It has been suggested to make the exploration as well as the drainage from the loin, but this procedure cannot be here advised, since it leaves too many features in doubt and affords insufficient means whereby to appreciate and cope with many grave complications. Calculi, either biliary or pancreatic, which are so often an exciting cause of these troubles, should be carefully sought for and removed if present. They could not be revealed nor removed through any small posterior opening. Other good reasons are also advanced, since the intensity of the symptoms is an expression of an intraperitoneal rather than retroperitoneal lesion.
The reader will note that but little has been said as to the distinction between the hemorrhagic, gangrenous, and other forms of acute pancreatitis, as these are for the surgeon, as such, side issues. His paramount duty is to open the abdomen of every such case, so soon as he can possibly effect arrangements.
Subacute Pancreatitis; Abscess.
—Under this term are included disease processes and lesions similar to or identical with those described as causing acute and even fulminating expressions of pancreatic obstruction, but less severe in their manifestations, less rapid in their course, and more localized in their boundaries. They are often so associated with a protective and natural walling off of the area of excitement by barriers, which outpour of lymph and its consequent condensation into adhesions afford, that they appear more often as abscess of the pancreas or hematoma of the lesser cavity of the peritoneum.
So far as concerns its etiology the causes are essentially the same as in the acute cases, only the results are brought about more slowly, weeks being in these cases as days in the others. Gallstones are by all means the most common cause, and the pancreatic disease is itself an expression of an infection travelling up its duct.
Symptoms.
—The symptoms usually include pain, which, however, lacks the agonizing intensity noted in the more acute cases. Vomiting is usually associated with constipation, but the vomitus is rarely or never bloody; jaundice of variable degree is a common feature, and collapse is rare. Distention of the upper abdomen and tumor formation come on more slowly. Tenderness is less extreme and muscle rigidity less marked. While the pulse is less affected the temperature is usually more so, often running high. Even early in the case we may note general expressions of septic intoxication, such as mild chills and a characteristic appearance of the tongue and face. Constipation is followed by diarrhea; at least the stools which are fetid contain blood, pus, fat cells, and undigested meat fibers. Pain is more or less constant, but increased in paroxysms. Loss of appetite and rapid emaciation are apparent from the outset. Albumin will be found in the urine, but rarely sugar. The peculiar reaction described by Cammidge will, according to Mayo Robson, give uniformly positive evidence. As abscess gradually or rapidly develops it will cause a swelling, which has its origin behind the stomach and may displace this viscus, as well as the colon, upward or downward, presenting usually toward the abdominal wall. In rare instances the direction of least resistance takes it toward one loin or the other, where it may appear as a perirenal abscess, or around the crus of the diaphragm and above the liver, where it would appear as a subphrenic abscess. It has been known also to burrow along the psoas muscle and appear at the groin, or even in the left broad ligament. Abscess of the pancreas may also burst into the stomach, when pus will be vomited, or into the bowel, whence it will be evacuated. A sudden relief, with disappearance of tumor, followed by diarrhea and purulent stools, would indicate this latter termination. Under these circumstances the abscess cavity may repeatedly refill and reëmpty itself. Spontaneous recovery in this way is possible, but septicemia and hectic usually persist until obviated by operation.
Diagnosis.
—The history, the evidently septic type of the case, and the distinct signs above noted will make almost certain the presence of pus, and Mayo Robson insists that the pancreatic reaction in the urine (Cammidge) will make clear its location and origin; but, with or without the latter, the important feature is that there must be a deep collection of pus somewhere in the neighborhood of the pancreas.
Treatment.