never be quieted with any form of opium, as by so doing the symptoms are masked. Treat the cause of the pain, which in all cases is pent-up secretions and infection. Establish free drainage through the drum membrane first. A free incision of the drum membrane, done under proper aseptic precautions, is comparatively harmless and at once opens an avenue for the escape of infectious material which for the want of an opening may be extended into the antrum or the brain cavity, because that direction may be the one of least resistance. With the establishment of free drainage the severe pain should cease. If pain persists you have something more serious than a simple middle-ear trouble to deal with. An acute suppuration of the middle ear, if it is progressing toward a cure, will subside gradually. If a profuse discharge stops suddenly, then look out for mastoid or intracranial complications, and especially if at the same time the temperature jumps upward. If mastoid symptoms develop, as evidenced by pain, tenderness, redness or swelling of the mastoid, apply cold to the mastoid at once, but do not persist in the use of cold if it does not produce a decided relief of all symptoms within a few hours, and do not try it at all if the mastoid symptoms have existed for thirty-six hours, but have the case operated.

If in the course of suppuration from the ear the patient has a chill, followed by high fever,

and sudden and radical fluctuations in the temperature, suspect sepsis in some of the venous channels, usually a thrombus of the sigmoid sinus, and urge immediate operation. You will have a funeral if the case is not operated, and you may have one anyway, but an operation offers the only hope.

Finally, remember that every middle-ear suppuration has elements of danger in it, and it should be given careful attention; that mastoid or intracranial complications and the indications for an operation therefor are clearly marked; and that 75 per cent. of the deaths as a direct result of extension of a suppuration from the middle ear can be prevented by early and proper operative procedures.

The general practitioner can improve the mortality and morbidity rate if he will recognize the importance of giving suppurations of the middle ear more attention and make more and earlier diagnoses. If he cannot diagnose and cannot operate his cases, and he is seldom capable of doing the latter, he owes it to himself and to his patient to call to his aid some one who can do it. 219 West Wayne Street.

TREATMENT OF PANCREATITIS.*

J. C. SEXTON, M.D. RUSHVILLE, IND.

In writing this review of treatment, I beg to disclaim any extensive personal knowledge of the subject, but have drawn at liberty from available essays and reports. The teaching, and in some instances the language, is that of our best authorities. Inflammation of the pancreas stands in such relation to disease of the gall-bladder and ducts, that no study of the surgical treatment of pancreatitis can be made apart from these anatomical, pathological and mechanical relations.

When we recall that the common duct runs through and is surrounded by the head of the pancreas, and cannot be separated from it except by dissection in a large majority of cases instead of merely traversing a groove upon its surface; and when we also remember the termination of the common duct and the pancreatic duct side by side in the ampulla of Vater in the duodenum "forming a common cavity within the papilla," we can understand at once how the pathology of one may readily be associated with the pathology of the other, and how the surgery of pancreatitis comes to us as a development of gall-bladder surgery.

As surgeons in their work upon the gall-bladder and ducts became more expert, painstaking and thorough, it was learned that certain conditions of the pancreas complicated the pathology and modified the results. It was learned that inflammations of the pancreas, whether arising on account of duodenitis or conveyed to it through lymphatic or other channels, produced symptoms very similar to gall-stone attacks; and, on the other hand, we have positive knowledge that gall-stones in the common duct, or the pathologic effects of their passing through the duct, are the most common cause of most of the cases of pancreatic inflammation,

The workers in this field of surgery have been many, and their contributions to the literature of the subject so comprehensive that we are now able to collect sufficient evidence to establish a symptomatology so marked as to render a diagnosis of pancreatitis reasonably certain in many cases. On the other hand, it is not possible, in an organ so deeply placed as to render palpation practically impossible, and connected with duodenum, liver, stomach and gall-ducts, by circulatory, lymphatic and nervous chains, to ever accurately estimate its pathologic changes, except by means of the exploratory incision. So I sub

Read before the Indiana State Medical Association. Oct. 8, 1909.

mit that the treatment of pancreatitis, to be at all certain or rational, must be surgical.

Pancreatitis presents itself in three forms with varying intensity, modifications, and terminations in individual instances. These are the acute, subacute and chronic.

Of the acute fulminating hemorrhagic form of pancreatitis, 90 per cent. of unoperated cases die after very brief and terrible illness. This form of pancreatitis cannot be differentiated from perforation of gall-bladder, of duodenum, or of stomach; or from acute intestinal obstruction. It has been confounded with renal colic, extrauterine pregnancy and appendicitis. The terrific sudden pain in the right upper abdomen, the shock, collapse, nausea, vomiting, rigid muscles and the rapidly increasing tympanites make a clear indication for immediate operative interference, no matter what the cause. The bloodstained serum and fat necrosis will at once establish the diagnosis. The exudate is to be removed as rapidly as possible and the abdomen irrigated with salt solution. The gastrocolic omentum is then opened and the pancreas exposed. Gauze drains in rubber tissue are secured in place by catgut stitch and the operation completed as quickly as possible. If the advice is correct to go in quickly, it is certainly imperative to get out as rapidly as possible.

Some surgeons advise incisions into the pancreatic substance, while others do not, but all agree on thorough irrigation and making free and ready exit for the inflammatory exudate which is extremely toxic. For it has been shown that the critical condition of these patients is due to trypsin intoxication, and the intensity of the symptoms depends on the amount of necrosis and pancreatic gland involved. Under this plan of early operation, irrigation, cleansing and free drainage, surgeons can show a mortality of 50 per cent., as against 90 per cent. without operation. Of the causes of the fulminating hemorhagic type, one we know positively, and that is gall-stone in the diverticulum of Vater and bile forced into the pancreatic duct. Patients may die in forty-eight hours of this disease, and a study of it enables us to understand why a patient who has passed through so many attacks of gall-stone colic, dies at last in one of them.

In the subacute form of pancreatitis, the onset may be just as sudden perhaps, but the symptoms lack the severity, the intensity of those of the acute fulminating type. Pain may persist. Jaundice develops. A tumor may or may not present itself. The symptoms may be identical with. those of gastroduodenitis, and catarrhal jaundice is known in many instances to be neither more

nor less than pancreatitis with the head of the swollen pancreas compressing the choledochus.

Most of the cases of this form of pancreatitis will recover under simple cholecystostomy, which provides an outlet for the bile until the swelling of the pancreas subsides sufficiently to permit the common duct to again become open. In many instances localized abscess in the head of the pancreas or surrounding tissues will have to be opened and drained. Collections of serum in the peritoneal cavity or behind it, not necessarily purulent, must be cleaned and drained. necrosis to a marked degree is not incompatible with recovery, provided free drainage is afforded to the toxic products of inflammation.

Fat

The treatment, then, of the subacute type is drainage, always of the gall-bladder and supplemented by drainage of the subhepatic and pancreatic areas when required.

In cases of chronic pancreatic inflammation, there is great infiltration and enlargement of the head of the pancreas. Hyperplasia, especially of connective tissue, develops. Deposits of exudate become organized into adhesions about the duodenum and gall-ducts so that in many instances the common duct seems to run into a solid tumor.

Such a condition has often been mistaken for malignant disease, even by the most experienced surgeons. Under such condition the common duct passing directly through and surrounded by this mass, becomes compressed, and can no longer serve its purpose of carrying bile into the intestines.

The problem of treatment merely resolves itself into making either a temporary outlet for the bile by means of drainage through the gall-bladder, or a permanent new channel for the bile by uniting the gall-bladder to some other portion of the alimentary canal. Speaking first of those cases that can be cured by a temporary outlet, we must recall again that over one-half, some say 60, some say 80 per cent., of these cases have been caused by gall-stones.

Gall-stones in the gall-bladder and cystic duct will be found to have coincident pancreatitis in 7 or 8 per cent. of cases; and gall-stones in the common duct will have pancreatitis in 22 per cent. of cases. These gall-stones caused by and attended with infected bile, as they always are, give rise to the irritation that produces the plastic inflammation in the pancreas and removing this cause will effect a cure. In nearly all the cases in which stones are found in the bile tract, the successful removal of these stones and temporary free drainage of the gall-bladder can be depended upon to cure chronic pancreatitis, just

as the same procedure will suffice to effect a cure in almost every case of the subacute form.

Taking up now the class of cases in which temporary drainage of the gall-tract will not do. Here we have permanent obstruction of the common duct. It is either permanently compressed from without by permanent over-growth or infiltration of the gland substance about it; or what very often has happened, is that the duct is stenosed by injury to its mucous lining from gallstones that have escaped into the intestine. In this class of cases the gall-bladder and duct wil! be found enlarged and dilated from long-continued back pressure of bile, and this bile must be turned into the intestine by uniting the gallbladder to some other portion of the alimentary canal by means of the well-known procedure of making a cholecystenterostomy. The gall-bladder has thus been successfully united to the alimentary canal, and the procedure gives nearly 80 per cent. of cures in a condition which must otherwise be inevitably fatal. The points at which union has been made have been four, namely, to the stomach, to the duodenum, to the jejunum and to the colon.

The relative merits of these different procedures will not be taken up here for discussion, but this brief review will serve to show how the profession can attack successfully both the acute and chronic forms of inflammation of this most deeply hidden of all the organs of the body.

REFERENCES.

Progressive Medicine for June, 1903-'04-'05-'06-'07-'08-'09.
Robson and Cammidge, 1907.

Surgery, Gynec. and Obst., December, 1908.
Kelly and Noble: Gynec. and Abdom. Surg.
Opie: Disease of Pancreas.

Mayo Jour. A. M. A., Vol. L, 1908.

Moynahan Keen's Surgery.

Surg., Gynec. and Obst., May, 1907.

DISCUSSION.

DR. T. VICTOR KEENE, Indianapolis:-Since my arrival in Terre Haute I have been asked to substitute for Dr. McCaskey, who is not able to be present. What I shall have to say on the subject will be based upon my experience with one case of pancreatitis, and the knowledge gained by studying the literature on the subject.

There are three great digestive stations within. the human body. The first is the mouth, with the saliva as its digestive element to take care of the starches and sugars. The second is the stomach, whose function in a broad way is to take care of the proteids and sugars. The third and last of the digestive stations is the duodenum, with the pancreatitic fluid as its medium. The pancreatic fluid has for its function to take care of such proteid and sugar as is undigested in the stomach and the fat in the food. The first effort at digestion and assimilation of the fat is made. in the duodenum by the pancreatic fluid. Now,

obviously a perversion of the character or a lack of pancreatic fluid would immediately and naturally lead to serious metabolic disorders, because if we have complete lack of pancreatic fluid or a change in its character we will have a lessened or the body as a matter of fact, possesses a very limtotal lack of fat absorption and digestion. Now, ited capacity, irrespective of the pancreatic fluid, to take care of fats, so that the total lack of pancreatic fluid as we frequently get it in a pancreatitis does not produce such serious metabolic disorder as would first appear likely.

The recognition of pancreatitis as a separate and distinct entity is a matter of recent years. It is well within the memory of many of the men here when we had an ill-defined disorder known as abdominal pain, popularly called bellyache. We have finally seen this diagnosed as a symptom of appendicitis and various other diseases. The latest distinct differentiation is the so-called pancreatitis. As a matter of fact, the first time we read of it in the literature, at least in a prominent way, was in 1900, which is, of course, within relatively recent times. Now, pancreatitis, as the name would readily indicate, is an inflammation of the pancreatic gland. The term is rather a misnomer, for we do not have in all cases a pancreatitis, the classical pathologic picture of inflammation of tissue. The disease is a disease of perverted activity of the glands rather than an anatomical physical inflammation of it.

Pancreatitis as a disease is a thing of very recent recognition. The reasons are many, the most prominent of which is that the pancreatic gland is the most prone of all the tissues within the human body to decompose after death; in fact, the gland is the most difficult of all the glandular structures to get in the various laboratories which use it in a teaching way. The proneness of the pancreatic gland to degenerate is a thing which is commercially recognized in a very practical way. The records of the post-mortem room would seemingly indicate that inflammation of the pancreas is a very rare disorder. However, for the reason just mentioned, the records are very likely to be untrustworthy, because any examinations made would not indicate the condition of the gland in life, but the condition in life plus post-mortem degeneration. The record of the operating room, however, would indicate that inflammation of the pancreatic gland is a much more common disease than is indicated by the record of the post-mortem room. In fact, we have various statistics offered from the wellknown statement of Mayo Robson, of England, a prominent worker in this line, who has found. that 60 per cent. of cases of gall-bladder lesions have inflammation of the pancreatic gland, to the records of Oser, of Vienna, who states that about 20 per cent. of his cases of inflammation of the gall-bladder of various types show an

associated inflammation of the pancreatic gland. The fact of the matter is, a great many men seriously question whether there is such a thing as primary suppuration and distinct inflammation of the pancreatic gland, holding that it is secondary to other disorders. That is a matter that cannot be determined yet. The condition has been studied and post-mortem records have been collected in many cases, so that we now describe a certain clinical order of infections which we term pancreatitis.

As a general rule, there are two main types of pancreatic disease. The one is the so-called atrophic pancreatitis and the other the so-called inflammatory type. The atrophic form is a disease in which we have an individual develop up to a certain period of years, seven or nine, in a normal manner. Then the physiological activity of the gland is incompetent to supply the needs of the body, and the individual remains in statu quo. He remains a 7 or 8 or 10-year-old individual indefinitely. This is simply due to a lack of development. That is the so-called pancreatic infantilism that has been described primarily by Oser, of Vienna, and is a disease of the same general type as cretinism and the other glandular inactivities. This disease has certain symptoms which cause it to be suspected and diagnosed. The first and most prominent symptom is the marked tendency toward arrest of development. The individual develops to a certain stage and develops no further. The mental and physical condition remains the same. It does not go back or does not progress. There are cases in which this arrest does not occur until 16 or 17. There are very few digestive disturbances in this disorder. The patient eats heartily. He has a marked tendency to bloating, because he prefers and elects in his diet fruits and foods which are largely composed of sugars, and possibly albumins. The pictures that appear in the literature of this type of cases remind you of the pictures you see of negro children in Central Africa, who are largely belly, the reason being when any individual develops the carbohydrate habit of life they have a tendency toward gaseous bloating and physiologically and anatomically a sugar eater must have a longer intestinal canal to admit of absorption than a meat eater has. The most common symptom present in the greatest number of cases is a tendency toward frequent movements of the bowel.

This is in no sense of the word a diarrhea. There is no griping. The stools are not watery. They are hardly formed, but they are rather solid and soft. It is remarked by all writers on the subject that the stools of this type of cases are peculiar, in that the amount excreted seems to be larger in bulk and greater in amount than the intake of food, the reason being ascribed to the tendency to gas production. Such cases, of course, are strictly and purely medical cases.

The treatment is capable of being administered anywhere by the profession. It consists in the administration of fresh pancreatic gland. For some reason unknown, the gland of the pig seems to be preferable, and it is simply macerated and extracted in glycerin, using two volumes of glycerin to one volume of gland, and such a digestive medium remains in good order from four to six weeks. The dosage of it is usually about three or four teaspoonfuls every four hours. Such a patient will rapidly progress; he will put on weight and develop mentally and physically. The literature is not particularly rich in this type of cases. Every text-book mentions this type prominently, but there are only about 40 cases listed in Robson's new book, and these include the complete series of cases in all the literature. monly the type which is an acute disorder of the When we say pancreatitis we mean more comgland. The etiology of pancreatitis is unknown. There are various theories offered, and as usual in such cases, none or very few are of value. It is the old principle, when you open a text-book and find fifty or sixty drugs of great value in a condition, none of them is of much value. The idea which appeals most strongly is that the acute disorder is occasioned by inability of the pancreatic gland to eliminate its secretions, or the walling back and damming of the bile salts from the intestines. The experimental data on which this is based are as follows: In a great many cases of acute pancreatitis we find the pancreatic gland stained with bile salts. It is well known from the classic experiments of Flexner, of the Rockefeller Institute, that we can take bile salts and dilute hydrochloric acid or dilute sulphuric acid, etc., and inject it into a gland of a dog and produce symptoms of pancreatitis. That is really the only fact that we have on which to hang our tion of the secretions, or by an intaking of the theory that pancreatitis is produced by a retencontents of the intestinal tract. Certain it is, however, that in many cases of pancreatitis we have the duct occluded by a stone in the common duct, or you will find the pancreatic duct pressed shut by a surrounding tumor.

The symptoms of this disease will be briefly recounted. It was my good fortune to see one case of what was unquestionably pancreatitis, a case referred to Rilus Eastman by Dr. Pearson, of Wabash. The case was sent in without a diagnosis, as there was such a rapid enlargement of the belly that physical palpation of the abdomen was out of question. The diagnosis was made, as will be related. Pancreatitis is extremely and most extraordinarily abrupt in its onset. Some patients have reported that they felt as if they were kicked in the pit of the stomach by a mule. This acuteness is common and very generally reported, and the pain radiates to the left. scapula. This rotation to the left is significant as well as interesting. We know that in a large

majority of gall-stone cases the pain is radiated to the right scapula. This differentiation may be rather far-fetched, but it is dwelt on prominently in all the texts. The patients immediately after they have the acute onset and the extreme pain develop a tumor which can usually be palpated posterior to the stomach and anterior to the spinal column. This tumor mass is usually rapid in development, so much so that three or four hours make a marked difference in the size of the tumor. Obviously, the great difficulty in arriving at a diagnosis of acute pancreatitis is to differentiate it, as the symptoms have been developed so far, from gall-stone disease. This is practically impossible to do absolutely, although there are suggestive tests. The nausea and vomiting you get in pancreatitis are the most prominent symptoms, and it amounts to what is practically projectile vomiting, very annoying and very continuous. This is present in every case I have seen reported in the literature. There are a number of cases reported that have been operated on under a diagnosis of intestinal obstruction, and when the abdomen was opened the only disorder found was that of the pancreas.

In the one case I saw the diagnosis was arrived at in this manner: The condition was suspected, of course, but there was such an acute peritonitis that we could not palpate the abdomen. The bowel movements were very frequent and there was no diarrhea. It was noted by the nurse that in one of the bowel movements there seemed to float an oil on the top of the water in the bed pan. That at once gave a good suspicion of acute pancreatitis, and a study of the literature showed that that was a rather common means of arriving at a conclusion. The urine was tested by the Cammidge reaction. The principle of this reaction is to find present in the urine a pentose which is not normally present in any other condition in the quantity we find it in this disease. It would not be proper to consider the technic of that here. But this reaction has been accepted very generally as at least highly significant of the possibility of pancreatitis.

The treatment of this type of pancreatitis is entirely surgical. I think that all cases of acute pancreatitis should at least be accorded the courtesy of competent surgical operation. It is a surgical disorder. However, the after-treatment of it is largely medical, and medical treatment has one idea in mind, and that is the withholding of fats from the patient as much as we can, giving fats only in the form of milk, in which form some of it will be absorbed, but the fats of meats and butter should be withheld, as they may distress the patient and do him no good.

DR. THOMAS B. NOBLE, Indianapolis:-When it is remembered that the pancreas is provided with more protection than any other organ in the body, that, roughly speaking, it lies in front of the immense barrier of bone and muscle in

the rear, that it lies under the eaves of the costal border above, that it is protected in front by the abdominal wall and the abdominal viscera, we have every reason to believe that Nature looks upon this organ as certainly sensitive, delicate and easy of insult. Such is observed clinically.

I only want to talk relative to the surgical aspect of this condition. The clinical features of pancreatitis one sees in a class commonly dominated by abdominal surgery. There is a reason for the clinical conditions we find here, a reason first in the anatomic structure and relationship of this gland, particularly to the liver, with which it seems to be closely associated in function, at least. In operative function the pancreas and its perijacent lymphatics and lymph nodes are continuous with the lymphatics and lymph nodes of the liver, as shown by Cuneo particularly. The pancreas is connected with the liver in direct channel route in quite a number of cases, as shown by the dissections of Mayo Robson. Some of these pancreases have a double outlet. You all remember the duct of Wirsung, and there is a superimposed duct in quite a percentage of these organs which has an independent auxiliary outlet through the channel of Santorini. The openings of these ducts are not at all constant. Sometimes the duct of Wirsung has a common opening with the common gall-duct at the papilla and opens as a crescentic auxiliary opening to the major opening of the common bile duct. It seems to be of lesser significance in that the major characters of the structures are devoted to the provisions for the biliary outlet, while that from the pancreas seemingly is of less importance, of more delicate structure and of more indifferent association and relationship, as evidenced by its elliptical opening. The opening of the bile duct will remain patulous longer than that of the pancreas. This pancreatic opening is sometimes directly in the ampulla of Vater, superimposed above the common duct or the papillary opening. It sometimes happens that the duct of Santorini opens in the common duct a considerable way above the common opening below, so that a closure at the papilla will allow a direct communication by a channel route from the biliary passage through the duct of Santorini directly into the substance of the pancreas. much, then, for the anatomic relationship.

So

We observe, then, that the pancreas is subject to insult from two routes-one directly through the discharge of the bile, and another indirectly through the lymphatic channels. It has been noted that the gall-ducts and the gall-bladder are very commonly disordered, gall-stones very frequent and are a very common cause of mechanical disturbance, as well as zymotic disturbance of these organs. We find that it is no more than a natural and logical sequence in biliary disease and cholelithiasis to find pancreatitis or pancreatic insult.