establishes the fact that Van Buren is entitled to the credit for
priority; that Marion Sims was the discoverer of the possibility of
atmospheric inflation of the hollow pelvic viscera; that there is much
similarity in the methods of the various operators quoted, some using
similar instruments and dissimilar technic, and _vice versa_; and it is
made obvious, also, that he who would most insist upon a credit for
originality must sometimes discount with the erudite his reputation for
literary research.
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.
[Illustration: FIG. 1.--Positions of the hands for the practice of the
simplest method of proctoscopy.]
[Illustration: FIG. 2.--Positions of the fingers for the practice of
the simplest method of proctoscopy.]
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.[13]
[Illustration: FIG. 3.--The chair, illumination-apparatus,
shoulder-suspender, and small pillow.]
[Illustration: FIG. 4.--The chair in the horizontal posture for
anoscopy.]
[Illustration: FIG. 5.--The position of the chair for the new posture
of the patient.]
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.
[Illustration: FIG. 6.--The anoscope.]
[Illustration: FIG. 7.--The obturator.]
[Illustration: FIG. 8.--The ointment applicator.]
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.
[Illustration: FIG. 9.--The two-way irrigator.]
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.
[Illustration: FIG. 10.--The proctoscope.]
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.
[Illustration: FIG. 11.--The ointment applicator at the time of the
placing of the ointment in contact with a diseased area.]
[Illustration: FIG. 12.--The proctoscope ready for introduction.]
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).
[Illustration: FIG. 13.--Sitting posture of the patient, the first step
toward proctoscopy.]
[Illustration: FIG. 14.--Horizontal posture of the patient for
anoscopy.]
_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.
(_a_) Digital examination and ocular inspection should now be made of
the anal verge, the external anus, and superficial ischiorectal space,
at a moment when the patient is relaxed, and, again, when he is bearing
down.
(_b_) Digital examination of the fixed or anal rectum, also, should be
made preliminary to the introduction of the anoscope.
(_c_) The anoscope should be gently pressed into the anus in the
direction of its axis till the sphincters relax to receive it. The
introduction of an instrument into the rectum may be much facilitated
by placing its lubricated end against the ectal sphincter and requiring
the patient to bear down; bearing down expands the ectal sphincters,
relaxes the levator ani, thins the pelvic floor, or shortens the fixed
rectum, and presses the ental sphincter over the instrument--in other
words, the patient’s anus is made to climb down upon the speculum.
After the introduction of the anoscope, its obturator should be
removed, and the inspection made. These observations should be made
coincident with the withdrawal of the anoscope. In cases of extremely
sensitive ani, a skillfully put hypodermic injection into the
sphincters of 10 or 20 minims of ⅒ of 1% solution of cocain may render
anoscopy painless.
A desire for precision requires that _lesions of the fixed or anal
rectum_ should be noted as occupying a given quadrant, and as situated
at a given zone, _e.g._, a circumscribed disease may be described as
situated at the ental sphincter zone, and in the left lateral quadrant.
[Illustration: FIG. 15.--Putting the patient into the new posture.]
[Illustration: FIG. 16.--The new posture.]
_Step 3_ (_a_) requires that the shoulder-suspender should be placed
and fixed to the chair, as shown in Figs. 5 and 16, that the knees be
drawn up, so that the thighs are at a right angle to the length of
the chair-top, and that the chair should be tilted to put the patient
in the new posture shown in Fig. 16. The leg foot-board should now be
lowered, and the operator’s stool placed in convenient position.
The illumination-apparatus should now be adjusted, as shown in the
illustrations. In this new posture, which is equivalent to the
knee-chest posture, the abdominal rectum is to be examined.
(_b_) Introduction of the proctoscope requires supported eversion
of the buttocks and steady gentle pressure of the well-lubricated
instrument upon the anus and in the direction of the umbilicus, until
the sphincters are felt to yield, or the patient may be required to
bear down to take the speculum; as the instrument enters the inflatable
movable rectum, it should be pointed toward the promontory of the
sacrum, and subsequently into the sacral hollow. The withdrawal of the
obturator is followed by atmospheric inflation of the rectum.
(_c_) The operator should observe the degree of rectal distention, the
situation and number of the rectal valves, their propinquity to one
another when passive, and the relation of one valve to another at the
time of the patient’s bearing down. Under pressure of the proctoscope
if possible, or the hook if necessary, each valve should be effaced or
displaced, and in regular order each of the rectal chambers should be
carefully inspected. A proctoscopic mirror may be necessary for viewing
the supravalvular surfaces (Fig. 18). The examination being finished:
[Illustration: FIG. 17.--The hook for testing the valves.]
[Illustration: FIG. 18.--The proctoscopic mirror.]
_Step 4._--The proctoscope should be withdrawn, the
illumination-apparatus fixed in the first position, the leg foot-board
lifted to its place, the lever extended, the crank turned and the chair
carried back to the horizontal and upright positions, and thus the
passive patient may be returned to his feet by the execution in the
reverse order of the several steps described.
This method of inspection does not subject the patient to struggle,
strain or embarrassment.
Observation by this method has taught me that in nearly all cases of
disease at the anus there is congestion or inflammation of the rectal
mucous membrane.
Those cases in which there is no apparent lesion at the anus, and which
are in a perfunctory way sometimes declared catarrh of the rectum,
will at once have the real condition, such as a high up rectal polypus,
congenital or organic stricture or ulceration, positively diagnosed,
and will be made accessible for intelligent treatment.
New growths and ulcerations may be seen and by means of a long-handled
curet scrapings made in order that the microscopist may determine their
exact character.
Stricture of the rectum need no longer be regarded as of only doubtful
presence, and this method proves positively, even to the casual
observer, how fallacious is the method of rectal sounding usually
employed for the diagnosis of stricture. I have repeatedly proved to
visitors how easy it is for an entering or returning bulb-sound to be
caught and held by the rectal valves,[14] and thereby yielding signs
generally considered diagnostic of organic stricture of the rectum.
Vesicorectal, vaginorectal and other deep fistulas are often apparent
at a glance, but in any case may be discovered by the use of the
proctoscopic mirror.
If this method of ocular examination be practised, I am convinced
there need be no longer any excuse for calling an undiagnosed disease
of the rectum obscure disease, and whatever the disease present this
method makes it susceptible of demonstration by the proctologist to the
attending physician. There is no necessity that a diagnosis be taken on
faith.
TOPOGRAPHIC ANATOMY.
A close study of the lesions of the rectum and their manifestations
and some experience in discussion of these subjects have convinced me
of the necessity of methods of greater accuracy than those generally
employed in designating the precise situation of a pathologic feature
in this organ. Mensural methods of designating the situation of
strictures in the rectum are of no surgical value.
The manner of the application of the details in a given method of
treatment for a disease situated in the fixed or anal portion of the
rectum should differ essentially from that employed in the application
of the same principles of treatment to a similar disease situated in
the movable abdominal rectum; and the application of the details of a
given kind of treatment should differ, too, according to the situation
of the disease at one point or another in the circumference of the
rectum. The prognosis as well as the treatment of rectal disease is
determined not only by the pathologic character of the lesion, but also
by its anatomic situation. “Two inches up,” or “one and a half inches
from the anus,”[15] if one were positively sure of the precise location
referred to as the anus, would point to very different anatomic parts,
whether the subject were male or female, and whether young or old, and
whether thin or stout.
The rectum, the terminal 8 or 10 inches (20.32 or 25.40 cm.)
approximately of the intestine, presents an upper abdominal and
essentially movable portion, which is about three-fourths the length of
the entire rectum, and a lower coccygeoischioperineal and essentially
fixed anal portion, which is about one-fourth the length of the rectum.
The upper half of the movable rectum is, in the majority of adult
persons, completely invested with peritoneum, which sometimes provides
this portion with a mesentery. The lower half of the movable rectum
begins at a point about the upper border of the second sacral bone,
and is not completely invested with peritoneum; the peritoneum is
reflected from the sides of the rectum toward the lateral masses of
the sacrum, so that the posterior wall of this part is not covered
by peritoneum. The movable rectum begins opposite the sacroiliac
synchondrosis. If a subject lies in the dorsal posture, and if the
abdomen be normal, the upper end of the rectum will lie opposite the
left sacroiliac synchondrosis. If the patient is inverted to the
knee-chest posture or its equivalent, and if the abdomen is normal,
the upper end of the rectum, if distended, is usually found nearer the
right sacroiliac synchondrosis. The movable abdominal rectum terminates
at the levator ani muscle.
[Illustration: FIG. 19.--Drawing of specimen No. 281 in the Anatomical
Museum of the Royal College of Surgeons, London. The dissection was
made by Mr. William Pearson. The drawing shows in the lower part of the
field the coccyx, in the upper part of the field the pubes.]
[Illustration: FIG. 20.--Drawing of specimen No. 284 in the Anatomical
Museum of the Royal College of Surgeons, London. The dissection was
made by Mr. William Pearson. The drawing shows in the lower part of the
field behind the rectum the coccyx, in the upper part of the field the
pubes.]
The fixed anal rectum begins at the levator ani and coccygeus muscles.
The levator ani has its origin at the sides of the bodies of the pubic
bones, the coccygeus at the spines of the ischii, and the levator ani
has additional origin from the fascia and bony parts on a line between
these two points. The fibers of these muscles are directed downward
and inward to the fixed anal rectum; many fibers are blended into the
contiguous structures of the pelvic floor. The coccygeolevator muscles
may be compared to an opened slat-fan, the apex having its place at
the anus, and its long border representing the line of origin of the
muscles, Fig. 19. The ental sphincter ani muscle, situated a few lines
below the levator ani, is made up of an aggregation of the fibers of
the circular non-striated muscular intestinal coat, Fig. 20. The ectal
sphincter ani striated muscle is situated immediately beneath the
external skin. It serves the present occasion to describe the ectal
sphincter of the male as a loop of muscle thrown about the terminal end
of the rectum and hitched to the terminal bone of the coccyx, and in
the female as a longer loop of muscle twisted upon itself so as to make
a tandem-loop, which, in the form of the figure eight (8), is thrown
about the vagina and terminal end of the rectum.