review of literature on clinical pancreatology - The Pancreapedia

derived from broadly Harveian anatomical and Helmontian chymical traditions. Experimentaltraditions and a comprehensive and materialistic chymical theory <strong>of</strong> acid-alkali interactionsunified the artificial and the natural and allowed de Graaf to create and use hybrid animalapparatusconstructions as tools to collect and assay the key ingredients <strong>of</strong> digestion anddisease [021].Acute pancreatitisThe death <strong>of</strong> Alexander the Great (356-323 BC) at the age <strong>of</strong> 33 has been ascribed to acutenecrotizing pancreatitis secondary to rich food and heavy alcohol consumption [022].Among the various pancreatic disorders, the pace <strong>of</strong> scientific discovery in acute pancreatitishas been particularly slow. A clinical description <strong>of</strong> acute pancreatitis was first presented in1652 by the Dutch anatomist Nicholas Tulp, and despite the nearly 350 years that havepassed, there continue to be many unanswered questions. In the late 19th and early 20thcentury, Reginald Fitz, Nicholas Senn, Eugene Opie, and others made seminal contributionsthat continue to influence our present understanding <strong>of</strong> acute pancreatitis [023].Nicholaes TulpThe first clinical description <strong>of</strong> acute pancreatitis is believed to have been published in 1652by the Dutch anatomist Nicholaes Tulp (1593-1674) [005, 024]. Tulp, who is alsoremembered for discovering the ileocecal valve, reported the case <strong>of</strong> a young man whosuccumbed to an illness characterized by incessant fevers and much distress. On autopsy,the pancreas was "swollen with dirty pus and filled with an excess <strong>of</strong> viscous mucus" [024].He speculated that the pancreas was "the origin <strong>of</strong> protracted and complicated diseases,such as consumption <strong>of</strong> the spine, continuous fever, cancer, abscesses, growths, vomiting,restlessness, sleeplessness, and other most dangerous affections, which from this source,like Pandora's box, frequently originate to the detriment <strong>of</strong> the human race." Tulp was a wellknownphysician and anatomist in Amsterdam and the praelector (lecturer) in Anatomy <strong>of</strong> theSurgeon's Guild from 1628 to 1653. In addition to being immortalized as the central figure inthe Rembrandt painting, "Lesson in anatomy," Tulp published a considerable amount <strong>of</strong> hisanatomical observations under the title "Observationum Medicarum Libri Tres” [025]. He wasthe chief editor <strong>of</strong> the Amsterdam Pharmacopoeia, and provided the first systematic catalog<strong>of</strong> medications in the Netherlands. Indeed, he was held in such public esteem that he waselected Burgermaster <strong>of</strong> Amsterdam four times. After Tulp's description, Théophile Bonet(1629-1689) [026] and JG Griesel [027] also reported on cases where the pancreas wasnecrotic on autopsy. Nearly a century later, Morgagni, in 1761, reported a clinical syndrome<strong>of</strong> severe upper abdominal pain, vomiting, and collapse in a patient whose autopsy revealedthat the "pancreas was enlarged and totally filled with knots, rather large, unequal and <strong>of</strong> theconsistency <strong>of</strong> cartilage" [010, 028].A new interest in pancreatitisThese early descriptions <strong>of</strong> pancreatic disease failed to discriminate between acute andchronic pancreatitis, presented little insight into the pathological features <strong>of</strong> the pancreas onautopsy, and were highly speculative with regard to causes and clinical symptoms <strong>of</strong>pancreatitis. Antoine Portal (1742-1832), who was pr<strong>of</strong>essor <strong>of</strong> medicine at the Collège deFrance, described the various pathological manifestations <strong>of</strong> pancreatic disease such asedema, hemorrhage, necrosis, and gangrene [029], although he considered thesemanifestations as different disease entities. Portal also reported recurring acute pancreatitispresenting with repeated bouts <strong>of</strong> intense pain that led to the eventual death <strong>of</strong> the patientfrom gangrene <strong>of</strong> the pancreas. Augustin-Nicolas Gendrin (1796-1890) also made