CHAPTER V.
DISEASES OF THE PANCREAS AND PERITONEUM.
Hemorrhage.
This is of great importance from the medico-legal point of view.
Remember that the onset is sudden, and the patient may be pursuing his usual occupation when he is seized suddenly with a severe epigastric pain, which steadily increases in severity. At the onset of the pain nausea and vomiting set in. The vomit- ing is obstinate, consisting at first of stomach con- tents and later is bilious, but never fecal.
Remember that this condition is nearly always mistaken for intestinal obstruction, but the absence of fecal vomiting and the appearance of a palpable swelling in the epigastric region would exclude ob- structions.
The patient becomes restless, surface cold and clammy, with a feeble, rapid, thready pulse. Tem- perature is normal or subnormal, and the patient loses consciousness, which terminates fatally in from twenty-four to forty-eight hours.
Treatment.
For loss of the blood use saline solution. Relieve pain and distress with morphin and atropin. Use
62
HEMORRHAGE ACUTE PANCREATITIS. 63
strychnin for heart depression, and do a lapar- otomy as soon as the patient can be prepared. The collapse and great prostration makes it extremely hard to get a surgeon to operate.
Acute Pancreatitis.
Remember that the onset is sudden in stout adult males with an alcoholic or gallstone history. Remember that the initial symptoms are:
Epigastric pain, usually severe and agonizing, and is diffused over the epigastric region.
Tenderness, usually over the head of the pan- creas, but may move to the left over the body or tail. The epigastric region is swollen and the recti are tense.
Collapse occurs early, and is an important sign; often severe, and threatens immediate death. The pulse is rapid and there may be cyanosis.
Vomiting is severe and obstinate. Food, mucus, and, at times, blood is brought up.
Constipation is present, and thus simulating intestinal obstruction, but remember that flatus is passed.
Remember that intestinal obstruction is less severe in onset; there is distention of the abdomen, which is very rarely confined to epigastric region, and the peristaltic waves may be seen above the obstruction, while blood and mucus will be found in the stool if the obstruction is not complete.
64 diseases of the pancreas and peritoneum.
Treatment.
Use morphin and atropin for the pain. Feed per rectum. Use stimulants freely in collapse. Opera- tion is indicated if the collapse is not too profound.
Chronic Pancreatitis.
Remember that this occurs most frequently in the fourth and fifth decades of life, at the time when malignancy may be expected. The onset is gradual, beginning as gradual emaciation and weakness. Anorexia, and in some a loathing of food.
Remember that the examination of feces reveals large amount of pale-colored passages, resembling the stools of icterus. Fat and muscle fibers of un- digested meat are found.
Remember that recurrent attacks of epigastric pain, with bilious vomiting, may occur. The pain is referred to a point a little above the umbilicus, but does not radiate.
Jaundice may occur, but it gradually deepens, and the gallbladder is distended.
Palpation reveals a hard tumor over the head of the pancreas, which may be at times mistaken for tumor of the gland.
Remember that in gallstones the onset is abrupt, with severe colicky pains, that radiate to the shoul- der, and jaundice, when present, is not so deep, while the gallbladder shrinks and is not palpable.
Remember that glycosuria is present only in those cases where the islands of Langerhans are in-
CHRONIC PANCREATITIS PANCREATIC CYSTS. 65
volved, but indican in the urine is decreased be- cause of the incomplete digestion of the proteids of the food.
Treatment.
In severe, long-standing cases, only operation will give relief. Opening and draining the gall- bladder or anastomosis is indicated. "Where icterus is present, calcium lactate gr. xv-3 j three times a day before operation increases the coagulability of the blood. Feeding extract of the pancreas is thought by some to be helpful in assisting in diges- tion of proteids and assimilation of fats.
Pancreatic Cysts.
Cysts are most often found between the twentieth and fortieth years.
Remember that most cysts are due either to trauma, inflammation, or impacted calculi.
Remember that palpation is the method of diag- nosing cysts, and reveals a deep-seated, retro- peritoneal swelling located in the epigastric region, usually in the median line or slightly to the left. Inflation of the stomach and colon shows the tumor lying between them. In form it is round, oval, and smooth.
- Remember that the tumor is immobile; has no respiratory movements, and very little, if any, on palpation.
Jaundice occurs only when a large cyst presses on the duct and is never deep. Vomiting and con-
66 DISEASES OF THE PANCREAS AND PERITONEUM.
stipation, wlien present, is due to the same cause. Fluctuation may be obtained in large cysts.
Remember that fatty stools, containing undi- gested muscle fibers, are not found in all cases, but are very significant when they occur. Glycosuria may be present when large portion of the gland is involved.
Always obtain a complete history in large abdomi- nal cysts, and make a thorough physical examina- tion with patient in Trendelenburg position in dif- ferentiating pancreatic and ovarian cysts.
Remember that tumor of transverse colon is much more superficial in location, and that pancreatic cysts have a very remarkable feature of transitory disappearance.
Treatment.
The treatment is entirely surgical. Opening and draining the cyst is much the better, as it gives a much lower death rate.
Carcinoma of the Pancreas.
When the growth starts in the head of the pan- creas, sooner or later the duct is completely ob- structed with dilatation and retention cysts in tail of the organ.
Remember that the common duct passes through the head of the pancreas or just behind it, and the hardened tumor eventually produces obstruction of the common duct, causing distention of the gall-
CARCINOMA OF PANCREAS. 67
bladder, enlargement of the liver, and a severe, progressive, and permanent jaundice.
Pressure on the portal vein causes ascites, which is often pronounced, and often edema of the legs is caused by pressure on the cava.
The bowels are irregular, and the striking fea- tures of the feces are their pale, soft, bulky, and offensive character and the great excess of fats, due to the lack of pancreatic ferments.
Remember that the rapid emaciation, the loss of strength, and anorexia, with dyspeptic symptoms, are present.
Remember that the intense, permanent jaundice, with little or no pain, and distended, palpable gall- bladder exclude biliary stones.
Remember that in interstitial pancreatitis the history is much longer, emaciation less marked, pain and tenderness above the umbilicus more common. In many cases a hard, immobile tumor is palpable in the epigastrium.
Treatmejstt.
Treatment is palliative. While the distended gallbladder may be opened and drained, or complete extirpation of the gland performed, it is doubtful whether permanent recovery follows. Morphin should be used if there be pain. Rectal feeding should be followed to keep up the strength as long as possible.
68 DISEASES OF THE PANCREAS AND PERITONEUM.
Acute Peritonitis.
Remember that Bright 's disease, gout, and arte- riosclerosis are often terminated by acute peri- tonitis.
Always get a careful history of previous condi- tion, as often a clew may be had of the starting point.
Remember that inflammation of the peritoneum is secondary to inflammation of contained viscera or trauma.
Remember that the mental condition of the pa- tient will modify the symptoms of onset.
Remember that shock is a conspicuous symp- tom, announcing the onset of peritonitis, and is due either to perforation or it may occur later from toxemia.
Remember that the chief features of the clinical picture are pain, tenderness, rigidity, vomiting, pulse, attitude, and facies.
Remember that, while the pain is usually greatest near the navel, yet the primary lesion may alter it some — as in gastric perforation the pain may be epigastric and in the back.
Remember that the important thing about the ten- derness is that it is deep and not superficial. The muscular rigidity is the same as found over an inflamed appendix, except it is found over all the abdominal muscles.
Remember that the pulse is rapid, small, and hard — the wiry pulse — occurring more often in this
ACUTE PERITONITIS. 69
than any other affection. The patient lies on his back, with limbs drawn up and shoulders elevated.
Early, the abdomen may be retracted — the scaphoid — but later is distended and tympanitic.
Remember that the facies, Hippocrates' descrip- tion, can not be improved — ''a sharp nose, hollow eyes, collapsed temples; the ears cold, contracted, and their lobes turned out; the skin about the fore- head rough, distended, and parched; the color of the whole face being brown, black, livid, or lead- colored." Vomiting occurs early, and soon be- comes bilious or even focal.
Respirations are shallow and of costal type. The diaphragm is high, liver and splenic dullness dis- appears, and the apex beat of heart pushed up into fourth costal space.
Remember that hysterical patients have so simu- lated peritonitis as to deceive the very elect.
Remember that in enterocolitis the pain is colicky; there is diarrhea and tenesmus; there is collapse, but it is due to rapid loss of water and toxemia.
Remember that in intestinal obstruction there is complete, sudden stoppage of the bowels — no flatus passing; or there are bloody stools (depending on the cause) ; an immovable, tense mass at the point of obstruction, which may be seen or felt.
Remember that tuberculosis must not be forgotten as a causative factor, and that usually symptoms of tuberculosis are found.
70 diseases of the pancreas and peritoneum.
Treatment.
Only surgical treatment is of any value. Open the abdomen; repair the cause if possible; drain; put the patient in Fowler's semi-erect posture, with the con- tinuous flow into the rectum of hot saline solution (page 29). This procedure is now saving three- fourths of these patients, which was formerly the death rate.
Diet. Allow nothing by the mouth. Add pano- pepton to the salt solution used in the continuous flow.
Never be guilty of willingly treating acute peri- tonitis medicinally. There is no valid reason for doing so, and the mortality is very high. Opium, or any of its derivatives, gives only a false sense of relief, and the saline treatment is no better.