The Surgical Treatment of Acute Haemorrhagic Pan creatitis. The author gives de tails of six recent cases occurring in the practice of himself and of his colleagues in Boston, one of which, operated on by Dr. J. C. Munro, recovered. Five of the cases were in women, one in a man. One that of the man, presented itself in a manifestly hopeless state, and died without operation on the third day after admission to hospital. One died on the operating table ; one three and a half hours after operation from shock; one on the third day after operation from peritonitis and sepsis ; one eight weeks after operation from secondary haemorrhage. Two of the cases were more properly peripancreatitis. Before operation or autopsy, an absolute diagnosis is generally impossible. The signs are those of an acute peritonitis originating in the epigastrium, which, from whatever cause, demands exploration of the abdomen.
Milder cases of acute pancreatitis or peripancreatitis recover both with and without operative intervention. Severer cases re quire operation, which should be performed early, for the follow ing reasons : ( ) Because the primary haemorrhage in itself leads to necrosis and disintegration of gland tissue, and the haemorrhage may be stopped and further necrosis both of fat and gland tissue prevented by gauze packing and adequate drainage. (2) Because the patient is in far better condition to withstand an operation early in the disease than later, when weakened by suppuration in the lesser peritoneal cavity, and necrosis of much fat and gland tissue.
A certain class of cases in which the primary shock is so severe as to render operation out of the question must be excepted from the operative cases.
The mortality from pancreatitis will undoubtedly be high, but there is reason to hope that with early operation and adequate provision for lumbar drainage it may be considerably diminished.
As the diagnosis must, in a large percentage, be tentative, the first or exploratory incision should be made in the median line above the umbilicus. This incision may, in severe eases, be made with advantage under local anaesthesia. On account of the weak condition of most of the patients rapid operating is essential. The great omentum must be traversed to reach the lesser peritoneal cavity. Masses of blood-clot and necrotic fat should be rapidly evacuated. Further haemorrhages may be stopped by gauze pack ing. It will be generally impracticable to search for bleeding points.
Where the mass of blood-clots or the abscess cavity has ex tended into the left lumbar region, adequate drainage must be provided by a lumbar incision made on the finger passed into the cavity. This dependent lumbar drainage is probably the most important step of the operation, since in the majority of cases it will probably not be possible to drain successfully through a median incision. In case symptoms at the base of the left pleural cavity point to pocketing of pus above the spleen, the subphrenic space should be drained by resecting the tenth or eleventh rib in the posterior axillary line. The pleural cavity will be opened, but will be probably walled off by adhesions. At any rate, drain age of this pocket is essential, in order to avoid perforation of the diaphragm by the abscess. Careful diagnosis, rapid operating, and careful nursing will be necessary to save these cases, as the proximity of the inflammatory process to the solar plexus, the diaphragm, heart, lungs, stomach, and duodenum, together with the deep situation of the pancreas, all contribute to make its in flammation so dangerous and difficult as to tax to the utmost the art and skill of the surgeon. Boston Medical and Surgical Jour nal, November 29, two.