INDEX 
' he >ilruk;tlf Treatment of 
Cysts of the Pancreas. 
N. SENN, M.D., 
OF MILWAUKEE, WIS. 
SURGEON TO THE MILWAUKEE HOSPITAL, AND PROFESSOR OF PRINCI- 
PLES AND PRACTICE OF SURGERY AND CLINICAL SURGERY IN THE 
COLLEGE OF PHYSICIANS AND SURGEONS, CHICAGO, ILL. 
Read in the Section on Surgery and Anatomy at the Thirty-Sixth 
Annual Meeting of the American Medical Association 
Reprinted from the Journal oj the American Medical 
Association, Sept. 26 Oct. j>, iSSj. 
CHICAGO: 
Printed at the Office of the Assoctatio 
i 8 The Surgical Treatment of 
Cysts of the Pancreas. 
N. SENN, M.D., 
OF MILWAUKEE, WIS. 
SURGEON TO THE MILWAUKEE HOSPITAL, AND PROFESSOR OF PRINCI- 
PLES AND PRACTICE OF SURGERY AND CLINICAL SURGERY IN THE 
COLLEGE OF PHYSICIANS AND SURGEONS, CHICAGO, ILL. 
Read in the Section on Surgery and Anatomy at the Thirty-Sixth 
Annual Meeting of the American Medical Association. 
Reprinted from the Journal of the American Medical 
Association, Sept. 26 Oct. j, iSSS- 
Printed at the Office of the Association 
1885. 
CHICAGO; THE SURGICAL TREATMENT OF CYSTS OF THE 
PANCREAS. 
Under the benign influence of aseptic surgery the 
domain of operative treatment of disease has been 
gradually but steadily expanding, so that, even at 
the present time, almost every organ of the body is 
within reach of surgical aid when it has become the 
seat of injury or disease. The sphere of the physi- 
cian is constantly being narrowed by successive 
achievements of modem surgery, which have been 
and are still multiplying with Avonderful rapidity. 
The useless and often pernicious administration of 
drugs for the cure of local affections must and will 
yield to rational local treatment. Aseptic surgery 
has created a new era in the diagnosis of disease. 
All the large cavities can now be opened and the 
organs examined with comparative immunity. In 
obscure cases, speculative diagnosis must give way 
to direct inspection and palpation. 
Aseptic surgery has also revolutionized that most 
important branch of medical science—experimental 
physiology and pathology. The realization of the 
object of our experiment is no longer marred or en- 
tirely frustrated by septic inflammation. Recent 
experimental research has established many new facts 
in physiology and has laid the foundation for modern 
pathology. Organs and parts of organs which were 
heretofore regarded as essential to the proper per- 
formance of the functions of life have been success- 
fully removed in animals without producing any 
immediate or remote effects, and the knowledge thus 
obtained has been applied in practice, with the result 4 
of establishing, upon legitimate grounds, a number of 
the most brilliant and life-saving operations. The 
surgery of the brain, the lungs, the heart, the liver, 
the kidneys, the gastro-intestinal canal, is only in its 
infancy, and yet it has contributed largely towards 
relieving suffering and prolonging life, and at the same 
time, it has added lustre both to the science and the 
art of surgery. Abdominal surgery is equivalent to 
aseptic surgery, and as such it is regarded favorably 
by many in the light of a new specialty. Modern 
surgery has not only added precision to the diagnosis 
of obscure abdominal affections, but in many in- 
stances offers the only inducement for successful 
treatment. Surgical affections of the kidney, spleen, 
stomach, intestines, and the essential organs of pro- 
creation in the female, have for some time constituted 
a fertile soil for surgical labor, with a certain promise 
for a rich harvest in the future. 
Of all abdominal organs, the pancreas has been 
least frequently subjected to surgical treatment. The 
anatomical location of the organ, and the obscurity 
of its affections, furnish a sufficiently satisfactory 
explanation for this statement. Situated high up in 
the abdominal cavity, and hidden behind such im- 
portant organs as the stomach, omentum, and trans- 
verse colon, it is the least accessible of all abdominal 
organs, and on this account, its affections, wrapped 
in obscurity, have for the most part constituted ob- 
jects for empirical medication. The relation of this 
gland to surrounding organs, and its great distance 
from the anterior wall of the abdomen, the only point 
of approach, necessarily offer serious obstacles to 
diagnosis and direct treatment. In a diagnostic 
point of view I may also refer to another great diffi- 
culty—our want of positive knowledge concerning 
the physiological functions performed by this gland 
in the process of digestion. As the symptomatology 
of all affections of the pancreas is always obscure, 
and a probable diagnosis can only be made in cases 5 
where the gland has become considerably enlarged 
by disease, it is apparent that our present clinical 
knowledge is limited to diseases which increase the 
size of the organ to a sufficient extent to determine 
their existence by palpation. Primary malignant 
disease of the pancreas, when it has advanced to such 
an extent that its presence can be diagnosticated with 
certainty by physical signs, will have invaded the ad- 
jacent tissues to such a degree as to preclude the 
advisability of an operation, consequently the efforts 
of the surgeon, for the present at least, must be di- 
rected exclusively towards the recognition and treat- 
ment of benign affections of this gland. Clinical 
experience does not extend beyond an imperfect 
knowledge of cysts of the pancreas. 
The pancreas, like other secretory organs, is prone 
to become the seat of cystic tumors, the result of 
obliteration or obstruction of the common duct, or 
one or more of its branches. Cysts originating in 
this manner are true retention cysts, containing the 
physiological secretion from the distal portion of the 
gland tissue, with perhaps accidental products, such 
as altered secretions, blood, and the products of 
inflammation. 
In the preparation of this paper it has been my 
intention to present to you a full report of a case of 
retention cyst of the pancreas which has recently 
come under my observation, and, at the same time, 
bring before you in a compact form the clinical history 
of similar cases, which will serve as a basis for some 
general remarks “on the surgical treatment of cysts 
of the pancreas.” 
Volz, set. 19, laborer, German, was admitted to Mil- 
waukee Hospital, Nov. 28, 1884. He is small for his 
age and not robust, but he claims that with one excep- 
tion, he has never been sick, and that no hereditary 
tendency to disease exists in his family. Five weeks 
CYST OF PANCREAS ; LAPAROTOMY; RECOVERY. 6 
ago, while enjoying perfect health, he was thrown 
from a wagon striking the ground on the left side of 
the abdomen, a heavy keg falling upon his back and 
increasing the force of the fall. The pain felt im- 
mediately after the accident was confined to his back, 
at a point where he was struck by the keg, but it was 
not sufficient in intensity to prevent him from follow- 
lowing his occupation as a mason’s apprentice. In a 
few days, however, diarrhoea set in, which persisted 
for two weeks, greatly reducing his strength and 
weight. If he had any fever during this time, it was 
not sufficiently severe to attract his attention. His 
appetite was not impaired, and, although he vomited 
occasionally, neither vomiting nor the diarrhoea 
seemed to be aggravated by the time of eating or the 
kind or variety of food. After two weeks he noticed 
a tumor in the left hypochondriac region which was 
round, smooth, and painless. The tumor increased 
rapidly in size, and soon gave rise to a sensation of 
fulness in the stomach, and later on to regurgitation 
and vomiting soon after meals. Appetite slightly 
impaired. At this time the patient was treated for a 
short time by my friend, Dr. F. H. Day, of Wauwatosa, 
Wis., who resorted to symptomatic treatment, and, 
observing no improvement, referred him to me for 
diagnosis, and, in case it should be deemed advisable, 
for surgical treatment. On his admission to the hos- 
pital he presented a considerable degree of emacia- 
tion, and complained principally of a sensation of 
fulness and weight in the region of the stomach, which 
was always aggravated after meals and only relieved 
by vomiting. On inspection a tumor was found, 
which occupied nearly the whole epigastric and the 
entire left hypochondriac region, its most prominent 
point being to the left of the median line, and about 
three inches below the xyphoid cartilage. Percussion 
revealed a line of dulness extending from the left 
nipple to within an inch above the umbilicus, poste- 
riorly the dulness reached from the eighth to the lower 7 
margin of the twelfth ribs, in the epigastric region a 
limited area of tympanitic resonance was discovered 
along the costal arch of the lower ribs on the right 
side. Palpation showed distinct fluctuation, the wave 
being conveyed from side to side across the whole 
area of dulness. The tumor was round in contour 
and presented a smooth surface. The measurements 
were as follows: From the left nipple to the lowest 
point downwards twenty-two centimetres, the trans- 
verse diameter twenty-one centimetres, and the an- 
terior circumference sixty-three centimetres. The 
heart was pushed upwards so that the impulse of the 
apex could be distinctly felt in the fourth intercostal 
space. The stomach was artificially distended with 
carbonic acid gas, when it was ascertained that it was 
pushed to the right and compressed by the tumor. 
The liver appeared to be unaffected by the tumor, as 
on percussion it was found in its normal location 
and of natural size. Both lumbar regions were tym- 
panitic. No evidences of ascites. Firm pressure over 
any part of the tumor could be made without causing 
pain. The peculiar fremitus often felt in cases of 
echinococcus cysts was absent. No pulsations could 
be felt in the tumor, and no impulse was imparted to 
it by the underlying abdominal aorta. The relative 
position of the tumor was changed during forcible 
inspiration and expiration. For the purpose of ascer- 
taining the nature of the contents of the tumor a 
hypodermic needle was thoroughly disinfected and 
introduced at a point where the tumor was most 
prominent, and, when in place, the distal end of the 
syringe moved upward and downward synchronously 
with the respiratory movements, showing that the ad- 
hesions with the parietal peritoneum, if any existed, 
were slight. The fluid which was removed was some- 
what viscid and slightly opalescent. It was alkaline 
in reaction and contained a considerable proportion 
of albumin, as it coagulated on applying heat and 
nitric acid. Under the microscope it showed only a 8 
few morphological elements, epithelial cells, a few 
leucocytes, granular matter, and no booklets or 
cholesterine crystals. 
Space within dotted lines indicates area of dulness; a-h, line 
of incision. 
By exclusion the diagnosis was narrowed down to 
one of two things: A sterile echinococcus cyst or 
cyst of the pancreas. Against the former spoke the 
rapid growth of the tumor, its primary origin away 
from the liver, its favorite location, the presence of 
considerable amount of albumin, and the absence of 
booklets, the presence of which are diagnostic of 
echinococcus cysts. In favor of a pancreatic cyst 
spoke the following; The history of traumatism in 
the region of the pancreas, the rapid growth of the 
tumor, and the early disturbance of digestion as 
manifested by diarrhoea and vomiting, presumably 9 
caused by the partial or complete retention of the 
pancreatic secretion. As the treatment remained the 
same in either case, it was decided to perform lap- 
arotomy and stitch the cyst walls to the peritoneal 
covering of the wound in the absence of adhesions, 
and to open and drain the cyst after adhesions had 
formed. This procedure was deemed preferable to 
the use of the trocar or aspirator as it would with 
certainty prevent extravasation of the cyst contents 
into the peritoneal cavity, and the drainage tube 
would guard against reaccumulation of the fluid, thus 
affording an opportunity of the cavity undergoing 
obliteration by adhesion of the inner surfaces of the 
cyst walls. The patient, being cognizant of the fact 
that no other form of treatment would promise any 
relief, readily assented to the operation proposed. 
Every precaution was observed to render the opera- 
tion aseptic. The patient was given several baths, 
the parts were shaved and carefully disinfected with 
a five per cent, solution of carbolic acid, the instru- 
ments, sponges, and operating room being prepared 
the same as for an ovariotomy. Before ether was 
administered the stomach was emptied and washed 
out by means of an elastic stomach tube, with a view 
to prevent retching and vomiting during and after 
the operation. An incision five inches in length was 
made obliquely over the most prominent portion of 
the tumor, about three inches below and parallel with 
the left costal arch. A portion of the rectus ab- 
dominis muscle was divided. After dividing care- 
fully all the tissues down to the peritoneum all hem- 
orrhage was carefully and completely arrested. 
On opening the peritoneal cavity, the omentum 
was brought into view, the portion exposed contain- 
ing an artery and a vein of considerable size. As 
these vessels were placed in a vertical direction, they 
crossed the wound; and it became necessary to apply 
a double ligature, the omentum being then incised 
between them to the extent of about three inches. 10 
The omentum was slightly adherent to the parietal 
peritoneum and the surface of the tumor. Through 
the omental incision the tumor could be distinctly 
seen and felt, presenting a smooth, whitish and glis- 
tening surface. As it had formed at least slight ad- 
hesions, it was decided to complete the operation. 
This plan was the more willingly adopted, as it was 
evident that the intra-cystic pressure was great, and 
the cyst walls thin—which would render stitching 
them to the margins of the wound difficult and unsafe. 
The surface of the tumor was then seized with two 
dissecting forceps about an inch apart, and gentle 
traction made during incision and evacuation of the 
cyst, so as to prevent all risk of extravasation of 
fluid into the peritoneal cavity. The peritoneal cov- 
ering was picked up and nipped, and a grooved 
director was inserted into the opening made; owing 
to the thinness of the walls of the sac it penetrated 
the interior, and fluid escaped along the groove with 
considerable force. The opening was enlarged with 
the knife, when the fluid gushed forwards in jets and 
was caught in basins. The contents were removed 
as completely as possible by making external pressure 
and by placing the patient on the side. As the cyst 
was emptied its walls were drawn forward into the 
wound and stitched to the peritoneum, which had 
been previously united with the skin. The interior 
of the cyst was explored by inserting the index-finger, 
which passed directly backwards toward the tail of 
the pancreas. The bottom of the cavity could, how- 
ever, not be reached. The inner surface of the cyst 
was smooth. Two large drainage tubes were inserted 
to the bottom of the cyst, and the remaining portion 
of the wound united in a similar manner as after 
ovariotomy, only that the rectus muscle was sutured 
separately. The fluid removed was estimated at 
three quarts, and presented the same appearance as 
that which was removed by exploratory puncture. 
The wound was dressed with a large antiseptic com- 11 
press, which was retained in situ with an elastic rub- 
ber bandage. This bandage made of rubber webbing 
not only retains the dressing perfectly, allowing at the 
same time the movements of the chest and abdomen, 
but has an additional advantage, inasmuch as it exerts 
equable pressure, an important element in the after- 
treatment of all abdominal operations. 
The patient never vomited during or after the oper- 
ation, and experienced immediate relief on removing 
the pressure which was caused by the tumor. The 
pulse never rose over 90°, and the highest tempera- 
ture observed was ioo° F., the day after the opera- 
tion. The appetite increased, and no unpleasant 
subjective symptoms were complained of at any 
time. On the third day the dressing showed moisture 
on the external surface, and it was changed. The 
gauze was saturated with the secretions from the cyst. 
The wound looked healthy, but the surrounding skin, 
as far as the dressing had extended, was red and 
macerated, and the epidermis could be removed in 
large flakes, leaving beneath a raw surface. The 
changes in the skin presented the same appearances 
as described by Kulenkampff and Gussenbauer, and 
claimed by them to be due to the digestive power of 
the pancreatic juice. The excoriated surface was 
sprinkled with salicylic acid, and was again covered 
with a Lister dressing. On account of profuse secre- 
tion from the cyst the dressings were changed every 
few days, and at every change the skin was found 
excoriated as far as it had been moistened by the 
secretion. At the end of the first week the sutures 
were removed and no further dressings were applied, 
whereupon the skin healed without suppuration, and 
only a minimum amount of pus escaped through the 
fistulous opening with the secretion. The secretion 
became clearer after the operation, and continued to 
discharge in varying quantities for almost four weeks. 
One of the drainage tubes inserted at the time of 
the operation was removed at the first change of the 12 
dressing, and the second was gradually shortened, 
and entirely removed three weeks after the operation. 
At the end of the second week, the cyst was explored 
with a disinfected probe which passed to a depth of 
eight inches in the direction of the tail of the pan- 
creas. The fistulous tract soon became live with 
granulations, and grew smaller in length and diam- 
eter so that at the end of eight weeks it was very 
narrow, so as to admit only a small probe, which could 
be passed only to a depth of four inches. The skin 
around the fistulous opening has been drawn inward, 
forming a deep funnel-shaped depression. 
Jan. 22,1885. Patient discharged cured. Fistula 
completely closed. Retraction of cicatrix very 
marked. General health good, digestion perfect. 
No swelling can be felt in the region of the pancreas. 
Remarks.— The clinical history is somewhat similar 
to analogous cases which will be referred to in this 
paper. It was my intention to collect some of the 
secretion for the purpose of ascertaining its digestive 
properties on different articles of food, but before 
this could be done the amount secreted daily became 
so small that it was impossible to obtain corroborative 
diagnostic evidence from this source. The anatom- 
ical location of the tumor, its relations to the sur- 
rounding organs, its rapid growth, and the character 
of its contents, can leave no possible doubt that we 
had to deal with a genuine retention cyst of the pan- 
creas. The question naturally arises, what was the 
cause of the obstruction? The history of the case 
points clearly to traumatism as the exciting cause. 
The patient had been in good health until he received 
the injury, and since that time he had not been well 
although he continued at his work for some time 
afterward. Whether the diarrhoea from which he 
suffered for the first two weeks resulted from injury 
to the pancreas, we are unable to prove, but it may 
be possible that a retention of the pancreatic secre- 
tion occurred after the traumatism, that diarrhoea may 13 
have been produced by the absence of the fluid in 
the intestinal tract. As the patient at this time was 
not under medical observation, the character of the 
stools was not ascertained. As the injury was in- 
flicted in the region of the pancreas, it is reasonable 
to assume that the pancreatic duct and the paren- 
chyma of the gland were lacerated at a certain point, 
producing obstruction to the outflow of the secretion 
from the distal portion of the organ, the nature of 
the injury and the manner of obstruction being the 
same as in cases of rupture of the male urethra. It 
would be difficult to imagine that the common duct 
could be distended by the accumulation of the re- 
tained fluid to such an enormous extent in such a 
remarkably short time, hence we are forced to con- 
clude that laceration of the duct took place, and that 
the pancreatic fluid infiltrated the gland, and the cyst 
formed at the expense of its parenchyma and by dis- 
tension of the capsule of the organ. The cyst wall 
anteriorly was so thin that after cutting the peritoneal 
covering the grooved director penetrated directly into 
the interior of the cyst without using more than the 
slightest force, which would show that nothing but a 
little connective tissue was interposed between the 
peritoneum and the cyst-contents. The rapid growth 
of the cyst would indicate that the obstruction oc- 
curred at some distance from the caudal extremity of 
the gland, thus making a considerable portion of the 
secreting tissue contributory to the formation of the 
cyst. The early cessation of the discharge of the 
secretion through the abnormal outlet would tend to 
prove either that after the removal of the intra-cystic 
pressure the duct again became permeable, and thus 
furnished a free passage to the secretions into the 
intestinal canal through the natural channel, or that 
the gland tissue in the vicinity and distal to the cyst 
had been destroyed. In regard to the operation, it 
is necessary to say that I deviated from the usual plan 
in not making the incision through the linea alba. 14 
The incision was made over the most prominent part 
of the tumor, for the following substantial reasons: 
1. If adhesions had formed, they would naturally 
begin at a point where the tumor impinged most 
firmly against the anterior abdominal wall. 
2. Incision over the most prominent portion of 
the cyst would afford the best point for effective 
drainage. 
The band of connective tissue which would result 
from atrophy and obliteration of the cyst would form 
a permanent bridge between the cicatrix of the ab- 
dominal wound and the gland, consequently it is 
advisable to establish this necessary evil where it will 
do the least harm by interfering with the functions of 
important organs. 
Aspiration of the cyst was not practised, because 
the exploratory puncture had demonstrated that firm 
adhesions had not taken place, and in the absence of 
these it was feared that some of the cyst contents 
might escape into the peritoneal cavity and produce 
peritonitis. The maceration of the skin was the 
result of the digestive action of the pancreatic juice, 
and this phenomenon furnished strongly corrobora- 
tive diagnostic evidence in this as well as in previous 
cases. 
The literature on the subject of cysts of the pan- 
creas is extremely meagre, and after diligent search 
I have only been able to find an account of the fol- 
lowing cases, of which I will give a brief report: 
Case ll.—Kulenkampff’s case.1 E., male, cet. 39, 
laborer, otherwise healthy, received a number of 
heavy blows on the abdomen on March 22, 1881. 
The blows were received, the patient believes, about 
the umbilicus and in the direction from below up- 
wards. When examined a few hours later, no external 
signs of contusion could be seen, although he com- 
plained of intense pain in the upper abdominal and right 
!Ein Fall von Pankreasfistel. Berliner Klinische Wochenschrift 
Feb. 13, 1882. 15 
hypochondriac regions. Great tenderness on press- 
ure. On the right side posteriorly, above the dia- 
phragm, dulness over an area three inches in height. 
As the patient complained of lancinating pains in the 
same locality, and respiration was difficult, the attend- 
ing physician was induced to diagnosticate traumatic 
pleurisy. In a few days the febrile symptoms and 
pain subsided, and in three weeks the patient seemed 
to be convalescent. Occasional attacks of pain in 
the hepatic and epigastric regions remained, and also 
tenderness on pressure. Physical examination at 
this time yielded only a negative result. Toward the 
latter part of May, a swelling made its appearance 
which seemed to take its origin from the liver. This 
swelling increased in size until September, when the 
following conditions were noted : In the epigastric 
region a round, dense, non-fluctuating tumor can be 
felt, of the size of a double fist. The larger part of 
the swelling is located on the right side of the mesial 
line. Its lower margin extends to within one and a 
half inches of the umbilicus. Percussion dulness con- 
tinues with liver, giving the impression as though the 
tumor sprang from the left lobe of this organ. Tumor 
ascends and descends during the respiratory move- 
ments. Pulsation in an anterior direction. No bruit. 
Palpation unsatisfactory on account of the contraction 
of the recti muscles. Appetite and digestion not 
impaired. Temperature normal, no icterus. Exam- 
ination of urine and stools furnished no clue to the 
diagnosis. 
As from the existing signs and symptoms no diag- 
nosis could be made, it was decided to render the 
tumor more accessible by dividing the tissues down 
to the peritoneum. On September 14, an incision 
was made through the linea alba down to the perito- 
neum. To the touch the tumor, which moved freely, 
imparted the sensation of a tense, nodular liver, as 
in cirrhosis of this organ. The trocar of an aspirator 
was now introduced towards the right of the mesial 16 
line, and after penetrating through dense tissue the 
distance of a centimetre, a cavity was reached, from 
which about a quart of clear fluid was evacuated. 
The peritoneal cavity was not opened and the wound 
was packed with gauze, over which an antiseptic 
dressing was applied. The diagnosis of an echino- 
coccus cyst, which had already been entertained, was 
strengthened by this examination. The fluid re- 
moved coagulated spontaneously on standing for some 
time, also on applying the tests for albumen. It con- 
tained no succinic acid. In the deposit, which was 
very scanty, blood and lymph corpuscles were dis- 
covered. On September 20 the peritoneum was in- 
cised and stitched to the skin. The finger which was 
introduced into the peritoneal cavity came in contact 
with a freely movable and nodular tumor which was 
supposed to be attached to the liver. Its size was 
fully as large as before the last operation. The in- 
cision was again filled with gauze, and four days later, 
adhesions having taken place, the tumor was incised, 
and about a quart of the same kind of fluid escaped 
through the wound. On digital exploration it was 
ascertained that the inner surface of the cyst was 
lined with mucous membrane, which was studded 
with polypoid growths. A large drainage tube was 
inserted and a Lister dressing applied. During the 
next two weeks there was no febrile reaction, the 
tumor disappeared, and large quantities of the same 
clear fluid escaped through the fistulous opening. 
On October xo the secretion had diminished greatly, 
and the tract had been reduced to the size of an 
ordinary lead-pencil. Injections of iodine were made 
with a view to hasten the obliteration of the cyst, but 
this procedure excited pain, emesis, and renewed 
secretion of fluid, of which from one-fourth to three- 
fourths of a quart were evacuated during twenty-four 
hours. Cauterisation with nitrate of silver produced 
no better result. The skin remained in a state of 
maceration wherever it was moistened by the secre- 17 
tion, in spite of often repeated changes of dressings. 
This peculiar condition of the skin first aroused the 
suspicion in Kulenkampff’s mind that he was dealing 
with a fistula of the pancreas. He therefore collected 
some of the fluid and handed it to a chemist for 
analysis. The fluid was almost clear, colorless, froth- 
ing upon being shaken, slightly alkaline in reaction. 
It contained but few inorganic salts, and coagulated 
on applying heat and nitric acid. It contained no 
succinic acid. Experiments were made to ascertain 
its effects on coagulated albumen, neutral fats, and 
starch, the substances being kept at a temperature of 
20-250 C. Special care was taken to preserve its 
alkaline reaction. A fresh paste made of four grms. 
wheaten flour and fifty grms. water was rendered very 
thin by the fluid. Fehling’s solution showed the 
presence of 0.g6 grms. glucose. Coagulated albu- 
men of an egg, kept in a one-fourth per cent, solution 
of salicylic acid it showed no appreciable change. 
0.195 grms. leucin and tyrosin were obtained from it. 
Three decigrammes freshly prepared lard were melted 
and subjected to the action of the fluid. A perfect 
emulsion was formed which had not given off free fat 
after the lapse of twelve hours. The chemical ex- 
amination showed in 100 parts : 3.65 parts of albumen 
which coagulated on addition of alcohol and again 
was soluble in water; 8.57 parts of organic matter of 
various kinds; 8.09 parts of inorganic substances. Ku- 
lenkampff is inclined to the belief that the traumatism 
caused some parts of the pancreas to become inflamed, 
thus causing a constriction or obliteration in the duct 
of Wirsung or some of its branches. As long as the 
fistula continued to discharge the patient became 
emaciated, but there was no disturbance of digestion. 
The urine at no time contained sugar. It was no- 
ticed that the secretion was more profuse during the 
afternoon. The patient recovered completely after 
the closure of the fistula. 
Remarks.—This case illustrates well the difficulties 18 
which are met with in diagnosticating affections of 
the pancreas. Repeated examinations carefully 
made, direct exploration of the tumor at the time of 
the second operation, failed to throw sufficient light 
upon the case to enable the attending surgeon to 
make a positive diagnosis. The peculiar effect of 
the pancreatic juice upon the skin turned the atten- 
tion of the operator in the right direction, and the 
chemical examination of the fluid, and the physio- 
logical tests to which it was subjected, finally resulted 
in a positive and correct conclusion. 
In the next case, the operator asserts to have made 
a probable diagnosis before the operation. 
Case lII.—-Gussenbauer’s Case.1 Male patient, 
musician, aet. 40, who has always been in good health 
and not affected by any hereditary taint, was taken 
suddenly ill after having, on a festive occasion, in- 
dulged too freely in the pleasures of the table. He 
complained of nausea, acute pain in the stomach, 
and, after having taken more alcoholic stimulants to 
relieve the symptoms, he vomited repeatedly. In a 
few days he recovered from this attack and remained 
well for two weeks, when he discovered a swelling in 
the region of the stomach, which increased rapidly 
in size, so that after two weeks it caused a visible 
bulging in the epigastric region. The appetite now 
became impaired, the patient complaining of a sen- 
sation of fulness after meals, accompanied by fre- 
quent eructations. During the next month he vom- 
ited after meals and became greatly emaciated. The 
treatment resorted to had no effect in arresting the 
rapid growth of the tumor, which soon became the 
source of radiating pains through the lumbar and sa- 
cral regions. When he was first seen by Gussen- 
bauer, Dec. 21, 1882, about ten weeks after the ill- 
ness had commenced, he was emaciated, skin pale 
and of a dirty grayish brown color. Respiration 
IZur operativen Behandlung cler Pankreascysten. Archiv. f. Klin 
Chir., vol. xxix, p. 355. 19 
thoracic, pulse full and regular. Percussion showed 
slight dulness in the right side (sternal region) from 
the third rib downward, complete dulness from the 
fifth rib. In the mammary line slight dulness at the 
upper margin of the fourth, complete dulness from 
fifth rib downward; in the axillary region, slight dul- 
ness over seventh, and complete dulness from eighth 
rib. On the left side slight dulness began at the up- 
per margin of the third and extended to the eighth 
in the axillary line. Auscultation showed vesicular 
breathing on both sides of the chest. On examina- 
tion of the abdomen, a prominent swelling attracted 
the attention, which extended over the right and left 
supraumbilical regions, and from the left costal arch 
into the right hypochondriac region. In the middle 
line the tumor measured centimetres from the 
xiphoid cartilage to two inches below the umbilicus; 
from the left costal cartilage to the right hypochon- 
drium, 22 centimetres. Over the anterior surface of 
the tumor, as far as it was not covered by the left 
lobe of the liver, percussion elicited clear, full tym- 
panitic resonance. If the abdominal wall was pressed 
against the tumor the percussion became dull. On 
inflating the stomach it could be seen rising above 
the tumor, its great curvature was easily mapped out 
by inspection and percussion. The transverse colon 
seemed to crop anteriorly over the middle of the 
tumor. It was movable only to a slight degree, and 
seemed to follow the respiratory movements. Ten- 
derness on deep and firm pressure. No ascites. 
Bowels somewhat constipated, stools natural, with 
no admixture of fat. No abnormal constituents in 
urine. The rapid growth of the tumor and its loca- 
tion in the bursa omentalis behind the stomach and 
transverse colon, led Gussenbauer to make a proba- 
ble diagnosis of a cyst of the pancreas or the supra- 
renal capsule. 
As the patient was in a critical condition, and all 
other measures had failed to afford relief, the only 20 
hope centred on a surgical operation, which was per- 
formed December 22, 1882. An incision was made 
in the linea alba about five inches in length, and the 
peritoneal cavity opened to the same extent. The 
stomach and great omentum were seen to cover the 
anterior surface of the tumor. The omentum was 
detached from the great curvature of the stomach 
for about three inches, several arteries were compress- 
ed temporarily and subsequently ligated. Through 
the omental incision the tumor came into view, cov- 
ered by peritoneum. Fluctuation was now distinctly 
felt in the tumor. The upper and lower portions of 
the incision were closed, the parietal peritoneum was 
sutured to the external skin, and the anterior surface 
of the cyst to the margins of the wound. Through 
one of the punctures in the cyst wall a dark brown 
fluid escaped, and, as the suture was tied, the open- 
ing enlarged and the fluid escaped in a jet. A part 
of the contents of the cyst were evacuated by means 
of a trocar, in order to diminish the intracystic press- 
ure and allow of a more perfect fixation of the cyst 
walls to the wound. When this had been done an 
incision three centimetres in length was made into 
the tumor, from which altogether 1,900 cubic centi- 
metres of fluid escaped. Exploration of the inte- 
rior of the cyst with the finger and sound indicated 
no traces of a solid tumor, but a smooth membrane 
lining the inner walls. The lower portion of the cyst 
walls were covered with black masses, which were 
easily detached and removed without giving rise to 
bleeding. The cavity was washed out with a solu- 
tion of thymol, a large drainage tube introduced, and 
iodoform dressing applied. The fluid was of a gray- 
ish black color, and contained in suspension large 
quantities of' masses of pigment, a few red corpus- 
cles, in a state of degeneration, representing all 
forms of retrograde changes. The specific gravity 
of the fluid was 1.6x0, and its reaction alkaline. The 
dark color was due to the pigment, which was found 21 
to be soluble in concentrated caustic soda and in 
acid alcohol. Spectrum analysis showed the pres- 
ence of haematin, but not not of haemoglobin. Fur- 
ther tests showed that it contained albumen, a body 
resembling mucin, and a material soluble in alcohol, 
but no bile pigment, metalbumen, peptones, or sugar. 
When the dressings were changed on the third day, 
the skin appeared to be macerated, which necessi- 
tated in the future a daily change of dressing. The 
patient was relieved promptly by the operation, and 
the wound healed without suppuration. After a few 
days the discharge from the fistula became clear, and 
on examination, it was found to contain leucin and 
tyrosin. Its reaction was alkaline, it digested albu- 
men, and converted starch into sugar. Patient made 
a good recovery and was dismissed three weeks after 
the operation, with a small fistulous opening, which 
continued to discharge a small amount of pancreatic 
fluid. During the time he was kept under observa- 
tion the fistula closed several times, and each time 
he suffered from a rise in temperature, which contin- 
ued until the fistula opened and discharged again. 
Remarks.—The origin of the cyst in this case was 
believed to be a haematoma of the pancreas. This 
assumption, however, lacks demonstation, and it is 
just as logical to assume that the cyst originated in 
the usual way from an obstruction, and that the blood 
in the cyst contents was an accidental product. The 
obstinacy of the fistula to close permanently would 
lead to the suspicion that the obstruction was of a 
permanent nature, either by the impaction of a cal- 
culus in the common duct, or obliteration of this 
channel by cicatricial contraction, the result of chron- 
ic inflammation. 
The next three cases of cysts of the pancreas were 
mistaken for ovarian cysts, and the operation of ova- 
riotomy was performed, when the nature of the cysts 
was discovered, in one instance during the operation, 
and in the remaining two at the necropsy. 22 
Case IV.—Bozeman’s Case.1 The patient was a 
lady 41 years of age, and perfectly healthy up to 
seven years ago, with the exception of occasional at- 
tacks of indigestion. Seven years ago she expe- 
rienced for the first time pain in the right iliac region, 
extending down the right thigh and at times attended 
with numbness. Five years ago the abdomen began 
to enlarge upon the left side, with a corresponding 
flatness upon the right side. The swelling increased 
slowly up to six weeks ago, when it suddenly began 
to grow rapidly. Finally, it filled symmetrically the 
entire abdominal cavity. At the same time the pa- 
tient became emaciated and weak. Dr. T. G. Rich- 
ardson, of New Orleans, who examined her at this 
time, diagnosticated the case as one of cystic tumor 
of one of the ovaries, and advised the patient to con- 
sult Dr. Bozeman. The patient entered the Woman’s 
Hospital in New York, Nov. 19, 1881, where she came 
under Dr. Bozeman’s care. The previous diagnosis 
was confirmed by Drs. Bozeman, Thomas, and Elm- 
met. December 2an operation was performed for 
the removal of the supposed ovarian cyst. Full an- 
tiseptic precautions were observed before and during 
the operation. When the tumor was reached through 
an incision below the umbilicus, its appearance was 
identical with that of an ordinary ovarian cyst, only 
that its color was of a more deep pearly hue. With 
a trocar two and one-half gallons of fluid were evac- 
uated. After the fluid had nearly escaped about two- 
thirds of the cyst was drawn through the incision, 
and then for the first time the operators’ suspicions 
were aroused that it was not ovarian. An explora- 
tion of the abdominal cavity revealed the presence 
of both ovaries in a healthy condition. The origin 
of the cyst was traced to the upper part of the ab- 
domen. The incision was enlarged upwards two 
inches above the umbilicus. Further examination 
IRemoval of a cyst of the pancreas weighing 20% pounds. Medical 
Record, Jan. 14, 1882. 23 
showed that the stomach had been crowded against 
the diaphragm by the tumor, while the intestines 
were displaced in the opposite direction. The cyst 
was found adherent to the transverse mesocolon. In 
tracing the cyst walls still further the pancreas was 
reached, where a large vein was discovered which 
was very tortuous and subsequently identified as the 
splenic. As this vein was in close relationship to the 
pedicle, its presence rendered the operation more 
difficult. The tail of the pancreas lay in contact 
with the side of the cyst wall and firmly adherent to 
it to the extent of two inches. When this portion 
was separated the organ spread out and presented 
its natural appearance. The cyst sprang from the 
pancreas at the junction of the outer with the inner 
two-thirds, the pedicle being three-fourths of an inch 
in length and about the same in thickness. The 
veins of the pedicle were very large. The pedicle 
was transfixed and secured in a double ligature and 
cut off. On examination of the cyst it was discov- 
ered that a portion of it remained attached to the 
pedicle; this was subsequently completely removed 
by a careful dissection. The artery which supplied 
the cyst was as large as the brachial, and appeared 
to be a branch of the splenic. Very little bleeding 
attended the operation, and no ligatures were re- 
quired. The fluid removed was of a light brownish 
color, acid reaction, and a specific gravity of 1.020. 
Tumor and contents weighed twenty and one-half 
pounds. Quinine, stimulants and opiates were given 
after the operation. The highest temperature, 101.50 
F., was noted on the third day; the pulse never rose 
above 98. After omitting the quinine, the tempera- 
ture rose to 102.8° F. on the eighth day, when qui- 
nine, in ten grain doses every six hours, reduced the 
temperature to nearly normal in the course of thirty- 
six hours. From this time the improvement contin- 
ued uninterruptedly to the time when the patient 
was discharged cured, on the thirty-eighth day. 24 
Case V.—K. von Rokitansky’s case, reported by 
Zukowski.1 The patient was a female, 36 years of 
age, who had suffered with symptoms indicative of 
ovarian cyst for nearly three years. The tumor was 
first noticed in the upper portion of the abdominal 
cavity. Laparotomy was performed Feb. 27, 1881. 
The usual incision was made in the linea alba, and 
the supposed ovarian cyst was found behind the great 
omentum, stomach, and transverse colon. The cyst 
wall adhered firmly to the surrounding organs, and 
on attempting to separate the adhesions between it 
and the transverse colon, a rent was made in the 
bowel two ctms. in length. The tear was at once 
closed with five sutures. The adhesions were so 
numerous, firm and vascular, that complete extirpa- 
tion of the entire cyst was found impossible, conse- 
quently the detached portion of the cyst was crushed 
off with an ecraseur, and the stump fastened in the 
abdominal incision, and the wound drained and 
closed. During the operation the cyst ruptured and 
a portion of its contents escaped into the peritoneal 
cavity. Fifty ligatures were applied in preventing 
and securing hemorrhage. After the operation the 
patient collapsed and came nearly dying on the table. 
She rallied from the immediate effects of the operation 
but died on the tenth day from suppurative peritonitis. 
Sometime before death, fecal matter escaped through 
the opening left by the drainage tube. At the autopsy 
it was shown that the remaining portions of the cyst 
were connected with the pancreas. Of this organ 
only the head was found in a normal condition, of 
the body only a few remnants remained, while the 
tail had disappeared completely. ■ 
Case Vl.—Luecke’s Case, reported by Luecke 
and Klebs.2 A female, 43 years old, with the excep- 
iGrosse Cyste des Pankreas. Laparotomie. Tod. Wiener med. Presse. 
1881, Nov. 15. 
2Beitrag zur Ovariotomie und zur Kenntniss der Abdominalge- 
schwuelste. Virchow’s Archiv. vol. xli, p. 9. 25 
tion of bronchial catarrh had always been in good 
health. In July, 1866, at the time when menstruation 
should have appeared, she experienced a severe pain 
in the right hypochondriac region, where a swelling 
soon afterward made its appearance. The tumor 
gradually increased in size and soon occupied the en- 
tire abdominal cavity. During the menstrual period 
the swelling always became tender and painful. She 
was admitted to the hospital under Luecke’s care, 
Nov. 29, of the same year, and then appeared pale 
and emaciated. She complained of difficulty in 
breathing, all other functions were unimpaired. The 
abdomen was symmetrically enlarged, its greatest 
circumference measured ninety-five ctms. The dis- 
tance from the xiphoid cartilage to the umbilicus 
measured fourteen ctm., from the umbilicus to the 
pubes eighteen ctm. Percussion revealed dulness over 
middle of the abdomen as far as half way between 
the umbilicus and xiphoid cartilage. Lumbar regions 
tympanitic. An examination, per vaginam and rect- 
um showed that the uterus was displaced backward 
and toward the left side; upon its posterior surface a 
hard nodule could be felt. Tumor appeared to have 
no connection with the uterus. On Dec. 1, menstrua- 
tion set in with severe pain in the lower part of the 
abdomen. No change in temperature or pulse rate. 
Dec. 6, the tumor was tapped at a point to the left 
of the median line, and twenty-three pints of a turbid 
yellowish fluid were evacuated. After tapping, a 
movable tumor was felt in the left side of the ab- 
dominal cavity, which was regarded as the collapsed 
sac of the ovarian cyst. The fluid removed contained 
only a small amount of albumen. The microscopic 
examination showed the presence of large pale cells, 
some of them filled with granular matter. The con- 
dition of the patient was considerably improved by 
the tapping. Four days after the operation the cyst 
was again filling rapidly, and on percussion it seemed 
to occupy the middle of the abdomen, its upper 26 
margin being somewhat below the umbilicus. Dec. 
22, the labia majora and lower extremities were 
oeclematous and the tumor was as large as before tap- 
ping. Jan. i, 1867, she suffered from a severe attack 
of dyspnoea during the night; at this time the area 
of dulness over the tumor had extended to within 
two inches of the ensiform cartilage, the umbilical 
depression was effaced, and the lumbar regions were 
resonant on percussion. On the following day the 
patient was removed to a private dwelling where ab- 
dominal section was performed. After cutting through 
the skin and muscular layers in the linea alba, a thin 
smooth and very vascular membrane protruded 
through the wound. Through a small puncture which 
was made into this membrane, a milkwhite fluid 
escaped. A trocar was pushed through the membrane 
and a large amount of the same fluid poured out. 
On making traction upon the membrane the umbilical 
depression was restored. This circumstance, as well 
as the difficulty which was experienced in an attempt 
to separate the membrane and the prolapse of the 
small intestine which now occurred, combined to 
prove that the supposed cyst wall was the parietal 
peritoneum. The abdominal cavity was opened and 
on exploration both ovaries were found normal in 
structure and position. The abdominal wound was 
closed with two rows of sutures. The fluid removed 
measured 27J2 pints and resembled milk in its gross 
appearance; it coagulated spontaneously and con- 
tained in suspension the same morphological elements 
as the fluid removed by tapping, with the exception 
that in addition numerous fat globules were found. 
The patient died Jan. 5, the symptoms during her 
illness indicating diffuse peritonitis. The post-mor- 
tem examination was made by Professor Klebs. 
Intestines crowded upwards, the transverse colon 
studded with numerous white or myxomatous nodules, 
very much contracted, forming a curve with the con- 
cavity directed upward, being separated from the 27 
stomach by a cyst with thin walls. The anterior 
wall of this cyst was made up of the lesser omentum. 
On opening the cyst, a large quantity of fluid es- 
caped resembling in every particular the fluid which 
had been removed from the peritoneal cavity. The 
floor of the cyst was covered with nodules composed 
of grayish jelly-like masses. The principal portion of 
this material belonged to the pancreas. This organ 
had been transformed into a mass four inches in 
width and twelve inches in length, and was composed 
almost entirely of gelatinous nodules; in the centre 
of the mass the common duct could be identified. 
The mesentery contained numerous miliary nodules, 
and in Douglas’s pouch large nodular masses were 
found. Left lateral ligament also contained gelati- 
nous nodules. Remaining abdominal organs healthy. 
The microscopical appearances were characteristic 
ol colloid cancer. The disease had evidently its 
primary origin in the pancreas. 
Remarks.—Although this case does not properly 
come within the scope of this paper it presents, how- 
ever, a few important and interesting points which 
have a direct bearing on the subject before us. The 
disease was malignant from the begining, and origi- 
nated primarily either in the capsule or the paren- 
chyma of the pancreas, and extended from there by 
continuity to the serous lining of the abdominal 
viscera. A cyst formed in the bursa omentalis an- 
teriorly to the pancreas which had no direct 
communication with the peritoneal cavity. The 
walls of this cyst were made up of adjacent organs. 
The cyst, occupying the same location as true re- 
tention cysts of the pancreas, gave rise to the same 
signs and symptoms. After the removal of the ascitic 
fluid, the hydropic bursa omentalis remained and was 
displaced toward the left side, and thus simulated to 
perfection on a movable cyst. Refilling of the cyst 
took place more rapidly than the accumulation of 
fluid in the peritoneal cavity. In a diagnostic point 28 
of view, the severity of the pain and presence of 
nodules which were felt through the vagina and rectum 
should have aroused suspicion in regard to the be- 
nign character of the tumor, as their presence in- 
variably indicate the existence of malignant disease. 
In the following case the cyst of the pancreas was 
mistaken for an abscess: 
Case Vll.—Reported by Thiersch.1 A case of 
pancreatic fistula was admitted to the hospital with 
the following history : The patient, a stone-cutter, 
38 years of age, in previous good health, was taken 
suddenly ill while at work. He complained of nausea 
and a sensation of great lassitude. A tumor devel- 
oped rapidly in the region of the stomach. The 
rapidity with which the tumor appeared and the dis- 
tinct fluctuation which could be felt, led the attending 
physician to diagnosticate an abscess in the anterior 
abdominal wall. An incision was made to evacuate 
the contents af the abscess, but, in place of finding 
pus, the operator, after cutting through the peritone- 
um, discovered a cystic tumor of the abdominal 
cavity. The wound was packed and incision of the 
cyst postponed until adhesions should form between 
the anterior surfaces of the tumor and the margins of 
the wound. Two and a half weeks after the incision 
was made, the cyst was laid open, and about three 
quarts of a chocolate colored fluid escaped. As the 
fistula which formed manifested no tendency to close, 
the patient sought relief in the hospital. The fistula 
secreted a moderate amount of a thin serous fluid. 
The chemical examination for pancreatic juice yielded 
a negative result. Thiersch dilated the fistulous 
tract, and ascertained by further examination that 
the tract was outside the parietal peritoneum and 
reached so far as the spinal column and the tail of 
the pancreas. Thiersch was of the opinion that the 
cyst originated from a haematoma of the pancreas 
Berliner klin. Wochenschrift, 1881 29 
and considered this the first case of recovery after 
such a lesion. 
Remarks.-—lf the statement is correct that at the 
first operation the peritoneal cavity was opened and 
the wound packed, and that the cyst was opened 
after firm adhesions had taken place, it is difficult to 
understand how the fistulous tract could be located 
outside of the peritoneal cavity, as Thiersch asserts. 
The location and rapid growth of the tumor, as well 
as the conditions found at the first operation, would 
certainly indicate the presence of a true retention 
cyst complicated by haemorrhage from the beginning 
or during the growth of the cyst. Although it is 
stated that the chemical examination of the fluid 
secreted yielded only a negative result, positive proof 
is lacking that it was not pancreatic juice, and we 
are entitled to the belief that the case was one of 
cyst of the pancreas, and the fistula a true pancreatic 
fistula. 
In all cases reported so far, with the exception of 
the fatal cases, it had been impossible to learn the 
exact seat and nature of the cause of obstruction. 
For the purpose of throwing some light on this part 
of our subject, I will refer briefly to a few post-mortem 
specimens which illustrate at least one variety of 
obstruction. 
Prof, von Recklinghausen1 gives the result of post- 
mortem examination in two cases of cystic disease of 
the pancreas in patients who had died of diabetes 
mellitus. The first case was a male, 40 years of age, 
who had suffered from diabetes mellitus for four years. 
The specific gravity of the urine was 1.030, and it 
contained from four to five per cent, of sugar. At 
the necropsy it was discovered that the pyloric end 
of the stomach was pushed forward by a large 
tumor, the lower portion of which was hidden behind 
the transverse mesocolon, which had been the seat 
lAuserlesene pathologische-anatomisch Beobachtungen. Virchow’s 
Archiv, vol. xxx, p. 360. 30 
of inflammation and cicatrization. The stomach 
was connected with the tumor by slight adhesions, 
but aside of a few haemorrhagic erosions beneath the 
mucous membrane, it showed no further signs of 
disease. Duodenum normal, ductus choledochus 
permeable. Portal vein passed along the lower right 
margin of the tumor, where it was somewhat flat- 
tened and compressed. Splenic vein slightly dilated. 
Between the right border of the tumor and the duo- 
denum the head of the pancreas could be seen, 
presenting a healthy appearance. The common 
pancreatic duct was pervious at its duodenal extrem- 
ity and had not suffered any alterations in the head 
of the gland, but in the body it approached the tumor 
directly, and was no longer surrounded by gland 
tissue, but by dense connective tissue which con- 
nected the head of the pancreas with the tumor. At 
the point where the duct terminated in the tumor its 
lumen was completely filled with a calculous concre- 
tion the size of a pea. The tumor was as large as a 
child’s head, nearly round, and consisted of a dense 
sac which contained a thin, yellowish fluid. In the 
fluid cholesterine and fat crystals could be seen with 
the naked eye. On standing, it deposited a white 
sediment which, under the microscope, showed gran- 
ular cells and deb?'is of cells. The cyst wall was of 
uniform thickness, measuring about three mm. The 
sections appeared somewhat gray, at some points in- 
terspersed with a slate-color. The inner surface of 
the cyst on the whole was smooth, with isolated 
thickened patches resembling the sclerotic patches 
in atheromatous arteries. At some points the inner 
surface is somewhat elevated by thick membranes of 
a pearly, glistening appearance and gray color, which 
could be easily detached. The surface underneath 
these membranous patches was somewhat rough. 
Upon the inner and posterior wall of the cyst a 
groove could be distinctly traced from left to right 
which, at its left extremity, terminated in a canal, 31 
the size of a crow’s quill, perforating the cyst wall. 
On tracing this canal beyond the wall of the sac it 
was found to dilate, its lining being white and smooth 
and, at some points, being thrown into transverse 
folds. The tail of the pancreas, which contained 
this duct, was indurated and sclerosed, containing no 
well marked acini, but it had retained its glandular 
structure. The terminal blind end of the duct, much 
dilated, was surrounded by dense connective tissue. 
The length of the duct from the sac to its termina- 
tion measured two inches. The right extremity of 
the groove terminated in a second opening, through 
which a probe three mm. in diameter could be 
passed directly into the common duct in the head of 
the pancreas, after passing the concretion which filled 
the duct. Between the tail and head of the pancreas 
the glandular tissue had entirely disappeared, and its 
space, to the extent of two and a half inches, was 
taken up by the posterior wall of the cyst, which 
rested directly against the soft tissues between it and 
the vertebral column. The large vessels behind the 
tumor were not adherent, and in nowise affected by 
the tumor. In his remarks on the origin of this cyst, 
the author expressed his belief that it was caused by 
dilatation of the ductus Wirsungianus from obstruc- 
tion to the free outflow of the pancreatic secretion 
by the calculus. The lungs and intestines were the 
seat of extensive tubercular disease. 
Remarks.—The specimen just described illustrates 
an important lesson in pathology, viz.; that long 
continued obstruction will eventually result in total 
destxnction of the anatomical structure, and physio- 
logical function of the organ or part of organ beyond 
the point of obstruction. This fact has a direct prac- 
tical bearing on the question of treating a cyst of the 
pancreas by the formation of a pancreatic fistula. 
The definitive closure of the fistula would be pre- 
vented if the distal portion of the gland tissue re- 
mained intact and the obstruction to its outflow 32 
remained permanent. Clinical experience and 
pathological specimens, however, tend to prove that 
the enormous distension and pressure produced by 
these cysts, as well as the etiological conditions which 
produce them, result in almost complete destruction 
of the secreting structure in the immediate vicinity 
of the cysts, and the distal portion of the gland, 
which is equivalent to cessation of the secretory 
function of that portion of the organ. 
The second specimen described by von Reckling- 
hausen was obtained from a male, aged 26 years, 
who also died of diabetes. The lungs, pleura, and 
intestinal canal revealed the presence of tubercular 
lesions. The pancreas had undergone fatty degener- 
ation so that only its head contained remnants of 
healthy glandular tissue. The common duct in the 
head of the organ was found dilated, and presented 
a varicose appearance. It contained a tenacious 
whitish fluid in which were suspended small calculous 
fragments composed of carbonate and phosphate of 
lime. In addition the duct contained two calculi, of 
which one measured one inch in length and three- 
eighths of an inch in thickness; the second, still 
larger in size, was one and one-third of an inch long 
and of the same thickness. Both of these stones 
presented depressions and elevations on their sur- 
faces which corresponded to the irregularities of that 
portion of the duct in which they were lodged. The 
common duct in the body and tail of the organ was 
dilated, its walls much thickened. The same changes 
were observed in the accessory ducts which could be 
traced through the fatty tissue, where they were seen 
to terminate in white strings of connective tissue. 
The distal ends of the small ducts contained mucus 
and fine calculous concretions. 
Remarks.—ln this instance, the dilatation of the 
duct did not proceed to any great extent, on account 
of the fatty degeneration of the organ, which prob- 
ably occurred pari passu with the formation of the 33 
cause of obstruction, consequently the physiological 
activity of the gland was abolished, and no pancre- 
atic juice was secreted behind the seat of impaction. 
The presence of the adipose tissue which preserved 
the shape and size of the organ is attributed by the 
author to a hypertrophy ol the interstitial and adipose 
tissue rather than to a fatty degeneration of the secre- 
tory elements of the gland. 
TOPOGRAPHICAL ANATOMY. 
For a correct interpretation of the signs and symp- 
toms of cysts of the pancreas, and for an accurate 
understanding of the relations of this organ to sur- 
rounding parts in their surgical treatment, it becomes 
necessary to allude briefly to the topographical anat- 
omy of the pancreas. The pancreas is a tongue- 
shaped gland placed transversely in the abdomen, at 
a point opposite the first lumbar vertebra behind the 
stomach, reaching from the hilus of the spleen to the 
concavity of the duodenum. Its right end, termed 
the head, is embraced by the curvature of the duo- 
denum, whilst its left or caudal extremity is in contact 
with the spleen. After opening the abdominal cavity 
in cadavers, it can be distinctly felt as a firm body 
through the walls of the stomach. The organ is 
made accessible and exposed to sight by cutting the 
ligamentum gastro-colicum transversely, and by push- 
ing the stomach upwards and the transverse colon 
downwards. In the saccus epiploicus, which has now 
been opened, the gland is seen in front of the large 
vessels. It presents three surfaces for examination. 
The anterior surface, somewhat concave, is in contact 
with the stomach throughout its entire extent, but 
separated from it by a covering from the omental 
bursa which renders the surface smooth and well 
adapted for the free movements of the stomach. The 
posterior surface is separated from the spine by the 
vena cava, aorta, the superior mesenteric artery, and 34 
vein, the pillars of the diaphragm, and towards the 
liver, the vena porta, as well as numerous lymphatic 
vessels and glands, all of which are firmly connected 
with this surface, and the spine, by connective tissue. 
To the left of the vertebral column it is attached in 
the same manner to the left suprarenal capsule, kid- 
ney, and renal vessels. The superior mesenteric 
artery and vein are embraced by the substance of 
the gland, so as sometimes to enclose these vessels 
in a complete canal. The inferior surface is narrow 
and directed toward the transverse colon, it rests at 
one end on the junction of the duodenum and jeju- 
num, at the left end on the extremity of the trans- 
verse colon. The intervening middle portion of the 
inferior surface has a special peritoneal covering 
derived from the lower layer of the mesocolon. 
Along the posterior surface and upper border of the 
gland are placed the splenic artery and vein, both 
pursuing a tortuous course from right to left. The 
cceliac axis is above the pancreas. The common 
bile duct is in close relation to the head of the gland, 
passing down along its posterior surface, and is gen- 
erally received into a groove or canal in its substance. 
The common pancreatic duct, or canal of Wirsung, 
is widest near its entrance into the duodenum, where 
it is from one-twelfth to one-ninth of an inch in 
diameter. Before its termination it unites with the 
common bile duct in the wall of the intestine, at the 
junction of the second and third portions of the duo- 
denum, between three and four inches below the 
pyloric orifice of the stomach. The lower extremity 
of the head, where it curves behind the mesenteric 
artery and vein, is sometimes marked off from the 
rest, and is then called the lesser pancreas, with a 
special duct which joins the common duct in the 
substance of the head of the pancreas. The pan- 
creas receives its blood supply from the superior and 
inferior pancreatico-duodenal branches of the hepatic 
and superior mesenteric arteries. The venous return 35 
takes place through the splenic and superior mesen- 
teric veins. The nerves are derived from the solar 
plexus. 
ACCESSORY PANCREAS. 
The pancreas, like many other glandular organs, 
sometimes presents rudimentary duplicities, and it is 
necessary to call attention to this fact for the purpose 
of considering the possibility of the origin of a pan- 
creatic cyst from one of these appendages. Roki- 
tansky1 mentions, as an exceedingly rare occurrence, 
duplicity of the pancreas and excessive development 
of accessory appendages. A frequent variety is 
represented by the head of the gland—the pancreas 
minus—the duct of which usually terminates in the 
common duct, but sometimes, as was first ascertained 
by Winslow, it takes an independent course and 
empties into the duodenum about one to one and 
one-half inches below the opening of the common 
duct. Afore recently, Hyrtl has called attention to 
an accessory pancreas consisting of a few isolated 
acini of the gland behind the superior mesenteric 
artery and vein. Klob has described an accessory 
pancreas distant and distinct from the normal organ, 
which was found between the muscular layers of the 
stomach, about the middle of the great curvature. 
On another occasion he found a similar organ in the 
posterior wall of the jejunum, near its upper termina- 
tion. In both instances, the true glandular structure 
of these bodies was confirmed by microscopical 
examinations. 
Zenker met with six instances of supernumerary 
pancreas. The accessory organ was invariably in 
the walls of the intestine, three times in the highest 
convolution of the jejunum, twice near the duode- 
num, and in the last case in the upper portion of this 
portion of the intestinal tract. In size the glands 
INebenpancreas in der Darmwand. Virchow’s Archiv, vol- xxi, 
P- 369. 36 
varied-from a lentil to a silver dollar. They were 
situated between the intestinal tunics, and presented 
a prominence on the serous surface. Klob found no 
excretory duct in his specimens. Zenker detected 
the terminal end upon the raucous surface of the in- 
testinal canal in the shape of a slightly raised papilla 
which could be seen with the naked eye or by means of 
a magnifying glass. The presence of pancreatic juice 
in the glands was also determined. In all instances, 
the gland proper was found in its normal location and 
of natural size. All patients were adults. Like other- 
accessory organs, the supernumerary pancreatic 
glands owe their origin to embryonal deposits of 
gland tissue. Although, as yet, no instance has 
been observed of cystic formation from an acces- 
sory pancreas, there is no reason why such an oc- 
currence should not take place, for the same reasons 
and in the same manner as has been observed in 
cases of cysts from supernumerary thyroid glands. 
PATHOLOGY AND MORBID ANATOMY. 
Cysts in the pancreas always result from retention 
of the secretion, and subsequent dilatation of the 
secretory duct, or, in case of laceration of this struc- 
ture, from extravasation of the secretion into the 
parenchyma of the gland and subsequent distension 
of its capsule. The size of the cyst is modified by 
the character and seat of the obstruction and its rela- 
tive position to the secreting gland structure. The 
walls of the cyst are usually thin, from over-distension, 
in cases of rapidly growing cysts, or much thickened 
when the growth of the tumor has been slow and 
accompanied by chronic proliferation and induration 
of the connective tissue. The cyst walls in chronic 
cases may become cartilaginous or even ossified. 
The inner surface is either smooth, or it presents 
evidences of degeneration similar to those which 
occur on the internal surface of arteries in the later 37 
stages of endarteritis. If the canal of Wirsung is 
obstructed at or near its proximal end, the entire 
duct and its branches may become dilated, presenting 
the appearance of varicose veins, or a more uniformly 
rounded cyst may form of the size of an orange, of 
a child’s head, or even so large as to occupy the 
whole abdominal cavity, as in Bozeman’s case. As 
the cyst increases in size, the gland-structure disap- 
pears by absorption in consequence of intra-cystic 
pressure. The same cause which constitutes the ob- 
struction will often also lead to destruction of the 
parenchyma of the organ, by inducing a chronic 
interstitial pancreatitis which is followed by cirrhosis 
or fatty degeneration of the organ. Virchow1 alludes 
to cysts of the pancreas under the name of ranula 
pancreatica, and describes two essential and distinct 
varieties: In the first class, the entire duct is found 
dilated, and resembles in appearance a rosary. In 
the second variety, the outlet of the excretory duct 
is obstructed, and behind the seat of obstruction the 
duct undergoes cystic dilatation. He mentions a 
case that came under his observation where such a 
cyst had attained the size of a fist.3 He believes 
that cicatricial contractions or pressure of tumors 
upon the duct constitute the most frequent source of 
obstruction. Pancreatic juice in its purity is only 
found in small and recent cysts. Later on, in old or 
large cysts, various accidental products are added. 
Albuminoid degeneration or suppuration not unfre- 
quently take place, or haemorrhage may occur, so 
that the cyst contents assume a bright red or choco- 
late-colored appearance. Pepper found in such a 
c/st numerous crystals of haematoidin, while Hoppe 
found in another instance urea in the proportion of 
0.12 per cent, as one of the constituents of the con- 
tents of the cyst. The pressure of the cyst upon 
1 Die Krankhaften Geschwuelste, vol. i, p. 276. 
2Ueber die Leucin u. Tyrosin Abscheidung an der Leber. Virchow’s 
Archiv, vol. viii, pp. 360, 361. 38 
neighboring organs will result in secondary patholog- 
ical conditions which will interfere with the physio- 
logical performance of the functions of other organs, 
thus endangering the life of the patient. 
ETIOLOGY. 
The causes which result in the formation of small 
cysts of the pancreas, or cysts which result from 
compression by tumors, which in themselves do not 
admit of an operation for the removal and at the 
same time constitute a source of danger to life, do 
not come within the scope of this paper. In the 
latter instance the cyst is simply a sequence of the 
primary cause, and as such it will seldom, if ever, 
become the sole or direct object of surgical treat- 
ment. The causes of retention in cysts amenable 
to operative treatment, are such which in themselves 
do not imperil the life of the patient. They may be 
classified as follows: i. Obstruction to the outflow 
of the secretion from impaction of calculi in the com- 
mon duct or its branches. 2. Partial or complete 
obliteration of a portion of the duct from cicatricial 
contraction. 3. Sudden or gradual obstruction of 
the duct without diminution of its lumen from dis- 
placements of the pancreas. 
1. Calculi.—The impaction of the pancreatic duct 
at its outlet may be caused by the presence of a 
biliary calculus in the ductus communis choledochus, 
at the junction of the former with the latter. A case 
of this kind has been reported by Engel.1 In such 
cases the obstruction gives rise to retention of the 
secretions from the liver, and the pancreas, and di- 
latation of the excretory ducts in both organs. Cal- 
culous concretions in the pancreatic ducts have been 
frequently observed to give rise to retention cysts. 
Johnston2 has collected 35 cases, in which, upon 
lOestr. Med, Jahrb. vol. xxiii and xxiv, 1841. 
2Calculous and other affections of the Pancreatic Ducts. Am. Jour. 
Med. Sciences, Oct., 1883. 39 
post-mortem examinations, stony concretions were 
found in the pancreas. Incrustations are not as fre- 
quent as free concretions. Gendrin has described a 
pancreatic cyst where the normal pancreatic secre- 
tion was converted into a fatty, chalky pap. The 
causes which produce a concretion in the pancreatic 
duct are chemical changes in the secretion itself, or, 
an obstruction to its free exit by inflammatory changes 
in or around the common duct. The degree of di- 
latation, other things being equal, is in direct pro- 
portion to the completeness of the obstruction to the 
outflow of the secretion. It maybe well to allude to 
the possibility that in some instances a pancreatic 
calculus may remain stationary for an indefinite 
period of time in the duct, giving rise to no symptoms, 
and only partial obstruction, until by the action of 
some determining causef it is forced into a position 
where it effects complete mechanical obstruction to 
the outflow of the fluid, and a rapid increase in the 
size of the cyst. As an impacted biliary calculus 
may give rise to pancreatic obstruction, so a pan- 
creatic calculus, when it is impacted at a point where 
compression of the common bile duct can take place, 
will produce icterus and dilatation of the gall bladder 
and bile ducts. Meckel has reported such a case.1 
Among the specimens of pancreatic cysts so far 
examined, which were caused by concretions, none 
of them had attained the size of those which have 
been submitted to surgical treatment. As in most of 
these preparations the calculi did not completely fill 
the calibre of the duct, they caused only partial ob- 
struction which would furnish an explanation of the 
slow growth and comparatively small size of the 
tumor. In the specimen described by Gould2, it ap- 
pears that the common duct was completely closed 
by two calculous concretions at its entrance into the 
iKoreff. Diss. sistens theoreticam considerationem icteri novis quibus- 
dam causis simul superstructam. Halle 1763. 
2Anatomical Musum of the Boston Society. Boston, 1847, p. 174. 40 
duodenum, and this cyst had attained considerable 
size, in fact, it is the largest cyst on record where it 
was proved that the dilatation was caused by the 
presence of a calculus. As in the successful opera- 
tions on cysts of the pancreas it has been impossible 
to ascertain the exact nature of the obstruction, the 
possibility of retention from a calculus cannot be 
eliminated with certainty. 
2. Cicatricial Contraction.—Cicatricial contraction 
is always the result of an antecedent inflammation. 
The cicatrix may be located in the peri-pancreatic 
tissue or in the substance of the gland itself. Hoppe1 
made a post-mortem examination of a patient who 
had been deeply jaundiced during life. The gall- 
bladder and bile ducts were distended with bile which 
contained blood; the pancreatic duct was also cyl- 
indrically dilated, and many of its branches were 
distended into cysts the size of a hazel-nut. The 
cause of retention of both secretions was found in a 
dense cicatrix which surrounded both ducts at their 
duodenal termination. Interstitial inflammation in 
the gland itself and subsequent cicatricial contrac- 
tion is one of the most frequent causes of retention. 
Wyss has reported a case where the interstitial in- 
flammation was limited to portions of the head of 
the pancreas, through which the common bile duct 
and the ductus Wirsungii passed, and which had re- 
sulted in dilatation of the latter and its branches, 
which again compressed the bile duct, producing in 
this manner intense icterus.2 Becourt has given a 
description of a similar specimen 3 which he found in 
the Strassbourg Pathological Museum. The patient 
had died of icterus. The gall bladder and bile ducts 
were found distended; the pancreas was converted 
into a dense tissue which, being cut into, presented 
njeber einen abnormen Harnstoff enthaltenden pancreatischen Saft 
vora Menschen. Virchow’s Archiv, vol. xi, p. 96. 
2Zur yEtlologie des Stauungsicterus. Virchow’s Archiv, vol. xxxvi, 
P- 455- 
3Recherches sur le pancreas. Strassbourg, 1830. 41 
a chalky deposit four to eight inches in length and of 
a yellowish color. The duct of Wirsung was dilated 
to such an extent as to form a large cyst which oc- 
cupied the whole length of the pancreas, its walls 
being inseparable from the substance of the gland. 
In this case the interstitial inflammation was more 
extensive and the cyst was much larger. In the cases 
reported by Pepper and Hjett the obstruction was 
due to the same cause. In Curnow’s case the com- 
mon duct had become obliterated at its entrance in- 
to the duodenum by catarrhal inflammation. The 
pancreas was atrophic, and its duct was filled with 
numerous calculi. The pancreatic juice had become 
inspissated. The cystic duct of the gall bladder was 
impermeable, while in the common bile duct a num- 
ber of small gallstones were found.1 
I have failed to find in the literature an allusion 
to stricture of the duct, the result of traumatism. 
The pancreas is an exceedingly slender organ of loose 
and somewhat friable texture, and hence, although 
remotely located and well protected by surrounding 
organs, I am of the opinion that it is more frequently 
the seat of injury than has been generally supposed. 
If the stomach is empty and the abdominal muscles 
relaxed, a blow over the region of the pancreas may 
result in serious contusion or laceration of the organ 
without rupture of its envelope. Again, a well di- 
rected blow over either extremity of the gland may 
cause a laceration of its tissues by traction force, the 
organ being securely fixed in its place by firm con- 
nective tissue attachments. The clinical history of 
several cases of rapidly growing cysts tends to prove 
that obstruction occurred in this manner. If the 
duct escapes injury, the cicatricial contraction at- 
tending and following the reparative process in the 
lacerated gland tissue will gradually compress the 
duct, or by lateral traction change its direction and 
of the Path. Society of London, vol. xxiv. 42 
thus impede the outflow of the secretion. If the 
duct is ruptured at the time of injury its lumen may 
become completely filled by a thrombus which ren- 
ders it impermeable, giving rise to retention and ex- 
travasation of the secretion primarily and secondarily, 
to definitive occlusion of the duct by cicatricial con- 
traction at the point of injury. I am quite con- 
vinced that in the case which I have reported the re- 
tention was the direct result of traumatic stricture of 
the common duct. Although this view is not sup- 
ported by evidence from post-mortem examinations, 
it is confirmed by analogous production of cysts in 
other locations. It is evident that this class of cases 
would furnish the most favorable conditions for suc- 
cessful surgical treatment. 
j. Obstruction from Displacement o* the Pancreas. 
As the pancreas is retained in its normal transverse 
position by the surrounding organs and connective 
tissue attachments, a relative change of position of 
portions of the gland would result in a bending of 
the organ and obstruction in the duct at the point of 
flexion. This condition was the cause of retention 
in a case related by Engel,1 who found in a woman 
60 years of age that the tail of the pancreas formed 
a right angle upwards with the principal duct of the 
gland. A dislocation of this kind can occur in one 
of the following ways; 
1. Abnormal relaxation of the connective tissue 
attachments of the gland permitting a portion of the 
organ to descend by its own weight lower in the ab- 
dominal cavity. 
2. Pressure upon the gland by tumors or exuda- 
tions. 
3. Cicatricial contractions in the substance of the 
organ or peripancreatic space. 
That the whole pancreas can become displaced is 
proven by the case reported by Dobrzycki.2 A man 
JOp. cit. 
2Fall von beweglicher Bauchspeicheldriise, Virchow u. Hirsch’s 
Jahresb, 1878, vol. ii, p. 215 43 
50 years of age fell from a distance of some yards. 
Symptoms arising after the fall similar to those of a 
floating kidney. By palpation the displaced organ 
could be located. Saline fluid was vomited, resem- 
bling pancreatic juice. In the hypogastrium a mov- 
able tumor could be felt corresponding in position 
and shape to the pancreas. 
DIAGNOSIS. 
The question of diagnosis can only be entertained 
in cases where the cyst has attained very considera- 
ble proportions. The most important points to be 
taken into consideration are the history of the case, 
the anatomical location of the tumor, and its rela- 
tions to the surrounding organs. The cases which 
have been reported have occurred exclusively in 
adults. Sex appears to exert no determining in- 
fluence. In a number of cases the clinical history 
alludes distinctly and forcibly to traumatism as the 
exciting cause. In Gussenbauer’s case the begin- 
ning of the illness was traced to indiscreet eating 
and drinking. 
In all instances of cystic tumors in the region of 
the pancreas, close inquiry should be made to ascer- 
tain the existence of antecedent inflammatory affec- 
tions of the organ, or in its immediate vicinity. . A 
history pointing towards the existence of a biliary or 
pancreatic calculi will also prove valuable in arriving 
at positive conclusions. Rapid growth of the tumor 
speaks in favor of its pancreatic origin. In Gussen- 
bauer’s, Kulenkampft’s, and my own cases the tumor 
attained an enormous size within a few weeks. Con- 
sidering the relations of these cysts to important sur- 
rounding organs, it is remarkable that they give rise 
to no serious symptoms aside from the pressure they 
exert upon adjacent organs. Pain is not a constant 
symptom, and when it is present it is due more to 
the causes which produce the cyst than the cyst it- 
self. In this respect cysts of the pancreas form a 44 
counterpart to malignant disease when it affects this 
or neighboring organs. Emaciation is due either to 
coexisting affection of the gland, or the impairment 
of function of important organs by pressure of the 
cyst. It is never as marked in these cases as in ma- 
lignant disease. The supervention of fatty stools 
would point towards the existence of some coexist- 
ing serious lesion of the pancreas rather than the ex- 
istence of a simple cyst of the organ. This symp- 
tom was not found present, or it was overlooked, in 
all cases which have been operated upon. Of twen- 
ty-eight cases of stearrhoea, which were compiled by 
Ancelet,’- sixteen were examined post-mortem. In 
five of these there was occlusion of the ductus chol- 
edochus and pancreaticus; in three, occlusion of the 
pancreatic duct alone; in one, inflammation of the 
pancreas and some of the adjacent organs. In the 
remaining cases disease of the liver and the bowels, or 
only marasmus, was found. In thirteen cases of 
pancreatic calculi collected by Johnston,2 only in 
three were fatty stools observed; in six cases, di- 
arrhoea; in four cases, melaena; and constipation 
in the remaining six. The presence of fat in the 
stools is a symptom of great importance in the recog- 
nition of pancreatic disease, but that it is not of ab- 
solute diagnostic significance is proved by the well- 
known fact that the same condition will follow upon 
the obstruction of the biliary passages and affections 
which impair the functional activity of other organs 
of digestion. 
Obstruction of the principal duct impairs diges- 
tion more than when its distal extremity or one ot 
the accessary ducts is involved. The actual illness 
of the patient is usually preceded, for a variable 
length of time, by more or less marked symptoms ot 
gastro-intestinal derangement, accompanied in some 
instances by pain in the region of the pancreas. 
xEtudes sur les maladies du pancrdas. Paris, 1867. 
2Op. cit. 45 
A peculiar color of the skin, which is believed by 
some to be characteristic of pancreatic disease, must 
be mentioned, as it was observed in several cases of 
calculous affection and cysts of the pancreas. The 
appearance presented by these patients is variably 
described as being unhealthy, pale-yellow, dirty, or 
earthy. The intimate relations of the cyst to the 
coeliac plexus will explain the cause of coeliac neu- 
ralgia which is met with in some of these cases. 
Atrophy of the coeliac plexus, from long continued 
pressure, may give rise to mellituria for the same rea- 
son that Klebs has affirmed, that partial extirpation 
or atrophy of the coeliac plexus will cause the pres- 
ence of sugar in the urine. Diverse diseases of the 
pancreas have also been known to produce diabetes 
mellitus. Cases of this kind have been reported by 
Cowley (1788), Bright, Elliotson, Frerichs, Fles, 
Hartsen, Silver, Recklinghausen, Munk, Seegen, and 
Friedreich. Klebs demonstrated by his experiments 
that complete extirpation of the pancreas or ligature 
of its duct invariably gave negative results, as far as 
diabetes was concerned, and this may account for 
the fact that no sugar was found in the urine of the 
cases i-eported in this paper. The cyst, when exam- 
ined early, before it has attained considerable size, is 
always found in the region normally occupied by the 
pancreas. The exact location, however, is not al- 
ways uniform, as it will depend upon the. portion of 
the pancreas from which the cyst has taken its pri- 
mary origin. It may be situated below the right lobe 
of the liver, as in Kulenkampff’s case; in the epi- 
gastric region, as in Gussenbauer’s case; or in the 
left hypochondrium, as noted in my case. When the 
tumor has attained a large size, or occupies the whole 
abdominal cavity, it will be difficult, and in the latter 
instance impossible, to determine by any known 
means its primary origin. In such cases it is of par- 
amount importance to study its relations to adjacent 
organs. The tumor is always and invariably situated 46 
in the bursa omentalis, and from this point, as it in- 
creases in size, it encroaches upon the space occu- 
pied by adjacent organs. The stomach is pushed 
forward in all cases, and later to the right. The 
transverse colon is displaced downwards, the spleen 
to the left, and the diaphragm and contents of the 
chest upwards. The cyst being in direct contact 
with the diaphragm, it usually ascends and descends 
with the respiratory movements of the chest. 
In doubtful cases it will become necessary to in- 
flate the stomach and colon, with a view to ascertain 
their relative position to the cyst. If the patient is 
a female, and the tumor occupies the entire abdom- 
inal cavity, it will simulate cystic disease of the ova- 
ry so closely that a differential diagnosis between the 
two is impossible. The cases reported by Luecke, 
Bozeman, and Rokitansky furnish adequate proof of 
the correctness of this statement. The proximity of 
the abdominal aorta is such that the impulse of the 
artery is imparted to the tumor, which, however, pul- 
sates only in one direction—away from the artery— 
a fact which will always distinguish it from an aneur- 
ism. Unless the cyst is exceedingly tense a sense of 
fluctuation is always imparted by palpation. Palpa- 
tion is rendered difficult on account of the deep lo- 
cation of the pancreas and the rigidity of the recti 
abdominis muscles. The normal pancreas can only 
be felt under certain favorable conditions. Con- 
cerning this point Sir William Jenner says: “By 
deeply depressing the abdominal walls about a hand’s 
breadth below the umbilicus, by then rolling the sub- 
jacent parts under the hand (the stomach and colon 
must be empty), it might be possible to detect it in 
an individual who is thin, and whose tissues are lax.” 
In case the examination is rendered difficult on ac- 
count of great rigidity of the abdominal muscles, 
this obstacle can be overcome by examining the pa- 
tient while under the influence of an anaesthetic. An 
exploratory puncture with a fine and perfectly aseptic 47 
needle of a hypodermic syringe will not only add 
material diagnostic information by revealing the char- 
acter of the cyst contents, but the procedure will 
also settle the question as to the existence or absence 
of adhesions between the cyst walls and the parietal 
peritoneum. In the differential diagnosis the follow- 
ing affections will come up for consideration; i. 
Malignant disease of the pancreas or adjacent or- 
gans. 2. Aneurism. 3. Echinococcus of liver, 
spleen, or peritoneum. 4. Affections of retroperi- 
toneal lymphatic glands. 5. Hydro- or pyo-nephro- 
sis. 6. Cystic disease of supra-renal capsule. 7. 
Circumscribed peritonitis with exudation. 8. As- 
cites. 9. Cystic disease of ovary. 
1. Malignant Disease of the Pancreas or Adjacent 
Orgajis.—Carcinoma, or sarcoma of the pancreas 
or adjacent organs, as in every other locality, always 
manifest their presence by their most characteristic 
clinical features—pain, emaciation, and progressive 
local and general infection. The age of the patient 
and the previous history of the case will also furnish 
important diagnostic information. Large pancreatic 
cysts are unilocular, while, on the other hand, if a 
malignant tumor has undergone cystic degeneration, 
usually more than one cyst can be recognized. 
Hardness and irregularity of surface speak in favor 
of malignancy; on the other hand, smoothness and 
a regular round or oval contour of the tumor 
are constant features of a pancreatic cyst. The 
time which has elapsed since the beginning of the 
illness is also of importance. A rapidly growing 
pancreatic cyst will assume a size in two or three 
weeks which even for a malignant tumor would re- 
quire as many months. 
2. Aneurism.—An aneurism of the abdominal aor- 
ta can be distinguished from a pulsating pancreatic 
cyst by its pulsations being felt in all directions, and 
by the presence of a bruit. As a further test, the sug- 
gestion of Dr. Pepper may be resorted to, which con- 48 
sists in placing the patient in the genu-pectoral posi- 
tion, when the tumor, by gravitation, will leave the 
aorta and all pulsation will cease. Steady pressure 
will diminish the volume of an aneurism, but will 
have no effect on a cyst of the pancreas. 
j. Echinococcus Cysts.—Echinococcus cysts of the 
liver, spleen, or peritoneum could be easily mistaken 
for a cyst of the pancreas. The peculiar fremitus 
sometimes felt on palpating an echinococcus cyst 
should always be sought for. Multiplicity of cysts 
would decide in favor of something else than a pan- 
creatic cyst. The presence of booklets in the aspir- 
ated fluid would furnish positive evidence in favor of 
the presence of an echinococcus cyst, while then- 
absence would not exclude the possibility of the 
tumor being a sterile echinococcus cyst. As the 
surgical treatment in both instances would be iden- 
tical, it is sufficient for practical purposes to narrow 
the diagnosis down to a probable existence of either 
affection. 
4. Affections of retroperitoneal lymphatic glands.— 
Neoplasms, inflammation, suppuration, or hypertro- 
phy of the retroperitoneal glands behind the pancreas 
might simulate a pancreatic cyst, and as a wrong 
diagnosis in such an event might prove disastrous to 
the patient, and reflect discredit upon the surgeon, 
every diagnostic resource should be exhausted in 
order to prevent such error. Enlargement of the 
lymphatic glands, from any cause, sufficient in extent 
to simulate a pancreatic cyst, would almost of neces- 
sity give rise to serious constitutional disturbances 
and extension of the disease to neighboring organs. 
5. Hydro- or Pyo-nephrosis.—In hydro- or pyo- 
nephrosis, the early clinical history will present a 
group of symptoms pointing toward some lesion in 
the pelvis of the kidney, or ureter. A chemical and 
microscopical examination of the urine may furnish 
conclusive evidence of the existence of some renal 
affection whichhas produced the obstruction. Tumors 49 
of the kidney usually occupy a lower place and are 
more laterally located than tumors originating in the 
pancreas. In case of a pancreatic cyst, the lumbar 
region below the kidney is tympanitic, which is not 
the case in hydro- or pyo-nephrosis. In case of 
doubt, an exploratory puncture may enable us to 
arrive at a positive conclusion. 
6. Cystic disease of the suprarenal capsule.—The 
suprarenal capsule may be the seat of cystic degen- 
eration, and simulate a cyst of the pancreas so closely 
that a differential diagnosis is impossible. In Gus- 
senbauer’s case, the diagnosis remained doubtful 
between a cyst of the pancreas and a cyst of the 
suprarenal capsule. The bronzed skin so frequently 
observed in diseases of the suprarenal capsule has 
been also seen in'affections of the pancreas. As the 
operative treatment in either case would be the same, 
it is not essential for practical purposes to make a 
positive diagnostic distinction between the two. 
7. Circumscribed peritonitis with exudation. 
Primary peritonitis, with a circumscribed exudation 
in the region of the pancreas, would reveal a history 
pointing toward an inflammatory affection accompa- 
nied by the usual symptoms attending inflammation 
of this membrane. Fever, pain, and tenderness are 
symptoms Which are either foreign to the history of 
cysts of the pancreas, or, when present, they are less 
intense than in peritoneal inflammations. In peri- 
tonitis, the exudation would be necessarily in the 
peritoneal cavity, while pancreatic cysts always oc- 
cupy the omental bursa. 
8. Ascites.—The question of diagnosis between a 
cyst of the pancreas and ascites can only arise in 
case the whole abdominal cavity is distended by the 
tumor or effusion. The causes which produce ascites 
must be considered separately and individually, as 
they are usually of such a character as to exclude 
a suspicion of pancreatic disease, a satisfactory 
diagnosis can be reached without an exploratory 50 
puncture; but, if any doubt remains, this harmless 
procedure will furnish the requsite information. 
(). Cystic disease of ovary.—From the cases re- 
ported we have gleaned that, in at least three cases, 
large cysts of the pancreas were mistaken for cystic 
disease of the ovary by surgeons of prominence and 
ability who made thorough and repeated examina- 
tions. It is not difficult to conceive that in case the 
tumor has assumed such dimensions as to fill the 
entire abdominal cavity, it would be impossible to 
differentiate between a cyst of the pancreas and the 
ovary, even by a most scrutinizing examination. 
The physical signs presented by either resemble each 
other so closely that they cannot be relied upon in 
discriminating one from the other. The early history 
of the case, if it can be obtained from a reliable 
source, is of more diagnostic value. In pancreatic 
cysts, the early symptoms are usually referred to dis- 
turbance of the digestive functions, and the patient 
has been aware of the presence of a tumor in the 
upper portion of the abdominal cavity. An ovarian 
tumor necessarily begins in the opposite portion of 
the abdominal cavity, and gives rise to pelvic distress 
and disturbances of the menstrual function. As the 
surgical treatment in both instances would be the 
same, it is practically not essential to make a positive 
distinction between the two before an exploratory 
incision will reveal the true nature and origin of the 
cyst. In recapitulation it may be stated that a posi- 
tive diagnosis has so far not been made in a single 
instance, and that for all practical purposes it is only 
essential to make a probable diagnosis between a 
pancreatic cyst, or some other kind of a cyst, which 
would call for the same kind of surgical treatment. 
In very obscure cases, an exploratory incision, under 
antiseptic precautions, for diagnostic purposes, is a 
justifiable procedure. 51 
PROGNOSIS. 
Physiologists are agreed in assigning to the pan- 
creas a most important function in the digestion of 
organic food. We know that by a special ferment it 
assists in the transformation of starch into dextrine 
and sugar, and in the digestion of albumens and fat. 
We should naturally expect that in diseases of this 
organ the digestion of these substances would be im- 
paired in proportion to the amount of gland tissue 
destroyed. On the other hand, we have abundant 
evidence to show that even total disorganization or 
destruction of the pancreas is not incompatible with 
normal digestion and perfect health. It would seem 
to appear that in the absence of the pancreatic secre- 
tion other organs assume a vicarious action, and 
digestion proceeds unimpaired. It is also important 
to remember that even a large cyst of the pancreas 
does not necessarily result in extensive destruction 
of the gland, and that the remaining gland tissue 
continues to secrete and discharge a sufficient amount 
of pancreatic juice. In Bozeman’s case, the cyst 
occupied the entire abdominal cavity, and yet, at the 
operation, the greater portion of the gland was found 
healthy in structure. The integrity of the structure 
and function of the gland depends less on the press- 
ure of the cyst than the causes which were concerned 
in its production. The dangersarising from the cyst 
itself consist in; i. Its interference with the func- 
tions of other abdominal organs by pressure. 2. 
Rupture of cyst and escape of its contents into ad- 
jacent hollow organs or peritoneal cavity. Com- 
pression of the stomach and interference with its 
normal peristaltic action is a constant occurrence 
when the eyst has developed to any considerable size. 
When such is the case, vomiting soon after meals takes 
place, as was noted in a number of cases which have 
been reported. When the cyst is of very large size 
most all of the abdominal organs suffer by compres- 52 
sion, and both digestion and absorption are impaired 
by mechanical pressure. Tire diaphragm being at 
the same time pushed upwards, the heart and lungs 
are displaced in the same direction, and embarrass- 
ment of circulation and respiration follows as a 
necessary sequence. Like any other benign abdom- 
inal tumor, the cyst proves dangerous to life by in- 
terfering mechanically with the functions of more 
essential and important organs. The second source 
of danger is rupture of the cyst and escape of its 
contents into adjacent organs, an accident which 
may be followed by immediate death from haemor- 
rhage, or the life of the patient is placed in jeopardy 
by suppurative inflammation in the interior of the 
cyst, or peritonitis in case the contents have escaped 
into the peritoneal cavity. In Pepper’s case, the 
immediate cause of death was haemorrhage conse- 
quent upon rupture of the cyst into the stomach.1 
At the post-mortem examination a large quantity of 
blood was found in the stomach and intestine, which 
had entered through an opening about one-half inch 
in diameter, close to the proximal termination of the 
ductus communis. A probe passed through this 
opening directly entered a cyst in the head of the 
pancreas. A communication with any portion of 
the gastro-intestinal tract would almost of necessity 
lead to infection and suppurative inflammation in the 
interior of the cyst, which, under unfavorable circum- 
stances, might lead to a fatal termination from septi- 
caemia or extension of inflammation to adjacent 
organs. The prognosis may be said to depend: i. 
On the nature and cause of obstruction. 2. Size of 
cyst. 3. The absence or presence of complications. 
In the treatment of a pancreatic cyst, the indica- 
tions are the same as in the treatment of any other 
TREATMENT. 
•Amer. Journ. Med, Sciences, 1871, p. 159. 53 
kind of cysts, viz.: i. Extirpation of the cyst. 2. 
Evacuation of its contents and obliteration of the cyst. 
Extirpation was attempted in Bozeman’s and Roki- 
tansky’s cases; in the former instance with complete 
success, in the latter the operation was not completed, 
and the patient died a few days afterwards, of septic 
peritonitis. It is proper to state that in both cases 
the operation was done for the removal of a supposed 
ovarian cyst and that a correct diagnosis was made 
in the first case during the operation, after the pedicle 
was traced to the pancreas and the intact portions of 
the gland were identified. In the second case the 
post-mortem examination revealed the true nature 
and location of the cyst. The brilliant result ob- 
tained by Dr. Bozeman is well calculated to stimu- 
late others to follow his example. Extirpation of 
the cyst would guard most effectually against the for- 
mation of a permanent pancreatic fistula, but, on 
account of the deep location of the pancreas, short- 
ness or absence of a pedicle, and the many obstacles 
thrown in the way of the operator by adjacent organs, 
the procedure becomes one surrounded by innumer- 
able difficulties, and in the present state of our 
science, of doubtful propriety. Simple evacuation 
of the cyst contents by means of the aspirator, oilers 
two principal objections against its adoption in the 
treatment of cysts of the pancreas. 1. Escape of 
cyst contents into the peritoneal cavity. 2. Re-ac- 
cumulation of secretion. 
Reasoning from analogy, we should naturally ex- 
pect that when pancreatic juice is brought in contact 
with the peritoneum, it would produce a destructive 
effect upon it by its digestive properties, or, it might 
be even followed by diffuse peritonitis. In oppo- 
sition to this assumption it is affirmed that in experi- 
ments on the pancreas it happens quite frequently, 
that pancreatic juice escapes into the abdominal 
cavity from the canula introduced into the pancreatic 
duct, without any bad results on the animals. Con- 54 
cerning this point Heidenhain1 says: “The animals 
do not suffer from this circumstance as the duct is 
regenerated in spite of the wounded surface being 
bathed in the secretion. Nevertheless it is difficult 
to explain this. Why do not the wounded and sup- 
purating tissues undergo digestion by the pancreatic 
juice? The efficacy of the albumin ferment is de- 
stroyed in some way I presume, probably by being 
changed into zymogen, the living tissues having the 
same effect on the juice as Podolinski observed by 
treating the pancreatic juice with ] lulverized zinc or 
yeast ferment. Although small quantities of pan- 
creatic juice may escape into tie peritoneal cavity of 
an'animal without any serious consequences, we have 
no evidence to show that the peritoneal cavity in 
man is possessed of the same immunity against such 
accident, and it would not be prudent to expose a 
patient to such risk until more light is thrown on this 
subject by further observation and experiment. At 
the same time we must not forget that pure pancreatic 
juice is only found in small cysts, as the contents of 
large cysts have undergone various transformations, 
and are mixed- with different accidental products, 
which might prove an additional source of danger in 
producing peritonitis. In all of the cysts where a 
pancreatic fistula was established, the artificial open- 
ing continued to discharge the secretion for a variable 
period of time, and in two cases the discharge had 
not ceased at the time the report was made, and hence 
re-accumulation would have been inevitable, in case 
the fluid had been removed by aspiration. For these 
reasons, the treatment by aspiration should be limited 
to cysts of moderate size, and where adhesions have 
formed between the cyst and the anterior walls of 
the abdomen. In cases presenting these favorable 
conditions, aspiration deserves a trial, and may be 
repeated as often as required, or until symptoms 
iArchiv. f. d. gesammte Physiologic, vol, xiv p. 466. 55 
arise, which call for more radical measures. The 
needle should always be thoroughly disinfected by 
passing it through the flame of a spirit lamp, and by 
dipping it in a five per cent, solution of carbolic acid. 
The puncture is made obliquely, so as to prevent the 
formation of a fistulous opening. The fluid should 
be withdrawn slowly and the cyst emptied as com- 
pletely as possible. 
After the operation gentle pressure should be made 
over the cyst, by applying a compress and elastic 
bandage. The safest, and at the same time the most 
efficient treatment, consists in establishing a pan- 
creatic fistula. The operation which accomplishes 
this purpose most safely and in the shortest time, 
consists in exposing the cyst by an incision, stitching 
its walls to the margins of the wound. The same 
aseptic precautions must be observed before, during, 
and after the operation, as in afiy other abdominal 
operation. The stomach being generally pushed 
forward, upward, and toward the right by the cyst, it 
is advisable to empty this organ completely as a pre- 
liminary measure by abstinence of food, and the use of 
the syphon irrigator. Except in my case the incision 
was always made in the linea alba. It seems to me 
that the incision should always be made over the most 
prominent part of the tumor, and as near as possible 
over the seat of obstruction. In following this rule, 
we select the place where we are most apt to find ad- 
hesions, at the same time we establish the straight- 
est and most direct route to the primary origin 
of the cyst. An incision through the linea alba, or 
parallel with the costal arch, will afford the easiest 
access with a minimum risk of injury to important 
parts. The external incision should be at least four 
inches in length, while the peritoneum should only be 
opened to the extent of two inches for the purpose 
of making an exploratory examination, to be en- 
larged as occasion may require. If adhesions are 
found between the cyst and the omentum, and the 56 
omentum and the parietal peritoneum, the cyst is 
punctured with an exploratory needle, and, if the 
diagnosis is corroborated, the operation is finished by 
incising and draining the cyst. If no adhesions are 
found between the omentum and peritoneum, the 
former is incised so as to expose the cyst wall, when 
either of the following plans may be pursued: The 
parietal peritoneum is stitched to the skin with cat- 
gut. The margins of the omental wound are pushed 
back under the abdominal walls so as to expose the 
cyst freely, when the wound is packed from the 
bottom with iodoform gauze, and an antiseptic dress- 
ing is applied and retained for six or eight days, or 
until adhesions have formed between the cyst and 
the margins of the wound which have effectually shut 
off the peritoneal cavity, when the cyst is incised 
and drained. 
Suturing of the cyst wall to the margins of the 
wound as a preliminary operation should never be 
resorted to, as on account of thinness of the cyst 
walls there is danger of escape of fluid into the per- 
itoneal cavity from the punctures made by the nee- 
dle, an occurrence which the procedure was intended 
to obviate. With proper care; however, the opera- 
tion can be completed at once. The cyst wall is 
grasped with two many-toothed forceps, and drawn 
forward so as to bring it in accurate and close con- 
tact with the margins of the wound, when the fluid 
is removed with an aspirator or trocar with the same 
care as in emptying an ovarian cyst. As the cyst 
becomes empty it is pulled through the wound, which 
obviates any further danger of escape of fluid into 
the peritoneal cavity. When the cyst is nearly empty 
it is freely incised and sutured to the peritoneal lining 
of the abdominal wound. The drainage tube should 
be fully three-quarters of an inch in diameter, and 
must reach from the bottom of the cyst to the sur- 
face of the wound. After emptying the cyst com- 
pletely by compression, and placing the patient on 57 
his side, a large Lister dressing is applied for the 
purpose of guarding against infection, and to absorb 
the secretions. Frequent change of dressing may 
be required on account of copious escape of pan- 
creatic secretion. Past experience would dictate 
the advisability of protecting the skin against the 
digestive action of the pancreatic juice by applying 
freely carbolated oil. The antiseptic dressings should 
not be abandoned until the peritoneal cavity has be- 
come completely closed by firm adhesions, and the 
size of the cyst has been reduced to a fistulous tract. 
The drainage tube is shortened from time to time, 
as the depth of the fistulous opening is diminished 
by obliteration of the cyst from the bottom of the 
tract. The speedy obliteration of the cyst will de- 
pend on the continuance, abatement, or removal of 
the obstructing cause, or the condition of the gland 
tissue distal to the seat of obstruction. If the strict- 
ure in the common duct of the pancreas is complete 
and of a permanent character, the obstruction will 
continue, and, if healthy gland tissue remains on 
the distal side, the fistula will continue to discharge 
pancreatic juice. If the inflammation which caused 
the obliteration of the duct subsides, and the passage 
again becomes permeable, the natural outlet will be 
again established and the artificial duct will become 
obliterated. If an impacted calculus has caused the 
retention, and the fistula continues to discharge, a 
careful examination should be made to detect the 
calculus, and, if found, an effort should be made to 
remove it through the fistulous opening. If the ob- 
struction has become permanent and the gland tissue 
on the distal side has become destroyed, either by 
the cause or causes which produced the obstruction, 
or by the intra-cystic pressure, that portion of the or- 
gan has been deprived of its functional capacity, and 
as no pancreatic juice is secreted, definitive oblitera- 
tion of the cyst and permanent closure of the fistulous 
tract will take place in a comparatively short time. 58 
In recapitulation, I believe I am justified in sub- 
mitting for your further consideration and discussion 
the following conclusions: 
1. Cysts of the pancreas are true retention cysts. 
2. Cicatricial contraction or obliteration of the 
common duct or its branches, and impacted calculi, 
are the most frequent causes of cysts of the pancreas. 
3. A positive diagnosis of a cyst of the pancreas 
is impossible; a probable diagnosis between it and 
some other kind of cysts amenable to the same sur- 
gical treatment, is adequate for all practical purposes. 
4. The formation of a pancreatic fistula under an- 
tiseptic precautions recommends itself as the safest 
and most expedient operation in the treatment of 
Cysts of the Pancreas.