524 DISEASES OF THE INSULAR APAPARTUS OF THE PANCREAS 



In human pathology, the conditions seem to me to be clearer and to justify 

 a single standpoint, v. Noorden and Salomon have pointed out in this re- 

 gard that in cases of absence or insufficiency of the pancreatic juice, the ab- 

 sorptive disturbances become manifest, if the intestine is overloaded with 

 fat; if in this functional test, butter stools occur we may take it for granted 

 that there is certainly a disease of the pancreas or absence of the pancreatic 

 juice. Also this is true if creatorrhea makes its appearance. It should 

 not be forgotten that in many of the cases of pancreatic disease in the litera- 

 ture (especially in carcinoma, in which fat stools are absent, on account of 

 the increasing cachexia), the intake of diet was very slight at the time of the 

 observation. We must here again refer to the anatomical relations of the 

 duct system. We must consider that if the second duct of the pancreas is 

 not obliterated or occluded, enough pancreatic juice may still reach the in- 

 testine, even if the principal duct be completely occluded, that the disturb- 

 ance does not become manifest even on heavy overloading. As far as the 

 fat splitting is concerned, Salomon has pointed out that during the tedious 

 procedure of drying the stools on. the water-bath, always more fatty acids 

 occur. If we do not take this into account, we may arrive at entirely false 

 values for fat splitting. We may summarize by saying that markedly 

 lessened or absent production of pancreatic juice, or cutting-off of the 

 pancreatic juice from the intestine, leads in man to characteristic absorptive 

 disturbances. 



I have entered into detail into these conditions, because we require a 

 clear formularization if we wish to enter into the question as to how far the 

 internal secretory activity of the pancreas is independent of the external 

 secretory activity, and whether these disturbances occur isolated in the 

 gross anatomical diseases of the pancreas. In the acutely onsetting, severe, 

 damagings of the organ (suppurative or acute hemorrhagic pancreatitis, 

 necrosis of the pancreas or apoplexy of the pancreas) it is intelligible that we 

 do not see much of the disturbance of the external or internal secretory 

 activity of the pancreas. Often, too, in complete extirpation of the pancreas 

 in animal experimentation, the sugar does not occur immediately if septic 

 processes are present at the same time. When diet is low or not ingested 

 at all, of course the absorptive disturbances do not occur either. If the course 

 is subacute, as a rule both disturbances are present. In tumors of the pan- 

 creas, the behavior of the disturbances varies very much. Cysts may leave 

 behind sufficient functionating pancreatic parenchyma and hence may pursue 

 their course without any disturbance whatsoever. If the greater part 

 of the pancreas takes part in the process sympathetically, a latent in- 

 sufficiency of both functions may develop that may eventually become 

 evident only on overloading; although it is intelligible that in individual cases 

 on account of especial anatomical relation the absorptive disturbances may 

 become more distinct through compression of the duct system. In carcinoma 



