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.
—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.
—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.
As such a cyst attains marked size it will displace the adjoining viscera, pushing the diaphragm upward and impeding heart and lung action, obstructing the pylorus and duodenum and causing gastric dilatation, pressing upon the intestines and perhaps even compressing the ureters, thus producing hydronephrosis. Other peculiar pressure effects may be met in particular instances. A sudden increase in size indicates a fresh hemorrhage, which may lead to its rupture and to death from peritonitis. These cysts rarely empty spontaneously into the bowel. Their contents are liable to infection, and thus a cyst may become converted into a large abscess.
Symptoms.
—Symptoms include especially pain, which may have been sudden, but becomes more or less constant, accompanied by a sense of oppression, according to the size and the pressure effects produced in each case. Digestion is always more or less disturbed; this may be attributed to the stomach dilatation, which is itself a sequel of the condition. The stools show little which is significant save that they are occasionally bloody. Undigested muscle fiber would indicate loss of pancreatic function. Other symptoms will vary so much with individual cases that it is not necessary to consider them here.
The physical signs, coupled with a suggestive history, especially one which includes an account of injury, are of the greatest importance in diagnosis. These physical signs will include usually a yellowish tinge of the skin, marked emaciation, dry skin, and the presence of a tumor in the upper abdomen, which is usually centrally placed, but not necessarily so. If the patient has carefully noted the development of his own symptoms it will be found that the enlargement commenced above and usually a little to the left, and developed in other directions from that location. Palpation reveals a smooth, elastic, usually fluctuating tumor, sometimes movable with respiration, rarely pulsating.
It must be remembered that a pancreatic cyst may rise above the stomach, may rest entirely behind it, or may protrude either below it and above the colon or else quite below the colon. Distention of the stomach will afford accurate location, in these respects, upon percussion, while percussion without distention may mislead. A tumor which gives dulness below the stomach and above the colon is extremely suggestive.
Diagnosis.
—Diagnosis by aspiration is inadvisable, even dangerous, for death has followed the introduction even of a needle into such a cyst. Aspiration, then, should be reserved for tumors already exposed through an abdominal incision.
For the purpose of differentiation it will suffice here to remind that tumors of the kidney, as well as hydronephrotic cysts, grow downward and forward from the loin, and can be pushed backward to their proper place unless too large, that they are not accompanied by digestive disturbances, while the urine is usually more or less indicative. A hydronephrotic cyst can scarcely be made to occupy a position between the stomach and the colon and present in the middle line in front. Ovarian cysts rise from the pelvis and will rarely occur in the upper location, save those provided with extremely long pedicles. Hydatid cysts of the liver show a continuity and fixation to that viscus which are usually diagnostic.
Treatment.
—The only treatment for pancreatic cysts is surgical, it remaining with the surgeon to decide as between drainage and extirpation. While it is indisputable that extirpation is the ideal method of dealing with all cysts and tumors, most of these cases are of such long duration that the adhesions contracted between their exteriors and the surrounding viscera are so dense and firm that much greater danger attaches to a radical operation than to one for simple incision and drainage. I have been able in at least one case to completely extirpate such a cyst, but it was one exceedingly favorably situated and surrounded.
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.
—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.
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.
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.