The principal exciting causes are the various infections which may proceed from the blood, as in pyemia or syphilis, or from the alimentary canal, which is never free from bacteria, either by adhesions and continuity, as from gastric ulcer and cancer, or by those natural passage-ways, the ducts.

When summed up the most common of all the causes of pancreatic disease, acute or chronic, will be found to be cholelithiasis, with some of its variant consequences or complications. This will help to make clear the reason for operating on the biliary passages in most cases of pancreatic disease, especially the more chronic forms. A stone impacted in any portion of the common duct, especially in its terminal portion, after it has come into relation with the duct of Wirsung, may cause an amount of disturbance disproportionate to its size. Moreover, a stone impacted at the orifice of the duct will permit the entrance of bile into the pancreatic canal, where it does not belong, and where of itself it may cause trouble.

ACUTE AFFECTIONS OF THE PANCREAS.

These include—

Acute Pancreatitis.

—Acute pancreatitis is a distinct form of disease, like appendicitis, with an etiology and symptomatology of its own, which has been recognized only within the past twenty-five years. This statement will account for the fact that so little reference to it is made in any but the recent text-books. In fact it is to the writings of Fitz, of some fifteen years ago, that the world owes its first keen interest in the subject. By no means a frequent disease, it nevertheless occurs with frequency sufficient to make it inexcusable for the practitioner to fail to take it into consideration, although he may waver in diagnosis.

The predisposition to infection which previous injuries, especially minute hemorrhages or previous pathological conditions, seem to afford has been already mentioned, and a history of previous injury or digestive disturbances will aid in diagnosis. The exciting cause is, however, in nearly every case when not distinctly traumatic, connected with previous disease in the biliary tract, either cholelithiasis or cholangitis. Reference to what has been said above, and a consideration of the anatomical relations, will show how readily an infectious process can travel upward from the duodenum into the pancreatic duct, as well as into the common duct; or how, passing down the latter, it may speedily find its way up the former. The previous condition of the tissues, and the activity or virulence of the infective organisms, have to do with the degree of acuteness of the resulting pancreatitis. This is sometimes of such overwhelming toxicity that the entire gland dies almost as does the appendix, within a few hours, the result being an acute necrotic condition that of itself is necessarily fatal.

Symptoms.

—Acute pancreatitis gives rise to symptoms which, in general, assume the clinical form of an acute peritonitis of the upper abdomen. It commences with sharp pain in the epigastrium, accompanied by faintness, nausea, vomiting, and collapse, while tenderness over the pancreas is an early symptom, and swelling or enlargement can sometimes be detected. Constipation is so frequently a feature that the diagnosis of acute bowel obstruction is sometimes made, but it will be found that obstruction is not complete, for flatus may pass and enemas may be successful. The pain becomes paroxysmal, is increased by movement and pressure, while the tenderness becomes more localized. Meteorism may so quickly succeed the other symptoms as to make physical signs uncertain, while rigidity of the abdominal muscles makes them still more vague, yet affording in itself a sign of value. Vomiting intensifies the pain and the vomitus changes from food to bile, and then to blood, which is dark and altered. Hence jaundice may be an early feature, in which case it becomes more marked as the disease progresses, and may become intense. This is likely to be the case if the exciting cause prove to be a stone impacted at the ampulla. The face indicates profound distress and disturbance. The temperature affords no certain indication, save that in the most serious cases it may be subnormal. On the other hand, as the case progresses, the pulse becomes small and rapid. Every expression of overwhelming toxemia is added, and delirium usually precedes death. In fact death may follow the first expression of pain, in unrelieved cases, in from two to three days. Other less acute expressions of the same general character are met with in the so-called subacute forms of pancreatitis.