XX. Diseases of the Pancreas.
So important is the function of the pancreas in its influence upon digestion, and upon the processes of nutrition, that those diseases to which it is liable, materially influence the nutritional processes of the body. Because of the remote position of the organ, these diseases are difficult of diagnosis, and are occasionally attributed to other causes or are supposed to be located in other organs. On the other hand, conditions that are supposed to be located in this organ may be due to disease of contiguous organs.
Definition:—An inflammation of the pancreas involving the entire structure of the organ. The condition may present itself in an acute, sub-acute or chronic form, but it is doubtless true that one of the forms may be mistaken for another or that they may overlap each other. A positive differential diagnosis is at times well nigh impossible.
Etiology:—The condition occurs much more frequently in men than in women, and is a disease of late middle life. It is found in those addicted to the excessive use of alcohol, and is often present with diabetes mellitus or glycosuria. It follows an injury, or hemorrhage, or it may result from septic infection as a secondary condition to suppurative inflammation in other organs, or as the result of infectious fevers. The influence of gall stone in inducing pancreatitis by forcing bile into the pancreatic duct is emphasized by some writers. It may also be due to gastric or intestinal ulcer, or to sub-phrenic abscess, or to infection from a nearby malignant growth.
Symptomatology:—If, in acute or sub-acute pancreatitis, the common symptoms of chill, fever and local pain were as invariable as they are in acute inflammation of most other organs, the determination of this inflammation wouW be simplified. Occasionally the temperature in this form of the disease will slowly rise until it reaches 104° F., and this may or may not have been preceded by a chill. In other cases the temperature is normal or even sub-normal, the pulse varies according to the arterial tension and to the seriousness of the attack. If the temperature is subnormal, the pulse will be feeble, soft and compressible. Among the first symptoms is a deep-seated, sharp, cutting pain, accompanied with severe retching and vomiting, with difficult breathing, rapid prostration, restlessness and anxiety. The pain is located between the ensiform cartilage and the umbilicus, rather low in the epigastric region. The pain may be paroxysmal, and pressure elicits great tenderness. Soon bulging or swelling of the region of circumscribed tenderness will be apparent, and there is slowly increasing distention, which ultimately includes the entire abdomen. At first, with the retching and vomiting there is considerable mucus, which later contains some blood. Finally the vomitus will become very dark or of the coffee-ground type, or it may clearly contain a large quantity of black blood.
The disease runs a rapid course, prostration or collapse is soon threatened, there is tympanites, a most distressing hiccough, a rapid and feeble pulse, and scanty urine, which contains albumin. There may be cyanosis both of the face and of the abdominal walls. These results occur more rapidly if the inflammation quickly involves the peritoneum, especially if the peritonitis becomes diffused.
When the symptoms develop more slowly with but little impression upon the vital forces at the first, and continue over a long period of time, it is usually diagnosed as sub-acute pancreatitis. If the condition runs a mild course for some time, to ultimately produce prostration, with chilliness, irregular fever and other evidences of septic infection, abscess will be diagnosed, and the condition will become more or less chronic in character. The abscess may not be walled off as in other conditions, but the pus may burrow into the deeper structures, or the condition may assume the form of a sub-phrenic, renal, perirenal or psoas abscess, or it may penetrate the abdominal walls or the wall of the stomach. When abscess is present, there is a recurrence of severe pain for a time, with chilliness, a marked septic temperature and a rapid development of tympanites, with occasionally an involvement of the spleen.
Persistent constipation is an accompaniment of pancreatitis. This has caused many physicians to diagnose intestinal obstruction as the cause of all the manifestations.
Diagnosis:—The diagnosis depends upon the location of the disease, its sudden onset, rapid progress and extreme asthenia. By carefully estimating each symptom no great difficulty will be experienced in distinguishing between this and peritonitis or other active local inflammatory condition. Fitz states that if a patient in previous good health, except, perhaps, occasional attacks of dyspepsia, is seized suddenly with extreme pain, low in the epigastrium, which is accompanied by vomiting and extreme prostration or collapse, and if in twenty-four hours later there is a circumscribed, tympanitic, epigastric swelling, this disease is to be strongly suspected.
Treatment:—In the acute or sub-acute forms, the severe pain should be immediately relieved, usually by the injection of a hypodermic of morphin. Cups should be applied upon either side of the spinal column, immediately behind the organ, and hot applications should be persisted in over the epigastrium for several hours. Belladonna and bryonia should be administered to anticipate or antagonize the congestive and inflammatory processes in the parenchyma of the organ or in its serous covering. The prostration should be anticipated by supportive measures, by the internal use of nux vomica, xanthoxylum or capsicum, or later by hypodermic injections of strychnin. This substance must be immediately used if collapse is threatened. It may be associated with digitalis or nitroglycerin.
So rapid is the development of the acute form of this disease that it is seldom that the physician has an opportunity to do other than to alleviate the distressing symptoms and to antagonize the threatened collapse. In the sub-acute form there is more time to obtain the action of remedies which exercise a beneficial physiological influence. Authorities are united upon the fact that surgical measures offer the best results. A free incision which will disclose the conditions which have caused the disease, and which will permit a possible removal of the cause, will also permit the evacuation of pus, and will do much toward abating the symptoms. Many surgeons believe the best results to be obtained by immediate operation, whatever the conditions present, some even arguing against waiting for a reaction from the collapse.