After reporting a ease of acute pan creatitis and necrosis of fat-tissue, in which death followed nine days after laparotomy and drainage, the authors noted the previous existence of two at tacks. presumably due to gall-stones; the extension of the fat-necrosis toward the left adrenal and kidney, emphasizing the value of posterior drainage in such cases: the possible importance of the destruction of the adrenal in producing time fatal issue; and, finally. the neg.a tire results of bacteriological examina tion in extensive necrosis of the pancreas and fat-tissue. G. FL Monks and D. D. Seannell (Roston Med. and Sorg. Jour., Jan. 22, 1903).
Prognosis.—Severe cases are generally fatal, but many mild cases probably oc cur and recover. Death may be due to collapse and occur within a few days, or cases that recover from the shock may succumb to septicaemia some weeks later. Osier and 'Corte report cases of recovery after laparotomy, and Trafoyer one of recovery after sloughing of the pancreas and its discharge by the rectum. In a case of my own in which there were some premonitory epigastric pains and distress followed by extreme pain and collapse, there was accumulation of rous exudate in the lesser peritoneal cavity. After its evacuation a cyst of the pancreas formed; recovery followed drainage.
Treatment.—This is purely symptom atic. The extreme pain and the lapse require the subcutaneous injection of morphine and the administration of stimulants by the stomach or rectum.
In hemorrhagic cases with a fatal lapse threatening, it may be justifiable to open the abdomen and relieve the pressure on the solar plexus, to which death is probably due, rather than to loss of blood. It is only by operation that existence of a remediable cause such as perforation can be excluded. In the in flammatory cases operation may be visable as soon as an accumulation about the pancreas or in the lesser peritoneal cavity can be demonstrated. In the meantime the patient's strength should be sustained as far as possible by easily assimilable nourishment.
In operating on the pancreas the sur geon should always endeavor to guard the surface of the peritoneum against contact with the pancreatic secretion. The abdominal cavity should be carefully plugged, or the operation as far as pos sible should be made an extraperitoneal one. Korte (Berl. Klin., Dec., '96).
Mild cases of pancreatitis recover with and without operative intervention, but severe eases require early operation, since the primary hfemorrhage in itself leads to necrosis and disintegration of gland tissue, and the hrnorrhage may be stopped and further necrosis. both of fat
and gland-tissue, prevented by gauze packing and adequate drainage. Again, the patient is in far better condition to withstand an operation early in the dis ease than later, when weakened by sup puration in the lesser peritoneal cavity and necrosis of much fat and gland tissue. In some cases the primary shock is so severe, however, that an operation is out of the question. F. B. Lung ton Med. and Sung. Jour., Nov. 29, 1900).
Chronic Pancreatitis.
Symptoms.—The symptoms of chronic pancreatitis are those of digestive dis turbance with epigastric distress, and are not distinctive of pancreatic disease. With atrophy of the gland diabetes not infrequently occurs. Enlargement of the head may cause obstruction of the common bile-duct, with jaundice and distension of the gall-bladder.
The chronic form of inflammation of the pancreas may arise from local or general conditions. The local are the most common, and consist of extension of an inflammation having its origin in catarrh of the duodenum or bile-passages and extending along the pancreatic ducts to the gland-tissue, or it may originate in an obstruction of the pancreatic duct. Of the general causes syphilis and alco hol are most common, the latter acting probably by exciting catarrhal inflam mation of the duct.
Pathology.—The whole gland may be affected or only a part of it, usually the head. This portion of the organ may be small and very hard from the fibrotic change, as is met with in some cases of diabetes. On the other hand. it may be so large as to form a palpable tumor; not infrequently the enlarge ment is confined to the head, which be comes so hard as to closely simulate car cinoma. The surface of the gland may be smooth or nodular, or even granular and of a grayish-white color. The duct may be normal or more or less irregu larly dilated, especially if there has been obstruction of the duct.
The most frequent cause (.d chronic pancreatitis is obstruction of the duct of Wirsung,, due to pancreatic calculi, to biliary calculi in the terminal part of the common bile-duct, or to carcinoma invading the head or body of the gland.