PRACTICAL CONSIDERATIONS : THE PANCREAS. 1739 



cated injury of very rare occurrence. In only three fatal cases in which all other 

 abdominal viscera escaped has it been found to be ruptured. 



In less severe cases it has been bruised or torn, hemorrhage has occurred, a 

 rapidly enlarging, fluctuating epigastric tumor has formed, and the patient has recov- 

 ered after a laparotomy, evacuation of the blood-cyst, and drainage. In such cases 

 it is probable that the traumatism has caused a laceration of the posterior layer of the 

 lesser sac of the peritoneum (with which the pancreas is intimately adherent) and of 

 the pancreas itself. Blood, or blood with pancreatic secretion, is poured into the 

 lesser sac, causing adhesive peritonitis and sealing the foramen of Winslow. The 

 lesser cavity, now converted into a closed sac, is distended with serous exudate, 

 blood, and pancreatic fluid. After evacuation and drainage, the pancreas may con- 

 tinue to pour its secretion into the cyst-cavity through the original peritoneal tear 

 (Robson and Moynihan). 



Pancreatitis. — The close relation of its duct to the common bile-duct, which it 

 often joins at the ampulla and before reaching the duodenum, explains the frequent 

 association of gall-stones with chronic inflammation of the pancreas. A small ball- 

 valve calculus in the ampulla has been thought, by occluding the duodenal orifice, to 

 convert the two ducts into a continuous channel, permitting, if the gall-bladder is 

 functionally active, the entrance of bile into the pancreatic duct (duct of Wirsung) 

 and causing pancreatitis. A larger stone might occlude also the orifices of both the 

 pancreatic duct and the bile-duct and produce in both glands the troubles associated 

 with retained secretions. In the pancreas these troubles are lessened by the fact that 

 occlusion of the main pancreatic duct does not of necessity completely obstruct the 

 egress of the pancreatic fluid (Opie). In about 50 per cent, of bodies the acces- 

 sory duct (duct of Santorini) communicates within the gland with the main duct 

 and opens into the duodenum by a separate orifice about 2.5-3.5 cm. (i-i^ in.) 

 nearer the stomach than the papilla at which the ampulla of Vater opens (Schirmer). 

 Nevertheless, just as jaundice follows occlusion of the common bile-duct by forcing 

 the secretion of the liver back upon that gland, whence it finds its way into the inter- 

 stitial tissue, the lymphatics, the thoracic duct, the blood, and the tissues at large, 

 so the fat-splitting ferment of the pancreatic juice, in cases of occlusion of the pan- 

 creatic duct, finds its way beyond the parenchyma of the gland and causes fat- 

 necrosis, first in the vicinity of the pancreas, later over widespread areas (Opie). 



There can, at any rate, be no question of the etiological association of gall- 

 stones with many cases of pancreatitis ; but it is probable that in a large proportion, 

 in addition to mechanical pressure or independently of it, bacterial invasion follow- 

 ing inflammation of the ducts or of the duodenum is an important factor. 



The anatomical symptoms of acute pancreatitis depend upon the close associa- 

 tion of the gland («) with the solar plexus through the coeliac, superior mesenteric, 

 and splenic plexuses; {b') with the duodenum ; (r) with the bile-ducts; (^ ) with 

 the great blood-vessels behind it; and (<?) upon its more remote relation "with the 

 epigastric region, directly beneath which, but at a considerable depth, it lies. These 

 relations explain {a) the acute and agonizing pain, vomiting, and collapse ; {b~) 

 the intestinal paresis and distention, often simulating intestinal obstruction ; (r) the 

 slight but deepening jaundice sometimes present; (^) the cyanosis of the face and 

 abdomen so commonly seen, and probably due partly to reflex cardiac disturbance ; 

 and ((f) the circumscribed, tender epigastric swelling which follows closely on the 

 above symptoms. In differentiating the condition from acute intestinal obstruction, 

 — for which it is most likely to be mistaken, — the immediate presence of localized 

 epigastric tenderness and the usual absence of both conspicuous general tympany and 

 of limited distention of intestinal coils should be given due weight. The rarity in 

 the epigastrium of an obstructed small intestine should be remembered, and the 

 patency and capacity of the large intestine should be determined (Fitz). 



Chronic obstruction of the duct may cause the development of retention-cysts, 

 of chronic interstitial pancreatitis, or of pancreatic calculi. The latter may later 

 become themselves the chief cause of continued obstruction and of further cystic 

 changes. 



In chronic pa^icreatitis , especially in thin patients and when the stomach and 

 colon are empty, it may be possible to feel the tender, swollen gland through the 



