review of literature on clinical pancreatology - The Pancreapedia

acute appendicitis, intestinal obstruction, complications <strong>of</strong> Meckel diverticulum, and acutepancreatitis [010].In 1889, at the New York Pathological Society's Middleton-Goldsmith lecture, Fitz presentedhis article entitled "Acute pancreatitis: a consideration <strong>of</strong> hemorrhage, hemorrhagic,suppurative, and gangrenous pancreatitis, and <strong>of</strong> disseminated fat necrosis" in which hesystematically <strong>review</strong>ed the clinical symptoms in 53 cases <strong>of</strong> pathologically documentedacute pancreatitis [043]. In addition, he detailed the various hemorrhagic, suppurative, andgangrenous changes in acute pancreatitis and their pathological differentiation. He furthercommented on various etiologies such as gall stones, alcohol, perforating gastric ulcer, andtrauma. Quite remarkably, Fitz also described pancreatic abscess, splenic vein thrombosis,and a likely pseudocyst <strong>of</strong> the pancreas as associated complications <strong>of</strong> acute pancreatitis. Inthis paper, Fitz also proposed a relationship between pancreatic hemorrhage andpancreatitis and a causal link between disseminated fat necrosis and acute pancreatitis[010].By his systematic analysis <strong>of</strong> the various facets <strong>of</strong> acute pancreatitis, Fitz laid the foundationfor antemortem diagnosis <strong>of</strong> this disease and greatly facilitated subsequent pancreaticresearch at the turn <strong>of</strong> the 20th century. Interestingly, Fitz initially advocated a conservativeapproach to the surgical management <strong>of</strong> patients with acute pancreatitis, noting that "anoperation… in the early stages <strong>of</strong> this disease, is extremely hazardous" [044]. However, hisrecommendation later changed to early laparotomy as performed for other causes <strong>of</strong> acuteabdomen [010].Two types <strong>of</strong> pancreatitisDespite the accumulating knowledge on pancreatitis, it was not until the middle <strong>of</strong> the 20thcentury that an understanding <strong>of</strong> the differences between acute and chronic pancreatitis wasappreciated. However, there were multiple descriptions <strong>of</strong> pancreatic concretions in the 18thand 19th centuries. In 1678, de Graaf recounted previous reports <strong>of</strong> pancreatic stones by hiscontemporaries. After this, there were also numerous reports <strong>of</strong> pancreatic lithiasis at thetime <strong>of</strong> autopsy by various authors including Bonet, Morgagni, and Johann Friedrich Meckel(1724-1774) [010]. In 1799, Matthew Baillie (1761-1823) <strong>of</strong> London published plates thatclearly depicted pancreatic ductal concretions, ductal dilatation, and changes <strong>of</strong> chronicpancreatitis [045]. At the turn <strong>of</strong> the 19th century, Sir Arthur Mayo Robson (1853-1933) <strong>of</strong>Leeds presumed the etiology to be <strong>of</strong> bacterial infection; however, the distinction amongacute, subacute, and chronic was still controversial [046, 047]. In 1946, Comfort [048], at theMayo Clinic, provided a significant analysis <strong>of</strong> the clinical entity <strong>of</strong> chronic pancreatitis and, inso doing, produced the seminal manuscript on the subject that has, for 50 years, remainedthe critical commentary on the disease.Nicholas SennOne <strong>of</strong> the contemporaries <strong>of</strong> Reginald Fitz who contributed extensively to the advancement<strong>of</strong> our knowledge <strong>of</strong> the pancreas was Nicholas Senn (1844-1908), a surgeon who was bornin Sweden but later moved to the United States and attended the Chicago Medical School[005]. He initially worked at the Cook County Hospital in Chicago and Milwaukee (Wisconsin)Hospital before proceeding to Munich for further training in surgery before finally returning toRush Medical College as pr<strong>of</strong>essor <strong>of</strong> surgery [010]. In 1886, Senn presented an extensiveaccount <strong>of</strong> his surgical experiments on the pancreas at the meeting <strong>of</strong> the American SurgicalAssociation as an article entitled "Surgery <strong>of</strong> the pancreas, as based upon experiments andclinical researches" [005, 049]. Starting with a <strong>review</strong> <strong>of</strong> the available surgical <strong>literature</strong> onthe pancreas, Senn noted that the only operations available were either excision <strong>of</strong> retentioncysts or formation <strong>of</strong> external pancreatic fistulas to drain such cysts [049]. He detailed a