PANCREAS. 



113 



oiliary ducts; the liver gorged with bile; fungoid 

 disease attacking the head of the pancreas ; 

 and malignant ulccration on the surface of the 

 duodenum. 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 fecu- 

 lent matter, I infer from cases both of that 

 form of disease and of mclanosis 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 diarrhoea, 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 pylorus 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 

 tlial part of the pancreas which is near the 

 duodenum ; and ulccration 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. Bright's paper, and even quite recently, 

 have proved that neither the malignant cha- 

 Supp. 



racter of the disease nor ulccration 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 Handbook 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. 



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* Archiv. Gen. de Me'd. t. xix. p. 215. 

 f P. 233. 



