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 In this case fluid could be withdrawn in portions as desired, or, making a small opening, one could arrange for its gradual escape.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.