noticeable as a symptom of disease of the pancreas only when there is
an associated lesion of the stomach, either of a catarrhal or cancerous
nature. Under these circumstances a quantity--six or eight
fluidounces--of a colorless, slightly opalescent, and adhesive and
alkaline fluid may be expelled from the mouth at once as an early
morning pyrosis; or by frequent and repeated acts of expectoration,
following a sudden filling of the mouth with fluid, a large bulk of
thin saliva may be expelled {1115} during the day. This hypersecretion
must not be looked upon as any indication of an especial sympathy
existing between the salivary glands and the pancreas, neither can it
be regarded as a pancreatic flux with a regurgitation of the fluid from
the duodenum into the stomach and thence through the oesophagus into
the mouth, since during the nausea that must always attend the passage
of the intestinal contents into the stomach the pancreatic secretion is
arrested, and since the liquid contains salivary, and not pancreatic,
elements.
The diarrhoea pancreatica is the least constant of all the objective
symptoms; in fact, constipation is present in many pancreatic
affections, notably carcinoma. The fecal evacuations in this condition
are frequent, thin, viscid, and contain an abundance of leucin. Under
the microscope the leucin appears either in the form of concentrically
sheathed globules, or as small crystalline rods and scales collected
together in the form of wheels or aggregated in clusters. This form of
diarrhoea may be attributed to a hypersecretion from the pancreas.
That the presence of fat in the stools is an important diagnostic
symptom of pancreatic disease is proved both by clinical and
experimental observations. The characters of these stools vary
considerably. The fat may appear mixed with the feces in small lumps,
ranging in size from a pea to a hazelnut, yellowish-white in color,
soluble in æther, and easily melted and burned. Again, after the
evacuation has become cool fat may be seen covering the fecal masses,
collected into a thick cake around the edges of the containing vessel,
or, when the feces are liquid, floating as free oil on the surface.
Finally, the fat may be in a crystalline form, the crystals being
needle-shaped and aggregated into sheaves and tufts. The quantity of
fat also varies. It may be present only in small quantities, or may
even be entirely absent from the evacuations in those cases in which
the secretion from the pancreas is simply diminished, and the amount is
greatest in those instances where there is a simultaneous arrest of the
pancreatic and hepatic secretions. It must be remembered, too, that
even in health the stools may contain fat; this occurs when an excess
of oleaginous food is consumed and after the administration of castor
oil or cod-liver oil. These conditions must be eliminated, therefore,
in estimating the value of fatty stools as a diagnostic symptom; if,
then, at the same time, coincident disease of the liver can be
excluded, the symptom becomes almost pathognomonic. The appearance of
fat in the stools may be due not only to an arrest of the pancreatic
secretion, but also to pressure upon the large lymphatic trunks,
interfering with the circulation of the chyle and checking the
absorption of fat from the intestine.
Usually, the amount of fat expelled is in direct proportion to the
quantity consumed, but occasionally the former greatly exceeds the
latter. In such cases there must be some other source for the evacuated
fat than the food; and it is probable that fat from the adipose tissue
passes into the blood, and thence through the mesenteric vessels into
the intestine. This theory would likewise account in part for the rapid
and extreme wasting, and for another less frequently observed
symptom--namely, lipuria. A case is recorded by Clark of medullary
cancer of the pancreas with nutmeg liver, and another by Bowditch of
cancer of the pancreas and liver in which lipuria was noted. The fat
was observed, after the urine had cooled, floating about on the surface
in masses or globules; differing, {1116} therefore, from chyluria, for
in this condition the fat is present in the form of an emulsion, and
gives the urine either a uniform milk-like appearance, or, after it has
been allowed to stand, rests upon the surface in a creamy layer.
When the pancreatic secretion is arrested, most of the animal food
which has escaped gastric digestion will pass unchanged through the
intestine and give rise to another characteristic condition of the
evacuations--namely, the presence in the feces of undigested striped
muscular fibres. The amount of these fibres, and indeed their
appearance at all in any given case, will depend directly upon the
nature of the food consumed.
SUBJECTIVE SYMPTOMS.--The subjective symptoms of disease of the
pancreas are abnormal sensations in the epigastrium, and pain.
The abnormal sensations in the epigastrium are weight and pressure,
attended at times by præcordial oppression and discomfort. The feeling
of weight is usually deep-seated, may be intermittent or constant, and
is generally increased or developed by pressure. It is often influenced
by position, the assumption of the erect posture or turning from side
to side giving rise to a stretching or dragging sensation, as if a
heavy body were falling downward or moving about in the upper abdomen.
The pain may be due either to an inflammation of the peritoneum
covering the gland or to pressure upon the solar plexus, and
consequently varies in character. When it depends upon localized
peritonitis, it is constant, circumscribed, and deeply seated in the
epigastrium at a point midway between the tip of the ensiform cartilage
and the umbilicus; it is rather acute, and is greatly augmented by
pressure. The second variety occurs in paroxysms, and is neuralgic in
character, the sharp, excessively severe lancinating pains extending
from the epigastrium through to the back, upward into the thorax, and
downward into the abdomen. These paroxysms--in reality attacks of
coeliac neuralgia--are attended by great anxiety, restlessness, and
oppression and a tendency to syncope. That calculi in the duct of
Wirsung, tightly grasped at the position of arrest, may give rise to
paroxysms of pain analogous to biliary colic, cannot be doubted, though
there are no positive facts in support of this view.
PRESSURE SYMPTOMS.--When the pancreas becomes enlarged it encroaches
upon the neighboring blood-vessels and viscera, interferes with their
functions, and thus produces prominent symptoms.
The ductus choledochus from its close relation to the head of the gland
is especially liable to become obstructed, with the consequent
production of chronic jaundice and the general effects of the absence
of bile from the intestinal canal. Pressure upon the portal vein gives
rise to enlargement of the spleen; on the inferior cava, to oedema of
the feet and legs; and on the aorta, occasionally, to aneurismal
dilatation of the vessel above the point of obstruction and to
subsequent alteration in the size of the heart. By encroaching on the
stomach an enlarged pancreas may cause either displacement of the
viscus or stenosis at its pyloric extremity, attended with occasional
vomiting of large quantities of grumous, fermenting liquid, pain,
constipation, general failure of health, and the distinctive physical
signs of dilatation of the stomach. The duodenum may also be pressed
upon and more or less occluded, and pain and vomiting occur several
hours after food is taken. Occasionally hydronephrosis is {1117}
produced, the accumulation being usually in the right kidney and due to
obstruction of the corresponding ureter.
A sufficient number of cases have been collected to show that there is
an intimate connection between disease of the pancreas and diabetes
mellitus. One or other condition may take the precedence, melituria
occurring during the progress of pancreatic disease, demonstrating the
onset of diabetes, and the appearance of fatty stools in diabetes a
secondary involvement of the pancreas. Various theories have been
advanced to account for this association, but the true explanation
seems to be based upon the experiments of Munk and Klebs. By
experimenting upon dogs these observers found that extirpation of the
solar plexus produced either permanent or temporary diabetes, whereas
section of the hepatic and splanchnic nerves, removal of the pancreas,
or ligature of the duct of Wirsung was without effect. From the
intimate anatomical relation of the pancreas to the solar plexus it is
easy to understand how disease of the gland may give rise to
alterations in the nerve-structure, either by direct pressure or by the
extension of inflammation along the nerve-fibres connecting the gland
with the ganglia; and these alterations in time produce diabetes. In
the instances in which diabetes is the primary affection the condition
of the pancreas, as proved by post-mortem section, is usually one of
simple or fatty atrophy; and it may be assumed that a lesion of the
solar plexus is the cause of both diseases, the changes in the pancreas
being produced in a similar way to the atrophy of the submaxillary
gland after section of the vaso-motor nerves in Bernard's experiments.
The same nerve-lesion may give rise to bronzing of the skin, and two
cases are recorded in which disease of the pancreas (cheesy
infiltration, cancer) was attended by this symptom.
PHYSICAL SIGNS.--To make a successful exploration of the pancreas the
stomach and colon should be as far as possible empty, and the patient
placed in a position, with the head and shoulders slightly elevated and
the thighs drawn up toward the belly, to relax the abdominal muscles;
or if necessary this relaxation must be brought about by the
administration of æther. The knee-elbow position is often preferable to
the dorsal position in practising palpation.
The condition of the gland giving rise to physical signs is one of
enlargement, affecting chiefly and primarily its head, and due
generally to the presence of some morbid growth.
Inspection reveals either a diffuse bulging of the upper third of the
abdomen to the right of the median line, or a well-defined tumor
situated beneath the right costal border, about the line of junction of
the right hypochondriac and epigastric regions. Often the pancreatic
tumor does not come in direct contact with the abdominal wall, but
presses against and thrusts forward the left lobe of the liver,
producing simply a prominence in the epigastrium. In the first
condition palpation elicits an ill-defined sense of resistance; in the
second, the fingers readily outline a tumor, which is slightly movable,
rounded in shape, firm or fluctuating, with a smooth or nodulated
surface, usually tender to the touch, and often giving a false impulse
transmitted from the aorta lying beneath; and in the third, the smooth
surface and the sharp edge of the left lobe of the liver are easily
distinguishable.
{1118} Percussion over a pancreatic tumor is commonly dully-tympanitic,
absolute flatness occurring only when it is very large and comes
directly in contact with the abdominal wall, pushing aside the stomach
and intestines.
On auscultation a blowing murmur may, in some instances, be heard over
the tumor. These murmurs are due to pressure upon the aorta, and must
be distinguished from the sound produced in aneurism of this vessel.
The various complications of pancreatic disease, such as dilatation of
the stomach, ascites, and secondary lesions of the liver, greatly
modify the physical signs, and sometimes entirely prevent an
exploration of the gland.
INFLAMMATORY AFFECTIONS OF THE PANCREAS.
Acute Idiopathic Pancreatitis.
This is a rare disease. It occurs most frequently in males during and
after adult life, and the strumous diathesis appears to predispose to
it. Intemperance, the suppression of normal or morbid discharges, and
traumatism act as exciting causes.
ANATOMICAL APPEARANCES.--The pathological changes may be divided into
two stages. In the first the gland is deep red in color, intensely
injected with blood, greatly increased in consistence, enlarged to the
extent of two or three times its normal size, and when an incision is
made the divided lobules feel firm and crisp. The interlobular tissue
is sometimes dotted with bloody points, and the same hemorrhagic
changes may occur in the connective tissue surrounding the gland. In
this stage resolution may occur or the inflammation may pass into
suppuration. At the beginning of the second, or suppurative, stage
numerous minute collections of pus are seen scattered throughout the
gland in the interacinous tissue; these gradually collect into a single
large abscess, and at times the whole gland is converted into a mere
pus-sac, the capsule being much thickened. In other instances the
formation of pus is entirely peripancreatic. The pus is usually
inodorous and creamy, but is sometimes grayish-white or greenish in
color; it then has a faint disagreeable odor, and occasionally is very
fetid. When mixed with pancreatic juice it becomes clear and yellowish
in color, and contains numerous minute curd-like masses.
In the first stage secondary peritonitis may arise from a simple
extension of the inflammatory process, and bands of lymph are formed,
gluing the pancreas to the neighboring organs. In the second, fatal
acute peritonitis may result from the bursting of an abscess into the
peritoneal cavity. These abscesses also occasionally open into the
duodenum or stomach. Gangrene and peripancreatic sloughing occur very
exceptionally, and are probably due to extensive hemorrhagic changes.
SYMPTOMS AND COURSE.--The disease may be preceded for an indefinite
period by symptoms of impaired gastric or intestinal digestion, but its
onset is usually sudden. The attack begins with colic or continuous
{1119} deep-seated pain, starting in the epigastrium and extending
toward the right shoulder or the back, and quickly becoming very
intense. The pain is attended by pallor of the face, great
restlessness, præcordial anxiety, dyspnoea, and faintness. The tongue
is furred or dry and red; thirst is increased; the appetite is lost;
there are frequent eructations, nausea, and constant vomiting of a
clear, greenish, viscid fluid; the vomiting produces no sense of
relief, and even increases the epigastric pain. The bowels are
obstinately constipated. The epigastric region is tense, tumid, and
excessively tender, so that it is usually impossible to elicit the
physical signs of enlargement of the gland. There is moderate pyrexia,
with evening exacerbations, and the pulse is increased in frequency.
Jaundice does not occur.
These symptoms progressively increase in severity, and reach their
maximum intensity in from three to five days. The pulse then becomes
small, compressible, and irregular, the extremities cold, the face
hippocratic, and death takes place in a state of collapse. The fatal
termination is preceded by the symptoms of acute peritonitis in the
cases which are complicated by an extension of inflammation or the
rupture of an abscess into the peritoneal cavity.
Recovery is quite possible in the early stage of the disease. On the
other hand, the course may be greatly protracted by a change in the
type of the inflammation, resulting in induration and enlargement of
the gland or in the formation of chronic abscesses. Again, when
peritonitis from extension has been confined solely to the portion of
the peritoneum that covers the gland, and has resulted in the formation
of fibrinous bands binding the pancreas to the adjacent viscera, the
symptoms of pancreatitis will on subsiding give place to those of
obstruction of the stomach, duodenum, or bile-duct.
DIAGNOSIS.--The diseases most likely to be confounded with acute
pancreatitis are biliary colic and the catarrhal form of acute
gastritis.
From biliary colic it is distinguished by the absence of rigors,
jaundice, enlargement of the liver, and a tender pyriform tumor
corresponding in situation to the gall-bladder and due to its
distension with accumulated bile. The pain in both affections is sudden
in its onset, and very similar in character and distribution; but when
caused by the passage of a gall-stone it usually begins either after a
heavy meal or after some severe muscular exertion or shaking of the
body--circumstances inoperative in the production of the pain of
pancreatitis. The pain, too, in the former condition is less severe at
first, increases gradually in severity, is more paroxysmal, is at the
outset lessened by pressure, and is often temporarily relieved by the
act of vomiting. The attacks at the same time are rarely isolated, and
all doubt is removed when the pain ceases suddenly and a calculus is
discovered in the feces.
Acute gastric catarrh is almost always traceable to the ingestion of
some irritant substance, usually alcohol or food of bad quality. This
history, together with the liability of the attack to occur during the
course of chronic dyspepsia, the comparatively trifling severity of the
pain, the headache, the irregularity of the bowels, the condition of
the urine, which is either high-colored or deposits lithates
abundantly, and the tendency of the affection to become chronic, are
the points of distinction between this and the pancreatic disease.
{1120} Acute inflammation of the stomach, or gastritis proper,
resulting from corrosive poisons, presents a train of symptoms entirely
different from those of acute pancreatitis.
TREATMENT.--Absolute rest is essential. The diet should consist of milk
guarded by lime-water and of meat-broths, this food being administered
in small quantities--one to two or three fluidounces of the milk and
lime-water or half as much broth--at proper intervals. In the early
stage an effort must be made to reduce the inflammation by the
application of ice to the epigastrium or of leeches to the same region,
or preferably to the anus. The excessive pain demands the free use of
opium. The nausea and vomiting may be relieved to some extent by
directing the patient to swallow small lumps of ice, and by the
employment of iced carbonic-acid water and the effervescing draught;
and the tendency to constipation may be overcome by enemata. Later in
the course of the disease, if the epigastric tenderness permits of it,
light linseed poultices should be placed over the upper abdomen. During
the stage of collapse alcoholic stimulants and the application of heat
to the extremities are necessary. The occurrence of acute peritonitis
or other complications and sequelæ demand appropriate treatment.
Acute Secondary Pancreatitis.
In this condition the pancreas may be the seat of either acute
parenchymatous inflammation or of metastatic abscesses.
Acute parenchymatous degeneration of the muscles, kidneys, liver, and
so on is recognized as a frequent lesion in the acute infectious
diseases, particularly typhoid fever; and it is under these
circumstances, and in association always with similar changes in some
of the organs mentioned, that parenchymatous degeneration of the
pancreas takes place.
Metastatic suppurative inflammation is very rare: it has been observed
in cases of disease of the testicles after the operation of extirpation
of these organs, and occasionally in puerperal peritonitis.
ANATOMICAL APPEARANCES.--In parenchymatous inflammation the gland at
first is hardened, swollen, and reddened, and on section presents a
reddish-gray surface, with indistinctness of the glandular structure,
due to the amount of swelling of the acini. Under the microscope the
gland-cells are found to be enlarged; they contain several nuclei,
their protoplasm is infiltrated with fatty granules, obscuring the
nuclei to a certain extent, and their outline is well defined. These
alterations are most marked in the head of the gland. After a time the
hypertrophy of the cells, by pressing upon the blood-vessels, produces
an anæmic condition and the organ becomes pale; in the advanced stages
softening occurs.
Metastatic suppurative inflammation leads to the formation of a single
large abscess or to multiple minute purulent collections.
SYMPTOMS AND COURSE.--Parenchymatous degeneration gives rise to no
distinctive symptoms. Its occurrence in typhoid fever or other
infectious disease may be suspected when after prolonged hyperpyrexia
there are enlargement of the liver and spleen and albuminuria. The
appearance of jaundice (from pressure) increases the probability of
involvement of the pancreas in the general gland-change.
{1121} The development of rigors, alternating with flushing, during the
course of one of the lesions liable to be attended with metastatic
abscesses in the pancreas might suggest the formation of pus in the
gland, but an absolute diagnosis is impossible.
Several cases are on record pointing to the possibility of a metastasis
of mumps from the parotid gland to the pancreas. In these the
disappearance of the parotiditis was followed by symptoms resembling
those of idiopathic pancreatitis--namely, thirst, fever, loss of
appetite, anxiety, and burning in the epigastrium, with deep-seated
pain extending toward the right side; in addition there was diarrhoea,
with numerous, yellowish, watery stools. In one case that resulted
fatally the secondary diarrhoea suddenly ceased and the parotid
swelling reappeared. At the autopsy the pancreas was found to be
swollen, reddened, engorged with blood, and indurated. Such a
metastasis, however, must be very infrequent, and more extended
observations are necessary to establish its course and clinical
features.
The first form of acute secondary pancreatitis may be a comparatively
unimportant complication of the acute infectious diseases, or, together
with the parenchymatous degeneration of other organs, may form a
distinct element in the fatal issue of these diseases.
Metastatic abscesses are prone to be followed by ulceration and the
formation of fistulous communications with the neighboring viscera.
TREATMENT.--The management of secondary inflammation of the pancreas is
regulated solely by the indications derived from the originating
disease.
Chronic Interstitial Pancreatitis.
Inflammation of the connective tissue of the gland usually occurs after
adult life, and depends upon a variety of causes.
The secondary form, due to long-continued venous engorgement resulting
from lesions of the cardiac valves and from chronic disease of the
lungs or liver, is the most frequently observed.
Other causes are closure of the duct of Wirsung, the retained secretion
producing pressure upon the glandular tissue; the extension of
inflammation from adjacent organs, as the bile-duct when there is an
impacted gall-stone, or the stomach and duodenum, especially in cancer
and perforating ulcer, where the floor of the ulcer is formed by the
pancreas; the pressure of tumors, as aneurisms of the abdominal aorta
and coeliac axis; chronic alcoholism; and syphilis.
ANATOMICAL APPEARANCES.--The lesion may be limited to the head or to
isolated portions of the gland, or be uniformly distributed. The
general changes are a hyperplasia of the interacinous connective
tissue, with subsequent contraction and atrophy, or, in extreme
instances, entire destruction of the glandular elements proper, the
organ becoming granular and firmer and tougher than normal. A section
shows a pale surface, studded at intervals with white spots, from which
little cheese-like and fatty masses may be squeezed, and, when there
has been intense hyperæmia, with minute collections of reddish pigment
and small hemorrhagic cysts, indicating previous interstitial
hemorrhages.
{1122} When the contraction causes closure of the small excretory ducts
or of the duct of Wirsung itself, the section shows secondary cysts and
beaded canals.