—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:

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.