The principles and practice of modern surgery

by Roswell Park

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.