found to be cirrhotic. Complete permanent occlusion is fatal either from
the condition itself or from the causative lesion. Patients with partial
stenosis may live, continuously jaundiced, for years.
In congenital obliteration haemorrhages, especially from the umbilicus,
are prone to occur. There is increase of the interstitial connective tissue
of the liver and the spleen is increased in size.
Ttreatment. If there is a S}^hilitic element in the condition appropriate
medical treatment should be prescribed. If no result is obtained operation
with a view of making an anastomosis between the gall-bladder and the
intestine, if the obstruction is in the common duct, should be undertaken.
PARASITES OF THE GALL DUCTS.
As previously stated round worms may find their way into the bile passages
and cause obstructive jaundice. The diagnosis of the condition can be made
only by finding worms or their ova in the stools. Infectious micro-organisms
may be carried with the worms into the ducts and cause suppurative inflam-
mation with its attendant symptoms.
The treatment of the condition is that of ascariasis (see the section upon
parasites), unless suppuration has supervened, when the indications should
be met as in similar infective processes from other causes.
Hydatid cysts due to lodgment of the echinococcus in the ducts may develop
and cause obstruction, or the tumors in the substance of the liver may press
upon the passages from without with similar result.
Other parasites which have found harbor in the gall ducts of man are the
distoma hepaticum, the coccidium oviforme, the pentastoma constrictum and the
balantidium coli. The diagnosis is well-nigh impossible although the ova
of the distoma have been demonstrated in the faeces; the symptoms are those
of bile duct obstruction due to more usual causes.
The treatment is also bafiiing save in the obstruction due to the distoma
when anthelmintics are indicated. Surgical treatment becomes necessary if
symptoms of suppuration supervene.
DISEASES OF THE PANCREAS.
ACUTE PANCREATITIS.
Definition. An acute inflammation of the tissues of the pancreas occur-
ring in three types, (a) haemorrhagic; (b) suppurative; (c) gangrenous, which,
although they often possess an intimate relation to one another, will be con-
sidered separately.
ACUTE HiEMORRHAGIC PANCREATITIS. 47 1
ACUTE HEMORRHAGIC PANCREATITIS.
Etiology. This, like other inflammations of the pancreas, is a rare affec-
tion. It is observed most frequently in adult males; alcohol seems to be a
factor in its incidence; it also occurs in patients who have suffered from severe
gastric symptoms and gall-stone disease. Parturition is mentioned as a cause,
the pancreas being either affected in a way similar to that met in the kidneys
and liver in the toxaemias of pregnancy or by embolism of giant cells from the
placenta. Traumatism has been held responsible in some instances.
Pathology. The pancreas is the seat of a general enlargement and is
infiltrated with blood which is sometimes present in clots. Gall-stones may
be found in the bile ducts. The cells of the organ may have undergone a
coagulation necrosis and at the borders of these necrotic areas the products of
exudative inflammation, fibrin, red and white blood cells, are found. Foci
of fat necrosis, white in color, may be observed in the lobules of the pancreas
and in the omentum and mesentery. Bacteria may be present.
Symptoms. The onset is characteristically sudden with severe abdominal
colic; this may be localized in the upper abdomen or general; there are nausea
and vomiting and symptoms of collapse depending in type upon the severity
of the attack. The pain and collapse are attributed to a stretching of the
cceliac plexus due to the suddenly appearing swelling. The abdomen becomes
swollen, tympanitic, and tender, and palpation of the epigastrium may reveal
a sense of resistance. At the invasion a chill may occur to be followed by
moderate fever.
The diagnosis is not easy. Intestinal obstruction may be very difficult
of differentiation, but sudden severe pain in the upper abdomen, accompanied
by tenderness and later a sense of resistance, with vomiting, collapse and
sHght fever, is suggestive of pancreatic lesion. According to Fitz, scattered
areas of abdominal tenderness and tenderness over the pancreatic region
are valuable signs.
The prognosis is distinctly unfavorable although recovery has been
observed in rare instances. Death usually takes place in from three to
seven days or, if life is prolonged, gangrenous pancreatitis may follow.
Treatment consists in the employment of means to lessen the pain such as
hot appHcations to the abdomen and the hypodermatic administration of
morphine. The symptoms of collapse should be combated by means of
entero- or hypodermatoclyses of hot normal saline solution and hypodermatic
stimulation.
ACUTE SUPPURATIVE PANCREATITIS.
Synonym. Pancreatic Abscess.
Etiology. The causation of this condition is indefinite; traumatism and
digestive disturbances due to dietetic errors have been considered as aetiolog-
472 DISEASES OF THE DIGESTIVE SYSTEM AND PERITONEUM.
ical factors. The infection reaches the organ through its ducts or by exten-
sion from some adjacent suppurative focus. Pancreatic suppuration may
also result from piurulent cholangitis which has spread to the organ through
its duct.
Pathology. The pancreas is enlarged and contains one large abscess
or a number of smaller ones; in other instances a diffuse purulent infiltration
has been observed. Extension of the inflammation into the tissues surround-
ing the pancreas may occur or rupture into neighboring structures, peri-
tonaeum, stomach, etc., may take place. Thrombosis of the portal and splenic
veins has been described. Fat necrosis is unusual.
Symptoms. In acute instances the onset is sudden with epigastric pain,
vomiting and a pyaemic temperature with rigors and sweats. The abdomen
is tense and tympanitic and the spleen may be enlarged. There may be
fatty diarrhoea, glycosuria and jaundice. The patient is markedly pros-
trated and death often takes place within a week. At other times the course
is more prolonged, emaciation is marked and progressive, and rupture of the
pus-containing cavity, with accompanying symptoms may occur.
The diagnosis is very difficult; the existence of a tender mass in the epigas-
trium with fatty diarrhoea and sugar in the urine should be of great aid in differ-
entiation.
The prognosis is unfavorable but recovery after operation has been ob-
served.
Treatment aside from symptomatic and supportive measures is essenti-
ally surgical.
ACUTE GANGRENOUS PANCREATITIS.
^Etiology. This affection is usually a sequela of pancreatic haemorrhage.
It may follow perforative ulcer of the stomach, intestine or biliary tract or
even extension through the pancreatic duct of a cholangitis. Traumatism
is also an aetiological factor.
Pathology. The pancreas is usually changed into a dark slate-colored
mass, soft and putrid, and is surrounded by a thin greenish or dark-colored
purulent fluid; it may lie nearly free in the cavity of the omentum or in an
abscess cavity which is plainly palpable externally. In other instances the
organ is dry and necrotic. Scattered areas of fat necrosis are frequent.
Symptoms. These are usually those of acute haemorrhagic pancreatitis
followed after a few days by fever, chills, abdominal distention with tenderness
and jaundice. Death in collapse takes place in a few days to two or three
weeks. Recovery has followed the discharge through the rectum of the
necrotic organ.
Treatment is symptomatic and supportive. Operation, if indicated, may
be undertaken.
CHRONIC PANCREATITIS. 473
CHRONIC PANCREATITIS.
Etiology. Chronic inflammation of the pancreas may follow acute pan-
creatitis or catarrhal inflammation of the duct of Wirsung which has resulted
from a chronic gastro-duodenitis. Gall-stone disease is, however, respon-
sible for a large proportion of instances and consequently the causation of
these cases is that of the primary cholelithiasis (see the section upon this
subject). Chronic pancreatitis may also arise by extension of neighboring
inflammations. Syphilis may be mentioned as a cause.
Pathology. The organ may be increased in size. Two types of chronic
pancreatic inflammation are described the interlobular and the interacinar.
The former is less diffuse than the latter and does not interfere by its new
growth of connective tissue with the functions of the islands of Langerhans.
Interacinar inflammation invades these structures and may result in their
obliteration. The changes in the two forms of the affection are comparable
to those occiirring in the liver in h3q)ertrophic and atrophic cirrhosis, the
distinctive featiure being an increased production of connective tissue which
may be more or less localized in one part of the organ.
Symptoms. These are not characteristic.
The patient may suffer for years from digestive disorders with intermittent
diarrhoea. Later jaundice and ascites may occur with paroxysmal pain
felt deep in the epigastric region. Faintness and gradual emaciation may
be present. The presence of glucose and fat may be demonstrated in the
urine and fat may appear in the stools. If there is organic change in the
pancreas, which permanently interferes with the functions of the islands of
Langerhans, the glycosuria is likely to be permanent (diabetes mellitus).
Should there be only temporary glycosuria the probability is that the affection
of the islands is merely functional.
Upon palpation a circumscribed resistance over the pancreatic region may
be detected and in rare instances the organ itself or its head may be distinctly
palpable.
The prognosis as to cure is unfavorable but there may be advanced disease
of the organ without great interference with general health.
Treatment. The similarity in the causation between this and gall-stone
disease is marked, consequently we could hardly do better than to prescribe
an analogous method of treatment. The dietetic and hygienic methods
suggested for cholelithiasis are applicable here and the administration of
such a pill as that mentioned on p. 467 and composed of i^ grains (o.i)
each of acid sodium oleate and salicylic acid, i grain (0.065) o^ phenolphtha-
lein and \ grain (0.016) of menthol, in the same fashion as there described, is
recommended.
It has been suggested that, since fats and sugars need the pancreatic secre-
474 DISEASES or the digestive system and peritoneum.
tion for their digestion, foods of these classes be restricted, or if allowed, that
pancreatin in doses of from 5 to 10 grains (0.33 to 0.66) be given. Diastase
and pancreatic substance chopped fine may also be given as an aid to their
digestion.
Accompanying biliary obstruction due to stone or other causes may necessi-
tate appropriate surgical measures.
TUMORS OF THE PANCREAS.
Pancreatic tumors occur as cancer (carcinoma, more rarely adenoma,
sarcoma or lymphoma), as non- malignant cystic growths, or as syphilitic
gummata.
Cancer of the Pancreas.
As previously stated the most common malignant growth affecting the
pancreas is the carcinoma; it may be of either scirrhous or colloid type. Pri-
mary tumors are usually situated in the head of the gland but the involvement
may be confined to any part of the organ. Secondary carcinoma may spread
to the pancreas from similar growths in contiguous structures. Like other
malignant tumors, cancer of the pancreas is usually observed in individuals
beyond middle age.
Symptoms. The condition is difl&cult of recognition; of the usual
symptoms the following are most important. Paroxysmal pain in the
epigastrium with gastric irritability; jaundice (when the growth is in
the head of the organ) due to pressure upon and obstruction of the
common bile duct; this icterus may be extreme and associated with bile-
stained urine, light colored stools, dilatation of the gall-bladder, fatty stools
and glycosuria which last, however, are by no means constant; emaciation
with steadily increasing cachexia; the presence of an immovable tumor in
the epigastrium, which may not be palpable unless the patient is subjected
to ansesthesia. In thin patients the pulsation of the aorta transmitted through
the overlying tumor may be appreciated.
The diagnosis. The distinctive features of the affection are the jaundice
and the presence of an immovable tumor with rapid emaciation. Cancer
of the pylorus is not associated with icterus, except in rare instances, and is
usually movable, the results of gastric analysis are characteristic and there
is consequent dilatation of the stomach. Carcinoma of the colon may be
movable and there is no icterus in this condition; intestinal obstruction occurs
in the late stages.
The prognosis is unfavorable unless the diseased portion of the gland can
be removed.
CYSTS OF THE PANCREAS. 475
Treatment from a medical standpoint is symptomatic and supportive
only. Surgical removal of the disease has resulted in cure in a number of
instances.
Cysts of the Pancreas.
.Etiology. Retention cysts of the pancreas result from occlusion of the
ducts of the organ due to compression. The pressure may be exerted by
influences within or without the substance of the gland. Traumatism or
prolonged pressure is responsible in certain instances. Obstruction occurs
as a result of the impaction of gall-stones or pancreatic calculi, of the contrac-
tion of newly produced connective tissue (sclerosis), of inflammations of the
lining of the pancreatic ducts occurring as a result of the extension of catarrhal
processes in the duodenal mucous membrane and of displacements of the
organ causing a kink in its duct.
Adults are more frequently affected with cystic conditions of the pancreas
but the affection has been observed in children.
Pathology. The cysts vary much in size and may be single or multiple;
single cysts containing several gallons of fluid have been found. In the
early stages the contents is normal pancreatic juice, later it becomes dark in
color and may contain albumin and blood. The reaction is alkaline and the
specific gravity from loio to 1025. The characteristic pancreatic ferment
may be present. Under the microscope, in addition to red and white blood
ceUs, oil droplets and degenerated epithelial cells, fatty acid and cholesterin
crystals may be found.
Symptoms. There may be colicky abdominal pain with nausea and
vomiting or these symptoms may be wholly absent; the patient may perceive
nothing unusual until the increasing size of the abdomen comes before his
notice. Jaundice and ascites, due to pressure upon the bile ducts and portal
vessels, may be present with large cysts. Fatty diarrhoea and pancreatic
salivation are rare; glycosuria may be present. Disappearance of the cyst
and its symptoms may take place suddenly, due to temporary relief of the
obstruction.
The diagnosis depends upon the result of physical examination. In
typical instances the tumor lies in the mid-line of the upper abdomen; in
extreme cases the cyst may fill almost the entire abdominal cavity. It is
seldom mobile and does not descend with inspiration; its surface is smoother
lobulated and it is elastic in consistency. The stomach may be demonstrated
above and the colon below the tumor. Percussion reveals the presence of a
flatness which is not continuous with the dull note elicited over the liver or
spleen. Fluid aspirated from the cyst should digest albumin and emulsify
fat, but the former characteristic only, is pathognomonic, for numerous ex-
udates and transudates contain fat emulsifying ferments.
476 DISEASES OF THE DIGESTIVE SYSTEM AND PERITONEUM.
The prognosis under proper treatment is good.
Treatment is exclusively surgical and consists of incision and drainage.
Extirpation of the cyst has been followed by diabetes mellitus.
PANCREATIC CALCULI. I
.Etiology. Pancreatic lithiasis is a rare condition. The stone is probably
the result of inflammation of the pancreatic duct with resulting abnormality
in the composition of the secretion and ultimate precipitation.
Pathology. The calculi are whitish in color and often multiple; in size
they vary from that of a grain of sand to that of a good sized pea. They
may be rounded and smooth or irregular and rough. They are composed
chiefly of calcium carbonate, sometimes with the addition of calcium phosphate.
The irritation caused by their presence may result in inflammation of the
pancreas, with dilatations of the duct or even of the gland itself, suppurative
inflammation of the organ or even cancer.
Symptoms. The colic due to passage of the stone into the duodenum is very
like that due to gaU-stones and it is practically impossible to differentiate the
two conditions, particularly since jaundice may be a feature of both. Glyco-
suria and fatty diarrhoea with colic in the upper abdomen may give the clue
to the diagnosis of pancreatic stone. If calculi composed of calcium carbonate
are found in the fasces the diagnosis is assured.
The prognosis depends upon the development of sequelae such as chronic
pancreatitis, suppuration or cancer.
Treatment. The attacks of colic should be controlled by the means sug-
gested for the relief of biliary coHc (q.v.). Disturbances of digestion should
receive appropriate treatment and one instance has been reported where the
administration of 8 to 15 minims (0.5 to i.o) of a i percent, solution of pilo-
carpine three times a week, with the object of increasing the pancreatic secretion,
was successful in checking the attacks. Hydrochloric acid is also said to
promote the flow of pancreatic juice and its employment is worthy of trial.
DISEASES OF THE PERITONEUM.
ACUTE PERITONITIS.
Definition. An acute inflammation of the peritonaeum.
^Etiology. Primary acute inflammation of the peritonaeal membrane is a
very rare affection but is said to occur as a result of exposure to cold and
wet and has been termed rheumatic or idiopathic peritonitis.
Secondary peritonitis is frequent and is due to the extension of an inflam-
mation of any of the structures adjacent to the peritonaeal membrane, to rupture
ACUTE PERITONITIS. 477
of any of the viscera which the membrane surrounds or to abdominal opera-
tions which have been performed without due regard to perfect asepsis.
Of peritonitis caused by extension, inflammations or tumors of any of the
following organs or structures may be at fault; the stomach, the intestines,
the Kver, the gall-bladder, the spleen, the pancreas, the organs of either the
male or female genito-urinary system. Abscess of the perirenal tissue, of
the spine, as in Pott's disease, or the cold psoas abscess may cause peritonitis
by rupture or by extension.
Peritonitis also may follow rupture of any of the viscera named above but
the most important causes of perforative peritonitis are appendicitis and
rupture of suppurative processes involving the structures about the ovaries
and Fallopian tubes. In considering the aetiology of peritonitis, perforation
of the viscera resulting from external wounds must not be forgotten.
Peritonitis also occurs as a complication of acute polyarthritis and pleuritic
inflammations and sometimes as a terminal infection in chronic nephritis,
arteriosclerosis and gouty conditions
Secondary peritonitis is without exception of microbic origin and the causa-
tive bacteria are either those responsible for the primary inflammation or those
introduced into the peritonaeal cavity with the contents of the ruptured viscus;
the most usually found organisms are staphylococci pyogenes aurei or albi,
streptococci and bacilli coli communes. Less commonly found are the tubercle
bacillus, the bacillus of enteric fever, the pneumococcus, the bacillus of epi-
demic influenza, the bacillus pyocyaneus, the bacillus aerogenes capsulatus,
the bacillus proteus and the gonococcus. The amoeba coli has been found
in peritonitis occurring with tropical dysentery. In some instances the
infection may be due to a single type of micro-organism but much more fre-
quently cultures from the inflammatory exudate vnll show a mixed infection.
The mono-infections occur more especially in peritonitis secondary to or
accompanying nephritis as a terminal infection, acute rheumatism, gout,
arteriosclerosis and pleurisy.
Pathology. The intestines are distended with gas and their peritonaeal
surface is congested; the coils of gut are more or less adherent to one another
due to an exudation of lymph-like substance which is made up of fibrin and
white blood cells. The inflammatory exudate upon the surface of the peri-
tonaeum or into its cavity may be of fibrin only, of serum with fibrin, of pus,
ereamy or greenish in color, or of bloody serum, especiafly in instances due to
external wound. In early stages, before the appearance of fluid, the peri-
tonaeum is slightly roughened and its lustre is dulled. Foul fluid mixed with
intestinal contents is present in peritonitis due to perforation of the intestine,
and after ruptiure of the uterus occurring in puerperal or carcinomatous con-
ditions a particularly foetid, grayish-green exudation is often observed. The
amount of fluid present varies from a small quantity to 20 quarts (litres) or
478 DISEASES OF THE DIGESTIVE SYSTEM AND PERITONEUM.
more. In instances of long standing the lymph adhesions between the coils
of intestine and other viscera become organized and may finally result in the
formation of dense bands of tissue. In circumscribed peritonitis these are
especially noticeable and the adhesions may wall off localized collections of
pus or abscesses which may rupture, which event is followed by a general
peritoneal inflammation.
Symptoms. Acute generalized peritonitis when due to perforation is sudden
in its onset and characterized, in very acute instances, by a fall of temperature
and evidences of collapse, such as great prostration, cold perspiration and
rapid, small and weak pulse; there is abdominal pain with general tenderness.
The respirations are shallow, rapid and thoracic rather than abdominal.
After the chiU of the invasion there may be moderate fever, rarely is the tem-
perature high, and it may remain normal or even below this point. The
urine is scanty and may contain indican. The pain is often severe and is
greatly increased by motion but at times the patient, if he is allowed to lie
quietly in the position which he chooses — usually with the thighs flexed and
the shoulders raised so as to relax the abdominal muscles — makes little com-
plaint. The abdominal wall is tense and hard and upon examination tend-
erness and a tympanitic percussion note are observed. The tongue is moist
at first; later it becomes dry and cracked. Vomiting is early, frequent and
very painftd; the vomitus consists of stomach contents, followed by thin bile-
stained fluid and ultimately by dark liquid, sometimes of faecal odor. The
bowels are often loose at first but constipation soon supervenes.
Physical examination, in addition to the signs already mentioned, reveals
a typical fades — the Hippocratic countenance — the eyes, cheeks and temples
being sunken, the nose pinched, the lobes of the ears turned out, the forehead
rough and dry and the skin dark or livid. The abdomen is tympanitic,
the diaphragm and the cardiac apex may be displaced upward and both
liver and splenic dulness may be obscured or even obliterated. These mani-
festations are particularly marked if air, in addition to fluid, is present in the
peritongeal cavity; this takes place when the perforation involves an air-con-
taining viscus. If the patient lives long enough, fluid, with its characteristic
signs, appears in the peritonaeum. It is evidenced by increasing dulness in
the flanks, the extent of which is altered by a change in the position of the
patient. There may, however, be a considerable effusion without movable
dulness; a peritonaeal friction sound may be detected. In determining the
presence of pneumoperitonitis one must remember that in this condition
hepatic dulness even in the mid-axillary line when the patient is on his left
side may be absent, while when fluid alone is present liver dulness exists under
these circumstances although it may be absent when he lies flat on his back.
The mental condition usually remains clear until near the termination of
the disease when coma or delirium may supervene. As the end approaches
ACUTE PERItONITIS. 479
the pulse becomes feebler and feebler, irregular and intermittent, the tem-
perature rises, although the skin may remain cold, and death occurs. In the