either by suitable incisions or by compassing the death of the
parasite, after which the power of nature may be adequate to the cure.
In Iceland large incisions are made into the tumor at its most
prominent part, and, although accidents are not uncommon, the results
in many cases are eminently satisfactory. The accidents are shock,
hemorrhage, and especially peritonitis. Under favorable circumstances
now no procedure is more satisfactory in its results than free incision
and drainage. The tumor should be prominent, adherent all round to the
peritoneum, and the walls of the abdomen thin to ensure complete
success without accident. At the present time, so great have been the
advances in abdominal surgery, this operative procedure may be
preferable in some few cases presenting the favoring conditions above
mentioned.
Very simple expedients, however, suffice in most cases. The most simple
is puncture. This is now much practised in Iceland, and, as the
statistics show, with considerable success. Thus, Hjaltelin[219]
reports 100 cases cured in this way, and in his own hands this
expedient proved successful in 41 out of 50 cases operated on. In
Australia, where hydatid disease is also quite common, simple puncture
has effected a large proportion of cures,[220] and is the method of
treatment usually pursued. In England puncture has the approval of some
of the best authorities.[221]
[Footnote 219: Davaine, _op. cit._, p. 605.]
[Footnote 220: _The Medical Times and Gazette_, August, 1873, p. 164.]
[Footnote 221: _Transactions of the Clinical Society_ for 1872:
discussion participated in by Gull, Bryant, Greenhow, etc.]
The mode of performing this operation consists in the introduction of
an exploring-trocar into the most prominent part of the tumor. It may
be withdrawn at once or be permitted to remain for a few minutes to
several hours. The dangers are suppuration in the sac and peritonitis;
but the former, although sometimes accompanied by severe constitutional
symptoms, is not likely to endanger life, and even formidable
disturbances due to the latter are usually recovered from. The facts
show that puncture very rarely indeed causes dangerous, especially
fatal, symptoms. An eruption of urticaria has been observed to follow
puncture with the trocar, and also aspiration, in a considerable
proportion of the cases, but it has no special significance.
Since the introduction of the aspirateur, puncture and withdrawal of
the fluid by means of this instrument has been practised more
frequently, and this appears to be a more effective procedure, than
simple puncture with an exploring-trocar, although in most cases the
escape of the contained fluids suffices to destroy the parasite. The
aspirateur is less likely to permit the escape of fluid into the
peritoneal cavity or the entrance of air into a vein punctured by
accident. If puncture with the trocar or aspiration be practised, shall
all the fluid be withdrawn at once? The answer to this question may be
decided by the character of the sac. Does it contain daughter and
granddaughter vesicles? If so, one puncture may not permit the escape
of much fluid; but in any event it is the practice of the most
judicious and experienced authorities[222] to withdraw as much as
possible of the contents of the cysts at the first operation. Formerly,
a method practised by some French surgeons consisted in successive
tappings, a small quantity of fluid being drawn off each time.[223]
{1108} There is no good reason for this method of treatment now, and it
seems to have been discontinued.
[Footnote 222: _Transactions of the Clinical Society_, _loc. cit._]
[Footnote 223: Davaine, _supra_.]
Yet another method of treatment, but less effective than puncture or
aspiration, consists in injecting into the sac, after the removal of
its contained fluid, certain agents toxic to hydatids. A solution of
the extract of fern, alcohol, solution or tincture of iodine, and bile,
are the chief remedies thus employed. It has long been known that bile
is destructive of these parasites, and cases have occurred of
spontaneous cure in which the opening of the growing cysts into a
bile-duct has secured the entrance of bile and consequent arrest of
growth and atrophy of the hydatids. Several successful cases have been
reported in which the injection of aspidium (male fern) was the
effective agent, but the threatening symptoms produced by it, and the
comparative freedom of other methods of treatment from such
disturbances, do not recommend the injections of fern. In the case
reported by Pavy[224] the extract of fern was mixed with a solution of
potassa.
[Footnote 224: _Lancet_ (London), July, 1865.]
Injections of iodine in solution or in the form of tincture have been
more frequently practised than of any other material. Davaine,[225] who
finds it less successful than simple puncture and aspiration,
recommends, as affording the best results, a dilute aqueous solution of
iodine. Alcohol, a solution of permanganate of potassium, and various
antiseptic agents have been used to some extent, but none of them
possess any advantages over more simple measures.
[Footnote 225: _Op. cit._, p. 650.]
The latest proposal for the treatment of hydatid cysts, and probably
the most effective consistent with entire safety, is electrolysis.
Originally suggested by Althaus[226] to those who first employed the
measure on any considerable scale, it had been mentioned thirty years
before by Budd, and appears to have been first practised in Iceland on
a single case. The first elaborate attempt to establish electrolysis on
a sound basis as a regular procedure was made by C. Hilton Fagge and
Mr. Arthur E. Durham.[227] They operated on eight cases, and all were
successful. The method consists in the introduction of two needles
connected with the negative pole, and the application of the
positive--a moistened sponge--on the exterior in the neighborhood of
the hepatic region. The strength of current employed by Fagge and
Durham was that furnished by a battery of ten cells, and which by
previous trial was found to decompose a saline solution. The two
electrolytic needles, connected with wires attached to the negative
pole, were introduced into the most prominent part of the tumor about
two inches apart. The current was allowed to pass about ten minutes
usually, sometimes a little longer, the sponge on the exterior--the
positive pole--being shifted occasionally. The immediate effects are
not considerable. The tumor may be rendered somewhat more tense and
appear to be enlarged, but more frequently it becomes softer and is
lessened in size, the increase of size being due to the disengagement
of hydrogen gas, and the diminution caused by the escape of more or
less fluid. The immediate effects of the operation varied. In one case
no symptom followed, and in this the result was regarded as doubtful,
although a cure was considered probable. In the others more or less
{1109} constitutional disturbance followed, the symptoms being pain and
fever, the temperature ranging between 100° and 103° F. The duration of
the fever was from two to nineteen days, the latter in one case only.
As has been observed in some of the cases treated by puncture or by
aspiration, a rash appeared on the skin--in some instances
scarlatinous, in others of urticaria. It is a curious circumstance that
an eruption of urticaria is reported to have appeared in one subject in
whom a rupture of the sac into the peritoneal cavity is supposed to
have occurred.
[Footnote 226: _On the Electrolytic Treatment of Tumors, etc._, London,
1867.]
[Footnote 227: _Medico-Chirurgical Transactions_, 1871, p. 1 _et seq._]
Although so little change in the tumor occurs immediately after the
operation, yet it undergoes slow absorption, and ultimately disappears.
The time occupied in the disappearance of the tumor varies from a few
weeks to many months, the difference being due probably to the
situation of the growth, those occupying the substance of the liver
requiring a longer time to fill up.
Fagge and Durham report a case in which simple acupuncture was followed
by a result apparently as good as obtained by electrolysis, and other
similar experiences have been published. If the simple introduction of
a needle suffices to arrest the growth of a hydatid cyst and induce its
atrophy, of course the more complex procedures will be abandoned.
The tendency of the treatment of hydatid cysts has constantly been
toward simplicity, and the success occurs in a direct ratio thereto. In
forming an estimate of the relative value of the methods of treatment,
the average of mortality of each plan becomes the most important
factor. Simple tapping and paracentesis, the most frequently adopted
mode of treatment, is not without immediate and remote danger. Of 46
cases carefully tabulated by Murchison,[228] there were 3 deaths
properly attributable to the operation; but the after
results--suppuration of the cyst and its consequences, peritonitis,
etc.--cannot be measured so accurately. About two-thirds of the cases
thus treated result in cure, and in a majority of these a single
operation suffices. The injection of the various substances which have
been employed for that purpose does not seem to increase the proportion
of cures, and their use distinctly enhances the dangers of the
treatment. At present, the decision as to the method of treatment to be
employed in any case should be made between simple tapping,
electrolysis, and acupuncture. Of these, the last mentioned, it can
hardly be doubted, is the method which is most desirable, for although
it has not been employed so largely as the others, thus far the results
have been better: the percentage of recoveries without accident has
been higher relatively than by other methods of treatment. As
acupuncture presents no special difficulties or dangers, and is but
little painful, it may be tried first, reserving more formidable
measures for the failures by this simple expedient.
[Footnote 228: _Clinical Lectures on Diseases of the Liver_, _loc.
cit._]
Distoma hepaticum and Distoma lanceolatum (Liver-Flukes).
The Distoma hepaticum, entitled by Linnæus Fasciola hepatica, occurs
very frequently in herbivorous animals and occasionally in the biliary
{1110} passages of man.[229] It is, however, less important than the
Distoma lanceolatum, which, although much smaller than the former,
occurs in much larger numbers.
[Footnote 229: Davaine, _Traité des Entozoaires_, Paris, 1877, p. 240
_et seq._; also, Cobbold, _Entozoa_, p. 148.]
Distoma hepaticum is a leech-like parasite from 25 to 30 mm. in length,
of a brownish color, smooth to the naked eye, but thickly covered with
minute spikes or spines to be seen with a low power, and provided with
a cephalic (entrance to oral cavity) and an abdominal sucking disk,
which are also organs of locomotion. The Distoma lanceolatum owes its
name to its lancet shape; it is smaller than D. hepaticum, measuring
about 8 mm. in length and half this or less in width; it is unprovided
with spines, but contains two suckers at the side. Both parasites are
hermaphrodite; the ova, according to Cobbold (p. 166), have "an average
longitudinal diameter of 1/180, whilst their greatest transversal
measurement is about 1/270." These ova are capable of some movement,
provided as they are with a ciliated envelope.
The disease known as the rot in sheep, and a peculiar cachexia entitled
by Davaine la cachexie aqueuse, are caused by the presence of distoma.
The ova gain access to man through the use of unwashed cress, lettuce,
and similar vegetables eaten in the raw state, and in drinking-water.
Fortunately, this accident is rare. The number of reported examples
collected from all sources by the indefatigable Davaine is twelve.[230]
[Footnote 230: _Ibid._, p. 253 _et seq._]
The larger distoma passes into the common and hepatic duct and
gall-bladder, whilst the smaller (lanceolatum) enters the finer
ramifications, and, there multiplying, several consequences may ensue.
The irritation caused by their presence and development will excite a
more or less severe cholangitis, or, accumulating in sufficient
numbers, an actual obstruction will be induced, and jaundice and
structural alterations of the liver will in turn be brought on.
The DIAGNOSIS of such a malady is, in the very nature of the case,
uncertain at best, and in most cases impossible. Nevertheless, it may
be made in rare instances. The existence of the rot may cast suspicion
on the mutton and kitchen vegetables so situated as to suggest the
possibility of contamination with the ova of distoma. Definite and
conclusive information will be afforded by the presence of the ova,
still more of the more or less fully-developed parasite, in the feces
of a patient effected by the symptoms of catarrhal jaundice or
occlusion of the biliary passages. By tapping the gall-bladder
parasites may be withdrawn.
The SYMPTOMS are those common to cases of catarrh of the bile-ducts
(cholangitis), catarrhal jaundice, or occlusion of the passages, as may
be. As these have been detailed under their respective heads, it is not
necessary to repeat the observations already made.
As regards the TREATMENT, in addition to the methods of management
recommended in such cases it may be stated that the use of certain
parasiticides offers a reasonable prospect of good results. Creasote,
bichloride of mercury, thymol, eucalyptol, oil of wintergreen
(gaultheria), and similar agents are rational remedies and should be
fairly tried.
{1111} Parasites in the Portal Vein.
The entozoön which by its presence in the blood causes the disease
chyluria also inhabits the portal vein. In some parts of the
world--Brazil more especially--this disease is exceedingly common. It
has occurred also in two or three instances in England, and the writer
has had a case within the past year (1884) in Philadelphia. The
parasites in this case were found in immense numbers in the urine.
The blood of the portal vein sometimes is actually filled, and the
liver substance itself is penetrated, by them, but nothing is known of
the alterations they induce in these organs. When cases of hæmaturia or
chylous urine due to the Filaria sanguinis hominis occur, the changes
are not confined to the urinary organs, but often, doubtless, involve
the liver. There are no signs in the present state of our knowledge by
which the existence of these parasites in the portal vein and liver can
be determined.
{1112}
DISEASES OF THE PANCREAS.
BY LOUIS STARR, M.D.
Until the middle of the seventeenth century the prevalent views upon
the functions and diseases of the pancreas were vague in the extreme.
By some the organ was regarded simply as a cushion provided for the
protection of the neighboring blood-vessels and nerves; by others it
was looked upon as the seat of lesion in many very diverse diseases, as
ague, hypochondriasis, melancholia, and so on.
In 1642, Wirsung's discovery of an excretory duct demonstrated the fact
that the pancreas was a special organ, and initiated the successful
investigation of the physiology and pathology of the gland. For many
years after this, however, little progress was made, and it is only
comparatively recent investigations that have furnished definite and
reliable information upon the subject. Even now our knowledge of the
clinical and pathological features of diseases of the pancreas is far
behind that of many of the other viscera of the body, the chief reasons
for this being the uncertainty in regard to the physiology of the gland
and the rarity with which its lesions are primary and uncomplicated.
ANATOMY AND PHYSIOLOGY.--The pancreas is a long, somewhat flattened,
narrow, acinous gland, pinkish-white in color, and of looser texture
than the salivary glands, which it otherwise closely resembles in
structure. It is hammer-shaped, measures from six to eight inches in
length, one and a half inches in breadth, and about three-fourths of an
inch in thickness, and varies in weight from three to five ounces. The
gland is situated in the upper part of the abdominal cavity; the
expanded portion, or head, lies in the concavity of the duodenum;
thence it extends transversely across the epigastric and both
hypochondriac regions on a level with the first lumbar vertebra and in
contact with the posterior abdominal wall. As it passes toward the left
it gradually decreases in size, and the narrowest part, or tail, rests
against the spleen. Behind the organ are the crura of the diaphragm,
the aorta, the inferior cava, the superior mesenteric vessels, and the
solar plexus; in front of it, the stomach and the left lobe of the
liver. Its anterior surface alone is invested with peritoneum, being
covered by the posterior layer of the lesser omentum. The ascending
portion of the head is intimately connected with the duodenum by dense
connective tissue, and at times the descending portion, by extending
backward and outward, forms an almost complete ring around the gut; the
body is loosely attached by connective tissue to the posterior
abdominal wall, and the {1113} left extremity and tail are joined to
the left kidney and suprarenal capsule and to the spleen by loose
areolar tissue. The gland is supplied with arterial blood by branches
springing from the pancreatico-duodenal and splenic vessels; its veins
join the splenic and superior mesenteric veins; its lymphatics
communicate with the lumbar glands; and its nerves are branches from
the solar plexus. The principal excretory duct, the canal of Wirsung,
has at its widest part the calibre of a goose-quill. It begins by the
union of five small branches at the tail, and extends transversely
through the substance of the gland from left to right, nearer the lower
than the upper border, and the anterior than the posterior surface; it
is joined throughout its course by numerous small branches from the
acini, which enter it at acute angles. In the head the duct curves
slightly downward, and as a rule opens with the ductus choledochus into
the ampulla of Vater in the second portion of the duodenum; sometimes,
however, it has a separate opening into the intestine. A second,
smaller, duct runs from the ascending portion of the head, and usually
joins the main duct, but may also open independently.
The acini of the gland are from .045 mm. to .090 mm. in diameter, and
are composed of a very thin membrane lined with pavement cells. The
thin walls of the excretory ducts are formed of connective tissue and
elastic fibres, and are lined by a single layer of small cylindrical
epithelial cells. The terminal extremities of the ducts form a complete
network around the glandular cells, resembling the intralobular biliary
canaliculi. The acini are imbedded in a mass of adipose tissue which
contains the vessels and nerves.
The topographical relation of the head of the pancreas to the ductus
choledochus is of clinical importance. As a rule (fifteen times in
twenty-two, Wyss), the bile-duct descends near the head, toward the
duodenum; frequently it runs through this part of the organ, being
either partially or entirely surrounded by the gland substance. Now,
when the bile-duct merely passes over the pancreas, any enlargement,
unless excessive, would simply push it aside, but when it passes
through the head, a comparatively slight amount of disease is
sufficient to close it entirely and cause jaundice.
It is only since the observations of Bernard in 1848 that the
prominence of the pancreatic juice as a digestive fluid has been
recognized. It fulfils several important purposes: in the first place,
it emulsifies the fatty articles of food; secondly, it converts starch
and cane-sugar into glucose; and, finally, it supplements the action of
the gastric juice upon nitrogenous materials and completes their
digestion. Each of these changes is probably brought about through the
agency of a special ferment (Danilewsky). The pancreatic juice is not
secreted continuously. According to the observations of Bernstein,
there are two separate secretory flows following each ingestion of
food--one occurring shortly after the food enters the stomach; the
other a few hours later, corresponding in time to the passage of the
food from the stomach into the intestine, the latter being followed by
a period of rest until the next meal. Both the condition of nausea and
the act of vomiting arrest the secretion. When the vagus is divided and
the central extremity of the cut nerve is irritated, the secretion is
also arrested, and remains checked {1114} for a long time. The arrest
in each instance is attributed to reflex action of the spinal cord and
sympathetic nerve. At the same time, irritation of the mucous membrane
of the stomach caused by the presence of food increases the flow of
pancreatic juice, and so too does simple section of the nerves which
accompany the arteries. It would seem, therefore, that the gland is
under the influence of two sets of nerves from the vagus--one
inhibiting, the other exciting, its secretion.
GENERAL ETIOLOGY.--Pancreatic disease occurs more frequently in men
than in women. No period of life is exempt from it, but it is most
commonly met with in the aged. The predisposing causes are
constitutional syphilis, pregnancy, and hereditary tendency. Among the
apparent exciting causes may be mentioned the habitual over-use of
alcoholic drinks, gluttony, the excessive use of tobacco, suppression
of the menstrual flux, the abuse of purgatives, excessive and prolonged
mercurial medication, and mechanical injuries, either prolonged
pressure or blows upon the epigastrium. As a secondary affection,
disease of the pancreas is associated with chronic diseases of the
heart, lungs, liver, alimentary canal, and abdominal glands, and the
organ may be the seat of metastatic abscesses and tumors.
GENERAL SYMPTOMATOLOGY.--The objective symptoms are--rapid and extreme
emaciation of the entire body; sialorrhoea; obstinate diarrhoea with
viscid stools; fatty stools; lipuria; and the presence of masses of
undigested striped muscular fibres in the stools.
The well-established fat-absorbing and peptonizing properties of the
pancreatic juice furnish a ready explanation of the wasting of the body
which occurs when this secretion is arrested, diminished in quantity,
or altered in quality by disease. Emaciation is not a constant symptom
of pancreatic disease. A number of cases are mentioned by Abercrombie,
Claessen, and Schiff in which, notwithstanding disease of the gland and
complete closure of the duct, revealed by post-mortem examination, the
patients during life were not only well nourished, but even moderately
corpulent. In such instances it is probable that the digestive
functions of the absent pancreatic juice are more or less adequately
performed by the bile and succus entericus. When present, emaciation is
an early symptom; it is at the same time progressive, and is usually
very intense in degree, being most marked in those cases where there is
associated hepatic disease or obstruction to the passage of bile into
the intestine, where the disease of the pancreas interferes
mechanically with the processes of nutrition by pressing upon the
pyloric extremity of the stomach or upon the duodenum, and when the
organ is the seat of carcinomatous growths. In the last-named
condition, in addition to the perversion or arrest of the secretion,
the loss of flesh is attributable to the general causes of malnutrition
attendant upon carcinoma wherever situated.