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—