In pancreatitis, if tumor be present, it is less mobile than such tumors of the pylorus, liver, omentum, or intestines as are likely to be located in the epigastric or umbilical regions.

The most common cause of epigastric tumor is cancer of the stomach, and a useful diagnostic sign is mobility of the tumor which is synchronous with respiratory movements. These respiratory excursions are not made by pancreatic tumors, on account of its vascular attachments.

It is a consolation, perhaps, that so few of the recorded cases have been diagnosed clinically as pancreatitis. Operative and post mortem diagnoses do not reflect a dazzling lustre on the clinician, and the latter certainly are not of great value to the patient.

I have intentionally not specified malignant diseases of the pancreas, as such conditions are essentially chronic and offer longer periods of investigation and study than are present in the acute inflammatory disorders. To attempt to differentiate pancreatic malignant diseases from those of the stomach, liver and duodenum would call for more time than I feel justified in occupying now.

THE RESULTS OF CURETTEMENT IN THE TREATMENT OF DYSMENORRHEA. Holden has obtained the post-operative histories of ninety-five persons on whom curettement was performed for painful menstruation. Four classes are made:

1. Complete or very great relief for one year or more. 32 cases, or 33 per cent. of the total number come into this division, some having had eight, nine, or ten years elapse since the operation.

2. Seven per cent. obtained great relief for two years or more, but with subsequent occurrence of the attacks.

3. In eight per cent. of the cases moderate relief was noted for a year

or more.

4. The fourth class contains 50 per cent. of the entire number and includes those who either obtained no relief, or merely a very little for a short time.

It seems probable that those individuals in whom the pain appears several days prior to the menstrual flow, are the most unfavorable subjects for curettement, while the prognosis is much better in those who have the pains come on the same day as the flow. Wherever the pelvic organs are poorly developed the outlook for the patient for cure by curettement is not very good.-American Medicine, Nov. 4, 1905.

DR. W. J. MAYO gave at the annual meeting of the New York Medical Association his results in the radical removal of the cancer of the stomach. In eighty-one resections there was a mortality of 14 per cent. One patient was living after nearly five years; seven or eight had lived three or four years with very few or no symptoms. All medical treatment gives a mortality of 100 per cent., so if surgery will cure some cases, and prolong the comfort and life of others, it is well worth trying.-Medical Record, Nov. 4. 1905.

SURGERY OF THE PANCREAS.*

BY J. EMMONS BRIGGS, BOSTON, MASS.

"For the purpose of operation the pancreas may be approached through a median abdominal incision made between the ensiform cartilage and the umbilicus. After opening the peritoneal cavity, it can be reached in five ways:

1. Above the Stomach. In thin persons, with prolapse of the stomach, after incising the gastro-hepatic omentum.

2. Through the Stomach. After incising both the anterior and posterior stomach wall.

3. Below the Stomach. This is the route chosen by the majority of operators. The omentum immediately below the greater curvature is torn through, thus entering the lesser peritoneal cavity.

4. Through the Transverse Mesocolon. The omentum and transverse colon are turned upward, the former incised and the lesser sac entered.

5. Incising the Peritoneum to Right of Duodenum, and slipping the second part of the duodenum upward toward the median line.

The pancreas may be reached through an incision in the left loin, commencing at the tip of the twelfth rib and extending obliquely forward to the umbilicus."+

In an operation upon the pancreas, we must remember that we have to deal with an organ in itself of the highest functional importance, as it supplies the most important digestive juice.

The blood supply to the pancreas comes by way of the splenic, pancreatico-duodenal branches of the hepatic and the superior mesenteric arteries. These vessels ramify in all directions in entering the gland, and cannot be avoided whenever incision into the organ is attempted. The free bleeding which is encountered is exceedingly difficult to control, as the ligature in mass of the friable gland tissue usually results in the cutting through of the ligature and augmentation of the bleeding. It is useless to attempt the ligation of the individual vessels, as the bleeding is parenchymatous.

A second danger lies in the escape of the pancreatic juice whenever the gland is injured. An outpouring of the pancreatic fluid causes fat necrosis and a digestion of structures

*Read before the Boston Homeopathic Medical Society, Dec. 7, 1905. † Abdominal Operations-Moynihan's, p. 593.

with which the juice comes in contact. After operating for acutely septic abdominal conditions, we rely upon the rapidly forming plastic exudations and adhesions to wall off septic areas, and thus prevent general peritoneal invasion. In case of escape of pancreatic fluid, these plastic exudations. and new adhesions are rapidly attacked and destroyed, thus greatly favoring general sepsis.

The pancreatic fluid probably does not in itself prove fatal by absorption, but, acting indirectly by its irritation, prepares a nutrient medium upon which septic bacteria subsist and multiply.

Thus it will be seen that hemorrhage and the escape of pancreatic juice are both serious complications to be encountered in the surgery of this organ.

Acute Pancreatitis: Perhaps there is no intra-abdominal disease which is more serious than acute pancreatitis. Certainly there is none which, from the symptoms it occasions, is more difficult to diagnose.

The pathology of acute pancreatitis is characterized by inflammation, hemorrhage, fat necrosis, suppuration and gangrene.

The inflammation is due to bacterial infection, usually via the pancreatic duct. Gall stones impacted in the common duct are active factors in the production of pancreatitis, either by ulceration and perforation or by occlusion of the duodenal opening, which would permit of infected bile invading the duct of Wirsung. A calculus, when lodged near the orifice of the common duct, may also obstruct the pancreatic duct. It is not difficult to understand how such an obstruction, with an existing sepsis, would be followed by a rapid phlegmonous inflammation of the entire pancreas, which would very rapidly convert that organ into a gan

grenous mass.

In the hemorrhagic stage of acute pancreatitis, that organ is often much enlarged, soft, and of a dark reddish-brown color. Occasionally, no discoloration is discernible, but, on section of the gland, we find the interlobular spaces filled with bloody accumulations. The duct and its ramifications contain blood and ichorous fluid. The hemorrhagic infiltration may extend into the mesentery and meso-colon, and become disseminated into the peritoneal cavity. The presence of this blood-stained peritoneal fluid is often the first intimation which the surgeon may have of pancreatitis.

Another condition found in cœliotomy, which should immediately direct the surgeon's attention to the pancreas, is the area of fatty necrosis to be found in widely disseminated areas upon the omentum, mesentery and subperitoneal fat. Langerhans demonstrated that these necrotic areas consisted of a combination of fatty acids with lime salts. He claims that the primary lesion of the pancreas offers opportunity for the escape of the fat-splitting ferment from the organ into the surrounding tissue, resulting in secondary fat necrosis. Although its cause may still be somewhat obscure, yet we find areas of fat necrosis in the majority of cases of hemorrhagic, and almost always in gangrenous pancreatitis.

The symptoms of acute pancreatitis are those of epigastric peritonitis. Fitz asserts that:

"Acute pancreatitis is to be suspected when a previously healthy person, who suffers from occasional attacks of indigestion, is suddenly seized with violent pain in the epigastrium, followed by vomiting and collapse, and in the course of twenty-four hours has a circumscribed epigastric swelling, tympanitic in resistance, with slight rise in temperature."

Great difficulty may be experienced in differentiating acute pancreatitis from acute intestinal obstruction, perforating gastric or duodenal ulcer.

The case of our lamented colleague, Dr. William Woods, may be cited as conveying a very clear picture of this rapidly fatal disease. I quote from a report of this case as presented by Dr. F. P. Batchelder at a meeting of the Massachusetts Homœopathic Medical Society, but have taken the liberty of abbreviating slightly.

"The patient, Dr. William Woods, aged sixty-two, a 'life member' of our Society, was taken ill soon after midnight of Monday, May 27, 1901." "Previous History:"

"At regular intervals extending over several years, he had suffered from short but very acute attacks of epigastric pain which he termed 'indigestion,' since they were apt to appear suddenly after an abundant meal. His general health has otherwise been good.". "Present Illiness."

"Last evening, (May 26, 1901) he partook of ice cream, etc.

Before midnight he did not sleep well and had some distress which he referred to the stomach. . . . After midnight the pain became suddenly excruciating, with much protracted vomiting, moderate diarrhoea and great flatulence

with some distension. I found him in bed, in a state of profound collapse, with cold extremities and forehead covered with clammy perspiration, great pallor of face, weak and somewhat rapid pulse, and subnormal temperature. He complained of excruciating epigastric pain at a point two or three inches above the umbilicus, and a little to the left of the median line. Examination of the abdomen showed some distension, tenderness in the painful area and a vague resistance covering an oval spot perhaps three or four inches in diameter. With all haste the patient was removed in the ambulance to the Massachusetts Homeopathic Hospital, where, as soon as was possible, he was seen by Dr. James B. Bell, the surgeon on duty, and four or five other members of the medical and surgical staff. The concensus of opinion was that an obscure abdominal condition was present, in all probability acute intestinal obstruction. . . . Dr. Bell made an exploratory incision. The colon and adjacent two feet of the ileum were apparently normal. The ileum for ten or more feet above that point, was abnormally dark in color with some distension of the mesenteric vessels. Several ecchymotic spots were found upon the mesentery. No indication of acute intestinal obstruction was present. The wound was closed. The examination was well borne by the patient.

The subsequent course of the case was characterized by temporary relief from pain, more or less continued vomiting, somewhat increased abdominal distension, some elevation of temperature and pulse, cold livid extremities and great 'air hunger.' Death occurred at 4.30 A.M. June 1, 1900, about ninety-six hours after the first symptom.

Autopsy. The following extract from the record of Dr. Watters is very instructive. With the lapse of time between exploratory incision and the fatal termination, the pathological process had progressed to a point where its true nature was unmistakeable.

"Incision from sternum to pubes. Wound in good condition. Omentum and mesentery very fatty and studded with small round or oval yellowish-white masses about 2 m.m. in diameter, fat necrosis. Slight inflammation of the peritoneum which is soft and easily torn. Congestion most marked in jejunum, appendix normal. A large clot of blood was found near the splenic flexure of the colon. A large gall stone was