Part 8

The time has arrived when the profession must recognize that the rectum need no longer be regarded a darkest continent. There remains, however, something further to be desired in the way of an easier and more convenient method of manipulation to secure inspection, but I am confident that ere long the profession will accept the newer mechanic means and contrivances which will render a proctoscopy of as practical simplicity as is laryngoscopy. But it behooves us to remember the words of Dr. Edmund Andrews: “The false method is that of the bungler and amateur, who is only right by haphazard; the true one is that of the professional expert, who can not be balked by petty obstacles, but who will reach success when others have failed, not less by his dogged persistence and thoroughness than by his superior knowledge.”

THE EXAMINATION OF THE RECTUM.

It has been complained that the best methods proposed for the inspection of the rectum require so expensive an armamentarium and such painstaking practice on the part of him who would see, that the general practician can not hope to invade with his keen glance this field which is generally regarded a terra incognita. On the contrary, as shall be seen, no artificial means whatsoever are required for a complete ocular inspection of the rectum.

The elevation of the hips which sets in operation that principle of physics which governs the methods of Marion Sims’ vaginal inspection (1845), Van Buren’s rectal inspection (1871), and the methods of the senior Allingham (1882), of Walter J. Otis (1887) and of Howard Kelly (1895), which controls my own proctocolonoscopy (1896), and which suggested Trendelenburg’s posture, is, also, the chief feature of the simplest proctoscopy.

NONINSTRUMENTAL INSPECTION OF THE RECTUM.

The essentials to this simplest method are a patient, an assistant and an operator having at least one finger on each hand. The patient is to be put into the knee-chest posture, the assistant is to put and to hold the patient, and the physician’s fingers are to be used to open the anus, all in the following manner, to wit:

1. The patient is to be completely anesthetized as he lies on his back, and then turned toward the assistant and into Sims’ posture.

2. The assistant is to station himself at the patient’s knees. In his left hand he is to grasp the patient’s feet. He is to lean himself against the patient’s knees. He is to pass his right arm under the patient’s hips. Now steadying the feet and bearing himself firmly against the subject’s knees, with his right arm he is to lift the hips and pull the patient into the knee-chest posture, where he is to be balanced on his perpendicular right thigh throughout the whole time of the physician’s manipulations.

3. The physician is to close his hands and to point each index-finger as shown in the accompanying illustration (Fig. 1). The wrists are to be crossed, the hands placed back against back, and the nails of the index-fingers placed one against the other, as shown in the accompanying illustration (Fig. 2). The physician is to lubricate these fingers and gently insinuate them through the anus and place their ends beyond the borders of the levatores ani. This accomplished, the anus is to be divulsed in the direction of the ischial tuberosities, by the physician forcibly parting his fingers as is shown in the accompanying illustration. Under this manipulation the rectum becomes atmospherically inflated.

Now, provided the physician lowers his head to the level of his fingers and then rises again, or stoops, or moves a little from side to side, he may command under his eye a view of the interior of the atmospherically inflated rectum to the depth of six or eight inches (15.24 or 20.32 cm.), and in some instances he may behold even a part of the sigmoid flexure.

It is possible for the operator to manipulate his patient and to finish his inspection within two and a half or three minutes, provided the patient be in a state of complete anesthesia.

If this method is practised, as I am persuaded it may be with facility by the general practician, I am convinced that the greater number of rectal diseases may be instantaneously diagnosed. But I must declare that here at diagnosis, the achievement of the simplest proctoscopy ends, for the reason that the operator’s hands are so full of his patient he can do nothing at all for the disease which he may have discovered.

Under some conditions and amid some circumstances the rectum will not inflate. If the bladder is much distended; if there is an inordinate hypertrophic rectitis; if there is a close tubular stricture of the rectum; if there is malignant growth or other disease of the rectum by means of which the gut’s coats have become extensively filled and fixed with an organized plastic exudate; if for some reason the extraabdominal pressure is abnormally increased, as it may be by the bearing down of the patient, or by enormous flatus, or by ascites; or if there is an impinging uterus, adrectal growth or extensive infiltrating disease of the contiguous textures, rectal inflation by this method or by any other which is governed by the same principle may be a physical impossibility--but this need not baffle the man bent on seeing by instrumental aid.

Practised as described, when not embarrassed by the exceptions specified, this method will achieve its purpose and reveal to the physician that the transverse diameter of the rectum is variable; that in some places it is not more than an inch (2.54 cm.), in others it is more than four times this diameter.

The rectum may present to the eye of the imaginative observer the appearance of a chain of urinary bladders, communicating one with another by means of irregularly elliptic openings set at varying axes, and bounded by the nonparallel borders of the rectal valves. In the normal rectum the air-pressure smooths the mucous membrane evenly over the entire surface of the gut, as may be observed in the photographic illustrations. The normal mucous membrane of the so-called ampulla appears at first wet and of a shining bluish gray. As it dries, under the influence of gravitation the blue venous tint fades out of the gray and the wall assumes a pink tint. Presently it acquires the appearance of parchment, and sometimes it appears painted at rare intervals with ramifying little arteries which may be crowded and overlapped by the larger companion veins; the latter are less arborescent and more suddenly dive and disappear in the bowel-wall. In time, over all there comes a sheen and the vascular pictures may fade away. These phenomena appear exactly as described only in the healthy rectum. In the diseased organ the color varies much.

Should the operator deviate from the described directions for the manipulation of his fingers and so twist his hands as to divulse the anus in the anteroposterior direction instead of laterally, he invites defeat upon himself, for in the male the fixation of the perineum and the immobility of the coccyx interfere with the requisite dilatation; while, in the female, the extreme mobility of the perineum and particularly the backward displaceability of the coccyx will allow such traction to be made upon the levatores ani as to pull their inner fibers parallel and almost together, and, in consequence, the wider the female’s anus be opened anteroposteriorly the closer is it made to contract laterally to rob one of his view.

INSTRUMENTAL INSPECTION.

Certain paraphernalia and much practice in their use are necessary for rapid, complete and painless inspection of the rectum.

The chair which is shown in the illustrations was designed by me to facilitate the placing of the patient in a new posture, which is equivalent to the knee-chest posture.

Fig. 3 exhibits the chair and the attached illumination-apparatus in the first position to receive the patient. Fig. 4 shows the chair and illumination attachment in the second position, and Fig. 5 shows the chair and illumination-apparatus in the position for the third step in the procedure. Fig. 3 shows, also, hanging from the head of the chair, a small pillow and the shoulder-suspender.

The anoscope (Fig. 6) consists of a short cylindric tube open at the ends. It is two inches (5.08 cm.) in length and seven-eighths of an inch (2.22 cm.) in diameter. The proximal end is provided with a trumpet-shaped expansion and a strong handle. The distinctive feature of the anoscope is the peculiar form of its obturator (Fig. 7), which has a capacity for a multiplicity of uses.

The obturator consists of a hard-rubber cylinder, in the middle of which is fixed a brass tube for the purposes of irrigation. Its surface is fluted in such a manner that it may be made to lock in any of several positions upon a tubercle within the cylinder. These flutes also provide for escape from the rectum of fluids and gases under certain conditions. The contracted neck near the distal end of the obturator provides a cup to facilitate the application of ointments to certain rectal areas.

The contracted neck is a feature which contributes to the instrument’s usefulness as a means for irrigation, providing in the one case a self-retaining direct-flow irrigator, and in the other case when locked in the position shown in Fig. 9, an unobstructed two-way irrigator. Platinum pins connect the centrally-placed brass tube with the surface of the neck of the obturator, which makes the instrument an anal electrode.

The proctoscope (Fig. 10) is of the same diameter as the anoscope, and is four inches (10.16 cm.) in length, which, because of the displaceability of the pelvic floor is usually of sufficient length to reach as high as the promontory of the sacrum, except in some especial instances, the management of which exceptions will be treated of in another place.

Special preliminary preparation of the patient is ordinarily not required, as the usual condition of the rectum is that of emptiness. In some cases, however, it facilitates the inspection if the patient employs rectal lavage an hour before the examination. This injection should not consist of more than one pint of fluid. The excess of this might be accidentally dejected from the sigmoid and obscure the field during examination. The bladder should be emptied, since its distention would necessarily interfere with the accuracy of the examination.

THE TECHNIC.

Step 1.--The patient should be required to sit on the operating-chair with his body turned to the left, facing the knee-board. The right knee should be crossed over the left knee, the left arm should embrace the right border of the chair-back, or it may be folded at the side as for Sims’ posture. The small pillow should be held in the patient’s right hand and against and upon his left shoulder (Fig. 13).

Step 2 consists in shifting the chair to the horizontal position shown in Figs. 14 and 4, and in adjusting the light-fixture. This movement brings the patient into Sims’ semiprone-semiflexed posture, without requiring any movement whatever on the part of the patient after he is properly seated. In this posture, the external anus and fixed rectum are to be examined.