Pancreas

PANCREAS. Contents: I. Embryology, anatomy and histology ... 16 II. Biochemistry................... 22 III. Pathological anatomy ......... 2 2 IV. Pathological physiology......... 28 V. Functional diagnosis........ 30 VI. Clinic................... 40 The pancreas, pancreas, is a parenchymal organ of clearly lobular structure, elongated shape, of varying thickness in different parts, and in most of its extent having a triangular-prismatic cross-section. The largest part of the gland, its head, is most closely connected with the loop of the duodenum, while the rest of it lies on the posterior abdominal wall retroperitoneally, behind the stomach, and reaches the hilum of the spleen in the left hypochondrium. I. Embryology, anatomy and histology. Embryology. From an embryological point of view, the pancreas is a derivative of the intestinal wall. In a very early stage of development, at an embryo length of 4.5 mm, the intestinal tube forms in the region of the future duodenum three buds of the pancreas: two ventral and one dorsal, but the left ventral soon disappears and only two buds remain for further development. The ventral is located in close proximity to the primordium of the common bile duct and lies more caudally on the intestine than the dorsal. Representing hollow tubes, these buds develop to different degrees: the ventral is smaller than the dorsal. Soon both fuse and form one common mass of the pancreas, but their excretory ducts remain and open at different places in the intestinal wall. At the same time, the excretory duct of the smaller (ventral) bud becomes the main one, while the excretory duct of the larger (dorsal) lags in development and becomes accessory. The small, ventral bud apparently forms only part of the head of the pancreas and part of the uncinate process, while the rest of the head, body, and tail develop from the dorsal bud (Hamburger). In terms of phylogenetic development of the P. gland, it is important to note that in animals standing at the lowest rungs of the phylogenetic ladder, small embryos of the P. gland are scattered throughout the small intestine and are also found in liver tissue. Hence the cases of accessory P. glands in humans, occurring as manifestations of atavism in various places of the gastrointestinal tract and among other places in the liver (Broman). Anatomy. The pancreas in the fresh state has a reddish-gray color, and during digestion it becomes darker. Its dimensions vary individually, and different authors give different figures. The length ranges from 14 to 30 cm. The width is 4-5-9 cm; the head is widest, the tail least so. The thickness of the P. gland, due to its soft consistency and pressure from surrounding organs, especially the stomach, changes at different periods of physiological state and is different in different parts of the organ; on average it is 1.8-3 cm. The weight of the P. gland ranges from 67-105 g, reaching up to 162 g; according to recent data, on average for men it is 90.3 g with variations of 15 g, for women 84.8 g with variations of 14.9 g; in the newborn 3-4 g; in a well-developed 5-year-old girl 36 g. The ratio of the P. gland of the newborn to the weight of the pancreas of an adult is 1: 28 (Vierordt). In the P. gland, three parts are usually distinguished: 1) the head (caput pancreatis), the largest part, embedded in the loop of the duodenum, 2) the body (corpus pancreatis), the middle part, separated from the head by a narrowing - the neck (isthmus), and 3) the tail (cauda pancreatis), the terminal part of the P. gland, the thinnest and weakly separated from the preceding one. Some authors designate both latter parts by one name: portio gastrica, s. lienalis, in contrast to the first part, which they call portio duodenalis, s. verticalis (Verneuil). Corresponding approximately to the triangular-prismatic shape of the body and tail, three surfaces and three edges of the P. gland are distinguished. Two surfaces, relatively broad, are directed one forward, the other backward (facies anterior and facies posterior), the third surface, narrow, is directed downward (facies inferior). The surfaces pass into each other with indistinct edges (or ribs): margo superior, anterior, inferior. All these relationships of the surfaces of the P. gland are expressed less clearly in the tail than in the body. The head of the P. gland has the most complex shape and relationships to neighboring organs. Filling the inner surface of the duodenal loop (see vol. X, art. 44 and 45, figures 11 and 12), it adapts its shape to this surface. Its right side, facing the descending part of the intestine, forms a groove in which the intestine is embedded; the edges of the groove are firmly fused with part of the anterior and posterior surface of the intestine and are covered in front by the common sheet of peritoneum; in addition, there are grounds for recognizing the existence of a special fascial sheet covering both the intestine and the P. gland in front and behind [fascia pancreatico-duodenalis anterior et posterior (Bobrov)]. The lower edge of the head does not lie tightly against the lower horizontal part of the duodenum. Here at the passage of the superior mesenteric vessels, a special deep notch is formed in the gland - incisura pancreatis, which at the lower edge is located on the anterior surface of the pancreas, and further upward passes to the posterior surface of the gland, right at the neck of the P. gland, and forms a groove (sulcus pancreatis). Both in the notch and in the groove lie laterally v. mesenterica sup., which higher passes into the trunk of the venae portae, and a. mesenterica sup. The part of the head of the P. gland, isolated by the notch and lying behind the superior mesenteric vein, has a special name: processus uncinatus, or pancreas Winslowi. The boundary between the head and body of the P. gland is, as stated, the neck of the P. gland, i.e., the thinnest and narrowest part of the organ, bending over v. mesenterica sup. and over the place of entry of this vein into the portal vein. At the bend, the axis of the head shifts from horizontal to vertical position. On the posterior surface of the head of the P. gland, at its upper edge, there is another groove, more or less deep, and sometimes (in 80%) turning into a canal, formed here between the posterior wall of the duodenum and the P. gland: the common bile duct. The body and tail of the P. gland, having the approximately triangular shape described above, lie transversely on the spine and to its left (see vol. XXIV, art. 532, fig. 11). In front of the aorta, the body protrudes strongly forward, forming a tubercle (tuber omentale) at the upper edge, covered by a translucent sheet of the lesser omentum directly above the lesser curvature of the stomach. On the posterior surface of the body of the P. gland, along its upper edge, from the tail to the head, runs the splenic vein, leaving a groove as far as sulcus pancreatis. The tail of the P. gland gradually thins and becomes rounded-flat. It touches the hilum of the spleen, but sometimes does not reach it. Topography. The P. gland is located on the posterior abdominal wall, adapting to its contours. The head lies most often in front of Li or Lh, with its right edge extending 2 cm to the right of the midline of the body. Depending on the position of the duodenum, the head can descend together with the intestine lower, but does not always accompany it to the extreme limits of descent (Schiefferdqcker). The body of the P. gland lies on the spine somewhat higher than the head, has on it a protruding point of the P. gland (tuber omentale). In the direction to the left, the body lies to the side of the spine and lies deeper. The tail represents the most deeply and highly located part, reaching the level of Dxi. Thus the P. gland does not lie strictly in the frontal plane and has a spiral curvature along its long axis. In relation to the anterior abdominal wall, the head projects 8 cm above the navel, and the end of the tail on the VIII rib. The relationship to neighboring organs is very diverse and complex (see vol. IV, art. 150, figure 3). On most of its anterior surface, the pancreas, being covered with peritoneum, faces the cavity of the lesser omentum and touches the posterior wall of the stomach, which is easily movable over the gland. The intimate relationship of the head to the wall of the duodenum is described above. This connection of the two organs is reinforced by the commonality of blood vessels and the excretory ducts of the P. gland penetrating into the intestinal wall. To the anterior surface of the head, the transverse colon sometimes touches directly, more often with the help of the mesentery, for a greater or lesser extent. Above it hang the peritoneum-covered upper horizontal part of the duodenum and the pylorus of the stomach. Directly on the head under the peritoneum lies a. gastro-epiploica dextra. Behind the P. gland is located a whole series of organs. Following from right to left, there are - ductus choledochus, v. mesenterica sup. and v. porta, a. mesenterica sup. (behind the neck), aorta, root of a. coeliacae, plexus coeliacus, v. lienalis and a. lienalis together with a number of lymph glands along the upper edge of the body and tail. Behind the latter directly lies the upper pole of the left kidney and adrenal gland. To the hilum of the spleen the tail of the P. gland either approaches directly or with the help of lig. pancreatico-lienale, in which the splenic vessels are located. The narrow lower surface of the P. gland, covered with peritoneum, comes into contact with loops of the small intestine. The excretory ducts of the P. gland

Wirsung's duct, or the main excretory duct (ductus pancreatis Wirsungi) (see vol. X, p. 208, fig. 11 and p. 211, fig. 16), which collects secretions from most of the pancreas, extends along the entire length of the organ within its substance, and empties into the ampulla of Vater along with the common bile duct, and is never absent. The accessory, or Santorini's (see vol. X, pp. 115-116, fig. 2) duct (ductus pancreaticus accessorius Santorini) is rarely absent, occurring in approximately 1-3% of cases. It is considerably shorter and thinner than the main duct. Often its central part gradually narrows and even becomes completely obliterated, so that it ends blindly in the intestinal mucosa (according to various authors, in 15% to 44% of all cases). In these cases, it empties its secretion through the main duct, with which it always has a powerful anastomosis. Both ducts usually empty into the descending part of the duodenum separately at a distance of 2.5-3.5 cm from each other, the accessory one being cranioventral to the main one. The latter at its point of entry often varies in relation to the opening of the common bile duct (see Gallbladder, fig. 16), emptying either into the diverticulum of Vater or separately, which is of great importance in case of obstruction by gallstones. The blood supply to the pancreas is provided by three sources: 1) from the hepatic artery, and specifically from its branch, the gastroduodenal artery, one or two branches arise to supply the head of the pancreas: the superior pancreaticoduodenal artery and the right pancreaticoduodenal artery; 2) from the superior mesenteric artery, several small arteries emerge to the head and one large branch, the inferior pancreaticoduodenal artery (left), which anastomoses with the aforementioned branches of the gastroduodenal artery and forms two arcades on the posterior surface of the head of the pancreas, supplying blood not only to the pancreas but also to the duodenum; 3) from the splenic artery, 4-8 short branches arise to supply the body and tail of the pancreas, one of which, the larger one, is called the great pancreatic artery (Haller). It should be noted that the vessels of this area often vary and are described differently by authors. For example, Popov also distinguishes another artery originating from the superior mesenteric artery, the so-called inferior pancreatic artery; Rio Branco distinguishes the transverse pancreatic artery. The veins of the pancreas generally correspond to the arteries and all belong to the portal vein system. The lymphatic vessels of the pancreas abundantly supply the organ and are in the closest connection with the lymphatic vessels of the duodenum through: a) anastomoses in the efferent lymphatic vessels of both organs, and b) the direct transition of the delicate network of the duodenum into the coarser network of the pancreas (Bartels). The lymphatic connection of the pancreas with the bile ducts and gallbladder deserves special mention. In general, lymph from the pancreas flows to numerous regional nodes upward (pancreaticolienal, superior pancreatic, superior gastric, and hepatic nodes), to the right (anterior and posterior pancreaticoduodenal nodes), downward and backward (mesenteric, mesocolic, inferior pancreatic, and periaortic nodes). Thus, a connection is also established with the mesocolon, mesentery, hepatic portal, and left adrenal gland (Sobotta). The innervation of the pancreas, according to Sobotta, is carried out predominantly or exclusively from the sympathetic system, and specifically from the celiac ganglion (solar plexus), through the perivascular plexuses (hepatic, splenic, and superior mesenteric plexuses). Rauber believes that the vagus nerve also supplies the pancreas with its branches. Two-thirds of the right vagus enter the celiac plexus and from there also reach the pancreas. Variations and anomalies of the pancreas concern the size of the organ and its multiplicity. Due to underdevelopment or complete disappearance of one of the embryonic rudiments, the size of the pancreas changes; thus, sometimes the tail is underdeveloped or absent, and very rarely the body is also absent (Duschl). Underdevelopment of the head mass is often observed, and then the head fuses with the duodenum over a smaller area and has an abnormal ratio of parts. More frequently (though also in isolated cases), an increase in the organ's mass is observed: the tail is enlarged and bifurcated; the head is larger than normal, surrounds the intestine over a larger area, and sometimes in a ring-like manner (annular pancreas). Annular pancreas is not particularly rare. This anomaly is explained differently: either by the development of the left ventral rudiment, which normally does not develop (Baldwin), or by the enhanced development of the normal right ventral rudiment and its fusion with the uncinate process (Cords). In some cases, annular pancreas causes significant narrowing (up to half of the lumen) of the duodenum. The clinical significance of this anomaly is discussed below. The existence of additional pancreases in some cases was mentioned above. It is important to note that these additional glands in the stomach (its pyloric part) may ulcerate, degenerate into cancer, and cause narrowing of the gastric outlet (Delhougne), and in the bile ducts-cause difficulties in bile outflow (Ochkin, Hedry). Delougne collected 40 cases of additional pancreases from the literature up to 1924. Age and sex, as far as is known, have no special influence on the size and position of the pancreas. The shape of the duodenum undoubtedly affects the shape of the head of the pancreas.

V. Bobrov.

Histology. In its structure, the P. z. (Pancreas) has much in common with the salivary glands, which is why the Germans call it Bauchspeicheldrüse—abdominal salivary gland. The glandular tissue consists of lobules clearly distinguishable to the naked eye, separated by loose fibrous connective tissue, so that sections of the gland, embedded in paraffin, usually break up into small areas. In the loose connective tissue pass the excretory ducts, blood and lymphatic vessels, and nerves. The main excretory duct of the gland extends from the duodenum along the entire length of the organ and along the way gives off a number of thin branches, which extend around the duct like the branches of a fir tree. Gradually thinning out, the excretory ducts end in glandular acini, having the form of large or small long tubes, so that the P. z. is considered to belong to the system of complex tubular glands. The relationship of the terminal branches of the excretory duct to the glandular acini can be different, as shown in the diagram, and in sections of the gland it is often possible to see that the flat cells of the duct lie inside the lumen of the glandular acinus—the so-called centroacinar cells. The wall of the main excretory duct is formed on the outside by connective tissue, behind which lies a layer of circular smooth muscle fibers; the inner layer is composed of connective tissue basis, lined with cylindrical epithelial cells; in places these cells form small crypts (glands), in the epithelium of which a secretion similar to mucus can be seen. In the thinner branches, the epithelium gradually becomes lower, and in the very thinnest it becomes flat; muscle cells disappear already in branches of medium thickness. The glandular acini are covered on the outside by their own capsule (membrana propria), consisting of stellate cells that form a kind of basket around the acinus, so that in sections it does not stand out as clearly as in the salivary glands (see). The glandular cells of the P. z. have a conical shape and with their apex are turned toward the lumen of the acinus. The nucleus lies "in the middle of the height of the cell and has a round shape. The basal part of the glandular cell, when fixed with ordinary fluids, appears homogeneous and is stained darker than the apical part. With special fixation and staining, filamentous mitochondria (ergastoplasm) can be seen in the basal part, as well as the Golgi apparatus, lying inside the nucleus. The part turned toward the lumen of the acinus contains more or less numerous (depending on the state of activity or rest) zymogen grains, which are well visible on preparations fixed with mercuric chloride and stained with iron hematoxin: in the resting state of the gland they accumulate in larger quantities, during activity their number decreases. In sections of the P. z., fixed with mercuric chloride solutions and stained with iron hematoxin, thin passages can be seen between the cells of the glandular acinus, which are continuations of the terminal branches of the excretory duct. When examining stained sections of the P. z. even at low magnification, small areas of different sizes clearly catch the eye, differing by their pale color and consisting of small cells arranged in a network, between which a network of blood capillaries is quite clearly visible. These are the islets of Langerhans. Their cells are clearly distinguished from the cells of the glandular acini—they are small, have no special structure, and are not connected with the excretory ducts of the P. z. These formations are areas of the gland having an endocrine character. The islets of Langerhans are not completely independent, isolated formations from the rest of the parenchyma. There are a series of transitional cell forms (so-called transitional cells) from the glandular parenchyma to the elements of the islets. Such transitions are particularly clearly revealed in animals with experimental ligation of the excretory duct. The blood vessels of the P. z. branch in the interlobular connective tissue and with their capillary branches surround the glandular acini; on injection preparations, among the uniform network of capillaries of the glandular acini, denser networks stand out in the place of the Langerhans islets. The lymph vessels lie in the interlobular connective tissue and between the acini. Nerve trunks run parallel to the course of the blood vessels and form plexuses between the acini, from which thin nerve fibers pass under the membrana propria and give their terminal branches in the form of knob-like thickenings on the glandular cells. In addition to secretory nerves, there are endings on the vessels, as well as frequently found in the connective tissue septa Vater-Pacini bodies and in the connective tissue itself (sensory endings). According to some data, the innervation of the parenchyma, Langerhans islets, and vessels is separate.

B.

Fomin. II. Biochemistry. The composition of the P. z. includes nucleoproteins and in small amounts globulins and albumins; the nucleoproteins of the P. z. are rich in guanylic acid. Among the extractive substances found in the P. z. are: leucine, tyrosine, purine bases, isatin, lactic acid, volatile fatty acids, fats, lecithin, pentose (it is possible that some of these substances are of post-mortem origin). The dry residue of the P. z. constitutes 33%, ash--6.31% (it is rich in silicic acid- 0.011%); its quantity sharply increases in tuberculosis and cancer. The external secretion of the P. z. is one of the most important digestive juices (see Digestion). The internal secretion of the P. z. contains the hormone insulin (see). Insulin apparently represents a protein rich in sulfur (3.2%); the products of its hydrolysis are cystine, tyrosine, histidine, arginine, lysine, leucine, glutamic acid and other amino acids with the exception of tryptophan. It is possible that in the insulin molecule there are special atomic groupings that determine its activity. It is believed that the active part of the insulin molecule includes residues of glutamine and cystine. III. Pathological anatomy. Developmental defects, malformations of the P. z. The absence of the P. z. belongs to the greatest rarities and is observed only occasionally in cases of general severe malformations. Various changes in the shape and size of individual parts of the P. gland are described. Among the most interesting malformations is the splitting of the P. gland into two separate sausage-shaped organs with separate ducts ("pancreas divisum") and the so-called "annular" P. gland ("pancreas annulare"), when the head of the P. z. surrounds the duodenum with a narrow or wide loop. The latter is usually narrowed at this place, sometimes almost to complete closure of the lumen. More often there is a developmental defect in the form of an accessory P. gland (pancreas accessorium or aberrans)-in 0.3-0.5% of all autopsies (Letulle, Opie); according to data from Japanese researchers more often-in 1.8% (Katsurada). Accessory pancreases are observed in numbers of 1-3, but individual cases have been described where small accessory P. glands were scattered throughout the tract of the small intestines (Broman). Usually they have small sizes, are equipped with an excretory duct; the favorite localization-duodenum, small intestines and stomach (most often pylorus). Rarer localizations have been described-the ileocecal valve, navel, floor of Meckel's diverticulum, mesentery of the intestines, wall of the gallbladder and bile duct, capsule of the spleen. The accessory P. gland is most often located under the serous membrane, in the muscular or submucosal layer. Histologically, as a rule, typical glandular parenchyma of the P. gland with excretory ducts is found. The presence of Langerhans islands is noted far from always. Some (Thorel) consider their presence in accessory P. glands to be a great rarity. The islands are rarely fully expressed, as a rule they are small in size and few in number. On the other hand, individual cases have been described where the accessory P. gland consisted entirely of Langerhans islands and excretory ducts (Askanazy, Saltykow). In individual cases, islands of splenic pulp were found in the tissue of the accessory P. gland. The presence of an accessory P. gland in the wall of the intestine or stomach in some cases was accompanied by the development of myomas or fibromyomas, and the presence in the tissue of a node of excretory ducts of an accessory P. gland gave a picture of adenomyoma; cases of true adenomas of the accessory P. gland have also been described (Cohen, Rollet, Torrel). Reliable cases of cancer developing from an accessory P. gland apparently do not exist. Atrophy of the P. gland is quite common in prolonged debilitating diseases, in old age, etc. The weight of the P. gland from the normal 90-80 g falls to 30-40 g and below, its configuration in cases of simple atrophy is preserved. Density is increased. Microscopically, excessive development of connective tissue is noted (see separate table, figure 3). Its proliferation may go around lobules and their complexes or diffusely. Hence two forms of atrophy of the P. gland-with perilobular and intralobular sclerosis. Of the rarer cases of atrophy of the P. gland, one can point out atrophy in cirrhosis of the liver, in scleroderma and secondary atrophy in closure of the excretory ducts (compression by a tumor, stones). From simple, "cachectic" atrophy, one distinguishes the atrophy of the pancreas in diabetes mellitus-"granular" or "diabetic" atrophy of Ganszemann, "diabetic cirrhosis" of Reitman. The organ is usually reduced in volume, flattened, its weight is lowered sometimes to 19-20-23 g, on average-40-50 g, consistency is dense, surface is finely and coarsely grained. Unlike simple "cachectic" atrophy, in this case adhesion of the gland capsule with the surrounding fatty tissue and neighboring organs is noted. Microscopically-diffuse proliferation of connective tissue ("intraacinar sclerosis" of Opie), coarsening of the entire stroma, death of cells of the glandular parenchyma, appearance of small fat droplets in them, death of Langerhans islands (see also Diabetes mellitus* pathological anatomy and Pancreatitis). In some cases, even with severe atrophy, a normal amount of completely preserved Langerhans islands is found. A special form of atrophy of the pancreas is its lipomatosis; the organ in volume is sometimes even larger than normal ("pseudohypertrophy"), however the larger part of it is replaced by fatty tissue with separate gray-pink glandular areas. In approximately half of all cases, along with lipomatosis, cirrhosis of the P. gland is also noted; atherosclerosis of the arteries of the P. gland is quite common. Lipomatosis is most often observed in elderly, obese subjects, with general atherosclerosis. The islet apparatus usually does not suffer, although individual cases of lipomatosis of the P. gland with damage to Langerhans islands and diabetes have been described (Weichselbaum). In atrophic lesions of the P. gland, sometimes increased pigmentation of the skin, mucous membranes, liver (with its cirrhosis), kidneys, etc. is noted-the so-called "bronze diabetes" (see Hemochromatosis). Among the degenerative processes of the pancreas, one should note degenerative obesity, expressed in the appearance of the smallest fat droplets in the gland cells (see separate table, figure 4) (in poisoning with phosphorus, mushrooms, alcohol, in severe pulmonary tuberculosis, cancer, etc.). Amyloid degeneration of the P. z. is observed in cases of general amyloidosis and is expressed in the deposition of amyloid substance in the walls of small vessels and in the stroma. Necrotic processes in the P. z. most often manifest in the form of so-called "fat necroses", i.e. focal necroses of fatty tissue caused by the action of steapsin on fat (see Fat necroses). With a more diffuse necrotic process, the latter can capture large areas: of the P. gland, up to its complete necrotization. As a rule, necrosis of the P. gland is accompanied by hemorrhages ("hemorrhagic pancreatitis"); the outcome of necrotic processes is scarring (of small necrotic foci) or sequestration. Often a secondary infection (most often Bact. coli commune) joins, as a result of which pus accumulates in bursa. omentalis with subsequent rupture into the abdominal cavity and general purulent peritonitis. Ruptures of softened, suppurated P. gland into the intestine (most often - the duodenum) have been observed.-From ante-mortem necroses it is necessary to distinguish "post-mortem" changes of the P. gland, occurring as a result of the action of the P. gland juice on its tissue. They occur very early (already after 7 hours after death) and in the early stage can be recognized only by microscopic research. With further development of post-mortem changes of the P. gland, it becomes flabby, its tissue acquires a dirty-pink tint. From ante-mortem necroses, post-mortem changes differ by the absence of hemorrhages, edema, inflammatory reaction. From circulatory disorders in the P. gland, venous stagnation is observed with general or local circulatory disorders. With prolonged stagnation, atrophy of the glandular parenchyma and coarsening of the stroma are observed; Langerhans islands do not suffer in this case. Hemorrhages in the P. gland are observed from pinpoint to continuous, capturing the entire organ, often with rupture of the capsule and effusion into the abdominal cavity. Petechial hemorrhages can be found in the stroma of the P. gland in prolonged stagnations (cirrhosis of the liver, etc.), in severe degrees of anemia, in scurvy, uremia, septicemia, some poisonings (phosphorus, potassium cyanide, morphine, carbon monoxide, strychnine), in eclampsia and in almost all infectious diseases (typhus, scarlet fever, anthrax, etc.). Large hemorrhages in the P. gland occur from various causes: trauma to the P. z. (mostly in newborns); arteriosclerosis with aneurysm and its rupture; destruction of the vessel wall by a tumor or by an ulcerative process coming from the stomach or duodenum; finally, corrosion of the vessel wall by the juice of the P. z. in its necroses. In the latter case, hemorrhage occurs already into dead tissue (see Pancreatitis). In some cases, after rupture of the capsule, blood soaks the retroperitoneal fat, spreading to the spleen, kidneys and into the mesentery of the small intestines. Sometimes bleeding into the abdominal cavity occurs. Cases of sudden, acute hemorrhage into the P. gland, usually quickly leading to death, deserve special interest.

On autopsy, the entire organ is found to be saturated with blood—the so-called "apoplexy of the P." (Zenker). The cause of almost instantaneous death is seen in shock due to compression of the solar plexus by the spilled blood. In rare cases of recovery, the hematoma becomes encapsulated, is absorbed, and a so-called "false" or "apoplectic" cyst results. Inflammations of the P. are generally observed rarely. The inflammatory process can develop either by a metastatic route or by extension from neighboring organs (lymph nodes, intestine, etc.) or through the excretory ducts. A distinction is made between non-specific (see Pancreatitis) and specific inflammation (i.e., infectious granulomas).—Tuberculosis of the pancreas, according to generally accepted opinion, occurs rarely, but according to Kudrevetsky's data, it is found in 10% of those who died from tuberculosis, and in children even in 44.5%. Most often, the process extends to the P. from neighboring lymph nodes and is manifested by the formation of miliary tubercles; in only individual cases have large tuberculous foci been described, sometimes accompanied by diabetes. In the tuberculous process in the P., a peculiar cirrhotic process is described, occurring in two stages—a hypertrophic and an atrophic stage, when the connective tissue becomes sclerosed and the P. sharply decreases in volume and weight (Walter-Sallis, Carnot, etc.).—Syphilitic changes are observed in the P. very rarely in acquired syphilis, somewhat more frequently in congenital syphilis. Some authors indicate the frequency of P. involvement in 12-40% of all cases of congenital syphilis, while others believe that the P. is affected almost preferentially, and in any case more frequently than other organs. Most often in congenital syphilis, proliferation of connective tissue is observed—congenital interstitial syphilitic pancreatitis—with an enormous number of spirochetes. More rarely, alongside the cirrhotic process, miliary gummas are found. A frequent finding is the accompanying underdevelopment of the P. to one degree or another. Involvement of the P. in acquired syphilis in the form of a diffuse interstitial sclerotic process or the formation of gummas occurs very rarely. Stolpe, in 61 autopsies of corpses with tertiary syphilis, found only 3 cases with involvement of the pancreas; Petersen, in 88 dissections, found 1 case. Tumors of the P. Benign tumors of the P. are observed extremely rarely, much less frequently than malignant ones. Lipomas, chondromas, myxomas, hemangiomas, lymphangiomas, myomas, adenofibromas, and adenomas have been described. Some adenomas, in their structure, resemble the islets of Langerhans and probably originate from them—"islet adenoma" ("Inseladenom"; Rollet, Priesel). Cases of diffuse proliferation of the islet apparatus, "adenomatosis insularis" (Lang), have been described. From true adenomas, it is necessary to distinguish rare cases of "regenerative adenomas" of the pancreas in its marked sclerosis in diabetes. The most common of the mature tumors of the P. is cystadenoma, usually a slowly growing multilocular cystic tumor, more frequently occurring in women, with a predilection for localization in the tail of the P. The cysts are usually of uneven size, the inner wall being either smooth or (less frequently) with papillary projections. The size of cystadenomas ranges from barely perceptible to that of an adult human head (in Martin's case—15 liters of content). The content is sometimes transparent, colorless, sometimes opalescent, yellowish; in case of hemorrhage (most often in large cysts), the color changes depending on the freshness of the hemorrhage from dark red to orange and yellow. Chemically, cholesterol, mucin, fatty detritus, pancreatic enzymes, leucine, tyrosine have been found in the cyst contents. Histologically, the cyst walls are formed by an epithelial lining with a connective tissue base (the latter may be hyalinized, edematous, fatty, etc.). The epithelium is most often single-layered, cylindrical, less frequently cuboidal or flat. Cystadenomas with a multilayered epithelial lining and malignant course with the formation of metastases have been described (Edling, Kaufmann, Prosorowsky). Malignant tumors of the P. are rare, but nevertheless occur somewhat more frequently than benign tumors. Sarcomas and carcinomas of the P. are known; the latter occur much more frequently.—Primary carcinoma of the P. most often has the form of a dense nodule located in the head. The cancerous nodule reaches large sizes (10-12 cm) only in rare cases; the volume of the entire P. is often reduced. In some cases, primary cancerous involvement of the pancreas was established only through detailed microscopic examination. There are three points of origin for the development of cancer in the pancreas: the excretory duct, the glandular parenchyma, and the islet apparatus. Most often, cancer originates from the epithelium of the excretory ducts. In most cases, this is an adenocarcinoma rich in connective tissue stroma. Somewhat less frequently, a solid cancer of the scirrhous type is observed, even less frequently medullary and colloid cancer. Cases of primary squamous cell carcinoma of the P. (from the metaplastic epithelium of the excretory duct) have been described. Cancer of the pancreas comparatively early causes compression of the common bile duct with the development of obstructive jaundice; sometimes compression of the portal vein is observed, leading to the development of ascites and cyanotic induration of the spleen. Wirsung's duct is often dilated, filled with a transparent fluid, sometimes with stones in its lumen. Cancer of the pancreas very early causes infiltration of the surrounding connective tissue, the wall of the duodenum, stomach, left adrenal gland, etc. Early and distant lymphogenous and hematogenous metastases are also characteristic (e.g., nodes in the lesser omentum, in retroperitoneal lymph nodes, in the liver, lungs, on the peritoneum). The development of cancer of the P. can sometimes be associated with chronic pancreatitis. Metastatic cancers of the P. occur somewhat more frequently than primary ones. The P. can be infiltrated by cancerous new growths "by continuity"—in cancer of the stomach, duodenum, gallbladder; somewhat less frequently, hematogenous metastases of cancer from the lungs, thoracic and prostate glands.—About 50 cases of sarcomas of the P. are known. The new growth can involve the entire gland or more often is located only in its head; in the latter case, earlier and distant metastases are noted. Sarcomas have been described at any age, including cases of congenital sarcomas of the P. Histologically, all varieties have been noted: lymphosarcoma, round-, spindle-, giant-, and polymorphocellular. Secondary sarcoma of the P. occurs more frequently and is observed in sarcomas of the retroperitoneal connective tissue, lymphosarcomas of lymph nodes, etc. In rare cases (about 0.1% of all autopsies), stones in the ducts of the P. are encountered ("sialolithiasis pancreatica," or "pancreolithiasis"). The stones are usually multiple (from 3-5 to 100-300 or more), irregular in shape, spiny, very rarely faceted, gray and yellowish, often soft. Individual cases of huge stones—5-10 cm in length and up to 60 g in weight—have been described. The composition of the stones varies; most often calcium salts (phosphoric and carbonic), magnesium, fatty acids, soaps, cholesterol, pigment, etc., were found. The stones cause marked dilation of the pancreatic ducts and atrophy of the parenchyma, often clinically giving a picture of diabetes. Occasionally, cysts are found in the pancreas (see below). Adjacent to the cysts is the echinococcus of the P., observed extremely rarely (according to Tokarenko, in 347 cases of echinococcosis, there was not a single case of P. involvement; according to Teichmann, in 2,462 cases, 3 cases in the P.—0.12%). The echinococcal cyst is most often located in the head, less frequently in the tail. A single case of a multilocular echinococcus of the P. was described by Melnikov-Razvedenkov.—Among parasitic worms, Opisthorchis felineus, trichinae (in general trichinosis), ascarids, and cysticerci have been observed very rarely in the P. (the latter has been described in humans in only one case; in dogs, it is found in the P. quite frequently). Opisthorchiasis of the P. is occasionally observed in the USSR, especially in Siberia. In the ducts of the liver and pancreas, hundreds of parasites, their eggs, desquamated epithelium, blood, mucus, etc., are found. On the side of the glandular parenchyma, atrophy and marked sclerosis are usually observed. Rindfleisch and Askanazy described 2 cases of opisthorchiasis, in one of which cancer of the head of the P. and bile ducts was found, which apparently developed as a result of opisthorchiasis. Ascarids can crawl through the ampulla of Vater into the lumen of Wirsung's duct. In some cases, several ascarids (in Klebs' case, 6 specimens) were found in the greatly dilated lumen of Wirsung's duct. As a result of ascarid invasion in the P., areas of necrosis of the parenchyma and fat, hemorrhages, and in later stages, sclerosis are usually observed (F. Shvarisky). IV. Pathophysiology. Disorders of the external secretion of the P. With complete cessation of pancreatic juice secretion (e.g., after ligation of its duct), disturbance of digestion occurs, mainly of fats, to a lesser degree of proteins; digestion of carbohydrates is almost not impaired. The amount of undigested fat excreted with feces reaches 50-60%, even 83% of that introduced with food. Emulsified fat is absorbed somewhat better. In rare cases, with abundant introduction of fat, the latter is excreted during defecation in liquid form and solidifies on the surface of the feces. Thus, the lipolytic enzymes of the stomach, bile, and intestine by no means can compensate for the absence of lipase in the pancreatic juice.

The loss of nitrogen with feces after ligation of the P. duct reaches 25% of dietary nitrogen and more. The abundant content of protein in the intestines in the absence of pancreatic juice secretion causes a sharp intensification of putrefactive processes in the intestine. In the fecal masses, along with numerous fat droplets, undigested muscle fibers are found. The presence of undigested cell nuclei in the feces (Schmidt's nuclear test) is considered particularly characteristic of severe disturbances in pancreatic juice secretion. Remarkably, sometimes despite complete closure of the pancreatic duct or its ligation, the digestion of fats and proteins is hardly impaired, and this phenomenon cannot always be explained by the presence of additional pancreatic ducts. Meanwhile, destruction of the gland tissue itself (e.g., by tumors), if it reaches a severe degree, or removal of the gland always leads to a decrease in the digestion of these substances. Likewise, after ligation of the pancreatic duct, there is initially a very severe disturbance in the assimilation of fats and proteins, which then gradually smooths out. Some explain this phenomenon by the fact that pancreatic enzymes, after duct ligation, can be absorbed into the blood and then be secreted through the intestinal glands; others believe that in these cases, pancreatic juice, similar to a hormone, enhances the secretory work of the intestinal glands (Brugsch) or the process of intestinal absorption. Perhaps some importance in this also belongs to intestinal bacteria that break down fats. Functional disturbances in pancreatic juice secretion are observed in the most severe degree (pancreatic achylia) in gastric achylia (absence of hydrochloric acid as a particularly important stimulator of pancreatic juice secretion). However, complete absence of pancreatic secretion is not observed in this case, since the pancreas has a periodic secretory function independent of other glands of the gastrointestinal tract (Boldyrev). Furthermore, bile and also plant "secretins" act as stimulators of pancreatic juice secretion. Under the influence of fever, pancreatic juice secretion initially somewhat increases, then sharply falls (Stolnikov and Velizhanin). Likewise, it is reduced in anemia and in various conditions of pancreatic atrophy. Reflex influences from the sensory nerves sometimes weaken and sometimes intensify pancreatic juice secretion (Heidenhain). The shock phenomena observed after pancreatic trauma, hemorrhages into it, acute pancreatitis, in addition to nervous influences, also depend, as experimentally proven, on the poisonous effect of active pancreatic juice upon its parenteral absorption. In cases of gland necrosis and hemorrhages, its enzymes are activated, and the latter are absorbed into the blood. Trypsin has particularly important significance in the subsequent picture of poisoning. Trypsin causes a fall in blood pressure due to decreased¹ vascular tone and weakening of heart function (I. R. Petrov). At the same time, leukopenia is observed (Migay). In general, all phenomena resemble the picture of anaphylactic shock. These phenomena can be prevented by immunization. Disturbance of the internal secretion of the pancreas (see also Diabetes mellitus) is reproduced in the most severe form by complete removal of the gland (Mering, Minkowski, 1889). Already on the 1st or 2nd day after the operation, dogs show symptoms of diabetes mellitus. Hyperglycemia begins several minutes after the operation and within the next few hours reaches 0.3-0.4%, remaining at these figures later, but sometimes reaching 0.5% or more. After a few hours, glycosuria sets in and reaches 6-9%, fluctuating later depending on the methods and type of food, but not ceasing even during fasting. With exclusively meat food, a fairly constant relationship of urine sugar to nitrogen i-^J is established, equal on average to 1.3. In addition to disturbance of carbohydrate metabolism in animals with removed pancreas, other disorders are noted: excretion of N in urine sharply increases (sometimes 2-3 times), the nitrogen balance becomes negative, gas exchange increases by 10-40%, there is increased combustion of fats, the amount of lipoids, in particular cholesterol, in the blood increases, acetone bodies always appear in the urine in an amount of approx. 0.1 g per 1 l. Polydipsia and polyuria are sometimes sharply expressed. The emaciation of animals after pancreatic removal proceeds very quickly despite severe polyphagia, death occurs (in dogs) 25-30 days after the operation, and by this time the weight loss reaches 50%. The sugar excreted by animals after pancreatic removal initially comes from glycogen stores, the latter rapidly disappearing from the liver, more slowly from muscles. Later, sugar is formed from proteins and fats; introduction of albumin increases glycosuria, as does introduction of certain amino acids (asparagine, glycine, alanine). Particularly convincing is the connection between pancreatic removal and the development of diabetes in a two-stage operation: first the entire gland is removed except the uncinate process, which is transplanted under the skin on a vascular pedicle—diabetes does not develop; after some time the transplanted piece is removed—diabetes immediately develops. Hence it is clear that it is not the operation of removing the pancreas itself, associated with great trauma, that causes diabetes, but the absence of the pancreas. Partial removal of the pancreas does not cause diabetes if 3/4-4/5 of the gland remains; if less remains, a moderate chronic diabetes develops, lasting several months. Ligation of the gland duct leads to its atrophy and sclerosis, but does not cause diabetes, which is explained by the preservation, and sometimes hypertrophy, of the islets of Langerhans in this case. Free transplantation of the pancreas only delays the development of diabetes for a short time, since the transplanted piece quickly necrotizes; only transplantations on a vascular pedicle are successful. Removal of the pancreas in pregnant females does not cause diabetes, since the pancreatic hormone of the fetus passes into the mother's blood; after the end of pregnancy, diabetes immediately develops. Diabetes can also be caused by ligation of the pancreatic veins (Gley) and by draining the lymph of the thoracic duct externally (Biedl). Removal of the pancreas in one of parabiotically connected dogs does not cause diabetes in them, and connecting a dog from which the pancreas has been removed with a normal dog leads to cessation of diabetes in the first of them.

N. Anichkov. V. Functional diagnosis. Functional diagnosis of the pancreas, as of any other organ, is based on the study of deviations of its function from physiological limits. In relation to the P. gland, functional diagnosis proceeds along two paths—investigation of the excretory and endocrine functions. It studies the change in the enzyme-forming, resp. enzyme-secreting function of the pancreas, on the one hand, and insulin-forming on the other. Enzymes are studied either in their pure form or by the products of their activity in gastric juice, urine, feces, blood, and duodenal contents. The insulin function is studied by changes in the amount of sugar in the blood and urine. In the historical development of functional diagnosis of the P. gland, in the methodology for determining its functional capacity, several stages can be distinguished. Initially, attempts were made to determine the degree of functional capacity of the gland by the changes observed in the fecal masses; this was based on the considerations that since the main task of the activity of the P. gland is to participate in the digestion of proteins, fats, and carbohydrates, it already seems most expedient from a physiological point of view, in cases that arouse suspicion regarding its damage, to pay attention to the qualitative and quantitative aspects of the processing of the aforementioned food substances. It was necessary to think that the non-entry of trypsin into the intestine would disrupt the assimilation of proteins and thereby increase the excretion of nitrogen with the feces. On this basis, it was proposed to examine the feces for the presence of undigested muscle fibers with unaltered cross-striations—the so-called creatorei. It is still considered a sign of violation of pancreatic function, since intestinal juice and specifically erepsin do not act on insoluble protein bodies. Indeed, sometimes despite the disease, undigested muscle fibers can be absent in the fecal masses; on the other hand, even with intact function of the P. gland, such fibers can appear in the feces; it is possible that this is explained by increased peristalsis, for example, in gastric achylia, gastro-enteroliths, etc. Usually, creatorei is a late symptom of disease of the P. gland. It can sometimes be determined even with the naked eye. If to the disease of the P. gland is joined gastric achylia, pieces of meat and connective tissue fibers can be seen in the feces. As a rule, undigested muscle fibers are determined by microscopic examination in the form of muscle fibers with cross-striations. Usually, Schmidt's test diet is used for this, consisting of a small amount of unroasted grated meat. Instead of it, slightly boiled calf thymus gland can be given. Pieces of it are excreted in the feces, differing by their white color on the dark general background of the feces. In suspicious cases, these pieces can be examined under a microscope. A modification of the above-mentioned test is another Schmidt test, based on the fact that nucleoproteins of cell nuclei are supposedly digested only by the nuclease of the P. gland. The test consists in that the patient is given a piece of meat placed in a muslin bag; the latter is found in the feces and examined microscopically, after pouring in paraffin and preparing sections. Instead of meat, pieces of thymus gland stained with hematoxylin along with spores of Lycopodium can be given in a gelatin capsule. The latter, due to their resistance, make it possible to quickly find them, and along with them the stained nuclei. The presence of unchanged cell nuclei supposedly indicates damage to the P. gland. However, the studies of Brugsch and Umber showed that nuclei lose their color also in gastric juice; on the other hand, intestinal nuclease can also digest them. Slowness of peristalsis and putrefactive processes, according to Schmidt, give the same effect. That is why this test is not exact; in evaluating it, one must always take into account the above-mentioned points. Much greater than the disturbance of protein digestion, the disturbance of fat digestion has significance for the diagnosis of disease of the P. gland. It has long been known that in diseases of the P. gland, fatty stool (steatorrhea) is often observed, similar to that observed in jaundices based on obstruction of the bile ducts. In this case, up to 50-60% of the introduced fat can be excreted with the feces instead of the normal 10% (Bylina, Zhebrovsky, Deikher). However, even in the most severe diseases of the P. gland, steatorrhea may not be present, since the lack of pancreatic lipase can be compensated for by the action of bile, intestinal juice, and probably bacterial and gastric lipase. On the other hand, steatorrhea can be observed in a number of diseases that have nothing in common with the P. gland (enteritis, tbc of the intestines, amyloid of them, tuberculous peritonitis, some forms of Basedow's disease, etc.), not to mention jaundices associated with the non-entry of bile into the intestine. Only in the absence of the mentioned diseases, significant steatorrhea (up to 60% of the introduced fat in the feces) can suggest insufficient function of the P. gland. Insufficiency of the lipolytic enzyme can also express itself in insufficient splitting of fats into glycerin and fatty acids and in insufficient saponification (hyposteatolysis; Müller); the percentage of fat excreted in a split state with the feces falls to 30-20% and below instead of the normal 75%. Analysis of unassimilated fat shows a sharp decrease in the amount of soaps: instead of the normal 40-50%, sometimes only 4-5% (Labbe). For the exact determination of fats and their components in the feces and their ratio to the amount of fats taken with food, the subject is usually given coloring substances (carmine and charcoal or bilberry and carmine, etc.) before and after food intake. These substances, being excreted with the feces, indicate that this particular mass of feces corresponds to the taken and dosed food. However, the said method does not ensure correct accounting of the excreted fat. Therefore, Labbe puts such patients on an appropriate diet for three days, isolating the feces for 3 days. In general, both clinical and experimental data indicate that in some diseases of the P. gland, fat splitting can be satisfactory. However, abnormal excretion of fat is not an indicator of disease of the P. gland, just as, on the other hand, the most severe diseases of the P. gland can occur without violation of absorption and splitting of fats. As for the digestion of carbohydrates, in view of the presence of ptyalin in saliva and invertin in intestinal juice, as well as the action of bacteria, the method of examining the feces for their digestion has no great significance for the functional diagnosis of the P. gland. In general, it must be said that the determination of disturbance of digestion and absorption of food substances on the basis of examination of the feces has only relative diagnostic value for determining the functional capacity of the P. As for the determination of enzymes in the feces, here one is limited only to trypsin and amylase (the method of determination—see Feces). To determine them in the feces, the following precautions must be observed. After cleansing the lower parts of the intestine with an enema, the patient receives a test meal and after 1-2 hours a large dose of a laxative. If the feces obtained in this way show an acidic or neutral reaction, they are brought to a clearly alkaline one by adding a solution of soda, passed through a compressed filter or Chamberland candles. The trypsin strength of the feces varies from 0 to 5,000 units. Where it is less than 50 units, according to Orlovsky, Lifshits, Brugsch, one must consider that there is damage to the P. gland. It must be said that the examination of feces for trypsin has largely lost its importance at present, since there are other proteolytic enzymes in the feces, first of all erepsin, and then leukocytic ones. Therefore, positive results of the examination for trypsin must be controlled by a parallel examination with the addition of antitrypsin (in the form of dried blood serum of cancer patients; A. M. Levin). Only where the addition of antitrypsin sharply reduces the digestion of casein, the test is conclusive. It must also be added that with slow passage of feces through the intestine, trypsin is destroyed. Finally, to obtain convincing data, it is necessary to exclude the presence of substances that inhibit trypsin digestion. That is why quantitative determinations of trypsin in the feces are generally unsuitable, and qualitative ones can be useful for diagnosis only in case of negative results. The same applies to the Müller-Schlecht test. It consists in that charcoal is sealed in a glutoid capsule, placed in a test tube with feces, and put in an incubator. Depending on the content of trypsin, dissolution of the capsule occurs after a more or less short period of time, the feces being colored black by the freed charcoal. If dissolution has not occurred after 24 hours, then there is no trypsin. The examination of amylase in the feces is also not especially conclusive, since the amylase of the feces comes not only from the P. gland but is also contained in intestinal juice (Strassburger).

The average diastatic strength of liquid excretions 'according to Wynhausen is 500 units; a decrease below 100 indicates difficulty in the entry of pancreatic juice into the intestine. Conversely, the presence of a sufficient amount of amylase in the feces does not allow one to completely exclude damage to the pancreas. Blood examination. In blood, to determine the function of the P. z., amylase and lipase are determined. Pavlov's school established that when the secretion of the P. z. is impaired, its enzymes instead of being secreted into the cavity of the duodenum, enter the blood, similarly to what is observed in some liver diseases, when bile pigments appear in the blood. Determination of amylase in serum should be carried out with the following precautions: 10 cm³ of blood are taken on an empty stomach and immediately defibrinated; then the blood is centrifuged for about 20 minutes and amylase is determined in it by the Wolgemuth method (see Wolgemuth method) or Goldstein's method. Studies on healthy people have shown that the amount of amylase in the blood under normal conditions when determined after 30 minutes ranges from 8 to 32 units, whereas in lesions of the P. z. the figures can rise to 512 and above,-- As for the determination of lipase in the blood, as shown by Rona, during tissue disintegration various lipases are released and enter the blood, and they can be differentiated and identified on the basis of their relationship to various poisons. In this case, pancreatic lipase is atoxil-resistant (not destroyed when atoxil is added), while other lipases present in the blood are destroyed by atoxil. On this basis, it is possible from a mixture of enzymes, by adding atoxil, to isolate pancreatic lipase. The technique for determining atoxil-resistant lipase in the blood consists in mixing 3 cm³ of serum with 3 cm³ of buffer solution and 2 mg of atoxil, after which the mixture is tested in the usual way for the presence of lipase. Previously the same is done without atoxil. If the difference in the number of drops (in the stalagmometric method of examination) exceeds 6, then there is a disease of the P. z. Both these methods--determination of amylase and lipase in the blood--are at present extremely common and conclusive, especially when compared with data obtained from examination for enzymes in feces, duodenal juice and urine. The ease and speed of determination also speak in favor of this method; however, it must be said that in some diseases of the P. z. the results are not entirely convincing. Thus, in atrophic processes of the P. z., in some forms of its cancer, one can obtain completely normal figures for the concentration of these enzymes in the blood. That is why they need to be compared with data obtained by other techniques.-Examination of antitrypsin in blood serum for the diagnosis of diseases of the P. z. is not applied at present. Some authors noted in diseases of the P. z. lipemia. This symptom is observed quite rarely, perhaps because it is not sought for. The same applies to the finding in the blood of the so-called hemokonia-shiny grains, visible in the ultramicroscope and distinguished by great mobility. Urine examination. As already indicated, when there are difficulties in the outflow of enzymes of the P. z. into the duodenum, they are absorbed into the blood and from there enter the urine. The examination of urine consists in determining in it mainly amylase. The amount of diastatic enzyme in urine under normal conditions is extremely insignificant. In case of obstruction of Wirsung's duct, the amount of enzymes in urine increases. Volgemut was the first to draw attention to this. When examined by his method (see, Wolgemuth method), the amount of amylase in urine in normal people ranges from 32 to 54 units, whereas in pancreatic diseases figures up to 3,000 can be obtained, not only in severe diseases but also in mild, quickly passing ones. This concerns mainly acute diseases. Where there are chronic diseases and especially those which are associated with atrophic or cirrhotic processes in the P. z., there can be obtained surprisingly low figures of amylase in urine. That is why even in acute diseases Volgemut, Gubergritz, Goldstein, Michelson recommend to make examinations of amylase daily in order to establish at least a quickly passing increase of it in urine. In acute cases the concentration of amylase in urine can even have prognostic value, falling with improvement of the process and increasing with its deterioration. This method is undoubtedly valuable in acute diseases of the P. z., in chronic ones it has relative significance, and in a number of destructive processes in the gland we can have normal or even decreased concentrations of it in blood and urine. It is also necessary to take into account that the result of the examination can be influenced by the absorption of ptyalin from the salivary glands into the blood and the formation of amylase in the kidneys. That is why in chronic processes, along with determinations of amylase in urine and blood, it is necessary to resort to other methods of functional diagnosis of the P. z., mainly to methods of determining it in duodenal juice or feces. Other methods of determining the functional capacity of the P. z. by means of urine examination find at present relatively less application. This applies in particular to the glutoid test of Sadi. The Kemmidge reaction, which had for some time great prevalence for the diagnosis of diseases of the P. z., is at present completely abandoned. Similarly, very little importance is now attached to the decrease in the amount of indican in urine in diseases of the P. z., as well as to the increased excretion of lecithin in it. Considerable prevalence, especially in Germany, has the so-called Pancreasdiagnosticum of Winteritz. In this test, together with a test breakfast, 5 cm³ of monoiodbenzoic acid ethyl ester in a gelatin capsule is given, and in healthy people after 4-5 hours iod appears in the urine. If it is not present after 24 hours, this means that the P. z. is damaged (Umber). This test is possible only with free entry of bile into the intestine; it is based on the fact that only pancreatic lipase is able to split ethyl esters of some fatty acids. This test also has only relative value, if only because it is conclusive only when bile enters the intestine, which deprives it of value in a significant number of cases of lesions of the P. z., combined with liver damage. Examination of gastric contents. Before the introduction of a thin tube into the clinic, attempts were made to determine the enzymes of the P. z. in gastric contents. The principle of the technique is based on the studies of Boldyrev, which showed that when fat is introduced into the stomach, duodenal contents are thrown back into it, in which the enzymes can be determined. For this, the subject is given 200 g of olive oil and after half an hour the gastric contents are pumped out, in which the fat located above and the yellowish-colored contents of the duodenum are easily separated from each other, which can be separated with a separating funnel and in which the enzymes can be determined. If the gastric contents are of very high acidity, then before the examination it is necessary to wash the stomach with an alkaline solution or introduce 0.7 of burnt magnesia in 30 cm³ of water. Instead of olive oil, a mixture of it with 2% oleic acid or 250 cm³ of cream can be given. This method has value in cases where by other means it is impossible to obtain pancreatic enzymes. In recent times, instead of olive oil, the introduction of other neutral fats is proposed, for example, palmin (Ehrmann). It must be said that the method of fat breakfasts in most cases does not give the desired results--firstly because from the quantitative content of one trypsin--which is mainly determined--one cannot judge about the disease of the P. z.; secondly, if even other enzymes are determined, it is not always possible to be sure that the pancreatic juice after a fat breakfast will enter the stomach. Finally, with very acidic gastric contents the acid may not be completely neutralized by alkali, and this of course can also affect the results of the examination, since acid can destroy pancreatic enzymes. In addition, it must be borne in mind that in case of narrowing of the pyloric part of the stomach, its spasms, etc., the throwing back of duodenal contents into the stomach may not occur. Examination of duodenal contents. Significant changes in the functional diagnosis of the P. z. have occurred since it became possible to directly obtain duodenal juice. This became possible thanks to the introduction into practice of the method of duodenal intubation (Einhorn). (Technique--see Duodenal tube.) It should be noted that spontaneous duodenal juice is usually secreted in very small amounts or its outflow quickly ceases, so that after the introduction of a duodenal tube in the vast majority of cases one has to resort to artificial provocation of reflexes from the P. z. This is quite understandable because under normal conditions the P. z. secretes its juice mostly in response to the entry of food into the body.

As irritants that cause secretion of the P. z., a whole range of different irritants has been proposed: ether, peptone, Magnesium sulfuricum, milk, hydrochloric acid, insulin, histamine, etc. It should however be said that all these irritants are not equivalent, since, on the one hand, simultaneously with stimulation of secretion of the P. z. they cause secretion of bile and intestinal juice, which naturally affects the results of research, on the other hand - some of them are not physiological, i.e. not occurring under natural conditions, which is why the results obtained from their introduction do not fully correspond to the actual state of the secretory capacity of the P. z. This is why the most commonly used is the introduction of hydrochloric acid, which is a physiological irritant of pancreatic secretion, or else milk (Levin). Hydrochloric acid is introduced after cessation of independent secretion of duodenal juice through a tube in an amount of 30 cm³ of a decinormal or half-percent solution of it (Goldstein). After 5 min. vigorous secretion of duodenal juice begins, which usually continues for 50-60 min. and longer. Duodenal intubation makes it possible to obtain enzymes of the P. z. in the form in which they are secreted by it, and this of course would represent an extremely great achievement in terms of functional diagnosis of its diseases, if together with its enzymes we did not also obtain enzymes of intestinal juice and bile and to a certain extent gastric juice, which to one degree or another can affect the results obtained when investigating the juice obtained by means of duodenal intubation. To accurately determine with our modern chemical methods what is due to the action of enzymes of the P. z. and what is due to other components of duodenal juice is very often generally not possible, and if it is sometimes possible, then by means of such complex methods (Willstätter) that they are inaccessible not only in ordinary polyclinics, but even in a well-equipped laboratory. In the obtained duodenal contents, all three enzymes are determined. This is the most accurate method. Some (Chiray, Lebon) consider it sufficient to determine only lipase, considering it the most characteristic enzyme of pancreatic secretion. To a lesser degree characteristic is trypsin, since its presence can be simulated by other proteolytic enzymes (pepsin, erepsin). However, if the reaction of duodenal contents remains alkaline, then the action of pepsin can be excluded; if its peptic action is excluded by appropriate precautions, using not albumoses but peptones as the object of action, then trypsin is a sufficiently accurate indicator of the function of the P. z. As for pancreatic diastase, in addition to it in the intestine carbohydrates can be digested by ptyalin and invertase. This may explain the lack of parallelism in the concentrations of enzymes in diseases of the P. z. (Shire, Goldstein, Michelson). All the above could make one think that the determination of amylase and to a certain extent trypsin in duodenal juice does not play a big role in the matter. of children, children had no rights. "Illegitimate" children were outside the law. The law of July 2, 1902 introduced the following half-hearted one-sided improvements in the position of the illegitimate child: 1) the very name "illegitimate" was replaced by the name "out-of-wedlock"; 2) an out-of-wedlock child could receive alimony from the father until adulthood, but a) only if such maintenance could not be "provided by the mother, b) in an amount depending on the social position of the mother (and not the financial ability of the father); 3) the father could not recognize his child, the child was not included in the father's family, he was not an heir after the father, he could not receive alimony from the father's relatives; 4) the child could receive the mother's surname only with her consent; he could inherit only from her acquired property; the establishment of maternity was conditioned by written evidence. The law on out-of-wedlock children of 1902, protecting the family from the intrusion of an out-of-wedlock heir, protecting above all the institution of private property, did not improve the position of out-of-wedlock children, the number of which at that time was counted at 112 thousand. The October Revolution, having eliminated the very concept of the out-of-wedlock child, brought fundamental changes to the position of abandoned children. The struggle with P. children in Soviet conditions is built on the widest measures of social-legal order. Political and economic equality of women, emancipation of women in the family, in her personal and property relations with her husband; full equalization of the child born out of wedlock with the child born in wedlock, laws on alimony and establishment of paternity; broad comprehensive protection of women's labor, a system of protection of motherhood and infancy - these are the main prerequisites for eliminating P. in Soviet Russia. The out-of-wedlock child enjoys absolute fullness of rights in relation to the father and mother. The form of marital relations (registered marriage, unregistered marriage or short-term relationship) does not affect the fate and interests of the child; only blood actual paternity of the child from a given father needs to be proven. Establishment of paternity in the interests of the child and mother is allowed long before the birth of the child; the legislation also knows a simplified method of establishing paternity by extrajudicial procedure: by submitting a statement of pregnancy to the registry office (arts. 28, 29, 30, 31 of the Code of Law on Marriage of 1926). Prenatal establishment of paternity also pursues the interests of the pregnant woman: the person recognized as the father of the future child before childbirth is obliged during the entire pregnancy and six months after childbirth to support the pregnant woman and participate in expenses related to pregnancy, childbirth and the birth of the child (art. 31 of the Code on Marriage of 1926). Issues of establishing paternity are not connected under Soviet laws with any complex and hypocritical procedures. Equalization in legal consequences of registered and actual marriage creates real protection of property, housing and alimony rights of the wife. Laws on divorce, allowing complete freedom of termination of marriages, provide for protection of children's interests: registering the termination of marriage, the civil status registration authorities are obliged to determine with which of the parents the children remain, who of them and in what amount will bear the expenses for supporting the children. The agreement reached between the parents is entered in the book of registration of termination of marriage; this agreement does not deprive the right of each of the former spouses subsequently to demand alimony in court in a larger amount (art. 22 of the Code on Marriage). In the absence of an agreement between parents and in case of unilateral registration of termination of marriage, the registry offices themselves transfer to court the case on establishment of alimony. While paying maximum attention to the legal protection of mother and child, organizing social assistance, Soviet legislation treats P. of children as a criminal offense. Art. 156 of the Criminal Code punishes with compulsory labor for up to 6 months or a fine of up to 300 rubles for knowingly leaving without help a person in a life-threatening situation, deprived of the possibility to take self-preservation measures due to minority, decrepitude, illness or generally due to helplessness, in cases where the one who left without help was obliged to care for the left behind and had the opportunity to provide help. Along with family and marital legislation, prevention of P. is the widely organized social assistance to the lone mother and child. At institutions for the protection of motherhood and infancy, social assistance councils were organized, later expanded into commissions for improving labor and living conditions (KOTIBs). These public organizations have special sections for social assistance to combat P. Delegates, members of the section, investigate the mother and provide her in advance with the necessary social assistance. A number of special government and departmental decrees are devoted to issues of providing social assistance to the lone mother: decree of the All-Russian Central Executive Committee and Council of People's Commissars of the RSFSR "on the plan for the fight against homelessness" of June 20, 1927 (item "d" of art. 3 of the introductory part, item "b" of section 4), "on measures to combat homelessness along the line of protection of motherhood and infancy", Instruction of the People's Commissariat of Health of September 26, 1927 (No. 242/5), Bulletin of the People's Commissariat of Health of the RSFSR of 1927 No. 19, decree of the Council of People's Commissars of the RSFSR of April 14, 1928 "on measures to provide material assistance to children of the poorest families" and others. One of the most effective methods of combating homelessness of young children - P. of children - is social patronage. Its essence comes down to: 1) timely taking into account lone mothers, if possible even before the birth of the child; 2) long-term observation of her and her child; 3) active provision of social assistance, distribution of all possible types of assistance. Social patronage is social-legal dispensarization of socially threatened mothers and children.

Mothers who are socially threatened should include materially and housing-unsecured pregnant women and single mothers who gave birth out of wedlock, divorced women, abandoned women; those who came temporarily for childbirth from other localities, refusing to state the address and identity of the child's father, minor pregnant women, pregnant women and mothers without certain occupations or places of residence, domestic workers, etc.; in addition to children of the aforementioned categories of mothers, children in unfavorable family conditions (children of alcoholics, etc.) are also considered socially threatened. Placement on the "3 register of socially threatened mothers is carried out by identifying them: 1) in the registry office where a single mother applies for prenatal establishment of paternity, for registering a child without indicating the father, where she comes for divorce, or where the husband registers unilateral termination of marriage, 2) in the women's consultation, where even before childbirth, if one of the above indicators is present, the mother is placed on the register, 3) in the maternity ward, where unfavorable living conditions, etc., are identified. Long-term observation of a single mother is conducted from the moment she is placed on the register—often even before the birth of the child—both through examination by the socio-legal office (see Consultation—legal consultations for women) and at her home, and through regular summoning her to the office to check the use of assistance provided, treatment of the child, etc. Active assistance is expressed in 1) timely—often even before childbirth—establishment of paternity; 2) collection of alimony; 3) settlement of housing matters; 4) provision of material and other assistance: placement in a mother and child home, placement in a dormitory, placement of the child, sending both to their homeland; issuance of temporary monetary allowance for payment of a bed and other needs; issuance of child care items, free food; 5) medical assistance, etc. Protection of motherhood and infancy, while having as the basic and decisive prerequisite the entire complex of socio-economic conditions, the fundamental changes in the socio-domestic conditions of the existence of mother and child created by the October Revolution, led to a sharp decrease in the number of foundlings. In the years before the revolution, the number of foundlings reached 70,000 per year, in 1925 this number had already halved, in 1927 it reached 15,000, and in 1929 it was determined at 6,000. The dynamics of Moscow as a place of greatest attraction for mothers who abandon their children are characteristic: the number of foundlings in Moscow, reaching 2,000 in the first years after the revolution, gradually decreased to 600 per year. The number of foundlings in Moscow over 10 years: table 1. Number of Years of abandonment of foundlings 1 213 At the same time, it is necessary to take into account the growth of Moscow's population and the growth of births—the latter increased in 1931 by 25-27 thousand compared to the previous year. The domestic and economic shifts in the life of the Union, although they have not yet completely eliminated abandonment, have already significantly changed the conditions for abandoned children: the socio-economic profile of the mother who abandons her child has changed. While in pre-revolutionary Russia the main contingent of mothers who abandoned their children consisted of factory workers and domestic servants, at present, production workers are found among mothers who abandon their children only in isolated cases; the majority of mothers who abandon their children are young illiterate peasant women, partially domestic workers, unskilled laborers, i.e., persons without qualifications, an element not yet economically and socially consolidated. The overwhelming majority of children are abandoned in the first two weeks, i.e., immediately after leaving the maternity ward, when the mother has not yet had time to get used to the child and has not been placed on the register to receive social and legal assistance. Of the 564 foundlings who entered the Moscow quarantine-distribution center for foundlings in 1931, the children were distributed by age: up to 10 days-210, from 11 to 14 days-85, from 15 days to 1 month-38, from 1 month to 2 months-68, from 2 months to 3 months-47, from 3 months to 1 year-116. For the upbringing of abandoned children in the system of institutions for the protection of motherhood and infancy, infant homes were organized, where children from birth to 1 year and single mothers with infants as wet nurses were admitted. The overcrowding of infant homes and the significant mortality caused by it forced the Department for the Protection of Motherhood and Infancy of the People's Commissariat of Health to introduce the placement of children in working families to relieve the infant homes. For the first time in 1924, the Moscow Soviet allowed the Department for the Protection of Motherhood and Infancy to experimentally place no more than 200 children for a period of 2 years. After a year, the experiment was considered successful. Moscow began to apply patronage more broadly. The experiment was conducted cautiously: of 1,260 women who applied to take a child, 415 were selected. The first instruction "On the placement of abandoned children for upbringing in OMM institutions" of August 25, 1925 (Bulletin of the People's Commissariat of Health 1925 No. 16) provided for the mandatory nature of regular medical observation: children could be placed only where there is a consultation. Children under 3 months of age, previously examined for tuberculosis and syphilis, could be placed. Only healthy children and only in healthy families could be placed for upbringing: the family taking the child had to be thoroughly examined; the caregiver before being given the child was sent for examination to venereal and tuberculosis dispensaries. Family examination was carried out by a patronage nurse and a member of the Social Assistance Council or KOTIB; children were given only to working families; children were not given to large families, unemployed, unprovided families, etc. When a child was placed, a contract was concluded with the family; the child was given a "trousseau"; payment was set at 20 to 30 rubles. A later instruction on patronage, issued to replace the first ("Health Issues", 1928, No. 21), clarifies the rules for placing children in private families and introduces some additions: 1) A definition of patronage is given as "a system of child upbringing by the organs of protection of motherhood and infancy, under which children are placed for temporary upbringing in working families for payment, with the organs of OMM retaining observation and control." 2) Placement of children for upbringing is handled by special commissions with the involvement of public organizations. 3) Children are given to peasant families only if there is a consultation in the given locality. 4) Unlike the first instruction, placement of a child for breastfeeding before 3 months of age is allowed. 5) Not only abandoned children, but also orphans and children actually left without parental care (with the consent of guardianship authorities) are placed for upbringing. 6) The instruction recommends paying attention to the possibility of adoption of the children being placed. 7) Transfer of the child by the caregiver, even temporarily, to other families without the permission of the consultation is not allowed; permission is also required when moving with the child from one city to another. The placed child is attached to the consultation for observation; the caregiver is obliged to bring the child to the consultation for examination, weighing, etc. The condition of children placed under patronage in the RSFSR under the constant observation of health authorities is quite satisfactory. An investigation conducted in 1929/30 by the State Scientific Institute for the Protection of Motherhood and Infancy of the People's Commissariat of Health named after V. P. Lebedeva of 1,105 patronized children (694 in Moscow and 411 in other cities-Leningrad, Saratov, Ryazan, etc.) showed a sharp difference in the socio-domestic conditions of patronage under Soviet conditions from pre-revolutionary ones. The majority of children placed under patronage are foundlings, as is evident from table 2: table 2. Cities Foundlings Orphans abs. % abs. % Moscow .... Leningrad. . . Other places . 153 134 91,7 72,8 69,1 2,9 5,5 Total . . . 36 - The age of children placed under patronage is as follows (table 3): Moscow Leningrad Other places Total Age of children abs. o/ /o abs. o/ /o abs. % abs. % i 3 years and more .... } 12 90 391 171 12 13 1,7 13,0 56,7 21,7 1,7 2,2 24 65 63 43 18 0,4 11,1 30,0 29,0 21,2 8,3 Ю 33 m 17,0 32,0 42,3 3,1 0,5 13,3 47,1 28,6 5,8 3,1 Total . . . 100,0 100,0 100,0 100,0 In Moscow, the main group of patronized children consists of children under 1 year - 71.4%, in Leningrad - over 1 year - 58.8%, in other localities under 1 year-54%, over 1 year-46%. In most cases, the child goes to a family caregiver (85%), only in 15% - to a single woman. The majority are housewives. The general development of the child usually proceeds satisfactorily: children gain weight, mental development quickly improves. Moscow notes the good influence of patronage on peasant life: the appearance of windows, washbasins and other sanitary-hygienic habits. The mortality rate of patronized children in Moscow for the years 1924-27 is lower than the city-wide average. A significant portion of patronized children are adopted; children are often taken immediately with the aim of adoption. Patronage was adopted in 1924 as a temporary measure, now in connection with the mass involvement of women in production, it is gradually being eliminated and all measures are directed toward combating abandonment by supporting single mothers, providing them with housing, work, and placing the child in a nursery.