518 DISEASES OF THE INSULAR APPARATUS OF THE PANCREAS 



nates not from glycogen, but from fat; in such a case the respiratory quotient 

 should, however, sink. 



II. CLINICAL PARTS 



Although we are informed as yet only by hypotheses as to the intimate 

 process by which the pancreas enters into the regulation of the carbohydrate 

 metabolism, we have no reason for doubting the fact that the pancreas be- 

 longs to the most important regulators of the carbohydrate metabolism and 

 plays a leading role in its disturbances. If now we try to enter further into 

 the question as to what role the pancreas or its inner secretory function plays 

 in human pathology, we find that it is more to our purpose to view the 

 problem from two different sides. On the one hand it will be necessary to 

 pass in review the clinical pictures in which gross anatomical alterations of 

 the pancreas have been observed, and tq analyze which symptoms of the 

 total symptom-complex can be referred eventually to the disturbance of the 

 internal-secretory activity. A thorough description of these disease pictures 

 does not lie within the province of the task I have set for myself, and is also 

 not necessary for the purpose I am striving for; yet it seems tome desirable 

 to delineate them, at least in coarse outlines. For as we have already 

 mentioned in the consideration of the experimental physiology, there have 

 been attempts to bring many symptoms that were formerly referred to as 

 the external secretion of the pancreas into connection with the internal 

 secretion. On the other hand I shall draw the essential features of the 

 metabolic disturbance that we designate diabetes mellitus, describe the 

 pathologico-anatomical alterations found in the condition, and discuss what 

 role the pancreas plays in it. 



It will be evident that there are a number of cases the analysis of which 

 we can approach as well the one way as the other. 



A. Gross Anatomical Disturbances 



An etiological classification of the diseases of the pancreas is not possible 

 to-day. As yet we know far too little in this respect. At any rate, the role 

 played by infection is important. This may occur hematogenously, or by 

 contiguity, in which case infectious processes of the neighboring parts affect 

 the pancreas; and finally especially in gall-stone affections (Hirschfeld} in 

 which infection reaches it from the intestines through the ducts. The route 

 last mentioned is by far the most frequent. An important role is played by 

 diseases of the vessels of the'pancreas and by cirrhotic process that depend 

 on the chronic action of poisons (alcoholism, etc.). Also trauma may come 

 into consideration as an etiological factor, especially in existing arterio- 

 sclerosis of the pancreas. Further we recognize a series of tumors of the 

 pancreas under which carcinoma is by far the most common; further cyst 

 formation, the genesis of which may be of various nature, and finally a con- 



