JAMES THORBURN, M D., Edin., Toronto. Ex-President College Physicians and Surgeons, Ontario: Ex-President Canadian Medical The Canada Lancet VOL. XXXVIII. DECEMBER, 1904 No. 4 ON PANCREATIC INFLAMMATIONS IN THEIR RELATIONSHIP TO CHOLELITHIASIS, AND THEIR TREATMENT. By A. W. MAYO ROB ON. F.R.C.S., Vice-President and Hunterian Professor Royal College of Surgeons of England. r. President and Gentlemen, Your kind invitation to give the Address in Surgery before the Canadian Medical Association, accompanied as it was by other temptations, especially that of a visit. to this delightful and important part of Greater Britain, left me no choice but to accept the proposed honor. My only difficulty lay in the selection of a subject, but as I have been for some time working on the pathology and surgery of the pancreas, I ventured to think that pancreatic inflammations in their relationship to cholelithiasis might prove of sufficient interest and importance to engage your attention. If my surmise falls short of my wishes and of your expectation, I must beforehand crave your forgiveness. Among the many complications of gall stones, pancreatitis in its various forms is now known to be one of the most important, though the relationship has only comparatively recently been recognized. The bile ducts and the pancreas are so intimately related in their development and their anatomy that it can excite no surprise to find them frequently associated in their diseases; and though we frequently find cholelithiasis without pancreatic troubles, it is much less common to have inflammation of the parcreas, whether acute, subacute or chronic, without finding common duct cholelithiasis. The reason for this association is not far to seek; it is due to the junction of the common bile duct and the duct of Wirsung at the ampulla of Vater, and their common opening into the duodenum, a channel always containing organisms ready, under certain conditions, to invade and become virulent. Pancreatitis is probably always a secondary disease and usually dependent on infection spreading from the common bile duct or duodenum. It may be asked, if common duct cholelithiasis and pancreatitis are so Address in Surgery delivered before the Canadian Medical Association at Vancouver, B. C,, August 24th, 1904. often associated, who should some cases of common duct obstruction go on for months or years without the pancreas participating? I hope to show by clinical evidence that the explanation of the presence or absence of pancreatitis as a complication of cholelithiasis is an anatomical one, though the degree of inflammation when infection does occur, is in a great measure a vital process, dependent on the powers of resistance of the individual. I must ask you to excuse me for taking you back to the dissecting room for a few minutes, as, though doubtless you are well acquainted with the normal anatomy of the pancreas there may be some who are unacquainted with the great number of variations that may be encountered; which varieties may save a patient from or may commit him to pancreatisis should he be unfortunate enough to suffer from common duct cholelithiasis. The common bile duct, starting by the junction of the cystic and hepatic duct, courses along the free border of the lesser omentum associated with the portal vein and hepatic artery; it then passes behind the irst portion of the duodenum, and soon comes into relation with the pancreas, which it either grooves deeply or passes through or behind, before it pierces the wall of the second part of the duodenum, where it empties into the diverticulum of Vater along with the duct of Wirsung. It may be divided into four portions; (a) The supra-duodenal portion; (b) the retro-duodenal portion; (c) the parcreatic portion; (d) the intraparietal portion. The latter two only are important for our present purpose. If the choledochus passes behind and not through the head of the pancreas, the duct may escape pressure when the pancreas is congested or otherwise swollen; whereas if it passes through the gland, any congestion or swelling of the pancreas will, by pressing on the common bile duct, bring on jaundice, with its various sequelæ. Thus is explained, to my mind, many of the cases of so-called catarrhal jaundice, which may come on as an extension from gastro-duodenal catarrh, or in the course of a pneumonia, or during typhoid fever, influenza and other ailments, and which I believe to be often dependent on catarrhal inflammation of the pancreas, leading to pressure on the bile ducts. In some cases I have proved this hypothesis to be correct at operations undertaken for chronic jaundice. As the duct is completely embraced by the pancreas in 62 per cent. of all cases, we may conclude that in nearly two-thirds a swelling of the head of the pancreas will produce jaundice; and curiously, this percentage coincides with Dr. Cummidge's and my clinical observations and pathological investigations on the urine of pancreatic cases. Not only so, but when the head of the pancreas embraces the common bile duct, should a gall stone pass down, it will almost certainly exercise pressure on the gland, and thus directly interfere with its function and with the discharge of its secretion. The fourth portion is where the duct enters the wall of the second part of the duodenum and ends in the ampulla of Vater, into which small cavity the duct of Wirsung also debouches. This part of the common duct comprises all that portion of the canal contained in the thickness of the wall of the duodenum. It passes obliquely through the muscular coat of the intestine, and then dilates into a little reservoir underneath the mucous membrane, into which the main pancreatic duct also opens. This is known as the ampulla of Vater. This ampulla, a little oval cavity, may be well seen in a section of the wall of the duodenum, in the axis of the common duct. The opening of the common duct is above that of the pancreatic duct, and the two are separated by a little transverse fold of mucous membrane. The ampulla measures from six to seven millimetres in length, and from four to five in breadth, and with the termination of the two ducts, is surrounded by a thin layer of unstriped muscular tissue, forming a sphincter (Oddi). The ampulla opens into the duodenum by a little round or elliptical orifice, which is the narrowest part of the bile channel. It is important to note that the length of the diverticulum of Vater may vary from zero to 11 millimetres, the average being 3.9 millimetres, according to Opie, who measured one hundred specimens. Viewed from the interior of the duodenum the ampulla forms a rounded eminence of the mucous membrane, known as the caruncula major of Santorini, the opening being seen at the apex of the caruncle. It is distant 8 to 12 centimetres from the pylorus. Above it there is constantly found a small fold of mucous membrane, which must be raised in order that the caruncle and its orifice may be clearly seen. Running downwards from the caruncle. is a small vertical fold of mucous membrane known as the frenum carunculæ. Above the caruncula major is found a smaller eminence, the caruncula minor, marking the termination of the accessory pancreatic duct, er duct of Santorini, which opens into the duodenum about three-quarters of an inch above the biliary papilla. The mode of formation of the ampulla of Vater and the termination of the common and pancreatic ducts are liable to great variations. Letulle and Nattan Lorrier distinguish four types, to which may be added a fifth, recently shown by a dissection now in the Hunterian Mu seum. The first type is the classical one described above. In the second type the pancreatic duct joins the common duct some little distance from the duodenum, the ampulla of Vater is absent, and the duct opens into the duodenum by a small, flat, oval orifice. In the third type the two ducts open into a small fossa in the wall of the duodenum, while the caruncle and the ampulla of Vater are absent. In the fourth type the caruncle is well developed, but the ampulla is absent, two ducts opening side by side at the apex of the caruncle. In the fifth type the common bile duct opens along with the duct of Santorini and Wirsung's duct enters the duodenum separately. It will be readily understood that under ordinary circumstances when a gall stone passes along the common bile duct and reaches the ampulla of Vater, it will not only occlude the bile passages, but also the chief excretory duct of the pancreas, the secretion of which will be retained. Should infection occur, pancreatitis becomes inevitable, and on the condition of the individual, as well as on the nature of the infection, will depend what occurs, whether a mild catarrh of the pancreatic ducts, an interstitial pancreatitis, an extremely serious suppurative catarrh, or a parenchymatous inflammation in the shape of acute pancreatitis. Opie, finding in one case a very small gall stone and a large ampulla of Vater, constructed a pretty theory, which is probably true in some rare cases, as in the one reported from Dr. Halsted's clinic in the Johns Hopkins Hospital, and in another case that occurred in Buffalo, which was mentioned to me by my friend, Dr. Roswell Park, but which I believe has not yet been reported. Opie says that under these circumstances the bile and pancreatic ducts are converted into one direct tube, as shown in the diagram, and that the bile being forced into the pancreatic duct, sets up acute pancreatitis. He appears to think that pure non-infected bile is capable of doing this, and he has apparently demonstrated the possibility by experiments on animals. For my own part, I believe that infection is the important factor, and that the bile is simply the conveyer of infection. That this anatomical arrangement described by Opie is not necessary in order that acute pancreatitis may develop is shown by cases reported where no gall stones were present, and by an instructive case under the care of Dr. Fison, of Salisbury, where at the autopsy of a fatal acute pancreatitis a gall stone was found completely filling the ampulla of Vater and occluding both the bile and pancreatic ducts. It will be seen that while the normal termination and the second variety of termination of the ducts will favor the onset of pancreatitis in case of common duct cholelithiasis, the variations 3 and 4, in which the two ducts are separate, will possibly save the patient from the serious secondary pancreatic troubles, and in variation 5, a small portion of the gland only will become infected. |