V I 620
3666p
1870
alifornia
rional
THE
LPHYSICAL EXPLORATION
K E C T U M ":
WITH AN APPENDIX ON THE
LIGATION OF MfflOBRHOIDAL TUMORS.
BY
WILLIAM BODEiraAMEK, A.M., M.D.
" The accuracy of our diagnosis is in direct relation to the thoroughness of physical
exploration."— PROP. G. T. ELLIOT, JK.
ILLUSTRATED BY NUMEROUS DRAWINGS.
NEW YOKE:
WIIyLIAM WOOD & CO., 61 WALKER STREET.
IST-O.
\/J J_ fl to P O
Entered according to Act of Congress, in the year 1870, by
WILLIAM BODENHAMER,
in the Office of the Librarian of Congress, at Washington, D. C.
J. O. SEYMOUR, KENNARD & HAT,
Printers and Stationers,
89 Liberty Street, New York.
PREFACE.
THERE are but few minor operations of surgery that require more knowl-
edge, experience and tact, in order to be enabled to perform them efficiently
and satisfactorily, than the physical exploration of the rectum, including the
sigmoid flexure of the colon. The natural obstructions in the way of such
an examination, in these portions of the intestinal canal, are many, and
others, still more numerous, may be found from disease and other circum-
stances. These various difficulties can only be successfully met and over-
come by a complete knowledge of the anatomy of the parts, both natural
and morbid, and by the adroit employment of suitable instruments.
Inasmuch as the general treatises upon surgery, as well as the most
modern writers on the diseases of the rectum, are almost wholly silent upon
this important point in the diagnosis of rectal diseases, the author conceives
that it will not be out of place to indicate the rules which he follows in ex-
ploring this portion of the intestinal canal, and to give different methods of
performing that operation.
A correct understanding of the manner of introducing the sound, bougie
or tube into the rectum, or into the sigmoid flexure of the colon, is often as
important to the safety of the patient as is the passage of the catheter into
the bladder ; yet, as before observed, it is scarcely ever mentioned by authors,
and is certainly not included in the catalogue of surgical operations. There-
fore, taking into consideration the anatomical relations of the parts con-
cerned, the construction of instruments especially adapted to the purpose,
and the various obstacles which may obstruct their passage, together with
the necessary measures of overcoming them, it is obvious that the subject
demands a more thorough examination than has yet been bestowed upon it.
This would appear to be the more particularly called for at this special junc-
ture of time, when nature, in other departments of the science, is being sub.
jected to so much a severer test of interrogation than has ever before been
adopted, and by so much superior and more thorough methods of investiga-
tion ; and more especially, too, since the scope of medical science is now
daily expanding, and an inquisitive public anxiously expecting and impa-
tiently awaiting the establishment and exposition of its unmystified rational
practice.
IV PREFACE.
Although the labor in this field of investigation is by no means inviting
and pleasant, but rather repulsive and distasteful, yet it must be admitted by
all to be highly important and useful, for upon it the life, health, comfort
and convenience of so many so much depend. No subject, however, should
be considered undignified, or unworthy of anxious attention, which involves
such serious consequences, or which has for its object the improvement of
the healing art or the extension of our knowledge of nature's operations.
No standard is known by which to determine the dignity or the respectabil-
ity of any branch of medicine, than its capability of saving life and suffering.
The ligation of haemorrhoidal tumors, the subject of the appendix,
although out of place here, should nevertheless attract the reader's attention.
It may seem to some that the descriptions in this work, both anatomical
and operative, are too unnecessarily minute in their details ; but the author
would observe to such, that it is the neglect of minuteness and the fondness
for generalization which involve a subject in obscurity. As long as we ad-
here to facts, we cannot be too microscopical, for facts, however simple, are
as essential to refute opinions as they are to establish principles.
Upon some points it will be seen that the author has not hesitated to
express opinions more or less at variance with those of surgeons of deservedly
high reputation and celebrity. If, however, he has done this in a respectful
manner, no just exception can be taken and no apology is necessary.
In conclusion, the author would remark, that while this little brochure
does not profess to be anything more than an introduction to, or an outline
of the subject, it nevertheless does not fail to include the most salient points.
He therefore trusts that sufficient has been presented to make it attractive
and useful, especially to the student and junior practitioner, to whom, with
its many defects, it is most respectfully addressed.
837 FIFTH AVENUE, NEW YORK, July, 1870.
TABLE OF CONTENTS.
SECTION I.
INTRODUCTORY REMARKS.
PAGE
The ignorance heretofore on the subject of the Diseases of the
Rectum. The causes of this ignorance attributed chiefly to the
neglect on the part of the practitioner to make a proper explora-
tion of the organ, and the great disinclination on the part of the
patient to submit to such examination. These causes, to a con-
siderable extent, are now being happily removed. . . .1-3
SECTION II.
THE ANATOMY OF THE RECTUM.
A description of the Rectum only so far as it relates to its position in
the pelvis ; its commencement ; its termination ; its length ; its
direction ; its form ; its capacity ; its relations ; its divisions ; its
mucous lining, with its rugfe or folds. The columns of Morgagni.
The lacunae of the Rectum. Are there veritable valves of the
Rectum ? The question important to the rectal explorer. The
declarations of Cheselden, Morgagni, Portal, Glisson, Boyer, Wil-
son and Horner in the affirmative. The ingenious hypothesis of
Mr. Houston to establish the existence of such valves. The
author denies their existence in the rectum.
SECTION III.
PHYSICAL EXPLORATION.
The diagnosis in the diseases of the Rectum and Anus chiefly deter-
mined by a visual and a tactile examination. The proper instru-
ments to be employed. Digital and specular examination. Pre-
liminary steps to an examination. The position of the patient
and the surgeon. The right index-finger. Palpation. A descrip-
tion of several speculse ani and the new instrument, the recto-colo-
nic endoscope. Prof. Storer repudiates the speculum ani as a
means of diagnosis in the rectal diseases of females, and substi-
VI CONTENTS.
PAOB
tutes rectal eversion for it. The author points out the difficulties
of rectal eversion, and shows that at best it is too limited in extent
to dispense with the anal speculum. Rupturing the sphincter
ani, as a means of diagnosis, as advised by Prof. Storer. The
author is of opinion that no such operation is ever justifiable for
such a purpose, inasmuch as the great capacity of the anus and
anal canal naturally for dilatation may always be dilated readily,
speedily, safely and sufficientlv under the influence of anaesthet-
ics or belladonna, without inflicting any injury whatever upon
the integrity of the parts. Splanchnoscopy by translucency.
Exploration by means of the probe 19-31
SECTION IV.
SOUNDING THE RECTUM.
Description of the instruments used in sounding the Rectum. The
method of introducing the sound, bougie or tube into the rectum,
and sigiuoid flexure of the colon. The operation divided into
four stages. The particular manipulation in each stage. Partic-
ular directions and precautions to be observed in sounding. . . 32-41
APPENDIX.
ON THE LlOATION OP H^EMORRIIOIDAL TUMORS. . 43-54
THE
PHYSICAL EXPLORATION
OF THE
IR, IB O O? TJ
SECTION I.
INTRODUCTORY REMARKS.
Mr. Lizars, in his " System of Surgery," very correctly
observes that, — " diseases of the rectum are very common, very
numerous and important ; still, however, they are out little
understood" Not many years ago, such was the ignorance on
the subject of some of those diseases, that a very able writer in
the " London Medico-Chirurgical Review " observed that, —
" beyond the treatment of Fistula in Ano and Haemorrhoids,
the surgery of the rectum is a sort of land of the Cimmerians,
where quacks alone can breathe, and where humbug darkens
the air"
But are not the diseases of the rectum just as susceptible as
any others of exact observation, of scientific analysis, and of
safe, certain and appropriate treatment ? Is it indeed impossi-
ble for light ever to dawn upon this region, said to be darkened
by humbug and inhabited alone by quacks ?
It may be observed that the ignorance on the subject of the
diseases of the rectum, which had so long prevailed, and which
to a certain extent still exists, may very justly be attributed to
the failure, on the part of practitioners generally, of making a
proper exploration of this organ. The rectum heretofore has
been a terra incognita in the domain of surgery, into which
THE PHYSICAL EXPLORATION OF THE RECTI'M.
the practitioner did not care to venture. But this ignorance
is now being rapidly dispelled, and this organ is becoming as
subservient to the laws of physical exploration as any other.
The surgery of the rectum, particularly as it regards its
manipulative branch, has made rapid strides since the intro-
duction of anaesthetics. These and the now common use of
the speculum ani and rectal endoscope are daily revealing the
dark and the hidden mysteries of this darksome passage.
Some of the reasons, however, why an examination of the
rectum is so universally omitted are obvious enough. Such an
inspection is not a very pleasant affair, either to the patient or
to the practitioner, but rather more or less repulsive to both.
In females, too, the delicacy of the sex often induces them to
conceal their maladies in this region, and throws various obsta-
cles in the way to an inspection of them ; yet, if the practi-
tioner consults his own reputation or the welfare of his patient,
he will insist on making an examination, especially when
positive symptoms are complained of, or when suspicious ones,
not otherwise well accounted for, do exist. The surgeon
should never prescribe for affections of the rectum and anus
without a proper visual and tactile inquiry into their real
character. I have often witnessed the folly and the mischief
arising from the practice of prescribing for supposed or im-
aginary complaints, the product of the patient's own
judgment or imagination, the real nature of which might
have been readily discovered by a proper examination of the
parts concerned. Patients most always call their maladies in
this locality — piles / indeed, all the various affections of the
rectum and anus are generally so denominated by them. The
surgeon, however, should not copy the errors of his patient in
this respect, to believe without evidence or conviction, which,
if he does, will assuredly lead him to prescribe for diseases
which exist only in the conjoint imagination of both.
It is, doubtless, owing to these several causes that so many
patients suffering from these affections have heretofore fallen
into the hands of empirical, unprincipled and reckless practi-
tioners, whose deceptions were favored by the locality of the
disease, and who were thus encouraged and emboldened to
continue to practice their impositions with impunity. Indeed,
it may truly be said that the general ignorance which pre-
THE PHYSICAL EXPLORATION OF THE RECTI'M. S
vailed in the profession with regard to those diseases, and the
locality of them, furnished the ignorant pretender with an
almost inaccessible asylum. But, as before observed, this
ignorance of the subject, and this repugnance to making or
submitting to a rectal examination, are now being rapidly dis-
pelled.
From the preceding considerations, it is of the utmost im-
portance, as a general rule, that a careful and minute explora-
tion of the rectum and anus should be made, as a preliminary
step to the treatment of the diseases of these organs, the diag-
nosis of some of which is often so very obscure. This examina-
tion, too, should not be long delayed, for, by the neglect of
this precaution, an aifection which, if timely attended to,
would readily yield, is suffered to make progress and to become
difficult of cure.
SECTION II.
THE ANATOMY OF THE RECTUM.
1. A knowledge of the anatomy of the rectum is an essen-
tial prerequisite to the successful exploration of the same. I
will here, however, only give a description of this intestine so
far as it relates to its position in the pelvis ; its commence-
ment ; its termination ; its length ; its direction ; its form ; its
capacity ; its relations ; its divisions, and the rugae or folds of
its mucous lining.
That portion of the alimentary canal which has obtained the
appellation, — rectum, occupies the posterior part of the pelvis,
and is continuous with the sigmoid flexure of the colon (Fig. 1).
[A view of the Rectum, together with the position and curvatures of the colon. 1. The
ilenm terminating in the caecum. 2. The appendicula vermiformis. 3. The caecum. 4.
The ascending, or right lumbar colon. 5. The transverse colon, or arch of the colon. 6.
The descending, or left lumbar colon. 7. The iliac colon, or sigmoid flexure of the colon.
8. The rectum. 9. The pouch of the rectum. 10. The anus.]
THE PHYSICAL EXPLORATION OF THE RECTUM.
5
It commences at a point horizontal with and quite contiguous
to the left ilio-sacral symphysis, and it terminates at the anus.
Its length in full grown subjects, taking the standard of the
human body at from five feet eight inches to five feet ten
inches, is about eleven inches. The rectum, however, is
neither of uniform length nor caliber, as the following admeas-
urements I made of it in the dead bodies of eight adult sub-
jects will show. The organ in each of these instances was
carefully examined whilst in situ. In these cases, if the rec-
tum had been detached from its natural situation in the pelvis
and dilated, a very different result would, doubtless, have
been obtained.
The following table, giving the results which I obtained,
presents the age of the subject, the sex, the whole length of
the rectum, the diameter at its commencement and at the
bottom of its pouch, immediately above the superior margin of
the internal sphincter of the anus : —
TABLE.
CO
5"
E.
H
Length
of
Diameter
at
Diameter
at
a
CD
I
Rectum.
Commencement.
Bottom of Pouch.
i
21
F
11 Inches and 5 Lines.
1 Inch and 5 Lines.
1 Inch and 10 Lines.
2
28
M
11 Inches and 11 Lines.
1 Inch and 9 Lines.
1 Inch and 11 Lines.
3
47
M
12 Inches and — Lines.
1 Inch and 8 Lines.
1 Inch and 11 Lines.
4
40
F
10 Inches and 11 Lines.
1 Inch and 2 Lines.
1 Inch and 9 Lines.
5
60
M
12 Inches and 2 Lines.
1 Inch and 10 Lines.
2 Inches and 3 Lines.
6
55
M
12 Inches and 3 Lines.
1 Inch and 11 Lines.
2 Inches and 1 Line.
7
35
M
11 Inches and 9 Lines.
1 Inch and 10 Lines.
1 Inch and 10 Lines.
8
45
F
11 Inches and 8 Lines.
1 Inch and 7 Lines.
2 Inches and 5 Lines.
The form of the rectum is cylindrical at its commencement,
and indeed throughout a considerable portion of its extent ;
but towards its inferior extremity, however, it becomes large
and saccated, forming a terminal pouch, which is dilated and
flattened from before backward, and the mouth of which is
closed by the internal sphincter muscle, like a purse. The
size of the rectum for some distance is nearly continuous with
that of the sigmoid flexure of the colon ; but it differs from the
other portions of the intestines by its becoming wider in. its
downward progress, until it reaches the superior margin of the
fi THE PHYSICAL EXPLORATION OF THE RECTUM.
internal sphincter muscle. From its commencement on the
left side, at the superior opening of the pelvis (Fig. 2),
FIG. 2.
[A side view of the pelvic viscera of the male in their normal situation. 1. The divided
surface of the pubic bone. 2. The divided surface of the sacrum. 3. The body of the blad-
der. 4. Its fundus, with the urachus at its apex. 5. The base of the bladder. 6. The
ureter. 7. The neck of the bladder. 8. The pelvic fascia. 9. The prostate gland. 10. The
membranous portion of the urethra. 11. The triangular ligament formed of two layers.
12. One of Cowper's glands. 13. The bulb of the spongy body. 14. The body of the
spongy structure. 15. The right leg of the penis. 16. The upper part of the superior por-
tion of the rectum. 17. The recto-vesical fold of the peritonaeum. 18- The central or middle
portion of the rectum. 19. The right seminal vesicle. 20. The deferent duct. 21. The
rectum covered by the descending layer of the pelvic fascia. 22. A part of the elevator
muscle of the anus. 23. The external sphincter ani. 24. The interval between the deep
and superficial perinieal fascia. 25. The anus.]
it is directed from above downward, and at first a little
obliquely from left to right, descending into the pelvis along
the anterior surface of the sacrum for about six inches, occa-
sionally undergoing, in some subjects, slight lateral inflections,
until it has arrived at the median line of the body, at a point
opposite the junction of the third and fourth bone of the
sacrum ; adapting itself, during its downward course, to the
curvature of the bone over which it has to pass. From this
point it is then directed obliquely from above downward,
and from behind forward, for about four inches, still in the
median line, to the extremity of the coccyx, arid on a level
with the prostate gland. Finally, from immediately below the
level of the prostate gland, it is directed obliquely from above
THE PHYSICAL EXPLORATION OF TIIK RKCTI'At. i
downward, and a little from before backward, for about one
inch and a half, to terminate at the amis.
2. Divisions of tJtv Iteciwm. — The rectum, for better eluci-
dation, may be distinguished into three divisions : — a superior,
a central, and an inferior ; the three main curvatures which
the organ describes, in its downward course, being made the
foundation of these natural divisions. (Fig. 3.) Each division
FIG. 3,
[A side view of the viscera of tho female pelvis in their natural situation. 1. The ^ym-
physis pubis. 2. The abdominal parietes. 3. The fat forming the mon* veneris. 4. The
bladder. 5. The entrance of the left ureter. 6. The canal of the urethra. 7. The nieatus
urinarious. 8. The clitoris and its prepuce. 9. The left nympha. 10. The left labium.
11. The orifice of the vagina. 12. Its canal and transverse rug*. 13. The vesico- vaginal
septum. 14. The vagino-rectal septum. 15. Section of the perin.eum. 1(5. The os uteri.
17. The cervix uteri. 18. The fundus uteri. 19. The rectum. 20. The anus. 21. The su-
perior portion of the rectum. 22. The central or middle portion of the rectum. 23. The
inferior portion of the rectum. 24. The peritomeum reflected on the bladder from the ab-
dominal parietes. 25. The last lumber vertebra. 26. The sacrum. 27. The promontory of
the sacrum. 28. The coccyx.]
is distinct in its situation, structure, and in the nature and im-
portance of its connections with regard to the several organs
in the pelvic cavity. Their several relations vary in the two
sexes, and a complete knowledge of which is of the highest
importance in a surgical point of view. (See Figs. 2, 3.)
The Superior Portion, — This portion of the rectum extends
from the commencement of this organ, at the inferior extrein-
8 THE PHYSICAL EXPLORATION OF THE RECTUM.
itj of the sigmoid flexure of the colon, to the junction of the
third and fourth bone of the sacrum, just where the organ
leaves its peritonaeal investment to curve below the bladder.
It is about six inches long, being the largest portion, and about
half the length of the whole ^organ itself. In its direction
downward, as has already been noticed, it describes a curve,
the convexity of which is turned backward, and corresponds
to the sacrum. Anteriorly it corresponds to the posterior sur-
face of the bladder in the male, and to the uterus and a small
portion of the vagina in the female, and in both sexes to a fold
of the ileum, lodged in the intervening cul-de-sac. It is tor-
tuous, smooth and loosely attached to the left half of the ante-
rior surface of the sacrum by a short fold of the peritonaeum,
the meso-rectum. This portion of the rectum might, with
great propriety, be termed the peritonceal portion, because of
its being completely invested by this membrane.
The Central Portion. — This portion commences where the
rectum leaves its peritonaeal envelop, and begins to pass below
the bladder. It is about four inches long, and its direction is
obliquely from above downward, and from behind forward,
slightly curving in the same direction, the convexity bearing
upward. It is fixed and immovable, and always corresponds
anteriorly to the vagina in the female ; and in the male to a
small portion of the posterior part of the bladder, from which
it is separated downward and outward by the seminal vesicles
and vassa deferentia, and lies in close relation with them.
Towards its termination it corresponds to the prostate gland
and the commencement of the membranous portion of the
urethra, and is in contact with them. In the female it is very
intimately and firmly connected to the vagina by a vascular
network constituting the recto-vaginal septum ; but in the
male it is but loosely connected to the base of the bladder and
prostate gland by a layer of cellular tissue of a soft and lax
character. It differs quite materially in its organization,
structure and attachments from the superior, or free portion,
and being destitute of the peritonaeal covering, except a small
portion on the upper part of its anterior face, over which the
peritonaeum is sometimes extended when the bladder is empty.
The Inferior Portion. — This portion of the rectum com-
mences at the extremity of the coccyx, and terminates at the
THE PHYSICAL EXPLORATION OF THE RECTUM. 9
anal orifice. Its length is about one inch and a half, and its
direction is obliquely downward and backward. This last in-
flection separates it from the urethra in the male, and from the
vagina in the female. It is of greater capacity above than
below, and is surrounded by dense adipose cellular tissue, ex-
cept at its upper extremity in front, where it is closely attached
to the prostate gland. In its lower three-fourths it is com-
pletely invested by the sphinctores ani. This portion of the
rectum might, with great propriety, be termed the anal por-
tion, or anal canal.
3. The Mucous M&mbrcme. The mucous tunic of the
rectum is quite redundant in every direction, but especially
so in the superior portion ; -as it approaches the inferior por-
tion, however, it begins to lose this redundancy to a consider-
able extent, and this is most evident, in its circular direction.
In consequence of its great amplitude, it is, when not dis-
tended, disposed into irregular undulating plicae which usually
assume a transverse direction. It is sometimes, however,
thrown into distinct ridges, which observe a slightly oblique
and circular direction, resembling very much the valvulse
conniventes of the small intestines. This corrugated condi-
tion of the mucous coat of the rectum is purely accidental and
caused by muscular contraction, since there are no valves
naturally furnished this organ. The duplications are not
permanent and may be entirely effaced by distention. They
neither observe any regular form, any regular number, nor
always any particular situation or direction.
4. Columns of the Rectum. The mucous coat of the rectum
after having presented itself in transverse folds, as has already
been observed, begins immediately above the superior margin
of the internal sphincter of the anus, to display itself in par-
allel longitudinal folds, which stand out or project in such a
remarkable manner, as to have obtained from Morgagni the
appellation columns or pillars of the rectum, hence they are
termed by the French — " colonnes dii rectum on de Morgagni ."
(Dictionnaire de Medicine et CMrurgie, p. 701. Paris,
1845.)
These duplicatures are not so numerous and so irregular as
to
THE PHYSICAL EXPLORATION OF THE KECTUM.
the transverse and oblique, nor as the radiated folds of the ex-
ternal integument at the anus. Their dimensions are unequal,
and they vary in number from four to ten or twelve, and when
they are more numerous some of them are rudimentary.
Their number and position, to a considerable extent, appear
to be fixed, by the peculiar terminal arrangement of the longi-
tudinal muscular fibres. They diner from the other mucous
folds of the rectum, by being formed of the mucous, as well as
of the adjacent cellular tissue and the longitudinal muscular
fibres, which give them additional density and strength ; by
their not being alone the result of muscular contraction ; and
by their not being capable of entire obliteration by distention.
These columnce after entering the anal canal and proceeding
downwards, diminish in size and terminate rather abruptly in
rounded extremities just above the inferior margin of the inter-
nal sphincter of the anus. They somewhat resemble the lon-
gitudinal duplications of the ossophagus.
FIG. 4.
[A vertical section of the parietes of the rectum, showing the bases of the columns of
Morgagni, and the lacunae or sacculi of the rectum. 1. The bases of the columns. 2. The
lacunae.]
5. Lacunce of the Rectum. (Fig. 4.) In the sulci formed by
the columns of the rectum, another arrangement of the mucous
coat takes place, which is always, however, most remarkable
at the termination of the sulci immediately below the inferior
margin of the internal sphincter ani. At this point membra-
nous folds, more or less numerous, of a semi-lunar form, present
themselves, their number corresponding to that of the grooves
THE PHYSICAL EXPLORATION OF THE RECTUM. 11
themselves, and their direction being usually transverse, though
sometimes, but rarely, oblique. These folds, occurring as they do,
at the lower end of the grooves, and between the columns, have
each of their ends attached to the base of one of these columns,
and their free and curving margins directed from below up-
ward, thus forming a series of narrow semi-lunar lacunae or pits,
varying in depth from one to four lines, and the orifices of
which presenting upward, whilst their bottoms are directed
downward. These lacunae or sacculi always contain more or
less mucus furnished them by the glands of the vicinity, and
ready to be poured out for the lubrication of the lower portion
of the anal canal, whenever they are compressed by the act of
extruding the fecal matter. Distention of the canal com-
presses them, but it does not entirely obliterate them. By
pressing them firmly at any time, a little viscid mucus may be
seen to issue from them. They have certain physiological and
pathological relations which are not necessary to notice here.
The existence of these lacunas or sacs in the lower portion
of the anal canal, has at an early day, been recognized by some
of the old anatomists. Astruc says that, — " In the margin of
the anus itself, several short ducts, or rather lacunae appear
which convey a viscid humour." (A Treatise on the Fistula
of the Anus, p. 6. London, 1738.) Winslow also notices them
in the following concise manner : — " Near the extremity of this
intestine (rectum) the rugae or folds become in a manner lon-
gitudinal and at last, towards the circumference of the inner
margin of the anus, they form little bags, or semi-lunar lacunae,
the openings of which are turned upward toward the cavity of
the intestine. These lacunae are sometimes like those at the
lower extremity of the ossophagus, or upper orifice of the
stomach." (An Anatomical Exposition of the Structure of the
Human Body. English translation. By G. Douglas, M. D.,
Vol. IL, p. 148. London, 1732.) Cruveilhier also mentions
these lacunae. He says that, — " The point at which it (the
skin) becomes continuous with the mucous membrane is de-
serving of notice ; it is within the rectum, at the distance of
some lines from the anus properly so called, and is marked by a
waved line, which forms a series of arches, or festoons, having
their concavities directed upward. Sometimes there are small
pouches in the situation of these arches opening upward.
2
12 THE PHYSICAL EXPLORATION OF THE KKOTUM.
From the angles at which the arches unite, some mucous folds
proceed, and small foreign bodies detached from the fteces, are
often retained in the cul-de-sac, and become the causes of fis-
tulas." (The Anatomy of the Human Body. Translated by
G. 8. Pattison, M. D., p. 380. New To/A, 1844.) H.
Cloquet also describes these lacunae very correctly. He says,
— " Entre ces colonnes, il existe presque constamment des
replis semi-lunaires membraneux, plus ou moins nombreux
obliques ou transverses, dont le bord est diringe de bas en
haut du cote de la cavite de I'intestin. Ces replis forment des
aspeces de lacunes dont le fond est etroit et tourne en bas."
(Traite d?Anatomie, tome II. , p. 343. Paris, 1822.) John
Bell, doubtless, alludes to these lacunae, under the phrase,
notched-like irregularities, when he says, — " Towards the anus
the folds become longitudinal, and terminate in the notched-
like irregularities of the margin." ( The Anatomy and Physi-
ology of the Human Body. Vol. III., p. 234. New York,
1817.) Horner also describes them. He says, — " At the
lower end of the wrikles, between the columns are small
Jxmches of from two to four lines in depth, the orifices of
which point upwards ; they are occasionally the seat of disease,
and produce when enlarged, a painful itching." (Op. tit., p.
47.) Some anatomists have failed to discover these lacunas,
and, consequently, have concluded that they do not exist. In
the numerous examinations I have made of the lower end of
the rectum, I have never failed to observe them. I have
generally found them more fully developed in the negro, and
to be larger and more open in the dog and in the rabbit.
They, doubtless, are normal and constant.
6. Are there Veritable Valves in the Rectum f I must here
observe that a question of no small importance to the rectal
explorer has arisen among eminent anatomists respecting the
existence or non-existence of valves in this organ. The pecu-
liar valve-like arrangement of the mucous membrane of the
rectum, already mentioned, has led some anatomists to infer
and to endeavor to prove that there are veritable valves in
this as in the small intestines. Cheselden among the old
anatomists alludes to valves in this organ. When speaking of
valves in the colon, he says, — " but as the gut approaches the
THE PHYSICAL EXPLORATION OF THE RECTUM. 13
anus, they (the valves) become less remarkable and fewer in
number." (Anatomy of the Human Body, p. 159. London,
1778.) Morgagni observes that he found valves in two sub-
jects, situated about a finger's breadth above the anus. The
form of the valves in one, he says, was circular, and in the
other transverse. (Adversaria Anatomica HI. Animad-
versio VI., p. 10. Lungduni Batavorum, 1723.) Portal also
speaks of these folds in the following language : — " Mais on
remarque a son extremite inferieure pres de 1'anus, divers
replis de sa lame interne, lequels forrnent des especes de valvu-
les rangees a peu pres circulairement. Glisson, qui les a
reconnues, les nomment les valvules semi-lunaires. La mem-
brane interne qui constitue ces replis se relache et se prolonge
quelquefois au point de former un bourlet qui s'oppose a la
sortie des excrements." (Cours d' 'Anatomie Medicale.
Paris, 1803.) The idea of calling these small folds valves,
and then of their becoming relaxed and prolonged, except in a
diseased state, so as to form a barrier or an obstruction to the
passage of the faeces, is, to say the least of it, hypothetical. If
ever such cases occur, they must be rare indeed. M. Boyer
seems to verify the description of Portal. He says, — " Quel-
quefois mais rarement, au lieu des replis semi-lunaires dont il
vient d'etre parle, on trouve de veritables valvules qui bouchent
en quelque sort 1'extremite inferieure du rectum." (Traite
d'Anatomie, tome IV., p. 377. Paris, 1815.) Wilson says,
— " In the csecum and colon the mucous membrane is smooth,
but in the rectum it forms three valvular folds, one of which
is situated near the commencement of the intestine ; the second
extending from the side of the tube, is placed opposite the
middle of the sacrum ; and the third proceeding from the
front of the cylinder is situated opposite the prostate gland."
(The Dissector. Edited ly P. B. Goddard, M. D., p. 52.
Philadelphia, 1844.) Horner says that, — " At a correspond-
ing part on each side of the gut in its interior, exists a trans-
verse doubling of the mucous membrane, forming the valvula
connivens alluded to. The result of this arrangement is a
semi-circular valve on each side, one above the other, the mar-
gins or diameters of which pass each other, in the empty and
contracted state of the rectum, but touching at the same time,
and they present an additional barrier to the involuntary
14 THE PHYSICAL EXPLORATION OF THE RECTUM.
evacuation of faeces." (Special Anatomy and Histology, Vol.
II., p. 47. Philadelphia, 1851.) Meckel speaks of several
kind of fishes which present very analogous transverse folds or
valves, as he terms them. He says they are often very numer-
ous and occupy the end of the intestinal canal. (JDeutsckes
Archiv fur die Physiologic, Band TIL, II. 11.)
The first anatomist, however, who called especial attention
to a valvular arrangement of the rectum was Mr. John Hous-
ton, of Dublin, curator of the Museum, and one of the demon-
strators in the school of the College of Surgery in Ireland.
This he did in a very able practical paper, entitled " Observa-
tions on the Mucous Membrane of the Rectum," inserted in
the fifth volume (1830) of the Dublin Hospital Reports.
Mr. Houston states that the tube of the rectum does not
form, as is generally conceived, one smooth uninterrupted
passage, it is on the contrary, made uneven in several places
by valvular projections of its mucous membrane, standing
across the passage. In a physiological point of view, he con-
siders that these valvular projections are necessary to support
the weight of faecal matter, and prevent its urging towards
the anus and exciting a sensation demanding its discharge.
Viewed pathologically, he believes that they explain the resist-
ance given to the introduction of bougies : that their arrange-
ment indicates the necessity of employing a spiral-shaped,
instead of a straight bougie ; that they may possibly become
the most frequent seat of stricture ; that they have often been
mistaken for strictures, and by leading to the frequent practice
of bougies, have brought on the very malady intended to be
removed ; that they have been entirely overlooked by all
authors who have treated of diseases of the rectum, and have
only been cursorily alluded to by M. Cloquet and some other
anatomical writers, &c.
After stating that there are usually three or four of these
valves, Mr. Houston proceeds to describe them as follows : —
" The position of the largest and most regular valve is about
three inches from the anus, opposite the base of the bladder.
The fold of next most frequent existence is placed at the upper
end of the rectum. The third in order occupies a position
about midway between these, and the fourth, or that most
rarely present, is attached to the side of the gut, about one inch
THE PHYSICAL EXPLORATION OF TUB KECTUM. 15
above the anus. In addition to these valves, of tolerably reg-
ular occurrence, there are frequently several intermediate
smaller ones, but which from their trifling projection and want
of regularity in their situation, merit comparatively little
notice.
" The form of the valves is semi-lunar ; their convex
borders are fixed to the sides of the rectum, occupying in their
attachments from one-third to one-half of the circumference of
the gut. Their surfaces are sometimes horizontal, but more
usually they have a slightly oblique aspect, and their concave
floating margins, which are defined and sharp, are generally
directed a little upwards. The breadth of the valves about
their middle, varies from a half to three-quarters of an inch
and upwards, in the distended state of the gut. Their angles
become narrow, and disappear gradually in the neighboring
membrane. Their structure consists of a duplicature of the
mucous membrane, enclosing between its laminae some cellular
tissue, with a few circular muscular fibres.
" The relative position of the valves, with respect to each
other, deserves attention. That situated opposite the base of
the bladder, most commonly projects from the anterior wall of
the gut ; the valve next above from the left, and the upper-
most from the right wall ; that near the anus, which is of least
frequent occurrence, occupies a place when present towards
the left and posterior wall. Many deviations from these stated
points of attachment for the folds will be found to occur, but
the arrangement is nevertheless always such, as to form by
their being placed successively on different sides of the gut, a
sort of spiral tract down its cavity.
" In regard to the sacculated form which the rectum ac-
quires by the presence of these valves, the gut resembles some-
what the colon in the condition of its interior, but in the pecu-
liar spiral arrangement of the valves, it bears more an analogy
to the large intestine of some of the lower animals, in which,
as for example, the caecum of the rabbit, the large intestine of
the serpent and dog-fish, a continuous spiral membrane traverses
the cavity from end to end, and gives to the alimentary matters
a protracted winding course towards the anus."
Mr. Houston further remarks, — "My attention was first
called to these valves by preparations which I made to demon-
16 THE PHYSICAL EXPLORATION OF THE RECTUM. *
strate the relative situation of the pelvic viscera, and to display
the natural state of their cavities ; and from the manner in
which the making of these preparations was conducted, viz. :
— by distending and hardening all the parts with spirit, pre-
viously to being cut open, the valvular condition above alluded
to, was most satisfactorily exhibited." He further says, —
" This is the only method by which the condition of these
valves in the distended state of the rectum can be displayed,"
and that " by the ordinary procedure of extending it, after re-
moval from the body, the valves are made to disappear."
Again, speaking of these so-called valves, he says, — " Their
presence may likewise be ascertained in the empty state, if
looked for soon after death, and before the tonic contraction of
the gut has subsided. They will then be found to overlap
each other so effectually, as to require a considerable man-
oeuvre in conducting a bougie or the finger along the cavity of
the intestine."
I have quoted quite sufficient from this ingenious author to
present him fairly, and I hesitate not to say at once that in my
opinion he has entirely failed to establish the verity of his
statements, that the folds or projections of the rectum are
genuine valves ; that they are sufficiently strong to bear the
whole weight of the faecal mass, and to retard its downward
movement and cause it to take a winding direction ; and that
they exert great opposition to the introduction of the finger,
the bougie or any other instrument not in the shape of a cork-
screw.
The anatomical evidence against the existence of veritable
valves in the rectum is corroborated by numerous facts, a few
of which I will now adduce.
I maintain that the irregular folds of the mucous membrane
of the rectum, supposed to be valves by the several authors I
have named, are not permanent, but purely accidental, and
are caused by the partial contraction of the intestine. This
can be verified by any one, by carefully examining this mem-
brane in the same subject on different days, at such time when
the rectum is not distended ; and these folds will be found
each time to be more or less changed in appearance, and to
occupy different situations. Not so with veritable valves any-
where in the body.
THE PHYSICAL EXPLORATION OF THE RECTUM. 17
I further maintain that valves, such as described by Mr.
Houston, capable of supporting the whole weight of the fsecal
matter collected in the rectum, and of resisting the introduc-
tion of the bougie or the finger, would most certainly be easily
distinguishable and demonstrable in the living body ; and in the
dead body the removal of the organ ought not to obliterate them,
but on the contrary, that they should be capable of being demon-
strated easily, and at any period previous to decomposition.
I deny most positively that these plicae, except in an indu-
rated or diseased state, are ever firm and unyielding ; on the
contrary, they are soft, pliable and unresisting, being easily
displaced by a proper size bougie, or, if in reach, by the ex-
tremity of the index finger, either being well lubricated, and
gradually introduced into the rectum. Should there be resist-
ance, it will be found not to be occasioned by valves, but
either by faecal accumulation, by the promontory of the sacrum,
by contraction of the rectum, by one or more tumors, by chronic
irritation or inflammation of the mucous lining, by spasm in
nervous and irritable subjects, &c. I have often found that a
small size rectal bougie, say a number two English, will be apt
to become hooked or entangled in these folds or superabundant
membrane, whilst one of a much larger size will so dispose of
them as to pass readily. A small sound, as a general rule, the
organ being in a normal and healthy state, will often encounter
much more resistance than a larger one, as any one must have ex-
perienced who has frequently sounded the rectum or the urethra.
Veritable valves contain muscular fibres and are capable of
firmly constricting the bowel, and can never be entirely effaced
by distension, I care not how far it is carried in length and in
width ; not so these irregular folds, for they may be completely
defaced by this process. In my anatomical investigations, I
have found in the small intestines, independent of the valvulse
conniventes, precisely such a valve-like arrangement of the
mucous tunic, which may also be entirely effaced by disten-
sion. Others have discovered and reported the same.
A very important office of the valvulse conniventes is doubt-
less to prevent the alimental mass from passing along the intestine
too rapidly, before its nutritive particles are taken up by the ab-
sorbents, which it would'otherwise readily do, being quite fluid.
The greater development of these valvulse in the superior por-
18 THE PHYSICAL EXPLORATION OF THE RECTUM.
tion of the small intestines is a curious phenomenon, since the
fluid contained in this portion possesses the most nutritious
properties. Yalves, besides delaying the substances in the
intestinal canal, also prevent the regurgitation or reflux of its
contents, provided they are fluid or gaseous. The reflux of
consistent faecal matter, however, is impossible. From these
considerations a very strong inference may be drawn that there
is no necessity for valves in the rectum, inasmuch as the faecal
mass, before reaching this point, has been entirely deprived of
its nutritious as well as fluid properties, and merely being ar-
rested here and detained, not by valves but by the sphinctores
ani muscles, to await its final expulsion.
Veritable valves sufficiently large and strong to obstruct or
dam up the inferior extremity of the rectum, is simply ridicu-
lous ; such never have, and in my opinion never can be demon-
strated, the able authorities I have quoted to the contrary not-
withstanding. I admit that these accidental folds of the rectum
resemble the valvulse conniventes of the small intestines, that
they look like valves ; yet they lack the essential attributes,
and consequently are not valves.
The foundation of Mr. Houston's error in relation to these
folds of the mucous membrane of the rectum, was his peculiar
method of investigation. He did not examine this membrane
in its natural state ; indeed, his procedure was anything but
natural, although he intimates that it is the only method by
which the condition of these valves, as he calls them, can be
displayed. Now it is well known to anatomists that such a
mode of proceeding is entirely unnecessary to the exhibition
of the valvulae conniventes, or of any valves in the body ; that
such valves were never discovered and demonstrated by such
a process. The following remarks of Dr. Bushe upon this
point are so just, that I will quote them. " With all due defer-
ence to Mr. Houston, I would beg to remark that his misap-
prehension of this piece of anatomy has arisen from his
methods of investigation : one by filling the intestine with
alcohol, and then opening it ; the other by inflation and drying.
In the first the accidental folds are rendered permanent by the
induration resulting from the action of the alcohol ; while in
the second, the projections resembling valves are produced by
the angles formed by the setting of the intestine during the
process of dessication." (Op. Git. p. 13.)
SECTION III.
PHYSICAL EXPLORATION.
1. In the diseases of the rectum and anus, the diagnosis is
principally determined by a visual and a tactile examination
of the parts. The proper instruments to be employed for this
purpose are the index-finger of the right hand, the 8peculv/m
ani, the rectal endoscope, the rectal exploring sound, the rectal
bougie, a gas or oil lamp with a reflector and a lens attached,
a suitable silver probe for the exploration of fistulas, fissure,
&c., and an acupuncture or exploring needle, or a small trocar,
to test the character of ambiguous swellings or fluid collections,
when met with in these parts. By this last-named instrument
we are enabled at once to determine whether fluid exists or
not in such, and, if it does, whether it is pus, serum, or blood.
2. Digital and Specular Examination. — In the inferior
portion of the rectum the principal information may be ob-
tained by the digital examination alone. By means of the
practiced finger, moved about in different directions within
the canal, tumors, foreign bodies and ulcers may readily be
detected when within reach, and their locality, size and char-
acter accurately determined ; by it, too, contractions of the
passage may also be discovered, when low down. Indeed, the
examination with the finger will generally enable the surgeon
to satisfy himself most fully as to figure, texture and tendency.
It cannot be expected, however, that practitioners in general,
who necessarily have not the opportunities of acquiring the
tactus erudinis, should be expert in determining by the finger
alone the true condition of the case. This knowledge can
only be acquired by time and extensive practice and experi-
ence.
The hand is sometimes used to explore the rectum, and aus-
cultation and percussion may also be advantageously employed
as diagnostic measures in diseases of this organ.
20 THE PHYSICAL EXPLORATION OF THE RECTUM.
3. Preliminary Steps. — Preparatory to making a thorough
inspection of the rectum, and a few hours previous, this intes-
tine should be completely emptied by either a dose of castor
oil, or a relaxing enema, or by means of both. The patient
should be requested to empty the bladder also. Should there
exist, as is sometimes the case, exquisite sensibility of the anus
and anal region, especially when attended by pain and spasm
of the anal sphincters, the patient for examination should
always, if nothing contra-indicates it, be put under the influ-
ence of sether or chloroform ; for without its use, it -would be
impossible, in such a state of the parts, to make any satisfactory
exploration. By its influence, the spasm of the excitable mus-
cles yields, and a thorough examination may be made, which
otherwise could not be without subjecting the patient to intense
suffering and distress. In such cases, instead of the ansesthetic,
I sometimes administer the following suppository an hour
before the examination, which usually has a most soothing,
relaxing and happy effect : —
Recipe, Extract! Belladonnas, granum unam,
Morphias Sulphatis, granum dimidiam,
Butyri Cacao, scrupulum.
Misce et fiat suppositorium.
4. Position of the Patient. — The rectum and the bladder
being both completely emptied, the patient should be placed
upon his left side, on the edge of a bed or table, at least two
feet and a half high, in front of a strong light ; the back and
hips as near the edge as possible ; the pelvis elevated, the
head and shoulders depressed, and the thighs flexed upon the
abdomen ; and in this position he should be anaesthetized, if
deemed necessary. Should the peculiar nature of the case,
however, require it, the patient may be placed precisely in the
position for lithotomy ; or, if a male, he might lean over the
back of a suitable chair, with his hands resting on the front
edge of it, his head being depressed and nates elevated ; or
place himself across a bed on his hands and knees, with his
head depressed. Whatever position is selected, a strong light
is indispensable to success, especially when the speculum is to
be used.
The surgeon being placed in an easy and convenient posi-
THE PHYSICAL EXPLORATION OF THE RECTUM. 21
tion, with his right arm next to the patient, who occupies the
first position named, should proceed to make the examination,
either with the right index-finger, the hand, the speculum, the
endoscope, the sound, the bougie, the probe, or any other in-
strument, or of each one of these in turn, if requisite.
5. The Index-Finger. — The index-finger of the right hand,
after paring the nail smoothly, and being warmed and well
lubricated with either cacao butter, cold cream, the white of an
egg, olive oil, or castile soap, should be gently and gradually
insinuated into the anus and anal canal. Any attempt to
penetrate roughly or rapidly will be very liable to excite
resistance from the anal muscles, and the passage of the finger
or other instrument in such manner would occasion more or
less suffering or after distress, and greatly interfere with the
progress of the examination. In the use of the finger, it is
well to know, that by introducing it from behind, the surgeon is
enabled to push it much further into the canal than if he intro-
duced it from before or laterally ; and it is also worth know-
ing, that a tumor or a stricture of the rectum, when beyond the
reach of the finger, may sometimes be pressed down within
reach of it, by the patient making defecating efforts.
6. Palpation. — In order to arrive at a positive diagnosis in
certain morbid conditions of the rectum or other pelvic viscera,
whether in reference to congenital malformations or to morbid
growths, &c., the right hand should be used. This method of
exploring the rectum is of great importance in some instances,
and will avail much in determining with certainty the real
state of this or the contiguous organs. The hand, being
warmed and well lubricated, should be gradually and carefully
introduced into the anus and anal canal, with the backs of the
fingers and the knuckles presenting to the hollow of the
sacrum, up which it will glide, as soon as the knuckles have
passed the sphinctores ani, by dilating them, and entered the
rectal pouch. It is remarkable how dilatable the anus and
the anal canal are.
7. Speculum Ani. — It is essentially necessary, however, in
many instances, especially in some morbid conditions of the
22 THE PHYSICAL EXPLORATION OF THE RECTUM.
mucous lining of the rectum inappreciable by the touch, to
add to these excellent means of exploration the use of the specu-
lum ani or rectal endoscope, which enables the surgeon to
judge of the disease by ocular inspection. By the aid of
these instruments he is enabled to appreciate the exact size,
shape, color and appearance of the lesion in the affected parts
— thus being in full possession of the facts as to the actual ex-
istence, situation and general appearance of such lesion. The
speculum ani is not only made available for diagnostic, but for
therapeutic purposes also. It may be used to great advantage
in some of the operations on this organ, as well as in making
caustic applications to diseased portions of its mucous lining, etc.
The anal speculum or endoscope is contra-indicated in acute
inflammation of the anus or the rectum, or when, by the touch,
the existence of extensive carcinomatus degeneration of the
rectum has been ascertained. In epithelioma, if the symptoms,
— such as continued severe pain and a constant discharge of a
sanio-purulent matter — show that extensive ulceration has
attacked the parts, it is useless and even hurtful to introduce
the speculum, bougie or sound, and indeed, in such a case, the
less interference, even with the finger, the better.
The speculum which I most commonly use is the bi-valve
instrument (represented by Fig. 5). It may be made of polished
FIG. 5.
steel or silver-plated. The only objection that can be urged
against this instrument is, that in instances in which there is a
superabundance of mucous membrane and integument at the
anal extremity of the rectum, it too readily permits their pro-
trusion between its blades, and thus more or less prevents an
accurate inspection of the parts. No straight speculum ani
should exceed four or four-and-a-half inches in length.
THE PHYSICAL EXPLORATION OF THE RECTUM. 2o
I usually make the digital examination first, before using the
speculum ; the finger dilates the anus and anal canal and pre-
pares the parts for the easy entrance of this instrument. The
speculum, like the finger, should be warmed and well lubricated
before being introduced ; it should then be inserted into the
anus, and gently and slowly directed a little forward and upward
for about one inch and a half, as if to pass from the perinseum
to the umbilicus, in order that it may follow the course of the
anal canal ; having reached this depth, which is a little greater
in the male than in the female, the point should then be in-
clined backward, first slightly, and afterwards to a greater
extent, and thus follow the curve of the sacrum, until the in-
strument is fully in ; it should then be opened and rotated
until the whole mucous surface of the lower end of the bowel
is clearly brought into sight. Should the view be obstructed
in the least, by either mucus, blood or faeces, a small mop,
made of fine sponge, and attached to the end of a rod, should
be at hand to remove any of these matters. The speculum
should then be carefully withdrawn with its blades partially
open.
I have found the tri-valve trellis speculum ani (represented
by Fig. 6,) a very valuable instrument for the purpose of discov-
ering fissures and other ulcers of the rectum. I devised it a
number of years ago, as an instrument to be used in detecting
the bleeding vessel in case of traumatic haemorrhage of the
rectum. It is small when closed, and easy of introduction,
and when introduced admits of extensive expansion by simply
revolving the handle.
24 THE PHYSICAL EXPLORATION OF THE RECTUM.
As an anal speculum, especially in cases of fissure of the
anus, I have also found the simple and highly polished steel
instrument, in the form of a large blunt gorget (as delineated
by Fig 7), very efficient and valuable. It is passed up into
FIG. 7.
the rectum on the finger with its concavity looking towards
the seat of the disease, and when in to the depth of two and a
half or three inches, the mucous surface of the canal at that
height can be plainly seen reflected on its polished concave
surface ; at the same time the lower portion of the canal can
be most accurately examined by the eye alone, by causing the
patient to evert the anus as much as possible. By passing
this instrument gently and slowly around the canal, the whole
internal surface of it may thus be accurately inspected. It
requires a strong and bright light. The idea of using an in-
strument of such a form was first suggested by the late and em-
inent Mr. Colles of Ireland, who objected to the various kinds
of anal speculae in common use, and employed for this purpose
the large blunt gorget, and found it superior to any other.
He subsequently made an improvement on it. In order to
introduce it with greater facility, he accurately fitted it to one
side of a conical piece of polished box -wood representing in its
transverse section a full ellipse, so that when both were joined
they presented a perfectly smooth outline. After the instru-
ment thus united was introduced to the proper depth, the
wooden plug was withdrawn. (Dublin Hospital Reports,
Vol. V., p. 155. Dublin, 1830.)
The instrument I designed is easy of introduction upon the
finger without the use of the plug. A somewhat similar in-
strument was designed by Mr. Mudge of England, in 1789, for
THE PHYSICAL EXPLORATION OF THE RECTUM. 25
facilitating the operation for anal fistula. (Memoirs of the
Medical Society of London, Vol. IV-, p. 16. London,
1795.)
On a dark day or whenever a strong light is required
in making rectal examinations, I always use the portable ap-
paratus (depicted in Fig. 8). It consists of a lamp with a
FIG. 8.
G.TLEMAHN & CO.
reflector and a lens attached. It can be used for gas, oil or
any other illuminating material. This apparatus is indispens-
able when the endoscope is used.
.8. Recto-Colonic Endoscope. I have thus denominated the
instrument by the use of which and a powerful light, the
superior portion of the rectum and inferior part of the sigmoid
flexure of the colon may be accurately and minutely examined.
It renders accessible to inspection a portion of the intestinal
canal, a part of the iliac colon, which has heretofore been
shrouded with impenetrable darkness, and which is so often
26 THE PHYSICAL EXPLORATION OF THE RECTUM.
the seat of disease. This instrument (represented by Fig. 9)
FIG. 9.
G.TIEMANW-CO.NY.
[1. The endoscope ready to be introduced, with the conductor in situ. 2. The
endoecope in the colon, with the internal mirror in situ. 3. The internal reflecting
mirror.]
is the result of the conjoint labors of the author and the in-
genious Mr. Stohlmann, of the firm of Messrs. George Tiemann
& Co., surgical instrument makers, New York. It consists of
a hollow cylinder, fourteen inches long and seven-eighths of an
inch in diameter, made of steel or German silver, the interior
of which being highly polished. Four inches of the proximal
end is solid, the remainder is flexible, so as to be capable of
adapting itself to the curve of the rectum and that at the junc-
tion of the rectum and colon. To facilitate the introduction
of the instrument, it is supplied with a conductor, consisting
of a slender whalebone rod about two inches longer than the
cylinder itself, to the end of which is fastened a conical piece
of ivory, ebony or hard rubber, an inch and a half long, and
of such diameter as to pass into and out of the cylinder -with
ease, and to project at least an inch beyond the distal end of it.
With the conductor thus in situ, the instrument is warmed, lu-
bricated and introduced to the desired height, and the conduc-
tor then withdrawn. The instrument is also furnished with
an internal reflecting mirror, fixed on the end of a wire rod at
least thirteen inches long. The mirror being attached to the
rod by a movable joint, enables it to be easily adjusted to any
desirable angle. The internal mirror is only used when the
inferior part of the sigmoid flexure of the colon is to be ex-
amined. It must be introduced into the cylinder as far as the
angle formed by the junction of the rectum and colon, at which
THE PHYSICAL EXPLORATION OF THE KECTUM. 27
point, if properly placed and adjusted, the mucous surface of
the inferior portion of the iliac colon for some distance beyond
may be plainly seen reflected in it, when the focus of light
from the external reflector is thrown upon it.
As this instrument was gotten up with considerable haste, it
may, upon further trial, be found to need some improvements.
9. Rectal Eversion as a Means of Diagnosis. Professor
Horatio R. Storer, surgeon to the Franciscan Hospital for
women, at Boston, repudiates the anal speculum as a means of
diagnosis in the rectal diseases of females, and substitutes for it
rectal eversion. The modus operandi of this proceeding, ac-
cording to him, is as follows : — " By passing the finger into
the vagina, and pressing it backward and downward over the
levator ani, the rectum can be everted through its sphincter,
like the finger of a glove. This can ordinarily be done to
a very great degree, it can always be done to a certain
extent. Should the sphincter be unusually irritable, and
spasmodically contracting with violence when touched from
below, or thus from above, it can be forcibly distended
by the thumbs, and temporarily ruptured, as I am in the habit of
doing in such cases ; the procedure above indicated thus be-
coming easy. We can in this manner ascertain the presence
of a chancre or chancroid, the character of polypi, the extent
and number of internal haemorrhoids, the position of the inner
orifice in fistula, &c., with far greater certainty and alacrity
than by the speculum, or can be done in the male, while the
mere eversion process, provided rupture of the sphincter is not
necessary, is attended by very little pain." (American Jour-
nal of Obstetrics. Vol. I., p. 71. New York, 1869.)
This expedient of Dr. Storer can only be made available to
the extent of the rectal eversion and no further. If the rectum,
therefore, cannot be everted to its full length, the speculum and
endoscope cannot be altogether dispensed with. He says the
rectum can be ordinarily everted through the sphincter like
the finger of a glove. Now, if he means what his language
implies, that the entire organ with its several coats can be so
everted, I do not agree with him. I cannot conceive how this
can ordinarily take place to any considerable extent, or to
such an extent as to dispense altogether with the rectal specu-
lum. I maintain that eversion of the rectum, under the most
3
28 THE PHYSICAL EXPLORATION OF THE RECTUM.
favorable circumstances, is only partially practicable. The
firm union of this intestine with the surrounding parts, the
longitudinal direction of its strongest and most numerous
fibres, together with the action of the levatores ani muscles,
offer too great a resistance ordinarily to the descent of but a
very limited portion of the rectum. A small portion of the
organ being acted upon by firm and severe pressure from with-
in the vagina, may be made to descend in an inverted state
through that part of the canal embraced by the anal sphincters,
leaving this lower or embraced portion, however, about one
inch and a half unmoved from its situation, and unaltered in
its connections with the surrounding parts. If Dr. Storer,
however, means by rectal eversion, eversion of the mucous
lining only of the rectum, then his procedure is a little more
plausible and will be found a little more practicable. This
membrane, for some distance above the anus, adheres but
slightly to the muscular coat, their connection being effected
by means of a very lax cellular tissue. The mucous tunic of
the rectum, then, in consequence of its great amplitude and
elasticity, and its very loose connection, may, indeed, be more
readily everted, and to a greater extent than the rectum itself.
But neither the eversion of the rectum nor its mucous mem-
brane can ever take place to the extent of superseding the use
of the anal speculum as an indispensable means of diagnosis in
the rectal diseases of females.
In connection with rectal eversion, Dr. Storer recommends
the rupture of the anal sphincter as a diagnostic measure, and
speaks of it as flippantly as if the operation and its conse-
quences were as trifling in their nature as the mere breaking
of a lady's garter or apron string. From the great capacity of
the anus and anal canal naturally for dilatation, I positively
assert that they can always be most readily, speedily and
safely dilated under the influence of anaesthetics or belladonna,
without carrying the dilatation to the extent of rupturing the
anal sphincter, or causing any injury whatever to the integrity
of the parts. This breaking of the anal sphincter then, merely
as a diagnostic measure, as advised by Dr. Storer, is, in my
opinion, not at all justifiable under the circumstances. It is
bad enough, in all reason, when practiced as a therapeutic
measure.
THE PHYSICAL EXPLORATION OF THE KECTUM. 29
10. Splanchnoscopy by Translucency . — This method of ex-
ploration is attracting great attention at present, and, if ever
perfected, might be made available in the examination of the
rectum. The method of illumination by translucency, as
advocated by M. Milliot, who demonstrated it to the late Inter-
national Congress in Paris, at one of its evening sessions, con-
sists in introducing into the stomach or rectum, glass tubes, of
small caliber, containing two platinum wires, connected with
the electrodes of the galvanic apparatus of Middeldorpff of
Breslau. It is in this manner that an intense illumination
may be transmitted into the visceral cavities, rendering them
translucent. At any rate, this artificial illumination, even if
it does not result in rendering the walls transparent or rather
translucent, might be made available in exploring or in operat-
ing upon the rectal, vaginal, buccal and nasal passages.
I have seen it stated, in a late number of the London Lan-
cet, that Dr. Richardson exhibited, at the British Society for
the Advancement of Science, a lamp which he had constructed
for transmitting light through the structures of the animal
body. He believed that the idea that this could be effected
was given in Priestley's Work on Electricity ; that great
chemist had observed, on passing a discharge of a Leyden bat-
tery through his finger, that the structure seemed to present
luminosity ; but the operation was painful. A suggestion of
Dr. Mackintosh, last year at Dundee, had been acted on by
Dr. Richardson, who had observed the motion of the heart
and of respiration by direct ocular demonstration, while these
organs were under the influence of various bodies belonging
to the ethyl and methyl series. Dr. Richardson had so far
extended the principle, that he was enabled to transmit light
through various tissues of the bodies of large animals. The
particular details of all these interesting and elaborate experi-
ments he described. In a child, the bones could be seen in
the arm and wrist. The movements and outline of the heart
could also be seen in the chest.
The numerous experiments now being made on the subject
of the transmission of light through the tissues of the body,
rendering them translucent, may ere long lead to the most
startling and wonderful discoveries.
30 THE PHYSICAL EXPLORATION OF THE RECTUM.
11. Exploration with the Probe. — In making anal and rec-
tal examinations, I sometimes use the silver probe alone (Fig.
FIG. 10.
G.U&MANN-CQ.
10). It is seven or eight inches long, and is valuable for de-
tecting blind external, internal and complete anal fistulae,
anal fissure, f*5 well as sacculi of the anus. The use of it obvi-
ates the necessity, generally, of distending the anus with the
fingerorthe speculum, hence the extreme suffering consequent
upon such distention, especially in anal fissure, is entirely
avoided. No anaesthetic generally need be employed. In
searching for anal fissure I use the probe slightly curved at its
distal end (Fig. 11). It should be dipped in olive oil or gly-
FIG. 11.
cerine, and gently introduced several inches up the canal ;
then it should be brought down gradually, with its curved
point pressing upon the side or wall of the canal, and as soon
as it comes in contact with the fissure, the patient will at once
manifest it by the sensation of pain he will experience. This
exploration with the probe may be continued around the whole
circuit of the canal, until the fissure or ulcer is detected. In
searching for occult or blind internal fistulas and preternatural
pouches of the anus, I also use a hooked probe, for they are
most easily detected by such an instrument. About half or
three-fourths of an inch of the distal end of the silver probe
should be bent back upon itself so as to form a kind of hook
(Fig. 12), somewhat like that already recommended for search-
FIG. 12.
THE PHYSICAL EXPLORATION OF THE KECTUM. 31
ing for anal fissure. The probe thus bent should be passed up
the canal three or four inches, and brought slowly back with
the point bearing successively on the different parts of the cir-
cumference of the rectum. Should an occult fistula or a sac
exist, the reverted point of the probe will pass into its orifice
and cavity, and render its existence and character 'at once
sufficiently obvious.
SECTION IY.
SOUNDING THE RECTUM.
1. Sounding the rectum and sigmoid flexure of the colon,
as the operation may be termed, is sometimes attended with
considerable difficulty. It is an operation which requires
practice, accurate anatomical knowledge, and a certain number
of precautions.
The operator must bear in mind that the rectum in its
course through the pelvis lies in close relation with the pros-
tate gland, vesiculce seminales, bladder and urethra, in the
male, and with the uterus and the vagina in the female ; and
he must also bear in mind the very important fact that this
intestine pursues a course by no means straight, as its name
imports, but that it is more or less curved, both in its antero-
posterior and lateral direction, hence in the introduction of the
finger, the pipe of the enema syringe, the bougie, the sound,
&c., it should be directed at first upward and forward, and
then upward and backward. In the child, however, this pre-
caution is not so necessary, for in it the course of this intestine
is not so much curved, the name rectum being then more ap-
propriately applied than in the adult. The introduction of in-
struments into the rectum, therefore, requires not only a
knowledge of the curve which this intestine takes, but of the
axis of the pelvis also. Particular attention should be paid to
the disposition or direction of the rectum, as an anatomical fact,
from which important practical inductions of the greatest in-
terest may be derived, especially as leading to a much greater
accuracy of diagnosis on the part of the surgeon.
The surgeon, too, must not forget that the mucous lining of
the rectum is quite delicate and highly sensitive, and very
liable to be injured by any rough manipulation. In consider-
ation, therefore, of these several facts, all instruments that are
to be passed along this canal should possess the commcn prop-
erties of smoothness and flexibility, and they should have a
THE PHYSICAL EXPLORATION OF THE EECTUM. 33
certain degree of curvature imparted to them prior to their in-
troduction, if intended to go up the canal more than three or
four inches.
The rectal sound, or rectal bougie, is the proper instrument
to be employed to detect contractions, tumors, foreign bodies,
or impacted faeces in the passage, when beyond the reach of
the finger.
2. Rectal Exploring Sound. The instrument which I have
long used for sounding the rectum, and which I prefer to any
other for this purpose, is represented by Fig. 13. It is com-
FIG. 13.
[ 1. The method of introducing the sound. 2. The rectal exploring sound.]
posed of a conical piece of ivory, ebony, or hard rubber, two
inches in length and two and a quarter inches in circumference
at its base, and well secured by a screw to the end of a slender
whalebone rod, fourteen inches long. The whole instrument re-
sembles the O3sophageal probang. The sound warmed and well
lubricated is introduced by inserting the left index-finger into
the anus, pressing the whalebone rod a little forward, and to
the left side, whilst with the right hand, it is urged steadily
upward. It will be perceived that this instrument being
conical in form does not, in this respect, resemble the ball
sound of Sir Charles Bell, (Diseases of the Urethra, Bladder,
Prostate and Rectum. Third Edition, p. 328. London,
1822,) nor the oblong sound of Dr. Bushe. ( A Treatise on the
34: THE PHYSICAL EXPLORATION OF THE RECTUM.
Malformations, Injuries and Diseases of the Rectum and
Anus, p. 284. New York, 1837.) My instrument, on account
of its form, can be introduced into the rectum, moved about
and withdrawn with much greater facility, and with much less
pain, if any, than that of either Bell or Bushe. A sound or
bougie from half to three-quarters of an inch in diameter is
quite large enough for sounding the rectum. If such a sized
instrument passes easily and without pain, it may be presumed
that there is no permanent obstruction or disease of the
organ. I make use of variable sizes of this sound for dilating
strictures of the rectum. It is a most valuable instrument for
this purpose.
3. The Rectal Bougie as a Sound. The bougie is some-
times used for sounding the rectum and sigmoid flexure of the
colon, and, in some instances, more accurate information might
perhaps be obtained by its use than by the use of the sound
already named. In a case of obstruction of the rectum,
caused either by a contraction, a tumor or foreign body, if a
soft and pliant bougie, especially one made of wax, is pressed
against the obstruction, the exact impression of it would be
given by the instrument, and thus some estimate could be
formed of the nature of the difficulty. In case of stricture, it
would give the exact size and form of it. The bougie, however,
is not generally well borne by the patient on account
of the uneasy or painful distention of the anus it produces
in some instances while exploring. In this respect, the
rectal sound, it will be observed, has decidedly the preference,
inasmuch as it produces no distention of the muscles of the
anus after having passed them and during the process of
sounding. A good bougie should always admit of being ren-
dered pliant and flexible by being immersed in hot water; yet
it should be of sufficient firmness to admit of the gentle pres-
sure necessary to urge it forward without too easily doubling
upon itself in case it meets with some obstruction. This
quality of the bougie is very important, when the anatomy of
the rectum is taken into consideration, which requires that the
instrument should be capable of ready adaptation to the
peculiar form and direction of the passage, otherwise its intro-
duction would be not only useless, but might be productive of
THE PHYSICAL EXPLORATION OF THE RECTUM. 35
the most serious mischief: hence, no bougies made of metal,
bone, wood, glass, or any other hard or unyielding substance,
should ever be used for exploring the rectum. No straight
and inflexible instrument can be inserted into the rectum
more than four inches without danger from its extremity
rudely pressing against either the angles of the intestine, the
promontory of the sacrum, the uterus, the bladder, &c. ; fur-
thermore, it should ever be recollected that even the best
sound or bougie for the purpose of exploring the rectum, is by
no means a harmless instrument in rude and unpracticed
hands.
When I use a rectal bougie for the purpose merely of search-
ing or sounding the rectum, I generally use one made of white
wax, seventeen inches long, and two inches in circumference,
and terminating: in a smooth round end. This instrument,
O '
properly made, possesses sufficient tenacity to prevent its
breaking in the rectum, and when sufficiently softened by heat,
so much flexibility, without elasticity, that if properly directed it
will readily accommodate itself to the curvatures of the passage.
Before using, it must always be immersed in hot water until
it is rendered soft and pliable, and yet sufficiently firm for the
purpose of the exploration. I have, on several occasions, used
a number three as well as a number four English rectal bougie
for sounding the rectum, and have found it a good instrument
for the purpose. The only serious objection to its use is that
it is not long enough, when the sigmoid flexure of the colon is
to be explored. It must also be immersed in hot water be-
fore using. The rectal tube of O'Bernie is also a valuable in-
strument for this purpose.
4. Method of Inserting the /Sound, J3ougie or Tube. The
operation of introducing the sound, bougie or tube, into the rec-
tum, or into the sigmoid flexure of the colon with facility,
requires, as before remarked, considerable dexterity and
practice. In order that students may become adroit in their
manipulations and conversant with the anatomy of the rectum,
they should frequently make explorations of it, as well as
frequent dissections of, and operations upon it, in the dead
body.
The operation of sounding the rectum may be divided into
36 THE PHYSICAL EXPLORATION OP THE RECTUM.
three stages in accordance with the three natural divisions of
the organ already described.
First Stage. In the first stage of the operation, the instru-
ment passes through the inferior third of the rectum. The
bougie, previous to insertion, being made pliant by immersion
in hot water and well lubricated, should have a double curve
given it, if intended to go beyond the rectum into the sigmoid
flexure of the colon. The first curve to correspond to the
hollow of the sacrum, and the second to the lateral inflection
of the sigmoid colon to the left.
The patient, after completely emptying the rectum and the
bladder, and being properly placed, an injection of two or
three ounces of the infusion of linseed should be thrown up
into the rectum, to be retained, in order to facilitate the oper-
ation ; after which, the point of the bougie directed by the
operator's right index-finger, should be inserted into the anus
with the convexity of the first curve of the instrument towards
the sacrum, and in this manner it should be guided upward
and backward for about two inches through the inferior third
of the rectum.
As the last inflection of the rectum is so very slight, it is not
so important whether the convex or concave part of the bougie
be introduced towards the sacrum ; by passing it, however,
with the concavity backward, the necessity is avoided of
changing the position of the instrument in passing the main
curve of the intestine.
Second Stage. In the second stage of the operation, if there
is no great pain to centra-indicate it, the operator should con-
tinue to propel the instrument in the same direction as last
mentioned, for about three inches and a half higher, through
the middle third of the rectum. The distal end of the bougie
will now bear directly upon the hollow of the sacrum, whilst
the proximal end will bear toward the left side of the body.
Third Stage. In the third stage of the operation, in order
to avoid the promontory of the sacrum, and to adapt the in-
strument to the main curve of the rectum, its position must be
changed, by describing the segment of a circle from left to
right, with the proximal end, by turning it upward and at the
same time continuing to propel the bougie for about five and
a half inches further. By this manoeuvre the instrument will
THE PHYSICAL EXPLORATION OF THE RECTUM. 37
have been carried through the superior third of the rectum to
the commencement of this intestine.
Fourth Stage. — With the design now of introducing the
bougie or tube into the colon, which may constitute the fourth
stage, the proximal end of the instrument must be slightly
depressed, and at the same time the bougie should continue to
be propelled for five or six inches further into the sigmoid
flexure of the colon. Should there be any doubt as to the
bougie having passed into the sigmoid flexure of the colon,
that doubt may be removed by removing the pressure from
the proximal end of the bougie, when if it has not entered
the colon but doubled on itself, it will slowly recoil. An evi-
dence, however, which almost invariably attends the passage
of the bougie or tube into the sigmoid colon, is the escape of
more or less gas at the moment of entrance.
I would here remark that the sacral promontory and the
inferior part of the sigmoid flexure of the colon, are the two most
prominent points which oppose the natural ascent of the instru-
ment. The degree of resistance, however, and the peculiar
sensation communicated to the hand by the instrument when
manipulated in the manner directed, will always enable the
intelligent and careful operator to recognize a real obstruction,
from the ordinary obstacles which oppose its ascent. At the
termination of the sigmoid flexure of the colon, and the com-
mencement of the rectum, so far as my examinations have
gone, there will be found in almost all cases a slightly narrow
neck or contraction, which seems to possess to a certain extent
the properties, and performs somewhat the office, of a sphinc-
ter. It is at this point or spot that the bougie or tube is mo-
mentarily arrested, and requires a little pressure and perse-
verance to make it pass. I would here remind the operator,
too, that the colon is occasionally found to incline to the right
instead of to the left side ; should he therefore meet with any
very ambiguous resistance at the commencement of the colon,
the instrument should be withdrawn a little, and again passed
forward, with its direction more or less changed, and in this
manner endeavor to find the natural course of the intestine.
The introduction of the bougie into the colon most always
produces an uneasy sensation over the surface of the abdomen,
more especially in the umbilical region, not amounting to
38 THE PHYSICAL EXPLORATION OF THE RECTUM.
pain, however, unless there should be more or less disease in
this portion of the colon.
In introducing the bougie into the sigmoid flexure of the
colon, I sometimes place the patient on his back, across the
bed or table, with his hips as near as possible to the edge, the
thighs abducted and semi-flexed upon the abdomen, and the
shoulders elevated. The bougie is then introduced into the
anus, as before directed, and passed upward, with the point
directed backward and toward the left, until it reaches the
projecting ridge of the sacrum, at which it is generally arrested,
when it should be withdrawn a few inches, and while it is
firmly pressed against the posterior margin of the anus, it
should then again be pressed forward, when it readily ascends
beyond this point and into the colon.
It is the opinion of some surgeons that the operation of in-
troducing the bougie or tube into the sigmoid flexure of the
colon is highly dangerous, whilst others are of opinion that it
cannot be done. I have introduced my bougie and tube with
perfect facility six inches into the iliac colon in numerous in-
stances, even in cases in which there was more or less disease
of some of the parts traversed by the instrument, and I have
never known the slightest injury or inconvenience to result
from so doing.
I prefer the bougie or the tube to the sound for exploring the
sigmoid flexure of the colon ; indeed, I have never used the
rectal sound for that purpose, but have confined its use solely
to the rectum.
As an example, however, of what may be accomplished by
way of introducing tubes not only into but through the iliac
colon, and even into the right lumbar colon, I will here cite
the very marvellous case reported by Professor Storer, of a
lady who was suffering from ulceration of the ascending colon
in the neighborhood of the caecum. In this instance a colonic
tube was introduced into the anus, passed up the rectum, into
and on through the sigmoid flexure of the colon, up the de-
scending colon, across the transverse colon, and down the
ascending colon, until its extremity could be felt by external
palpation in the right inguinal region, at the seat of the dis-
ease, after having traversed a distance of from four to five feet.
Through this long and tortuous tube the ingenious Professor
THE PHYSICAL EXPLORATION OF THE RECTUM. 39
injected a strong solution of the nitrate of silver. The manner
in which this wonderful feat was accomplished, is, we regret to
say, entirely left to conjecture. (American Journal of Ob-
stetrics, Vol. I., p. Y4, New York, 1869.)
5. Particular Directions and Precautions. — I will here
refer to several points in the manipulation that must be ob-
served in the introduction of the sound, bougie or tube into
the rectum and sigmoid flexure of the colon.
Great care is necessary to keep the point of the instrument
always moving upward in the axis of the canal. This the ex-
perienced explorer will generally be able to decide, merely
from the sensation communicated to his hand. We can only
suppose that the point of the instrument keeps in the axis of
the canal by the facility with which it moves on ; and the
delicacy of touch necessary to regulate his judgment of this
will be entirely lost, if the instrument is too firmly grasped by
his hand, or too firmly pressed against any part of the canal.
No force should therefore be employed if the instrument en-
counters firm opposition, but careful pressure may be main-
tained for a few seconds ; should this increase the pain, how-
ever, and the instrument remain stationary, it should be
withdrawn. Occasionally when the instrument meets with
firm opposition, and much force is applied, it bends upon
itself, and communicates to the inexperienced hand an impres-
sion that it has passed an obstruction, and that it is moving on.
When such is really the case, by relinquishing the pressure
entirely from the instrument, it will be observed to slowly recoil.
Sometimes the point of the instrument, when not moving
in the axis of the canal, becomes hooked in the lax walls of
the rectum or in the loose folds of its mucous lining, and
pushes up before it the same, in the form of a cul-de-sac, so
that the operator, if not experienced, will be apt to imagine
he has encountered a stricture, when in reality none exists.
Indeed, in some instances, it requires considerable adroitness
to prevent the intestine from being thus caught up in sacs by
the point of the instrument, and requires some nicety of obser-
vation to distinguish the yielding resistance which such a sac
offers, from the resistance of a stricture. However, should the
opposition experienced be a sac of intestine which the instru-
40 THE PHYSICAL EXPLORATION OF THE KECTUM.
ment has temporarily caused, it should be withdrawn a little,
and again passed up gently, with its direction slightly altered,
and, by this manosuvre, it will keep in the channel, and at
least not sacculate it at the same place. Sometimes the bou-
gie or sound comes in direct and firm contact with the promon-
tory of the sacrum, and an ignorant operator imagines that
this also must be a stricture. It is very certain that occasion-
ally practitioners are thus misled, and assure their patients
that they have stricture or some other obstruction, when there
is none whatever. It is, useful also to bear in mind that some-
times a mistake may occur when the upper part of the intes-
tine, being distended with faeces, is forced down, and to a
certain extent turned upon itself. The point of the bougie
being directed against this projecting point, may also give rise
to the idea of a stricture.
During the process of exploration, violent expulsive efforts
of the intestine sometimes take place. Should these occur, it
would be best for the operator to yield somewhat to them by
waiting a little, and then to take advantage of their intermis-
sion in order to pass the instrument higher up.
In very delicate, nervous and irritable subjects, especially in
those in whom there exists more or less irritation or chronic
inflammation of the mucous membrane of the rectum, the
introduction of the sound, bougie or any instrumental inter-
ference, will frequently cause an irregular spasmodic action of
the intestine, and consequently its sudden contraction upon
the instrument at different points in its passage. The con-
stricting portion will often be found to vary at each introduc-
tion of the instrument. On one day it will be found at one
place, whilst on another at quite a different one. Some days
it will be entirely absent, whilst on others it will be much
more active ; all depending upon the health and peculiar con-
dition of the patient, or upon vitiated and stimulating secre-
tions from the bowels. This condition of the intestine must,
of course, be first corrected by judicious remedies, by strict
diet, by emollient enemata, &c., before the examination can be
satisfactorily determined. The spasmodic actions or contrac-
tions of the bowel, in some instances, continue for a consid-
erable length of time, and are no doubt often mistaken for
organic or permanent stricture of the rectum, and treated as
THE PHYSICAL EXPLORATION OF THE RECTUM.
such, to the great injury and inconvenience of the patient.
Such cases have repeatedly fallen under my own observation.
In the withdrawal of the instrument, the same gentleness
and care should be observed, in conducting it slowly and cau-
tiously, as in its introduction, so as not to suffer its point to
strike against the angles of the intestine or against the bladder
or the uterus.
I would here observe, that in order to lessen, as far as prac-
ticable, the moral and physical distress that are the ordinary
accompaniments of sounding the rectum in females, that this
operation may be performed under the bed covering, and of
course without the least exposure.
In conclusion, I would remark, that when the bougie or
sound meets a real obstruction in the rectum, the important
fact then to be determined is, what are its true cause and na-
ture. An obstruction of this intestine may arise from numer-
ous and various causes. It may be a spasmodic or a perma-
nent stricture, adventitious adhesions, a foreign body, an
accumulation of hardened faeces, a prolapsus of the mucous
lining, a tumor or tumors, an enlargement of the prostate
gland ; and in females it may be from either a retroversion or
an anteversion of the uterus encroaching upon some point or
other of the rectum, or from an enlargement of the ovaries,
pressing upon the same, &c. The qualified surgeon, however,
when he meets an obstruction or a resistance, is enabled by his
anatomical knowledge at once to comprehend and to sur-
mount it.
APPENDIX.
ON THE
LIGATION
OF
fL^MORRHOIDAL TuMORS,
BY
WILLIAM BODENHAMER, A.M., M.D.
ON THE LIGATTON
OF
HJIMOBRHOIDAL TUMORS.
[ Explanation. The following article was originally intended for publi-
cation in a medical periodical, but the author believing that if it had any
merit, by presenting it in the form of an addendum to the preceding little
work, it might, perhaps, prove more convenient and useful to the student ;
he, therefore, determined to offer it to the profession in its present form.]
At a meeting of the New York Medical Journal Association,
held on the 19th of March, 1869, and reported in the Medical
Record of October 1st, 1869, page 356, the subject of ligating
hsemorrhoidal tumors, was introduced by Dr. Post, who re-
marked that — " When a patient from the country could stay
but a week or two, he commonly employed the ligature instead
of the nitric acid, for the removal of piles. The severe pain
attending its use was diminished, by having the ligature very
strong and drawing it very tightly. If one side of the pile was
covered with skin, it might be well to incise this, though it was
not his habit. The tumor would slough off in a week or ten
days."
Dr. I. E. Taylor said that, " the ligature would give little
pain, if it included only mucous membrane, but if any portion
of the skin were included, the pain would be severe."
" Dr. Post thought the mucous membrane more sensitive
than that of almost any other part."
" Dr. Carroll had operated on a lady, where the pain was ex-
cruciating until the ligature came away, though this was made
as tight as he could draw it, and no skin whatever was included,
the tumor being quite high up. The patient was not nervous,
but could bear pain well."
46 APPENDIX.
" Dr. Ilubbard described Dr. Dixon's method of tying piles,
in a case he had witnessed ; and Dr. Carroll remarked that
several of the irregular practitioners had some peculiar skill in
this matter ; an acquaintance of his had his piles tied by one
such, with no pain to speak of, and had gone regularly to his
business every day ; the operation effected a cure."
I have not the honor of being a member of the " New York
Medical Journal Association," and, consequently, can only
through this medium, compare my own observations with those
of some of its members, as above quoted. I would here remark,
however, so as not to be misunderstood, that although not a mem-
ber, I nevertheless highly approve of the objects of that society.
Nothing has contributed more to the advancement and to the
elevation of the science of medicine, than the establishment of
well regulated medical societies. These excite a generous
ardor and rivalry in cultivated and liberal minds, and rouse
even envy itself into useful emulation. The principal part of
our knowledge must ever be derived from comparing our own
observations with those of others. In this view, the utility of
medical societies, which afford an opportunity for the mutual
communication of our thoughts, must be sufficiently apparent.
The great improvements which have already resulted from the
formation of such societies are well known to the medical
world.
The declaration made by Dr. Carroll — that several of the ir-
regular practitioners of our city have some peculiar skill or know
something more or something superior in relation to the opera-
tion of ligating hsemorrhoidal tumors, than is known or practiced
by members of the regular profession, strikes one with some
surprise, and induces one to ask the question, why is this?
Now, taking it for granted that this is so, and without stopping
to answer the question, why it is, I will at once, with a view to
aid in removing this reproach against the regular profession,
endeavor to contribute my mite of experience upon this sub-
ject, which I consider an important one, with the hope that
others of the regular profession, especially those of the
" Medical Journal Association " will likewise contribute of their
abundance to the same end, until this particular stigma upon
the escutcheon of our profession, shall be entirely effaced. This
should be done at once, for the operation, as before remarked,
ON THE LIGATION OF H^EMORRHOIDAL TUMOKS. 47
is an important one and worthy of investigation, and one which
affords much scope for ingenuity ; and furthermore, I consider
it one of the best of maxims, that every man should, in some
way or other, leave the world benefitted by his life.
Having been in the constant practice, for about thirty years,
of removing hsemorrhoidal tumors, almost exclusively by the
silk ligature, I have necessarily acquired more or less know-
ledge and experience in relation to the operation. In my
opinion, if it is judiciously and properly performed, it is the
safest, most certain, and most effectual of all known methods,
and this opinion is now gradually becoming the settled con-
viction of the profession at large.
The old method of tying piles, that which is recommended
in the books taught in the schools, and usually practiced, is
(after the bowels have been evacuated and the tumors pro-
truded as much as possible) to seize each tumor by either
tenaculum or forceps, and draw it down fully out of the anus,
and apply closely to the base of the part thus drawn down, a
strong heavy silk or hempen cord, and then the same drawn
and tied as tightly as can be ; or a curved needle armed with
a double ligature, is passed through the base of the tumor, so
as to divide it into two, and the cords tied as tightly as pos-
sible on each side. After the tumors are all tied, they are
returned within the anus, and an enema of starch and lauda-
num administered, the patient required in the meantime to
maintain the horizontal posture, to live on meagre diet, and to
avoid having any fsecal evacuation for six or eight days.
Sometimes immediately after tying the tumors, they are then
amputated closely to the ligature. This, in short, is the usual
process now practiced in the ligation of haemorrhoidal tumors,
and from the very nature of the case, must necessarily be at-
tended with more or less danger, and with severe pain and
inconvenience.
The great objection to this method of operating is. the ex-
treme suffering which follows and continues for a considerable
time, and the confinement to either bed or room for several
days. It is said, too, by some authorities, that the operation is
attended with great danger from tetanus, phlebitis or pyaemia,
&c. This danger, however, has been and is, in my opinion,
greatly exaggerated. The few fatal cases reported were never
48 APPENDIX.
verified by a post-mortem examination, and consequently are
deserving of but little confidence. I believe when danger, ex-
treme pain or failure attends the operation, it is generally re-
ferrible to the unsuitableness of the ligature, and the injudicious
manner in which it has been placed upon the tumor. I have,
by my peculiar method, operated in thousands of instances,
and have yet to encounter the first serious accident.
The circumstance, then, of the danger, pain and inconve-
niences attending the old operation, led me, about twenty-five
years ago, to seek for information in relation to it, with a view
if possible to remove some of the obnoxious features of it, or
so to modify it as to make it less objectionable and serious ;
without at the same time rendering it any less efficacious in
the cure of the disease. I first began by making some experi-
ments upon both internal and external hsemorrhoidal tumors,
when in a quiescent state, expressly with a view to ascertain
whether any one point or portion of the tumor was more sen-
sitive than another ; and more especially whether the mucous
membrane, or other tissue from which such tumor proceeded, was
more or less sensitive than the tumor itself or its covering.
The experiments were conducted by means of a peculiar for-
ceps, expressly made for the purpose. The apex of the tumor
was first seized by the instrument, and firm compression made ;
the middle portion next, then the base, and lastly a portion of
the lining membrane of the rectum, to which the tumor was
attached, was included in the blades of the forceps. I found
that in proportion as the compression reached the base of the
tumor the pain was increased, and when a portion of the mu-
cous membrane of the rectum or other tissue was included in
the blades of the forceps, the pain was very severe. I have
ever since, in operating, been very careful so to adjust the liga-
ture as not to tie it too close to the base, and that nothing but
the tumor itself should be included in its grasp. Now the
question naturally arises, what is the cause of this difference in
the sensibility of the natural textures from which the tumor
proceeds, and those of the tumor or foreign growth itself?
The most rational inference which occurs to my mind at pres-
ent is, that the former are more abundantly supplied with
nerves and nervous influence than the latter. Be this as it
may, however, the fact is as I have stated it, and it is in the
ON THE LIGATION OF H.EMORRHOIDAL TUMORS. 49
power of any student to verify it. But on this, as on many
other points of pathology and physiology, we are sometimes
much better acquainted with the quo than with the quomodo /
In other words, we know the facts, but we cannot well explain
them. My researches on this subject have plainly taught me
that so far as the natural tissues are concerned, the fine and
delicate skin immediately without the anal orifice is the most
sensitive; that the muco-cutaneous coat immediately within
the anal orifice is next in point of sensibility, and that the
mucous membrane of the rectum is the least sensitive of the
three. I, therefore, do not agree with Dr. Post, when he says
he thinks the mucous membrane more sensitive than that of
almost any other part. I, however, have found the mucous
membrane of the rectum much more sensitive than the mucous
membrane covering the tumor. This must not be forgotten.
Indeed the foreign body and its covering, unless entirely ex-
ternal and covered with true skin, are much less sensitive than
the three natural textures previously named.
I now propose to offer some improvements in the operation
of ligating haemorrhoidal tumors, the success of which has
been invariable, and warranted by an experience of upwards
of twenty-five years.
By my method of operating, the tumor to be ligated is
never seized by tenaculum nor forceps, and pulled down ; for
if this is done, a portion of the elastic mucous membrane of
the rectum, to which the tumor adheres, also comes down with
it, and therefore is almost certain to be included in the grasp
of the ligature — hence the additional pain and suffering which
necessarily follow; for the operator caunot distinguish the
true base of the tumor from any other part when drawn down
in this manner, for all the parts generally have the same ap-
pearance. I always require my patients to extrude the tumors
simply by defecating efforts, or by the efforts produced by
means of an aperient or a relaxing enema. If one or all these
means should fail to protrude the tumors, I employ a bi-valve
speculum ani, introducing and arranging it in such manner
that the tumor which I design to ligate should fall between
its blades ; then, with suitable instruments, it can be ligated
within the canal, just as easily as if it were extruded or exter-
nal. I scarcely ever take up more than one tumor at one time,
50 APPEITDIX.
and never employ a heavy silk cord with a hard twist in it,
such as saddler's silk, which is the article often used for this
purpose, but use a fine silk ligature, well waxed, with scarcely
any twist in it, somewhat like floss or dentist's silk ; for in
proportion to the size of the ligature and the hard twist in it,
will be the increased pain it will occasion, and the length of
time it will take the tumor to slough off. As before observed,
I am careful so to adjust the ligature as to exclude everything
but the foreign body itself, and only make the ligature suffi-
ciently tight to cut off the circulation — nothing more nor less.
This can be known and adjudged by the appearance of the tu-
mor whilst the ligature is being tightened. I am also careful
not to place the ligature very close to the base of the tumor, as
this produces more pain, and is not any more effectual in re-
moving the whole of it. The small portion of the base of the
tumor below the ligature, will also sooner or later completely
slough off. When the tumor is very large, or too large for one
ligature, I divide it into two or more sections, according to its
size, and multiply the ligatures, including but a small portion
of the tumor in each. This is done by arming a suitably
curved needle with a double ligature, passing it through the
base of the tumor, and if necessary repassing it, and tying
each ligature separately — thus including in the stitches every
part of the tumor, and underlaying it, as it were, with a double
uninterrupted suture. When part of the tumor is covered
with true skin, or muco-cutaneous tissue, I usually incise this
upon the same circle which is to receive the ligature afterwards,
by which more or less suffering is avoided. I sometimes, when
the tumor is entirely external and covered with true skin, and
objection made to the knife or curved scissors, ligate it subcu-
taneously, which causes it to shrivel and gradually to disappear.
By this operation the integument is not interfered writh, and
much pain, suffering and inconvenience from the ligature other-
wise applied are avoided. The subcutaneous ligation of ex-
ternal haemorrhoids, consists in encircling the base of the tumor
with a ligature passed immediately beneath the skin. This is
accomplished by the use of a proper needle, describing a con-
siderable curve, and with it to puncture the tumor at a suitable
place, and to carry a ligature subcutaneously half round the
same. The needle is then to be brought out at this point, and
ON THE LIGATION OF HJEMORRHOIDAL TUMORS. 51
re-introduced at the point of exit, and carried round the other
half to the original point of entrance, and then tied. If the
tnraor is large it may be divided into two or more sections as
before described. This is the operation which is sometimes
employed for the removal of naevi.
The modus operandi of the ligature is this — it removes the
tumor or foreign growth by two processes : first, by depriving
it of its due supply of blood, and secondly, by making its way
through the base of the tumor by ulcerative absorption. Now,
while it is obvious that the first of these effects may be accom-
plished by the application of the finest and softest ligature, it
is equally clear that the larger and harder the substance of the
ligature is, the longer the time it will take, and the more
extensive the inflammation, pain or irritation it will produce in
accomplishing the second. I repeat, then, that when a strong
silk cord is used as a ligature, which is comparatively a rough
substance, especially when hard twisted, it will, by its mechan-
ical attrition, produce more inflammation and pain, and con-
tinue them longer, than when the ligature is finer, softer, not
much twisted and not drawn too tightly. I therefore again
disagree with Dr. Post, who maintains that " the severe pain
attending the use of the ligature is diminished by having it
very strong and drawing it very tightly." Sir Astley Cooper
says that the pain which the ligature produces may be miti-
gated by not drawing it too tight. This excellent advice,
however, is liable to be abused, inasmuch as it is not sufficiently
definite. The ligature must be drawn tight enough to inter-
rupt all kind of circulation and physiological action in the
tumor ; if this is not accomplished, the tumor will not perish,
or perish very slowly, and more or less sensibility will remain
in it. The desirable end, the complete destruction of the
tumor, can be attained, however, without making the ligature
as tight as it can be. The amount of strangulation should be
just sufficient to arrest the passage of the fluids. The tumor,
thus deprived of its vitality, first becomes blue or livid, and
then softens, shrinks and loses its volume, and acts in the same
manner as any dead foreign body which must necessarily come
away through the eliminating powers of the system. When
the entire physiological circulation of the tumor is suspended
for twenty-four hours, the principal object of the operation is
52 APPENDIX.
attained. After this, the final result will be the same, whether
the ligature remains on till the tumor drops, comes off acci-
dentally, or is intentionally removed. "When there is pain,
after a certain period, the pain is not in the tumor itself, but
in the contiguous natural textures not included in the grasp
of the ligature.
As true haeinorrhoidal tumors vary in locality, structure,
numbers, size, vascularity, sensibility, <fec., so do they require
modifications of treatment. Those in which, more than any
others, ligation is more especially indicated, are the internal
ones, which are florid, soft and highly vascular, which protrude
readily and bleed freely ; also those internal ones which are
indurated, dark, firm, with little sensibility, protruding at
each evacuation, and attended with a free mucous discharge.
Those round and sometimes blue tumors, located at the mar-
gin of the anus, and covered partly with mucous and partly
with muco-cutaneous tissue, should, when large, be ligated,
after incising that part covered with the muco-cutaneous tis-
sue. When any of these are very small and quiescent, they
may be let alone, but when any of these small ones are hard,
distended and painful, they should be punctured with a lancet
and their contents completely let out. Those tumors that are
altogether external, or completely without the anus, and cov-
ered with true skin, should be removed by the knife or curved
scissors, or ligated sub-cutaneously.
I am never in the habit of ligating haemorrhoids when they
are in an irritable or inflamed condition, but wait until the
irritability or inflammation has spontaneously subside!, or has
been subdued by proper treatment. It often occurs, that
among several tumors which are in a quiescent state, there
will be found one highly sensitive and irritable. This one
may be easily distinguished from the rest by its florid appear-
ance, or by its being tense, tender and painful upon pressure.
If the operation is performed when the tumor or tumors are
irritable or inflamed, the pain and suffering will be greatly
augmented. I sometimes remove the inflammation, the irrita-
bility or the sensibility of the tumor or tumors by the applica-
tion of a solution of the nitrate of silver, applied by means of
a camel-hair pencil, and immediately after apply olive oil to
the same. Two or three of these applications in as many days
ON THE LIGATION OF H.EMORRHOIDAL TUMORS. 53
are usually sufficient. The solution should be of such strength
as not to produce a slough, not to abrade or to injure the sur-
face. All that is required is the sedative power of the caustic,
without its injurious effects. If applied of a certain strength,
say from ten to fifteen grains of the crystals to one ounce of
distilled rose water, it will diminish the sensibility and irrita-
bility in a most remarkable manner. The patient, in the
meantime, should live on bland and unirritating diet, and his
bowels should be relieved entirely by enemata of the infusion
of linseed, to which a little castor or olive oil should be added.
Now, if what I have stated in relation to the ligation of
hsemorrhoidal tumors be true, and the statements can easily be
verified by competent persons, my method of operating is far
superior to that practiced by surgeons generally, and at least
equal, if not superior to that practiced by some of the irregular
practitioners mentioned by Dr. Carroll. It is much safer, very
much milder, and equally as certain and effectual. It is sel-
dom that my patients, during the whole course of treatment,
are ever confined for a moment to either their rooms or their
beds, but are enabled at all times to be up and attend to ordi-
nary business.
Very much might be said profitably in drawing a parallel
between ligation on the one hand, and the several surgical
measures adopted for the removal of hsemorrhoidal tumors, on
the other — such as excision by knife or scissors, ecrasement,
the actual cautery, the potential cautery, Dupuytren's combi-
nation of forceps, scissors and actual cautery ; the same modi-
fied by Mr. Smith, of London, of clamp and knife or scissors,
and actual or potential cautery ; M. Amussat's method of
clamp and caustic potash ; Houston's method of nitric acid ;
the galvano-caustic method of Middledorpff ; and the method
of M. Richet, of cauterizing the tumor in several sections by
means of a peculiar forceps brought to a white heat ; all of
which find advocates in able authorities ; but this article is
already extended much further than at first designed. I can-
not, however, resist making one single remark more, by way
of conclusion. That is, that thousands of persons who are
daily suffering from this affection, who should at once undergo
surgical or radical treatment for the same, are deterred from
so doing from a great dread they have of the formidableness,
54 APPENDIX.
severity and danger of the operations ; or from a belief they
entertain that this disease can never be radically cured ; or that
it is salutary and designed to ward off some other more serious
affection, and therefore should not be cured ; or that it is never
local, but always constitutional, and cannot be cured by any
local measure, &c. — hence such patients, receiving but little
information and encouragement from the regular profession,
many of whom themselves entertain similar erroneous notions,
generally fall into the hands of empirics or irregular practition-
ers, or are in the constant use of some of the one thousand and
one quack remedies found in the drug shops, and recommended
in the papers, or by some of their numerous kind friends. Let
it then be our united aim to rescue this affection from out of
the hands of the quacks, who have too long already monop-
olized it, to the exclusion and the disgrace of the regular
profession.
237. Fifth Avenue, New York.
[By the same Author.]
PRACTICAL OBSERVATIONS ON THE AETIOLOGY,
PATHOLOGY, DIAGNOSIS, AND TREATMENT
OP
-A.:tT.A_I_, IE1 1 S S TT IR, IE .
Illustrated by numerous Cases and Drawings.
In one neat 8vo. volume, bound in extra muslin. Price, $2.25 by mail,
free of postage.
WM. WOOD & CO., Publishers,
61 Walker Street, New York.
JSOTICEB OF THE MEDICAL PRESS.
" Dr. Bodenhamer is already well and favorably known in the department
of practice to which this book refers, as the author of the most complete
treatise in existence on the malformations usually classed together as
' Imperforate Anus.' The present volume equals that mom 'graph as an
exhaustive statement of the matter to which it refers. * * * *
After a minute and very good and accurate account of the symptoms and
diagnosis of anal fissure, the author proceeds to detail the treatment appro-
priate to the different forms of the disease. We can only quote here the
brief description given in the table of contents of ' the treatment as pursued
by the author.' " It consists of topical medication combined with dilatation,
and sometimes scarification or incision of the mucous membrane. The chief
indication is to modify the surface of the ulcer, and transform it into a simple
or common sore." For the methods by which Dr. Bodenhamer endeavors to
fulfill these indications, as well as for the elaborate review which he gives of
the treatment recommended by others, we must refer to the original. Its
perusal, or rather its study, will be found highly remunerative by all who
have much opportunity of treating the affections of the rectum." — British
and Foreign Medico-Chirurgical Review.
" In this monograph of one hundred and ninety-two pages, the author gives
not only the literature of the subject, but presents the conflicting opinions of
eminent surgeons, from the time of Boyer to the present day, in regard to the
pathology and treatment of anal fissure.
" He demonstrates clearly, by clinical records, the relation existing between
anal fissure and spasm of the sphincters, taking the opposite views to the one
entertained by Boyer and others. He considers the anal spasm the result of
the anal fissure. ' This spasmodic contraction,' he writes, ' is a phenome-
non which may or may not accompany fissure of the anus. It is not the
anal spasm that constitutes the disease, for anal fissure may exist without
this arbitrary contraction ; but such contraction of the sphinctores am never
exists without an irritable fissure, an inflammation, tumefaction or some other
primary disease of the inferior extremity of the rectum ; or of some disease
of the genito-urinary organs.'
" The importance of this view of the pathology of the disease is not less
striking than the revolution in the treatment which must necessarily result
from it. For while Boyer and Dupuytren, Brodie and others, regarding the
spasm as a primary and essential condition, deemed incision or rupture of
the sphincter necessary for the radical cure of the ulcer, the author, on the
other hand has succeeded uniformly in effecting cures without so severe a
procedure. He employs the knife only in very intractable cases, and then
only to the extent of dividing the mucous membrane through the long axis
of the fissure.
" The author divides the various kinds of fissure into classes according to
the site of the disease, viz. : (1) Those on the outside of the anal orifice ;
(2) those immediately within the anal orifice ; (3) those situated above the
external sphincter; (4) those situated on and a little above the internal
sphincter.
" His description of the signs and symptoms, rational and physical, his
enumeration of the minute details of an examination per rectum wither with-
out instruments, and of the various points to be observed in order to accom-
plish a speedy and permanent cure with the least amount of pain, are con-
cise and graphic. The reader will perceive throughout the whole work
marked evidences of close clinical observation, respect for the opinions of
others, the absence of dogmatism and a desire to impart, without reserve, full
measure of the author's knowledge of a disease with which he has grown
familiar by years of experience.
" It would be impossible to do full justice to the merit of this little work,
without making a full review of it. Those practitioners who read it will find
many useful hints to guide them in the diagnostication and treatment of this
painful and obstinate malady.
" The work is illustrated by a number of well executed drawings, and by
twenty-nine type cases of the disease." — Richmond and Louisville Medical
Journal.
" In this book of 192 pages, we find a complete resume of the subject of
Fissure of the Anus, its Anatomy, Physiology, Symptomatology, and Treat-
'ment. The author quotes the opinions of different authors upon the various
points discussed, referring in an extensive bibliographical section to the
original sources of his information.
" His own views are nevertheless expressed with independence and clearness
and his principal points of difference are defended and supported with appar-
ent candor, and in a fair logical manner. The style of the author is rather
pointed and forcible, of the two calculated perhaps to impress more than to
convince. The method is good and the arrangement of the book convenient.
" The existence of spasmodic contraction as ' an entity ' is disputed. In
cases supposed to be of this nature the author thinks its cause is always due
to a fissure or ulcer undetected.
" A fissure of the anus is described as a superficial breach of the surface in
the anal region, of a highly sensitive, irritable, or painful character, of what-
ever shape. The various theories advanced in explanation of the interval
between evacuation and the characteristic accession of pain in the fissure
are ably discussed. That of Dr. Van Buren seems to be fairly refuted, though
the author frankly confesses his own incompetence to substitute one satis-
factory to himself. Objection is made to the treatment of fissure by Beyer's
method, viz., the complete division of the sphincter, as also to the method
first recommended and practiced by Nelaton, by forcible dilatation and rup-
ture with the thumbs.
" The author's treatment consists mainly of the topical use of nitrate of
silver combined with dilatation without rupture of the sphincter, with the
addition sometimes of scarification and incision of the mucous membrane.
The objects sought are to change the character of the ulcer to a simple sore,
and to secure rest so that it may heal without disturbance. It is alleged that
this treatment, though apparently only palliative, is sufficient to induce a
complete and satisfactory cure in the large majority of cases ; in proof of which
twenty-nine cases with their histories are appended. This book is a credit
to its author. It is a clear, succinct, and complete summary on the question
up to the present date." — Medical Record, New York.
" The author of this monograph is already favorably known by his work
on ' Congenital Malformations of the Rectum and Anus,' published some
years since. The class of diseases to which he has given his attention is by
no means small, and counts some of the most annoying to which the human
frame is subject. What is more, owing to a false delicacy, sometimes on the
part of the patient, sometimes on that of the doctor, they are frequently
overlooked or misunderstood.
" The first chapter treats of the history of anal fissure, and of its very
troublesome concomitant spasmodic contraction of the anus ; the second ex-
amines into the name fissura ani, and the physiology of the complaint ; its
aetiology, in which constipation has a prominent share, comes next, and then
a classification and description of the various varieties of fissure, their symp-
toms and signs, diagnosis and prognosis. The fifth chapter gives at consid-
erable length the different methods of treatment, and the sixth and conclud-
ing chapter presents a variety of illustrative cases, of no little clinical value.
A short bibliography is appended.
" The treatise is throughout carefully prepared, and we recommend it as a
valuable practical book, worth a place in any working library." — Medical
and Surgical Reporter, Philadelphia.
" The large number of cases of Anal Fissure which are unrecognized
and which are either improperly treated or not treated at all, is sufficient
excuse for an attempt to enlighten the profession upon their diagnosis
and management. This Dr. Bodenhamer has done, and we think well
done. The opening chapters of his monograph are devoted to the patho-
logical conditions involved, with copious references to the opinions held
by the older and by contemporary surgeons. These are succeeded by
sections devoted to the ^Etiology and Diagnosis of the affection and the
physical exploration of the lower part of the Rectum. The affection, as
most are aware, consists in an Ulcer or Fissure of the mucous membrane
of the lower portion of the Rectum, or verge of the anus, and frequently
accompanied with an irritable or spasmodic condition of the Sphincter
muscles. The author recommends the application to the Ulcers or Fissures
of active stimulants, such as the solid Nitrate of Silver, the Acid Nitrate
of Mercury, &c., together with gradual dilatation by means of Rectal Bou-
gies, believing that with these simple measures he will succeed in the
vast majority of cases, and render unnecessary division of the sphincters
or their forcible dilatation. The volume concludes with an extended list
of cases treated by him and a Bibliographical appendix." — Medical Ga-
zette, New York.
" There are few physicians of any considerable experience who have not
encountered, more or less frequently, cases of this diminutive, but horribly
painful, wearing and often very grave malady. Those who have met them,
and have realized the excruciating nature of the disease and the frequency
with which it defies all ordinary means of treatment, cannot be but gratified
with the perusal of this little volume.
" The author has devoted some twenty-five years to the investigation of
the diseases of the rectum and anus, and speaks with the tone of a master.
It is surprising that so much can be said on, apparently, so small a matter.
The author gives the bibliography of the disease, from the first recorded
observations to his own contemporary writers, together with the various
methods of treatment which have from time to time obtained, adding his
own experiences and practice, and illustrating them with full records of
cases.
" We welcome the appearance of such works, as all practitioners must,
who having cases to treat of small diseases, find so little information and
satisfaction in the general text books, where they are often run over in a few
lines. We hope the day will come when only text books on the general
history and principles of disease will be written, and the consideration of
special diseased action will be left to monographs or articles in a standard
encyclopaedia of medicine.
" There are grave consequences sometimes attending some of the recom-
mended methods of treating anal fissure, as that of rupturing the sphincters
by forcible dilatation, and it would be well for all physicians, at least before
resorting to any operative procedures for relief, to read this little work of
Dr. Bodenhamer." — Leavenworth Medical Herald.
" We have space but to notice the reception of this work, and will review
it in a future number. To those who are interested in the subject, however,
we may say that it is very thorough and explicit." — Eclectic MtdicalJournal
" After a lengthy historical introduction, the author treats first of the phy-
siology and aetiology of this affection, which he ascribes to spasms and to
constipation. Next he describes the symptoms and diagnosis ; and finally,
the treatment of anal fissure. The different methods are — Topical applica-
tions, cauterization, dilatation, incision, excision and complete division of the
sphincter. A chapter of illustrative cases completes the work, which is a
very complete treatise on this painful affection." — Boston Medical and Surgi-
cal Journal.
" Judging from the works before us, Dr. Bodenliamer is one of those whose
labors are now most wanted in the profession. It has become too much the
fashion to write books ostensibly to advance medical science, in reality to
subserve the personal interests of their authors. Selecting a neglected field,
Dr. Bodenhamer has gone to work with great industry and patience, with no
• special' treatment to present, no novel operations to suggest, but chiefly to
gather from all quarters material for its illustration, and to put it in order
for more general usefulness. While clear in the expression of his own opin
ions, he has not made a book merely to enunciate or support them.
" The treatise on the Malformations of the Rectum and Anus is the most
elaborate monograph upon the subject within our knowledge. Arranging
under appropriate heads the varieties of these malformations, our author di-
vides them into nine species, each of which is fully described, with its treat-
ment, and illustrated by cases drawn from all sources. The cases reported
amount to two hundred and eighty-seven, embracing many of interest. A
chapter on Abdominal Artificial Anus appropriately concludes the subject.
The book is also illustrated by sixteen finely-executed plates.
" The work on Anal Fissure is not so free from the ' personality ' of the
author as the one just spoken of, the cases in his own practice being some-
what ostentatiously given. A criticism might also be made upon the size of
the work, as evidencing too much diffuseness, but the care and completeness
with which the subject has been treated are so evident, that possibly any
attempt to condense would have impaired the value of the book as a thorough
treatise." — The Baltimore Medical Journal.
\JBy the same Author. .]
A PRACTICAL TREATISE ON THE AETIOLOGY,
PATHOLOGY, AND TREATMENT OF THE
CONGENITAL MALFORMATIONS
HECTTJM ^.ND A.NTJS.
8vo. 16 Plates. Price $4, free of postage.
WILLIAM WOOD & CO.,
61 Walker Street, New York.
NOTICES OF THE MEDICAL PRESS.
" This work constitutes one of the most complete monographs with which
we are acquainted. In it we have collected, and apparently with accuracy,
no less than 287 cases, from every available source, and also a review of both
the medical and surgical treatment in full from the earliest times, with all
the improvements down to the present time."
" The iraterials collected and introduced into the work are well digested,
with full and particular references to their sources ; and in the relation of the
various cases, the remarks of the original writers are given in connection
with them. The volume is well illustrated by 16 plates, each containing
several drawings. Altogether, the book is a complete and valuable compen-
dium on the subject up to the time of its publication, and a monument of
industry and patience." — British and Foreign Madico-Ghirurgical Review.
" This is a most complete and valuable work, treating in an exhaustive
style of a class of affections on which no complete systematic or practical
treatise has hitherto been published. A copious bibliographical index is
given, and on the whole the treatise is most complete, ranging throughout
almost the whole literature of the subject, and nearly exhausting all that is
to be said on it in the present state of our knowledge." " The subject is one
well worthy of the labor Dr. Bodenhamer has bestowed upon it, and worthily
has he worked it out." — Dublin Journal of Medical Science.
•'The style of this author is concise and agreeable, and his subject inter-
esting ; his work will well repay perusal, although its immediate study may
not be required. Unfortunately it belongs to that class of books which a
physician having no cases of the kind to treat, feels indifferent in possessing,
and scarcely willing to admit as necessary. It shows itself forth, however, in
bold relief, as one of the most important and useful, when he is called to
operate on some unfortunate child thrown suddenly in his charge. Glad of
the opportunity of examining its valuable pages, he will then agree with us
on its extreme utility, and in considering that no medical library can be
called complete without it. It is a large octavo of upwards of 300 pages,
tilled with beautiful lithographs ; and besides separate and distinct treatises
on the different species of malformation and their treatment, containing in
elucidation of the subject, upwards of 200 cases, gathered from every reliable
source, classified and tabulated. By these we find that of 156 on which
operations have been performed, 87 have recovered ; this is encouraging, for
of 42 for which nothing had been done, all but 12 succumbed. Finally, 50
pages are devoted to the different modes of performing the operation for ab-
dominal artificial anus, which are plainly illustrated by lithographs."—
Canada Lancet. (Montreal.)
"To the practitioner who desires to be prepared for every emergency, we
commend this volume as an indispensable addition to his library.'' — . I mericfin
Medical Times.
"This is a most valuable monograph on subjects on which little knowl-
•jdge is to be derived from our surgical books. The author appears to have
fully elaborated and exhausted the subject, having collected from all sources
nearly three hundred cases, and illustrated the most remarkable by 16 plates,
which are well executed, and render the volume an attractive and useful one."
— American Medical Gazette.
" This is an opportune and valuable addition to the means of acquiring a
knowledge of the diseases of the rectum, which the excellent works of Ash-
ton, Quain, Syme, Bushe and Copeland have so clearly and fully furnished to
English and American readers. As a practical monograph it is not inferior
to either of these, so far as it relates to its particular department of the sub-
ject ; while it surpasses them all in completeness and extent of illustration,
and in the facilities afforded to the student for the purpose of further investi-
gation. The work is no empty compilation, since the author's views are
clearly and precisely given upon all practical points, and many useful prac-
tical details are pointed out in a manner which shows them to be the product
of much especial thought and observation as well as practical skill and intel-
ligence."— American Journal of the Medical Sciences,
" The work before us is one that cannot fail to interest all diligent inquirers
in the ranks of the medical profession, at the same time that it will add much
to the reputation of one of its laborious members. As a monograph it may
be taken almost as a model, while the subject is one upon which the profes-
sion were little enlightened, its literature being principally scattered through
the published transactions of various medical societies, or appearing in iso-
lated cases reported in various medical journals."
" In conclusion we would merely say that the volume which Dr. Boden-
hamer has given to the profession, is most creditable to himself and to the
profession in this country ; and must be considered by far the most valuable
if not the only text-book on this subject." — Boston Medical and tiurgical
Journal.
" We give this work of Dr. Bodenhamer's a cordial welcome to our table,
both on account of the intrinsic value of the work itself, and our esteem and
friendship for the author, who has labored hard but successfully, for many
years in this branch of medical science."
" The work is unique, being the only complete, systematic and practical
treatise upon the subject ever published. It contains, in addition to his own
vast experience, the productions and contributions — to the literature of this
subject — of all the eminent surgeons of Europe and America — thus collecting
and combining, in a compact and condensed form, what has heretofore been
scattered over the two hemispheres, in brief and detached article?, memoirs
and essays, as presented in the transactions of medical societies ; in brief
monographs ; in different periodicals, &c."
" Dr. B. has devoted an immense amount of labor and time in the produc-
tion of this valuable work, for which he richly merits the thanks and the
gratitude of the entire medical profession." — Eclectic Medical Journal.
"Congenital vices of conformation constitute many of the most unfortunate
disorders to which the human frame is liable. Some of them are incurable,
either causing early death, or allowing life to be prolonged in suffering and
deformity (Spina Bifida, Extrophy of the Bladder, Deformities of the Limbs,
Phocomele, <&c.). Others are curable, but demand for their relief the highest
resources of the medical art (Hernia, Cleft Palate, Hare Lip, Club Foot). The
congenital malformations of the rectum and anus include representatives of
both these classes. Although of not infrequent occurrence, they are not
sufficiently numerous to permit the general possession of experience in their
management among practitioners ; so that a practical treatise on the subject,
embodying the requisite details of diagnosis and treatment, is of great value
to the profession. The able work of Dr. Bodenhamer before us has this
merit. It is concise, full and practical ; and in addition to this claim, possesses
that of being the only complete and practical work on congenital malforma
tions of the rectum and anus which 'has ever been published in this, or in
any other country.' " — Berkshire Medical Journal.
" This able work of Dr. Bodenhamer will be welcomed by the profes-
sion, as filling a void which has heretofore existed, and as presenting the
opinions and reports of cases that have been made through journals, reports
of medical societies, or published as monographs, and were beyond the reach
of the mass of the profession." — Journal of Rational Medicine.
" We cordially recommend this work to the profession." — Savannah Jour-
nal of Medicine.
" Is the most complete work of the kind that has ever been published." —
Medical Journal of North Carolina.
WILLIAM WOOD & CO.,
Pral$]lte]i©'ifti w^A
61 Walker Street, New York,
Desire to call the attention of the Medical Profession to their stock of Medi-
cal and Scientific Books. Having made this a specialty for forty years, they
have acquired a thorough knowledge of the business, and an acquaintance
with Medical literature, which enables them to serve the Profession as effect-
ually aa promptly. They have on their shelves by far the
LARGEST STOCK OF MEDICAL, BOOKS
in the country. Their assortment of
A.NTA.TOMIC.AX, PLA.TES
is large and peculiarly adapted to the wants of the Medical Profession, both
for Office and Lecturing purposes.
5j^° Priced Catalogues sent gratis on application.
I^T Gentlemen visiting the city are invited to drop in at any time they
may have leisure.
University of California
SOUTHERN REGIONAL LIBRARY FACILITY
405 Hilgard Avenue, Los Angeles, CA 90024-1388
Return this material to the library
from which it was borrowed.
00869 7051
WI 620
B666p
Bodenhamer, William.
The physical exploration of
the rectum
WI 620
B666p
1870
Bodenhamer, William.
The physical exploration of the
rectum. . .
MEDICAL SCIENCES LIBRARY
UNIVERSITY OF CALIFORNIA, IRVINE
IRVINE, CALIFORNIA 92664
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