When pancreatic calculi produce symptoms they resemble those of cholelithiasis, causing paroxysmal pain, with vomiting, and perhaps transient jaundice. Glycosuria is an occasional feature.
The condition is rarely diagnosticated previous to operation. Should a calculus be met in this location during the progress of any operation it should be removed by an incision made parallel to the duct, with such closure of the wound in the pancreas as can be subsequently effected and with ample drainage of the deep wound, in order that pancreatic fluid may not escape into the peritoneal cavity. If encountered during operation for pancreatic cyst the same advice will apply.
CHAPTER LIV.
THE KIDNEYS.
CONGENITAL ANOMALIES AND DEFECTS OF THE KIDNEYS.
Recent embryological studies have established the fact, in regard to the kidneys, and given rise to the inference in regard to the other viscera, that the primary cause of congenital variations has much to do with the earliest development of the bloodvessels. The general inclination has been to view the vessels as following the organs. This should be reversed, as we are now learning that organs develop around the bloodvessels, and that so-called congenital variations arise from departures of vascular arrangement from the ordinary types. Without pursuing this subject further it is sufficient to say that, aside from defects of such character that the newborn infant can live but for a few hours or days, those which have most surgical interest mainly comprise variations in number and in size, including every possible combination, from absence of an entire kidney to horseshoe forms, and various anomalies of the ureters including defects and redundancies, double ureters, and the like. While supernumerary renal tissue or kidneys are extremely rare, the presence of supernumerary adrenal tissue in one or both kidneys (even in adjoining organs) is not uncommon. Here it may lead to the development of a distinct form of tumor, hypernephroma, which will be discussed later. The complication of absence of an entire kidney is sufficient to give it actual surgical importance, since it has repeatedly happened that the remaining kidney has been removed for disease, the inference being that its work could be carried on by its fellow, which proved to be lacking. This accident might be prevented by a careful cystoscopic examination. Nevertheless the rarity of this condition permits it to be almost excluded from ordinary consideration. After removal of one kidney the other undergoes compensatory physiological enlargement and does double duty, if indeed this has not already occurred.
Acquired defects may be due to intrinsic or extrinsic causes, e. g., disease within the renal structures or ureters, or lesions in adjoining organs and tissues, producing mechanical or other disturbances. Thus the functionating capacity of one or even both kidneys may be seriously compromised by either internal or external conditions, and it behooves the surgeon to estimate the degree of renal disability or inadequacy before operating upon either of these organs. On the other hand if the disease be confined to one kidney he may feel that it is doing so little good and so much harm that the patient will be really relieved by its removal. Nearly everything, then, depends upon a determination of the precise existing conditions. They should be ascertained by means of the catheter, the cystoscope, the microscope, and by the careful chemical study of the urine. These methods have been developed into a specialty of considerable complexity, but of great practical importance. The surgeon should not fail to employ them. If he is not familiar with the technique he should seek special assistance.
Fig. 632
Laceration fragmentation of kidney. (Güterbock.)