—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.