b. The Rectal Examination by the half or the entire Hand.—In cases where examination by one or two fingers does not give sufficient informa tion, Simon was the first to teach the advisability of using the half or the entire hand. According to him, the procedure is as follows: The patient must be told of the necessity of such an examination, and that for some days afterwards she may suffer pain and from incontinence of faeces. The rectum is to be cleared out by profuse irrigation, and the patient deeply anesthetized, for only under complete anesthesia does the sphinc ter relax sufficiently to permit the introduction of the entire hand. With the woman occupying the dorsal position and with sharply flexed thighs, the examiner inserts two and then four well-oiled fingers by slow rotatory movements into the rectum. In case the entire hand must be intro duced the thumb is also inserted, and if the conditions are favorable, penetration may be accomplished as far as the wrist. A hand of not more than nine and three-quarter inches in circumference, may be in serted frequently without causing hemorrhage, but if the borders of the anus are too tense or if they seem on the point of rupture, slight incisions may be made by a blunt-pointed bistouri, or else a deep cut may be made through the sphincter in the posterior median raphe. Such incisions heal after a few days, but in case of the posterior it is well to insert a suture to guard against hemorrhage. Incontinence should never be lasting.
Under favorable conditions, where the rectum is wide and distensible, and the pelvis is not invaded by an immovable tumor, the hand may move around in the ampulla of the rectum, and the four fingers may reach into the narrower upper portion. This upper portion is narrowed by the bands of peritoneum which form the posterior uterine ligaments, and which extend backwards in concave folds from the junction of the neck with the body of the uterus. The anterior folds, the semicircular liga ments of Douglas, form with the recto-uterine ligament a crescent, with concavity downwards, which bounds Douglas's fossa above, and below it the peritoneum sinks to the extent of one and a half to two inches.
Penetration into the rectum may be very dangerous, and we must be careful not to penetrate further than the upper portion, since the peri toneum is readily separable from its attachments, and rupture of the blood-vessels may result. Still, under very favorable conditions the greatest circumference of the hand may reach the folds of Douglas, and the four fingers may extend beyond the upper third of the rectum into the lower part of the sigmoid flexure, when we may palpate to the height of the umbilicus, and reach the anterior abdominal wall. Ordinarily, however, the most possible is to reach beyond the uterus in its normal position. It goes without saying that an examination of this nature must be accompanied by the use of the external hand on the abdomen.
As to how high now it is possible to examine the pelvic cavity beyond the point reached by the finger alone. Simon places it in favorable cases as five and three-quarter inches, and for cases where the insertion of only the half hand is possible as two and three-quarter inches, figures which, as Landau justly remarks, are only approximate, seeing that, owing to the curve of the rectum, the hand does not follow a straight line, but quite a curved one. Nevertheless, this method of rectal examination may give
excellent results, seeing that thereby the pelvic organs may be felt more directly than by any other way, since only the thin rectal walls intervene. We obtain not alone indirect evidence, but direct as well of the state of these organs, and are able to state positively as to whether a questionable tumor is ovarian, for instance, or not (Landau). Still it is not rational to consider this method as always certain in its results. Only in the hands of the most expert is it always applicable to purposes of diagnosis, and there are numerous cases on record where it has yielded very insufR, cient data (Spiegelberg, Landau).
Ordinarily the question to be solved is the connection between tumors and the uterus or ovaries, questions which can only be answered in cases where the tumors are not too large, and where the uterus may be differ entiated by means of the bimanual palpation. The method is also of value for the determination of retro-peritoneal tumors, such as of the mesenteric glands, the kidneys, the intestine, and in case of invagination. In case of faecal impaction, where it is difficult to insert the syringe, the method has proved of service to us.
Rectal examination by the hand is not entirely free from danger. In Simon's master hand there never occurred anything beyond slight tears, but a number of instances of deep lesion have been recorded (Weiss has reported an instance of rupture of the anterior rectal wall), and small tears of the rectum sometimes do not readily heal. Aside from these facts, the method itself is such a disagreeable one that it should never be resorted to except in the presence of strict indication. • Among the contra-indications are to be noted all those tumors which fill the pelvis, great narrowing of the rectum as the result of cicatrices or infiltration of its walls, by carcinoma for instance, recent inflammatory processes in the pelvic organs, or the pelvic cellular tissue, abscesses, hematocele, pyocele, hernatometra even, since the great pressure induced might lead to rupture.
Altogether we may say that Simon's method of rectal examination does not accomplish all that was at the outset claimed for it. The more expert the examiner the better will he be able to make a rectal examina tion by the finger alone, which will often yield better results than the half hand.
In case of the simple rectal examination or that by the hand, the bi manna] must be resorted to in the same manner, and under the same rules as in the vaginal examination. It is further possible to combine the rectal with examination by the vagina or bladder. By the vagina either the thumb of the same hand or else the index of the other hand may be used. In either way the recto-vaginal septum lies between the fingers, and its condition may be determined, and by imparting movement to the cervix by the vaginal finger, the effect on the body of the uterus may be noted by the rectal finger. If the fingers are inserted still higher, the entire lower uterine segment may be palpated, and in this instance it is preferable to use the index fingers, since with them we may reach higher and feel better than with the thumb.