Etiology:—This disease is of insidious development and is probably always secondary. It follows mild attacks of acute or sub-acute pancreatitis, or it may result from chronic catarrhal thickening of the pancreatic duct, which in its turn is due to irritation transferred from the gall bladder, from disease of the ducts, or from hepatic calculi, or from gastroduodenal catarrh. It is supposed to follow suppurative pancreatitis, but this is problematical. It may proceed from chronic inflammation of contiguous structures also. Obstruction of the pancreatic duct by calculi, or disease of the vessels of the organ, will induce it. It follows chronic infectious disease, and is common among alcoholics.
There are probably two types of chronic pancreatitis: In the first form there is an increase of the connective tissue between the lobules, constituting an intralobular pancreatitis. In this the islands of Langerhans are not involved, at least not until late in the progress of the disease; consequently no glycosuria is present. The other form is characterized by the formation of new connective tissue within the lobules, constituting interacinar pancreatitis. In this form the islands of Langerhans are involved early, and glycosuria is an almost constant result.
Symptomatology:—In the milder form of the disease, that which is of slower development, pain is not a characteristic symptom. There is distress in the epigastric region, which resembles that of chronic dyspepsia, with frequent nausea and occasional vomiting. Or the symptoms may closely resemble those of chronic gastric catarrh. There is anorexia and epigastric fulness, with tenderness on pressure, and eructations of gas or of a very sour fluid. With these symptoms there may be diarrhea, and in an occasional case there is jaundice.
There is a distinct class of cases in which the pain, severe and intractible, is an early symptom. With this there is chilliness and perhaps some elevation of the temperature; the pain is deep seated in character, perhaps a little to the left, but low in the epigastric region; it is usually tensive and boring. There is an expression of anxiety upon the countenance: the patient is pale, has a cachectic appearance, and there is progressive emaciation. There may be headache, dizziness or syncope. Liver complications are apt to be present, or there may be enlargement of the spleen.
Diagnosis:—A positive diagnosis is usually difficult. The symptoms named may be present, but the pathognomonic evidences of other diseases for which this may be mistaken may be absent. There is a distinctly circumscribed hardness, with marked resistance in the pancreatic area. Usually the stools are clay colored, although there may be found in them an abundance of bile, due to the absence of the pancreatic fluid.
Prognosis:—It is questionable if this disease is ever cured. It may extend over a period of years, or it may be associated with glycosuria and the real condition be overlooked.
Treatment:—Inasmuch as an absolutely positive diagnosis is probably not made, the treatment will be similar to that of the sub-acute form of the disease, and yet a plan must be advised which shall cover a considerable period of time. It will be wise to put the stomach and digestive apparatus in the very best possible condition. If free fat is found in the feces, this will be a positive indication for the use of pancreatin as other assistant to the digestion. Fats, sugars and starches should be administered sparingly. Constipation must be overcome, and the condition of the kidneys must receive attention. But little will avail from the use of medicinal agents. The soreness and sharp cutting pains indicate bryonia, and there will be found cases which will receive benefit from the persistent use of this agent. On general principles, this should be combined with phytolacca and collinsonia. The influence upon the general structure of the gland will thus be promoted. If there is marked circumscribed hardness, with pain, the use of hydrastis and conium, or hydrastis and cannabis indica, will give satisfactory relief. When the liver is plainly involved, iris, or leptrandin, or chionanthus will be of benefit, and polymnia should be given if there is splenic enlargement. Arsenic has been prescribed in some cases with apparent benefit, especially where glycosuria is present. The use of a saline laxative or the carbonated mineral waters, with considerable regularity, is frequently indicated.