mesocolon, where they may be retained as in a
sac, or, having perforated one of its lamina?,
may be effused into the general cavity of the
abdomen. It is supposed also that the pus
of a pancreatic abscess may find its way into
the intestinal canal, and be discharged by stool
without any obvious communication being
established between them. Thus, in a case
communicated by Dr. Haygarth to Dr. Per-
cival, in which, on dissection after death, the
pancreas was found to contain a considerable
abscess, blood and, at length, fetid pus had
been discharged by stool during life.
According to Dr. Pemberton*, ulceration
is a very frequent result of inflammation of
the pancreas ; and from the small degree of
sensibility with which the organ is endowed,
the destruction may go a great way without
pain or any symptom previously existing
which could lead to a suspicion that inflam-
mation was going on.
Portal alleges that gangrene of the pancreas
is a frequent consequence of its inflammation,
and that he has met with it in several in-
stances. In one case, which he particularly
specifies, the pancreas was found, on examina-
tion, to be of a violet purple colour, softened,
and allowing a blackish fetid humour to exude
from its external surface. " In short," he
says, " it was gangrenous almost throughout
its whole extent." Gendrin quotes what he
conceives to have been a case of gangrene of
the pancreas, occurring after chronic inflam-
mation, and suggests it as probable that in
this, as in other tissues, acute inflamma-
tion passes readily and completely into the
state of sphacelus, only in cases in which
the organ has been weakened by previous
disease.
c. Haemorrhage. I have only met with two
cases of haemorrhage in the pancreas : one
recorded by Mr. Fearnside, in which the right
extremity was occupied by a large coagulum ;
the other related by Storck, in which the
pancreas was so large and heavy that it ex-
ceeded thirteen pounds in weight. On cutting
into this mass, it was found to consist merely
of a sac filled with blood, partly grumous,
partly coagulated, and beginning, it is stated,
to become organised.
d. Structural changes, 1. Non-malignant;
cartilaginous transformation. Many cases are
on record in which the pancreas had been
found cartilaginous ; it is generally enlarged,
nodular on the surface, and very hard. In the
majority of cases, one or more neighbouring
organs have been found similarly affected ;
but in some rare cases the pancreas has been
the exclusive seat of the cartilaginous de-
generation. In persons affected with it
* On Diseases of the Viscera, p. G3. et seq.
nausea, vomiting, thirst, pain in the epi-
gastrium, &c., had existed, and it was pro-
bably the remote consequence of chronic
inflammation.
Steatomatous concretions. Portal states
that the pancreas is sometimes found full of
Steatomatous concretions, hard or softened,
white like suet, or yellowish like honey.
Sometimes the pancreas is enlarged by this
matter throughout its whole substance, some-
times it exists only in particular parts. Those
who have died of scrofula, and in whom the
glands of the neck, axillae, groins, or me-
sentery were obstructed, had likewise the pan-
creas equally affected. He mentions a par-
ticular case in which the mesenteric glands
were full of Steatomatous concretions, and
in which the pancreas, besides being enor-
mously enlarged and full of similar concre-
tions, was covered by one of the consistence
of suet and more than five or six lines in
thickness. In this case the surrounding cel-
lular texture, the mesocolon, and the parietes
of the stomach, were cartilaginous and thick-
ened, in consequence, he supposes, of the
pressure of the tumour. He states, however,
that the pancreas has been found affected
when no marks of scrofula were observable
in any other part of the body. Meckel states
that he has seen the organ changed to an
almost tophaceous mass.
The Steatomatous concretion of Portal
seems to be identical with the tubercle of the
present day ; and accordingly, both in the
human subject and in the lower animals, tu-
bercles of the pancreas have been occasionally
met with, particularly in cases in which the
lungs had undergone a similar degeneration.
M. Lombard states that of one hundred cases
of tuberculous disease in children which he
examined, he found, in five, tubercles exist-
ing in the pancreas.*
Cystic tumours ; hydatids. These are of
rare occurrence. M. Becourt has described a
preparation in the Museum of the Medical
School at Strasburg, of a cyst of very large
size in the body of the viscus. Dr. Gross
has given the following description of one, in
a communication to the Medical Society of
Boston.f On opening the body, a voluminous
fluctuating tumour of oval form was found
situated beneath the right lobe of the liver,
with which it had contracted intimate ad-
hesions. It was placed between the intestines
and the posterior abdominal wall, passed a
little to the left of the vertebral column, and
had in front of it the curvature of the duo-
denum. It contained from 10 to 14 ounces
of a sero-sanguinolent fluid without clot,
slightly viscid, and without any appearance
of fatty matter. There was not a trace in
its walls of any of the normal tissue of the
pancreas, although it was evidently formed
by that organ. It contained some very small
calculi, resembling those ordinarily met with in
the ramifications of the pancreatic duct, and
two of these, from three to four lines in dia-
* Library of Medicine, vol. iv.
f Archiv. Ge'n. de Mod. iv. serie, t. 218.
PANCREAS.
Ill
meter and rough on their surface, completely
obliterated the opening of the pancreatic canal
into the duodenum ; they were composed of
carbonate of lime. The rest of the pancreas
that is to say its left extremity was about
two inches long and very hard : the pancreatic
canal of this portion of the gland opened into
the cavity of the cyst. This circumstance, and
the fact that that portion of the duct leading
from the cyst to the duodenum was blocked
up by the calculi, make it exceedingly probable
that the cyst was primarily nothing but a
dilatation of the duct in consequence of this
obstruction. It is possible that this may be
the origin of most of these cysts, and much
to be regretted that the fluid contained in
them has not been submitted to a rigorous
examination, with the view of ascertaining
whether it has any analogy to the secretion,
or admixture with it. Two cases of reten-
tion of the pancreatic fluid recorded by Cru-
veilhier, confirm the probability of this sup-
position. " The dilated canal resembled a
transparent cyst ; the contained fluid was
extremely viscid and clear, but of a whitish
hue like a solution of gum arabic ; it had
a slightly saline taste ; the collateral ducts
were extremely dilated. There were some
white patches, resembling plaster, in the centre
of many of the lobules. This substance was
more abundant in some of the lobules, and,
when removed, presented the appearance of
small lumps of plaster or chalk." These creta-
ceous lumps might have been of the nature of
pancreatic calculus, which we have already
seen associated with a cyst involving the duct,
or the earthy remains of old tubercle.
Fatty degeneration. I have frequently met
with fatty degeneration of the pancreas, and all
the instances in which I have detected it have
been cases of diabetes. After finding it in
four successive cases of this disease, I fancied
that I had hit upon its cause and the secret of
its true pathology. Although it seemed rather
a " lucus a non lucendo " argument to at-
tribute an undue formation of sugar to the de-
rangement of a sugar-forming organ, yet in a
class of bodies so full of instances of isomerism
as the starch and sugar series, it appeared to
me possible that an imperfect or depraved
pancreatic secretion might give rise to the
formation of an imperfect glucose incapable
of those after changes by which it is worked
out of the circulation. The meeting, how-
ever, with other cases of diabetes in which the
pancreas was not fatty, and, still more, the
perusal of M. Bernard's observations with re-
gard to the part that the liver plays in the
formation of sugar, and the disease of diabetes,
dispelled my theory, and compelled me to re-
gard the fatty state of the pancreas as the
consequence, and not the cause, of the diseased
condition, undergoing this degeneration in
comra-jn with other organs ; for I never found
fat in the pancreas without finding it in enor-
mous quantity in the liver and kidney. I may
here remark, that I have not been able to
confirm Dr. Johnson's observation*, that in
* Diseases of the Kidney, p. 395.
diabetes, when the kidncy^ cells contain a
large quantity of oil, the hepatic cells contain
an unusually small amount, and have a
" starved " appearance ; for I have invariably
found the accumulation of fat in the liver and
kidney cells, in cases of diabetes, in direct, and
not in inverse, proportion.
The microscopical appearances of fatty pan-
creas are of two kinds, depending, I think, upon
the length of time the degeneration has existed,
and the amount of fat (jftg. 75.). In one, the
amount of fat is small, the globults very
minute, confined to distinct epithelium cells,
Fig. 75.
Fatty Degeneration of the pancreas.
A. The process here is but slightly advanced, the
oil-globules small, and the epithelium distinct, par-
ticularly where some cells have escaped, as at b ; at
a, too, within the follicles, they are visible.
B, another specimen, in which the fat was more
abundant, and the destruction of the tissue com-
plete.
and giving them, from the increased opacity it
imparts to them, a mot e definite individuality
(A. a.) ; in such a case, if a follicle is ruptured
the epithelium escapes, each cell containing
its own minute fat globules (A. B ), and the
amount of free fat, if any, is very small. In
the other case, the appearance of individual
epithelium cells in the follicle is altogether
lost, the fat globules are larger and n;oie nu-
merous, and the rest of the contents indis-
tinctly granular. (B. a.) Sometimes the oil
globules completely fill the follicle ; when in
such a case pressure is applied, and the follicle
contents forced out, no distinct epithelial cells
are seen floating about, but all that is not fatty
is amorphous and broken down. (B, b.)
2. Malignant. Scirrhus and carcinoma.
These appear to be among the commonest af-
fections of the pancreas. The disease gene-
rally affects, or commences in, a part only of
the organ ; and appears to be primarly pan-
creatic, for in some cases the pancreas alone
has been found affected. Dr. Bisby enunie-
112
PANCREAS,
rates twenty-eight cases in which the disease
appeared to be idiopathic, and in eight, which
were of long standing, did not extend beyond
the pancreas; more frequently, however, it
implicates neighbouring parts in some degree,
particularly the duodenum, stomach, and py-
lorus. It may exist without any increase of
size, but more frequently is attended by some
enlargement, which may be considerable. Scir-
rhus rarely goes on to ulceration, the asso-
ciated lesions terminating fatally before that
time. It often gives rise to constriction of the
bile-duct and deep jaundice, and even com-
pression of the aorta : this compression and
constriction of the aorta have been known
to occasion aneurismal dilatation above the
seat of the constriction, as seen by Portal and
Salmade.
Of the twenty-eight cases analysed by Dr.
Bigsby, in seventeen the disease had not ar-
rived at the stage of softening, although some
of them had existed for years ; it was purely
scirrhus. In five cases he states the scirrhus
had, at the time of death, passed into the soft
state called cephaloma by Dr. Carswell, and
medullary sarcoma by previous writers. Some
parts, however, were as hard as cartilage ; but
others had all the pulpy, pale yellow, brain-
like character of the second stage of scirrhus.
In one case, the pancreas was changed into a
sac, with a few shreds of cephaloma here and
there on its sides. Lastly, in two cases no
vestige of any form of scirrhus remained, the
gland being altogether in a state of cancerous
ulceration.
Fungo-h(smaioid disease has been found in
the pancreas in three cases by Dr. Aber-
crombie, and in single instances by Dr. Bright
and others. Dr. Copland found this lesion in
the pancreas of a boy fourteen years of age ;
several other organs were also affectedby it.*
e. Ca/culous concretions in the pancreatic duct
and its branches are by no means uncommon,
and appear not unfrequently to be the cause
of some of those morbid changes that have
been already noticed. Sometimes they are
manifestly in the duct ; at others, though pro-
bably primarily so, they appear, from oblite-
ration of the duct in which they were lodged,
to be in the gland substance. They are usu-
ally white, but occasionally black ; they vary
much in shape, being sometimes round, and
sometimes irregular ; their size ranges from
that of a pea to that of a small walnut, and
their number from one to twenty ; sometimes
they are scattered throughout the gland,
sometimes aggregated in a mass. Gendrin
mentions that the pancreatic duct is some-
times clogged, not with distinct concretions,
but with a chalky powder. In respect to
chemical composition it seems probable that
pancreatic calculi are liable to some varia-
tions. Dr. Pemberton-j- mentions having re-
ceived one from Dr. Baillie from the human
pancreas which consisted entirely of carbonate
of lime ; whereas, one from the ox analysed by
Dr. Wollaston turned out to be phosphate of
* Medical Diet. Loc. cit.
f On the Viscera, p. G8.
lime. Portal mentions that in a case in which
he met with a dozen of light, round, whitish
calculi in the pancreas, he found that when
he reduced one or two to coarse powder,
and threw this into boiling water, it readily
dissolved ; and Fourcroy states, as the result
of his examinations, that pancreatic concre-
tions are composed of phosphate of lime com-
bined with some animal matter, just as is the
case with salivary calculi.
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 panweatic 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 faeces 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
faeces are deposited. This oily matter has
generally a slight yellow tinge, and a most
disgustingly foetid 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 all obstructed
PANCREAS.
113
oiliary ducts; the liver gorged with bile; fungoid
disease attacking the head of the pancreas ;
and malignant ulceration 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 faecu-
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 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 weans 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 near the
duodenum ; and ulceration of the duodenum
f'/.vc//." 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-
Svpp.
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 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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