526 DISEASES OF THE INSULAR APPARATUS OF THE PANCREAS 



of this fact the appetite remained very good, the patient fell off rapidly. The patient is 

 almost entirely impotent. More severe jaundice, hair on head very much thinned out, 

 that in the axillae almost entirely absent, sparse on the pubis. Colossal hydrops of the 

 gall-bla-dder. In addition, in the middle line, very deep, is a resistance hard to outline. 

 Ascites. 



Rontgen examination: diffuse aortic extension of a moderate degree. Wassermann 

 negative. Increased peristalsis of the stomach, although emptying of the stomach is not 

 essentially slowed. Urine deeply jaundiced, no sugar. Chemical examination of the 

 stomach contents normal. 



The stools (3-4 daily) are very massive and are acholic; urobilin test constantly nega- 

 tive; minimal, quantitatively not estimable amounts of urobilogen (Dr. Charnas). The 

 stools are of gray-white color, glittering with fat, of very foul odor, microscopically show 

 much neutral fat, soap and fatty acid needles and striated muscle fibers. By loading with 

 fat (250 gm. oats, oatmeal, and 300 gm. butter) there occur typical butter stools. The 

 test was repeated five times always with positive results. 



The chemical examination of the stools (with the overloading test) showed 38.5 per 

 cent, unsplit fat and 64.2 per cent, fat in the form of fat acids and soaps. The chemical 

 examination of the butter-stools showed 71.7 per cent, neutral fat. 



The examination of the stool for tryptic ferment according to Gross, and also for dia- 

 static ferment according to Wolgemut showed only traces. In one examination, however, 

 there was found slight, but distinct tryptic and diastatic action. 



Five tests for alimentary glycosuria (100 gm. of dextrose, fasting) were always negative. 



During the stay at the hospital there often occurred colicky pains in the gall- 

 bladder region. 



The ascitic fluid had a specific gravity of 1012, 8 per cent, albumin. The albumin 

 bodies precipitated by acetic acid were present only in traces. 



The Salomon-SaxVs carcinoma reaction was positive. 



Although the Salomon-SaxVs test as well as the ascites spoke for a new growth, yet the 

 possibility of an occlusion of the ductus choledochus by stone could not be excluded; so that 

 the patient was operated on. There was found at operation, deep down in the abdominal 

 cavity, a tumor whose situation was not quite clear. Cholecystogastrostomy was done. 

 Death occurred some weeks afterward. Section showed a scirrhous carcinoma of the 

 head of the pancreas, with closure of the pancreatic duct, marked dilatation of the passages 

 in the body and tail of the pancreas. The ducts were filled with a milky yellowish fluid. 

 The ductus choledochus was occluded about ij^ cm. above the papilla of Vater, and 

 there was marked dilatation of the bile ducts above it. 



The case described fulfills all the conditions that we could establish 

 at a physiological experiment. There are present all symptoms that are 

 characteristic for the cutting-ojf of the pancreatic juice (and the bile) , while 

 the carbohydrate metabolism was entirely normal even on heavy overloading. 

 Such cases have an important significance. They show us that in human 

 beings the internal secretory and the external secretory activity of the pancreas 

 are fully independent of each other within wide limits. 



B. Genuine Diabetes Mellitus 



It is not my intention here to depict the symptomatology of diabetes 

 mellitus in exhaustive fashion. Much more will I limit myself merely to 

 sketching the clinical picture, assigning only somewhat more space to the 



