GROSS ANATOMICAL DISTURBANCES 525 



of the pancreas it seems that the islands of Langerhans hold out longer against 

 the carcinomatous infiltration than do the acini. As the carcinoma usually 

 is seated in the head of the pancreas it not infrequently happens that there 

 is. complete shutting of! of secretion through compression of the chief duct, 

 and hence a distinct prominence of absorptive disturbances. We should 

 consider, of course, that the ingestion of food in such a case is very slight on 

 account of the cachexia. 



In carcinoma we not rarely observe, in addition to this that the intensity 

 of the glycosuria diminishes with increase in the cachexia, or the sugar en- 

 tirely disappears. This is entirely comprehensible. We see even in the 

 pancreasless dog the glycosuria diminish, if with the weakening of the liver 

 processes the mobilization of sugar is also less. In slight grades of chronic 

 indurative or more atrophic pancreatitis no disturbances in carbohydrate 

 metabolism need necessarily be present. In advanced cases it may very well 

 be assumed that the function of the insular apparatus has often suffered 

 previous damage and has thus led to disturbances in the sugar metabolism. 

 We shall see later that this form of pancreatitis not rarely forms the patho- 

 logico-anatomical stratum for the "genuine" diabetes mellitus. In this, 

 as is well known, no absorptive disturbances occur, although the antidia- 

 betic diet mostly means a considerable and permanent overloading of the 

 fat absorption. In former times this was associated with a heavy overload- 

 ing of the intestines with meat. Thus can the production of pancreatic juice 

 be strongly limited without disturbances of absorption becoming manifest. 

 These occur only with the higher grades of atrophy of the pancreas. The 

 most important are the cases with occlusion by stone, and those of consecutive 

 sclerosis. In stoppage of the duct by stone we have in addition the suddenly 

 appearing characteristic absorptive disturbances, which are fully developed, 

 and most often the latent or manifest disturbances in carbohydrate me- 

 tabolism that had already been present, perhaps because the catarrh of the 

 duct system has for a long time led to incrustation of the ducts and to in- 

 durative pancreatitis. There are, however, cases in which, at least at the 

 beginning, there exist fully developed disturbances of absorption, but only 

 minimal latent disturbances of carbohydrate metabolism. These cases are 

 entirely intelligible, if through impaction of a gall-stone or through other 

 factors leaving the pancreas for greater part intact, the supply of pancreatic 

 juice is interrupted. Ehrmann and others, have described such cases. As 

 example I submit the following: 



Observation LXVIII. R. M., thirty-five years. Entrance into the clinic Nov., 1911. 

 Until one and one-half years ago the patient was entirely well. Then obstipation that 

 often lasted four or five days set in, and also slight headache. For about seven months 

 severe colicky pains in the right hypochondrium, about ten days after this jaundice, that 

 has lasted until to-day. Since this time four or five bowel movements daily that were 

 very voluminous, " more than he ingested as food." The stools are clay-colored. In spite 



