PATHOLOGICAL ANATOMY OF DIABETES MELLITUS 551 



the cause can be ascribed to high-grade arteriosclerosis of the vessels of 

 the pancreas; in other cases an ascending catarrh of the duct system might 

 be the cause. The latter cases go over without sharp boundary into that 

 large group of high-grade atrophies of the pancreas, which we previously 

 treated under the gross anatomical alterations of the pancreas. In all 

 these cases are found in addition to changes in the insular apparatus more or 

 less pronounced alterations of the glandular acini, which is true of the cases 

 that proceed from catarrhs of the excretory ducts only when the process is 

 more advanced. It is comprehensible why these cases do not lead to absorp- 

 tive disturbances, for there is still enough functionating parenchyma present, 

 and it is to be expected that such disturbances became manifest only on high- 

 grade diminution of pancreatic juice production. The decision as to whether 

 the alterations in the insular apparatus observed in this form suffice to explain 

 the disturbance in carbohydrate metabolism is certainly very difficult, and 

 is further complicated by the occurrence, commonly observed, of regenera- 

 tive manifestations in the islands. It is indeed very questionable whether 

 these new-formed islands have the same functional integrity. We see, how- 

 ever, in many forms of cirrhosis of the liver often strongly developed and wide- 

 spread regeneration of the liver tissue, and yet we find in these cases signs 

 of deficiency of liver function. Also the occurrence of individual hyper- 

 trophic islands and adenomatous proliferations of islands does not furnish a 

 certain conclusion as to the function of the entire insular apparatus. Like- 

 wise, as Saltykow points out, just as little does the finding of partially normal 

 islands speak against the island theory; for example, we have in cases 

 of nephritis, large amounts of normal renal parenchyma visible micro- 

 scopically, without casting doubt as to the insufficiency of the renal tissue. 

 That also in this group are found cases in which the insular apparatus has 

 suffered relatively severe damage need cause no wonderment. Weichselbaum 

 emphasizes the fact that the cases with isolated hyaline sclerosis of the insular 

 apparatus probably form only a subdivision of this group; also here is 

 commonly found a sclerosis of the vessels of the organ; it seems to me very 

 likely, however, that in these cases of isolated sclerosis of the insular ap- 

 paratus there is expressed a certain undervaluation in the rudiments of the 

 insular apparatus, that becomes manifest only on the additional occurrence of 

 further damaging influences. 



For the judgment of the role that the pancreas plays in the pathogenesis 

 of diabetes mellitus, no doubt the second group that which affects youthful 

 individuals is the more significant. Most important for us are those cases 

 in which the diabetes commences at an early age, and, ceaselessly progressing, 

 leads to fatal coma. It is these cases that up to the present have furnished so 

 unsatisfactory pathologico-anatomical findings. The monographs on dia- 

 betes by Naunyn and by von Noorden state likewise that in the rich experi- 

 ence of these authors numerous cases are met with, in which even the most 



