PALPATION BY THE RECTUM.
The following report is fromMr.Walsham, of St. Bartholomew’s Hospital, who, having a small hand (somewhat less than seven and a half inches round), has had opportunities of introducing it up the rectum, in the living subject, for the purpose of diagnosis:—
‘It is possible to introduce the hand (if small) into the rectum; in many cases into the sigmoid flexure, and in rare instances into the descending colon.
‘Once beyond the sphincter, the hand enters a capacious sac, and the following important parts can be felt through its walls:—
‘Through the anterior wall the hand first recognises the prostate, which feels like a moderately large chestnut. Immediately behind the prostate, the vesiculæ seminales may be distinguished as two softish masses situated one on either side of the middle line. Internal to them, the whipcord-like feel of the vasa deferentia can be readily traced over the bladder to the sides of the pelvis.
‘The bladder is easily recognised, when moderately distended, as a soft fluctuating tumour behind the prostate; when empty it cannot be distinguished from the intestines, which then descend between the rectum and the pubes. The arch of the pubes can well be defined when the bladder is empty.
‘Through the posterior wall of the bowel the coccyx and sacrum can be felt, the curve of the sacrum being readily followed by the hand.
‘The projecting spine of the ischium on each side of the pelvis is a valuable landmark. From this point the outlines of the greater and lesser sacro-ischiatic foramina can be traced by the fingers; and any new growth, encroaching on the pelvic cavity through these apertures, could be easily detected.
‘If the hand be now pushed farther up the gut, the promontory of the sacrum is reached; the pulsation of the iliac vessels becomes manifest, and the course of the external iliac can be traced along the brim of the pelvis to the crural arch, the loose attachments of the rectum permitting very free movement in this direction. The internal iliac artery can also be followed to the upper part of the great sacro-ischiatic foramen.
‘By semi-rotatory movement, and alternately flexing and extending the fingers, the hand can gradually be insinuated into the commencement of the sigmoid flexure. In the sigmoid flexure the fingers can explore the whole of the lower part of the abdomen, the loose attachment of this portion of the gut permitting the hand to travel freely over the iliac and hypogastric regions.
‘The parts that can here be felt are the bifurcation of the aorta, the division of the common iliac arteries, the iliac fossa, and the crest of the ilium.
‘In the female, the uterus in the middle line, and the ovaries on either side, can be readily distinguished.
‘In the introduction of the hand into the rectum, in a patient under chloroform, the dilatation of the sphincter ani should be very gradual: first two fingers, then four, and finally the thumb should be passed. It is necessary to use considerable force, and unless care be taken, not only the integumentary edge of the anus, but the sphincter itself, may be lacerated. The introduction is facilitated by the application of the other hand upon the abdomen.
‘When the dilatation has been gradual and the hand not too large, no incontinence of fæces and no very considerable amount of pain has resulted.
‘We have been informed on reliable authority that permanent incontinence of fæces has occasionally followed these examinations.’
Lastly, we think it right to insist upon the important fact that, in some subjects, even a small hand cannot be passed up the rectum beyond the reflection of the peritoneum over the second part of the gut. In such instances the peritoneum offers a resistance like a tight garter, and prevents the farther advance of the hand without great risk of laceration of the parts.[12]