Large Bowel & Rectum: A Magnificent Work of Art
Midway, his last resistance yielding, he allowed his bowels to ease themselves quietly as he read … Hope it’s not too big to bring on piles again. No, just right.
James Joyce, Ulysses
HUMANS COULD BE DESCRIBED as tube-like animals, our skeletons and organs as elaborations to support a length of gut. From that perspective we’re not all that different from nematode worms, primitive organisms that seem to exist primarily to ingest and excrete. Food goes in one end, faeces out of the other, and nutrients and water are extracted. In nematodes, it takes just a fraction of a millimetre to accomplish, but in us it’s between twenty and thirty feet. Our bowels are forced into loops and spirals in order to fit in the space they’re allocated; they squirm and twist constantly as they squeeze food and faeces along. The rectum is the terminus of that tube, and isn’t free to move around – it’s stuck down to the back wall at the spine. Its name comes from the Latin meaning ‘straight’: as the bowel jinks its way out of the sigmoid colon it makes a straight run through the pelvis for the exit.
In terms of function, the rectum is really just a waiting room: a place for faeces to accumulate until it’s convenient to let it out. Bowel habit comes to most as a birthright: morning or evening, regular or irregular, loose or firm, we grow accustomed to the way waste exits, and alarmed if its pattern begins to change. For the most part that’s with good reason: doctors are interested in changes to bowel habit because they can signal deeper disturbance. Diarrhoea can be a sign of thyroid disease, constipation a warning of malignancy, and oily, floating faeces suggest that your pancreas has packed in.
Just as a great deal of information can be revealed about someone’s state of health from asking about how often they open their bowels, there is a lot to be gleaned from checking the inside of the rectum itself. In men it’s the main way of examining the prostate, which can be felt by a (gloved) finger through the thin anterior wall. In women the cervix lies in about the same place, and in some women, particularly if they’ve never had sex, it’s more acceptable to check the cervix rectally rather than vaginally. If someone is passing blood, an examination is necessary to find out if the blood is coming from haemorrhoids, from a tear in the anal skin, or from a tumour – I’ve found several rectal cancers this way (the medical school aphorism goes: ‘If you don’t put your finger in it, you’ll put your foot in it.’)
Stand-up comedians might suggest that to have your large bowel inspected you should drop your trousers and bend over, but the best way is actually to lie on your side, up on a couch, and draw your knees towards your chest. It’s always surprising how many people apologise or make an embarrassed joke as they get into the position: ‘I hope you haven’t just had breakfast’; ‘I’m so sorry that you have to do this,’ as if the rectum is so sordid that, as the examiner, I might feel repulsed. It’s an understandable belief: we’re taught from our earliest years that faeces are untouchable, and that the rectum and anus are dirty and disgusting.
For most doctors, disgust at suppurating wounds, prolapsed bowels, or gangrenous limbs is beside the point: they have to be examined, so their aesthetics are irrelevant. But though ugliness has little place in the consulting room, there is still room for beauty, in the dictionary’s sense of ‘calling forth admiration’. The intricacy and economy of human anatomy, both in health and in sickness, is often beautiful. And if imagining the harmony beneath the skin can be beautiful, medical images such as ultrasound scans are, too – think of those grainy, chiaroscuro scans given pride of place on the mantelpiece or on the first page in a baby’s album. X-ray images have a particular ethereal beauty to them, whatever part of the body they represent; contemplating them is a reminder not just of the skeleton and our mortality, but a way of transforming perspective and imagining the body anew. Sometimes they are like portraits, but they can also resemble landscape paintings with contours, horizons and cloudscapes. There are parallels in nomenclature: in emergency departments I’ve often ordered ‘skyline’ views of the knee, or ‘panoramic’ views of the jawbone. That those images have clinical importance, useful in diagnosis and treatment, makes them more, rather than less, beautiful.
The sculptor Rodin said that there was no ugliness in art if that art offered some insight of truth, and the same could be said for the practice of medicine, and the images that it creates. Medically speaking the body is rarely ugly, and images of it can have an aesthetic that approaches art – even if those images are of … the rectum.
DOUGLAS DULETTO was a thin, middle-aged man who wore horn-rimmed spectacles and a starched white shirt. He had neat greying hair, parted in the centre, and sat primly on the emergency room gurney as if waiting patiently for the second half of a chamber music recital. He was wearing a thin hospital gown, and had neatly rolled up his corduroy trousers and placed them to one side of the gurney.
I picked up a clipboard from a holder on the cubicle wall and glanced down at the sheet: ‘Foreign body, rectum’ it said.
‘I’m mortified to be here,’ he said, flushing suddenly, ‘but I can’t get it out.’
‘What’s “it”?’
‘A bottle,’ he replied. ‘I’ve been trying to get it out all evening.’
‘A bottle of what?’
He flushed an even deeper scarlet: a senator snapped at a strip club.
I asked him to lie on his left side with his knees drawn up to his chest – ‘I’ve left my dignity at the door anyway’ – then pushed a gloved finger into his rectum. ‘Just bear down,’ I said, ‘squeeze as if you’re trying to open your bowels.’ At the tip of my finger, as far in as I could push, I could feel an edge of hard glass – too deep to get a finger on either side of it. I inserted a clear plastic tube – a proctoscope – and shone in a light. At the clear plastic edges of the instrument I could see healthy pink walls of rectum flecked with yellow sluglets of faeces. At the centre, just at the limit of my view, there was a glint of glass. ‘It’s going to be tricky I’m afraid,’ I said, ‘it’s quite far in.’
He sank forward, head in his hands, and his shoulders began to shake. At the ward’s ‘sluice’ – the area where all the urine and faeces are disposed of – I found a commode, and from the surgical ward some ointment ordinarily used in the treatment of tears in the anal skin. The ointment relaxes the sphincter, which can allow tears to heal, but I wondered if it would also allow the bottle to pass. I applied the ointment, and asked him to sit on the commode.
After he’d strained a few times I got him back up on the couch, then tried for the bottle again. This time I thought I had it, when at the last minute it slipped away deeper into the swampy anatomy of the abdomen. I swore under my breath, but he heard me.
‘What’s wrong?’ he asked, nervously.
‘Nothing,’ I told him. ‘But we’re going to have to get an X-ray.’
At that time X-rays were still produced on large acetate films. Once Mr Duletto was back in the cubicle I took the envelope containing the film back to the doctor’s room, and put it up on a light box. It gathered quite a crowd.
The bowl of the pelvis stood in the foreground, shaped like the two flanks of a valley, beneath vague, gaseous bowel shadows – a Turner-like sky. Rising up through the middle was an incongruous form: a skyscraper dropped into a pastoral scene. It was the crisp, instantly recognisable outline of a branded bottle of ketchup. It lay along part of the rectum and into the sigmoid colon, with the shoulders of the bottle and its metal lid tapered like an arrowhead pointing deeper into the guts.
‘I’m sorry,’ I said when I got back to the cubicle, ‘I’m going to have to refer you to the surgeons. There’s no way I’m going to be able to get that thing out on my own.’
ACCORDING TO THE PSYCHOLOGY of aesthetics, art is appreciated not just through the perception of something as beautiful, but because it can elicit a wide variety of emotions: confusion, surprise, disgust and even embarrassment. Looking at the X-ray, it undoubtedly had an aesthetic value: the grainy forms of bone and bowel against the moulded artistry of glass and metal. There was pop-art appeal to the juxtaposition of a mass-produced bottle against the organic shape of Mr Duletto’s pelvis. This X-ray is a work of art, I thought to myself: it could be submitted to a gallery, or projected at night onto the hospital building. I pictured it for a moment hung in MoMA or the Tate Modern, protected by glass and cordoned by rope.
I dictated a letter for the surgeons, and a porter came down to take Mr Duletto up to their ward. ‘Surgical?’ the porter asked, and I pointed to the cubicle. He pulled the gurney out into the corridor, and Mr Duletto lifted a hand to wave as he headed towards the door. ‘Any X-rays?’ the porter called out.
‘Oh yes,’ I said, turning to the light box, but there was no X-ray there. It had been stolen: someone else must have appreciated it for a priceless work of art.