the paralysis is not as effectual as when the stretching is done more gradually. A better way is to introduce first one finger, then two, and finally four, in the form of a funnel and gradually bore into the anus ; or to introduce two fingers, and make pressure on all sides of the opening till it becomes patulous. Instead of one or two seconds, this procedure should occupy five minutes, and should be done so gently as not to lacer- ate the mucous membrane. The dilatation should also be made to include the internal as well as the external muscle. If this dilatation be carried to a sufficient extent, the firm, cord-like feel of the external sphincter may be made to completely disappear. The paralysis induced in this way is always temporary, and I have never known it to be followed even by a temporary incontinence of faeces. After coming out of the ether, the patients are usually conscious of only a sense of soreness in the part, but are never incapacitated for their usual duties. This stretching of the sphincters is a necessary preliminary in almost all operations within the rectum. With the patient in the proper position on the side, under the influence GENERAL RULES REGARDING EXAMINATION, DIAGNOSIS, ETC. 61 of ether, with the sphincter thoroughly dilated, and with a good reflected light, the lower four or five inches of the rectum may be thoroughly illuminated and examined. A couple of inches more may be seen by the nse of the cylindrical speculum, with the patient standing and bending for- ward oyer the table, and assisting the examiner by straining down ; and in this way a stricture may sometimes be brought into yiew which could not be seen with the Sims's speculum alone. As a rule, howeyer, a speculum will be found of yery little use in the examination of stricture, but is chiefly available for obtaining a good yiew of other morbid processes affecting the rectal pouch and for making applications to them or performing operations for their cure. By its aid the different varieties of ulceration may be inspected and thus difr ferentiated, the internal openings of fistulae may be located, and the whole rectal pouch may be brought into yiew. From what has been said it may readily be seen that the diagnosis of stricture above the reach of touch or vision is a difficult matter. So dif- ficult is it in some cases that no less an authority than Syme has written that there is good reason to suspect the honesty of a man who pretends to detect such a condition. Such is, indeed, the case, for "strictures high up " are favorites among a certain class of quacks, and the passage of a bougie two or three times a wee.k for an indefinite period is profit- able business. In reality stricture above the rectal pouch is rare; when they exist they are usually malignant, for this part of the bowel is not subject to the influences which, by exciting ulcerative action, result in the cicatricial contractions which so often affect the lower three inches of the rectum ; and malignant disease of the sigmoid flexure or descending colon will manifest itself by a well-marked train of constitutional and local symptoms, and can generally be felt better through the abdominal wall than per rectum. After the use of the bougie, which is at best an uncertain means of diagnosis for this condition, and after a study of the symptomatology, and a careful examination through the abdominal wall, there is still one other means of exploration open to the surgeon if he have a sufficiently small hand — the passage of the whole hand into the rectum.' A hand which measures seven and a half inches in circumference can gen- erally be passed easily ; one measuring more than nine is unfit for the purpose. With a small hand there is no danger of permanent incontin- ence of faeces, but the sphincter should be dilated gently and gradually, rather than forcibly torn open. When the anus has been sufficiently dilated to allow the hand to enter iQ. Simon, Ueber the ktinstliche Erweiterung des Anus und Rectum, Arch. f. kUn. Chir., xv., 1, 1872; Dtsch. Klin. f. Chir., Nov., 1882; W. J. Walsham, Some Remarks on the Introduction of the Whole Hand into the Rectum, St. Bartholomew's Hosp. Rep., vol. xii., 1876, p. 228. 62 DISEASES OF THE RECTUM AND ANUS. the rectum, if the bladder is empty, the arch of the pubes may be felt above the prostate, if full it will be easily distinguished at the same point. The uterus and ovaries are easily made out anteriorly, and the whole curve of the sacrum may be followed posteriorly. The next point to feel for IS the spine of the ischium on either side, and with this as a guide, the greater and lesser sciatic notches may be outlined. The whole brim of the pelvis may be traced, and the external and internal iliac arteries followed with the fingers. All this may be done while the hand is in the rectal pouch, and it may be done upon almost any patient, male or female, though more easily upon the female, with a small hand, without causing any unpleasant after-results. But in many persons this is all that can be gained by this method, for the anatotnical reason that to pass the hand above into the sigmoid flexure is often attended with great danger from the narrowing of the bowel at this point. When the hand is met by a sense of constriction at about the level of the third sacral vertebra, where the lateral fold of Douglas is reflected from the bowel, the limit of ex- amination has been reached, and no force should be used to overcome the constriction, which can only be accomplished by a rupture of the peritoneal coat. In many cases, however, by carefully following the natural windings of the canal, and by a semi-rotatory movement of the hand, combined with alternate flexing and extending of the fingers, this point of danger may be surmounted, and the hand be passed fairly into the sigmoid flexure, and sometimes into the descending colon. Here the comon iliacs, the bifurcation of the aorta, the left kidney, and, m fact, nearly all of the abdominal contents may be touched. ^ By this method of examination, a stricture situated in the sigmoid flexure, or even m the descending colon, may sometimes be discovered after all other methods of examination have failed ; but, as we have shown, the method is not always applicable, and the diagnosis of stric- ture high up still remains one of the most diflScult things in surgery. In the great majority of cases in general practice, in which such a diagnosis has been made, it may be proved false by the introduction of a full-sized bougie after a few trials, and in the remainder the diagnosis will be con- firmed sooner or later by the well-marked symptoms of intestinal ob- struction. Before attempting any surgical operation upon the rectum, the bowela should be thoroughly emptied by a cathartic. It is well to begin with three compound cathartic pills, or with five grains of mass, hydrarg. on the second evening before the operation where the patient's general con- dition admits of these remedies; to follow them with a slight saline or a dose of castor oil on the night immediately preceding; and finally to clear out the rectum with a simple enema on the morning of the day of the operation. After this the bowels may easily be confined for a week if desirable without inconvenience to the patient, and the passage of hard masses of faeces over a wounded surface is avoided. J GENEBAL BULE8 BEOABDING BXAMINATIOM, DIAOKOBIB, KTO. 63 In all operations in which ether is used, three assistants will be neces- sary and four are preferable. Each assistant shoald have his place as- signed to him — one for the anEesthetic, one to keep each leg of the patient in position and to hold the apecalum, and one to assist the operator in whatever way may be necessary. A state of profound anasthesia -will generally be necessary, though with intelligent patients I have often taken advantage of the primary auEesthetio state which ether produces for opening abscesses, dividing fistulie, and cutting off external htemor- rhoids. Accidents are not common in operations about the rectum, but there is one for which the surgeon should always be prepared — hfemorrhage. For this reason a bottle of dry persulphate of iron, and a Paqnelin's thermo-cautery should always be at hand. The thermo-cautery as now made, Fig. %Q, is not at all cumbersome, and is exceedingly useful in many operations about the rectum. The bulb containing the sponge for the benzine should never be filled with an excess of fluid which may run down into the point and interfere with the working of the instrument; Tia. ae.— Fsquelin'B thermivcauter;. and the platinum point shoald be thoroughly heated before the assistant begins to ase the bulb to drive the air over the sponge. If proper regard be paid to these points the instrument is a most reliable one, and in every case where hsemorrhage is to be apprehended it should be ready for use, and an alcohol lamp or gas jet should be ready to heat the point — which is sometimes forgotten. A hEemorrhage seldom occurs from the rectum after a surgical opera- tion — BO seldom as to be almost unknown — which cannot be controlled by the cautery or by packing the rectum. The rectum may be packed with either sponges or lint, and these may be used either with or without the persulphate of iron. Most cases of bleeding may, however, be eon- trolled by the use of simple ice-water and a moderate amount of pres- sure properly applied to the bleeding surface without the necessity for a systematic packing of the whole rectal cavity. It is not long since I was colled in the middle of the night to stop the bleeding from an incision which I had made into an abscess of the ischio-rectal fossa about eight honrs before. I found, as is too often the case, that the patient was 64 DISEASES OF THE RECTUM AND ANUS. thoroughly immersed in a mixture of blood and persulphate of iron which covered him from the pubes to the middle of the back and had thor- oughly permeated the bed. On entering the room I was informed that the wound had been carefully stuffed with lint and persulphate of iron ' several times," and that the case was undoubtedly one of the haemor- rhagic diathesis. A case like this is easily managed. The treatment consists first of all in providing a good light, next in cleaning up the general nastiness, then in finding the bleeding point and making pres- sure upon it. In this case the bleeding came from a small spouting cutaneous vessel and was at once controlled by filling the incision I had made with picked lint thoroughly pressed home into the wound. Most cases of bleeding .may be controlled in the same way, but where the haemorrhage is within the bowel it is not always easy to make pressure upon the right point without packing the entire rectal cavity. For this purpose AUingham recommends the following procedure which is equally simple and effectual. Take a medium-sized bell-shaped sponge and pass a strong dou^le ligature through the apex from within outwards and back again so as to include a considerable part of the sponge in the bite of the ligature — enough so that when the cord is pulled upon strongly from below it will not tear out. After wetting the sponge and squeezing ij^ out it should be powdered with the persulphate of iron and passed as far up the rectum as possible with the aid of a rectal bougie, the apex being upwards. The whole of the rectum below the sponge should then be carefully filled with pledgets of cotton-wool powdered over with the iron, each roll being carefully and firmly 'packed away. An exceedingly large quantity of cotton may be crowded into the rectum in this way, and when the cavity is filled the sponge should be drawn down by means of the string hang- ing out of the anus, so that the whole mass may be tightly compressed. If the bowel has been thoroughly emptied as recommended, sufch a plug may be left in for a week or more without causing any discomfort and no bleeding can occur while it is in place. If, however, it is intended to leave the packing in for such a length of time it is better to pass a large- sized, stiff rubber male catheter through the apex of the sponge and pack the cotton around it. In this way a chance is given for wind and fluid faeces to escape. By this simple means, when properly used, any haemorrhage after an operation upon the rectum m ly be controlled. After operations upon the rectum or anus, a suppository of one grain of opium may generally be placed in the rectum with advantage, and the surgeon should always be provided with them. The usual dressing con- sists in placing a pad of lint and a soft towel over the anus and fastening them in place with a T bandage. This form of bandage will generally be found the best in any case where a continuous dressing is needed. * Op. cit., p. 154. GBNEBAL BULES BEOABDING BXAMINA.TION, DIAGNOSIS, ETO. 65 Lister's impervious dressing has been applied to wounds of the rec- tum in some of the more extensive operations, such as excision of cancer, by the German surgeons; but it has not become popular, and the use of free drainage and plenty of carbolic acid or some other disinfectant is generally considered all that is necessary or desirable in this line. Ver- neuil recommends the free use of a solution of chloral as an antiseptic for this part. Wounds of the rectum will always heal more kindly when the patient is in the horizontal position than when standing or walking, there being less tendency to venous congestion in the former case. Almost any op- eration may result in a sluggish open sore if the patient be allowed to disregard this rule. # Betention of