Nicholas Senn (1844 –1908). A childhood immi- grant from Switzerland, Senn graduated from Chicago Medical School in 1868. After working at Cook County Hospital for several years, he journeyed to Munich for postgraduate studies under Professor Johann von Nussbaum. In 1878, he joined the faculty at Rush Medical College as Professor of Surgery. While at Rush, he carried out numerous animal experiments involving surgery of the pancreas, thereby providing the investigative basis for future generations of surgical scientists. He left his position in 1898 to become Chief Sur- geon of the Army Medical Corps in Cuba during the Span- ish-American War. 

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... 1886, Nikolas Senn ( Fig. 2) published extensive animal experiments describing surgery of the gland. 12 Furthermore, he offered his own clinical classification of acute pancreatitis, embod- ying gangrene, abscess, and hemorrhage of the gland, 3 years prior to the classification proposed by Fitz. Senn wrote that "One of the terminations of acute inflammation of ...

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... and continuing well into the Middle Ages, such diverse diseases as pancreatic malignancy, chronic pancreatitis, and various forms of acute pancreatitis and its complications were all lumped together under the heterogeneous classification of “scirrhi” (hard) conditions. The longevity of ancient medical dogma was considerably abetted by the edict from the medieval Catholic Church prohibiting human dissection, as well as to the unwillingness of scholars to chal- lenge the classic opinions of Galen. As a result, clinicopathologic differentiation among human diseases did not begin to emerge until late in the fifteenth century, when human postmortem dissection began to be practiced in Bologna, Padua, and other European university centers. The first recorded description of necrotizing pancreatitis is apparently that of Nikolaus Tulp, a Dutch physician and anatomist, who in 1652 performed a postmortem examination upon a young man afflicted by an apocalyptic attack of abdominal pain that proved to be fatal after 5 days. 2 At autopsy, the gland was found to be enlarged, purulent, and “rotten.” No explanation was offered for the observed changes in the pancreas. Similar anatomic studies were infrequent, however, and acute inflammation of the pancreas continued to be considered a rare condition. Failure to recognize acute pancreatitis as a separate disease entity was partly because symptoms were often attributed to other, more well-known diseases, and partly due to the relatively small number of postmortem examinations being performed. It was not until 1842 that acute pancreatitis was proposed as a distinct clinical entity. Heinrich Claessen, a physician in Cologne, collected a series of 6 fatal cases of severe acute pancreatitis from the literature of the times. 3 He noted a common clinical and pathologic presentation among these cases, and suggested that this commonality in presentation might be useful for diagnosis. Over the next 50 years, increasing numbers of autopsy-based studies of necrotizing pancreatitis by such eminent pathologists as Rokitansky, Klebs, Friedrich, and Chiari, confirmed Claessen’s initial clinical observations. 4 –7 Theodor Klebs, a student of Virchow, and professor of pathologic anatomy and bacteriology in Berne, proposed that hemorrhagic pancreatitis was related to necrotizing pancreatitis, and to subsequent suppuration of the gland. Moreover, he first postulated that the destruction of the pancreas was caused by the well-known “corroding qualities” of the gland secre- tions. Nikolaus Friedreich, also a student of Virchow, who later rose to become professor of pathology in Wurzberg, suggested a postmortem classification of acute pancreatitis in 1882 consisting of hemorrhage, gangrene, and abscess formation. His classification was admittedly restricted as it was based upon but 4 cases, only one of which was personally observed by the author. A year later, Hans Chiari, professor of pathology in Prague, published his findings concerning the pathophysiology of acute pancreatitis, attributing the destruction of the gland to the “autodigestive” properties of pancreatic ferments. In 1889, Reginald Fitz, the Shattuck Professor of Pathoanatomy at Harvard, former pupil of Rokitansky, Virchow, and Billroth, and already well known for his clinicopathologic description of appendicitis, published a Hunterian Lecture in which a pathology-based classification system for acute pancreatitis was proposed (Fig. 1). As a result of Fitz’ classification system, clinicians were enabled to make an antemortem diagnosis of acute pancreatitis. 8 Although this autopsy-based classification system, including hemorrhagic, gangrenous, and suppurative forms, was superficially similar to the earlier one proposed by Friedrich, Fitz’s classification system involved a melding of clinical symptomatology and pathologic findings derived from a painstaking collective review of prior cases in the literature, with a few cases added from the Boston area. Even though Fitz noted that the hemorrhagic, suppurative, and gangrenous forms of acute pancreatitis were often combined with disseminated fat necrosis, he was seemingly unaware that fat necrosis was a different manifestation of the same disease process. During this period of awakening interest in the pancreas, surgeons were not idle. According to Hollender, 9 Wandeleben had incised and drained a pancreatic abscess as early as 1845, although the result of this effort is unknown. In 1882, Rosenbach marsupial- ized an abscess of the pancreas. Unfortunately, the patient died, reportedly in “schock” 6 hours after surgery. 10 Hirschberg performed an exploratory laparotomy in 1887 in an obese male who had suffered a “collapse” 4 days after the onset of hemorrhagic pancreatitis, but within 5 hours after exploration, his patient also expired. 11 These initially unsuccessful forays into the surgical management of necrotizing pancreatitis did not deter surgical interest. In 1886, Nikolas Senn (Fig. 2) published extensive animal experiments describing surgery of the gland. 12 Furthermore, he offered his own clinical classification of acute pancreatitis, embod- ying gangrene, abscess, and hemorrhage of the gland, 3 years prior to the classification proposed by Fitz. Senn wrote that “One of the terminations of acute inflammation of the pancreas is gangrene. It would seem plausible that timely removal of the necrosed organ by surgical interference would add to the chances of recovery. Conse- quently, we shall add gangrene as one of the diseases of the pancreas which should be treated by operative measures” (p 175). Of note, however, although Senn remained a staunch advocate for surgical intervention in acute pancreatitis for his entire career, there does not seem to be any record of whether he actually performed such operations. Nevertheless, his influence on the so-called “Chicago School of Surgery” was profound and long-lasting. Senn’s application of the scientific method to a clinical problem ignited the interest of many other surgeons to employ surgical techniques in human acute pancreatitis. Many students of surgical history are aware that 3 years later in 1889, Fitz was adamant that surgery would not benefit patients with acute pancreatitis, and that fatalities could not be prevented by operative “meddling.” Less well known, however, is the observation that Fitz appeared to modify his antisurgical stance in a subsequent publication in 1903, in which he allowed that some surgical successes had been reported in these desperately ill patients. 13 The initial operative success in the management of necrotizing pancreatitis was reported by Werner Koerte (Fig. 3) in 1894. He described the successful drainage of a large pancreatic abscess via a left flank incision in a 48-year-old obese woman 1 month after the onset of severe pancreatitis. 14 Iodoform gauze-wrapped drains were placed into the retroperitoneum, and postoperative management consisted of repeated changes of the gauze. After wound discharge of a considerable amount of necrotic pancreas and fatty tissue, and the formation of a pancreatic fistula, the patient was discharged completely healed 5 months later. Unfortunately, 2 other cases of postnecrotic abscess in his series that were treated similarly expired due to recurrent infection. Koerte advocated delayed exploration of pancreatic infections: “In the acute stage, surgical treatment is not recommended, wherein patients have the propensity for cardiovas- cular collapse. If pancreatic apoplexy occurs, surgical treatment cannot help. Later, when we can prove that a purulent collection is arising from the gland, surgery is indicated” (p 739). These thoughts antedate the contemporary approach to surgery for necrotizing pancreatitis by more than 90 years. One year later, in 1895, Thayer from the Johns Hopkins Hospital reported a similar case of necrotizing pancreatitis with secondary infection that had been operated upon by JMT Finney, using debridement and closed drainage. The patient recovered and was discharged 4 months after the initial exploration. 15 Six years later, from the same institution, Opie generalized from a single autopsy case that hemorrhagic pancreatitis resulted from unremitting obstruction of the pancreatic and bile ducts by biliary calculi. 16 Given these initial successes, surgeons flocked to the banner of operative intervention in acute pancreatitis. 17–19 At the turn of the twentieth century, such surgical stalwarts as Mayo Robson and Mickulicz also reported successful surgical interventions in necrotizing pancreatitis. In the second of 3 scholarly Hunterian Lectures given before the Royal College of Surgeons of England in 1904, Mayo Robson (Fig. 4) described 2 survivors in 4 early operations for necrotizing pancreatitis, and 5 survivors in 6 operations for pancreatic abscess. 20 He noted that in contrast to previous beliefs “... inflammatory afflictions of the pancreas are very much more com- mon than is generally supposed” (p 846). Johann von Mikulicz, Professor of Surgery in Breslau, and also a former student of Billroth, advocated early exploration in necrotizing pancreatitis, but favored pancreatic marsupialization by “pancreatostomy,” rather than by gauze drainage. 21 In rapid succession, other surgeons reported successful procedures in patients with necrotizing pancreatitis and its complications. Woolsey, a Professor of Surgery at Columbia, described 3 cases of successful early exploration in necrotizing pancreatitis employing debridement and gauze drainage. 22 Similarly successful anecdotal experiences with this approach were reported by Bunge 23 and Villar. 24 The favored technique consisted of surgical intervention early in the course of acute hemorrhagic/necrotizing pancreatitis, incisions into the pancreatic “capsule,” and gauze drainage of the peripancreatic region. In contrast, delayed intervention for pancreatic abscesses was preferred, employing ...