PRACTICAL CONSIDERATIONS : THE LARGE INTESTINE. 1693 



give a sensation of a broad muscular band around the bowel" (Cripps). This is 

 more distinct posteriorly and represents the posterior edge of the levator ani. It is 

 from 1^2 in. from the anus. A patulous condition of the anus or a cavernous or 

 1 ' ballooned' ' condition of the rectum should suggest stricture, the muscles below 

 which, having no function to perform, become enlarged and yielding. An excep- 

 tionally tight grip of the finger, with marked tenderness, should suggest fissure. 



If the patient is asked to strain, a slightly increased area of bowel will be made 

 accessible to examination by the finger, but, except anteriorly, the finger cannot, as 

 a rule, reach beyond the portions uncovered by peritoneum. The upward distance 

 thus made palpable is on the average from 3-4 in. The distance from the anus to 

 the recto-vesical pouch, when the bladder and rectum are empty, is about 2^ in.; 

 when they are distended, it is about 3^ in. Growths in the sigmoid often descend 

 so that they may be felt through the rectal wall with the finger. 



Anteriorly, from 1^-2 in. from the anus, the prostate may be felt in the male. 

 Between its apex and the anus the membranous urethra is accessible to digital 

 examination and can be distinctly outlined when a catheter or sound occupies it. 

 Posterior to the prostate there may be felt the triangular area of the base of the 

 bladder, which is closely held to the rectum by dense connective tissue, and the sides 

 of which are formed by the seminal vesicles, the base by the edge of the recto- 

 vesical peritoneal pouch. It is through this triangle, and as near its apex i.e., the 

 prostate as possible, that the bladder is tapped per rectum, and it may be noted in 

 connection with what has already been said as to the lack of sensibility in the upper 

 rectum, that the operation now rarely performed is almost painless. The seminal 

 vesicles, and in some cases a portion of the vas deferens, can be felt above the pros- 

 tate and at the sides, especially if diseased. Their relations to the rectum explain 

 the spurious cases of spermatorrhoea in which, during defecation, their contents are 

 squeezed into the urethra by the descending fecal masses, exciting the apprehension 

 of the patient, usually a young neurasthenic. 



In children the bladder may be examined to its bas-fond, and, even if not dis- 

 tended, may be felt by bimanual palpation, one hand being above the pubes. 



The back of the pubic bones and symphysis and the obturator foramina may also 

 be reached anteriorly. 



In females the recto- vaginal walls and the os uteri may be felt anteriorly and the 

 broad ligaments and (in some cases of disease) the ovaries laterally. Laterally also, 

 in both sexes, the inner aspect of the ischial tuberosities and part of the rami may be 

 felt, as well as the inner walls of the ischio-rectal fossae, which will be soft and yielding 

 under normal conditions, and tense, tender, and bulging if an abscess occupies the 

 ischio-rectal space. 



The pulsations of some of the hemorrhoidal arteries may often be felt, and one 

 or more of Houston's folds and the lower portion of the columns of Morgagni and 

 the ' ' valves ' ' of the same name recognized. Posteriorly the front of the coccyx 

 and the sacro-coccygeal junction can be reached. 



(t>) By inspection, with the aid of various specula, and with reflected or electric 

 light, ulcers, polyps, or other new growths, the internal openings of fistulous tracts, 

 hemorrhoids, fissure, and other pathological conditions may be seen. By placing 

 the patient in the ' ' knee-chest position' ' the intestines gravitate towards the dia- 

 phragm, the recto-vesical and recto-vaginal pouches are emptied, downward pressure 

 upon the sigmoid and rectum is removed, the latter has room to dilate upon the 

 admission of air, and inspection is thus facilitated. 



(e) By bougies stricture may be recognized, but care must be taken that ob- 

 struction due to contact with one of the so-called "valves" Houston's folds is 

 not mistaken for a contraction. It should be remembered, too, that the sigmoid is 

 quite movable, and that the demonstration by touch of the presence of the end of the 

 bougie close to the abdominal wall, even if it is also near the median line, does not 

 prove that it has passed into the colon. It may have carried the sigmoid with it. 



(d) By the whole hand introduced into the bowel there may be felt (in addition 

 to the structures mentioned in a) (r) the spines of the ischium ; (2) the curve and 

 promontory of the sacrum ; (3) the outlines of the greater and lesser sacro-ischiatic 

 foramina ; (4) the external iliac artery from the brim of the pelvis to the crural 



