552 DISEASES OF THE INSULAR APPARATUS OF THE PANCREAS 



careful microscopical examination of the pathological anatomists did not show 

 anything certain. In one of these cases the count of the islands has furnished 

 inferences worthy of remark. It is shown in this group that the number of 

 islands and also their size is markedly diminished, and indeed there are 

 statements that the islands are entirely wanting. The supposition of 

 Heiberg that in such cases the defect in islands can be referred to a preceding 

 inflammation with the formation of scars has much in its favor. In many 

 cases of juvenile severe diabetes, however, the number and size of the islands 

 is insignificantly and perhaps not even at all diminished. In these cases 

 Weichselbaum constantly found the hydropic degeneration. This statement 

 of W 'eichselbaum 's has up to the present time not been recognized by all 

 pathological anatomists. If, however, the hydropic degeneration in such 

 cases is found to be constant, we must also ask the question if the alterations 

 are not of a secondary nature, brought into existence by the long duration 

 of the hyperglycemia and acidosis, and if. these relatively slight alterations 

 suffice to explain the high-grade functional deficiency. This form of diabetes 

 always commences with heavy elimination of sugar. In the majority of 

 cases there is found in the later stages an intensity of glycosuria, that comes 

 up to that seen in pancreasless dogs, and in the most of cases even exceeds 

 this. On the whole we can hardly be mistaken if we were always to assume a 

 participation of the pancreas in such cases. The hereditary element so 

 conspicuous in the pathology of this form of diabetes points to a weakness 

 in the "Anlage" of the insular apparatus, as a result of which any toxic or 

 infectious deleterious influence at all finds a locus resistentiae minoris. In 

 spite of all this we cannot reconcile the incongruity of the pathologico- 

 anatomical findings and the intensity of the metabolic disturbance and must 

 ask ourselves the question whether if in this form of human diabetes, and 

 perhaps in the most cases of severe human diabetes, there is not present, in 

 addition to the insufficiency of the pancreas, also another disturbance that 

 we have essentially to regard as an increase of sugar production dependent on 

 a nervous basis. 



Before we enter into this question, it is necessary to observe more care- 

 fully those forms of diabetes in which the clinical observation or the patho- 

 logical anatomy points toward a prominent participation of the nervous 

 system in the coming about of the diabetic disturbance of metabolism. 



The question as to whether we are justified in recognizing a "nervous 

 form" of diabetes has been discussed in a lively manner for a long time. 

 The discovery of the "piqure" happened before that of diabetes after extir- 

 pation of the pancreas. Since the time that the discovery of pancreatic 

 diabetes turned the general 1 attention toward the pancreas, the interest in 

 nervous diabetes has fallen behind. The greater part of the clinical observa- 

 tions of "nervous" diabetes come from earlier times, thus making critical 

 observations not less difficult. 



