Part 5

Handle the parts with extreme gentleness and deliberation.

See all that can be seen and treat all that can be treated without the aid of a speculum.

Protect the under parts from excoriation by waste and overflow of medicine.

Evacuate the bowels previously and constipate for four days after operation on large growths, or when several small tumors are taken at one time.

Hot water sponge compresses, early, often and continuously, are indispensable and unequaled for the relief of a pain, swelling and soreness. To be effective it should be applied as hot as can be borne.

Wait until the soreness disappears before performing a second operation. This will require from one to two weeks, according to the extent of the first operation and the physical condition of the patient.

Take great pains and care to perform a neat operation. A certain amount of ingenuity and tact are required, which, unfortunately, all do not possess. If a bungling job be made, the bowel punctured, a pile injected on one side only and the surfaces excoriated, do not attribute an unnecessary amount of pain and suffering to the preparation used or the method employed.

As a general alterative and curative agent in many diseases, and particularly to relieve and prevent hemorrhoidal congestion in rectal troubles, sulphur in small doses, persisted in for some time, probably has no equal. The most convenient form for administration is a palatable tablet (Wyeth & Co.), containing 2½ grains, or 5 grains with 1 grain of cream of tartar. Reference to the learned articles on the physiological and therapeutical uses of sulphur, by Dr. John V. Shoemaker, published in the Dietetic Gazette, Sir Alfred B. Garrod in the Lancet, and in Ringer’s hand-book of therapeutics, will be amply repaid.

It is unnecessary for a lady to disrobe herself for examination, or suffer immoderate exposure. A cloth cover should be used, when a lady patient is placed on the chair, the same as in gynæcological practice.]

RECTAL EXAMINATION.

The first step to be taken in making an examination of the rectum, where disease of this organ is present or suspected, will be to obtain a history of the case as given by the patient, supplemented by questions naturally suggested. This will furnish an idea of what might be looked for, but the patient’s interpretation will often be found quite erroneous and misleading.

Should there be an undue protrusion at stool, pursue the same course recommended for the examination of internal hemorrhoids. If protrusion be absent, direct the patient to lie on the side with knees drawn up, separate the buttocks and inspect the anus; or, in other words, all that presents to view externally at the terminal orifice of the rectum. Now draw down and evert the mucous membrane at the verge with the thumbs, asking the patient at the same time to extrude the parts as much as possible. This will enable you to see all there is half an inch or more above the entrance.

Next, anoint the finger, pass in gently and examine all the surface limited by the sphincters, a distance upwards of not over an inch, being careful lest you be deceived by the mobility of the tissue, when introducing the finger, and a small marginal growth be carried up and appear as one of internal origin.

Any one familiar with vaginal examinations can detect a rough or a broken mucous membrane, an indurated spot or prominence as soon as touched. Next, feel above the internal sphincter, keeping in mind the anatomy of the parts, turn the finger slowly, posteriorly you can hook it behind the muscle. Here is situated the bottom or floor of the rectum which forms a cul-de-sac (Fig. 11). By asking the patient to strain down moderately, its surface will be thrown up against the end of the finger and in this manner properly explored.

A digital examination reveals, in the normal state, a soft, velvety, unbroken mucous membrane, the parts pliable and yielding, with no reflex excitability of the sphincters. The position and sensibility of the uterus should be noted in the female, and size of the prostate gland in the male of advanced years.

The first three or three and a half inches of the rectum can be brought within reach of the finger. Explorations farther up will require a rectal sound and a long tubular speculum. Nine-tenths of all rectal ailments are found within the first two inches. Therefore, few general practitioners will ever be called upon to treat anything beyond the reach of the finger or the scope of a common speculum.

All hemorrhoids of any appreciable size, or other tumorous growths in the same vicinity, will show at defecation and can be treated while the parts are extruded. All abrasions, ulcerations, indurations, etc, are discoverable by the sense of touch. Hence, it will be seen that the uses of the speculum are narrowed down to a few in number. Namely: in that of bringing to view for observation and treatment diseased surfaces previously located; small, soft hemorrhoids and other minor affections which may have escaped detection by a careful digital examination.

Then, in view of the foregoing facts, and in consideration of the anatomical formation of the parts, being a collapsable tube, highly sensitive and extremely difficult of accessibility, quite unlike the vaginal canal, which is closed at one end, more capacious and dilatable, and designed by nature to be approached from the exterior, a speculum should be so constructed as to not only be easy of introduction and withdrawal, but to exclude all the surface except a limited portion, and permit the greatest amount of available light possible to fall on the exposed part shown in situ.

The greatest barrier to the successful use of a speculum is the unruly external sphincter and the excessive mobility of the mucous and muco-cutaneous surfaces. The upper margin of the external sphincter terminates beneath the junction or the skin with the mucous membrane, which place also marks the beginning of the internal sphincter and its junction with the external muscle by a more dense connective tissue, sometimes appearing as a white line at the muco-cutaneous junction called the white line of Hilton.

According to Dr. Andrews, Hilton has demonstrated that the locality where the two muscles join by the intervention of this fibrous ring forming the anal verge, the junction of the skin and mucous membrane, and the exit of the branches of the pudic nerve, is identical.

The internal sphincter is a collection of the circular fibres of the muscular coat of the bowel, about five-eighths of an inch in width, and constitutes in reality the terminus of the gut. For the external sphincter is a thin band of distinct and separate muscular fibres, elliptical in shape, between three and four inches from its anterior to its posterior extremity, and expands out around the margin of the anus like the flaring end of a trumpet; with its superficial layer in close relation to the skin which it draws down in radiating folds.

With this understanding of the anatomical relations, it will be seen that the external muscle contributes so slightly to the length of the canal, that it might be considered wholly on the outside, where it guards closely the entrance, and is nowise concerned in an examination with a speculum except as a feature of incumbrance.

To correct an erroneous idea that there is any considerable depression or space intervening between the muscles, we mean, when we say between the sphincters, the distance bounded by the fibrous ring uniting the two muscles below, and the upper portion of the internal muscle above. More simplified, we mean all the surface included between the upper margin of the internal sphincter and its junction with the external muscle at the anal verge.

All examinations with a speculum should be preceded by an enema of warm water to wash away the mucous and retained feces in and about the sphincters. Let the patient lie on either side, turning partially on the chest, with knees drawn up, the one uppermost more firmly flexed on the abdomen, and hips so elevated that the speculum, when introduced points or inclines downward, and admits of strong natural light to fall in parallel rays to its axis.

Warm the speculum by dry heat over a single blast kerosene stove, where gas is not convenient. A suitable kerosene stove is an indispensible adjunct to an office for heating instruments, water, etc., causing no smell and leaving no deposit of sut on the bottom of vessels as done by gas or alcohol. Use white vaseline as a lubricant; everything that tends to whiteness helps the sight. The vaseline may be squeezed from a tin-foil tube, and the finger not soiled in preparing the speculum for insertion.

To prevent the loose tissue from rolling up and being pushed in with the speculum, the patient may assist by holding the upper buttock away, while the physician introduces the instrument with one hand and retracts the opposite buttock with the other.

Introduce slowly, giving time for the muscles to relax, bearing in mind that all movements about the rectum and anus must be extremely easy and gentle. The proximal end of the slot must be carried and kept above the external sphincter during the entire course of the examination. It matters not what kind of a speculum is being used, the value of the instrument will greatly depend upon its power to hold this muscle out of the way.

A closed end speculum, with a proportionate slot and smooth corners, can be slowly rotated without any difficulty where the mucous membrane is not very loose and baggy and no prominences in the route. But if a hemorrhoid be in the way it will immediately drop in the slot and further progress is thus impeded.