Ifydronephrosis, especially of the left kidney, and dropsy of the gall-bladder have to be excluded, as has also a large ovarian cyst. Distension of the lesser peritoneal cavity is often indistinguish able from pancreatic cyst. As a rule, the contents consist of serous fluid, do not contain the digestive ferments. and do not reaccumulate after evacuation.
The following common symptoms are of value in making the diagnosis of cysts of the pancreas: (1) gastric symptom', pain. tenderness, vomiting. signs of dila tation, etc.; (2) emaciation: (3) their development in the epigastrinm. gen erally somewhat to the left side: (4) their situation near the posterior ab dominal wall, upon the aorta, so that its pulsation is seen and felt; (3) their immobility; (0) the stomach (dilated) and the transverse colon are found lying upon the cysts. Pancreatic symptoms were absent in four personal cases. one of which died. G. Seefisch (Deutsche Zeit. f. Chic.. March, 1001).
Etiology.—Cysts probably form in the pancreas most frequently from obstruc tion of the duct or one of its branches; they may arise also from circumscribed collections of fluid in the substance of the gland. Many supposed cysts of the pancreas doubtless form wholly outside the gland.
They occur equally in both sexes and usually in adult life, but are met with occasionally in young children. The largest group of cases results from in flammation of the gland or the duct. The tumor may develop rapidly, or may not appear for some weeks or even a year or two.
A second group of cases follow trau matic injury of the abdomen. Of 33 cases collected by Korte, 30 were in males. Probably many of them were due to accumulation of fluid in the lesser peritoneal cavity or to cystic for mation in the vicinity of the gland. Doubtless some of them were due to in flammation of the gland or duct, causing occlusion of the latter and retention of secretion as in the first group. Some of them may have originated from limmorrhage into the pancreas.
Seventeen eases collected in which cysts of the pancreas had been attributed to traumatism, the time between the in jury and the cyst-formation varying from ten days to eight years. The view as suggested by Senn and Cathcart be lieved that at first the cyst is due to rupture of tissue and the escape of blood and pancreatic fluid; that an ad ventitious wall forms around this and becomes distended by the escape of more fluid. Leith (Edinburgh Med. Jour.,
Nov., '95).
In a third group there is no history of injury or of inflammation. These are met with in women especially, and run a very protracted course: some years usually.
Pancreatic cysts generally project for ward between the stomach and trans verse colon. in some cases, however, it appears above, the stomach pushing it downward, and in rare cases it develops low down in the abdomen, both stomach and transverse colon lying above the tumor. They are usually in the middle line of the body, but may lie to the left.
near the spleen if developed from the tail of the pancreas.
The contents of cysts vary in charac ter. Probably in smaller cysts the fluid is dark brown and contains blood or blood-pigment, fat-granules, degener ated epithelial cells, and, it may be, cholesterin. Large cysts are older and the contents are usually grayish, of alka line reaction, and from 1010 to 1024 specific gravity. The fluid may not only emulsify fat and convert starch into glu cose, but also digest albumin and fibrin. The last only is distinctive of the pan creatic origin of the fluid, as the con tents of other cysts may possess diastatic and emulsifying power. It is also impor tant to note that the fluid of pancreatic cysts in time loses digestive power. Treatment. — The smaller pancreatic cysts accidently discovered call for no treatment. Large cysts require surgical intervention, removal when possible; but drainage is all that can be effected in most cases. Either method is usually successful; however, a fistula may remain open even for years in cases of drainage.
The treatment of pancreatic cysts is divided into incision of the sac and drainage—the walls of the cyst being attached to the abdominal parietes, a drainage-tube inserted, this being con stantly shortened until finally removed —and the complete removal of the cyst. The objection to drainage by incision of the cyst is, in some cases, the establish ment of a permanent pancreatic fistula, the escape of the fluid into the peri toneal cavity, and the reaccumulation of the cyst after evacuation.