The pancreas, its surgery and pathology

Front matter

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Preface

Our present knowledge of the physiology, pathology, and surgery of the pancreas, like so many other advances in medicine in recent years, was rendered possible by the beneficent work of Lister. So long as clinical observation was only capable of being checked by the experience of the post-mortem room, and by an occasional accidental experiment on the living subject, the important and complex part that the pancreas plays in the physiology of the body remained unsuspected, and descriptions of the diseases to which it is liable were confined to a few lines on malignant disease, cysts, and calculi. Animal experiments, now rendered safe by antiseptic surgery and improved technique, have thrown a flood of light on the physiology of the organ and elevated it from the position of a mere accessory digestive gland to the rank of a structure indispensable for the metabolic needs of the organism. The numerous laparotomies undertaken in recent years have afforded the surgeon opportunities of observing and handling the living organ, both in health and disease, and a comparison of the conditions noticed, together with a closer investigation of the symptoms and after-histories of the cases, has very considerably widened our conception of the pathological changes that may occur in the gland and afforded a basis for their clinical differentiation. Histological and post-mortem inquiries, stimulated by the impetus thus given, have still further increased our knowledge, and confirmed the conclusions of the bedside and the operating theatre. There are as yet many points on which observers are not agreed, and there are questions lo Preface

which still call for elucidation, but the enormous literature of to-day as^ compared with that prior to 1886, when Professor Senn of Chicago published his valuable experimental work on the pancreas, shows the great advances that have been, and are being, made in the subject.

The symptomatology and pathology of the pancreas are so intimately bound up with the physiology and anatomy of the gland, and these again are rendered so much more easily understood if the comparative anatomy and development of the organ are borne in mind, that we have prefaced the pathological and clinical sections of this work with a brief, but we hope sufficiently comprehensive and accurate, account of those subjects.

In the chapter on histology, and again later under the heading of diabetes, we have discussed the structure and supposed functions of those characteristic groups of cells known as the islands of Langerhans. In doing so we have endeavoured to impartially summarise the evidence for and against the contending \dews that are held with regard to them, but, as will be gathered from the text, we personally are of opinion that the balance of available evidence strongly points to their being independent structures related to the control of carbohydrate metabolism within the body that the pancreas undoubtedly exerts.

A thorough comprehension of the chemical changes induced in the body by diseases of the pancreas would include a knowledge of the pathology of diabetes, but at present we are still in the dark as to the true essentials of that condition. Our description of the chemical pathology of the pancreas is therefore largely confined to the condition of the urine and faeces found to accompany disease of the gland, and although we have now devoted special attention to this subject for six or seven years, we are conscious that as yet only the fringe has been touched upon. The so-called '* pancreatic'* reaction in the urine is still \mder investigation. The improved

Preface 1 1

method described in these pages is undoubtedly a distinct advance on the original process described in the Arris and Gale lecture of 1904, but it is not yet as perfect as it might be. The difficulty of the investigation is considerable, for the quantity of material to be obtained from any one case, even when a well-marked reaction is given, has proved to be small, and it is only by collecting very large amounts of urine from suitable cases, whenever they have occurred, that we have been able to make slow advances. We do not consider that at present we are in a position to make more positive statements than those expressed in the chapter on chemical pathology, but we hope that we may shortly be able to do so. In our own practice we never rely upon the "pancreatic'* reaction alone in making a diagnosis of pancreatitis or malignant disease of the pancreas, but always take into account the results of a complete analysis of the urine and a chemical examination of the faeces, as well as the clinical symptoms ; it is from neglect of these precautions, and under the false notion that the "pancreatic*' reaction was claimed to be pathognomonic, that the mistakes made by some writers have arisen. The examination of the faeces often gives important confirmation of the presence or absence of disease of the pancreas, but this is not always the case, and the possible causes of unexpected results described in the text have always to be borne in mind. The question of the cause of the absence of colour in the stools in various pathological conditions has excited attention for many years, and, although we do not suggest that the explanations our investigations and observations have enabled us to make are true of all cases in which the faeces are white, they appear to be so for pancreatic disease.

There seems to be an impression in the minds of nearly all members of the profession that diseases of the pancreas, excepting some of the grosser lesions, are unrecognisable during life, but we venture to think that a careful

12 Preface

perusal of the chapter dealing with general symptomatology and diagnosis will show that while no single sign or symptom is t^haracteristic of disease of the pancreas, no more than of any other organ, the cumulative evidence to be obtained by a careful investigation of the history, clinical symptoms, and signs, and the indications to be obtained by the methods of the laboratory, should leave no doubt as to the presence or absence of pancreatic trouble in any particular case and, in the large majority, allow of a definite opinion as to the nature of the lesion being arrived at.

The classification of inflammatory lesions of the pancreas is the same as that outlined in the Hunterian Lectures of 1904. Increased experience has only served to demonstrate its clinical utility, and its adoption by subsequent writers shows that they recognise the numerous forms that inflammation of the pancreas may assume under various conditions. We have emphasised the intimate etiological relation existing between gall-stones and pancreatitis and pointed out the conditions under which biliary calculi in the common bile-duct are likely to cause, and will fail to give rise to, pancreatic inflammation. We have also laid stress upon the no less important, but less commonly recognised, association of inflammation of the pancreas with catarrhal conditions of the upper part of the gastro-intestinal tract. Pancreatitis resulting from a duodenal catarrh may, under certain conditions, give rise to more or less persistent jaundice, and, in our experience, is the most common cause of the conditions usually known as acute and chronic '* catarrhal*' jaundice.

In dealing with the subject of diabetes we have devoted much space to a consideration of its relations to the pancreas, and have quoted the more important experimental evidence and clinical work bearing upon the subject. Between the ofttimes conflicting, and even contradictory, statements of different authors it is difficult to arrive at

Preface 13

any very definite conclusions as to the frequency of pancreatic lesions in diabetes and as to how these are related to the disease, but one fact that has been clearly established is that a small portion of normal gland is capable of averting the onset oi the condition. It is therefore important that diseases of the pancreas should be recognised at the earliest possible moment, and that conditions likely to give rise to pancreatic lesions should be radically treated before they have had time to bring about permanent, and may be progressive, injury of the gland. For this reason we strongly advocate the early treatment of gall-stones, especially when they are present in the common duct and an examination of the urine and faeces shows that a pancreatic lesion exists. The very striking increase in the death-rate from diabetes shown by the Registrar-Generars returns is possibly not unconnected with the greater prevalence of digestive disturbances in recent years, and we therefore think that duodenal catarrh and the frequently associated catarrhal pancreatitis always call for prompt attention.

One of the most important practical results that has followed from modem observations on the pancreas is the recognition of the very close similarity of the symptoms of cancer and chronic pancreatitis in the head of the gland. Many cases of the latter have in the past been allowed to die unoperated on, under the mistaken impression that they were suffering from cancer, and our experience would suggest that, even at the present time, there are many who do not realize the importance of a differential diagnosis between the two conditions. We have dealt with this subject under the headings of chronic pancreatitis and cancer, and it is also referred to in the chapters on pathology and symptomatology.

While a considerable number of the illustrations in this work are original and have been taken from preparations in our own possession, we are deeply indebted to

14 Preface

the various museums mentioned for permission to have drawings or photographs made from their specimens. Our thanks are also due to the authors and pubKshers, to whom acknowledgments are made, for the pictures appearing above their names.

To the end of each chapter we have appended a list of the more important papers and publications bearing on the subjects therein discussed. These do not make any pretense at completely exhausting the bibliography, but as a rule merely represent an alphabetical list of the authors mentioned in the text. In writing this work we have laid imder contribution all the monographs available to us, as well as those papers that have appeared on the subject in the current literature. We have endeavoured as far as possible to credit each author with the views and cases of which he has written, and are particularly indebted to Opie, Oser, RoUeston, and Flexner. A certain number of illustrative cases and illustrations have also been taken from a work on '* Diseases of the Pancreas '' by A. W. Mayo Robson and B. G. A. Moynihan (Saunders & Co.), which has been for some time out of print. Each case and opinion has, as far as possible, been attributed to its original author, but should we inadvertently have misrepresented any of the writers quoted, or attributed a view or opinion to some other than its original author, we crave forgiveness and ask for correction.

A. W. Mayo Robson.

P. J. Cammidge.

London, August, 1907.

Chapter I Comparative Anatomy

In unicellular organisms all the activities of life are embraced within the compass of a simple unit of living matter; it moves by contracting its substance, it draws back from hurtful influences, it absorbs oxygen, it engulfs and digests food, and gets rid of the waste products of its metabolism. But, early in the communal life of the multicellular metazoa, a tendency is seen to limit the physiological activities of the groups of cells, and to concentrate special functions in particular areas. As we advance up the scale of life this tendency becomes more and more marked, and these aggregations of cells, set apart to subserve particular ptu"poses in the economy of the body, are differentiated as distinct organs. The more complicated and active the life of the animal, the more numerous are its organs, for, by the concentration of the activities of the cells on the performance of some special work, energy is economised, in the same way as division of labour in the commercial world is found to contribute to economy of production.

One of the most primitive areas to be set apart for the

performance of a special function is that which deals

with the absorption of food. First distinctly seen as a

mere folding in of the surface to form a pouch, it assumes,

2 17 in most of the metazoa, the form of a canal passing through the tissues and connected with the external world by an apeture at either extremity. The cells lining the alimentary area, in its simplest form, show but little differentiation of structure, and, although they are predominantly digestive in character, they have not lost the primitive and many-sided qualities of the protozoon, as is shown by the ease with which a change of environment will bring about a change of function, so that those which were previously subsidiary become predominant. In the higher forms the characters of the cells become more fixed, their structure is modified to suit their special work and surroimdings, and their power of reverting to the primitively complex physiological, but anatomically simple, type is lost.

Up to the echinoderms there is no indication of a particular concentration of the digestive powers in any one part of the alimentary tract. The walls may be pouched or ridged, to increase the surface, and one portion may be more muscular or harder than another, in order that the food may be better ground or mixed, but the whole extent of the tract is in contact with its contents, and no part is to be distinguished as especially set apart for the elaboration of digestive ferments. In a type such as the starfish, however, such glandular structures can be recognised. In this animal five branches are given off from the pyloric portion of the stomach, and each of these divides into two large digestive caeca. The glands themselves do not come into contact with the food, but secrete a ferment, which is said to have tryptic, peptic, and diastatic powers, thus showing the first definite step in the further differentiation of the functions of digestion and absorption.

Most of the Crustacea, Insecta, and MoUusca possess one or more pairs of similar digestive caeca, or glands, which join the alimentary tract in the region of the midgut, or stomach. Their function is still complex, and no advance to a higher and simpler physiological type than that seen in the starfish is to be recognised.

In the lower members of the vertebrate series a similar state of things is found, and even in certain fishes the length of the intestine, a thickening of the mucous membrane of the duodenum, or the inactive nature of the species renders any special digestive glands unnecessary. In most osseous fishes, however, there is a well-defined gland having the characters and functions of a liver, and in addition an extension of the secreting surface of the intestine by the presence of a number of long, slender pouches, w^hich are connected with the commencement of the duodenum. These differ in length and width, and, while the widest are sometimes found to be filled with the same contents as the intestine, the narrowest serve only as secreting organs, and are apparently specialised for the elaboration of digestive ferments. Their number and arrangement vary in different types. In the sandlance there is only one, but in the whiting and salmon there are a hundred or more. In the herring, haddock, and salmon they are disposed in a line along the whole length of the duodenum, while in the whiting they are arranged in a circle around the distal end of the pylorus. A tendency to concentrate these intestinal outgrowths into a more typical glandular structure is seen in some

Fig. I . — Pyloric pendages of the (after Gun t her).

apsalmon members of the class, especially in the more active types, in which rapid and complete digestion is a necessity. The 50 caeca of the pilchard open into the duodenimi by 30 orifices, but the 1 20 of the whiting progressively imite into four or five groups, each communicating with the duodenum by a single duct. The swordfish has but two

openings, and in the sturgeon a single wide duct terminates by a papilla on the internal surface of the duodenal wall, close to the ductus choledochus. The long, slender, ramified caeca are, in the two last, boimd loosely together by connective tissue and possess a rich vascular supply, the whole being enclosed in a capsule, thus corresponding in structtu"e to a conglomerate gland of the type of the pancreas. In many fishes that have typical pyloric caeca, and in some that do not possess these structures, there exists a conglomerate glandular organ opening by a duct into the duodenum, which is apparently the true homologue of the pancreas in air-breathing animals.

A large-lobed structure of this description, the duct of which is so intimately connected with the bile-duct that both appear as a single structure externally, is found in the salmon. In the catfish it is very large, and the bile-duct passes through its substance. In the plaice, flounder, gar-pike, etc., it is situated in the mesentery and is smaller, but its duct in each instance accompanies the terminal portion of the ductus chole-

Fig. 2. — .'\limentary canal of the whiting, showing the arrangement of the pyloric cicca (after Owen).

dochus. The characters of this organ in the sturgeon have already been referred to. A similar glandular mass of considerable size, lying behind the stomach, and close to the spleen, is met with in sharks and other elasmobranchs.

The liver in reptiles is proportionally large, and they

Fig. 3. — Pancreas and spleen of the turtle (after Owen).

possess a distinct and well-defined pancreas. The latter is a yellow or pink gland, consisting of many acini, each opening into a small duct. These ducts unite into larger ducts, and these again form a common channel, which opens into the intestine with, or close to, the bile-duct. The acini round the smaller ducts are aggregated together to form lobules^ and the lobules are again collected into lobes. In some members of the group the pancreas is spread out in the duodenal mesentery, but in most serpents and lizards it has a compact form; in the crocodile it is divided into two elongated lobes, and sometimes communicates with the duodenum by two distinct ducts ; in the turtle the pancreatic duct terminates by a papilla opening into the expanded end or ampulla of the bile-duct. The pancreas of the carnivorous types of the reptilia is more bulky and compact, forming a larger proportion of the total weight of the animal than in the vegetable-feeders.

The pancreas of birds is usually firmer than that of reptiles. It is also relatively larger, probably to compensate for the absence of mastication and the salivary digestion of the food. It is long and narrow, lying in the space between the duodenal loops, and generally consists of two, and sometimes of three, portions. It communicates with the intestine by two, and occasionally by three, separate ducts, which open near the hepatic and cystic ducts.

In the mammalia the pancreas is more plainly of the conglomerate type. It is paler, and of a firmer structure, than in birds, and also differs by the development of a part, stretching towards the spleen, which is more or less distinct from that lodged within the duodenal loop. In the simpler members of the series, such as the marsupials, the gland is bent upon itself, running from the

Fig. 4. — Pancreas and duodenum of goose (after Owen).

duodenum to the spleen, behind the stomach, and giving off into the duodenal mesentery and omental folds more or less numerous processes. The main duct opens into the bile-duct, the bile and pancreatic secretion reaching the intestine through a common opening.

The main mass of the gland in rodents follows the curve of the duodenum, but sends numerous ramifying processes into the mesentery. The main duct, into which the minor

Fig- 5- — Pancreas of the rat (after Owen).

channels collect, enters the duodenum a considerable distance from the point of entry of the bile-duct. In the beaver 18 inches separates the papilla of the biliary passage from that of the pancreatic duct, and the latter is some 21 inches from the pylorus. A small, and usually impermeable, duct, corresponding to the main channel of the pancreas of most of the mammalia, can, in some instances, be made out joining the intestine in the neighbourhood of the biliary papilla. The functioning duct in this group probably represents one of the lower members of the series of digestive caeca found arranged along the length of the duodenum in some fishes.

The pancreas of the aquatic mammals (Cetacea) is long, narrow, and compact. It crosses the spine at the root of the mesentery, the left end terminating near the spleen,

and the right being expanded A and adherent to the curve of

■ the duodenum. The pancre-

J^ atic duct joins the bile-duct.

•^ The transverse or splenic

' \ " portion of the gland is still

better developed in the ungulates, and, in this order, forms the larger part of the gland. Its duct, which is separate from that of the duodenal part, joins with the hepatic duct to form an ampulla before entering the intestine. The smaller, duodenal portion of the gland lies at right angles to the transverse part. It expands downwards and backwards in the duodenal mesentery. Its duct enters the duodenum about the same distance from the pylorus as the common bile and pancreatic opening, but by quite a distinct aperture. The divisions of the pancreas in the ruminants are somewhat less well defined, the gland being broader and flatter in character.

The long, narrow pancreas of the camivora shows a well-marked division into splenic and duodenal sections, which are of unequal length. The splenic part is straight

Fig. 6. — Terminal bilepouch of the elephant, formed by the union of the common bile-duct and pancreatic duct (after Owen).

and runs transversely across the spine ; the duodenal segment follows the curve of the duodenum. Both are covered by the peritoneum. In most members of the order the ducts of the transverse and descending portions anas-

Fig. 7. — Pancreas of the dog, dissected to show the relations of the common bile-duct and pancreatic ducts and their openings into the duodenum.

tomose at two points, and the main duct communicates with the bile-duct before entering the duodenum.

The pancreas of the cat and dog calls for special mention, owing to the frequent use made of these animals in experimental work. The duodenal part of the gland in

Fig. 8. — Dissection of an abnormal pancreas of a dog, showing separate openings for the common bile-duct and two pancreatic ducts.

the dog is larger than the splenic portion, which it joins at right angles. As a rule, the smaller duct joins with the common bile-duct within the walls of the duodenum, but is externally quite distinct. The larger then enters the

26 The Pancreas: Its Surgery and Patholog}'

bowel half an inch or more below. Occasionally the bile-duct and two pancreatic ducts have separate openings, as in the case of a dog dissected by one of us. In the cat there is a large duct, communicating with both sections of the gland, which joins with the bile-duct, and enters the duodenum by a common orifice with it. A smaller duct is also present, which anastomoses with the main channel within the gland, but possesses a separate opening into the intestine a short distance below. Occasion-

Fig. 9.— Pancreas of the cat, laid open to show the main ducts and their relation to a large vein near the junction of the two ducts (after DeWitt).

ally a lateral reservoir, communicating with the main channel by a short duct just before its junction with the bile-passage, is found.

The pancreas of the anthropoidea is less mobile than in any other group of animals, and is found to be more completely applied and fixed to the posterior abdominal wall, the more adapted the animal is to the upright position. The duodenal part is reduced to an enlargement termed the **head,** while the splenic portion narrows at its termination near the spleen to form **the tail/' The intervening portion forms *'the body*' of the gland, along the thick upper border of which run the splenic artery and vein. The main duct traverses the substance of the gland, nearer its lower than its upper border, and usually commtmicates, near its termination, with the lesser duct which drains the head. The latter may have a separate entrance into the duodenum, placed somewhat nearer the pylorus than the papilla by which the main pancreatic channel and bile-duct open, or it may be obliterated, the whole of the pancreatic secretion, including that from the head, then finding its way into the intestine by way of the common opening.

Rachford has pointed out that the nearer an animal approaches to the purely carnivorous type, the more likely are the bile and pancreatic juice to be passed into the intestine through a common opening, and the closer is this opening to the pylorus.

Gtinther: "The Study of Fishes."

Owen: ** Comparative Anatomy and Physiology of Vertebrates."

Rachford: Jour, of Physiol., xxv, 165.

Thompson : * ' Outlines of Zoology. ' *

Chapter II Anatohy

The greater part of the pancreas in man lies in the epigastrium, but a portion of the body and the tail extend into the left hypochondrium, and the head may project into the umbilical region.

To expose the organ from the front the stomach must be detached from the great omentum and be turned upwards. It is then seen as a long, pinkish, cream-coloured gland, stretching transversely across the posterior abdominal wall, from the concavity of the duodenum to the lower and inner border of the spleen. In the fresh condition it has a firm consistency and a markedly lobulated appearance. In length it varies from 5 to 6 inches (12 to 15 cm.). Its average weight ranges from 2.25 to 3.5 ounces (66 to 102 grams) . The general shape of the gland is aptly compared by Birmingham, in Cunningham's ** Text-Book of Anatomy/* to the letter J placed upon its side, i-i , the loop being thickened to represent the head, the thickened stem corresponding to the body, and the narrow bend joining the two indicating the neck.

The enlarged right extremity, or ** head," extends downwards and to the left, lying in the concavity of the duodenum in contact with its second and third parts, and opposite to the second and, upper part of, the third lumbar vertebra. The short and comparatively narrow portion of the gland termed the **neck** arises from the upper and right part of the head. It nms upwards and to the left, and, after a course of about one inch, merges into the **body." This, which is the longest section of the gland, runs backwards and to the left at the level of the first lumbar vertebra. The pointed left extremity, or ** tail/* is the least firmly attached portion of the organ. It merges so gradually into the body that no sharp line of distinction can be drawn between the two.

The disc-shaped head is flattened from before backwards. Its right and lower borders are closely united to the duodenum, one-third of the circumference of which may te enveloped by the gland substance in a well-

Fig. 1 1 . — Transverse section of the abdomen at the first lumbar vertebra, to show the relations of the pancreas (after Braune).

developed organ. The right half, above, is continued into the neck. To the left, it is separated from the neck by a deep groove, the **incisura pancreatis.'* In this groove lie the superior mesenteric vessels, which are continued over the anterior surface of the head, near its left border. That portion of the gland which lies to the left of the vessels, along the third part of the duodenum, is termed the **imcinate process,'' and when, as happens occasionally.

it is separated from the rest, it is known as the ** lesser pancreas." The superior and inferior pancreatico-duodenal vessels also course over the head, near its right and left borders respectively, to break up on its anterior surface. Above and to the right, the anterior aspect of the head is in contact with the commencement of the transverse colon, the posterior surface of which is directly attached to the pancreas by areolar tissue. The lower part of the anterior surface of the head of the gland is covered by peritoneum, reflected from the lower surface of the colon and entering into the formation of the greater sac. This part is in contact with portions of the small intestine.

The posterior surface of the head is devoid of peritoneum, and is directly applied to the front of the inferior vena cava, the left renal vein, and the aorta. The common bile-duct also lies in a groove, or canal, in this surface.