DISTURBANCES OF PANCREATIC METABOLISM 665 



ferments, or for functional variations in the strength of the pancreatic 

 secretion so obtained. It has been shown that normal human pancreatic 

 ferments as obtained from the duodenum have a constant value ('Crohn(a), 

 Einhorn and Rosenbloom, McClure), and that in diseased conditions of 

 the pancreas affecting any of its ducts these ferments either are -absent 

 or definitely diminished (Hess(c), Chace and. Myers (a), Bondi and 

 Solomon, Einhorn(c), Crohn(&)), etc. The latter or duodenal method, 

 being the most direct, lending itself to the more exact chemical studies, 

 bids fair to replace most of the older and more, indirect methods for 

 demonstration of the presence of the active ferments of the gland in the 

 intestinal tract. 



Objections can be found to most of the tests as practiced, and in the 

 older ones, the clinical application of the tests has failed to substantiate 

 the claims made for them by their originators. 



There are, however, reported in the literature many cases of verified 

 pancreatic disease in which exact clinical data regarding metabolism and 

 food absorption have been obtained, and in which at autopsy or operation 

 the exact status of the pancreas has been ascertained. It is on the basis 

 of these data that there has been accumulated a composite picture of the 

 disturbances in metabolism that accompany pancreatic disease. 



As a clinical observation, disturbances of fat metabolism were first 

 observed by Kuntzmann, and independently by Richard Bright. The 

 picture of the typical "fatty stool" pathognomonic of pancreatic disease 

 was clearly described by the latter ; many years later Fles made his re- 

 markable observation on the large amount of muscle fiber remaining in 

 the feces of patients suffering from pancreatic disease (creatorrhea). 

 Clinical observations in the next decade were numerous but threw no 

 more exact light on the phenomenon. Stimulated, however, by the careful 

 animal experiments of von Mering and Minkowski(a), Abelmann, Sand- 

 meyer, and others, accurate chemical data began to accumulate after 1895 ; 

 since that time there has been an increasing number of careful chemical 

 studies on human digestion and absorption in pancreatic disease. 



Friedrich Muller(a) noted three cases in which complete obstruction 

 of the pancreatic duct occurred. The percentage of fat content in the feces 

 was 28 per cent, 29.5 and 44 per cent; normal about 14-26 per cent (von 

 Oefele). Miiller attributed the large loss of fat more to the associated 

 jaundice than to the closure of the pancreatic duct. 



Deucher in a case of carcinoma of the pancreas with closed duct of 

 Wirsung and only slight compression of the bile duct, found a fat absorp- 

 tion of only 17 per cent and a nitrogen absorption of 70 per cent. 



In a second case of carcinoma, the obstructive jaundice had been re- 

 lieved by a cholecystoduodenostomy, thus eliminating the icterus as a 

 disturbing factor. The percentages of absorption were, fat 47.4 per cent, 



