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In Abdominal Disease JULY 2, zgzo.J "PANCREATIC REACTION " IN ABDOMINAL DISEASE. 1B and, if we cannot finally conquer, at least prolong for chemical syntheses effected by its cells in the formation years a life which unaided would have rapidly been of urea; it protects the body from the action of various sacrifioed. toxins in virtue of its detoxicating powers; and by virtue of its glycogenic function it is a centre of stored - REFERENCES. energy IGlomerular Lesions of Diffuse Nephritis, Herringham and Thurs- producing material. Its influence through the bile on field, Trans. Path. Soc. of Lond., vol. lv, 1904, p. 283, with photo- digestive processes is relatively insignificant. mnicrographs. 2Tigestedt and Bergmann, Skandinavisches Arch. f. Physiol., 1898. Band viii, 223; corroborated by Batty Shaw. Goulatonian The pancreas, on the other hand, is a great secretory Jiectures, 1906, Lancet, 1906. vol. i. 8 L. S. Foster, Joural of Medical gland; it performs no such functions as the liver performs; Besearch, vol. xxi, No. 2. p. 297, 1909. it is comparable to the salivary glands, not to the liver. Its disturbances affect the value of its secretion, either internal or external. There is nothing else to be disturbed. THE " PANCREATIC REACTION" IN The liver, in virtue of the scope of its functions, is exposed to injurious influences vastly more numerous than ABDOMINAL DISEASE. the pancreas. In neither is injury by extension from the BY WILLIAM RUSSELL, M.D., F.R.C.P.EDIN., duodenum along the ducts common. Injury to the liver PHYSICIAN AND LECTURER ON CLINICAL ZJEDICINE, ROYAL INFIRMARY; by way of the blood or lymph is common from acute AND LECTURER ON PRACTICE OF MEDICINE, SCHOOL OF parenchymatous inflammation ending in abscess to slow ME,DICINE, EDINBURGH. interstitial hyperplasia ending in cirrhosis. In the pancreas acute necrotic and haemorrhagic in- IN no department of internal medicine is accurate differen- flammation is known as a highly mortal malady, but it tial diagnosis so called for in the interest of the patient as has not been shown that these conditions arise from duct in diseases and disorder of the abdominal viscera. infection; while the cirrhoses of this organ have no known This general proposition is, I think, fully accepted by clinical significance apart from the production of diabetes my surgical colleagues, for the immature period of the in some instances. Apart, indeed, from the severe forms exploratory laparotomy has been succeeded by a desire for of inflammation, it may be fairly postulated that other accurate diagnosis, so that the abdomen may not be opened pathological changes in the gland can hardly be expected unless the prospect can confidently be entertained that the to do more than influence its secretory function. symptoms which justify surgical interposition will be Of the internal secretion and its modifications we are removed. That this highly desirable accuracy in differen- still in comparative ignorance, althongh much suggestive tial diagnosis has not yet been universally attained may be work has been done on this highly subtle question; while assumed from some recent writings. It surely, however, as regards the external secretion, diminution or increase does not ask for unattainable skill on the part of the in quantity of one or other or of all its ferments can be physician that an accurate differential diagnosis should be thought of only as affecting the processes of digestion in made between primary and secondary gastric symptoms, the intestine. between disturbances of gastric function and duodenal There is no failure in excretory function to consider, as ,ulcer, and between gastric catarrh and appendicitis. such failure has to be reckoned with in hepatic disorder. In view of the importance to be attached to accurate Any absorption from the gland must be the absorption differential diagnosis in the abdomen, all new aids claim- of some of its secretion, or of an altered enzyme; and the ing to further this object demand to be carefully tested enzymes are protein bodies, not carbohydrate bodies, and and exatmined. It was with this object in view that,'some presumably cannot, therefore, be the source of the -eighteen months ago, I, for the second time, took up the substance in question. -examination of the urine by Cammidge's method to ascer- The clinical pathology of the two glands is thus tain whether it would facilitate differential diagnosis in fundamentally different, and care has to be taken that -abdominal cases. clinical contentions regarding the pancreas are not based The claim of the author of this test was that, with upon an imaginary pathology of the organ. certain reservations, the reaction was indicative of the In the investigation undertaken I confined myself to existence of pancreatitis. This was not merely a new the examination of the urine in patients with abdominal test for a hitherto unrecognized product in the urine, but symptoms, or definite abdominal lesion, as my aim was ,the presence of this product was claimed to indicate the to ascertain whether any assistance was to be obtained presence of a certain condition in the pancreas, which from the presence or absence of the reaction in making condition, in its turn, was placed in the position of a a differential diagnosis. Cases were selected in which common and serious disease, and recognized as such for it was thought that the reaction might be helpful in one the first time. We were, in fact, brought face to face with or other direction. what was practically almost a new disease. We had I have tabulated 78 cases which are fairly representa- -before this recognized necrotic, haemorrhagic, and purulent tive of the types of abdominal cases met with. They pancreatitis; the metastasis of mumps to the pancreas; are as follows: of cases of diabetes associated with atrophic cirrhosis of the gland; and the contentions relating to the islands of TABLE A.-Mlarked Positive Reaction (4 Cases). Langerhans were well known. But here was a condition suggested to be common and important, which had hitherto Name and Diagnosis. Reaction. Remarks. escaped notice, the test of its existence being the presence Sex. of a urinary reaction. The Cammidge reaction claimed to be a pancreatic Veitch (m.)... Necrotic Positive, marked Abdomen opened; pancreatitis died. Decoction of reaction. With such reservations as are usually applic- the pancreas gave -able in clinical work, a positive reaction was to be markedreaction. No -regarded other organ simi- as strongly suggestive of the existence of larly tested. pancreatitis. Hay (m.) ... Necrotic malig- Positive, Gastric symptoms not If this is not to be the claim based upon 'the nant ulcer, size marked; crystals marked; patient de- reaction, of florin, pos- appeared in ten veloped profound -the performance of the test can at best merely be the terior gastric minutes intoxication sugges- demonstration of a chemical vagary in the individual; wall; extensive tive 'of severe pan- while, if the infarction, and creatic disease. Pan- claim be abandoned, and at the same time growths in liver creas showed neither the value of the reaction be asserted, we get into a region macroscopic nor ,somewhat outside either the pale of scientific medicine or microscopic change. Guthrie (m.)IHyperchlor. (1) Positive, Relieved by medical of logical thinking. The reaction cannot both be and hydria marked; treatment; returned ,not be a sign of pancreatitis. appeared imme- - 6 months later with In approaching this diately. symptoms of gastric subject it is necessary to bear in (2) Positive, ulcer, for which a mind that, although the pancreas and the liver are so medium gastro - enterostomy was done. -closely associated anatomically that their ducts may have Hoggan (f.)..... Pain in Positive, Died soon after ad- a common opening in the duodenal wall, their functions abdomen, with marked, and mission. No post- are totally dissimilar. !profound intoxi- rapidly mortem exramina- The liver is a great excretory gland, through its biliary Ication (cause appearing tion. funection; it is indirectly the same in virtue of the unknown) B 1 6 mau ;Oww I " PANCREATIC REACTION " IN ABDOMINAL DISEASE. [JULY 2, logo. TABLE B.-Hepatic Cirrhosis; Gall-Stone Colic; Catarrhal TABLE D.-Ga,tro-intestinal Cases with Positive Reaction Jaundice (12 Cases). (18 Cases). I~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Name and Sex. Diagnosis. Reaction. Remarks. Name and Sex Diagnosis. Reaction. Remarks. Welsh (f.) ... Cirrhotic liver Positive Died. Todd (f.) Gastric symptoms Twice positive, Cured. and ascites and constipation small Greig (m.) ... Cirrhotic liver Positive Ascitic fluid posi- Fox (f) ... Indigestion and Positive Cured. and ascites tive. constipation McKay (f.) ... Cirrhotic liver Positive Died; ascitic fluid Alexander (f.) Gastric symptoms Positive Cured. and ascites positive. and constipation Result: 3 positive and ascitic fluid positive in 2, Reid (f.) ... Gastric symptoms Positive Cured. Keddie (f.) ... Gall-stone colic I (1) Positive Operated on second Privatecase(f.) Great nausea and Positive 1(2) Negative time and stones skin irritation removed. Brown (f.) ... Obstinate vomit- Positive Cured. Cairns (f.) ... Gall stone colic Positive Operated on, stones ing. neurotic and tender gall removed. Mack (f.) ... Obstinate vomit- Twice positive Cured. bladder ing, neurotic Slater (f.) .. History of gall- Negative Improved. Knowles (f.) Gastric symptoms Positive Improvecl. stone colic McGruer (f.)... History of biliary Positive Cured. Turnbull (f.)... Gastric symptoms, Positive Improved. colic and consti- previous appendi- pation citis Henderson (f.) Gall-stone colic Positive Left hospital, Lees (f.) Gastric symptoms, i Positive Cured. sent in as ulcer Henderson (f.) Readmitted Negative Stone removed. Christie (f.) Gastric symptoms Positive Former gastrec- tomy, died. Private (f.) ... Hepatic colic Positive Latent case. McDonald (f.) Duodenal ulcer Twice positive, Gastro-enteros- small tomy, cured. Hanley (f.) ... Gall-stone colic Positive Stones found in Allen (f.) ... Gastric synmptoms Positive Old gastro- faeces. enterostomy. 6 Gillies (m) ... Constipation, ten- Positive Sent in as pneu- Result: positive, 3 negative.
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