CHAPTER LIII

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THE OMENTUM, THE MESENTERY, THE SPLEEN, THE PANCREAS.

THE OMENTUM.

The omentum is something more than what it generally appears, _i. e._, a more or less thick and extensive apron of fat, hanging down in front of the small intestines, although in this respect alone it serves as a sort of reservoir or storehouse for fat, which is always drawn upon as the needs of the system may require. The omentum varies within wide limits from being the flimsiest veil of peritoneum, whose four original layers have become so blended as to be lost to recognition, and which may even be perforated in places with openings through which strangulation of the bowel is possible, to the thickest and grossest mass of fat found in the human body, resembling a coarse mat rather than any finer texture, and having a thickness, in obese individuals, of two to four inches. Under these circumstances it makes a formidable obstacle to nearly all abdominal operations. The thickness of the omentum sustains usually a pretty constant proportion to the amount of adipose between the skin and the abdominal muscles. In certain enormously fat individuals one has then to go through from four to six inches of tissue, mostly adipose, before reaching the rest of the abdominal contents. This necessitates a longer incision and is always a disadvantage and impediment. To the operating surgeon, then, the omentum sometimes appears a nuisance.

It does not deserve, however, to be so regarded, and when properly viewed the omentum will frequently appear in the role of the surgeon’s as well as the patient’s best friend. This is due to its power of shifting itself, and, as it were, enclosing actively dangerous foci due to any variety of infection, the natural intent being, as it were, to wrap itself around and thus completely imprison the source of the trouble, a fact which is often actually accomplished, and by which life-saving protection is frequently afforded. This is true of the omentum whether thick or thin. By virtue of the adhesions which often annoy the surgeon, and which necessitate separation and perhaps considerable work before the actual trouble is exposed, a protective barrier is formed and the greater portion of the abdominal cavity shut off from danger of spreading infection. Moreover, that the omentum has a really valuable purpose appears from the fact that its removal from young animals seems to cause retardation of development, and from adult animals a diminution of resistance to the action of poisons introduced into the peritoneum. It is the omentum which, to a large extent, absorbs foreign corpuscles, such as those from extravasated blood. It helps, moreover, to dissolve blood clots and to facilitate their disappearance, and after the removal of the spleen it would appear to vicariously perform at least some of its duties. Thus when the complete blood supply of the spleen is cut off the organ almost completely disappears as the result of its absorption by the omentum. (This at least in experimental animals.)

The omentum serves further useful purpose by plugging various openings and wounds in the abdominal walls, and thus affording at least a temporary protection, just as the mucosa sometimes acts in reference to the stomach. Moreover, it is so vascular, so flexible, and so available that it may be used for plastic purposes in covering weak spots, lines of sutures, and the like, in the small intestine or even elsewhere. These same physical qualities make it extremely prone to escape through the natural outlets. Hence the frequency of epiplocele or omental hernia (_q. v._). By a species of such hernial protrusion it has saved many a life after bursting open or re-opening of recent abdominal wounds. Sometimes it will escape after removal of a gauze drain which has not been judiciously placed and protected, this accident then constituting one variety of postoperative or traumatic hernia.

By virtue of its adhesions, which at first are short and flat, but which later become stretched into bands, _obstruction of the bowels_ may be produced, or by atrophic or absorptive processes openings or windows may occur in it with the same result. When participating in septic processes it becomes infiltrated, is often covered to a large extent with breaking-down lymph, and may become gangrenous. All portions thus compromised are best tied off and removed when exposed during operation. Nevertheless the omentum should be gently handled, because its venous walls are thin and liable to rupture, and its bleeding points should be carefully secured, especially after separation of adhesions.

INJURIES TO THE OMENTUM.

By contusions, lacerations, and punctures various injuries to the omentum may be inflicted, naturally more commonly when it is the anterior abdominal wall which has sustained the traumatism. As result of lacerations, hemorrhages or strangulations may occur. The immediate danger is, then, from hemorrhage. Indications of such lesions of the omentum are not specific, but grave symptoms after any abdominal injury require exploration, and that minute punctures or lacerations should be repaired, while other injuries should be treated according to obvious indications.

TORSION OF THE GREAT OMENTUM.

Torsion of the great omentum was first described by Oberst, in 1882, as a condition found in the sac of a large irreducible hernia. As a distinct and serious condition it has been reported in about sixty instances. The condition occurs within the abdomen as simple torsion, also within hernial sacs, or in both, where the torsion is not limited to the sac, but extends upward into the abdomen. It is more frequent in males, and its onset is usually sudden. Of all its symptoms pain is the most constant and the earliest. This is usually acute and persistent, and in a large proportion of cases is referred to the right iliac fossa. Vomiting is not constant; bowel conditions are not significant. Absolute obstruction is usually rarely noted. In most of the recorded cases some tumor can be felt on examination, which is hard, tender, dull to light percussion, and irregular in shape. Meteorism is not common. Death has occurred in about 15 per cent. of known cases. Diagnosis previous to exploration can be inferential only, but such symptoms as above noted should lead to exploratory laparotomy.

TUMORS OF THE OMENTUM.

The most common of the omental tumors are _cysts of inflammatory origin_, such as may, for instance, be formed by inclusion between surrounding adhesions or by previous hemorrhage; _lymph cysts_, often large and multiple, and sometimes of congenital but often of lymphatic origin, are also occasionally seen. The so-called _omental dermoids_ are usually ovarian products. _Hydatid cysts_ have been found in the omentum, but only as secondary products. _Omental cysts_ are difficult or almost impossible of diagnosis previous to operation, which latter should always be performed, and without previous aspiration, as the presence alone of any such tumor requires removal. If large they are most likely to be confused with ovarian cysts. Those which may prove not to be removable should be drained, after being fastened to the abdominal wall--that is, marsupialized. _Angioma_ in the omentum is rare, but has been recorded by Homans and others. _Fatty_ or other benign tumors are also rare. Primary _sarcoma_ is rarely seen here, but most of the sarcomas, and all of the carcinomas which never arise here primarily, but are often seen, are either metastases or direct extensions. In these forms cancer of the omentum is common.

With extensive involvement of the omentum radical operations in these cases are seldom advisable. A circumscribed involvement may, however, be removed, while such operations as anastomoses, enterostomies, and the like are often necessitated.

Omental tumors are difficult of diagnosis, although they are usually superficial and overlie the intestines. They are not affected by respiration. They move laterally and upward, but not downward. If confined to the omentum proper they cause no functional but only mechanical disturbances. Obviously in the presence of extensive adhesions every distinctive feature may be confused.

OMENTOPEXY; OMENTOSPLENOPEXY; TALMA’S OR MORRISON’S OPERATION.

The effect of stasis in the portal circulation is to produce outpour of varying amounts of serous fluid into the pleural cavity. This condition, long known as ascites (dropsy), is the most distressing terminal feature of such diseases as cirrhosis of the liver, cancer, and the like. The osmotic direction of fluid seems to be reversed, and transudation tends to go on until intra-abdominal pressure equals that within the vessels. Absorption is always impeded and finally prevented. Reflecting on the biophysics of this condition Talma and Morrison, independently, and at about the same time, suggested an expedient by which a portion at least of this fluid might be brought back into the general venous circulation. The plan was to attach the epiploön (the omentum) to the peritoneum of the anterior abdominal wall in such a way and over such an area that, by virtue of the adhesions thus produced and the new vascular anastomosis thus established, a new line of vascular connections should be formed, so that fluid not returnable to the vena cava by the usual route should be given a new and artificial direction. To this fundamental proposition much detail has been added.

Thus Schiassi has shown that, so far as the supply of toxins which shall pass through the liver is concerned, there are really two portal veins--the superior mesenteric and the splenic--or he would call what we usually name the portal system the _splenoportal_. Consequently he would include the spleen in the above mechanical procedure, especially in those cases where it participates in the morbid process--_e. g._, in the hepatosplenic or pre-ascitic form of Banti’s disease, and the splenomegalic cirrhosis described by Gilbert. In 1904 this problem was studied from its surgical aspects by Monprofit (French Congress of Surgeons), who collected 224 operated cases. Of these 84 died, 129 recovered from the operation, and 11 could not be traced. In 25 cases relapse occurred, in 26 there was improvement, while in 70 there was claimed complete recovery.[64] In other words about one-third of the cases thus reported have recovered. He insists, as would every other surgeon, that with this showing the results would be far better were cases seen and operated earlier. His statistics are not widely variant from those of Zesas, who found that out of 254 cases which he collected 67 recovered and 82 died, while 42 were greatly improved.

[64] It is but fair to add that, at the same time, Delagenière maintained that since, in his opinion, cirrhotic processes in the liver are due to intestinal infection, the treatment should consist of combating this and its possible consequences, to which end he would make a temporary cholecystostomy, having found it of benefit even in the atrophic, but mostly in the hypertrophic, forms of disease. Thus in two cases of this procedure, combined with hepatopexy, the patients survived eight and two years respectively. Nevertheless he acknowledged that the best results would probably be secured from combination of cholecystostomy, hepatopexy, and omentopexy.

In brief, we may hold, with Rolleston and Turner, that it is no longer advisable to treat ascites by repeated tappings, when the patient is otherwise in fairly good general condition, for numerous surgeons have warned against repeated punctures. When liver cirrhosis can be diagnosticated with fair certainty in the pre-ascitic stage, and when there is evidence of splenic enlargement or hematemesis, operative intervention would probably succeed far better than in the later stages. So far as special indications for operation are concerned they may perhaps be listed as follows:

1. Thrombosis of the portal vein or its compression by inflammatory products or by tumor;

2. Cirrhosis of cardiac origin, of the ordinary hypertrophic or even atrophic types, as well as that due to syphilis or malarial disease;

3. Pseudoliver cirrhosis of pericardial origin;

4. Diabetes of hepatic origin;

5. Splenomegaly combined with hepatic cirrhosis.

_If these indications be met by reasonably early omental fixation there would seem to be a well-marked place for the procedure_, while they cannot give rise to any worse results than the repeated puncture methods of old.

Among contra-indications to such operations may be mentioned the presence of much biliary pigment in the urine, its absence from the feces, jaundice, or marked pigmentation of the skin, while distinct renal insufficiency would also make any surgical procedure hazardous.

The _operation_ itself, done according to the simpler and earlier recommendations of Morrison and Talma, consists in median abdominal section, withdrawal of all ascitic fluid, and the deliberate provocation of adhesions between the diaphragm and the upper surfaces of the liver and the spleen. This is produced by vigorous swabbing to a degree sufficient to cause a little oozing from the surfaces attacked. The margin of the liver may then be fastened to the costal border. After this the anterior surface of the omentum is also scarified or swabbed and affixed to the anterior abdominal wall, which has been similarly treated over as large an area as possible, by means of catgut sutures placed to the best possible advantage for the purpose. Some operators have preferred to close the abdomen without drainage, some to insert a tube in the lower margin of the wound for a day or two, and others to drain the lower abdominal cavity through a small, distinct opening above the pubes. Theoretically much advantage attaches to permitting no immediate re-accumulation of fluid. Practically, however, danger also attaches to it, _i. e._, from the difficulty of so managing the dressings as to avoid infection.

Schiassi has modified the above procedure and has made an _omentosplenopexy_ of it as follows: He makes a right-angled incision across the median line and then another several inches downward along the left semilunar. The tissues down to the peritoneum are reflected toward the umbilicus, and a transverse deep opening is made just below the horizontal skin incision. Through this the omentum is drawn upward and spread over the right portion of the exposed peritoneum, where it is sutured in place. Through another vertical opening in the peritoneum, near the vertical skin incision, the spleen is then exposed, a piece of gauze is placed under each pole of that organ, and, while thus lifted, by means of a long curved needle three to six catgut sutures are passed through it, including also the peritoneum and all the superficial structures except the skin, this being closed later and separately.

Finally, whatever operative method be selected it is important that it be done _early rather than late_, bearing in mind that “the resources of surgery are rarely successful when practised on the dying.”

THE MESENTERY.

No one has done more to forcibly place before the surgical profession those anatomical features of the mesentery which most concern them than Monks, who, for instance, has demonstrated the fact that the mesentery is practically an enormous fan, composed of two layers of peritoneum, between which are spread out the vascular structures and more or less fat, and whose border contains the intestinal tube. This fan at its base is but a few (six) inches in length, while along its outer border, when completely unfolded, one may measure a distance of twenty-one to twenty-three feet. Not one of the structures contained between its layers can be regarded as a negligible quantity. The arterial distribution in the mesentery is _terminal_ in the same sense that it is in the brain. Consequently dependence can be placed only on a sufficient blood supply for any given portion of the intestinal tube when its mesentery is intact. If necessary to sacrifice a portion of the mesentery it is requisite to resect that portion of the bowel which is dependent upon it for blood. This will explain the reason why thrombosis or embolism of the mesenteric vessels so quickly determines the death of that portion of bowel supplied by the occluded branches, this being equally true of the tiny fragment known as the appendix or of the entire bowel.

The root of the mesentery is placed obliquely across the spinal column, arising from the left side above and crossing obliquely to the right side below. Monks has shown how easily we may make practical application of this fact in determining approximately to what part of the bowel tube a given loop may belong, since it is necessary only to follow it down to the mesenteric insertion, and from this estimate what proportion of the entire distance is represented.

INJURIES OF THE MESENTERY.

Obviously the mesentery may be injured in the same way as any other of the abdominal viscera, either by contusions, lacerations, punctures, or otherwise. Here the immediate danger is from hemorrhage, while a more remote but quite possible danger is that of _thrombosis_ of some of the vessels and its consequences in the direction of _necrosis_.

Erdmann has recently reported two cases of complete detachment, for several inches, of the mesentery at the intestinal border, as well as a case of multiple lacerations in the peritoneal coat of the mesentery with hematoma. While the latter might not be so serious, the former will almost invariably determine gangrene of bowel from lack of blood supply; all of which shows the difficulty of diagnosis, and furnishes a further argument for intervention when, after an abdominal contusion, the patient has abdominal rigidity or pain, with or without evidences of hemorrhage, either from the stomach, rectum, or bladder. These features are sufficient without the addition of those by which a more certain or minute diagnosis can be made.

THROMBOSIS AND EMBOLISM IN THE MESENTERIC VESSELS.

Mesenteric occlusion was first described by Virchow in 1859. Whether it involves first the arterial or the venous circulation seems to matter but little. Of course in one case it is to be regarded as embolic, in the other as thrombotic. In this location either condition is harder to explain than in many other places. The mesenteric veins have no valves and collateral circulation is poor. Mitral stenosis and arterial sclerosis will often account for the former. For thrombosis search has to be made for some local infectious process, either in the veins of the pelvis, the kidney, or the intestines. It seems to occur least often when it might be most expected, _i. e._, after typhoid.

The blood supply may be simply shut off from portions supplied by one of the mesenteric vascular branches, or, should the main branches be involved, from the entire intestinal tract. I have myself reported two cases of practically complete rapid gangrene of the entire alimentary canal, due to lesion of this kind, explanation being forthcoming in neither case.

=Symptoms and Signs.=--The more complete the occlusion and the more extensive the area deprived of blood the more sudden and overwhelming will be the onset. This is always sudden and characterized by intense and often paroxysmal pain, so agonizing, in fact, as scarcely to be quieted even by morphine. While this is common, instances have been known in which the disease has run an almost painless course. Diarrhea is frequently an early symptom, evacuations being profuse and bloody. Symptoms of obstruction are not uncommon, perhaps followed later by loose stools. Vomiting occurs usually early and becomes fatal in a few hours. The general physical signs are intensely acute, with rapid pulse, subnormal temperature, and meteorism, beginning early and becoming more pronounced. Abdominal rigidity also constitutes a distressing feature, which, while indicating the gravity of the condition, masks its diagnostic features. If the patient live long enough fluid will accumulate in the peritoneal cavity. The cases terminate with complete collapse and delirium. When the inferior mesenteric vessels are involved tenesmus is a more prominent characteristic than when the lesion is confined to the upper, as the colon and rectum are supplied from the former.

The surgeon may have to distinguish between the condition just described and the following: Perforating ulcer of the stomach or duodenum (which will have a previous history), possibly so-called phlegmonous gastritis; acute obstruction of the bowel (whose onset is rarely so acute); pancreatitis, which would, at least at first, produce almost identical symptoms; acute splenic infarct (when the early symptoms would probably be referred to the region of the spleen); acute appendicitis; acute cholecystitis, and that acute peritonitis to which either of these might lead; a ruptured ectopic pregnancy; and possibly certain intrathoracic lesions, especially pneumonia in the lower lobes. Mesenteric occlusion is essentially a fatal condition, at least when extensive. There have been known cases where so limited an extent of the bowel and mesentery were involved that an exsection, made early, has proved successful, but when anything like the entire alimentary canal or its major portion becomes necrotic there is no hope for the patient.[65]

[65] Annals of Surgery, April, 1904.

ABSCESS OF THE MESENTERY.

Abscess formation may take place within the mesenteric structures, as an expression of acute septic infection or of a mixed infection of old tuberculous foci in the nodes. A careful case history or some peculiarity of local conditions may occasionally furnish a clue to the conditions, otherwise it will not be distinctly revealed until such operation as may be necessitated by unmistakable indications of the presence of pus or by autopsy. Inasmuch as operation can scarcely exaggerate the danger of the condition it would be best attempted when such abscess is suspected. When the meso-appendix is involved, as is often the case, the trouble may be so walled off that it is almost a purely local affair.

TUBERCULOSIS OF THE MESENTERY.

Aside from the common miliary expressions of acute tuberculosis which are seen so frequently dotted all over the bowel surfaces and the expanse of the mesenteric folds, there is a peculiar form of involvement of the mesenteric nodes, _i. e._, those which are especially clustered along its root. These are always involved in general tuberculous peritonitis, though but slowly in the absence of such generalized features. To the slow forms of this condition the early writers gave the name _tabes mesenterica_. The more limited the involvement the greater interest the lesion has for the surgeon, since it may be so limited to the nodes of a single coil as to justify extirpation. In fact, if such a focus could be easily and thoroughly removed without too much disturbance of circulation, tabes might be remedied by surgery. Not very frequently, however, do the location or the arrangement of a collection of tabetic nodes permit of their enucleation. They are usually too numerous, too large, too degenerated, too adherent, or the patient otherwise too extensively infected.

The acuter expressions of mesenteric tuberculosis may be considered as already sufficiently discussed under the caption of Tuberculous Peritonitis.

Occasionally a localized, slightly mobile tumor, especially in the ileocecal region, may cause suspicion, or may be correctly diagnosticated, by taking note of other symptoms, along with a good case history. Especially is this the case in patients known to be tuberculous. This is particularly true of the appendix and its mesentery, where a tuberculous gumma may attain considerable size before there is any active breakdown. The relation between this condition and tuberculous ulceration within the bowel will also be obvious. Moreover, it is of interest to recall that calcification of mesenteric nodes is not impossible, and that occasionally chalky tumors in this location may be thus explained.

There is also a possibility of involvement of the mesenteric nodes in _constitutional syphilis_ and in _actinomycosis_.

The _treatment of mesenteric tuberculosis_ should consist of exploration and orientation, followed by whatever procedure the condition thus revealed may require--_e. g._, abdominal irrigation, with or without antiseptics, extirpation, drainage, or even resection of a portion of the bowel (appendix, cecum, etc.).

CANCER OF THE MESENTERY.

The other condition in which the mesenteric nodes are especially involved is the cancerous. In this location, as in the omentum, sarcoma may be primary and endothelioma may occur, but carcinoma is never primary, although it invariably occurs as an extension from epithelioma or adenocarcinoma of the bowel. Otherwise cancer will appear here as an expression of metastasis. In all primary cancers of the intestine early involvement of the mesenteric nodes may be looked for, while involvement of everything in the vicinity, even the aorta or spine, will occur in due time, often with more or less breaking down. There would be little justification for attacking any cancerous portion of the mesentery or any cancerous nodes unless the primary lesion could be radically removed. Generally speaking, in bowel cancer invasion of the deep-seated nodes imparts to the case such an unfavorable aspect as to justify only palliative (anastomotic) rather than radical measures.

CYSTS OF THE MESENTERY.

Cysts of the mesentery are, in the main, similar to those met with in the omentum (Fig. 631). A peculiar form of mesenteric cyst is produced by obstruction and consequent dilatation of one or more of the lacteals, and is known as _chyle cyst_. It may attain considerable size and occur in multiple form. The contained fluid is naturally milky and corresponds to that seen in chylous ascites and hydrocele. These lesions are only recognized after exploration. When found they are to be extirpated, on general principles, usually by enucleation, with ligature of the connecting lacteals and avoidance of all unnecessary disturbance of blood supply.

[Illustration: FIG. 631

Cyst of the mesentery, containing clear fluid. The hour-glass constriction passes through the layers of the mesentery. (From a case occurring in Richardson’s practice.)]

THE SPLEEN.

The spleen is often an object of surgical interest, not alone because of the frequency with which it is enlarged in the course of the acute surgical infections, but because it is something more than a reservoir for blood. Thus it seems to enlarge to accommodate blood forced in from the exterior under conditions of extreme exercise, etc., and in the higher vertebrates it seems to be a place where blood corpuscles are destroyed, especially those which are already disintegrating, rather than one in which they are manufactured. It is claimed by Ehrlich that the splenic enlargement of the infectious diseases is produced mainly by the products of disintegrating leukocytes which are allowed to accumulate.

ANOMALIES OF THE SPLEEN.

Of the _congenital anomalies_ or defects the surgeon is mainly interested in the fact that _supernumerary spleens_ are common, being found perhaps in one out of four bodies varying in number up to thirty or forty, located near the hilus in the gastrosplenic omentum, in the great omentum, or even in the pancreas. Doubtless after some splenectomies no peculiar symptoms are produced, which is due to the fact that some of the supernumerary organs have taken up the splenic function. The spleen varies in shape to such an extent that the notch upon which so much stress is often laid in diagnosis will not always be found along the anterior border. In cases of transposition of the viscera the spleen may be found on the right side. It has been found in the sacs of large umbilical hernias and in the left thorax after defects of the diaphragm.

INJURIES TO THE SPLEEN.

The spleen may be injured by itself or along with other viscera. The most common injury is from contusion, which produces more or less disintegration or rupture and hemorrhage. The organ is so friable that it may literally burst under a comparatively slight force, other conditions being favorable. Doubtless minor degrees of these injuries pass unnoticed or are followed by some local peritonitis and adhesions. On the other hand the spleen may be actually fragmented, with necessarily fatal consequences unless promptly operated. _Rupture_ is especially likely to occur after those infectious diseases which cause its enlargement--_e. g._, typhoid.

In case of injury there is, in addition to the history, a prompt location of pain in the region of the spleen, with signs of intra-abdominal hemorrhage, but without blood in the urine; perhaps with tumor or dulness on percussion, and always with abdominal rigidity, all of which point to the serious nature of the injury and _demand exploratory section_. Should this reveal a slight injury it may be repaired with ligatures or sutures. More serious tears or perforations are treated by gauze packing through a sufficiently open wound, while the most serious cases of pulpifaction call for complete _extirpation_. When the blood supply of the spleen is left in doubt its total removal will be far the safer course to adopt. Obviously such an operation should include examination of all the viscera and a careful toilet of the peritoneum.

ABSCESS OF THE SPLEEN; SUPPURATIVE SPLENITIS.

Pus may form within the spleen in consequence of septic infarcts or thrombosis, or it may be due to the extension of trouble from adjoining foci, or to pyemic metastasis. Splenic abscesses are usually localized, but the pyemic forms are always multiple, miliary at first, but coalescing into larger collections, and practically destroying the organ if the patient live long enough. The infectious fevers may be followed by suppuration of the spleen, which is also known to occur rarely in malaria.

=Symptoms.=--The symptoms of splenic abscess are indeterminate until the capsule is involved and a perisplenitis--_i. e._, a local peritonitis--results, after which pain becomes severe. These collections occasionally discharge spontaneously into the colon or even into the stomach.

On general principles any abscess which can be located, even somewhat vaguely, should be attacked. After the abdomen is opened, preferably through the left semilunar line, the exploring needle may be used, especially if adhesions be present.

GANGRENE OF THE SPLEEN.

Gangrene of the spleen is the result of a still more rapid, otherwise similarly septic or thrombotic process, or of severe injury, by which circulation is practically cut off. It is a condition which rarely permits of any surgical help, though if it could be foreseen it might be prevented by an early splenectomy.

HYPERTROPHIES OF THE SPLEEN.

Enlargement of the spleen occurs during numerous acute and chronic _infections_--_e. g._, typhoid, malaria--in connection with certain affections of the _liver_; in consequence of interstitial or gummatous forms of _syphilis_, with or without similar lesions in the liver; in acute _peritoneal infections_; in general _septic_ and _pyemic_ disturbances; in _rickets_ and the _status lymphaticus_; in the various forms of _leukemia_, _Hodgkin’s disease_, and _pseudoleukemia_, and in that somewhat peculiar type known as Banti’s disease, or _splenomegaly_. In fact the spleen enlarges under so many conditions that its hypertrophy is an expression of a general infection rather than of any pronounced or particular type of the same. Minor degrees of enlargement have often passed unnoticed or given little or no trouble. When seriously overgrown its principal features are its inconvenience, weight, and size. The condition is recognized by its characteristic shape and notch (See above.) By its extension upward it can be usually distinguished from a tumor, of the kidney.

Every splenic enlargement, especially chronic, should lead to a careful blood examination, by which, among other things, malaria may be recognized or excluded, while the degree and form of leukemia, if present, may be estimated. The lymph nodes throughout the body should also be carefully examined. Splenomyelogenous leukemia, for example, is progressive, severe, and marked by cachexia and anemia of peculiar type. In many of these cases there is a tendency to hemorrhage, both from surfaces and into the tissues. The hemoglobin is much reduced and prognosis after any operation is unfavorable. (See chapters on the Blood and the Lymphatic System.)

_Banti’s disease_, or _splenomegaly_, seems also a somewhat peculiar type of lesion which is probably due to an infection proceeding from the intestinal canal, and involving the liver in its later course. In its last stage there is a tendency to hepatic cirrhosis, with ascites, and hemorrhages in any part of the body are frequent.

_Removal of the spleen_ for any of these conditions is usually a precarious procedure. It has been more successful when performed for malarial hypertrophy than for other conditions, the patient’s chances being then about three out of four; but here, too, the lesion is usually amenable to other treatment. If done in the early stages of Banti’s disease it would seem to be strongly indicated, but not in the later stages, when the liver is involved and the abdomen full of fluid. In the leukemias it has succeeded in a few instances. It is mostly indicated in those cases where hemorrhages occur early.

The Röntgen rays have recently been shown to have an excellent effect in many of these cases and are worthy of trial. Especially in the leukemic forms, in connection with arsenic internally, they offer probably the best prospects.

SPLENIC DISPLACEMENTS.

While, under ordinary circumstances, the supports of the spleen may seem equal to ordinary needs they prove insufficient in many cases of marked enlargement. Hence results _displacement_, or the so-called “wandering spleen,” which may be due to the results of injury, to tight lacing, possibly to congenital relaxation of ligaments, but mainly to hypertrophy, with increase in size and weight. When the spleen enlarges it descends toward the umbilicus, but it has even been found in the pelvis. As it prolapses it brings down with it the stomach and the pancreas, thus interfering with the circulation of all three organs and producing a train of distressing secondary consequences. A long-drawn-out splenic ligament may be much stretched and may even become finally _twisted_, thus causing gangrene of the spleen from torsion of its support. Moderate displacement and stretching produce discomfort, pain, and disturbance of function. Such a displaced spleen is to be recognized by its shape, size, and notch, and is occasionally to be distinguished from a wandering kidney. When displaced its normal location will not be dull upon percussion.

=Treatment.=--Palliative treatment, which may be tried first, calls for whatever drugs may be needed to unload the bowels, but especially for rest in bed and support by suitable abdominal binder, with or without a pad. If the spleen itself be much enlarged it may also be subjected with a judicious frequency to the _x_-rays.

_Operative help_, which is the only measure when other treatment fails, should come either through a _splenopexy_ or _splenectomy_, preferably the former, save in the presence of serious disease which may call for its extirpation. Nevertheless splenopexy, which seems so simple and so promising, is often unsatisfactory because of the friability of the spleen itself and the weakness of its capsule. Here, as in hepatopexy, the intent is to produce adhesions, by scarification of the external peritoneal surroundings, which is made through a suitable incision, directed usually along the left costal border; after thus intentionally provoking adhesions, sutures may be used if there be any prospect of their being serviceable.

[Illustration: PLATE LVI

Upper Abdominal Viscera, showing their Normal Relations. (Sobotta.)]

NEOPLASMS OF THE SPLEEN.

Splenic _cysts_ of the _serous_ or _blood type_ are seldom seen. Even _hydatids_ here are uncommon. _Sarcoma_ of the spleen may be primary; _carcinoma_ is due to extension or metastasis. In proportion as splenic tumors develop they may be recognized as involving this particular organ. While a careful blood examination may permit the exclusion of certain conditions, exact early diagnosis will scarcely be made without exploration, which is justifiable whenever the blood count would indicate it. After exposing the lesion the surgeon is for the first time in a position to judge whether to drain or extirpate a cyst, or remove part or the whole of the spleen itself.

OPERATIONS UPON THE SPLEEN.

Besides those operations addressed toward fixation of a more or less enlarged or wandering spleen a _splenotomy_ can be made--_i. e._, incision and drainage at any suitable point, anterior or posterior, which can be satisfactorily exposed; and evacuation of fluid may be followed, with or without suture of the deep to the external wound, by gauze packing or tubage, combined, if necessary, with counteropening or posterior drainage.

=Splenectomy.=--Total removal of the spleen is performed through an incision which should be made ample for the purpose, either along the costal border or the left semilunar line or by combination of both. A median incision may be also utilized if it will permit better access. Splenectomy, under ordinary circumstances, would not be a difficult operation, but with the organ enormously enlarged and the vessels dilated, as they may be, it becomes usually a formidable procedure. The most serious difficulty and danger arise from the numerous adventitious vessels which may connect the spleen with the diaphragm or with some of its other surroundings, and whose location is to be made out before an attempt is made to remove it. Thus, in one instance, I have seen an adventitious vein, the size of the little finger, between the upper splenic surface and the diaphragm. Through such large vessels torrents of blood will pour unless they be first secured. All such connections then with the stomach and the diaphragm have to be ligated and separated with great care, while gentleness of manipulation is requisite throughout the operation. The spleen may be reached and adhesions be located with great speed of manipulation, but in the depths of such a wound valuable time may be consumed and much blood lost, all at a time when the patient can least tolerate them. Oozing from vessels which cannot be secured should be checked by gauze packing.

THE PANCREAS.

The anatomical features of the pancreas which have most interest for the surgeon are the facts that its head is in contact with the duodenum, and lies usually so closely against the second portion of the former as to surround from one-fourth to one-third of its lumen. Becoming adherent at this point it may then produce obstruction high up in the intestine. In rare instances it may even completely surround the duodenum, and thus may, when swollen, cause tight constriction of the latter. Should this condition be met with a gastro-enterostomy would be the proper measure for relief. These intimate relationships account for the spread of disease from the pancreas to the intestine, rarely in the reverse direction. The pancreas lies also in contact with the stomach along its anterior peritoneum-covered surface, and malignant disease travels easily from one to the other. Ulcers of the stomach, favorably situated, may also be followed by adhesion and inflammatory infiltration of the pancreas, by which the viscera are cemented together, the same result following duodenal ulcer, as well as serious disease about the biliary passages. Thus under a variety of circumstances the operator may find these parts so cemented as to be separated only with the greatest difficulty, or perhaps not at all, without causing laceration or rupture of one or more of them, with escape of contents which are often septic. Therefore when there is reason to fear this accident it will usually be safer to simply make a gastro-enterostomy. (See Plate LVI.)

The relations of the biliary ducts to the pancreas are most important, the association of the common duct with that of Wirsung having the greatest bearing upon a variety of conditions, which are nearly all essentially surgical. The former, descending along the head of the pancreas, comes in contact with the duct of the latter, and passes alongside of it for a short distance before entering the intestinal wall. In about two-thirds of individuals it is completely enclosed by the pancreas. In the other third it lies in a deep groove upon it. Resting here, as it were like Siamese twins, it will be easily seen how disturbance in one duct or its source may be reflected to the other. When the common duct lies in a groove it is less likely to be seriously compressed by pancreatic engorgement than when actually embedded in pancreatic tissue. The degree of resulting jaundice may thus be dependent upon anatomical conditions not determinable before exploration. Such pressure doubtless accounts for many cases of so-called catarrhal jaundice. When the condition becomes constant, or nearly so, a chronic interstitial pancreatitis may be assumed, which really warrants an operation--_i. e._, cholecystostomy with drainage. When a gallstone is passing through the common duct, especially when lingering or impacted, it may have in turn reversed this condition, and, by obstructing the pancreatic duct, set up as a consequence pancreatic stagnation and consequent digestive disturbance, and such other internal conditions as invite infection from the duodenal cavity, with a more or less lively pancreatitis, perhaps even of fulminating type, by which life may be jeopardized.

The pancreas, however, being usually provided with two ducts, the second (that of Santorini) is often represented as an additional safeguard, since it usually has a separate opening into the duodenum below the ampulla. Opie carefully studied 100 cadavers and found that in more than 50 of them the accessory duct could be of no use or relief, and that in only 10 instances did two independent ducts enter the intestine, while in the other 90 they were united, and in 21 of the latter the accessory duct had become obliterated. Moreover, in only 6 of the 100 instances was it larger than the duct of Wirsung. This will show, then, how little reliance may be placed upon the duct of Santorini. Moreover, no matter which duct is opened, or whether both are, so long as pancreatic fluid can escape there is an open channel for infection, and when it cannot escape it may be seen that infection has already occurred and is manifesting its pressure consequences. Chemosis of mucous membrane may be the first mechanical result of such infection, but this is sure to be followed by interstitial sclerosing and compressing effects.

The normal duct opening in the duodenum is also a matter of surgical interest. The ampulla of Vater, within the second portion of the duodenum, is usually described as a conical protrusion or papilla, having an average length of 4 Mm., with an opening 2.5 Mm. in diameter, this being the narrowest portion of the common duct, but from this arrangement there are many variations. The ducts may join at some distance from the intestine, or they may open independently into a depression or into a protrusion, and the ampulla be thus totally wanting, all of which has the greatest possible bearing upon what may happen during the passage of gallstones, for instance, or by infection and according to its direction; and may account for the difficulty met in certain cases, as when, for example, it becomes necessary to incise the duodenum and open the ampulla for the removal of a pancreatic or biliary calculus. It will emphasize, too, the necessity for always exploring the common duct by opening the biliary passage and thus making sure of its patency.

ANOMALIES OF THE PANCREAS.

Congenital anomalies include not only those of the ducts above mentioned, but the presence of _accessory masses_, like the accessory thyroids, which may occasionally lead to confusion and perplexity. Furthermore, accessory nodules of pancreatic tissue may be found alongside the ducts, or even in the walls of the stomach and intestine, where they are probably present more often than is generally appreciated, and are to be explained by the embryology of the parts, since the pancreas is known to take origin from a cluster of cells in the wall of the upper end of the developing intestinal canal. They have been seen also along the line of a persistent vitelline duct. Such small accessories, when present, usually empty by minute independent ducts into the intestine. On the same embryonal grounds are to be explained other anomalies occasionally met, such as separation into detached portions. The existence of accessory pancreatic glands is also held to account for the absence of glycosuria in certain cases where the principal portion of the pancreas is itself extensively diseased.

GLYCOSURIA.

Glycosuria is so associated with the popular conception of pancreatic disease that it seems imperative to state what importance should be attached to it. It is now clearly established that the so-called “islands of Langerhans” have to do with the elaboration of a certain glycolytic ferment, and that the failure in its supply to the blood (it being regarded as an internal secretion) is followed by the appearance of sugar in the urine. These islands are not connected with the ducts, at least not in the vertebrates, and usually escape pressure effects in chronic interstitial pancreatitis of the interacinous as well as of the interlobular form. This explains the accompaniment of diabetes in some instances of pancreatic disease and its absence in others. Again, if only part of the pancreas be affected, as in cancer, the remaining healthy portion may still afford a sufficient amount of this ferment to supply the body needs.

The uncertain symptomatology of the slower forms of pancreatic disease is to be accounted for by the fact that, with the exception of its glycogenic function just mentioned, all its other functions may be vicariously assumed by other organs of the body. Thus as a compound racemose gland it furnishes--

1. Trypsin, a proteolytic ferment;

2. Amylopsin, a starch-splitting ferment;

3. Steapsin, a fat-digesting ferment; and

4. A milk-curdling ferment.

The first of these functions may to some extent at least be assumed by the stomach and the others by the bile and intestinal juices. (Mayo Robson.)

INJURIES TO THE PANCREAS.

Injuries to the pancreas may occur with or without external traumatisms. By any kind of injury which affects the gland it is probable that its glandular structure may be so disrupted as to set free an autodestructive secretion, which, by softening and weakening vascular walls, may lead to hemorrhage and to the accumulation of a collection of inflammable material, which is a good culture medium, and which needs only the spark of infection to be easily aroused into a conflagration. That possibility of infection is imminent is apparent from the relations of the adjoining viscera and their ducts, as already outlined. However, the same is true of even a first and spontaneous hemorrhage, as of the clot, however produced. It has been held that the manipulations to which the pancreas has been unavoidably submitted during many operations may lead to its acute inflammation or destruction. On the other hand, there seems no doubt but that it is sometimes much relieved or benefited by a mild massage as a part of the operative procedure. Mayo Robson has suggested that concretions may thus be pushed along or adhesions removed, or, as it seems to me, circulatory equilibrium restored and autonutrition improved.

Aside from the injuries which the pancreas may receive during operations it is unquestionably the site of hemorrhages produced by _contusions_ of the abdomen, although these are rare, and of injuries produced by deeply penetrating _wounds_, especially those caused by a stab or gunshot. The immediate result of a serious wound might be hemorrhage, perhaps even a large escape of blood filling the lesser cavity of the peritoneum. Such injuries are always to be treated surgically, _as any external contusion followed by serious collapse and evidences of internal hemorrhage should be promptly explored_, and, even more so, _every case of penetrating wound_. Should blood be found to be escaping from the pancreas the bleeding vessel may be sought and secured, or, if necessary, a portion of the organ extirpated, since no danger can be greater than that of uncontrolled bleeding. It is on record that through an extensive gash in the abdomen the pancreas has not only been exposed, but has partially escaped, and one case report, apparently authentic, details its subsequent sloughing and spontaneous separation.

Any wound of the pancreas which needs no further attention may at least be sutured if it can be exposed. Nearly all surgical attacks upon this viscus will require extensive incision and more or less emptying of the upper abdominal cavity. It may now be of great assistance to place the patient in the semi-upright position in order that the viscera may gravitate toward the lower part of the abdomen--_i. e._, to reverse the ordinary Trendelenburg position.

NON-TRAUMATIC SURGICAL DISEASES OF THE PANCREAS.

These diseases include especially the acute infections, the chronic lesions, and the occurrence of neoplasms or calculi.

Certain local and general conditions predispose to pancreatic disease of any type. Among them are to be reckoned--

1. _Injury_, either by accident in the ordinary course of events, as by contusions or penetrating wounds, or bruising during the manipulations of operation;

2. _Anatomical anomalies_;

3. _Hemorrhages_ into the substance of the gland, whether from vascular changes or other causes;

4. _Obstruction along either the biliary or pancreatic ducts_, whether due to catarrh, calculi, adhesions or stricture, parasites (worms) or cancer;

5. General _toxemias_: typhoid syphilis, influenza, mumps, and the like.

The principal exciting causes are the various infections which may proceed from the blood, as in pyemia or syphilis, or from the alimentary canal, which is never free from bacteria, either by adhesions and continuity, as from gastric ulcer and cancer, or by those natural passage-ways, the ducts.

When summed up the most common of all the causes of pancreatic disease, acute or chronic, will be found to be _cholelithiasis_, with some of its variant consequences or complications. This will help to make clear the reason for operating on the biliary passages in most cases of pancreatic disease, especially the more chronic forms. A stone impacted in any portion of the common duct, especially in its terminal portion, after it has come into relation with the duct of Wirsung, may cause an amount of disturbance disproportionate to its size. Moreover, a stone impacted at the orifice of the duct will permit the entrance of bile into the pancreatic canal, where it does not belong, and where of itself it may cause trouble.

ACUTE AFFECTIONS OF THE PANCREAS.

These include--

1. _Hemorrhagic pancreatitis._

(_a_) Ultra-acute, where hemorrhage precedes infection, and bleeding occurs outside as well as inside the gland.

(_b_) Acute, where inflammation precedes hemorrhage, the latter being less profuse and occurring in patches.

2. _Gangrenous pancreatitis._

3. _Suppurative pancreatitis._

(_a_) Diffuse, destructive.

(_b_) Subacute, localized, with abscess formation.

=Acute Pancreatitis.=--Acute pancreatitis is a distinct form of disease, like appendicitis, with an etiology and symptomatology of its own, which has been recognized only within the past twenty-five years. This statement will account for the fact that so little reference to it is made in any but the recent text-books. In fact it is to the writings of Fitz, of some fifteen years ago, that the world owes its first keen interest in the subject. By no means a frequent disease, it nevertheless occurs with frequency sufficient to make it inexcusable for the practitioner to fail to take it into consideration, although he may waver in diagnosis.

The predisposition to infection which previous injuries, especially minute hemorrhages or previous pathological conditions, seem to afford has been already mentioned, and a history of previous injury or digestive disturbances will aid in diagnosis. The exciting cause is, however, in nearly every case when not distinctly traumatic, connected with previous disease in the biliary tract, either cholelithiasis or cholangitis. Reference to what has been said above, and a consideration of the anatomical relations, will show how readily an infectious process can travel upward from the duodenum into the pancreatic duct, as well as into the common duct; or how, passing down the latter, it may speedily find its way up the former. The previous condition of the tissues, and the activity or virulence of the infective organisms, have to do with the degree of acuteness of the resulting pancreatitis. This is sometimes of such overwhelming toxicity that the entire gland dies almost as does the appendix, within a few hours, the result being an acute necrotic condition that of itself is necessarily fatal.

=Symptoms.=--Acute pancreatitis gives rise to symptoms which, in general, assume the clinical form of an _acute peritonitis of the upper abdomen_. It commences with sharp pain in the epigastrium, accompanied by faintness, nausea, vomiting, and collapse, while tenderness over the pancreas is an early symptom, and swelling or enlargement can sometimes be detected. Constipation is so frequently a feature that the diagnosis of acute bowel obstruction is sometimes made, but it will be found that obstruction is not complete, for flatus may pass and enemas may be successful. The pain becomes paroxysmal, is increased by movement and pressure, while the tenderness becomes more localized. Meteorism may so quickly succeed the other symptoms as to make physical signs uncertain, while rigidity of the abdominal muscles makes them still more vague, yet affording in itself a sign of value. Vomiting intensifies the pain and the vomitus changes from food to bile, and then to blood, which is dark and altered. Hence jaundice may be an early feature, in which case it becomes more marked as the disease progresses, and may become intense. This is likely to be the case if the exciting cause prove to be a stone impacted at the ampulla. The face indicates profound distress and disturbance. The temperature affords no certain indication, save that in the most serious cases it may be subnormal. On the other hand, as the case progresses, the pulse becomes small and rapid. Every expression of overwhelming toxemia is added, and delirium usually precedes death. In fact death may follow the first expression of pain, in unrelieved cases, in from two to three days. Other less acute expressions of the same general character are met with in the so-called subacute forms of pancreatitis.

While the postmortem findings differ in various instances the symptoms above noted do not vary conspicuously. They differ rather in intensity only, in accordance with the gravity of the case.

The pathologists have described various forms of pancreatitis as the _hemorrhagic_, the _gangrenous_, the _suppurative_, and those distinguished by _fat necrosis_, as well of the omentum as of the pancreas itself. These distinctions have the greatest interest for those engaged in minute research and are not to be regarded lightly. They have no small interest for the clinician, since prognosis is in some measure dependent upon them. Nevertheless the symptoms of the condition are but slightly modified, whether the destructive process assume one or the other of these types, and the therapeutic indication is the same for all--namely, the _earliest possible operation_.

If pathologists were better agreed on their pathology it might be worth while to give more space here to this aspect of the subject. It is, however, not yet certain, for instance, whether in a given case inflammation precedes hemorrhage, or whether hemorrhage occurs first and the outpour of blood is suddenly invaded by bacteria. In fact it is probable that sometimes one thing occurs and sometimes the other. Certain it is that the pancreas is not only loosely held together, and consequently disrupts easily, but that it quickly succumbs both to its own digestive juices and the disintegrating effect of bacteria, so that putrefaction quickly occurs hours before life is extinct. The morbid excitement quickly spreads to the adjoining peritoneum, and along it, so that a more or less generalized peritonitis soon complicates the case. Mayo Robson inclines to the view that in the most fulminating cases the hemorrhage is the prior lesion.

=Diagnosis.=--The diagnosis should be made mainly from perforating gastric or duodenal _ulcer_; phlegmonous or gangrenous _cholecystitis_ or _cholangitis_; rupture of the biliary tract, with escape of contents; fulminating _appendicitis_; acute intestinal _obstruction_, including internal hernias, and acute _mesenteric thrombosis_ or _embolism_. Fortunately in every one of these conditions prompt operative intervention is alike demanded, save possibly in the last named; while even in the latter diagnosis cannot be made without it, and it may still be possible to accomplish something if the occlusion be not too widespread. A history of previous “dyspepsia” or “indigestion” may point to the stomach or the biliary channels; repeated hemorrhages to gastric ulcer, and repeated attacks of pain to gallstone trouble. General tympanitis would indicate intestinal obstruction, especially if no flatus were passed, while when limited to the upper abdomen it would be more suggestive of pancreatic disease. This would be corroborated by vomiting of blood, while fecal vomiting would indicate obstruction. Tenderness and tumor located in the region of the gall-bladder would point rather to it as the source of trouble, while in pancreatitis something distinctive may be perhaps made out by palpation and percussion, and the tenderness will be complained of alike on each side of the middle line. Abdominal rigidity, while general, is usually most pronounced near the site of the most important lesion. Much importance is attached by Halsted to excessive pain, and to cyanosis of both the face and the abdomen. The latter may be helpful as a corroborative indication, but is certainly not always present, and, on the other hand, is seen in many cases of general peritonitis. Glycosuria is rarely a feature of the acute cases.

=Treatment.=--This is of necessity not only _surgical_, but, to be effective, should be _prompt_, every added hour of delay causing increased danger. While arranging for this it is possibly justifiable to allay pain by giving morphine hypodermically. The colon should be emptied by a copious enema. Collapse is to be combated by the usual means, including hypodermoclysis or infusion, perhaps with the addition of a little adrenalin to the saline solution. The preparation of the patient, both before and during anesthesia, should include the same scrubbing of and attention to the skin of the _back_ as that of the abdomen, as there is much probability in any such case that posterior drainage will be needed.

The _operation_ is begun as an exploration, through a median incision above the umbilicus, some three inches in length, through which the operator may inform himself as to the state of affairs within the abdomen. Should fat necrosis be revealed, and first noticed in the omentum, no doubt need be felt as to diagnosis. Any tumefaction by which the stomach or colon is displaced, or the gastrocolic omentum placed upon the stretch, calls for further and deeper exploration. The upper abdomen should next be walled off with gauze and a small rent made through the gastrocolic omentum; or it may in rare instances prove wiser to push down an already depressed stomach, or more likely to lift up the greater omentum and enter the lesser peritoneal cavity through the mesocolon. In the majority of instances the condition can be best appreciated and relieved by separating the stomach from the colon.

The condition may be one of extensive fat necrosis, disseminated, but with its most abundant expressions in the neighborhood of the pancreas, or there may be found evidence of extensive gangrene, the pancreas itself sloughing and involved past any possibility of repair, surrounded by disintegrating clot and debris; or there may be found a more or less localized abscess, and perhaps evidences of putrefaction. In at least two instances reported by Muspratt and Porter the pancreas itself was not yet dead, but was so darkly discolored and swollen, as well as so dense, that it was freely incised, the bleeding vessels being tied and the clot removed. Both of these cases recovered. Such incisions, if made in the gland, should always run parallel with the duct and not across it. Whether pus be found or not will depend in large degree upon the time that has elapsed since trouble began. It is most desirable to expose the focus before pus has had time to form, just as it is in acute appendicular disease.

The further operative treatment consists essentially in checking and preventing hemorrhage, in removing all sloughing tissue which can be safely taken away (and this may involve the greater part of the entire gland), in disinfection of the cavity and general toilet of the upper abdomen, with ample provision for drainage. This may be anterior or posterior, and in bad cases should be both, unless procedure is hastened by collapse. Posterior drainage is effected by having the patient turned upon the right side, then making an incision 3 or 4 Cm. long at the left costospinal angle, where, if the advice above given have been followed, the skin will have already been prepared. Here the outer border of the erector spinæ group of muscles is quickly exposed and the blades of a pair of stout forceps entered and pushed toward the inner cavity, within which the operator’s left hand is acting as a guide. In this way it is possible to quickly insinuate the blades so that the large vessels and the upper end of the kidney are preserved from harm. A suitably prepared drain, preferably tubular, may then be introduced deeply enough through the anterior wound to be seized by the forceps and pulled through the tunnel made by their introduction. It is thus drawn backward and outward to such an extent that its inner end shall rest just where it is desired in the cavity of the lesser peritoneum, the unnecessary external part of the drain being now cut away. The whole procedure consumes but little time. Anterior drainage will also be necessary, and the wound may then be closed.

It has been suggested to make the exploration as well as the drainage from the loin, but this procedure cannot be here advised, since it leaves too many features in doubt and affords insufficient means whereby to appreciate and cope with many grave complications. Calculi, either biliary or pancreatic, which are so often an exciting cause of these troubles, should be carefully sought for and removed if present. They could not be revealed nor removed through any small posterior opening. Other good reasons are also advanced, since the intensity of the symptoms is an expression of an intraperitoneal rather than retroperitoneal lesion.

The reader will note that but little has been said as to the distinction between the hemorrhagic, gangrenous, and other forms of acute pancreatitis, as these are for the surgeon, as such, _side issues_. _His paramount duty is to open the abdomen of every such case, so soon as he can possibly effect arrangements._

=Subacute Pancreatitis; Abscess.=--Under this term are included disease processes and lesions similar to or identical with those described as causing acute and even fulminating expressions of pancreatic obstruction, but less severe in their manifestations, less rapid in their course, and more localized in their boundaries. They are often so associated with a protective and natural walling off of the area of excitement by barriers, which outpour of lymph and its consequent condensation into adhesions afford, that they appear more often as abscess of the pancreas or hematoma of the lesser cavity of the peritoneum.

So far as concerns its etiology the causes are essentially the same as in the acute cases, only the results are brought about more slowly, weeks being in these cases as days in the others. Gallstones are by all means the most common cause, and the pancreatic disease is itself an expression of an infection travelling up its duct.

=Symptoms.=--The symptoms usually include pain, which, however, lacks the agonizing intensity noted in the more acute cases. Vomiting is usually associated with constipation, but the vomitus is rarely or never bloody; jaundice of variable degree is a common feature, and collapse is rare. Distention of the upper abdomen and tumor formation come on more slowly. Tenderness is less extreme and muscle rigidity less marked. While the pulse is less affected the temperature is usually more so, often running high. Even early in the case we may note general expressions of septic intoxication, such as mild chills and a characteristic appearance of the tongue and face. Constipation is followed by diarrhea; at least the stools which are fetid contain blood, pus, fat cells, and undigested meat fibers. Pain is more or less constant, but increased in paroxysms. Loss of appetite and rapid emaciation are apparent from the outset. Albumin will be found in the urine, but rarely sugar. The peculiar reaction described by Cammidge will, according to Mayo Robson, give uniformly positive evidence. As _abscess_ gradually or rapidly develops it will cause a swelling, which has its origin behind the stomach and may displace this viscus, as well as the colon, upward or downward, presenting usually toward the abdominal wall. In rare instances the direction of least resistance takes it toward one loin or the other, where it may appear as a perirenal abscess, or around the crus of the diaphragm and above the liver, where it would appear as a subphrenic abscess. It has been known also to burrow along the psoas muscle and appear at the groin, or even in the left broad ligament. Abscess of the pancreas may also burst into the stomach, when pus will be vomited, or into the bowel, whence it will be evacuated. A sudden relief, with disappearance of tumor, followed by diarrhea and purulent stools, would indicate this latter termination. Under these circumstances the abscess cavity may repeatedly refill and reëmpty itself. Spontaneous recovery in this way is possible, but septicemia and hectic usually persist until obviated by operation.

=Diagnosis.=--The history, the evidently septic type of the case, and the distinct signs above noted will make almost certain the presence of pus, and Mayo Robson insists that the pancreatic reaction in the urine (Cammidge) will make clear its location and origin; but, with or without the latter, the important feature is that there must be a deep collection of pus somewhere in the neighborhood of the pancreas.

=Treatment.=--This is necessarily operative, and in such cases as those now considered there will be plenty of time afforded for all the precautions known to careful surgeons. The aspirator should never be used, at least not until the abdomen has been opened, then usually with caution, lest pus escape along the needle track. The operation is made as described above for the acute form of this disease. The greatest care should be given to protecting the general peritoneal cavity against infection. When adhesions to the anterior abdominal wall are met they should be separated as little as possible, only to such an extent as will permit direct approach to the collection below. Only after the abscess cavity has been thoroughly emptied, disinfected, and packed with gauze should the surgeon proceed to clear away or break down adhesions so as to permit a suitable exploration of the lower surface of the liver and the biliary passages.

And now perhaps comes the necessity for operative attention to these latter, as one or many stones may be recognized in the gall-bladder or the ducts. In this case there must be followed those general directions elsewhere given in regard to the technique of operations upon the gall-bladder and ducts. _Biliary drainage_ will in these cases be nearly always indicated, for which a separate small opening in the usual position may be made, if desirable, as it probably will be, for one wishes usually to continue such drainage for several weeks, whereas it is desirable to have a median incision heal as rapidly as possible. The question of posterior drainage will also be raised. Ordinarily it is of advantage, as the time required for anterior drainage can be materially shortened, the abdominal wound be encouraged to close, and because the natural effect of gravity is thus afforded. Moreover, by it the whole period of confinement to bed may be materially reduced. Therefore, unless the condition of the patient absolutely contra-indicate, it will usually be a wise measure. In a few instances it has been possible to drain a pancreatic abscess by a tube in the common duct, after removal of the stone which has been obstructing either it or the duct of Wirsung.

CHRONIC AFFECTIONS OF THE PANCREAS.

Chronic affections of the pancreas which interest the surgeon are:

1. _Interstitial pancreatitis_:

(_a_) Interlobular.

(_b_) Interacinous, leading to--

2. _Cirrhosis_ with accompanying diabetes.

3. _Neoplasms_:

(_a_) Cysts.

(_b_) Solid tumors.

4. _Calculi._

=Chronic Pancreatitis; Cirrhosis.=--The interlobular and interacinous forms can both be considered under one heading so far as we are concerned, their symptoms being similar, save that in the former the compressed connective tissue by its presence causes atrophy of true glandular elements, and thus by preventing their function interferes with digestion; while in the interacinous type the proliferations of this same sort of tissue invade the islands of Langerhans, impair their glycolytic secretion or suppress it, and add a glycosuria to those features common to both forms--moreover, their treatment is essentially the same. In the advanced form of either type the pancreas may be reduced in size and somewhat cirrhotic. This chronic affection may be the result of an incomplete recovery from one of the more acute conditions previously described; it may also have its origin in the chronic irritation of the poisons of syphilis, typhoid, alcoholism, and the like; but by far the most common causes are obstruction of the pancreatic duct, either by biliary or pancreatic calculi, cicatricial stenosis, the presence of tumors or the encroachment and erosion of gastric ulcers and cancers. The morbid condition may involve the whole gland or be localized, in the latter case particularly about its head.

=Symptoms.=--These should be studied with particular attention to the case history, for a previous record of pain, cramps, chills, fever, jaundice, very slight digestive disturbances, soreness, or local tenderness will be suggestive and valuable if obtainable. As symptoms gradually arrange themselves it will be found that tenderness over the pancreas becomes constant, and is accompanied by at least a mild degree of muscle spasm, that pain increases and is referred more widely, often to the left side or even the scapula, while there may be some fulness in the epigastrium. Dyspepsia and emaciation become more marked. By the time the obstruction of Wirsung’s duct has become complete, perhaps previous to it, fat and undigested muscle fibers will be found in the stools, which are light-colored, bulky, and sometimes contain blood. As pressure effects become more prominent evidences of biliary obstruction, if previously lacking, present themselves; the gall-bladder usually distends; the liver enlarges or may even become cirrhotic from the irritation of pent-up toxic bile. Even the spleen may become enlarged. In the urine sugar will be found in cases of the interacinous type, though usually only at a late date; while bile pigments are usually present and Cammidge’s test may reveal his peculiar pancreatic reaction.

=Diagnosis.=--If the peculiar symptoms above rehearsed are present diagnosis is not difficult. In many cases it is not easy to go beyond the point of recognizing that both the pancreas and the biliary tract are at fault, without deciding as to the exact degree of culpability of each. The question of possible cancer arises in almost every one of these instances. Should the ordinary pancreatic reaction in the urine prove all that has been claimed for it, this grave problem can often be settled previous to operation. If the operator satisfies himself by any method short of actual operation that he has to do with cancer of the pancreas, then operation may be considered inadvisable unless for some special reason.

=Treatment.=--At least a reasonably long trial will usually be made, in these cases, of medical, hydrotherapeutic, and other non-operative treatment, with little or no benefit. When after appreciation of the condition and intelligent treatment but slight relief accrues, the case may be regarded (as it really is upon its commencement) as surgical. Treatment, then, consists of _removal of the obstructing cause by drainage of the biliary passages_. The operative procedure will therefore take the form elsewhere described for this purpose. Should deep exploration reveal no calculi it will be well to make sure at least of the patulency of the ducts, by opening the gall-bladder or common duct and exploring with the probe, or possibly even opening the duodenum in order to do the same with the pancreatitic duct. Whether calculi are discovered or otherwise a gentle stripping or massage of the pancreas may be made to advantage. Biliary drainage should then be established, and usually externally.

It has been difficult for the profession to appreciate why and how these measures, which seem to be directed rather to the biliary passages than to the pancreas, have given such brilliantly satisfactory results as are everywhere reported. These are to be accounted for by the facts that the primary cause most often lies in the former rather than the latter, and is thus removed, and that one source of constant irritation--namely, infected bile--is thus done away with, while tension is removed and pancreatic juice again permitted to flow on as it should; that a chronic toxemia (cholemia) is relieved, and that physiological rest is afforded to the affected and disturbed organs. When the operation is thus performed benefit may be expected; even when done late it may be capable of great good.

NEOPLASMS OF THE PANCREAS.

=Cysts.=--In addition to _true cysts_ of the pancreas there have been described so-called “_pseudocysts_” in the lesser peritoneal cavity, and more or less surrounding the pancreas. They are rarely of congenital origin, but are probably due rather to traumatism than to any other cause. By many they have been likened to ranulas, or the cysts which form in the salivary glands in consequence of obstruction to ducts or their branches. Anything which obstructs any portion of the pancreatic duct may lead to the formation of a retention cyst, the true proliferation cyst--adenomas being practically unknown. That traumatism figures so largely is due to the fact that injury is followed by hemorrhagic extravasation, and this by more or less liquefaction or degeneration, both of contents and of surrounding tissue, with the secondary formation of a cyst whose walls are made of new connective tissue.

A _true pancreatic cyst_ is a retroperitoneal tumor, while pseudocysts are intraperitoneal. In front of the former lie four layers of peritoneum, which may be completely merged together, but through which a passage must be made when opening into it from the front. The etiology of old pancreatic cysts may be completely concealed by the changes which have slowly occurred since their origin. They may be single or multiple, occur in any portion of the gland, and increase even by coalescence. Within some of them, especially those of the duct type, papillomatous excrescences may be found. The more distinctly traumatic cysts occur perhaps oftener near the tail of the pancreas, while into them repeated hemorrhages may take place, and the sac will become quite thick, even exceptionally calcifying in places. These have been described as _apoplectic cysts_.

Altogether, up to date, at least 150 of these cysts have been subjected to operative intervention.

Pancreatic cysts contain a fluid which may be variously colored or sometimes colorless, which is usually alkaline, and contains fat globules, cholesterin crystals, blood crystals, albumin, and various salts, most of these being evidences of their hemorrhagic origin. The fluid may also contain the specific pancreatic ferments, of which the diastatic is the more common, tryptic ferment being met occasionally, while the fluid may also possess emulsifying properties. In size these cysts vary from minute sacs to enormous collections of fluid.

As such a cyst attains marked size it will displace the adjoining viscera, pushing the diaphragm upward and impeding heart and lung

## action, obstructing the pylorus and duodenum and causing gastric

dilatation, pressing upon the intestines and perhaps even compressing the ureters, thus producing hydronephrosis. Other peculiar pressure effects may be met in particular instances. A sudden increase in size indicates a fresh hemorrhage, which may lead to its rupture and to death from peritonitis. These cysts rarely empty spontaneously into the bowel. Their contents are liable to infection, and thus a cyst may become converted into a large abscess.

=Symptoms.=--Symptoms include especially _pain_, which may have been sudden, but becomes more or less constant, accompanied by a sense of oppression, according to the size and the pressure effects produced in each case. Digestion is always more or less disturbed; this may be attributed to the stomach dilatation, which is itself a sequel of the condition. The stools show little which is significant save that they are occasionally bloody. Undigested muscle fiber would indicate loss of pancreatic function. Other symptoms will vary so much with individual cases that it is not necessary to consider them here.

The physical signs, coupled with a suggestive history, especially one which includes an account of injury, are of the greatest importance in diagnosis. These physical signs will include usually a yellowish tinge of the skin, marked emaciation, dry skin, and the presence of a tumor in the upper abdomen, which is usually centrally placed, but not necessarily so. If the patient has carefully noted the development of his own symptoms it will be found that the enlargement commenced above and usually a little to the left, and developed in other directions from that location. Palpation reveals a smooth, elastic, usually fluctuating tumor, sometimes movable with respiration, rarely pulsating.

It must be remembered that a pancreatic cyst may rise above the stomach, may rest entirely behind it, or may protrude either below it and above the colon or else quite below the colon. Distention of the stomach will afford accurate location, in these respects, upon percussion, while percussion without distention may mislead. A tumor which gives dulness below the stomach and above the colon is extremely suggestive.

=Diagnosis.=--Diagnosis by aspiration is inadvisable, even dangerous, for death has followed the introduction even of a needle into such a cyst. Aspiration, then, should be reserved for tumors already exposed through an abdominal incision.

For the purpose of _differentiation_ it will suffice here to remind that tumors of the kidney, as well as hydronephrotic cysts, grow downward and forward from the loin, and can be pushed backward to their proper place unless too large, that they are not accompanied by digestive disturbances, while the urine is usually more or less indicative. A hydronephrotic cyst can scarcely be made to occupy a position between the stomach and the colon and present in the middle line in front. Ovarian cysts rise from the pelvis and will rarely occur in the upper location, save those provided with extremely long pedicles. Hydatid cysts of the liver show a continuity and fixation to that viscus which are usually diagnostic.

=Treatment.=--The only treatment for pancreatic cysts is surgical, it remaining with the surgeon to decide as between _drainage_ and _extirpation_. While it is indisputable that extirpation is the ideal method of dealing with all cysts and tumors, most of these cases are of such long duration that the adhesions contracted between their exteriors and the surrounding viscera are so dense and firm that much greater danger attaches to a radical operation than to one for simple incision and drainage. I have been able in at least one case to completely extirpate such a cyst, but it was one exceedingly favorably situated and surrounded.

_Incision and drainage_ may be effected in one operation or in two sittings, and as between them it must be decided according to the merits of the case. It is undesirable to permit the escape of the contents of these cysts into the abdomen. In some instances, therefore, it would be much better to make a small abdominal incision and through it attach the surface of the cyst to the margins of the parietal peritoneum, reserving the actual opening into the tumor until a day or two later, when it may be expected that firm adhesions will have attached the sutured surfaces. In this way any leakage within the abdomen may be avoided. Care must be exercised, even in such cases, as a large cyst too suddenly emptied may cause sudden displacement of the heart or of other viscera, which would not be to the advantage of the patient. In this case fluid could be withdrawn in portions as desired, or, making a small opening, one could arrange for its gradual escape. On the other hand, there are cases where it would be of great advantage, if the cyst could not be emptied, to so open it as to permit posterior drainage to be made, by which the period of recovery would be much abbreviated.

No case of this kind can be treated without drainage, the explanation being that the cyst being emptied will collapse, its walls coming into more or less close contact with each other, that the presence of drainage material will provoke exudate and the formation of granulation tissue, and that a complete obliteration will thus in time occur--but drainage in the natural direction of gravity as the patient lies upon the back will permit of much more speedy fulfilment of one’s hopes; hence its advantage. Better still, perhaps, would be through-and-through drainage, with such irrigation as might be needed, practised daily, or oftener if necessary.

=Tumors of the Pancreas.=--While _sarcoma_ and other forms of malignant disease, as well as _adenoma_ of the pancreas, have been described, they require no special consideration here, since the surgeon has so rarely to do with anything of this character save _adenocarcinoma_ of the pancreas. This is a disease of middle or advanced life, more common in males than in females, usually of scirrhous type, and localized, though it may appear in softer forms or be disseminated. It takes its origin from the epithelial cells lining the acini and the ducts. Metastasis is common and direct extension by continuity most easy and frequent. It is made known by its pressure effects rather than by any other important signs or constant features. It has been known to lead to chylous ascites.

It is difficult in many exploratory operations to decide as between a chronic induration or cirrhosis of the pancreas and that due to cancer, and, in fact, in certain cases it may be impossible to clear up the difficulty, leaving it to be solved either by recovery or death in consequence of extension of malignant disease. Thus when operating for biliary obstruction, where the parts are surrounded by adhesions and the organs are only indistinctly palpable, it may be impossible to decide as to the nature of a hard mass felt in the head end of the pancreas, especially when other distinct expressions of cancer are absent.

_Cancer of the pancreas_ is at present a primarily hopeless disease, and is of interest to the surgeon only in that some of the most distressing features which it causes may be temporarily relieved by biliary drainage. The symptoms which will bring such a patient to him will be essentially those of biliary obstruction, perhaps with the accompaniment of glycosuria or the discovery of fat in the feces. Neither of these, however, is an invariable symptom. Diarrhea is but an occasional feature, and colorless stools may be discharged when there is no jaundice. A perfectly painless progressive (bronzing) jaundice, with distention of the gall-bladder, would perhaps more than any other single feature indicate pancreatic cancer. When such a growth has attained a size sufficient to make it discoverable on palpation it might be mistaken for a biliary cancer, from which it would have to be differentiated especially by the movability usually noted in the latter.

The only treatment for pancreatic cancer is operative, and consists in _drainage of the gall-bladder_, and after a manner elsewhere described in the section on Diseases of the Biliary Passages.

PANCREATIC CALCULI.

From the true pancreatic secretions precipitations of mineral salts, combined with organic elements, may occur, just as from the saliva, the latter thus furnishing the salivary calculi elsewhere described, the two varieties having many points of resemblance. Again, calculi, evidently of biliary origin, may be met with in the pancreatic duct. The former consist largely of calcium oxalate, combined with calcium carbonate and phosphate. They may be single or multiple, and vary greatly in size up to that of a robin’s egg. Hypothetical calculi, with consequent duct obstruction, have been held to be responsible for many pancreatic cysts. Thus one may explain cyst formation, even though no calculi be found at the time of operation.

Calculi reposing within the structure of the pancreas have much to do with the acute and subacute, as well as the more chronic types of pancreatitis, the latter when they act alone, the former when to their essential disturbances are added the possibilities of bacterial infection.

When pancreatic calculi produce symptoms they resemble those of cholelithiasis, causing paroxysmal pain, with vomiting, and perhaps transient jaundice. Glycosuria is an occasional feature.

The condition is rarely diagnosticated previous to operation. Should a calculus be met in this location during the progress of any operation it should be removed by an incision made parallel to the duct, with such closure of the wound in the pancreas as can be subsequently effected and with ample drainage of the deep wound, in order that pancreatic fluid may not escape into the peritoneal cavity. If encountered during operation for pancreatic cyst the same advice will apply.

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