[Reprinted from Ihk Mf.IHCAL Nkws, December 30, 1893 ] 
CELIOTOMY FOR ABSCESS OF THE PANCREAS; 
WITH THE REPORT OF A CASE. 
By JOHN E. WALSH, M.D., 
GYNECOLOGIST TO ST. ANTHONY’S HOSPITAL, DENVER, COL. 
Mrs. G., aged forty-seven, of good personal history, 
had also no hereditary taint. For four months before 
admission to the hospital she was practically bed- 
ridden. For six months she suffered from sharp 
burning pains in the epigastric region and complained of 
tenderness on pressure. Prior to this, with the exception 
of an occasional mild attack of pelvic peritonitis, her 
general health was good. 
On admission to the hospital she presented a deplor- 
able condition. Her abdomen was distended and very 
sensitive to touch. There was an area of dulness, ex- 
tending from the ensiform cartilage half-way to the um- 
bilicus and reaching to the left costal arch. Examina- 
tion revealed an enlarged uterus, a slight bilateral cer- 
vical laceration, and a chronic endometritis. The woman 
was extremely emaciated; and during the few days she 
was in the hospital before operation, she suffered from 
diarrhea, going to stool at least every half-hour. Her 
stomach would retain little or no nourishment, and her 
great pain demanded frequent doses of opium. Her 
pulse was small, rapid, and wiry. The temperature at 
no time exceeded 98° ; it was always subnormal in the 
morning. There was no history of rigors or chills ; 
but the woman stated that previous to the onset of the 
diarrhea, which began about a month before coming 
under observation, she had fever every evening. 2 
Nothing of clinical importance was elicited from an 
examination of the urine. The stools were watery, of a 
yellowish-gray color, and had a very strong odor. The 
vomited material had a greenish tinge and smelled sour. 
The tongue was dry and had a thick, brown coating. 
The examination of the lungs and heart was negative. 
There was no edema of the lower limbs. The pain in 
the epigastrium was aggravated during the acts of 
vomiting or coughing ; but the woman experienced relief 
when her stomach was empty. 
An effort was made to improve her general health, by 
carefully prepared liquid food and the administration of 
alcoholic stimulants, but without result. 
At the earnest request of the patient, it was decided 
to make an exploratory incision both for the purpose of 
elucidating the diagnosis and with the hope that some- 
thing might be done to relieve her sufferings and im- 
prove her condition. On July 16th, with the assistance 
of Drs. Cuneo, Hally, and Edward Walsh, an incision 
was made in the abdomen, beginning at the tip of the 
ensiform cartilage, running obliquely downward and 
ending about one inch above and two inches to the left 
of the umbilicus. 
The abdominal wall was unusually vascular. On 
passing the hand into the abdominal cavity, a fluctuat- 
ing mass could be felt beneath the greater curvature of 
the stomach. The great omentum was now incised, 
and the stomach pushed upward and the abscess-wall 
freely exposed. The margins of the wound were then 
pressed inward by an assistant and the abscess-wall 
stitched to them. On account of the deep seat of the swell- 
ing, I was unable to approximate the peritoneal surface 
with the margins of the wound. The sutures, however, 
answered a very good purpose, in preventing a recession 
of the abscess-wall after tapping, and in supporting the 
gauze packing, which I resorted to for the protection of 
the peritoneal cavity. The abscess-cavity contained 3 
over a pint of pus, in which could be seen portions of 
the pancreatic gland and a curdy-like substance. At 
the bottom of the abscess-cavity a small portion of the 
body and tail of the pancreas was found attached. 
These attached portions were soft and easily removed 
by cureting with the finger. The cureting was followed 
by a brisk hemorrhage, which necessitated a firm pack- 
ing of the cavity with iodoform-gauze. The wound was 
now dressed in the usual manner, the bandage being 
pinned as tightly as possible to keep the margins of the 
wound pressed inward, and to prevent any undue ten- 
sion on the stitches. 
At the completion of the operation, which lasted 
about forty minutes, the patient was very weak and 
had to be freely stimulated. No rise of temperature 
followed until the third morning, when the thermom- 
eter registered ioo°. After a thorough purge it dropped 
to normal. On the fifth day the gauze packing was 
removed ; by this time adhesions had formed between 
the abscess-wall and the margins of the wound, com- 
pletely shutting off the peritoneal cavity. After a copious 
irrigation with a hot boric-acid solution, the cavity was 
dusted with iodoform, and a drainage-tube inserted sur- 
rounded by iodoform-gauze. 
The most prominent symptoms before operation, such 
as pain, diarrhea, and vomiting, disappeared within forty- 
eight hours after the operation, and there was a rapid 
and marked change for the better. During the first four 
days rectal feeding was resorted to, after which the 
patient was able to partake of large quantities of liquid 
nourishment without experiencing any feeling of nausea 
or distress. On the eighth day the stitches were re- 
moved. The fistulous tract was now well established 
and the abscess-cavity had contracted to about one- 
fourth its former size. On the eleventh day, much 
against my wishes, the woman got up, dressed and left 
the hospital, walking to her carriage without assistance. 4 
In reviewing the literature at my command on abscess 
of the pancreas, I find no case reported in which surgi- 
cal interference has been successfully resorted to for the 
relief of this condition. Cases have been reported from 
time to time in which the pancreas was found to be the 
seat of suppuration, but in the majority of these the 
actual conditions were discovered on post-mortem exam- 
ination. “The two principal reasons for this may be 
found in the facts that abscess of the pancreas is of rare 
occurrence, and that the recognition of the lesion when 
it does exist is surrounded by many difficulties.’’ (Senn.) 
The recorded symptoms of this disease are very in- 
definite, and would scarcely lead one to a diagnosis. 
The emaciation, vomiting, constipation or diarrhea, 
localized tenderness, etc., are symptoms frequently asso- 
ciated with diseases of adjacent organs. 
In the case here reported even the usual symptoms of 
pus-formation were wanting, so far as I could learn. 
According to Fitz, the symptoms are essentially those of 
peritonitis, beginning in the epigastrium; and he 
mentions pain, tenderness, localized tympany, and the 
gradual development of a deep-seated inflammation in 
the region of the pancreas, as diagnostic points. 
Age, says Senn, is an important element to be con- 
sidered in the diagnosis, as most of the cases of abscess 
of the pancreas were found in patients over forty years 
of age. He also states that nausea, vomiting of a clear, 
greenish or viscid fluid, thirst, loss of appetite, constipa- 
tion, progressive emaciation, and distention of the epi- 
gastrium have been observed as prominent and some- 
what constant symptoms. Taken singly or as a whole, 
none of these symptoms can be said to be pathogno- 
monic ; in fact, they are symptoms common to many 
other diseases that have their origin in the epigastric 
region. 
We are forced, then, to the conclusion that with our 
present knowledge of the clinical history of abscess of the 5 
pancreas we cannot make an accurate diagnosis without 
resorting to exploratory incision ; and in all cases of 
doubtful diagnosis, when several of these symptoms are 
associated and when the health or life of the patient 
seems seriously threatened, I believe we are justified in 
giving the patient the benefit of operative procedures. 
The operation will vary according to the size of the 
swelling. The cases must be rare wherein the swell- 
ing is so prominent as to permit the stitching of its 
peritoneal surface to the peritoneal surface of the ante- 
rior abdominal wall, but when this can be done it simpli- 
fies the operation. 
It is to those cases in which the distance between the 
anterior abscess-wall and the margins of the wound is 
so great as to preclude the possibility of bringing them 
in contact that I wish more particularly to call attention. 
The management of this part of the operation will 
tax the ingenuity of the surgeon. In my own case I 
found this to be the most difficult step in the operation ; 
and while the method employed as described gave good 
results and is an ideal way of dealing with such cases, 
providing the gauze packing would in all cases afford 
ample protection against infection of the peritoneal 
cavity, nevertheless if it is ever my fortune to have 
to deal with a similar case I am inclined to think that I 
would perform the operation in the following manner: 
After passing several sutures through the abdominal wall 
and the abscess-wall for the purpose of lessening the dis- 
tance between their peritoneal surfaces, the wound should 
be packed from the bottom with iodoform gauze, which 
should be allowed to remain for several days, until firm 
adhesions had formed between the anterior abscess-wall 
and the margins of the incision. The abscess could 
then be freely incised and drained without the slightist 
danger of infecting the peritoneal cavity.