operation to he a fluid collection in the lesser sac (pseudocysts) of more or
less completely disintegrated blood. If the contents contain a diastase fer-
ment — i.e., convert starch into sugar- — a pancreatic origin from injury is
66
210 INJURIES AND DISEASES OE THE PANCREAS
probable (Jordan Lloyd). In some cases the development of the cyst is
delayed for months or years. Such patients may have suffered from pain in the
epigastrium from time to time, or have had no symptoms. In other cases there
will be no history of injury, but preceding the formation of the cyst the patient
will have suffered from attacks of epigastric pain and digestive disturbances,
suggesting an inflammatory origin of the cyst (Korte). The symptoms pro-
duced by the cyst itself are usually slow to develop, and are observed only after
it has reached a certain size, so that it interferes with the functions of the
stomach. There will then be nausea, attacks of vomiting, gastric dyspepsia,
palpitation of the heart, occasionally there will be jaundice, rarely interfer-
ence with the function of the pancreas itself. Some of these patients suffer
some disturbance of nutrition after the cyst has reached a considerable size,
but not always. I recall three cases, two of my own and one of Dr. McBur-
ney's, in which, though the tumor was quite large, no disturbances of general
health and no symptoms other than distress after eating were present. In one
of my cases the cyst grew from the tail of the pancreas toward the left and
presented beneath the costal border in the left flank. In the other two
the cysts were centrally situated. If the cysts are permitted to grow
very large, they may cause, like any other tumor occupying an undue share
of the abdomen, very serious symptoms indeed — violent vomiting, obsti-
nate constipation, emaciation, prostration, and dyspnea. The diagnosis of cysts
of the pancreas is sometimes easy, sometimes difficult. It is to be borne in mind
that a slowly growing cystic tumor of the upper part of the abdomen, especially
if a little to the left of the middle line, since the cysts usually form in the
body and tail of the organ rather than the- head, is more likely to be a cyst
of the pancreas than anything else. The cysts may develop and approach the
front of the belly in several positions. The commonest type is: (1) The cyst
grows into the lesser sac and appears between the stomach above and the colon
below, having the gastrocolic omentum in front of it. (2) It may push the
stomach in front of it and appear above the lesser curvature, having the gastro-
hepatic omentum in front of it, (3) It may grow in between the layers of
the transverse mesocolon, so that the colon rides across its front or lies just
above it. In one case (Albert and Payr) the cyst emerged to the right through
the foramen of Winslow into the greater sac (Korte). In one case of my own,
as related, the tumor grew from the tail of the pancreas and presented pre-
cisely like a hydronephrosis in the left flank, fluctuating, flat on percussion,
and with the colon in front of it. This tumor exhibited a moderate degree
of passive mobility in a vertical plane. These various relations between the
cyst, the stomach, the colon, are very important in the diagnosis. They are to
be made out by inflation of the stomach and colon respectively. When the
cyst presents between colon and stomach, the inflated stomach will, if the cyst
be not too large, lie in front of it, the colon below. In group number two the
inflated stomach lies below the cyst, the latter being crowded upward more or
less beneath the liver, when it may be mistaken for echinococcus cyst of the
THE DISEASES OF THE PANCREAS 211
liver. When the colon lies in fronl of the cyst, as in group three, or cr
[ta upper border, one would be al a I" - to distinguish ii from a mesenteric
cysl < Korte), or anj of the other cysl ic retroperitoneal growths; and, as stated,
when thej presenl in the loin, it is scarcely possible to distinguish them from
cystic tumors of the kidney by physical examination. In addition to tli<- above
characters, the history of the case, as outlined under symptoms, is a history of
injury or of attacks of colicky pain ; i - « •< • I :i t • •< 1 with tenderness in the epigas
trium. The slow growth, the absence of acute pain and tenderness on palpa-
tion, the relatively i^» »• >< 1 health, as compared with malignanl disease, the physi-
cal characters of a tense, fluctuating, rounded, rather immobile tumor, -
for a probable diagnosis. Under no conditions is the introduction of an
aspirating needle into the cyst free from risk. The fluid of these cysts is usu-
ally irritating, and may be infectious. Moreover, nothing characteristic in
tlie aspirated llni<l may appear. It may contain no ferments; and, <»n the
other hand, ascitic fluid may occasionally have the power of digesting cooked
starch to some decree. A number of cases of traumatic or spontaneous rup-
ture of pancreatic cysts have been reported with fatal results. An aseptic
incision in the abdomen over the tumor, suture of the cyst to the belly wall,
and drainage at one or two sittings, is the safest diagnostic and therapeutic
measure. Only rarely arc these cysts suitable for extirpation. The sinuses
after incision and drainage of pancreatic cysts are always slow to close; they
may remain open eighteen months or longer. I have watched seven cases, and
all closed eventually without any special treatment, except the use of a small
drainage-tube and asepsis, after from three to eighteen months. The surround-
ing skin can be protected by any bland ointment.
CHAPTEE VIII
THE RECTUM
GENERAL REMARKS
Anatomical details from Woolsey, " Applied Surgical Anatomy," and
from Merkel. Formerly the rectum was described as that portion of the large
intestine commencing at the level of the left sacro-iliac joint at the brim of
the pelvis and extending to the anus. At present it is customary to include
what was formerly regarded as the upper portion of the rectum — namely, from
the pelvic brim to the middle of the third sacral vertebra as a part of the
colon and to regard the rectum as that portion of the large intestine extend-
ing from the middle of the third sacral vertebra to the anus. In other
words, that portion of the gut having a mesentery is now included in the
colon. Regarded in this way, the rectum forms a canal which is truly
straight in one plane at least — that is, while it curves in an anteroposterior
direction it has no lateral curve. The rectum for purposes of description may
be divided into two parts : an upper or pelvic portion, three inches and a half in
length, which follows the curve of the sacrum and coccyx, and the lower or
anal portion, about an inch and a half in length, which bends sharply back-
ward and downward just below the tip of the coccyx. In introducing rigid
instruments into the rectum it is important to remember the direction of these
two portions, so that undue violence may not be exerted upon the wall of
the canal. The axis of the anal portion of the rectum is directed toward the
apex of the prostate or toward the rectovaginal septum in the case of the female.
In introducing an instrument into the rectum, therefore, it should be intro-
duced upward and forward for an inch and a half, and then rotated backward
into the hollow of the sacrum, so that at first it passes upward and forward, and
subsequently upward and backward. The dividing line between these two
portions of rectum corresponds to the point where the rectum pierces the pelvic
floor. The lower or anal portion, therefore, lies entirely without the pelvis,
and the same is true of the lower part of the upper portion, which lies below
the reflection of the pelvic fascia. In children the rectum is much straighter
than in adults, and for that and other reasons prolapse of the rectum is more
common from comparatively slight causes — i. e., great straining at stool, etc.,
than is the case with adults.
The Pelvic Portion of the Rectum. — Above the anal portion of the rectum
there is a dilated pouch, known as the ampulla, lying between the apex of the
212
GENERAL REMARKS 213
prostate and coccyx. This portion "f the rectum is capable of great dis
ii,, M . and is the seal of large fecal accumulations in certain cases of chronic
( stipation with atony of the gut seen chiefly in old people, aa will be de-
scribed. Distention of this portion of the rectum in the male pushes the
bladder upward and forward and elevates the rectovesical fold of peritoneum.
The attachmenta of the rectum to the Burrounding strueturea are relati
loose, so that the rectum ia really a very mobile portion of the gut In order
to completely free the rectum, so thai it may be pulled down in certain oper-
ations, the fibers of the levator ani muscle musl be divided and the peritoneal
attachments loosened. This may be accomplished for the mosl pari by blunt
dissection with the fingers. In front the rectum ia s< swhat firmly attached
to the prostate and bladder, but these attachmenta may be loosened with the
finger8 quite readily, in operationa upon the prostate and seminal vesicles, for
example, or upon the rectum itself. In the female the rectum ia attached to
the posterior wall of the vagina by loose connective tissue. The relation- of
the rectum are very importanl from a diagnostic as well as from a therapeutic
point of view, since by rectal examination we are able to, as will be described,
palpate with comparative ease a good many structures and to acquire valuable
information nol obtainable in any oilier way.
Relations to the Peritoneum. — The anatomical details are adapted from
Woolsey, "Applied Surgical Anatomy." Commencing opposite the third
sacral vertebra the peritoneum alone represents the mesorectum. Tt covers
at first the front and sides of the bowel, and is reflected from the latter along
an oblique line descending from behind forward. It is finally reflected from
the front of the rectum on to the bladder in the male and on to the vagina,
cervix, and uterus in the female, forming the rectovesical and rectovaginal
pouch (Douglas's pouch) respectively. The distance of the rectovesical peri-
toneal pouch from the amis is of importance; it measures about three inches
when the bladder is empty and as much as four when it is full. The distance
of the rectovaginal pouch from the anus in the female is somewhat less than
in the male. It is important to hear in mind that a complete prolapse of the
rectum of considerable size carries with it this pouch of peritoneum, and
intestinal coils may also be contained in such a prolapse. On the posterior
wall of the rectum the peritoneum reaches downward to a point about five
inches or more from the anus. Thus cancers of the rectum situated on its
anterior wall are more apt to invade the peritoneal cavity than those situated
on the posterior wall. As has already been pointed out in the diagnosis of
abdominal diseases, an examination of the rectum is highly important under
a great variety of conditions. By rectal palpation in the female we van readily
feel the position of the uterus, if retroverted especially, or a prolapsed ovary,
and by bimanual palpation the rectum servea aa well as the vagina for map-
ping out the position of the pelvic organs, whether healthy or diseased. In
the male we can feel the base of the bladder which is applied to the rectum
over a triangular area, the size, conformation, and consistence of the prostate,
214 THE EECTUM
and in conditions of disease, when enlarged by ordinary inflammation or tuber-
culosis, we can feel on either side above the prostate the seminal vesicles;
if enlarged and hardened from tuberculosis, we may also be able to feel the
vas deferens on either side. It is also frequently possible to feel a stone
impacted near the lower end of the ureter, and occasionally I have felt through
the rectum a large stone in the bladder. In cases of difficult catheterization
the finger in the rectum enables us to feel the tip of a sound or catheter in
the membranous urethra, and is sometimes of great assistance in the passage
of an instrument in cases of stricture or of enlargement of the prostate gland,
and the same may be true in operations upon the perineal urethra (external
urethrotomy). By rectal palpation the bony walls of the pelvis may be exam-
ined for deformity, fracture, or disease. Posteriorly the front of the coccyx
and sacrum may be examined, laterally the spines of the ischia as well as the
tuberosities and the bodies of these bones. We may also examine the sacro-
sciatic foramina, and in front we can examine the posterior surface of the
pubic bones, the pubic symphysis, and the obturator foramina. By invaginat-
ing the pelvic floor, we can, under an anesthetic, reach with the tip of the
finger the sacral promontory. Sometimes it is of advantage, when attempting
a high digital examination of the rectum, to examine the patient in the erect
position and tell him to strain downward. The lower or anal portion of the
rectum is an inch and a half in length. It is the narrowest part of the large
intestine; but since its narrow caliber is due largely to muscular contraction,
it is readily dilated. Formerly it was the occasional practice of surgeons
after dilating the anus to introduce the entire hand into the rectum for the
purpose of palpation. While this was possible, it is no longer practiced, since
serious injury to and even rupture of the rectum have been produced in this
way. The anal portion of the rectum is surrounded by the internal sphincter,
and to its sides are attached the levator ani muscle, together with its inclosing
layers of fascia. In the female the perineal body lies in front, separating the
gut from the lower end of the vagina, and the perineum in the male, separating
it from the urethra.
Structure of the Rectum. — The longitudinal muscular fibers of the rectum,
although somewhat more abundant in front and behind, are more uniformly
distributed here than in the upper portion of the large intestine. The circular
fibers become much more abundant in the upper inch of the anal portion ; they
form the internal sphincter. The lower limit of the anal portion is repre-
sented on its interior by a circular white line which marks the junction of
the skin and mucous membrane. The external sphincter surrounding the anal
orifice is a striped or voluntary muscle. The submucous tissue of the rectum
has so loose an attachment to the mucous membrane of the bowel that, espe-
cially in children, irritation of the rectum, such as is caused by the presence
of worms and polypi, producing straining at stool, makes prolapse of the rectum
quite common in early life. When present only to a slight degree, the prolapse
may involve the mucous membrane merely, but in well-marked cases all the
GENERAL REMARKS 215
structures of the recta] wall may be included in the prolapse and the peritoneal
pOUcli lis well.
Houston's Folds or Valves. — Certain obliquely transverse folds of muc
membrane exisl in the rectum which are uo1 effaced by distention of the boweL
These may catch the poinl of a bougie or other instrumenl introduced into
the rectum and impede its progress. An overdevelopment of these valves is
believed by certain practitioners to be a cause # of constipation. Whether this
contention rests upon any basis of fact T know not. Then- are usually three
such folds: One, the largest, on the righl ;m<l anterior aspecl of the gut, is
Dear the rectovesical pouch of peritoneum, or about three inches from the anus,
and projects from half an inch to three fifths of an inch into the gut, extending
around one half of its circumference. It is sometimes described as tlio third
or upper sphincter. The other two folds arc on the left above and below the
former, and the three are so arranged as to form a kind of spiral valve. They
may be more or less distinctly seen when examining a patient in the genupectoral
position when a tubular speculum is introduced into the anus, so that the bowel
becomes distended with air. In the anal portion of the rectum, commencing just
above the orifice, are from three to eight longitudinal columns or folds of mu-
cous membrane from a third to half an inch long. Between the lower end- of
these columns are semilunar folds or valves whose upturned concavities form
little sinuses. These are known as the columns, valves, and sinuses of Morgagni.
The epithelium lining the rectum is of three different types: Tn the lowest
zone as far up as the lower border of the internal sphincter the epithelium is
of the ordinary cutaneous type, flat squamous epithelium. Above the white
line is the so-called intermediate zone, about half an inch broad, covered with
flat epithelium, but not of the horny type. Above this point the epithelium
is of the columnar variety, and, as will be noted when speaking of the tumors
of the rectum, the cancers originating in the anal portion are of the flat,
squamous, epithelial-celled type, whereas cancers beginning in the mucous
membrane of the rectum proper are usually of the type of adenocarcinoma —
that is, the cells arc columnar.
Blood Supply of the Rectum. — The arteries of the rectum are derived from
three principal sources: The inferior mesenteric, the internal iliac, and the
internal pudic. The superior hemorrhoidal vessels on either side pierce the
muscular wall of the rectum about three inches from the anus and form a
longitudinal network in the submucous tissues. Hence, transverse incisions in
the wall of the rectum are to be avoided, since they bleed profusely. The
arteries communicate very freely in a plexiform network near the anus. The
veins have much the same plexiform arrangement in the submucous tissue of
the lower rectum, but most of the blood is returned by the superior hemor-
rhoidal to the inferior mesenteric vein. Hence anything which interferes with
the portal circulation, such as the pressure of tumors, cirrhosis of the liver,
etc., will cause congestion of the hemorrhoidal veins, such as also occurs from
a general interference with the venous circulation from heart disease, diseases
216 THE KECTUM
of the lungs, etc. (See Hemorrhoids.) The inferior hemorrhoidal veins
empty into the caval system, and thus a free anastomosis exists here between
the portal and caval circulation.
Nerve Supply of the Rectum. — The nerve supply of the rectum is from the
inferior mesenteric and hypogastric sympathetic plexuses and the sacral plexus
(fourth sacral nerve). The latter nerve supply accounts for the paralysis
of the sphincter, with incontinence of feces that follows spinal injuries or dis-
eases in the lumbar region of the cord, or above, and is largely responsible
for the close nervous connection between the anus and the outlet of the bladder
which is supplied by the same nerve, so that retention of urine frequently fol-
lows operations upon the rectum, and inflammatory or other diseases of the
bladder are often accompanied by rectal tenesmus. The skin of the margin
of the anus is exquisitely sensitive to painful impressions, so that it is wise to
administer a general anesthetic for all but very small operations in this local-
ity. The anal margin is supplied by the internal pudic nerve. Above this
point the rectal wall is ordinarily sensitive for a distance of two inches. The
deeper portion of the rectum, on the other hand, is far less sensitive. It is,
however, well to bear in mind that just behind the cervix there is a more ten-
der area, pressure upon which in rectal or vaginal examinations will cause pain,
though no pathological condition be present. The lymphatics of the rectum
enter the pelvic and lumbar lymph nodes, those of the anus the inguinal lymph
nodes. Hence, cancer and inflammatory processes of the anus cause infection
and enlargement of the inguinal glands. Similar processes of the rectum
proper infect the pelvic glands.
The Anus. — The anus is an oval orifice with a long anteroposterior diam-
eter; therefore flattened instruments should be passed through the anus with
this fact in view. The anus is in the middle line, an inch and a half in front
of the coccyx, equidistant from the ischial tuberosities. In health the external
sphincter is in a state of tonic contraction and keeps the skin of the anus under
normal conditions puckered into radiating folds. Painful fissure of the anus
forms in the sulci between these folds, and in order to see these shallow cracks
or ulcers it is sometimes necessary to spread the anal orifice a little with the
fingers. Secondary syphilitic mucous plaques, on the other hand, form- along
the tops of the cutaneous ridges, and may be differentiated from simple ulcer
or fissure at a glance. In painful fissure the sphincter is in a condition of
spasm from reflex irritation. Certain conditions cause the external sphincter
to become relaxed and flabby, the ridges and furrows disappear, and the skin
of the anus is smooth. One sees this in very old and feeble persons, after
injuries of the spinal cord, in obstruction of the upper portion of the rectum
from tumors or strictures, and during the later stages of labor when the head
begins to press upon the perineum. The habitual practice of passive pederasty
is said to produce permanent relaxation of the anal sphincter and a peculiar
funnel-shaped appearance of the anus — the so-called " infundibuliform anus."
This appearance is of possible diagnostic importance.
METHODS OF EXAMINING THE ANTS AND RECTUM 217
METHODS OF EXAMINING THE ANUS AND RECTUM
The examination of the rectum begins properly with the inspection of the
anal orifice. For a simple examination, including merely digital explora-
tion of the rectum, the patient, if a male, may be asked to bend bis body far
forward over the back of a chair. If the patienl is a woman*, or it' a thorough
examination is necessary, Sims's position, or the knee-elbow position, should
be used. TIk- dorsal position is useful for palpating the rectum, bu1 unless
the pelvis is raised higher than the bead, it is nol as good for examining the
rectum with a speculum as the knee-chesl or Sims's position. It is, however,
useful in a considerable proportion of the operations upon the rectum. After
inspecting the anal orifice, the folds of skin should be obliterated by separat-
ing the margins of the amis a little with the fingers. In palpating the interior
of the rectum, it is desirable thai the surgeon should wear upon his forefinger
a thin rubber finger cot If such is not obtainable, a rubber glove may be worn,
or in default of this, the space beneath the finger nail may be filled with soap.
The finger should be well lubricated Avitli vaselin or some other lubricanl and
introduced gently. The various normal structures to be palpated have already
been mentioned; in addition, the existence of strictures, of tumor-, of ulcerated
surfaces, and cicatrices can be readily detected. It is not easy to feel internal
hemorrhoids; they arc soft tumors, and frequently produce no palpable ma—.
By stretching the anal orifice a little and asking the patient to bear down, they
may often be made to protrude through the anus. In females one finger may be
introduced into the vagina, and the anterior wall of the rectum may be everted
by the pressure of the finger. As already noted, if one wishes to palpate the
rectum very deeply, it is sometimes of advantage to examine the patient in the
erect posture.
For purposes of inspection we may use one or other form of speculum.
The bowel should have been previously emptied by purgatives or enemata. The
knee-chest position is in every way the most desirable for this examination.
The patient should be close to the v^sso of the table, the thighs should be verti-
cal, the hack depressed, and the chest as close as possible to the table. There
should be no constricting garments about the waist. One may use an ordinary
tubular speculum of glass or of hard rubber with an obturator, or, better, one of
Kelly's instruments. The set of specula necessary for all purposes include four:
A short and a long proctoscope, a sigmoidoscope, and a sphincteroscope. The
cylinder of the short proctoscope is 5i inches long and 22 nun. in diameter:
the long proctoscope is 8 inches in length and 22 mm. in diameter. The sig-
moidoscope is 14 inches in length and •_'■_' mm. in diameter (Kelly). The
cylindrical tube has a funnel-shaped rim at its upper end, to which is attached
a stout handle large enough to he grasped in the entire hand. Each speculum