=Treatment.=--The general subject of cholelithiasis and its associated

lesions constitutes an important topic in the so-called “border-land”

between medicine and surgery, where views and advice regarding

prognosis and treatment will depend on the experience and the training

of the medical attendant. Surgeons now recognize, and physicians are

being gradually converted to their view, that _gallstone disease

is essentially a surgical disease_, _i. e._, one to be combated by

surgical intervention. While it is not to be gainsaid that many

patients live and die with gallstones who are never conscious of

their presence, and while others who have had serious attacks live

to die of some other disease, nevertheless the general statement may

be boldly made and easily defended, that _when the disease is well

marked and when patients suffer more or less constantly from it the

only successful method of treatment is the surgical_, and that, in

other words, operation offers the only prospect of permanent relief.

Regarding its associated dangers it may be said that _danger comes

from delay rather than from operation_, and that here, as with many

other conditions, patients often wait too long, partly from lack of

proper advice, partly from timidity, and that a septic and moribund

patient, allowed to become so for lack of earlier application of the

resources of surgery, is a reflection on the one who waits rather than

on the surgeon, who, endeavoring to save, still unfortunately loses his

patient.

This is not the place to discuss non-operative measures--_i. e._,

medicinal and dietetic treatment--valuable as they may be in certain

cases. Most of the drugs which are supposed to be effective in their

power of solution of gallstones or of facilitating their escape are

disappointing, and at best are vague and uncertain in their action.

The hydrotherapeutic treatment, such as carried out, for instance, at

Carlsbad, will do good in many cases, especially for those who have

been indulgent in their appetites and careless in their habits. Cases

of any description not too far advanced would be benefited by a careful

regimen of this character, but that Carlsbad or any other waters

will certainly cure cholelithiasis is now absolutely disproved. As a

preparation for operation a sojourn at some such place may be advised;

as a substitute for it, never. Large doses of glycerin (50 to 150 Cc.)

often temporarily relieve the pain of biliary colic.

In general, then, it may be said that cases which give a history of

recurring attacks of biliary colic, with or without recurrent jaundice,

and with those varied concomitant symptoms which are usually grouped

under the term “indigestion,” in which there is definite tenderness

over the region of the gall-bladder, with or without muscle spasm,

and with the other referred pains so often present in this condition,

should be regarded as legitimately surgical, where operation is more

than justifiable and usually decidedly advisable, even too often

imperative. The same is true of those cases of distended gall-bladder

with obstruction of the duct where perhaps no calculi are present, but

where the patient suffers in much the same way as though they were

present. _Biliary drainage is equally called for, and the presence or

absence of calculi is but a minor feature_ upon which too much stress

should not be laid nor too much disappointment expressed if they be not

found.

Many cases of chronic cholelithiasis have become more or less toxemic,

as well as cholemic. It is a well-recognized fact that cholemic

patients are more likely to cause inconvenience to the surgeon from

free hemorrhage or persistent oozing, because of the slowness with

which coagulation of their blood takes place. When time is afforded for

preparation it is of great value in these cases to administer calcium

chloride, of which several doses may be given each day, in considerable

water, the former varying in amount from 1 to 2 Gm. When time suffices,

too, it is always of value to prepare these patients for the operation

by measures already discussed, improving their elimination, reducing

the degree of their toxemia, and fortifying their circulatory systems

by well-known measures. The value of such preparation is perhaps more

apparent in such instances than in most others. On the other hand, many

cases calling for operation are almost as imperative as those of acute

appendicitis, where every hour’s delay is to the disadvantage of the

individual. The operations which are practised upon the biliary tract

will all be discussed together in a section by themselves.

TUMORS OF THE GALL-BLADDER.

This expression refers rather to actual neoplasms of the gall-bladder

itself than to distention of the sac by which an intra-abdominal tumor

may be formed. The latter subject may be dismissed with the mere

statement that the gall-bladder may become distended with bile, with

mucus, with pus, with concretions, or with the products of such disease

as echinococcus, actinomycosis, etc. In this way it may be so much

enlarged as to be easily felt through the abdominal walls or to be even

mistaken for other conditions. In the latter case it may have to be

differentiated between such a condition and a movable right kidney, a

tumor of the kidney itself or of its capsule, as well as from tumors of

the stomach, especially the pylorus, of the liver, or of the intestine

and from the enlargement of the right lobe which often accompanies

cholelithiasis, or from fecal impaction. It would be best to abstain

from the use of the aspirating needle in these cases, as more harm

might be done by the escape into the abdomen of deleterious fluid

than would be atoned for by the information which the procedure would

afford. Even when the abdomen is open the gall-bladder should rarely

be punctured in this manner, unless one is prepared at the same time

to open it and drain. In other words, there is less risk about a small

exploratory incision than in puncture.

Nearly all varieties of _malignant_ and many of _benign_ tumors have

been reported as occurring in this location. It will be sufficient in

this place, however, to say that _cancer_ of the gall-bladder, which,

of course, may extend in various directions, is by no means an uncommon

affection, and is _usually a complication of gallstones_. In fact, it

may be doubted whether primary cancer of the gall-bladder ever occurs

in the absence of such a source of irritation. These cancers vary in

type between the round-cell and the squamous, most of them, however,

being of the former character. Although Musser has put the percentage

at 65 and Zenker as high as 85 of instances where gallstones are found

within cancerous gall-bladders, it does not follow that the above

statement may not be true regarding their almost universal association

and causal relation, for any gall-bladder found empty at a given

time may at some other time have contained a calculus. This frequent

association is justly among the valid arguments which surgeons may now

use in making a plea for earlier operation, and for making it a more

standard procedure.

_Cancer_ may be suspected in cases of progressive and unintermittent

jaundice, especially when there can be felt in the region of the

gall-bladder a distinct tumor or an enlargement of the liver. Pain

is a frequent but by no means a constant or reliable symptom. As the

disease spreads the adjoining textures will become matted together, and

a low grade of local peritonitis may still further cement them into a

mass which will occupy a considerable portion of the upper part of the

abdomen.

But few cancers of the gall-bladder which are so apparent as to be

recognized without exploration can be considered as still amenable to

surgery, which for them can hold out but little prospect save perhaps a

temporary relief by biliary drainage. It is the cases in their earlier

stages, when the condition is made out by exploration, and by it alone,

which still afford prospects of more or less permanent relief. The

very impossibility of detecting the condition in these earlier stages

without exploration affords one of the strongest arguments for such a

procedure in every vague case of the kind. That cases of this character

are not necessarily hopeless is instanced by an experience of my own,

where on opening the abdomen of a large and fleshy woman I found a

distinctly cancerous gall-bladder containing two large calculi, and

removed the entire mass, with a considerable portion of the surrounding

hepatic tissue, the removal being effected with the actual cautery.

At present date of writing, nearly six years after the operation, the

patient is apparently perfectly well and doing her own housework.

OPERATIONS UPON THE GALL-BLADDER AND BILIARY PASSAGES.

The small area included under the above title has been made the field

for a variety of operations, dignified with formidable names, the

entire list of which might be made quite long. In order to simplify

their arrangement and illustrate their purposes they may be referred

to as (1) operations upon the _gall-bladder proper_; (2) those _upon

the ducts_; and (3) the more complicated operations upon one or

both of these in connection with some other part of the intestinal

tract; or, to catalogue them somewhat definitely, the operations upon

the gall-bladder include _cholecystotomy_, _cholecystostomy_, and

_cholecystectomy_, according as the surgeon opens the gall-bladder

and closes it, makes a more or less permanent opening, or completely

removes it. Again, upon the _ducts_ he may make _cholangiotomy_ or

_cholangiostomy_, or, using their practically equivalent synonyms,

_choledochotomy_ or _choledochostomy_, these terms referring to

operations upon the cystic and the common ducts; while when similar

procedures are applied to the hepatic duct they have been spoken of

as _hepaticotomy_ and _hepaticostomy_. _Cholecystenterostomy_ refers

to an anastomosis between the gall-bladder and the upper bowel, while

when this is effected between the common duct and the bowel it is

referred to as _choledochenterostomy_. When a stone lies partly in the

common duct and partly within the wall of the duodenum, and it becomes

necessary to incise the latter, it may be spoken of as _duodenotomy_.

The operation of merely crushing biliary calculi, hoping that the

fragments will be passed on with the flow of bile, and spoken of as

_cholelithotrity_, is now almost abandoned, and the term has historical

rather than present value.

To even attempt to epitomize directions for these various operations

into space available here would be impossible, for large volumes have

been devoted to this subject alone. The main thing for the student

and the junior practitioner is to appreciate the indications for

their performance, at which he should certainly have assisted before

attempting to perform them himself. General directions, however, may

be given as follows, the usual preparations having been made both

of the patient and the environment: A woman who has borne children

and who has, in consequence, relaxed abdominal walls, makes a more

favorable subject for operation than a muscular man whose abdominal

muscles cannot be relaxed until a profound degree of anesthesia has

been obtained. In many instances exposure is made better by placing

a sandbag behind the region of the liver, especially on the side to

be operated, by which the costal angle is more outlined and the parts

pushed forward.

A preliminary incision should be made of, say, three inches in

length, and is best placed a little to the inner side of the outer

border of the rectus, whose fibers are separated and its tendinous

intersection divided. This incision may be extended upward and curved

toward the middle line, as recommended by Bevan, or downward, as the

exigencies of the case may require. The beginner especially should

provide himself with sufficient space for manipulation. The posterior

sheath of the rectus and the peritoneum are best divided together.

Sufficient opening being thus made, a finger may be inserted for the

purpose of exploration. In the presence of adhesions, and especially

in acute cases in which pus is likely to be present, this should be

done with great caution. When no adhesions are present gauze pads may

be inserted and so disposed as to permit exposure to view of the lower

surfaces of the liver. The operator should be prepared for any and all

conditions--one of dense adhesions or their complete absence, as well

as for cobweb-like adhesions which surround foci of infected exudate

or of pus. The more reason he may have for suspecting the presence of

pus the more carefully should the region be walled off with protective

gauze. Adhesions are most likely to form between the omentum and

the colon, in front and below, and with the stomach, duodenum, and

colon below and behind. Those who have had experience with abdominal

operations will appreciate whether these adhesions are recent and

likely to cover purulent foci, or old, and will proceed accordingly.

Occasionally tissues will be so matted that even an experienced

operator will scarcely be able to differentiate them.

The endeavor should be, if possible, to expose the gall-bladder itself,

both to touch and sight, in order that after orientation concerning its

actual condition its duct may be followed into the common duct, and

this into the intestine. This is sometimes an exceedingly easy matter,

and again impossible. The presence or absence of pus will of itself

indicate what should be done. When, for instance, the gall-bladder is

found black or partly gangrenous the surgeon will content himself

with doing the least possible amount of separating, endeavoring rather

to provide the widest outlet for drainage. It might be better to make

simply a small opening and permit the escape of fetid débris, and to

postpone until a later day further attempt to remove the calculus,

which presumably has produced the difficulty. Local indications, then,

should be considered along with the general condition of the patient.

The lower surface of the liver will afford the guide to the location

of the gall-bladder, and when the latter is nearly obliterated its

discovery sometimes taxes the resources of the surgeon. When not

contracted it is usually easily exposed, and so far freed that it

may be even drawn up into the wound. After having thus isolated and

perhaps secured it, it must be decided by further exploration how it

shall be treated. It is of great importance to liberate the ducts from

surrounding adhesions.

=Cholecystotomy.=--Cholecystotomy, sometimes fallaciously spoken of

as ideal, consists in simply opening the gall-bladder, emptying it of

calculi or other contents through a small incision, and closing this by

sutures. The operation is ideal in but one way, but conditions which

permit it rarely justify it, for any gall-bladder so diseased as to

call for operation needs either removal or drainage.

=Cholecystostomy.=--Cholecystostomy includes provision for drainage

over a considerable length of time. A distended gall-bladder which

permits of easy manipulation and isolation may be sufficiently long and

large to justify uniting its surface to the peritoneum and deep margins

of the wound, in such a way as to permit discharge of its contents

through the latter. The old method was to unite it to the skin. This

should never be done, as fistulas thus resulting are more likely to

be permanent. If the gall-bladder be thus affixed to the parietal

peritoneum the better way is to insert a drain, its arrangement being

left somewhat to the choice of the operator. For my own part I prefer

a rubber tube, not too flexible, inserted two or three inches into

the gall-bladder, through a small opening closed around it, with

invaginated edges, by a purse-string suture of chromic gut, by which it

is intended to prevent leakage into the abdominal cavity. By another

suture of common gut the tube may be so fixed as to avoid danger of

being lost in either direction. If the gall-bladder be sufficiently

long to permit additional fixation to the depths of the abdominal wound

the operation is made still more ideal; but in the case of a short and

contracted cavity the tube may be left to follow it into the abdominal

recesses. Within forty-eight hours the exudate which has been thrown

out around it will have become sufficiently organized and well ordered

to form a canal in which the tube shall rest, and which shall serve

later as a conduit to conduct bile to the surface after removal of the

tube itself. Into such a tube, after the application of the dressings,

may be conducted another more flexible tube, whose upper end shall

connect with a receptacle of some kind, which may later be a bottle

held within the dressing, to receive the discharge, and thus avoid

soiling.

This operation has been done occasionally in two sittings, the

gall-bladder being brought into the upper part of the wound and

fastened to the peritoneum by sutures, which should not perforate its

walls, as that leakage would occur which the method is intended to

avoid. After waiting a day or two for adhesions to form the cavity is

then opened with a knife or scissors and drainage thus accomplished.

This method has been practically abandoned, for the reason that it

permits no digital exploration by combined manipulation.

=Cholecystectomy.=--Cholecystectomy includes the removal of the whole

or the greater part of the gall-bladder. It has already been stated

that this is a _reservoir_, convenient and advantageous, but not needed

in a way, and not essential to life. It figures as a superfluous

organ, then, similar to the appendix, and there is no reason why, when

diseased and troublesome, it should not be _extirpated_. Its removal

will sometimes be a matter of choice, and at other times a necessity.

The former is the case when the surrounding conditions lend themselves

to its dissection from the lower surface of the liver without too

much violence to other tissues; the latter when it is involved in

malignant processes or when its interior is seriously infected. An

incomplete method of treating the gall-bladder under the latter

circumstances might include the _scraping or removal of its thickened

mucosa_, without removing the entire thickness of its structure. In

this case, however, drainage would be required. That the gall-bladder

may be completely separated and thus isolated, with comfort and

speed, requires that its wall be sufficiently strong to stand the

ordinary manipulation. This may not be true of the perfectly normal

gall-bladder, but in such case no one would think of removing it,

whereas the cyst, which is diseased sufficiently to justify removal,

will usually permit of the necessary manipulation. Even if somewhat

torn in the process the procedure may be effected without much added

difficulty. This procedure consists essentially in separation of the

overlying peritoneum and enucleation of the gall-bladder from its bed

or the depression in the liver in which it lies, which, as already

indicated, may be narrow or wide and deep. Actual separation from liver

tissue will be followed by oozing and at least two or three vessels

in the surrounding structures and at the neck of the gall-bladder

will require to be secured. Removal should not be attempted in cases

which do not permit of it, but may be practised in those cases not

too infected, when after emptying the sac (full of calculi, for

instance) it can still be established with the probe that the common

duct is patulous. These are ideal cases for such complete work. The

gall-bladder having thus been isolated down to its cystic termination,

the surgeon proceeds much as though it were the appendix, by firmly

ligating the duct with chromic gut, guarding against escape of contents

while it is divided on the distal side of the ligature thus applied.

The stump of the duct is then cauterized with pure carbolic, after

which oozing is checked by tamponing for a few moments. It then is

often possible to bring together the peritoneum beneath the torn liver

surface and almost completely cover it anew. The liver tissue will bear

a ligature or suture not too tightly drawn. If the case have been one

otherwise surgically clean, and the operation properly conducted, the

abdominal wound may be closed without drainage. If, however, doubt be

felt a small cigarette or a tubular drain may be placed, to be left

not more than thirty-six hours. Every infected gall-bladder, if not

removed, should be thoroughly cleansed, its interior being mopped with

gauze, preferably with the addition of hydrogen dioxide. An important

step, next to attention to the gall-bladder proper, is to demonstrate

the patency of the ducts. This is done by gently passing a probe,

which should be bent to suit the case, along the duct and into the

intestine. This, of course, cannot be done if calculi are discovered

by manipulation, neither can it always be done when calculi are not

present. Gallstones in the duct can usually be distinguished by the

fingers with which the exploration is made, and failure to thus pass

a probe may be brought about by stricture rather than by calculous

obstruction. The importance of this determination will be seen in

removing the gall-bladder, as to remove it in an obstructed case is to

leave no outlet for bile except into the abdominal cavity, whereas to

fail to drain such a case is to plainly neglect to meet the indication.

[Illustration: FIG. 628

General scheme of cholecystectomy; detachment of gall-bladder and duct

from their investments; ligation of cystic duct and arteries. (After

Kehr.)]

=Cholecystendysis.=--The term cholecystendysis, now almost obsolete,

implies practically a cholecystotomy with drainage, the gall-bladder

having been opened for the purpose of removal of one stone or more and

then united to the abdominal wound.

Of the _operations upon the ducts_ there is something to be said

in addition to the directions already given. Inasmuch as they lie

more deeply they are more difficult of access, and variously shaped

retractors, with walling off the cavity with gauze, are more often

required, while in proportion as deep adhesions have enwrapped the

structures they are made more difficult of exposure. At present

surgeons have less hesitation in leaving duct incisions unclosed than

was formerly felt. It was formerly held that every incision into

a duct should be closed with sutures. It has been later found that

satisfactory results ensue when the end of the drainage tube is left

resting, or even fastened, within the duct opening, the operation being

thus made shorter and simpler and the difficulties of deep suture thus

obviated. As elsewhere noted the common duct may become enormously

_dilated_, and may be almost mistaken for the small intestine. The

passage-way between this duct and the gall-bladder may be so obstructed

that double drainage will be of advantage, or this may be a case where

partial removal of the gall-bladder may be effected, with drainage

of the common duct. Such cases should be judged upon their merits.

The more infectious the existing condition the more is free drainage

demanded. When a stone is impacted in the ampulla of Vater there should

be no hesitation in dividing the walls of the duodenum in order to

extract it. In such a case the duodenum is sutured, but the duct or the

gall-bladder must be drained (Fig. 629).

These deep operations require free incision, several inches in length,

and it will astonish the beginner to see how the liver may be delivered

from the abdominal cavity through such an opening. Much assistance

will here be gained by a large pillow or sandbag placed beneath the

back. Bleeding vessels need to be secured, at least temporarily, with

forceps, and usually with sutures or ligatures _en masse_. The exposed

or torn surfaces of the liver will ooze freely at first, but bleeding

usually ceases with the pressure of a gauze tampon. From the uninflamed

gall-bladder the peritoneum is usually easily separated, with but

trifling hemorrhage. For deep work traction on the middle portion of

the duodenum makes more prominent the junction of this part of the

bowel with the gastrohepatic omentum, at which point the peritoneum may

be incised and separated along the free border of the duodenum until

this portion is free from external peritoneal covering. There will be

exposed here the second portion of the common duct where it lies upon

the pancreas, it being more or less embedded in the latter further

along. When it is necessary to cut away more tissue it is better to

sacrifice a portion of pancreas rather than of duodenum itself. Blunt

dissection alone should be made here. When it is necessary to cut it

will be better to use the thermocautery.

[Illustration: FIG. 629

Removal of gallstone entangled at the papilla. Kocher’s method of

displacing the duodenum: _a_, incision in the paraduodenal peritoneum;

_b_, pancreas; _c_, location of the stone; _d_, duodenum; _e_, sutures

used either for retracting or closing opening in the common duct; _f_,

retroduodenal venous plexus. (Kehr.)]

These various cutting operations have superseded the previous methods

of endeavoring to crush stones within the duct and force the fragments

along by pressure. The Mayos have recommended the use of two fine

parallel sutures, introduced longitudinally into the duct, between

which the incision should be made, and which may be used as tractors,

or subsequently for purposes of closure.

Practically every gall-duct case should be drained with a tube

extending down to the deepest portion of the site of the operation.

This may be done with what has been called a “dressed tube,” made

by surrounding an ordinary rubber drain with a few layers of gauze

and covering this with oiled silk. The lower end of the tube is then

bevelled or trimmed in fish-tail fashion. This may be passed into the

depths, or it may be used for gall-bladder drainage as well.

Of the _anastomotic operations_ there is less heard now than a few

years ago. There are now considered to be but a few conditions which

are not better dealt with by biliary drainage as made above than by any

other method. Occasionally, as, for instance, when the common duct is

strictured or involved in pancreatitis or cancerous deposit, and bile

is backing up into the gall-bladder, it may be of great advantage to

effect an anastomosis between the latter and the bowel. At one time

the colon was used for the purpose, but this prevented the utilization

of the bile in the upper bowel, where it is most needed. Consequently

it should always be made into the upper portion of the bowel, the

duodenum, or one of the upper loops of the jejunum. For this purpose a

small Murphy button is probably still the speediest and best expedient.

This is true also when it seems necessary to drain the common duct

into the bowel, since the field of operation in most cases lies too

deeply to permit of accurate and satisfactory suturing. A further and

more difficult as well as later application of this principle has been

suggested for certain cases of permanent obstruction of the common

and main hepatic ducts. Under these circumstances the operation last

mentioned would be useless and a cholangiostomy would be objectionable,

as it would constitute a permanent fistula. As practised by Kehr and

others this _hepato-cholango-enterostomy_ is performed by removing from

the lower surface of the liver a strip of its tissue about 7 Cm. long

and 2.5 Cm. wide. The hemorrhage is checked with the thermocautery, and

with it an opening is made into the liver, of such a depth that several

of the bile ducts are thus divided and opened. The uppermost loop of

bowel which then can be utilized without tension is opened and sutured

to the margins of liver wound. The method is still on trial, and yet

in at least one successful case it was shown that the liver tissue

tolerated this unavoidable contact with the contents of the upper

abdomen (Fig. 630).

[Illustration: FIG. 630

Demonstrating the technique of anastomosis between the gall-bladder and

the jejunum. (Cordier.)]

=After-management.=--What to do with these cases of biliary drainage

after it has been effected is sometimes a serious problem. No

hard-and-fast rules can be laid down regarding the length of time

during which drainage should be maintained. In instances where the

gall-bladder has been removed the drain should be taken out within

thirty-six hours, but in those cases where a tube has been fastened

into the gall-bladder for so-called permanent drainage the term

“permanent” may be regarded as elastic, and covering a period of from

ten days to perhaps ten weeks. In the majority of instances three weeks

or so of such drainage suffice to meet the original indication. In

cases, however, of chronic pancreatitis a long period of easy outflow

will be demanded, while in rare cases of cancer drainage once thus made

cannot be abandoned.

When the gall-bladder has not been fastened nor allowed to adhere to

the skin, but only to the peritoneum, the fistulas thus made will

usually close and rarely need stimulation. Should, however, the

granulation process by which closure is effected be too sluggish it

may be stimulated by the application of nitrate of silver, either in

solution upon a swab, or in solid form, as when melted into a bead upon

the end of a suitable probe. Firm pressure will also assist in final

closure.

It is not reasonable to expect that after so much intervention, within

the rudely triangular potential cavity occupied by the gall-bladder and

the ducts, adhesions will not form as a part of the reparative process.

In fact it may rather be expected that as it becomes obliterated

adhesion must necessarily follow. In consequence there may result an

agglutination around the gall tract, and into a common mass, of the

liver, the colon, and the pyloric end of the stomach. In spite of these

adhesions bad symptoms rarely ensue, and when discomfort persists it

is usually in those cases in which no stone was found or those in

which stones have been overlooked. Andrews regards such postoperative

adhesions as unavoidable and even desirable, and, having no faith

in any measures to prevent their formation, differs from Morris in

regard to the technique of their subsequent removal. It appearing from

observation and experience that the stomach is the organ which suffers

most by extensive adhesion to the liver, he has proposed to substitute

the colon for the stomach in this necessary union of surfaces, and

would even practise it in old cases after separation of old adhesions.

The operation suggested by Andrews, and which he calls

_cholehepatopexy_, or _colon substitution_, is made with an incision

through the middle line of the right rectus, avoiding any old scar,

long enough to afford plenty of room. The stomach is then carefully

separated from the liver, tearing liver tissue rather than that of

the former, if something must be torn, and checking bleeding by hot

sponges. The pylorus having been exposed the stomach is invaginated

into it in order to demonstrate its patency. The freshly separated

viscera will now fall again into immediate contact unless the

transverse colon be pulled up and held in place between the liver and

the pylorus, this not being so much of a displacement as would appear,

as the bowel is not rotated and does not cross over the stomach.

The colon is held in its new relation by attaching its omentum to

the gastrohepatic ligament, to the liver surface, or to remnants of

old adhesions in the angle between the pylorus and the liver. The

looser the omentum and the more easily it can be interposed in this

way the better. Andrews’ conclusions are that gall-tract adhesions

are unavoidable, both in disease and after operation, that they are

harmless except in a very few cases, and often beneficial, and that in

the few cases where they do harm this comes from malposition rather

than from adhesions _per se_. He even believes that certain vague

gastric adhesions which might have been benefited by this operation

have been previously treated by gastro-enterostomy.

CHAPTER LIII.

THE OMENTUM, THE MESENTERY, THE SPLEEN, THE PANCREAS.

THE OMENTUM.

The omentum is something more than what it generally appears, _i. e._,

a more or less thick and extensive apron of fat, hanging down in front

of the small intestines, although in this respect alone it serves as

a sort of reservoir or storehouse for fat, which is always drawn upon

as the needs of the system may require. The omentum varies within

wide limits from being the flimsiest veil of peritoneum, whose four

original layers have become so blended as to be lost to recognition,

and which may even be perforated in places with openings through which

strangulation of the bowel is possible, to the thickest and grossest

mass of fat found in the human body, resembling a coarse mat rather

than any finer texture, and having a thickness, in obese individuals,

of two to four inches. Under these circumstances it makes a formidable

obstacle to nearly all abdominal operations. The thickness of the

omentum sustains usually a pretty constant proportion to the amount

of adipose between the skin and the abdominal muscles. In certain

enormously fat individuals one has then to go through from four to

six inches of tissue, mostly adipose, before reaching the rest of the

abdominal contents. This necessitates a longer incision and is always

a disadvantage and impediment. To the operating surgeon, then, the

omentum sometimes appears a nuisance.

It does not deserve, however, to be so regarded, and when properly

viewed the omentum will frequently appear in the role of the surgeon’s

as well as the patient’s best friend. This is due to its power of

shifting itself, and, as it were, enclosing actively dangerous foci

due to any variety of infection, the natural intent being, as it

were, to wrap itself around and thus completely imprison the source

of the trouble, a fact which is often actually accomplished, and by

which life-saving protection is frequently afforded. This is true of

the omentum whether thick or thin. By virtue of the adhesions which

often annoy the surgeon, and which necessitate separation and perhaps

considerable work before the actual trouble is exposed, a protective

barrier is formed and the greater portion of the abdominal cavity shut

off from danger of spreading infection. Moreover, that the omentum has

a really valuable purpose appears from the fact that its removal from

young animals seems to cause retardation of development, and from adult

animals a diminution of resistance to the action of poisons introduced

into the peritoneum. It is the omentum which, to a large extent,

absorbs foreign corpuscles, such as those from extravasated blood.

It helps, moreover, to dissolve blood clots and to facilitate their

disappearance, and after the removal of the spleen it would appear to

vicariously perform at least some of its duties. Thus when the complete

blood supply of the spleen is cut off the organ almost completely

disappears as the result of its absorption by the omentum. (This at

least in experimental animals.)

The omentum serves further useful purpose by plugging various openings

and wounds in the abdominal walls, and thus affording at least a

temporary protection, just as the mucosa sometimes acts in reference to

the stomach. Moreover, it is so vascular, so flexible, and so available

that it may be used for plastic purposes in covering weak spots, lines

of sutures, and the like, in the small intestine or even elsewhere.

These same physical qualities make it extremely prone to escape through

the natural outlets. Hence the frequency of epiplocele or omental

hernia (_q. v._). By a species of such hernial protrusion it has saved

many a life after bursting open or re-opening of recent abdominal

wounds. Sometimes it will escape after removal of a gauze drain which

has not been judiciously placed and protected, this accident then

constituting one variety of postoperative or traumatic hernia.

By virtue of its adhesions, which at first are short and flat, but

which later become stretched into bands, _obstruction of the bowels_

may be produced, or by atrophic or absorptive processes openings

or windows may occur in it with the same result. When participating

in septic processes it becomes infiltrated, is often covered to a

large extent with breaking-down lymph, and may become gangrenous.

All portions thus compromised are best tied off and removed when

exposed during operation. Nevertheless the omentum should be gently

handled, because its venous walls are thin and liable to rupture, and

its bleeding points should be carefully secured, especially after

separation of adhesions.

INJURIES TO THE OMENTUM.

By contusions, lacerations, and punctures various injuries to the

omentum may be inflicted, naturally more commonly when it is the

anterior abdominal wall which has sustained the traumatism. As result

of lacerations, hemorrhages or strangulations may occur. The immediate

danger is, then, from hemorrhage. Indications of such lesions of the

omentum are not specific, but grave symptoms after any abdominal injury

require exploration, and that minute punctures or lacerations should be

repaired, while other injuries should be treated according to obvious

indications.

TORSION OF THE GREAT OMENTUM.

Torsion of the great omentum was first described by Oberst, in 1882,

as a condition found in the sac of a large irreducible hernia. As a

distinct and serious condition it has been reported in about sixty

instances. The condition occurs within the abdomen as simple torsion,

also within hernial sacs, or in both, where the torsion is not limited

to the sac, but extends upward into the abdomen. It is more frequent in

males, and its onset is usually sudden. Of all its symptoms pain is the

most constant and the earliest. This is usually acute and persistent,

and in a large proportion of cases is referred to the right iliac

fossa. Vomiting is not constant; bowel conditions are not significant.

Absolute obstruction is usually rarely noted. In most of the recorded

cases some tumor can be felt on examination, which is hard, tender,

dull to light percussion, and irregular in shape. Meteorism is not

common. Death has occurred in about 15 per cent. of known cases.

Diagnosis previous to exploration can be inferential only, but such

symptoms as above noted should lead to exploratory laparotomy.

TUMORS OF THE OMENTUM.

The most common of the omental tumors are _cysts of inflammatory

origin_, such as may, for instance, be formed by inclusion between

surrounding adhesions or by previous hemorrhage; _lymph cysts_, often

large and multiple, and sometimes of congenital but often of lymphatic

origin, are also occasionally seen. The so-called _omental dermoids_

are usually ovarian products. _Hydatid cysts_ have been found in the

omentum, but only as secondary products. _Omental cysts_ are difficult

or almost impossible of diagnosis previous to operation, which latter

should always be performed, and without previous aspiration, as the

presence alone of any such tumor requires removal. If large they are

most likely to be confused with ovarian cysts. Those which may prove

not to be removable should be drained, after being fastened to the

abdominal wall--that is, marsupialized. _Angioma_ in the omentum is

rare, but has been recorded by Homans and others. _Fatty_ or other

benign tumors are also rare. Primary _sarcoma_ is rarely seen here,

but most of the sarcomas, and all of the carcinomas which never arise

here primarily, but are often seen, are either metastases or direct

extensions. In these forms cancer of the omentum is common.

With extensive involvement of the omentum radical operations in these

cases are seldom advisable. A circumscribed involvement may, however,

be removed, while such operations as anastomoses, enterostomies, and

the like are often necessitated.

Omental tumors are difficult of diagnosis, although they are usually

superficial and overlie the intestines. They are not affected by

respiration. They move laterally and upward, but not downward. If

confined to the omentum proper they cause no functional but only

mechanical disturbances. Obviously in the presence of extensive

adhesions every distinctive feature may be confused.

OMENTOPEXY; OMENTOSPLENOPEXY; TALMA’S OR MORRISON’S OPERATION.

The effect of stasis in the portal circulation is to produce outpour

of varying amounts of serous fluid into the pleural cavity. This

condition, long known as ascites (dropsy), is the most distressing

terminal feature of such diseases as cirrhosis of the liver, cancer,

and the like. The osmotic direction of fluid seems to be reversed, and

transudation tends to go on until intra-abdominal pressure equals that

within the vessels. Absorption is always impeded and finally prevented.

Reflecting on the biophysics of this condition Talma and Morrison,

independently, and at about the same time, suggested an expedient by

which a portion at least of this fluid might be brought back into the

general venous circulation. The plan was to attach the epiploön (the

omentum) to the peritoneum of the anterior abdominal wall in such a way

and over such an area that, by virtue of the adhesions thus produced

and the new vascular anastomosis thus established, a new line of

vascular connections should be formed, so that fluid not returnable to

the vena cava by the usual route should be given a new and artificial

direction. To this fundamental proposition much detail has been added.

Thus Schiassi has shown that, so far as the supply of toxins which

shall pass through the liver is concerned, there are really two portal

veins--the superior mesenteric and the splenic--or he would call what

we usually name the portal system the _splenoportal_. Consequently he

would include the spleen in the above mechanical procedure, especially

in those cases where it participates in the morbid process--_e. g._,

in the hepatosplenic or pre-ascitic form of Banti’s disease, and the

splenomegalic cirrhosis described by Gilbert. In 1904 this problem

was studied from its surgical aspects by Monprofit (French Congress

of Surgeons), who collected 224 operated cases. Of these 84 died, 129

recovered from the operation, and 11 could not be traced. In 25 cases

relapse occurred, in 26 there was improvement, while in 70 there was

claimed complete recovery.[64] In other words about one-third of the

cases thus reported have recovered. He insists, as would every other

surgeon, that with this showing the results would be far better were

cases seen and operated earlier. His statistics are not widely variant

from those of Zesas, who found that out of 254 cases which he collected

67 recovered and 82 died, while 42 were greatly improved.

[64] It is but fair to add that, at the same time, Delagenière

maintained that since, in his opinion, cirrhotic processes in

the liver are due to intestinal infection, the treatment should

consist of combating this and its possible consequences, to which

end he would make a temporary cholecystostomy, having found it of

benefit even in the atrophic, but mostly in the hypertrophic, forms

of disease. Thus in two cases of this procedure, combined with

hepatopexy, the patients survived eight and two years respectively.

Nevertheless he acknowledged that the best results would probably

be secured from combination of cholecystostomy, hepatopexy, and

omentopexy.

In brief, we may hold, with Rolleston and Turner, that it is no longer

advisable to treat ascites by repeated tappings, when the patient is

otherwise in fairly good general condition, for numerous surgeons

have warned against repeated punctures. When liver cirrhosis can be

diagnosticated with fair certainty in the pre-ascitic stage, and when

there is evidence of splenic enlargement or hematemesis, operative

intervention would probably succeed far better than in the later

stages. So far as special indications for operation are concerned they

may perhaps be listed as follows:

1. Thrombosis of the portal vein or its compression by inflammatory

products or by tumor;

2. Cirrhosis of cardiac origin, of the ordinary hypertrophic or even

atrophic types, as well as that due to syphilis or malarial disease;

3. Pseudoliver cirrhosis of pericardial origin;

4. Diabetes of hepatic origin;

5. Splenomegaly combined with hepatic cirrhosis.

_If these indications be met by reasonably early omental fixation

there would seem to be a well-marked place for the procedure_, while

they cannot give rise to any worse results than the repeated puncture

methods of old.

Among contra-indications to such operations may be mentioned the

presence of much biliary pigment in the urine, its absence from the

feces, jaundice, or marked pigmentation of the skin, while distinct

renal insufficiency would also make any surgical procedure hazardous.

The _operation_ itself, done according to the simpler and earlier

recommendations of Morrison and Talma, consists in median abdominal

section, withdrawal of all ascitic fluid, and the deliberate

provocation of adhesions between the diaphragm and the upper surfaces

of the liver and the spleen. This is produced by vigorous swabbing to a

degree sufficient to cause a little oozing from the surfaces attacked.

The margin of the liver may then be fastened to the costal border.

After this the anterior surface of the omentum is also scarified or

swabbed and affixed to the anterior abdominal wall, which has been

similarly treated over as large an area as possible, by means of catgut

sutures placed to the best possible advantage for the purpose. Some

operators have preferred to close the abdomen without drainage, some to

insert a tube in the lower margin of the wound for a day or two, and

others to drain the lower abdominal cavity through a small, distinct

opening above the pubes. Theoretically much advantage attaches to

permitting no immediate re-accumulation of fluid. Practically, however,

danger also attaches to it, _i. e._, from the difficulty of so managing

the dressings as to avoid infection.

Schiassi has modified the above procedure and has made an

_omentosplenopexy_ of it as follows: He makes a right-angled incision

across the median line and then another several inches downward along

the left semilunar. The tissues down to the peritoneum are reflected

toward the umbilicus, and a transverse deep opening is made just

below the horizontal skin incision. Through this the omentum is drawn

upward and spread over the right portion of the exposed peritoneum,

where it is sutured in place. Through another vertical opening in

the peritoneum, near the vertical skin incision, the spleen is then

exposed, a piece of gauze is placed under each pole of that organ, and,

while thus lifted, by means of a long curved needle three to six catgut

sutures are passed through it, including also the peritoneum and all

the superficial structures except the skin, this being closed later and

separately.

Finally, whatever operative method be selected it is important that it

be done _early rather than late_, bearing in mind that “the resources

of surgery are rarely successful when practised on the dying.”

THE MESENTERY.

No one has done more to forcibly place before the surgical profession

those anatomical features of the mesentery which most concern them

than Monks, who, for instance, has demonstrated the fact that the

mesentery is practically an enormous fan, composed of two layers of

peritoneum, between which are spread out the vascular structures and

more or less fat, and whose border contains the intestinal tube. This

fan at its base is but a few (six) inches in length, while along its

outer border, when completely unfolded, one may measure a distance of

twenty-one to twenty-three feet. Not one of the structures contained

between its layers can be regarded as a negligible quantity. The

arterial distribution in the mesentery is _terminal_ in the same sense

that it is in the brain. Consequently dependence can be placed only

on a sufficient blood supply for any given portion of the intestinal

tube when its mesentery is intact. If necessary to sacrifice a portion

of the mesentery it is requisite to resect that portion of the bowel

which is dependent upon it for blood. This will explain the reason why

thrombosis or embolism of the mesenteric vessels so quickly determines

the death of that portion of bowel supplied by the occluded branches,

this being equally true of the tiny fragment known as the appendix or

of the entire bowel.

The root of the mesentery is placed obliquely across the spinal

column, arising from the left side above and crossing obliquely to the

right side below. Monks has shown how easily we may make practical

application of this fact in determining approximately to what part of

the bowel tube a given loop may belong, since it is necessary only to

follow it down to the mesenteric insertion, and from this estimate what

proportion of the entire distance is represented.

INJURIES OF THE MESENTERY.

Obviously the mesentery may be injured in the same way as any other of

the abdominal viscera, either by contusions, lacerations, punctures, or

otherwise. Here the immediate danger is from hemorrhage, while a more

remote but quite possible danger is that of _thrombosis_ of some of the

vessels and its consequences in the direction of _necrosis_.

Erdmann has recently reported two cases of complete detachment, for

several inches, of the mesentery at the intestinal border, as well as

a case of multiple lacerations in the peritoneal coat of the mesentery

with hematoma. While the latter might not be so serious, the former

will almost invariably determine gangrene of bowel from lack of blood

supply; all of which shows the difficulty of diagnosis, and furnishes a

further argument for intervention when, after an abdominal contusion,

the patient has abdominal rigidity or pain, with or without evidences

of hemorrhage, either from the stomach, rectum, or bladder. These

features are sufficient without the addition of those by which a more

certain or minute diagnosis can be made.

THROMBOSIS AND EMBOLISM IN THE MESENTERIC VESSELS.

Mesenteric occlusion was first described by Virchow in 1859. Whether it

involves first the arterial or the venous circulation seems to matter

but little. Of course in one case it is to be regarded as embolic, in

the other as thrombotic. In this location either condition is harder

to explain than in many other places. The mesenteric veins have no

valves and collateral circulation is poor. Mitral stenosis and arterial

sclerosis will often account for the former. For thrombosis search

has to be made for some local infectious process, either in the veins

of the pelvis, the kidney, or the intestines. It seems to occur least

often when it might be most expected, _i. e._, after typhoid.

The blood supply may be simply shut off from portions supplied by one

of the mesenteric vascular branches, or, should the main branches be

involved, from the entire intestinal tract. I have myself reported two

cases of practically complete rapid gangrene of the entire alimentary

canal, due to lesion of this kind, explanation being forthcoming in

neither case.

=Symptoms and Signs.=--The more complete the occlusion and the more

extensive the area deprived of blood the more sudden and overwhelming

will be the onset. This is always sudden and characterized by intense

and often paroxysmal pain, so agonizing, in fact, as scarcely to be

quieted even by morphine. While this is common, instances have been

known in which the disease has run an almost painless course. Diarrhea

is frequently an early symptom, evacuations being profuse and bloody.

Symptoms of obstruction are not uncommon, perhaps followed later by

loose stools. Vomiting occurs usually early and becomes fatal in

a few hours. The general physical signs are intensely acute, with

rapid pulse, subnormal temperature, and meteorism, beginning early

and becoming more pronounced. Abdominal rigidity also constitutes

a distressing feature, which, while indicating the gravity of the

condition, masks its diagnostic features. If the patient live long

enough fluid will accumulate in the peritoneal cavity. The cases

terminate with complete collapse and delirium. When the inferior

mesenteric vessels are involved tenesmus is a more prominent

characteristic than when the lesion is confined to the upper, as the

colon and rectum are supplied from the former.

The surgeon may have to distinguish between the condition just

described and the following: Perforating ulcer of the stomach or

duodenum (which will have a previous history), possibly so-called

phlegmonous gastritis; acute obstruction of the bowel (whose onset is

rarely so acute); pancreatitis, which would, at least at first, produce

almost identical symptoms; acute splenic infarct (when the early

symptoms would probably be referred to the region of the spleen); acute

appendicitis; acute cholecystitis, and that acute peritonitis to which

either of these might lead; a ruptured ectopic pregnancy; and possibly

certain intrathoracic lesions, especially pneumonia in the lower lobes.

Mesenteric occlusion is essentially a fatal condition, at least when

extensive. There have been known cases where so limited an extent of

the bowel and mesentery were involved that an exsection, made early,

has proved successful, but when anything like the entire alimentary

canal or its major portion becomes necrotic there is no hope for the

patient.[65]

[65] Annals of Surgery, April, 1904.

ABSCESS OF THE MESENTERY.

Abscess formation may take place within the mesenteric structures,

as an expression of acute septic infection or of a mixed infection

of old tuberculous foci in the nodes. A careful case history or some

peculiarity of local conditions may occasionally furnish a clue to

the conditions, otherwise it will not be distinctly revealed until

such operation as may be necessitated by unmistakable indications of

the presence of pus or by autopsy. Inasmuch as operation can scarcely

exaggerate the danger of the condition it would be best attempted when

such abscess is suspected. When the meso-appendix is involved, as is

often the case, the trouble may be so walled off that it is almost a

purely local affair.

TUBERCULOSIS OF THE MESENTERY.

Aside from the common miliary expressions of acute tuberculosis

which are seen so frequently dotted all over the bowel surfaces

and the expanse of the mesenteric folds, there is a peculiar form

of involvement of the mesenteric nodes, _i. e._, those which are

especially clustered along its root. These are always involved in

general tuberculous peritonitis, though but slowly in the absence of

such generalized features. To the slow forms of this condition the

early writers gave the name _tabes mesenterica_. The more limited

the involvement the greater interest the lesion has for the surgeon,

since it may be so limited to the nodes of a single coil as to justify

extirpation. In fact, if such a focus could be easily and thoroughly

removed without too much disturbance of circulation, tabes might be

remedied by surgery. Not very frequently, however, do the location

or the arrangement of a collection of tabetic nodes permit of their

enucleation. They are usually too numerous, too large, too degenerated,

too adherent, or the patient otherwise too extensively infected.

The acuter expressions of mesenteric tuberculosis may be considered

as already sufficiently discussed under the caption of Tuberculous

Peritonitis.

Occasionally a localized, slightly mobile tumor, especially in

the ileocecal region, may cause suspicion, or may be correctly

diagnosticated, by taking note of other symptoms, along with a good

case history. Especially is this the case in patients known to be

tuberculous. This is particularly true of the appendix and its

mesentery, where a tuberculous gumma may attain considerable size

before there is any active breakdown. The relation between this

condition and tuberculous ulceration within the bowel will also be

obvious. Moreover, it is of interest to recall that calcification of

mesenteric nodes is not impossible, and that occasionally chalky tumors

in this location may be thus explained.

There is also a possibility of involvement of the mesenteric nodes in

_constitutional syphilis_ and in _actinomycosis_.

The _treatment of mesenteric tuberculosis_ should consist of

exploration and orientation, followed by whatever procedure the

condition thus revealed may require--_e. g._, abdominal irrigation,

with or without antiseptics, extirpation, drainage, or even resection

of a portion of the bowel (appendix, cecum, etc.).

CANCER OF THE MESENTERY.

The other condition in which the mesenteric nodes are especially

involved is the cancerous. In this location, as in the omentum, sarcoma

may be primary and endothelioma may occur, but carcinoma is never

primary, although it invariably occurs as an extension from epithelioma

or adenocarcinoma of the bowel. Otherwise cancer will appear here as

an expression of metastasis. In all primary cancers of the intestine

early involvement of the mesenteric nodes may be looked for, while

involvement of everything in the vicinity, even the aorta or spine,

will occur in due time, often with more or less breaking down. There

would be little justification for attacking any cancerous portion of

the mesentery or any cancerous nodes unless the primary lesion could be

radically removed. Generally speaking, in bowel cancer invasion of the

deep-seated nodes imparts to the case such an unfavorable aspect as to

justify only palliative (anastomotic) rather than radical measures.

CYSTS OF THE MESENTERY.

Cysts of the mesentery are, in the main, similar to those met with

in the omentum (Fig. 631). A peculiar form of mesenteric cyst is

produced by obstruction and consequent dilatation of one or more of

the lacteals, and is known as _chyle cyst_. It may attain considerable

size and occur in multiple form. The contained fluid is naturally milky

and corresponds to that seen in chylous ascites and hydrocele. These

lesions are only recognized after exploration. When found they are to

be extirpated, on general principles, usually by enucleation, with

ligature of the connecting lacteals and avoidance of all unnecessary

disturbance of blood supply.

[Illustration: FIG. 631

Cyst of the mesentery, containing clear fluid. The hour-glass

constriction passes through the layers of the mesentery. (From a case

occurring in Richardson’s practice.)]

THE SPLEEN.

The spleen is often an object of surgical interest, not alone because

of the frequency with which it is enlarged in the course of the acute

surgical infections, but because it is something more than a reservoir

for blood. Thus it seems to enlarge to accommodate blood forced in from

the exterior under conditions of extreme exercise, etc., and in the

higher vertebrates it seems to be a place where blood corpuscles are

destroyed, especially those which are already disintegrating, rather

than one in which they are manufactured. It is claimed by Ehrlich that

the splenic enlargement of the infectious diseases is produced mainly

by the products of disintegrating leukocytes which are allowed to

accumulate.

ANOMALIES OF THE SPLEEN.

Of the _congenital anomalies_ or defects the surgeon is mainly

interested in the fact that _supernumerary spleens_ are common, being

found perhaps in one out of four bodies varying in number up to

thirty or forty, located near the hilus in the gastrosplenic omentum,

in the great omentum, or even in the pancreas. Doubtless after some

splenectomies no peculiar symptoms are produced, which is due to the

fact that some of the supernumerary organs have taken up the splenic

function. The spleen varies in shape to such an extent that the notch

upon which so much stress is often laid in diagnosis will not always

be found along the anterior border. In cases of transposition of the

viscera the spleen may be found on the right side. It has been found

in the sacs of large umbilical hernias and in the left thorax after

defects of the diaphragm.

INJURIES TO THE SPLEEN.

The spleen may be injured by itself or along with other viscera. The

most common injury is from contusion, which produces more or less

disintegration or rupture and hemorrhage. The organ is so friable

that it may literally burst under a comparatively slight force, other

conditions being favorable. Doubtless minor degrees of these injuries

pass unnoticed or are followed by some local peritonitis and adhesions.

On the other hand the spleen may be actually fragmented, with

necessarily fatal consequences unless promptly operated. _Rupture_ is

especially likely to occur after those infectious diseases which cause

its enlargement--_e. g._, typhoid.

In case of injury there is, in addition to the history, a prompt

location of pain in the region of the spleen, with signs of

intra-abdominal hemorrhage, but without blood in the urine; perhaps

with tumor or dulness on percussion, and always with abdominal

rigidity, all of which point to the serious nature of the injury and

_demand exploratory section_. Should this reveal a slight injury it

may be repaired with ligatures or sutures. More serious tears or

perforations are treated by gauze packing through a sufficiently open

wound, while the most serious cases of pulpifaction call for complete

_extirpation_. When the blood supply of the spleen is left in doubt its

total removal will be far the safer course to adopt. Obviously such an

operation should include examination of all the viscera and a careful

toilet of the peritoneum.

ABSCESS OF THE SPLEEN; SUPPURATIVE SPLENITIS.

Pus may form within the spleen in consequence of septic infarcts

or thrombosis, or it may be due to the extension of trouble from

adjoining foci, or to pyemic metastasis. Splenic abscesses are usually

localized, but the pyemic forms are always multiple, miliary at first,

but coalescing into larger collections, and practically destroying the

organ if the patient live long enough. The infectious fevers may be

followed by suppuration of the spleen, which is also known to occur

rarely in malaria.

=Symptoms.=--The symptoms of splenic abscess are indeterminate

until the capsule is involved and a perisplenitis--_i. e._, a

local peritonitis--results, after which pain becomes severe. These

collections occasionally discharge spontaneously into the colon or even

into the stomach.

On general principles any abscess which can be located, even somewhat

vaguely, should be attacked. After the abdomen is opened, preferably

through the left semilunar line, the exploring needle may be used,

especially if adhesions be present.

GANGRENE OF THE SPLEEN.

Gangrene of the spleen is the result of a still more rapid, otherwise

similarly septic or thrombotic process, or of severe injury, by which

circulation is practically cut off. It is a condition which rarely

permits of any surgical help, though if it could be foreseen it might

be prevented by an early splenectomy.

HYPERTROPHIES OF THE SPLEEN.

Enlargement of the spleen occurs during numerous acute and chronic

_infections_--_e. g._, typhoid, malaria--in connection with certain

affections of the _liver_; in consequence of interstitial or gummatous

forms of _syphilis_, with or without similar lesions in the liver;

in acute _peritoneal infections_; in general _septic_ and _pyemic_

disturbances; in _rickets_ and the _status lymphaticus_; in the various

forms of _leukemia_, _Hodgkin’s disease_, and _pseudoleukemia_,

and in that somewhat peculiar type known as Banti’s disease, or

_splenomegaly_. In fact the spleen enlarges under so many conditions

that its hypertrophy is an expression of a general infection rather

than of any pronounced or particular type of the same. Minor degrees of

enlargement have often passed unnoticed or given little or no trouble.

When seriously overgrown its principal features are its inconvenience,

weight, and size. The condition is recognized by its characteristic

shape and notch (See above.) By its extension upward it can be usually

distinguished from a tumor, of the kidney.

Every splenic enlargement, especially chronic, should lead to a

careful blood examination, by which, among other things, malaria may

be recognized or excluded, while the degree and form of leukemia, if

present, may be estimated. The lymph nodes throughout the body should

also be carefully examined. Splenomyelogenous leukemia, for example,

is progressive, severe, and marked by cachexia and anemia of peculiar

type. In many of these cases there is a tendency to hemorrhage, both

from surfaces and into the tissues. The hemoglobin is much reduced and

prognosis after any operation is unfavorable. (See chapters on the

Blood and the Lymphatic System.)

_Banti’s disease_, or _splenomegaly_, seems also a somewhat peculiar

type of lesion which is probably due to an infection proceeding from

the intestinal canal, and involving the liver in its later course. In

its last stage there is a tendency to hepatic cirrhosis, with ascites,

and hemorrhages in any part of the body are frequent.

_Removal of the spleen_ for any of these conditions is usually a

precarious procedure. It has been more successful when performed for

malarial hypertrophy than for other conditions, the patient’s chances

being then about three out of four; but here, too, the lesion is

usually amenable to other treatment. If done in the early stages of

Banti’s disease it would seem to be strongly indicated, but not in the

later stages, when the liver is involved and the abdomen full of fluid.

In the leukemias it has succeeded in a few instances. It is mostly

indicated in those cases where hemorrhages occur early.

The Röntgen rays have recently been shown to have an excellent effect

in many of these cases and are worthy of trial. Especially in the

leukemic forms, in connection with arsenic internally, they offer

probably the best prospects.

SPLENIC DISPLACEMENTS.

While, under ordinary circumstances, the supports of the spleen may

seem equal to ordinary needs they prove insufficient in many cases of

marked enlargement. Hence results _displacement_, or the so-called

“wandering spleen,” which may be due to the results of injury, to tight

lacing, possibly to congenital relaxation of ligaments, but mainly

to hypertrophy, with increase in size and weight. When the spleen

enlarges it descends toward the umbilicus, but it has even been found

in the pelvis. As it prolapses it brings down with it the stomach

and the pancreas, thus interfering with the circulation of all three

organs and producing a train of distressing secondary consequences.

A long-drawn-out splenic ligament may be much stretched and may even

become finally _twisted_, thus causing gangrene of the spleen from

torsion of its support. Moderate displacement and stretching produce

discomfort, pain, and disturbance of function. Such a displaced spleen

is to be recognized by its shape, size, and notch, and is occasionally

to be distinguished from a wandering kidney. When displaced its normal

location will not be dull upon percussion.

=Treatment.=--Palliative treatment, which may be tried first, calls for

whatever drugs may be needed to unload the bowels, but especially for

rest in bed and support by suitable abdominal binder, with or without

a pad. If the spleen itself be much enlarged it may also be subjected

with a judicious frequency to the _x_-rays.

_Operative help_, which is the only measure when other treatment fails,

should come either through a _splenopexy_ or _splenectomy_, preferably

the former, save in the presence of serious disease which may call for

its extirpation. Nevertheless splenopexy, which seems so simple and so

promising, is often unsatisfactory because of the friability of the

spleen itself and the weakness of its capsule. Here, as in hepatopexy,

the intent is to produce adhesions, by scarification of the external

peritoneal surroundings, which is made through a suitable incision,

directed usually along the left costal border; after thus intentionally

provoking adhesions, sutures may be used if there be any prospect of

their being serviceable.

[Illustration: PLATE LVI

Upper Abdominal Viscera, showing their Normal Relations. (Sobotta.)]

NEOPLASMS OF THE SPLEEN.

Splenic _cysts_ of the _serous_ or _blood type_ are seldom seen. Even

_hydatids_ here are uncommon. _Sarcoma_ of the spleen may be primary;

_carcinoma_ is due to extension or metastasis. In proportion as splenic

tumors develop they may be recognized as involving this particular

organ. While a careful blood examination may permit the exclusion of

certain conditions, exact early diagnosis will scarcely be made without

exploration, which is justifiable whenever the blood count would

indicate it. After exposing the lesion the surgeon is for the first

time in a position to judge whether to drain or extirpate a cyst, or

remove part or the whole of the spleen itself.

OPERATIONS UPON THE SPLEEN.

Besides those operations addressed toward fixation of a more or less

enlarged or wandering spleen a _splenotomy_ can be made--_i. e._,

incision and drainage at any suitable point, anterior or posterior,

which can be satisfactorily exposed; and evacuation of fluid may be

followed, with or without suture of the deep to the external wound, by

gauze packing or tubage, combined, if necessary, with counteropening or

posterior drainage.

=Splenectomy.=--Total removal of the spleen is performed through an

incision which should be made ample for the purpose, either along the

costal border or the left semilunar line or by combination of both. A

median incision may be also utilized if it will permit better access.

Splenectomy, under ordinary circumstances, would not be a difficult

operation, but with the organ enormously enlarged and the vessels

dilated, as they may be, it becomes usually a formidable procedure. The

most serious difficulty and danger arise from the numerous adventitious

vessels which may connect the spleen with the diaphragm or with some

of its other surroundings, and whose location is to be made out before

an attempt is made to remove it. Thus, in one instance, I have seen

an adventitious vein, the size of the little finger, between the

upper splenic surface and the diaphragm. Through such large vessels

torrents of blood will pour unless they be first secured. All such

connections then with the stomach and the diaphragm have to be ligated

and separated with great care, while gentleness of manipulation is

requisite throughout the operation. The spleen may be reached and

adhesions be located with great speed of manipulation, but in the

depths of such a wound valuable time may be consumed and much blood

lost, all at a time when the patient can least tolerate them. Oozing

from vessels which cannot be secured should be checked by gauze packing.

THE PANCREAS.

The anatomical features of the pancreas which have most interest

for the surgeon are the facts that its head is in contact with the

duodenum, and lies usually so closely against the second portion of

the former as to surround from one-fourth to one-third of its lumen.

Becoming adherent at this point it may then produce obstruction high

up in the intestine. In rare instances it may even completely surround

the duodenum, and thus may, when swollen, cause tight constriction of

the latter. Should this condition be met with a gastro-enterostomy

would be the proper measure for relief. These intimate relationships

account for the spread of disease from the pancreas to the intestine,

rarely in the reverse direction. The pancreas lies also in contact

with the stomach along its anterior peritoneum-covered surface, and

malignant disease travels easily from one to the other. Ulcers of the

stomach, favorably situated, may also be followed by adhesion and

inflammatory infiltration of the pancreas, by which the viscera are

cemented together, the same result following duodenal ulcer, as well

as serious disease about the biliary passages. Thus under a variety of

circumstances the operator may find these parts so cemented as to be

separated only with the greatest difficulty, or perhaps not at all,

without causing laceration or rupture of one or more of them, with

escape of contents which are often septic. Therefore when there is

reason to fear this accident it will usually be safer to simply make a

gastro-enterostomy. (See Plate LVI.)

The relations of the biliary ducts to the pancreas are most important,

the association of the common duct with that of Wirsung having the

greatest bearing upon a variety of conditions, which are nearly all

essentially surgical. The former, descending along the head of the

pancreas, comes in contact with the duct of the latter, and passes

alongside of it for a short distance before entering the intestinal

wall. In about two-thirds of individuals it is completely enclosed

by the pancreas. In the other third it lies in a deep groove upon

it. Resting here, as it were like Siamese twins, it will be easily

seen how disturbance in one duct or its source may be reflected to

the other. When the common duct lies in a groove it is less likely to

be seriously compressed by pancreatic engorgement than when actually

embedded in pancreatic tissue. The degree of resulting jaundice may

thus be dependent upon anatomical conditions not determinable before

exploration. Such pressure doubtless accounts for many cases of

so-called catarrhal jaundice. When the condition becomes constant, or

nearly so, a chronic interstitial pancreatitis may be assumed, which

really warrants an operation--_i. e._, cholecystostomy with drainage.

When a gallstone is passing through the common duct, especially when

lingering or impacted, it may have in turn reversed this condition,

and, by obstructing the pancreatic duct, set up as a consequence

pancreatic stagnation and consequent digestive disturbance, and such

other internal conditions as invite infection from the duodenal cavity,

with a more or less lively pancreatitis, perhaps even of fulminating

type, by which life may be jeopardized.

The pancreas, however, being usually provided with two ducts, the

second (that of Santorini) is often represented as an additional

safeguard, since it usually has a separate opening into the duodenum

below the ampulla. Opie carefully studied 100 cadavers and found that

in more than 50 of them the accessory duct could be of no use or

relief, and that in only 10 instances did two independent ducts enter

the intestine, while in the other 90 they were united, and in 21 of the

latter the accessory duct had become obliterated. Moreover, in only

6 of the 100 instances was it larger than the duct of Wirsung. This

will show, then, how little reliance may be placed upon the duct of

Santorini. Moreover, no matter which duct is opened, or whether both

are, so long as pancreatic fluid can escape there is an open channel

for infection, and when it cannot escape it may be seen that infection

has already occurred and is manifesting its pressure consequences.

Chemosis of mucous membrane may be the first mechanical result of such

infection, but this is sure to be followed by interstitial sclerosing

and compressing effects.

The normal duct opening in the duodenum is also a matter of surgical

interest. The ampulla of Vater, within the second portion of the

duodenum, is usually described as a conical protrusion or papilla,

having an average length of 4 Mm., with an opening 2.5 Mm. in diameter,

this being the narrowest portion of the common duct, but from this

arrangement there are many variations. The ducts may join at some

distance from the intestine, or they may open independently into a

depression or into a protrusion, and the ampulla be thus totally

wanting, all of which has the greatest possible bearing upon what may

happen during the passage of gallstones, for instance, or by infection

and according to its direction; and may account for the difficulty met

in certain cases, as when, for example, it becomes necessary to incise

the duodenum and open the ampulla for the removal of a pancreatic or

biliary calculus. It will emphasize, too, the necessity for always

exploring the common duct by opening the biliary passage and thus

making sure of its patency.

ANOMALIES OF THE PANCREAS.

Congenital anomalies include not only those of the ducts above

mentioned, but the presence of _accessory masses_, like the accessory

thyroids, which may occasionally lead to confusion and perplexity.

Furthermore, accessory nodules of pancreatic tissue may be found

alongside the ducts, or even in the walls of the stomach and intestine,

where they are probably present more often than is generally

appreciated, and are to be explained by the embryology of the parts,

since the pancreas is known to take origin from a cluster of cells in

the wall of the upper end of the developing intestinal canal. They have

been seen also along the line of a persistent vitelline duct. Such

small accessories, when present, usually empty by minute independent

ducts into the intestine. On the same embryonal grounds are to be

explained other anomalies occasionally met, such as separation into

detached portions. The existence of accessory pancreatic glands is also

held to account for the absence of glycosuria in certain cases where

the principal portion of the pancreas is itself extensively diseased.

GLYCOSURIA.

Glycosuria is so associated with the popular conception of pancreatic

disease that it seems imperative to state what importance should be

attached to it. It is now clearly established that the so-called

“islands of Langerhans” have to do with the elaboration of a certain

glycolytic ferment, and that the failure in its supply to the blood (it

being regarded as an internal secretion) is followed by the appearance

of sugar in the urine. These islands are not connected with the ducts,

at least not in the vertebrates, and usually escape pressure effects

in chronic interstitial pancreatitis of the interacinous as well as of

the interlobular form. This explains the accompaniment of diabetes in

some instances of pancreatic disease and its absence in others. Again,

if only part of the pancreas be affected, as in cancer, the remaining

healthy portion may still afford a sufficient amount of this ferment to

supply the body needs.

The uncertain symptomatology of the slower forms of pancreatic disease

is to be accounted for by the fact that, with the exception of its

glycogenic function just mentioned, all its other functions may be

vicariously assumed by other organs of the body. Thus as a compound

racemose gland it furnishes--

1. Trypsin, a proteolytic ferment;

2. Amylopsin, a starch-splitting ferment;

3. Steapsin, a fat-digesting ferment; and

4. A milk-curdling ferment.

The first of these functions may to some extent at least be assumed by

the stomach and the others by the bile and intestinal juices. (Mayo

Robson.)

INJURIES TO THE PANCREAS.

Injuries to the pancreas may occur with or without external

traumatisms. By any kind of injury which affects the gland it is

probable that its glandular structure may be so disrupted as to set

free an autodestructive secretion, which, by softening and weakening

vascular walls, may lead to hemorrhage and to the accumulation of a

collection of inflammable material, which is a good culture medium,

and which needs only the spark of infection to be easily aroused

into a conflagration. That possibility of infection is imminent is

apparent from the relations of the adjoining viscera and their ducts,

as already outlined. However, the same is true of even a first and

spontaneous hemorrhage, as of the clot, however produced. It has been

held that the manipulations to which the pancreas has been unavoidably

submitted during many operations may lead to its acute inflammation or

destruction. On the other hand, there seems no doubt but that it is

sometimes much relieved or benefited by a mild massage as a part of

the operative procedure. Mayo Robson has suggested that concretions

may thus be pushed along or adhesions removed, or, as it seems to me,

circulatory equilibrium restored and autonutrition improved.

Aside from the injuries which the pancreas may receive during

operations it is unquestionably the site of hemorrhages produced by

_contusions_ of the abdomen, although these are rare, and of injuries

produced by deeply penetrating _wounds_, especially those caused by

a stab or gunshot. The immediate result of a serious wound might be

hemorrhage, perhaps even a large escape of blood filling the lesser

cavity of the peritoneum. Such injuries are always to be treated

surgically, _as any external contusion followed by serious collapse and

evidences of internal hemorrhage should be promptly explored_, and,

even more so, _every case of penetrating wound_. Should blood be found

to be escaping from the pancreas the bleeding vessel may be sought and

secured, or, if necessary, a portion of the organ extirpated, since

no danger can be greater than that of uncontrolled bleeding. It is on

record that through an extensive gash in the abdomen the pancreas has

not only been exposed, but has partially escaped, and one case report,

apparently authentic, details its subsequent sloughing and spontaneous

separation.

Any wound of the pancreas which needs no further attention may at least

be sutured if it can be exposed. Nearly all surgical attacks upon this

viscus will require extensive incision and more or less emptying of

the upper abdominal cavity. It may now be of great assistance to place

the patient in the semi-upright position in order that the viscera may

gravitate toward the lower part of the abdomen--_i. e._, to reverse the

ordinary Trendelenburg position.

NON-TRAUMATIC SURGICAL DISEASES OF THE PANCREAS.

These diseases include especially the acute infections, the chronic

lesions, and the occurrence of neoplasms or calculi.

Certain local and general conditions predispose to pancreatic disease

of any type. Among them are to be reckoned--

1. _Injury_, either by accident in the ordinary course of events,

as by contusions or penetrating wounds, or bruising during the

manipulations of operation;

2. _Anatomical anomalies_;

3. _Hemorrhages_ into the substance of the gland, whether from

vascular changes or other causes;

4. _Obstruction along either the biliary or pancreatic ducts_,

whether due to catarrh, calculi, adhesions or stricture, parasites

(worms) or cancer;

5. General _toxemias_: typhoid syphilis, influenza, mumps, and the

like.

The principal exciting causes are the various infections which

may proceed from the blood, as in pyemia or syphilis, or from the

alimentary canal, which is never free from bacteria, either by

adhesions and continuity, as from gastric ulcer and cancer, or by those

natural passage-ways, the ducts.

When summed up the most common of all the causes of pancreatic disease,

acute or chronic, will be found to be _cholelithiasis_, with some of

its variant consequences or complications. This will help to make clear

the reason for operating on the biliary passages in most cases of

pancreatic disease, especially the more chronic forms. A stone impacted

in any portion of the common duct, especially in its terminal portion,

after it has come into relation with the duct of Wirsung, may cause

an amount of disturbance disproportionate to its size. Moreover, a

stone impacted at the orifice of the duct will permit the entrance of

bile into the pancreatic canal, where it does not belong, and where of

itself it may cause trouble.

ACUTE AFFECTIONS OF THE PANCREAS.

These include--

1. _Hemorrhagic pancreatitis._

(_a_) Ultra-acute, where hemorrhage precedes infection, and bleeding

occurs outside as well as inside the gland.

(_b_) Acute, where inflammation precedes hemorrhage, the latter being

less profuse and occurring in patches.

2. _Gangrenous pancreatitis._

3. _Suppurative pancreatitis._

(_a_) Diffuse, destructive.

(_b_) Subacute, localized, with abscess formation.

=Acute Pancreatitis.=--Acute pancreatitis is a distinct form of

disease, like appendicitis, with an etiology and symptomatology of its

own, which has been recognized only within the past twenty-five years.

This statement will account for the fact that so little reference to

it is made in any but the recent text-books. In fact it is to the

writings of Fitz, of some fifteen years ago, that the world owes its

first keen interest in the subject. By no means a frequent disease, it

nevertheless occurs with frequency sufficient to make it inexcusable

for the practitioner to fail to take it into consideration, although he

may waver in diagnosis.

The predisposition to infection which previous injuries, especially

minute hemorrhages or previous pathological conditions, seem to afford

has been already mentioned, and a history of previous injury or

digestive disturbances will aid in diagnosis. The exciting cause is,

however, in nearly every case when not distinctly traumatic, connected

with previous disease in the biliary tract, either cholelithiasis or

cholangitis. Reference to what has been said above, and a consideration

of the anatomical relations, will show how readily an infectious

process can travel upward from the duodenum into the pancreatic duct,

as well as into the common duct; or how, passing down the latter, it

may speedily find its way up the former. The previous condition of the

tissues, and the activity or virulence of the infective organisms, have

to do with the degree of acuteness of the resulting pancreatitis. This

is sometimes of such overwhelming toxicity that the entire gland dies

almost as does the appendix, within a few hours, the result being an

acute necrotic condition that of itself is necessarily fatal.

=Symptoms.=--Acute pancreatitis gives rise to symptoms which, in

general, assume the clinical form of an _acute peritonitis of the upper

abdomen_. It commences with sharp pain in the epigastrium, accompanied

by faintness, nausea, vomiting, and collapse, while tenderness over the

pancreas is an early symptom, and swelling or enlargement can sometimes

be detected. Constipation is so frequently a feature that the diagnosis

of acute bowel obstruction is sometimes made, but it will be found that

obstruction is not complete, for flatus may pass and enemas may be

successful. The pain becomes paroxysmal, is increased by movement and

pressure, while the tenderness becomes more localized. Meteorism may so

quickly succeed the other symptoms as to make physical signs uncertain,

while rigidity of the abdominal muscles makes them still more vague,

yet affording in itself a sign of value. Vomiting intensifies the

pain and the vomitus changes from food to bile, and then to blood,

which is dark and altered. Hence jaundice may be an early feature,

in which case it becomes more marked as the disease progresses, and

may become intense. This is likely to be the case if the exciting

cause prove to be a stone impacted at the ampulla. The face indicates

profound distress and disturbance. The temperature affords no certain

indication, save that in the most serious cases it may be subnormal.

On the other hand, as the case progresses, the pulse becomes small and

rapid. Every expression of overwhelming toxemia is added, and delirium

usually precedes death. In fact death may follow the first expression

of pain, in unrelieved cases, in from two to three days. Other less

acute expressions of the same general character are met with in the

so-called subacute forms of pancreatitis.

While the postmortem findings differ in various instances the symptoms

above noted do not vary conspicuously. They differ rather in intensity

only, in accordance with the gravity of the case.

The pathologists have described various forms of pancreatitis as

the _hemorrhagic_, the _gangrenous_, the _suppurative_, and those

distinguished by _fat necrosis_, as well of the omentum as of the

pancreas itself. These distinctions have the greatest interest for

those engaged in minute research and are not to be regarded lightly.

They have no small interest for the clinician, since prognosis is in

some measure dependent upon them. Nevertheless the symptoms of the

condition are but slightly modified, whether the destructive process

assume one or the other of these types, and the therapeutic indication

is the same for all--namely, the _earliest possible operation_.

If pathologists were better agreed on their pathology it might be

worth while to give more space here to this aspect of the subject. It

is, however, not yet certain, for instance, whether in a given case

inflammation precedes hemorrhage, or whether hemorrhage occurs first

and the outpour of blood is suddenly invaded by bacteria. In fact it

is probable that sometimes one thing occurs and sometimes the other.

Certain it is that the pancreas is not only loosely held together, and

consequently disrupts easily, but that it quickly succumbs both to its

own digestive juices and the disintegrating effect of bacteria, so that

putrefaction quickly occurs hours before life is extinct. The morbid

excitement quickly spreads to the adjoining peritoneum, and along it,

so that a more or less generalized peritonitis soon complicates the

case. Mayo Robson inclines to the view that in the most fulminating

cases the hemorrhage is the prior lesion.

=Diagnosis.=--The diagnosis should be made mainly from perforating

gastric or duodenal _ulcer_; phlegmonous or gangrenous _cholecystitis_

or _cholangitis_; rupture of the biliary tract, with escape of

contents; fulminating _appendicitis_; acute intestinal _obstruction_,

including internal hernias, and acute _mesenteric thrombosis_ or

_embolism_. Fortunately in every one of these conditions prompt

operative intervention is alike demanded, save possibly in the last

named; while even in the latter diagnosis cannot be made without

it, and it may still be possible to accomplish something if the

occlusion be not too widespread. A history of previous “dyspepsia”

or “indigestion” may point to the stomach or the biliary channels;

repeated hemorrhages to gastric ulcer, and repeated attacks of pain

to gallstone trouble. General tympanitis would indicate intestinal

obstruction, especially if no flatus were passed, while when limited to

the upper abdomen it would be more suggestive of pancreatic disease.

This would be corroborated by vomiting of blood, while fecal vomiting

would indicate obstruction. Tenderness and tumor located in the region

of the gall-bladder would point rather to it as the source of trouble,

while in pancreatitis something distinctive may be perhaps made out

by palpation and percussion, and the tenderness will be complained

of alike on each side of the middle line. Abdominal rigidity, while

general, is usually most pronounced near the site of the most important

lesion. Much importance is attached by Halsted to excessive pain, and

to cyanosis of both the face and the abdomen. The latter may be helpful

as a corroborative indication, but is certainly not always present,

and, on the other hand, is seen in many cases of general peritonitis.

Glycosuria is rarely a feature of the acute cases.

=Treatment.=--This is of necessity not only _surgical_, but, to be

effective, should be _prompt_, every added hour of delay causing

increased danger. While arranging for this it is possibly justifiable

to allay pain by giving morphine hypodermically. The colon should be

emptied by a copious enema. Collapse is to be combated by the usual

means, including hypodermoclysis or infusion, perhaps with the addition

of a little adrenalin to the saline solution. The preparation of the

patient, both before and during anesthesia, should include the same

scrubbing of and attention to the skin of the _back_ as that of the

abdomen, as there is much probability in any such case that posterior

drainage will be needed.

The _operation_ is begun as an exploration, through a median incision

above the umbilicus, some three inches in length, through which the

operator may inform himself as to the state of affairs within the

abdomen. Should fat necrosis be revealed, and first noticed in the

omentum, no doubt need be felt as to diagnosis. Any tumefaction by

which the stomach or colon is displaced, or the gastrocolic omentum

placed upon the stretch, calls for further and deeper exploration. The

upper abdomen should next be walled off with gauze and a small rent

made through the gastrocolic omentum; or it may in rare instances prove

wiser to push down an already depressed stomach, or more likely to lift

up the greater omentum and enter the lesser peritoneal cavity through

the mesocolon. In the majority of instances the condition can be best

appreciated and relieved by separating the stomach from the colon.

The condition may be one of extensive fat necrosis, disseminated,

but with its most abundant expressions in the neighborhood of the

pancreas, or there may be found evidence of extensive gangrene, the

pancreas itself sloughing and involved past any possibility of repair,

surrounded by disintegrating clot and debris; or there may be found a

more or less localized abscess, and perhaps evidences of putrefaction.

In at least two instances reported by Muspratt and Porter the pancreas

itself was not yet dead, but was so darkly discolored and swollen, as

well as so dense, that it was freely incised, the bleeding vessels

being tied and the clot removed. Both of these cases recovered. Such

incisions, if made in the gland, should always run parallel with the

duct and not across it. Whether pus be found or not will depend in

large degree upon the time that has elapsed since trouble began. It is

most desirable to expose the focus before pus has had time to form,

just as it is in acute appendicular disease.

The further operative treatment consists essentially in checking and

preventing hemorrhage, in removing all sloughing tissue which can be

safely taken away (and this may involve the greater part of the entire

gland), in disinfection of the cavity and general toilet of the upper

abdomen, with ample provision for drainage. This may be anterior

or posterior, and in bad cases should be both, unless procedure is

hastened by collapse. Posterior drainage is effected by having the

patient turned upon the right side, then making an incision 3 or 4 Cm.

long at the left costospinal angle, where, if the advice above given

have been followed, the skin will have already been prepared. Here the

outer border of the erector spinæ group of muscles is quickly exposed

and the blades of a pair of stout forceps entered and pushed toward

the inner cavity, within which the operator’s left hand is acting as a

guide. In this way it is possible to quickly insinuate the blades so

that the large vessels and the upper end of the kidney are preserved

from harm. A suitably prepared drain, preferably tubular, may then be

introduced deeply enough through the anterior wound to be seized by

the forceps and pulled through the tunnel made by their introduction.

It is thus drawn backward and outward to such an extent that its inner

end shall rest just where it is desired in the cavity of the lesser

peritoneum, the unnecessary external part of the drain being now cut

away. The whole procedure consumes but little time. Anterior drainage

will also be necessary, and the wound may then be closed.

It has been suggested to make the exploration as well as the drainage

from the loin, but this procedure cannot be here advised, since it

leaves too many features in doubt and affords insufficient means

whereby to appreciate and cope with many grave complications. Calculi,

either biliary or pancreatic, which are so often an exciting cause of

these troubles, should be carefully sought for and removed if present.

They could not be revealed nor removed through any small posterior

opening. Other good reasons are also advanced, since the intensity

of the symptoms is an expression of an intraperitoneal rather than

retroperitoneal lesion.

The reader will note that but little has been said as to the

distinction between the hemorrhagic, gangrenous, and other forms of

acute pancreatitis, as these are for the surgeon, as such, _side

issues_. _His paramount duty is to open the abdomen of every such case,

so soon as he can possibly effect arrangements._

=Subacute Pancreatitis; Abscess.=--Under this term are included disease

processes and lesions similar to or identical with those described

as causing acute and even fulminating expressions of pancreatic

obstruction, but less severe in their manifestations, less rapid in

their course, and more localized in their boundaries. They are often

so associated with a protective and natural walling off of the area

of excitement by barriers, which outpour of lymph and its consequent

condensation into adhesions afford, that they appear more often as

abscess of the pancreas or hematoma of the lesser cavity of the

peritoneum.

So far as concerns its etiology the causes are essentially the same as

in the acute cases, only the results are brought about more slowly,

weeks being in these cases as days in the others. Gallstones are by all

means the most common cause, and the pancreatic disease is itself an

expression of an infection travelling up its duct.

=Symptoms.=--The symptoms usually include pain, which, however, lacks

the agonizing intensity noted in the more acute cases. Vomiting is

usually associated with constipation, but the vomitus is rarely or

never bloody; jaundice of variable degree is a common feature, and

collapse is rare. Distention of the upper abdomen and tumor formation

come on more slowly. Tenderness is less extreme and muscle rigidity

less marked. While the pulse is less affected the temperature is

usually more so, often running high. Even early in the case we may

note general expressions of septic intoxication, such as mild chills

and a characteristic appearance of the tongue and face. Constipation

is followed by diarrhea; at least the stools which are fetid contain

blood, pus, fat cells, and undigested meat fibers. Pain is more or

less constant, but increased in paroxysms. Loss of appetite and rapid

emaciation are apparent from the outset. Albumin will be found in the

urine, but rarely sugar. The peculiar reaction described by Cammidge

will, according to Mayo Robson, give uniformly positive evidence. As

_abscess_ gradually or rapidly develops it will cause a swelling, which

has its origin behind the stomach and may displace this viscus, as

well as the colon, upward or downward, presenting usually toward the

abdominal wall. In rare instances the direction of least resistance

takes it toward one loin or the other, where it may appear as a

perirenal abscess, or around the crus of the diaphragm and above the

liver, where it would appear as a subphrenic abscess. It has been

known also to burrow along the psoas muscle and appear at the groin,

or even in the left broad ligament. Abscess of the pancreas may also

burst into the stomach, when pus will be vomited, or into the bowel,

whence it will be evacuated. A sudden relief, with disappearance of

tumor, followed by diarrhea and purulent stools, would indicate this

latter termination. Under these circumstances the abscess cavity may

repeatedly refill and reëmpty itself. Spontaneous recovery in this way

is possible, but septicemia and hectic usually persist until obviated

by operation.

=Diagnosis.=--The history, the evidently septic type of the case, and

the distinct signs above noted will make almost certain the presence

of pus, and Mayo Robson insists that the pancreatic reaction in the

urine (Cammidge) will make clear its location and origin; but, with or

without the latter, the important feature is that there must be a deep

collection of pus somewhere in the neighborhood of the pancreas.

=Treatment.=--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:

1. _Interstitial pancreatitis_:

(_a_) Interlobular.

(_b_) Interacinous, leading to--

2. _Cirrhosis_ with accompanying diabetes.

3. _Neoplasms_:

(_a_) Cysts.

(_b_) Solid tumors.

4. _Calculi._

=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.=--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.

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.

=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.

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.

[Illustration: FIG. 632

Laceration fragmentation of kidney. (Güterbock.)]

INJURIES TO THE KIDNEYS.

Although the kidneys lie in a protected position they are not

infrequently injured, both by contusions and by penetrating wounds.

From the latter blood will escape externally. In the former it can

only extravasate when the cortex and capsule are torn, or escape

through the ureter into the bladder, when it will be seen in the urine,

which, however, may have to be drawn by the catheter on account of

retention. _Blood in the urine after a local injury denotes serious

mischief inside the kidney or along the urinary tract._ If continuing

for several hours, but especially if accompanied by local indications,

swelling or other evidences of extravasation, by muscle rigidity or

by severe pain, with general symptoms, it should be assumed that

these fluids are escaping into the perirenal tissues, perhaps into

the peritoneal cavity, and that an immediate exploratory operation

should be urged. When once this indication is clearly recognized the

condition brooks no delay. The same is true of penetrating wounds. On

general principles, with a patient in such a condition and showing

no improvement, or especially if the reverse, _exploration offers

the safer course_ in by far the greater number of cases. The surgeon

need only convince himself that such blood as the urine contains does

not come from the lower tract, but rather from the kidney or ureter.

_Exploratory nephrotomy_ is by itself so harmless that one need never

hesitate to urge it. A kidney found slightly lacerated may be repaired

with sutures, while one found seriously disorganized should either

be sutured and drained or totally removed, as the case may require.

There is little room for doubt that it is better to institute such a

measure early rather than to permit the dangers and even ravages of

infiltration of blood and urine. In fact it may almost be laid down as

a precept that _every patient who has received an injury in the loin or

flank and who repeatedly passes blood in the urine should be explored_.

PAIN IN THE KIDNEY; NEPHRALGIA.

This is a vague term, implying pain or neuralgia in the kidney, and can

refer only to symptoms, not to any particular disease. Yet it must be

confessed that for certain cases of so-called nephralgia no physical

cause is easily discovered. Pain in the kidneys--or, as patients will

often say, in the back--may be associated with excess of oxalic and

uric acids and salts in the urine, and is then relieved by a steady

course of alkaline diuretic treatment, with plenty of fluid, the

severe pain being combated with aspirin. Nephralgia may be expected in

connection with many renal disorders, but the term should ordinarily be

confined to cases of pain without known cause.

When such pain is uncontrollable and intolerable the indication is to

make an exploratory operation, by which the kidney should be at least

exposed, perhaps delivered upon the external surface of the body, and

carefully examined. Its capsule should be split (capsulotomy), as

Harrison and others have suggested, and if on palpation or needling

(using a needle as a probe) there be any good reason for opening it

this may be done, so that with the finger its pelvic cavity may be

carefully explored, in order to find any previously unrecognized

calculus or other surgical lesion. The mere operation of _capsulotomy_

or capsule splitting has proved of such great value that I always

practise this measure upon any kidney which for any reason it may seem

wise to expose.

INFLAMMATIONS AND INFECTIONS OF THE KIDNEYS.

Under this head it is intended to consider (1) acute or subacute

specific infections of the upper urinary passages, due to bacteria,

with the effects of which we are familiar, _i. e._, septic, gonorrheal,

and tuberculous lesions, and (2) chronic nephrites of irregular or

uncertain type, for which operative treatment has been recently

proposed.