678 BURRILL B. CROHN 



jaundice may cause colorless large movements containing up to 45 per cent, 

 of fat (Brugsch), but never free neutral fat that is visible under the 

 microscope or with the naked eye. 



Nitrogenous metabolism disturbance is often indicated in pancreatic 

 disease by the finding of large excesses of undigested muscle fibers, a 

 phenomenon known as creatorrhea and described among others by Ehr- 

 mann. The phenomenon is dependent upon the inability of the digestive 

 juices to digest muscle fibers and their nuclei, in the absence of pancreatic 

 secretion. The striations of the meat fibers are clearly preserved and the 

 particles, though small, are larger than those seen in normal stools and 

 often have square or slightly rounded edges (Pratt (6)). Normally small 

 particles of incompletely digested muscle fragments are seen ; these may be 

 more numerous in diarrheal conditions in which the intestinal motility is 

 much hastened. But the finding of a large excess of such muscle particles 

 is clearly indicative of pancreatic disturbance. 



Increased amounts of fat in the diet, in the form of butter or lard 

 are sometimes necessary to bring out typical fatty stools. 



Clinical Occurrence of Steatorrhea and Creatorrhea 



When Richard Bright first described fatty stools as characteristic of 

 pancreatic disease, he immediately recognized the inconstancy of the symp- 

 tom and the impossibility of harmonizing it with the pathological condi- 

 tions of the gland. For the symptom was present in three cases of car- 

 cinomatous obstruction of both bile and pancreatic ducts, but was absent 

 in three other similar cases, in two of which the pancreas itself was actu- 

 ally invaded by neoplasm. Fitz(c) in 1903 could find in the literature 

 only 29 cases of fatty stools undoubtedly associated with pancreatic disease. 

 Of these 29 cases, 12 had associated jaundice and 11 had diabetes. Von 

 Mikulicz said that signs of functional disturbance in the stool do not 

 appear until the greater portion of the gland is affected. This statement 

 is corroborated by the fact that the author has observed a case of car- 

 cinomatous obstruction of the ducts, verified by duodenal analysis for fer- 

 ments, in which no neutral fat or excess muscle fiber appeared for the 

 first few weeks but did appear later in the disease. At the autopsy, the 

 new growth was noted to have begun at the head of the gland, about the 

 ducts, and to have subsequently invaded the body and part of the tail of 

 the organ. 



In the literature, all stools that, have shown microscopically neutral fat, 

 so-called "butter stools," have shown on chemical examination a large per- 

 centage of fat loss in the feces. The same observation holds for creatorrhea. 

 Conversely, however, many cases with definitely disturbed nitrogen and fat 

 absorption fail to show typical stools; in many of these, however, an in- 



