FATTY STOOLS FROM DISEASE OF THE

MESENTERIC GLANDS.'

THE digestion and absorption of fatty matters claim more than usual attention at a time when these substances are considered as having an especial value in the treatment of strumous affections. It is therefore remarkable that the evacuations are so little studied as a means of informing us to what extent cod-liver oil and the like remedies are absorbed.

With the healthiest digestive organs there is a somewhat definite limit to the absorption of fat, the excess of it in the food passsing away in the evacuations; this limit is obviously much narrowed when the mucous membrane of the small intestine is diseased, or where the mesenteric glands prevent the onward passage of the chyle.

With their imperfect means of observation, the older physicians often surpassed us in their knowledge of symptoms; and though their pathology, from the want of chemistry and the microscope, had a vague expression about it, it was more or less true to nature. Diarrhea chylosa and Fluxus cœliacus were recognised by them, and attributed to some impediment in the absorbent system, whereby the chyle was left to escape with the fæces, an opinion which appears to be well founded, though it is probable they often mistook inflammatory exudation for chyle. Modern authors have passed over the subject, or have treated it lightly.

The normal absorption of fatty matters is prevented from 1 Reprinted from the 'Guy's Hospital Reports,' vol. i, 1855, p. 369.

two causes; either from a defect in the digestive and emulsifying process, or from disease of the absorbent system. The instances of fatty stools from disease of the pancreas and duodenum, as described by Dr. Bright and others, belong to the former, and are characterised by the fat passing from the intestines, more or less separate from the general mass of the fæces, and concreting upon them; but in the latter case, where the lesion is in the absorbent system, the fat, being emulsified, becomes incorporated with the evacuation, and is consequently not so easily recognised. If, however, there be with defective absorption, an inflammatory condition of the mucous membrane and diarrhoea, the oily matters rise to the surface of the evacuations as a creamy film, and produce the pale, chalky, and soapy appearance so characteristic of chronic muco-enteritis and mesenteric disease.

In the following case the mesenteric glands were enlarged from strumous deposit; the appetite was voracious, and the emaciation, as usual, extreme. The oily matters of the food passed freely from the intestines, but being blended with the fæces, were not so readily recognised as in fatty stools from disease of the pancreas. Cod-liver oil was administered in small doses experimentally, and passed through the intestines but little changed. The evacuations were for the most part semi-solid. When broken up by a stream of water, and allowed to stand, the oily matter separated as an alkaline soapy cream upon the surface. Under the microscope this consisted of large globules of oil, finely divided oily particles, granular matter, and inflammatory exudation. A quantitative analysis of the fat in the fæces, without a similar one of the food, would have been valueless; for the digestive powers being weak, and the appetite great, the bulk of the fæces was disproportionately large, and consequently any estimate of the mere percentage of fat they contained fallacious.

Reported by MR. HALL.

Henry 0, æt. 13, a delicate child, with light hair and fair complexion, came under treatment in the Clinical Ward, June 8th, 1855. He had been losing strength and gradually emaciating since the beginning of the year, and now presented the appearance of advanced mesenteric disease. Pulse

100, small and feeble. Tongue glazed and red. Appetite very great. Stools loose, and of a light colour. Urine pale, without albumen. Frequent cough without expectoration. Dulness on percussion below the left scapula, with gurgling and pectoriloquy. In the left infra-mammary region the breathing defective, at other parts puerile. The abdomen distended with flatus, and enlarged mesenteric glands can be felt in the umbilical and hypogastric regions. The bowels were generally moved three times in twentyfour hours. The evacuations were pultaceous or liquid, of a dull chalky colour, frothing like soap when a stream of water was poured on them. Under the microscope they were seen to contain muscular fibre in different stages of disintegration, starch cells, &c., and finely divided oily and granular matter like chyle, and inflammatory exudation. Shaken with ether, a large amount of fat separated. The cod-liver oil administered was readily obtained from the evacuations, so as to be recognised by its colour and odour, after being exposed to the air and losing the fæcal smell. The appetite was voracious, the emaciation extreme. He died 15th July.

Sectio cadaveris.-In the left chest twelve ounces of sero-purulent effusion. The lung adherent to the ribs at the base of the upper lobe, the free surface covered with a thick layer of rather recent fibrinous exudation. In the compressed lung, at the lower part, several vomicæ, one as large as a pigeon's egg. At the left apex two smaller ones. The right lung crepitant but congested; near the apex a small vomica. Heart normal in structure but extremely wasted. The mesenteric glands much enlarged, and universally affected with strumous disease. The intestinal mucous membrane, from the commencement of the jejunum to the rectum, dotted over with patches of ulceration, with here and there prominent masses of strumous deposit under the surface. The appendix vermiformis was ulcerated through, and the two portions adherent to the cæcum. Pancreas and duodenum healthy. Liver and kidneys healthy.

Although, from the extent of disease in the glands and the mucous membrane, this case may be considered as an extreme instance of the class it is intended to illustrate, it is not the less valuable for the purpose of drawing attention to similar conditions existing in a less degree. It must be of daily occurrence in the treatment of phthisis and other strumous affections, that cod-liver oil fails in doing any good from a morbid state of the mucous membrane of the small intestine, and of the glands of the mesentery; yet its routine administration is persisted in, and a means in itself most valuable is prejudiced, through the carelessness and oversight of those who employ it. If it be ever admissible to limit the attention to one organ in treating disease, it is so in strumous affections, where, as all will admit, the condition of the gastro-intestinal membrane is of paramount import

ance; yet our remedies at present rarely extend beyond bitters, and alkalies, and cod-liver oil, together with such general palliatives for the cough as naturally suggest themselves.

The disproportionate frequency of tubercular deposit in the intestinal mucous membrane, the mesenteric glands, and the lungs, which organs lie directly in the course of the newly assimilated material, points with no doubtful sign to the defective constitution of the chyle, as having an important influence in such a result. Though this view of the subject is generally entertained, and even by some, as by Dr. Hughes Bennett, much insisted on, it is curious to observe that writers make no mention of the character of the evacuations, from the study of which alone can any opinion be formed as to the condition of the digestive and absorbent functions.