All of which properly leads up to the subject of rectal examination and how to make it complete. Much can be learned here by use of the educated finger, as well as in the vagina, and the surgeon should cultivate that tactile sense which will orient him so soon as the finger-tip comes in contact with a morbid or diseased surface. In this way it is possible to detect ulcers which are within reach by the finger alone, without having to use the speculum, at least to make a diagnosis sufficient to indicate what further procedure is required. The rectum and lower bowel should be thoroughly emptied. It is safe to assume that exquisite sensibility and pronounced sphincteric spasm are the result of morbid conditions. The use of a local anesthetic will in many instances be sufficient to permit at least of a preliminary digital examination, the suggestive characteristics especially sought being the general size of the rectal tube, infiltration or fixation of its walls, and the presence of stricture, tumor, or other impediment to insertion of the finger, including pronounced spasm at the anus. The presence of bloody mucus or pus should also be noted. In addition the rectal surroundings should be examined and the presence of any phlegmon, fistula, sinus or other evidence of present or past disease, including old scar, either of ulcer or incision, should be noted. The degree of pain as well as of hypersensitiveness produced should also be noted. With tact and gentleness satisfactory knowledge of the condition of the parts within reach may be obtained.
A rectal bougie may be used should suggestions of the presence of stricture be present. Rectal bougies are usually made of soft rubber of various sizes, with tips variously shaped, of which the tapering and conical are the most useful. One of these may be anointed and gently introduced, the endeavor being to guide it first in the middle line along the course of the rectum and then gently toward the left as the rectum swerves in this direction as it comes down from above. With such a bougie the presence of a stricture beyond reach of the finger may be detected. When recognized its nature is, however, still left in doubt, to be decided by the history or other features of the case. There is never excuse for roughness in handling a rectal bougie, since perforation or serious injury might result.
The next method of more complete examination of the rectum is through one of the various forms of specula, from the so-called rectal speculum, with its blades only a couple of inches long, to the more formidable proctoscope or sigmoidoscope, with their possibilities or artificial illumination, etc. According to the nature of the lesion and the sensibility of the surface exposed various specula may be used, with or without an anesthetic. For the majority of purposes local anesthesia is sufficient. One will furthermore often need the aid of position. The ordinary digital examination may be made with the patient upon the side or back. When an ordinary speculum is used a position corresponding to Sims’ for gynecological work is far preferable. For more thorough work when the long, tubular instruments are used, the knee-chest position is necessary. The specialists have devised certain elaborate chairs, instruments, and methods by which exceedingly complete and satisfactory exposures of twelve or fifteen inches of rectal and colonic mucosa can be made. What is written here, however, is not for their purposes, but rather for those of the general practitioner, who must work with ordinary means and methods. The knee-chest position, for instance, can be assumed upon the ordinary table or it may be facilitated by certain additions made to a regular operating table. With all these facilities and the peculiar skill which specialization produces it is possible to make striking demonstrations of the valvular arrangement of the rectal mucosa, and of the varying degrees of obstruction which mucous folds or cicatrices may produce, as well as to successfully dilate or divide them. In the hands of a limited number of skilled surgeons local treatment of obstipation, as well as of various other conditions of the sigmoid or upper rectum, has become extremely satisfactory. These are, however, in the writer’s estimation, methods and procedures which are scarcely within the domain of the general practitioner or even the general surgeon, as they require a degree of peculiar facility and an amount of time which can scarcely be expected of him. Therefore the conditions and methods of treatment here considered will be limited to those intended for general use.
CONGENITAL DEFECTS AND MALFORMATIONS OF THE RECTUM AND ANUS.
The lowermost portions of the intestinal tube are by far the most common sites of congenital anomalies and defects. These rarely occur in the direction of excess, rather of atresia or entire deficiency. The lower end of the alimentary tube is differentiated from the balance of the original neurenteric canal, and connected with the exterior, in ways similar to those followed at its upper extremity. The canal itself should early become obliterated at a point whose site is marked by that small collection of lymphoid tissue known as the coccygeal or Luschka’s body, corresponding in this respect and location to the pituitary body at its other extremity. The rudimentary rectum is then connected with the surface by the formation of a depression and disappearance of tissue in just the same way that the mouth is formed, and as about the mouth we find atresia or incomplete communication, so we may find the same condition in various expressions about the termination of the rectum. Moreover, there may occur also more or less arrest or abnormal development of the tissues which eventually shut off the rectum from the genito-urinary tract. In consequence, we have various degrees of rectal atresia, and, finally, actual imperforation. Beyond this we may more rarely meet with complete absence of the rectum, and even of some portion or of nearly all of the entire large intestine. In one case under my observation this entire tract was represented by little more than a mere cord.
PLATE LII
Cancerous Stricture of Rectum. Bowel Laid Open for Inspection.
The mildest degree of such malformation refers to partial occlusion of some portion of the rectum, or extreme smallness of its natural opening, either of which constitutes essentially a stricture of congenital origin, which may be sufficiently tight to barely allow passage of meconium. Such strictures may escape notice for a considerable length of time and will always tend to produce dilatation and consequent displacement of bowel above.
Ordinary imperforate anus is produced by its closure by a more or less thick, membranous diaphragm, which may act, in some cases, like a thin but imperforate hymen, or, in others, be so dense and massive as to act more like a plug than a partition. The thinner the diaphragm and the more perfect its structure as such the simpler the case, for it simply needs perforation, with sufficiently frequent subsequent dilatation to maintain the proper size of the aperture.