Chap, xvii.] THE PANCREAS. 325 



corresponds to the centre of the cut. The viscus is 

 then slowly pressed out of the wound. The only 

 difficulty is with the gastro-splenic ornentum, which 

 has to be divided and its vessels secured. 



The pancreas lies behind the stomach, in front 

 of the first lumbar vertebra. It crosses the middle 

 line on a level with a point about three inches above 

 the umbilicus. In emaciated subjects, and when the 

 stomach and colon are empty, it may sometimes be 

 felt on deep pressure. It is in relation with many 

 most important structures, but presents but little 

 surgical interest (Figs. 33 and 34). It has, I believe, 

 never been ruptured alone, and it could scarcely be 

 wounded without the wound implicating other and 

 more important viscera. It has been found herniated 

 in some very rare cases of diaphragmatic hernia, but 

 never alone. 



It may become invaginated into the intestine, and 

 portions of the gland have sloughed off and been 

 passed in the stools. In resections of the pylorus 

 and spleen it is undesirable that a ligature be placed 

 on any part of the pancreas during the operation. 

 There are two reasons for this precaution : " First, we 

 know that after ligature of the parotid (a gland of like 

 character to the pancreas) great swelling and numer- 

 ous small abscesses not infrequently form, leading 

 to necrosis of portion of the gland ; secondly, there is 

 some fear that (in pyloric resections) the secretion 

 escaping from the pancreas may dissolve the cicatrix 

 of the stomach by its peptonising properties" (Billroth). 



The common bile-duct is covered by, or included 

 in, the head of the pancreas. It thus happens that 

 in carcinoma of this part of the gland the duct may 

 become entirely occluded and jaundice result. Or the 

 duodenum and even the colon may be more or less 

 obstructed by pressure, or the neighbouring vessels 

 be closed. 



