"But it is proper for us to remark that these oily evacuations generally occur only in chronic affections of the pancreas, because in acute disorders of that organ the patients have fever, and eat nothing. Mr. Fearnside has noted several cases of acute disease of the pancreas, giving various other symptoms, but in which he remarks the absence of fatty matters, which he is able to explain up to a certain point by abstinence from food, and the consequent non-ingestion of fatty substances in the intestine. It is in fact impossible to comprehend the evacuation of fatty matters without their ingestion with the food. In many of the cases we have cited, as well as among the lower animals, it was always readily observed that this fatty excretion was in direct relation to the ingesta. If in certain cases this relation has not been established, it is proba ble that it does exist, for otherwise it would be necessary to admit that the fat may be evacuated by the intestine, and be derived from some other source than the food. It is said, it is true, that cases have been observed of the excretion of fatty matters from strumous tumors of the mesentery, with integrity of the pancreas. But these cases are not sufficiently clear respecting any alteration of the pancreas, and if they do exist, they will not in any manner invalidate those which we have seen, and have reported." From an examination of the cases in the preceding table, there appear several notable objections to the theories of M. Bernard, that these oily dejections are derived wholly from the ingesta, i. e, directly, and that their existence in the intestines depends upon chronic disorders of the pancreas, while acute derangments of that organ are necessarily free from such results. The first objection is, the enormous quantity reported in some cases to have been discharged, amounting in one instance to thirty pounds in twenty-four hours, though in this case it all came via the stomach. Admitting the truth of this statement (and there appears no reason to doubt it), the theory of Bernard is utterly untenable, that it was derived from the ingesta. Besides this, in 1 In allusion to the cases of Dr. Bright and the matters discharged, it is stated by Dr. Chambers in his work on Digestion and its Derangements, "most of course have been thrown away, but one example" (doubtless the second in the preceding table) "which has been preserved in the Museum of the College of Physicians, turned out, when the museum was put to rights in 1850, not to be fat at all. In fact, microscopic examination showed it to be muscular fibre, a lump of meat washed white in its passages through the bowels of a dyspeptic patient." several cases the ingesta were mostly vomited, emesis being a troublesome and persistent symptom. In the cases of the two children mentioned, one, four and a half, the other six years of age, the amount discharged would appear inconsistent with the idea of its being all derived from the ingesta. Again, as to the suggestion of Bernard, that it is in connection with chronic and not acute diseases of the pancreas, that these discharges must occur, an examination of the table will develop inconsistent facts. In the first place, the very brief duration of the phenomenon, in some instances from one day to three weeks, would indicate, if any disease of the pancreas at all, one of very ephemeral duration and minor consequence, forbidding the idea of chronicity or severity. Again, the complete re-establishment of health, with the entire disappearance of the oily discharge in several instances, would seem also to militate against the "chronic" judgment, especially if under that designation the disorder must be supposed to be malignant and incurable. Further, the occurrence of several cases of disordered pancreas, unattended with the oily or fatty discharge, and the presence of it in several cases in which no disease of that organ existed (which occurred to Dr. Bright, who at first maintained the connection of this symptom with disease in that locality) would seem sufficient to dispel, emphatically, the idea of a necessary connection between the disease and the symptom. Without pursuing this line of reflection further, it may be remarked that the attendant symptom most common in these cases is, deficiency of bile. Either jaundice or clay-colored stools, or both, appear in a majority of instances. As the sum of the matter, derived from the consideration of the reported cases, diarrhoea adiposa appears to be associated with a great variety of conditions of body, differing considerably from each other, and it sometimes appears to be unconnected with any other very marked evidence of disorder of the general system, or of any of its parts. In the last case reported, the interesting fact of the amount of oil evacuated being controlled by the exhibition of a moderate amount of alcoholic stimulus, would seem to indicate that the producing lesion was somewhere in the assimilating function; but, admitting this, the question is still unanswered, as to the precise organ or part of the function involved. The marked ability evinced by the author of the original essay on Cholesterine,' in the American Journal of Medical Sciences for October, 1862, which itself places American reputation for physiolo gical knowledge, and ingenuity, and skill in research on a par with any held abroad, affords an earnest hope that the arcana of the diges tive functions will not much longer remain such. The specimen of the oily discharge herewith exhibited, presents under the microscope, pure oil globules, without any appearance of cholesterine or other animal products. Its combustibility is demonstrated by the burning of the taper made of it, and its saponifiable property by the small cake of soap prepared with it. Respectfully submitted, JOHN H. GRISCOM. 1 Austin Flint Jr., M. D. |