THE TECHNIQUE OF RECTAL EXAMINATION.

BY JAMES P. TUTTLE, M.D., NEW YORK.

Without unduly estimating the branch with which I have been somewhat identified, it seems to me there is no class of diseases in which an early and accurate diagnosis is of so great benefit to the patient as in those of the rectum.

In constitutional and self-limited diseases a tentative course, until the true nature of the trouble be determined, is not likely to be of any detriment to the patient, but in affections of the rectum, most of which are progressive, a day's delay allows the condition to grow worse, and a very simple affection may soon become a serious one. Especially is this true of thrombotic hemorrhoids, perirectal abscesses, fecal impaction, lodgment of foreign bodies, prolapses of the second and third degree and malignant neoplasms. This is no imaginative assertion. I have seen disastrous results follow inaccurate diagnosis and symptomatic treatment in each of the conditions mentioned.

Let me detail just one case in substantiation of these statements. Mr. P., aged 32, merchant, was seized with a sharp pain at the margin of the anus in the summer of 1894, and upon examination found a small round swelling at that point. He consulted a physician who, without examination, accepted the patient's own diagnosis of an inflamed pile, and gave him an ointment which he said would cure it in a few days. Two days later the patient called on him again, saying the pain was no better. This time the doctor turned him over a chair, made an ocular examination of his anus and said the affair was a mere trifle, and that a little "stronger salve" and some medicine for his bowels would cure him soon. Two days later the patient had a chill, followed by high temperature, for which he was given quinine and opium. On the sixth day of the disease the writer examined him and found an abscess which burst into the rectum on introduction of the finger, thus constituting a blind internal fistula requiring operation and two months to get well. In the abscess was a broken-down clot, showing clearly that the trouble had originated in a simple thrombotic hemorrhoid, which, with proper diagnosis and treatment, should have been cured in three or four days.

It is so embarrassing for a patient, male or female, to have a rectal examination, and so disagreeable for the doctor to make it, it is so easy to give a pile salve or a pill for constipation and say, "If not relieved come back," that most of us yield too easily to the demurrers of our patients, and let them go out of our offices with only a dim inference of what is the matter in such cases. Blood may pass from the anus from many causes, protrusions are not all hemorrhoids, and constipation is more frequently due to disease in the rectum and sigmoid flexure than in any other portion of the intestinal tract. An immediate and careful examination is of paramount importance in all such cases, for in the early stages of benign conditions proper treatment is nearly always followed by a rapid cure, and in malignant cases only in the early stages have we any hope of cure. The early diagnosis of rectal diseases is attended with some difficulties, because in this stage the subjective symptoms are referred elsewhere. The knowledge of these reflex symptoms should be possessed by every physician, and the importance of local examination in all cases, with such symptoms as may possibly arise from diseases of the rectum, should constantly be borne in mind. Among the symptoms which suggest rectal examination let me call attention to the following:

1. Vague pains or aching about the pelvis, sacrum, or coccygeal region and shooting down the left leg.

2. Flatulence, with indigestion, loss of appetite, and irregularity or constipation of the bowels.

3. Tendency to diarrhea, especially in the morning.

4. Sense of constriction or weight about pelvis. Espe cially important in males.

5. Spasmodic or periodic dysuria without adequate cause in genito-urinary apparatus.

6. The presence of mucus, pus, shreds, or blood in the dejections.

7. Irregular menstruation or dysmenorrhea, especially in young women and schoolgirls.

8. Picking of the nose, scratching of the abdomen, restlessness at night and constipation in young children.

All or most of these symptoms may arise from disease elsewhere, but failure to find such positive conditions as will account for them renders examinations of the rectum and sigmoid flexure imperative, and it is the general practitioner who should make them, or at least recognize the importance of their being made, for almost none of our patients would consult a rectal specialist for such symptoms at first. It is therefore to the general practitioner, the family doctor, that I address these remarks upon the extreme importance of local examination and a somewhat detailed description of the technique thereof. Some of the methods are not without danger, and, it is held by some, should not be used except by experienced hands, but experience only comes from practice; we must all begin, and with care and common sense and a little manual dexterity all the methods advised, except one, can be learned by any physician.

Until within recent years all internal diseases were diagnosticated through subjective symptoms, auscultation, and palpation. With the advent of the concave mirror and reflected light, as applied to medicine, came the new era of actual sight, and following this came the invention of instruments for examining the various organs of the body having apertures of approach from without. The various specula, the cystoscope, the endoscope, the gastroscope, and the proctoscope are all the products of a desire to see and know what we hitherto inferred or guessed.

As a teacher, it has been my aim to recommend the smallest number of instruments consistent with painless, accurate work. My friend, Dr. Howard Kelly, to whom we all owe so much in this line, tells me that he has nearly a hundred specula which he uses in rectal work. I find myself succeeding fairly well with about eight. I have bought many more but rarely use them. A large number of instruments will, therefore, not be described, but we will content ourselves with the fewest possible consistent with good work.

Before the actual examination of the rectum is begun certain subjective symptoms should be inquired into and their suggestions as to the probable cause be borne constantly in mind. Among these may be mentioned:

1. The habitual state of the bowels--whether regular, constipated or diarrheal if constipated, is the stool, when it appears, soft and consistent, of normal shape, tape-like, or hard and ball-like; is it clean or covered with mucus or tinged with blood; if diarrheal, is it watery, free and painless, or scanty, mucous and attended with pain and subsequent exhaustion.

2. Pain-when does it occur, at, before or after stool; how long does it last; what is its nature, acute, cutting, burning or a dull ache; where is it experienced, at the anus, the sacral region, about the pelvis, in the inguinal region, or shooting down the leg, or is it, as often happens, in the uterus, neck of bladder, or urethra?

3. Itching and spasmodic twitching of the sphincter. 4. Discharge what is its character-bloody, mucous, watery, purulent, or fetid; is it alone or mixed with fecal matter; when does it occur, at, before, after or independent of the stools?

5. Protrusion-when does it occur; is it brought on by long straining or upon slight exertion; is it permanent; does it disappear spontaneously or is it difficult to restore; is it hard or soft, smooth and general, or localized and nodular? If down at the time of the examination, the direction of the rugæ, whether circular or running up and down, should be carefully observed, as in these we have the pathognomonic distinction between complete and partial procidentia.

6. What are the habits and history of the patient? Has there been much use of enemas; is he in the habit of sitting long at the shrine of Cloacus with his pipe and paper as companions; is there an unsatisfied sensation after stool, a feeling of something more to come away-of "unfinished business" as it were; is he the victim of pederasty; has he a history of gonorrheal or syphilitic infection; or has he hereditary tendency to tuberculosis or malignant disease?

Having satisfied ourselves with regard to all these conditions, the actual examination of the rectum may be begun.

Position. There are three positions in which a patient may be placed for rectal examination: the Sims, the kneechest and the lithotomy, in the order of their importance. The Sims position, on the left side with the thighs drawn well up to the body, should always be resorted to at first, because it is the most comfortable, the least embarrassing and generally the only one necessary. It is very easy and less embarrassing to change the patient to the knee-chest posture afterwards if it is wanted. Dr. Martin, of Cleveland, has devised an addition to the Yale chair through which he