Duct obstruction may be followed by the invasion of bacteria, which take part in the production of the resulting lesion.
Ascending infection of the unob structed duct of Wirsung may follow an acute lesion of the duodenum or of the bile-passages, and may cause chronic in flammation. In cases which have given a history of long-persistent vomiting, chronic diffuse pancreatitis may be found at autopsy, and is probably the result of an ascending infection of the gland. General or local tuberculosis is occasionally accompanied by chronic diffuse pancreatitis, affecting chiefly the interstitial tissue of the gland. Chronic interstitial pancreatitis is not infre quently dependent upon the same etio logical factors, notably alcohol, which produce cirrhosis of the liver, and in about one-fourth of the cases the two lesions are associated.
Following duct-obstruction and as cending infection the lesion affects prin cipally the interlobular tissue, only secondarily invading the lobular tissue and sparing the islands of Langerhans. Diabetes results only when the lesion is far advanced. Accompanying the so called atrophic or Laennec's cirrhosis of the liver, the pancreas is at times the seat of a diffuse chronic inflammation, characterized by diffuse proliferation of the interacinar tissue, which invades the islands of Langerhans. A similar lesion accompanies hyaline degeneration of the islands of Langerhans mid the condition known as hmmochromatosis. Inter acinar pancreatitis is usually accom panied by diabetes mellitus. When diabetes is absent the lesion is of such slight intensity that the islands of Langerhans are little implicated. E. L. Opie (Amer. Jour. Med. Sciences, May, 1902).
Treatment.—The treatment is essen tially dietetic, the aim being to reduce the quantity of articles of food requiring the pancreatic ferment for their conver sion. Hence the consumption of fats and starches should be restricted. Minced animal pancreas has been used by Abelmann with success; pancreatin Small doses of bicarbonate of soda, twenty minutes after meals, tend to al lay the local pain.
In chronic interstitial pancreatitis oper ation advocated at the earliest possible moment. To attack the head of the pan creas or the pancreatic duct a vertical in cision should be made through the right rectus, and not in the middle line. When
deep jaundice is present, calcium chloride in 20-grain doses should be given three times daily for twenty-four or forty-eight hours before operation and in the form of an enema for twenty-four hours after ward in 60-grain doses thrice daily. Of 17 patients operated upon, 16 recovered, while, in cancer of the pancreas in 16 patients operated upon, only 9 recovered from the operation, the ultimate dura tion of life thereafter being very brief. A. W. Mayo Robson (Lancet, July 2S, 1900).
Cysts of the Pancreas.
Symptoms.—The symptoms are indefi nite. The onset may be with the symp toms of acute pancreatitis, or only with disturbance of digestion and epigastric discomfort. The attention may first be arrested by the discovery of a tumor, which may grow rapidly; in chronic cases it usually develops slowly. It may be subject to rapid enlargement from time to time, possibly on account of hwmorrhage. The tumor is usually smooth and rounded, lying chiefly to the left of the middle line of the body. It is only slightly movable and is not af fected by respiration. It may transmit the aortic impulse, but it is not ex pansible. In large cysts fluctuation can sometimes be elicited. The cyst may grow- until it distends the whole abdo men, extending from the ensiform car tilage to the pubes. It projects into the left lumbar region, rendering it flat to percussion and resistant. By its press ure it may interfere with respiration and disturb digestion. Sugar is present in the urine of some cases.
Diagnosis.—The diagnosis is usually only probable. The position of the tumor, its relation to the stomach and colon which can be determined by in flation of these organs, its general char acters, and the history of its develop ment, usually indicate its pancreatic origin. Even after exploratory puncture the nature of the cyst may remain un certain, as the contents may have lost the digestive ferments, and these may be present in cysts communicating with the pancreas. A persistent discharging si nus is in favor of a pancreatic cyst.