CYST OF THE PANCREAS SUCCESSFULLY 
REMOVED. 
By W. S. TREMAINE, M.D, 
OF BUFFALO, N. Y. 
James H., aged twenty, was injured August 2, 1886, while coupling 
cars for the D. L. & W. R. R.; one car being lower than the other, 
he was squeezed in the abdominal region. 
The history of the case as given me by himself and family was, 
that he had no fever, was not confined to bed, but that he suffered 
with pain and “ burning distress” in the epigastric region ; about four 
weeks after the injury, frequent vonjiting set in, with rapid emaciation. 
During this time he had been under the care of a physician. 
On September 20th, he came under the care of Drs. King and 
Rogers, who called me in consultation October 17, 1886. At this 
time he had a marked swelling in the epigastric region, extending from 
the ensiform cartilage to the umbilicus, great emaciation, unable to 
retain food of the simplest character, pain and distress in the abdomen, 
bowels moved, in response to cathartics, pulse 100, temperature normal. 
Diagnosis.—A circumscribed tumor of the abdomen containing fluid, 
probably either a cyst of the pancreas or hydatids. October 21st, was 
removed to the hospital, when I drew off with a large hypodermatic 
syringe a small quantity of clear slightly opalescent fluid, which showed 
a slight coagulum after heating, redissolved on the addition of acetic 
acid; upon adding nitric acid a deep orange-yellow precipitate formed. 
A small quantity of lard was melted in a test-tube and about twice 
the quantity of the fluid added to it; a permanent emulsion was the 
result; a solution of starch was thinned by the fluid after standing in a 
warm place for twenty-four hours, and .gave with the Fehling’s test the 
reaction of grape sugar. 
The microscopic examination was negative, no hooklets. 
I considered diagnosis of cyst of the pancreas fairly established, but 2 
TREMAINE, 
referred a sample of the fluid to Prof. A. R. Davidson for examination, 
with the following result: 
“ Reaction slightly alkaline. 
Chloride of sodium, 0.57 per cent. 
Albumin, 10 per cent, by volume. 
Urea, none. 
Succinic acid, none. 
Sugar present in small quantities. 
Paraglobulin, none. 
Fibrinogen, none. 
Spectroscopic examination negative. 
Specific gravity, 1.0075. 
“Cod-liver oil mixed with the fluid in the proportion of one-tenth 
its volume was completely emulsified. The small quantity of fluid 
received prevented any experiments as to action on starch or examina- 
tion for leucin and tyrosin.” 
On the night of the 24th, the patient had violent pain in the abdo- 
men, copious vomiting, and collapse. 
On the 25th of October, at 11 a. m., with the assistance of Dr. 
Mickle, and in the presence of Drs. King, Rogers, and Davidson, I 
made an opening into the abdominal cavity about midway between the 
end of the sternum and the umbilicus in the median line ; after the peri- 
toneum (which was normal) was opened, a quantity of fluid similar to 
that withdrawn by the syringe welled up from the peritoneal cavity. 
The cyst had evidently ruptured, and collapsed probably during the 
manipulation antecedent to the abdominal incision. The finger was 
used to explore. The colon was displaced downward on a level with 
the umbilicus; behind the stomach, and below its greater curvature 
could be felt the collapsed cyst wall; the peritoneal cavity was emptied 
of fluid by turning the patient on one side and compressing the ab- 
dominal walls. The ragged edges of the cyst wall were stitched with 
the peritoneum, and the abdominal wound closed with aseptic silk 
sutures and dressed with a pad of iodoform gauze. The condition of 
the patient before the operation led us to think that death was immi- 
nent. After the operation he rallied and seemed better. 
October 26. Temp. 990, pulse 84, no vomiting, no pain. Ordered 
peptonized milk, two tablespoonfuls every hour, with hot water occa- 
sionally in small quantities to allay thirst. 
2'jth. Patient passed a comfortable night, no pain, no abdominal CYST OF THE PANCREAS. 
3 
tenderness, no tympanites. Pulse 84, temp. 990. Continued pep- 
tonized milk, which is retained and does not cause nausea, this being 
the first food retained for four weeks. 
joth. Pulse 84, temp, normal, no pain, no vomiting, bowels moved. 
November 1. Dressing changed ; union by first intention, except a 
small point about half an inch long at the upper angle of wound. 
jd. Dressing removed, prominence showing in epigastric region, 
dulness on percussion. Cyst evidently refilling. Lower angle of 
wound opened under chloroform and drainage tube introduced, about 
one and a half ounces of fluid escaped. 
5th. Patient passed a bad night from pain and vomiting, which was 
relieved by morph, sulph. gr. hypodermatically. Pulse 90, temp, 
normal. Vomited occasionally a greenish frothy fluid, and constantly 
spitting a mouthful of saliva. Ordered peptonized milk and beef by 
enema. 
yth. No vomiting, no pain, fluid discharging through drainage tube 
and macerating skin of abdomen. 
From this time on the patient rapidly improved, the discharge gradu- 
ally diminished. His appetite and nutrition improved, he was dis- 
charged cured on December 6, 1886. 
When I last him, about three months after the operation, he was 
quite well, fat, and to all appearances completely cured. 
The subject of the surgery of the pancreas has been ably and 
exhaustively treated by Dr. Senn, in a paper read by him before 
the American Surgical Association, in Washington, D. C., April, 
1886, and also in a paper on “ Cysts of the Pancreas,” read in the 
Section on Surgery and Anatomy, at the thirty-sixth annual 
meeting of the American Medical Association. In the latter 
paper he describes a case of cyst of the pancreas occurring in 
his own practice, apparently from injury. So far as I know, 
these are the only two cases reported in America, in which a 
correct diagnosis was made, and the cyst successfully treated 
by surgical measures.