A NEW RECTAL DILATOR AND EXPLORER, WITH TWO CASES ILLUSTRATING THEIR USE; BY PHILIP S. WALES, M. D., MEDICAL INSPECTOR, U. S. NAVY. WASHINGTON : COLUMBIAN PRESS. 1877. A NEW RECTAL DILATOR AND EXPLORER, WITH TWO CASES ILLUSTRATING THEIR USE; BY PHILIP S. WALES, M. D., MEDICAL INSPECTOR, U. S. NAVY. WASHINGTON: COLUMBIAN PRESS. 1877. i 2 5*3 Fig. 1.-Dilator unexpanded. Fig. 2.-Dilator expanded. Fig. 3.-Explorer unexpanded. Fig. 4.-Explorer expanded Fig. 5.-Irrigator. A NEW RECTAL DILATOR AND EXPLORER WITH TWO CASES ILLUSTRATING THEIR APPLICATION. By Philip S. Wales, M. D. Medical Inspector, U. S. Navy. The treatment of stricture of the rectum is always tedious, pain- ful and difficult, and in an increasing proportion to its distance from the anus. The malignant forms are uniformly fatal, and it is only in the non-mallgnant varieties that a successful issue may be secured by surgical measures. The ordinary appliances employed in the latter class of cases have not been altogether satisfactory, particularly in those instances in which the obstruction is seated high up in the bow- el and beyon 1 the reach of the finger. Having recently had two cases of this latter sort, in one of which particularly the practical diffi- culties culminated from the height of the stricture, I had recourse to certain mechanical contrivances with the most gratifying results. I shall first relate as succinctly as possible the cases and then describe the instruments with which they were treated. Casyl.- rhe Admiral of the Navy consulted me, November 23rd. 187*>. He state 1 that he had been id for four or five years, had lost much flesh, his mental powers-especially memory-had become impaire 1. that he was gloomy and foreboding; the slightest exertion exhausted him so that he rarely took exercise. The bowels had been obstinately constipated, requiring numerous and daily injec- tions. in connexion with cathartic medicines to a movement and then but a trifling amount could be passed, Ills appetite was poor and capricious, and his sleep was disturbed and unrefreshing. The abdomen was distended and often tender, and one of the most annoying symptoms was frequent and painful contractions of the an- terior crural muscles. His skin had assumed a decidedly yellow tinge and his countenance wore a haggard and very painful expression. He said he had consulted many physicians, and had had his case made out to be cancer of the bowels, disease of the kidneys, liver, spleen and stomach, in fact all the chylo-poietic viscera had been, from time to time, charged with occasioning all the trouble, hence the variety in the plans of relief. 4 A NEW RECTAL DILATOR AND EXPLORER. in a great degree. In 1872 I noticed that my stools were composed of balls about one half of an inch in diameter, and three or four in number during the morning; besides this sort of dischar ,es. the least excitement or passing into a damp or cold room caused an evacuation of about a tablespoonful of semi-transparent mucus. The balls passed became smaller gradually and'at last the stools consisted of a flat or three-cornered strip about six or seven inches long, of good color but coated with slime. 1 consulted with many physicians most of whom said that 1 was notional, having so many symptoms I was finally obliged to abandon my professional ('utie . My mind was much confused at times. I had intense hea laches. 1 >.ss of memory, and great dread of any difficulties or excitement. In the spring of 1875, I felt satisfied that there must be some stoppage or obstruction in the intestine and forthwith consulted an eminent physician. He made an examination with his finger and stated tha; there was no stricture; copaiba was prescribed but I had to gi\ e it up in a few days as it affected my kidneys and gave me sever • pain in my back. T had many functional difficulties, my eyes beca no very sensitive to light, and there was a continual burning sensation in the bowels, accompanied with great depression of spirits, fullness of the head and a sensation of weight on the top of it, a continual sense of fullness and burning in the back as if there were veins starting from the lower part of the spine and branching out towards the shoulders, and distended with hot. burning blood. This feeling in my back was so great that I could not lie on my back or lean against a chair. I was obliged to pass my urine every two or three hours, and have been afflicted with seminal emissions throughout my troubles. At present, January 1st., T am free from all the foregoing distressing symptoms and have figured discharges of good size." In this case the stricture was found to be located seven inches up the rectum and has been sufficiently dilated to permit the passage of an instrument three quarters of an inch in diameter. The dilators used in the cases above related were manufactured, as stated, out of pure rubber with a canal running the whole length, and gradually increasing in size by an eighth, from a quarter of an inch to an inch in diameter : each dilator is fitted with a gum sheath of corresponding dimensions. In order to secure the most perf*ct construction, a model was submitted to Mr. J. H. Gemrig, of Phila- A NEW RECTAL DILATOR AND EXPLORER. 5 delphia who has. with his wi ll-known skill, macle an admirable set of eight dilators. The accompanying cut wid furnish a good idea of them. It represents one of the dilators with its sheath undilated, and another dilated an 1 connecre 1 with the syringe by which the sheath has been (listen led with water. The sheaths may als i be in- flated by Pulitzer's air-bag or other suitable contrivance. The points of the dilators may be terminated spherically, or taper for an inch and a half or two inches conically, the latter form on the whole being more easily introduced. The sheaths made by Gemrig do not burst u i ler ordi lary pressure, as th >se di 1 1 e noloye I at first; be- sides the loss of the sheath, no damage is otherwise done. A low thud and a peculiar sensation felt by the patient at the moment an- nou ice the accident and alarm nervous subjects. The whole length of the sheath, both inside and outsi le the bowel, or any portion of it, may be filled with water; in the latter case a thread of silk is to be twisted around the dilator at any point that it miy be desirable t > limit the distention. Indeed the sheath might be made in one piece with the central portion for one hah'or one third of its length, a modification which I shall test at an early period. Ordinarily, how- ever, I believe it will be advantageous to distend tlie entire bowel bel >w the stricture at the same time that the stricture is being acte d upon, as I have several times observed a general narrowing below the obstruction, which 1 presume is owing in part to the fact that the bowel is bereft of the habitual distention from the daily passage of moulded fecal matter in the normal condition. The method of introducing the dilator is simple. I prefer placing the patient reclining on his left side, upon an ordinary operating table, the thighs flexed and the buttocks just overhanging the lower edge. The operator may then comfortably seat himself during his manip- ulations. aii a Ivantage of no ordinary character, if they are to be at all prol >nge 1. The smallest size I instrument is smeared with grease and its point inserted into the anus and gently pushed onward in the following manner. The right hand grasps the dilator close to the anus, an I the wh lie perineum is to be pressed upwards, which will a Iva ice the point of the instrument; the left hand now steadies it, while th? right is slid d iw.iwir Is for a lower hold, the perineum of c mrse settles with it; the dilator is again pushed forwards in the sa ne manner until the obstruction is passed. I have occasionally 6 A NEW RECTAL DILATOR AND EXPLORER. f >uii I that this may be greatly facilitated by sinking the fingers of the left hand deep into the left iliac region, and drawing upwards as though an effort was being made, so to speak, to stretch out the sig* m >id flexure, while pressure is maintained at the same time upon the dilator in the manner described. Another practical point of prime importance is to employ an abundant stream of water, projecting it through the conduit of the instrument, as warm as can be comforta- bly borne, whenever its point is arrested from any cause. The water fl nving from the distal aperture will distend the bowel, efface its f )lds. and break down any hardened feces that may exist, obstruct- ing the ascent of the dilator. While the operator is engaged with the dilat >r. an assistant may manage the syringe and throw in the water in such quantities as may be needed. It must be borne in m id however, that no great volume should be used at once, other, wise the bowel will be excited to energetic contraction and compel 11 • dilator t > be withdrawn before it has been properly lodged. In preliminary trials, the dilator m ay be permitted to remain two or three nf nut's. an I aft awards when greater tolerance is established, a long- er stay may be allowed. I rarely exceed half an hour in any case, ev ■ i when the patient makes no complaint of irritation or pain. After several introductions of one size of the dilators, perhaps sev- en or eight, the next largest may be taken and so on until the strict- ure has been sufficiently expanded. The application of the instrument may be repeated twice or thrice a veek according to circumstances, such as the irritability of the rec- tum, temperament of the individual, and intercun/nt attacks of diar- rhea or other trouble. Twice a week, in my experience, suffices in most cases of rectal catherterism : a fortunate issue, if attainable, can only be brought about by patient and prolonged treatment. Rude- ness or vio'ence inflicted with a view of hastening the case, can effect n (thing but harm and may jeopardize the life of the patient. If the instruments be hastily thrust in. the bowels may be perforated espe- cially in those cases in w hich inflammatory softening or ulceration exists : or if they be too large, the rectal mucous membrane may be ruptured giving rise to smart hemorrhage, as happeqd in one of mv early cases; or the entire wall of the bowel may be ruptured into the peritoneum; an accident that is pretty sure to be followed by peritonitis with all of its attendant dangers. A NEW RECTAL DILATOR AND EXPLORER. 7 These funest sequences are infinitely less liable to follow the u e of pure india rubber dilators than that of any other sort; for cei- tainly. a priori, nothing could furnish a milder, more equable and less dangerous force than these, and experience sustains this view. That the pressure possessing these merits is all sufficient to effect the result desired, is shown by the cases cited above ; indeed, the maximum distention obtainable by the dilator can not, even were it safe to exercise it. be supported by any person not anesthetized, and hence the unnecessariness, in the majority of cases, of the nu- merous forms of those dilators constructed with a view of gaining great mechanical power. Possibly, in exceptional instances, they may be found applicable and any severe suffering may be easily elim- inated by chloroform, but the only safe plan in rectal instrumenta- tion. is to proceed with the patient iu the full possession of his con- sciousness, so as to secure the assistance of his sensibility in guiding the hand while managing the dilator. I have not yet encountered a single stricture case that did not suffer very much, both in the intro- duction and the expansion of these contrivances ; and in constriction situated high up the bowel, they are altogether inadequate. I have now introduced these rubber instruments into the intestine several hundred times, without discovering any major objection or defect. Some of my friends have, however, expressed a suspicion 8 A NEW RECTAL DILATOR AND EXPLORER. that being so soft and flexible, they ate likely to deceive by doubl- ing in the intestine instead of slipping along the mucous membrane. This is, of course, possible : but I have not as yet seen them perform the whimsical caper of knotting, which occurred in the first case re- lated in this paper, yvith a flexible tube such as is ordinarily used in with the stomach pump. It was passed eighteen inches into the boyvel and. as I supposed, stretched out its full length. On attempting to withdraw it some resistence was felt, which required no little tractile force to overcome. The difficulty was at once ap- parent, the tube yvas tied in a single knot, as shown in the appended sketch made by the admiral himself who has kindly furnished me yvith it. I have also been using the dilators in applying ointments. various- ly medicated yvith astringent and anodyne substances, in cases of relaxation of the intestinal mucous membra .e, prol ip.-e. hemorrhoi- dal tumors, and other morbid rectal conditions. A slight modifica- tion converts the dilator into an irrigator; that is, by having tyvo par- allel conduits in it. one for the fluid to pass in. and the other for it to escape externally. The boyvel may be thus irrigated quite high up; for I have frequently inserted the instrument twenty eight inch- es into the colon, In one case, the patient passed every morning, one or two large and yeasty stools mixed yvith mucus and followed by much mental depression : a cure yvas obtained by the injection, three times a yveek. of a solution of carbolic acid, after internal medication had failed. Much advantage may be realized from the use of yvarm irrigation in various diseases of the contiguous pelvic and abdominal organs : as. cystitis, prostatitis, suppression of urine and intussusception. The half inch dilator yvill furnish a ready tube for introducing alimentary substances into the stomach or rectum. Stricture of the oesophagus, though I have treated no case of this sort yvith the dilator, yet with my present experience in rectal con striction. I feel pretty sure, may be most satisfactorily managed in an analogous manner. To supply a want long felt of a facile and reliable means of diag- nosing intestinal diseases, I have constructed an explorer,yvhich has worked admirably in my hands; and some of my friends, who have employed it in cases in yvhich stricture yvas suspected to be present, have assured me that they regarded the evidence furnished by the A NiAV RECTAL DILATOR AND EXPLORER. 9 instrument as \ery conclusive. It may be prepared in the following manner : take a dilator, say one half an inch in diameter, and, over its distal extremity, draw a hood of thin india rubber two inches long, securing its margin with a fine silken thread. If the rubber is not at hand, a piece of moistened blal ler or gold-beaters' skin will answer very well. The instrument thus made ready should be well coated with a stiff grease, like simple cerate or zinc ointment, which, I find, works better than sweet oil in facilitating its gliding over the mucous membrane, and introduce I in the manner I have already described for the dilator, until its p >int is lodged far above in the descending colon. A syringe is attached to the instrument, and its point expanded into the form of a ball an inch or more in diameter. Gentle traction is now to be made, whidh will cause the ball filled with water, to move slonly down the bowel. If no obstacle is pre- sent the ball will soon emerge from the anus; on the contrary, any obstruction will arrest it above. It may be that spasmodic contrac- tion will have a like effect, but this can be easily distinguished from permanent stricture by keeping up the traction a few mo neats, un- til the muscular force of the intestinal walls is exhausted, when the ball will again slip alo ig. T always use hot water, an 1 often smear the explorer with belladonna or iodoform ointment, with a view of eliminating this source of error. In cases of organic narrowing, its degree may be determined ap- proximately by maintaining the traction on the explorer, while the water is permitted to flow out in small quantities at a time, until the size of the ball is sufficiently reduced to slip past the constricti m ; the diameter of the ball, which represents that of the strict ire. na be now ascertained by mere inspection. Although, practically, an explorer prepared in this simple manner is quite efficient, yet to se- cure an instrument always ready and more artistic. I am endeavor- ing to get the point and body made in one piece, with a second con- duit running along the stem and terminating behind the ball, so that a stream of water may be ejected at any mom* nt should the point catch in the intestinal wall.