There is one circumstance connected with the morbid anatomy of the pancreas worthy of special note, and with a short reference to this I shall finish this paper ; it is The occurrence of fatty stools in connection with pancreatic disease. Attention was first drawn to this subject twenty years ago by the simultaneous publication, in the eigh teenth volume of the Medico-Chirurgical Transactions, of papers by Drs. Bright and Elliotson and Mr. Lloyd ; but although the subject excited considerable interest at the time, it has since been suffered to lapse, from want apparently of due appreciation of its import ; and it is only recently that it has emerged from its obscurity in consequence of the new interest with which recent physio logical discoveries have invested it. It is only the most hasty and superficial glance that it will be possible here to give to this most interesting subject : for further details I must refer the reader to the original papers, to others that have since been published, and to an admirable article in the twenty-third number of the British and Foreign Medico Chirurgical Review.
The first of these papers — first as much in importance as in time — was that of Dr. Bright. Not only was he the first to point out the pathological relations of this remarkable phenomenon, but his paper is distinguished by a singular clearness and impartiality, and by a thorough digestion of its carefully ga thered materials. He thus describes the pe culiar condition of the evacuations that first excited his attention A portion more or less considerable assumes the character of an oily substance resembling fat, which either passes separately from the bowels, or soon divides itself from the general mass, and lies upon the surface, sometimes forming a thick crust, particularly about the edges of the vessel, if the firces are of a semifluid con sistence ; sometimes floating like globules of tallow which have melted and become cold ; and sometimes assuming the form of a thin fatty pellicle over the whole, or over the more fluid parts in which the more solid figured fxces are deposited. This oily matter has generally' a slight yellow tinge, and a most disg,ustingly fcetid odour." After detailing the cases, Dr. Bright insti tutes the following analysis of them :—" In all of these, chronic ailments terminated, soone, or later, in jaundice ; and in all of them a great peculiarity in the character of the dejec tions existed. In the result of the examina tion after death we have likewise some cir cumstances which coincide in — obstructed oiliary ducts; the liver gorged with bile; fungoid disease attacking the head of the pancreas ; and malignant ulceration on the surface of the duodemunz. The question to be solved is, upon which of the conditions indicated or caused by these morbid changes, if upon either, the peculiarity of the alvine evacu ations depended ? That the obstruction of the biliary ducts, or even the total absence of all indication of biliary secretion, is not usually attended by the same peculiarity in the eva cuations, many cases which have been cau tiously' detailed by various authors, and many which we have all observed, bear sufficient testimony ; and I was therefore induced to ascribe it, either to the existence of malig nant disease, or to that disease being situated in the pancreas. That the simple fact of malignant disease existing is not necessarily productive of such appearances in the feu lent matter, I infer from cases both of that form of disease and of melanosis in the liver to a very great extent being, within the scope of my experience, unaccompanied by any such discharge, though the evacuations were sub mitted to the most rigid observation. That
simple ulceration in the bowels to any known extent, is not attended by any such symptom I am led to believe from knowing that neither in the most extensive ulceration of the large intestines in cases of dysentery, nor in the worst cases of ulceration of the small intes tines in fever, in diarrhcea, or in phthisis, does anything, of the kind occur. Whether, how ever, malignant ulceration of the mucous membrane is accompanied by this symptom I cannot assert, though I have often seen most extensive ulcers of the py torus and of the rectum, where, although the evacuations were attentively observed, such fatty matter was not detected. As, however, a malignant ulceration of membrane did exist in each of the foregoing cases, it is not impossible,that this was the cause of this symptom ; but we must bear in mind that such ulcerations are by no means uncommon, and that the pheno menon of which I am speaking is uncommon ; and that in each of the cases it was accom panied by another morbid appearance, which is not common ; namely, the malignant disease of the pancreas. The fact of the intestinal ulceration having in each case occupied the duodenum does, however, somewhat diminish the weight of this observation, for that cer tainly is not so frequent an occurrence." By this process of elimination, and by the in stance of other cases more or less analogous, Dr. Bright conceives that we may bring the circumstances of the diseased structure in connection with this symptom within a nar row limit —" disease, probably malignant, of that part of the pancreas which is year the duodenum ; and ulceration of the duodenum itself" To this conclusion, however, so care fully arrived at, subsequent observation has shown that exception must be taken : cases that have occurred since the publication of Dr. Brighes paper, and even quite recently, have proved that neither the malig,nant cha racter of the disease nor ulceration of the duodenum is necessary to the production of the fatty stools. In a case in which fatty stools occurred, communicated to the Society of Medicine of Boston*, in one reported by Dr. Alfred Clarke, of Twickenham, in the Lancet for August 16. 1851, and in one re ferred to by Dr. Kirkes in his IIandbook of Physiology the pancreatic disease appears to have been clearly non-malignant, and to have consisted in the conversion of the organ into a serous cyst in consequence of obstruc tion of its duct ; and the duodenum seems to have been quite healthy. In two, however, of these cases, there was jaundice, and in the third deficient bile in the evacuations, so that the pancreatic disease was not pure. What we want for the clearing up of this subject as far as the pancreas is concerned is, a case in which the pancreas alone is affected, other organs not being even functionally implicated, and in which there is during life a clear pre sence, or a clear absence of fatty stools. Until such a case or cases can be brought forward, the light which this section of pathology has thrown upon physiology will still leave unde termined the relative importance, in effecting the absorption of fat, of the different digest ing agents supplied by or poured into the duodenum.