Chapter LIII (2)

The pathologists have described various forms of pancreatitis as the _hemorrhagic_, the _gangrenous_, the _suppurative_, and those distinguished by _fat necrosis_, as well of the omentum as of the pancreas itself. These distinctions have the greatest interest for those engaged in minute research and are not to be regarded lightly. They have no small interest for the clinician, since prognosis is in some measure dependent upon them. Nevertheless the symptoms of the condition are but slightly modified, whether the destructive process assume one or the other of these types, and the therapeutic indication is the same for all--namely, the _earliest possible operation_.

If pathologists were better agreed on their pathology it might be worth while to give more space here to this aspect of the subject. It is, however, not yet certain, for instance, whether in a given case inflammation precedes hemorrhage, or whether hemorrhage occurs first and the outpour of blood is suddenly invaded by bacteria. In fact it is probable that sometimes one thing occurs and sometimes the other. Certain it is that the pancreas is not only loosely held together, and consequently disrupts easily, but that it quickly succumbs both to its own digestive juices and the disintegrating effect of bacteria, so that putrefaction quickly occurs hours before life is extinct. The morbid excitement quickly spreads to the adjoining peritoneum, and along it, so that a more or less generalized peritonitis soon complicates the case. Mayo Robson inclines to the view that in the most fulminating cases the hemorrhage is the prior lesion.

=Diagnosis.=--The diagnosis should be made mainly from perforating gastric or duodenal _ulcer_; phlegmonous or gangrenous _cholecystitis_ or _cholangitis_; rupture of the biliary tract, with escape of contents; fulminating _appendicitis_; acute intestinal _obstruction_, including internal hernias, and acute _mesenteric thrombosis_ or _embolism_. Fortunately in every one of these conditions prompt operative intervention is alike demanded, save possibly in the last named; while even in the latter diagnosis cannot be made without it, and it may still be possible to accomplish something if the occlusion be not too widespread. A history of previous “dyspepsia” or “indigestion” may point to the stomach or the biliary channels; repeated hemorrhages to gastric ulcer, and repeated attacks of pain to gallstone trouble. General tympanitis would indicate intestinal obstruction, especially if no flatus were passed, while when limited to the upper abdomen it would be more suggestive of pancreatic disease. This would be corroborated by vomiting of blood, while fecal vomiting would indicate obstruction. Tenderness and tumor located in the region of the gall-bladder would point rather to it as the source of trouble, while in pancreatitis something distinctive may be perhaps made out by palpation and percussion, and the tenderness will be complained of alike on each side of the middle line. Abdominal rigidity, while general, is usually most pronounced near the site of the most important lesion. Much importance is attached by Halsted to excessive pain, and to cyanosis of both the face and the abdomen. The latter may be helpful as a corroborative indication, but is certainly not always present, and, on the other hand, is seen in many cases of general peritonitis. Glycosuria is rarely a feature of the acute cases.

=Treatment.=--This is of necessity not only _surgical_, but, to be effective, should be _prompt_, every added hour of delay causing increased danger. While arranging for this it is possibly justifiable to allay pain by giving morphine hypodermically. The colon should be emptied by a copious enema. Collapse is to be combated by the usual means, including hypodermoclysis or infusion, perhaps with the addition of a little adrenalin to the saline solution. The preparation of the patient, both before and during anesthesia, should include the same scrubbing of and attention to the skin of the _back_ as that of the abdomen, as there is much probability in any such case that posterior drainage will be needed.

The _operation_ is begun as an exploration, through a median incision above the umbilicus, some three inches in length, through which the operator may inform himself as to the state of affairs within the abdomen. Should fat necrosis be revealed, and first noticed in the omentum, no doubt need be felt as to diagnosis. Any tumefaction by which the stomach or colon is displaced, or the gastrocolic omentum placed upon the stretch, calls for further and deeper exploration. The upper abdomen should next be walled off with gauze and a small rent made through the gastrocolic omentum; or it may in rare instances prove wiser to push down an already depressed stomach, or more likely to lift up the greater omentum and enter the lesser peritoneal cavity through the mesocolon. In the majority of instances the condition can be best appreciated and relieved by separating the stomach from the colon.

The condition may be one of extensive fat necrosis, disseminated, but with its most abundant expressions in the neighborhood of the pancreas, or there may be found evidence of extensive gangrene, the pancreas itself sloughing and involved past any possibility of repair, surrounded by disintegrating clot and debris; or there may be found a more or less localized abscess, and perhaps evidences of putrefaction. In at least two instances reported by Muspratt and Porter the pancreas itself was not yet dead, but was so darkly discolored and swollen, as well as so dense, that it was freely incised, the bleeding vessels being tied and the clot removed. Both of these cases recovered. Such incisions, if made in the gland, should always run parallel with the duct and not across it. Whether pus be found or not will depend in large degree upon the time that has elapsed since trouble began. It is most desirable to expose the focus before pus has had time to form, just as it is in acute appendicular disease.

The further operative treatment consists essentially in checking and preventing hemorrhage, in removing all sloughing tissue which can be safely taken away (and this may involve the greater part of the entire gland), in disinfection of the cavity and general toilet of the upper abdomen, with ample provision for drainage. This may be anterior or posterior, and in bad cases should be both, unless procedure is hastened by collapse. Posterior drainage is effected by having the patient turned upon the right side, then making an incision 3 or 4 Cm. long at the left costospinal angle, where, if the advice above given have been followed, the skin will have already been prepared. Here the outer border of the erector spinæ group of muscles is quickly exposed and the blades of a pair of stout forceps entered and pushed toward the inner cavity, within which the operator’s left hand is acting as a guide. In this way it is possible to quickly insinuate the blades so that the large vessels and the upper end of the kidney are preserved from harm. A suitably prepared drain, preferably tubular, may then be introduced deeply enough through the anterior wound to be seized by the forceps and pulled through the tunnel made by their introduction. It is thus drawn backward and outward to such an extent that its inner end shall rest just where it is desired in the cavity of the lesser peritoneum, the unnecessary external part of the drain being now cut away. The whole procedure consumes but little time. Anterior drainage will also be necessary, and the wound may then be closed.

It has been suggested to make the exploration as well as the drainage from the loin, but this procedure cannot be here advised, since it leaves too many features in doubt and affords insufficient means whereby to appreciate and cope with many grave complications. Calculi, either biliary or pancreatic, which are so often an exciting cause of these troubles, should be carefully sought for and removed if present. They could not be revealed nor removed through any small posterior opening. Other good reasons are also advanced, since the intensity of the symptoms is an expression of an intraperitoneal rather than retroperitoneal lesion.

The reader will note that but little has been said as to the distinction between the hemorrhagic, gangrenous, and other forms of acute pancreatitis, as these are for the surgeon, as such, _side issues_. _His paramount duty is to open the abdomen of every such case, so soon as he can possibly effect arrangements._

=Subacute Pancreatitis; Abscess.=--Under this term are included disease processes and lesions similar to or identical with those described as causing acute and even fulminating expressions of pancreatic obstruction, but less severe in their manifestations, less rapid in their course, and more localized in their boundaries. They are often so associated with a protective and natural walling off of the area of excitement by barriers, which outpour of lymph and its consequent condensation into adhesions afford, that they appear more often as abscess of the pancreas or hematoma of the lesser cavity of the peritoneum.

So far as concerns its etiology the causes are essentially the same as in the acute cases, only the results are brought about more slowly, weeks being in these cases as days in the others. Gallstones are by all means the most common cause, and the pancreatic disease is itself an expression of an infection travelling up its duct.

=Symptoms.=--The symptoms usually include pain, which, however, lacks the agonizing intensity noted in the more acute cases. Vomiting is usually associated with constipation, but the vomitus is rarely or never bloody; jaundice of variable degree is a common feature, and collapse is rare. Distention of the upper abdomen and tumor formation come on more slowly. Tenderness is less extreme and muscle rigidity less marked. While the pulse is less affected the temperature is usually more so, often running high. Even early in the case we may note general expressions of septic intoxication, such as mild chills and a characteristic appearance of the tongue and face. Constipation is followed by diarrhea; at least the stools which are fetid contain blood, pus, fat cells, and undigested meat fibers. Pain is more or less constant, but increased in paroxysms. Loss of appetite and rapid emaciation are apparent from the outset. Albumin will be found in the urine, but rarely sugar. The peculiar reaction described by Cammidge will, according to Mayo Robson, give uniformly positive evidence. As _abscess_ gradually or rapidly develops it will cause a swelling, which has its origin behind the stomach and may displace this viscus, as well as the colon, upward or downward, presenting usually toward the abdominal wall. In rare instances the direction of least resistance takes it toward one loin or the other, where it may appear as a perirenal abscess, or around the crus of the diaphragm and above the liver, where it would appear as a subphrenic abscess. It has been known also to burrow along the psoas muscle and appear at the groin, or even in the left broad ligament. Abscess of the pancreas may also burst into the stomach, when pus will be vomited, or into the bowel, whence it will be evacuated. A sudden relief, with disappearance of tumor, followed by diarrhea and purulent stools, would indicate this latter termination. Under these circumstances the abscess cavity may repeatedly refill and reëmpty itself. Spontaneous recovery in this way is possible, but septicemia and hectic usually persist until obviated by operation.

=Diagnosis.=--The history, the evidently septic type of the case, and the distinct signs above noted will make almost certain the presence of pus, and Mayo Robson insists that the pancreatic reaction in the urine (Cammidge) will make clear its location and origin; but, with or without the latter, the important feature is that there must be a deep collection of pus somewhere in the neighborhood of the pancreas.

=Treatment.=--This is necessarily operative, and in such cases as those now considered there will be plenty of time afforded for all the precautions known to careful surgeons. The aspirator should never be used, at least not until the abdomen has been opened, then usually with caution, lest pus escape along the needle track. The operation is made as described above for the acute form of this disease. The greatest care should be given to protecting the general peritoneal cavity against infection. When adhesions to the anterior abdominal wall are met they should be separated as little as possible, only to such an extent as will permit direct approach to the collection below. Only after the abscess cavity has been thoroughly emptied, disinfected, and packed with gauze should the surgeon proceed to clear away or break down adhesions so as to permit a suitable exploration of the lower surface of the liver and the biliary passages.

And now perhaps comes the necessity for operative attention to these latter, as one or many stones may be recognized in the gall-bladder or the ducts. In this case there must be followed those general directions elsewhere given in regard to the technique of operations upon the gall-bladder and ducts. _Biliary drainage_ will in these cases be nearly always indicated, for which a separate small opening in the usual position may be made, if desirable, as it probably will be, for one wishes usually to continue such drainage for several weeks, whereas it is desirable to have a median incision heal as rapidly as possible. The question of posterior drainage will also be raised. Ordinarily it is of advantage, as the time required for anterior drainage can be materially shortened, the abdominal wound be encouraged to close, and because the natural effect of gravity is thus afforded. Moreover, by it the whole period of confinement to bed may be materially reduced. Therefore, unless the condition of the patient absolutely contra-indicate, it will usually be a wise measure. In a few instances it has been possible to drain a pancreatic abscess by a tube in the common duct, after removal of the stone which has been obstructing either it or the duct of Wirsung.

CHRONIC AFFECTIONS OF THE PANCREAS.

Chronic affections of the pancreas which interest the surgeon are:

1. _Interstitial pancreatitis_:

(_a_) Interlobular.

(_b_) Interacinous, leading to--

2. _Cirrhosis_ with accompanying diabetes.

3. _Neoplasms_:

(_a_) Cysts.

(_b_) Solid tumors.

4. _Calculi._

=Chronic Pancreatitis; Cirrhosis.=--The interlobular and interacinous forms can both be considered under one heading so far as we are concerned, their symptoms being similar, save that in the former the compressed connective tissue by its presence causes atrophy of true glandular elements, and thus by preventing their function interferes with digestion; while in the interacinous type the proliferations of this same sort of tissue invade the islands of Langerhans, impair their glycolytic secretion or suppress it, and add a glycosuria to those features common to both forms--moreover, their treatment is essentially the same. In the advanced form of either type the pancreas may be reduced in size and somewhat cirrhotic. This chronic affection may be the result of an incomplete recovery from one of the more acute conditions previously described; it may also have its origin in the chronic irritation of the poisons of syphilis, typhoid, alcoholism, and the like; but by far the most common causes are obstruction of the pancreatic duct, either by biliary or pancreatic calculi, cicatricial stenosis, the presence of tumors or the encroachment and erosion of gastric ulcers and cancers. The morbid condition may involve the whole gland or be localized, in the latter case particularly about its head.

=Symptoms.=--These should be studied with particular attention to the case history, for a previous record of pain, cramps, chills, fever, jaundice, very slight digestive disturbances, soreness, or local tenderness will be suggestive and valuable if obtainable. As symptoms gradually arrange themselves it will be found that tenderness over the pancreas becomes constant, and is accompanied by at least a mild degree of muscle spasm, that pain increases and is referred more widely, often to the left side or even the scapula, while there may be some fulness in the epigastrium. Dyspepsia and emaciation become more marked. By the time the obstruction of Wirsung’s duct has become complete, perhaps previous to it, fat and undigested muscle fibers will be found in the stools, which are light-colored, bulky, and sometimes contain blood. As pressure effects become more prominent evidences of biliary obstruction, if previously lacking, present themselves; the gall-bladder usually distends; the liver enlarges or may even become cirrhotic from the irritation of pent-up toxic bile. Even the spleen may become enlarged. In the urine sugar will be found in cases of the interacinous type, though usually only at a late date; while bile pigments are usually present and Cammidge’s test may reveal his peculiar pancreatic reaction.

=Diagnosis.=--If the peculiar symptoms above rehearsed are present diagnosis is not difficult. In many cases it is not easy to go beyond the point of recognizing that both the pancreas and the biliary tract are at fault, without deciding as to the exact degree of culpability of each. The question of possible cancer arises in almost every one of these instances. Should the ordinary pancreatic reaction in the urine prove all that has been claimed for it, this grave problem can often be settled previous to operation. If the operator satisfies himself by any method short of actual operation that he has to do with cancer of the pancreas, then operation may be considered inadvisable unless for some special reason.

=Treatment.=--At least a reasonably long trial will usually be made, in these cases, of medical, hydrotherapeutic, and other non-operative treatment, with little or no benefit. When after appreciation of the condition and intelligent treatment but slight relief accrues, the case may be regarded (as it really is upon its commencement) as surgical. Treatment, then, consists of _removal of the obstructing cause by drainage of the biliary passages_. The operative procedure will therefore take the form elsewhere described for this purpose. Should deep exploration reveal no calculi it will be well to make sure at least of the patulency of the ducts, by opening the gall-bladder or common duct and exploring with the probe, or possibly even opening the duodenum in order to do the same with the pancreatitic duct. Whether calculi are discovered or otherwise a gentle stripping or massage of the pancreas may be made to advantage. Biliary drainage should then be established, and usually externally.

It has been difficult for the profession to appreciate why and how these measures, which seem to be directed rather to the biliary passages than to the pancreas, have given such brilliantly satisfactory results as are everywhere reported. These are to be accounted for by the facts that the primary cause most often lies in the former rather than the latter, and is thus removed, and that one source of constant irritation--namely, infected bile--is thus done away with, while tension is removed and pancreatic juice again permitted to flow on as it should; that a chronic toxemia (cholemia) is relieved, and that physiological rest is afforded to the affected and disturbed organs. When the operation is thus performed benefit may be expected; even when done late it may be capable of great good.

NEOPLASMS OF THE PANCREAS.

=Cysts.=--In addition to _true cysts_ of the pancreas there have been described so-called “_pseudocysts_” in the lesser peritoneal cavity, and more or less surrounding the pancreas. They are rarely of congenital origin, but are probably due rather to traumatism than to any other cause. By many they have been likened to ranulas, or the cysts which form in the salivary glands in consequence of obstruction to ducts or their branches. Anything which obstructs any portion of the pancreatic duct may lead to the formation of a retention cyst, the true proliferation cyst--adenomas being practically unknown. That traumatism figures so largely is due to the fact that injury is followed by hemorrhagic extravasation, and this by more or less liquefaction or degeneration, both of contents and of surrounding tissue, with the secondary formation of a cyst whose walls are made of new connective tissue.

A _true pancreatic cyst_ is a retroperitoneal tumor, while pseudocysts are intraperitoneal. In front of the former lie four layers of peritoneum, which may be completely merged together, but through which a passage must be made when opening into it from the front. The etiology of old pancreatic cysts may be completely concealed by the changes which have slowly occurred since their origin. They may be single or multiple, occur in any portion of the gland, and increase even by coalescence. Within some of them, especially those of the duct type, papillomatous excrescences may be found. The more distinctly traumatic cysts occur perhaps oftener near the tail of the pancreas, while into them repeated hemorrhages may take place, and the sac will become quite thick, even exceptionally calcifying in places. These have been described as _apoplectic cysts_.

Altogether, up to date, at least 150 of these cysts have been subjected to operative intervention.

Pancreatic cysts contain a fluid which may be variously colored or sometimes colorless, which is usually alkaline, and contains fat globules, cholesterin crystals, blood crystals, albumin, and various salts, most of these being evidences of their hemorrhagic origin. The fluid may also contain the specific pancreatic ferments, of which the diastatic is the more common, tryptic ferment being met occasionally, while the fluid may also possess emulsifying properties. In size these cysts vary from minute sacs to enormous collections of fluid.

As such a cyst attains marked size it will displace the adjoining viscera, pushing the diaphragm upward and impeding heart and lung action, obstructing the pylorus and duodenum and causing gastric dilatation, pressing upon the intestines and perhaps even compressing the ureters, thus producing hydronephrosis. Other peculiar pressure effects may be met in particular instances. A sudden increase in size indicates a fresh hemorrhage, which may lead to its rupture and to death from peritonitis. These cysts rarely empty spontaneously into the bowel. Their contents are liable to infection, and thus a cyst may become converted into a large abscess.

=Symptoms.=--Symptoms include especially _pain_, which may have been sudden, but becomes more or less constant, accompanied by a sense of oppression, according to the size and the pressure effects produced in each case. Digestion is always more or less disturbed; this may be attributed to the stomach dilatation, which is itself a sequel of the condition. The stools show little which is significant save that they are occasionally bloody. Undigested muscle fiber would indicate loss of pancreatic function. Other symptoms will vary so much with individual cases that it is not necessary to consider them here.

The physical signs, coupled with a suggestive history, especially one which includes an account of injury, are of the greatest importance in diagnosis. These physical signs will include usually a yellowish tinge of the skin, marked emaciation, dry skin, and the presence of a tumor in the upper abdomen, which is usually centrally placed, but not necessarily so. If the patient has carefully noted the development of his own symptoms it will be found that the enlargement commenced above and usually a little to the left, and developed in other directions from that location. Palpation reveals a smooth, elastic, usually fluctuating tumor, sometimes movable with respiration, rarely pulsating.

It must be remembered that a pancreatic cyst may rise above the stomach, may rest entirely behind it, or may protrude either below it and above the colon or else quite below the colon. Distention of the stomach will afford accurate location, in these respects, upon percussion, while percussion without distention may mislead. A tumor which gives dulness below the stomach and above the colon is extremely suggestive.

=Diagnosis.=--Diagnosis by aspiration is inadvisable, even dangerous, for death has followed the introduction even of a needle into such a cyst. Aspiration, then, should be reserved for tumors already exposed through an abdominal incision.

For the purpose of _differentiation_ it will suffice here to remind that tumors of the kidney, as well as hydronephrotic cysts, grow downward and forward from the loin, and can be pushed backward to their proper place unless too large, that they are not accompanied by digestive disturbances, while the urine is usually more or less indicative. A hydronephrotic cyst can scarcely be made to occupy a position between the stomach and the colon and present in the middle line in front. Ovarian cysts rise from the pelvis and will rarely occur in the upper location, save those provided with extremely long pedicles. Hydatid cysts of the liver show a continuity and fixation to that viscus which are usually diagnostic.

=Treatment.=--The only treatment for pancreatic cysts is surgical, it remaining with the surgeon to decide as between _drainage_ and _extirpation_. While it is indisputable that extirpation is the ideal method of dealing with all cysts and tumors, most of these cases are of such long duration that the adhesions contracted between their exteriors and the surrounding viscera are so dense and firm that much greater danger attaches to a radical operation than to one for simple incision and drainage. I have been able in at least one case to completely extirpate such a cyst, but it was one exceedingly favorably situated and surrounded.

_Incision and drainage_ may be effected in one operation or in two sittings, and as between them it must be decided according to the merits of the case. It is undesirable to permit the escape of the contents of these cysts into the abdomen. In some instances, therefore, it would be much better to make a small abdominal incision and through it attach the surface of the cyst to the margins of the parietal peritoneum, reserving the actual opening into the tumor until a day or two later, when it may be expected that firm adhesions will have attached the sutured surfaces. In this way any leakage within the abdomen may be avoided. Care must be exercised, even in such cases, as a large cyst too suddenly emptied may cause sudden displacement of the heart or of other viscera, which would not be to the advantage of the patient. In this case fluid could be withdrawn in portions as desired, or, making a small opening, one could arrange for its gradual escape. On the other hand, there are cases where it would be of great advantage, if the cyst could not be emptied, to so open it as to permit posterior drainage to be made, by which the period of recovery would be much abbreviated.

No case of this kind can be treated without drainage, the explanation being that the cyst being emptied will collapse, its walls coming into more or less close contact with each other, that the presence of drainage material will provoke exudate and the formation of granulation tissue, and that a complete obliteration will thus in time occur--but drainage in the natural direction of gravity as the patient lies upon the back will permit of much more speedy fulfilment of one’s hopes; hence its advantage. Better still, perhaps, would be through-and-through drainage, with such irrigation as might be needed, practised daily, or oftener if necessary.

=Tumors of the Pancreas.=--While _sarcoma_ and other forms of malignant disease, as well as _adenoma_ of the pancreas, have been described, they require no special consideration here, since the surgeon has so rarely to do with anything of this character save _adenocarcinoma_ of the pancreas. This is a disease of middle or advanced life, more common in males than in females, usually of scirrhous type, and localized, though it may appear in softer forms or be disseminated. It takes its origin from the epithelial cells lining the acini and the ducts. Metastasis is common and direct extension by continuity most easy and frequent. It is made known by its pressure effects rather than by any other important signs or constant features. It has been known to lead to chylous ascites.

It is difficult in many exploratory operations to decide as between a chronic induration or cirrhosis of the pancreas and that due to cancer, and, in fact, in certain cases it may be impossible to clear up the difficulty, leaving it to be solved either by recovery or death in consequence of extension of malignant disease. Thus when operating for biliary obstruction, where the parts are surrounded by adhesions and the organs are only indistinctly palpable, it may be impossible to decide as to the nature of a hard mass felt in the head end of the pancreas, especially when other distinct expressions of cancer are absent.

_Cancer of the pancreas_ is at present a primarily hopeless disease, and is of interest to the surgeon only in that some of the most distressing features which it causes may be temporarily relieved by biliary drainage. The symptoms which will bring such a patient to him will be essentially those of biliary obstruction, perhaps with the accompaniment of glycosuria or the discovery of fat in the feces. Neither of these, however, is an invariable symptom. Diarrhea is but an occasional feature, and colorless stools may be discharged when there is no jaundice. A perfectly painless progressive (bronzing) jaundice, with distention of the gall-bladder, would perhaps more than any other single feature indicate pancreatic cancer. When such a growth has attained a size sufficient to make it discoverable on palpation it might be mistaken for a biliary cancer, from which it would have to be differentiated especially by the movability usually noted in the latter.

The only treatment for pancreatic cancer is operative, and consists in _drainage of the gall-bladder_, and after a manner elsewhere described in the section on Diseases of the Biliary Passages.

PANCREATIC CALCULI.

From the true pancreatic secretions precipitations of mineral salts, combined with organic elements, may occur, just as from the saliva, the latter thus furnishing the salivary calculi elsewhere described, the two varieties having many points of resemblance. Again, calculi, evidently of biliary origin, may be met with in the pancreatic duct. The former consist largely of calcium oxalate, combined with calcium carbonate and phosphate. They may be single or multiple, and vary greatly in size up to that of a robin’s egg. Hypothetical calculi, with consequent duct obstruction, have been held to be responsible for many pancreatic cysts. Thus one may explain cyst formation, even though no calculi be found at the time of operation.

Calculi reposing within the structure of the pancreas have much to do with the acute and subacute, as well as the more chronic types of pancreatitis, the latter when they act alone, the former when to their essential disturbances are added the possibilities of bacterial infection.

When pancreatic calculi produce symptoms they resemble those of cholelithiasis, causing paroxysmal pain, with vomiting, and perhaps transient jaundice. Glycosuria is an occasional feature.

The condition is rarely diagnosticated previous to operation. Should a calculus be met in this location during the progress of any operation it should be removed by an incision made parallel to the duct, with such closure of the wound in the pancreas as can be subsequently effected and with ample drainage of the deep wound, in order that pancreatic fluid may not escape into the peritoneal cavity. If encountered during operation for pancreatic cyst the same advice will apply.