IDENTIFICATION OF DIABETES AS
PANCREATIC.

The identification of a glycosuria as due to pancreatic diabetes is usually very uncertain, because it implies the notoriously hazardous diagnosis of pancreatitis. Further difficulties arise when gall-stone disease or other hepatic involvement, as is so often the case, coexist, for hepatic insufficiency, due to any cause, per se often produces an alimentary glycosuria that may be genetically quite independent of pancreatic disease. If, clinically, similar conditions obtained as in experimental ablation of the pancreas, the diagnosis of pancreatic diabetes would be exceedingly simple. Cases presenting such a syndrome must, however, be considered great rarities; they occur only in very advanced stages of pancreatic disease, with complete obliteration of the glandular parenchyma, and not always then.

DIFFICULTY OF DIAGNOSIS IN PANCREATIC DISEASE.

The diagnosis of pancreatitis is rendered particularly difficult for the following rea

sons:

The close proximity of the pancreas to liver, stomach and duodenum; the intimacy of the vascular, lymphatic, nervous, supply between these organs, renders it apparent that symptoms emanating from the pancreas can very well be referred to adjacent organs, and explains why disorders about the liver, stomach, and duodenum so often actually precede, accompany or follow pancreatic disease.

The enlargement of the head of the pancreas, the most constant and most striking gross manifestation of pancreatic disorders, moreover, produces pressuresymptoms upon blood-vessels, bile-channels and nerve-trunks, thus producing a great variety of remote symptoms, the primary pancreatic origin of which very well may and usually does escape detection.

Again, it must be remembered that the whole glandular parenchyma of the pancreas is rarely involved, so that, on account of the different functions exercised by the various glandular areas of the organ, only one or the other of these functions may be perverted or suppressed. When one considers, finally, that none of the various pancreatic functions are exclusively specific to the gland, but that each can, to some extent at least, be vicariously assumed by other organs of the body, then

the enormous difficulty of making the diagnosis of pancreatic disease, either from general symptoms or from specific symptoms of pancreatic debility, must be recognized.

AMBIGUITY OF GENERAL SYMPTOMS.

The general symptoms never suffice alone to make a diagnosis. There is nothing typical about the pain, nothing about its location, intensity or character that indicates the pancreas and the pancreas alone; generally, in fact, the pain simulates very closely the distress in cholelithiasis, the paroxysms of gall-stone colic, even the radiations into the subscapular and lumbar regions and the location of the most tender pressure-point very near the gall-bladder region. There is nothing about the digestive disorders--the nausea, belching, vomiting (often of bile-stained material), the diarrhea, the constipationthat might not be found in many gastrointestinal disorders. There is not infrequently icterus; some irregular fever of no particular type, or occasionally subnormal temperature. In advanced cases of chronic pancreatitis there is generally much emaciation, a profound anemia with oligocythemia, oligochromemia, and degenerative signs about the erythrocytes resembling closely the picture of a primary pernicious anemia. Sometimes the skin becomes bronzed. Two general symptoms that point with a little more directness to the pancreas remain to be mentioned, viz., a peculiar disarrangement of the fat distribution about the body, leading to the formation of rolls of adipose tissue, especially about the front and side of the chest and the abdomen, resembling somewhat the picture of Dercum's disease (adiposis dolorosa); and profuse salivation (sialorrhea pancreatica), possibly due to reflex stimulation of the salivary glands from the diseased pancreas (may be a vicarious hypersecretion of amylolytic material).

SPECIFIC FUNCTIONAL TESTS.

More definite information can, as a rule, be gleaned from a study of those phenomena that are attributable to inadequacy or debility of some of the pancreatic functions; often these symptoms can be brought out with special clearness if special functional tests are made to determine the power of the pancreas to properly disassimilate the albumins, the fats, the carbohydrates, in the intestinal canal. In obstruction of the pancreatic duct, and, not

The steatorrhea, however, is by no means a constant phenomenon, for the emulsification, splitting, saponification of the fats can be vicariously assumed, in part at least, by the gastric juice, the bile and intestinal bacteria; hence, in early stages of pancreatic disease marked disturbances of the fat assimilation are really quite rare and often absent. The sign is really only of distinct diagnostic value if very large quantities of fat appear in the stools. without the existence at the same time of icterus, acholic stools or severe intestinal disturbances, for in the presence of either or all of the latter symptoms the steatorrhea might very well be due not to pancreatic disease, but to disease of the bilepassages. Sometimes the production of an alimentary steatorrhea by giving a fat testmeal (50 c.c. of 'olive oil) after two or three days of an ordinary mixed diet is of value; for a normal subject should absorb the bulk of these 50 c.c. of oil. In pancreatic disease most of this fat reappears in the stools, imparting a peculiar consistency to the feces and causing the appearance of grayish-white flakes and lumps in the stools. Chemically, too, of course, a quantitative fat determination shows an increase above the normal. These fat stools differ from the fat stools of cholelithiasis by the appearance of the fat as neutral fat and the presence of bile pigments or their congeners.

THE NUCLEAR TEST.

The appearance of large quantities of undigested muscle fibre is an altogether ambiguous symptom occurring in many disorders involving the disturbances of the function of the small intestine. The appearance of undigested nuclei in the stools is indicative of pancreatic disease only, provided there is no profuse diarrhea causing the muscle fibre to be rushed through the intestine, and provided the muscle fibres are not allowed to remain in

the bowel longer than twenty-four hours, for putrefactive processes, too, may cause disintegration of the nuclei

THE GLYCOSURIA.

Glycosuria, finally, is an altogether inconstant symptom. The pancreas, presumably by means of an internal secretion furnished by the cell groups of Langerhans, aids in the regulation of the carbohydrate metabolism. How, we do not know. Complete removal of the pancreas in animals invariably produces the complete syndrome of diabetes, and one should expect the same in complete destruction of the glands in man. There are a number of cases of carcinoma of the pancreas and of advanced chronic pancreatitis on record with destruction of most of the acini and the islands of Langerhans, in which glycosuria either failed completely to make its appearance or appeared for a time only to vanish again later on. This seems to indicate quite clearly that, if time enough is given, the regulation of the carbohydrate metabolism can be assumed by other organs, notably, in all probability, by the glands of Brunner in the duodenum, that are genetically very closely related to the pancreas.

FREQUENCY OF PANCREATIC DIABETES.

Hence glycosuria, scil., pancreatic diabetes, is a much more common symptom in acute pancreatitis and at the onset of pancreatic disease, especially when associated with cholelithiasis, than in later stages. This is very important. In occlusion of the pancreatic duct (or experimental ligation), with damming back of the pancreatic secretion, glycosuria is rare, for the islands of Langerhans seem to resist this insult very well, and only undergo degeneration when nearly all the other glandular elements of the pancreas are destroyed. It appears that in individuals with a diabetic heredity the occurrence of glycosuria is much more apt to take place in even slight pancreatic involvement. The administration of large quantities of starchy or sweet food may occasionally demonstrate the existence of a reduced tolerance for carbohydrates; therefore a special test for alimentary glycosuria should be made in every case presenting symptoms significant of pancreatic involvement.

The glycosuria, therefore, is a symptom of peculiar value in pancreatic disease; its presence being indicative of pancreatic in

volvement, its absence not necessarily invalidating this diagnosis.

PANCREATITIS SIMULATING CHOLE

LITHIASIS.

Given a more or less vague and inconstant syndrome of the above type, simulating in many important aspects, as I have taken pains to point out, the common picture of cholelithiasis, it is not surprising that the latter diagnosis is so often arrived at when in reality the pancreas is, at least originally, at fault. It is due chiefly to failure to perform specific functional tests for pancreatic involvement, not once, but several times, in all cases presenting the picture of cholelithiasis, that pancreatic involvement is so often overlooked, pancreatitis considered to be so rare, and the disease so commonly discovered only on the operating-table or at autopsy. For this reason, too, surgeons were the first to recognize the frequency of the disorder and to forcibly call our attention to its importance. Hence, finally, many cases that are diagnosed as cholelithiasis and operated on for this disease, recover, despite the fact that the bile-passages are found quite intact and gall-stones absent. These are often cases of unrecognized pancreatitis.

CHOLELITHIASIS AND PANCREATITIS.

Aside from the cases of pancreatitis in which the syndrome of cholelithiasis is simulated, but in which gall-stone disease is not present, we have much more frequently a combination of gall-stone and diabetes in which the type of the diabetes should properly be specified as pancreatic. What has been said in the preceding paragraph in regard to the necessity of performing tests of the functional capacity of the pancreas when cholelithiasis is simulated, applies with particular emphasis to cases in which the presence of gall-stones is determined or rendered probable and that run their course accompanied by diabetes. For in all such cases the prognosis of the diabetes is as a rule much better, and the treatment quite different, than in the so-called ordinary idiopathic types of the disease.

In attempting to interpret the occurrence together of pancreatic diabetes and gall-stones, three possibilities must be taken into consideration, viz.:

1. The presence of stones in the gallbladder or their passage through the bilepassages into the duodenum may produce the pancreatic changes.

2. The disorder about the pancreas may be the cause of the gall-stone formation.

3. Both the gall-stones and the pancreatic diabetes may be due to some common cause acting simultaneously upon the liver and the pancreas.

The pathogenetic relationship of the two diseases has been fully discussed by the essayists who have preceded me, so that it is unnecessary to enter into further details myself. Gall-stone disease precedes the pancreatic disease in most cases, and chronic pancreatitis must be considered a common sequel of cholelithiasis. Here and there a pancreatitis, by mechanical compression of the common duct passing through the head of the gland, or by secondary infection, causes stasis of bile, infection of bile-channels, cholelithiasis; now and then infection, enterogenous or hematogenous, lues, alcohol, trauma, cause both pancreatic and hepatic involvement.

THE TREATMENT.

Medical treatment of pancreatic diabetes, especially when complicated with cholelithiasis is exceedingly unsatisfactory. In fact, drinking cures are as a rule very poorly borne, although after operative treatment they are of great value and often materially aid in the production of recovery. Antiluetic treatment is sometimes of value. Pancreas preparations never do harm, but at best they are a substitution remedy that may palliate some of the most distressing derangements about the digestive tract, may aid a great deal in promoting better absorption of the food, hence better nutrition, but never produce

a cure.

In view of our inability in many cases to distinguish between gall-stone disease and pancreatitis, or to determine whether or not pancreatitis complicates gall-stones, or vice versa, an exploratory laparotomy is always indicated. The surgical standpoint has been fully discussed by the other essayists.

The good effects of a laparotomy in both acute and chronic cases of pancreatitis are often striking, the active hyperemia from the incision probably of itself acting beneficially, as in tuberculous peritonitis.

The removal of hepatic concretions very generally exercises a beneficial effect upon the pancreatitis and the glycosuria. Removal of pancreatic concretions, the better drainage of the abdominal cavity (ascites,

fat necrosis), are all useful and necessary steps. The presence of pancreatic diabetes

in these cases does not counterindicate laparotomy.

INTRODUCTION.

Digestion, absorption and assimilation of the body are primary functions, and were accomplished facts before there was nervous system. The necessary control was obtained from certain organic internal secretions.

The sympathetic nervous system, probably mesoblastic in origin, came next as an aid to internal secretions, and is still found closely connected with the organs which produce internal secretion. The thyroid is closely associated with the cervical sympathetic, the adrenals were for a long time supposed to be sympathetic ganglia, and the pituitary body is half sympathetic ganglia and half gland.

The development of the cerebro-spinal nervous system was a later evolution, which has become predominant. Nature has, however, not allowed the central nervous system to wholly usurp these original methods of control; hence internal secretions still act as chemical messengers, or, as they are called by Starling, "hormones," and to a large extent they control digestion and assimilation. The struggle for supremacy of the advancing central nervous system over the internal secretions and the sympathetic ganglia gives rise to irregular function, and may lie back of much of the prevalent neurasthenia, digestive neuroses, visceral ptosis,

etc.

The surgeon cannot intelligently operate upon organs of double function without a full knowledge of their internal as well as their external secretions, for herein may lie the cause of the failure of a mechanically well-executed operation to cure the patient.

The pancreas is an organ of internal and external secretion. Its internal secretion is actively associated with those of the intestinal glands, especially Brunner's glands in the duodenum, and also with the thyroid and adrenals. This activity is probably expressed through the islands of Langerhans, which seem to have a large influence on carbohydrate metabolism.

The external secretion of pancreatic juice is even more closely associated with that of bile from the liver, and so important is this latter association that by a process of evolution the pancreatic and common bile-ducts have become joined just before entering the duodenum, and a small cavity, the ampulla of Vater, results, which acts as a mixing-chamber.

A study of the comparative embryology of the derivatives of the primitive foregut, from which the stomach and the duodenum to the common duct and the pancreas and liver are formed, throws an interesting side-light on this anatomical relationship. The fetal pancreas has two lobes, each with a duct having a separate opening into the duodenum. In the adult the upper, or duct of Santorini, although it has an orifice uncomplicated with the common bile-duct, has become more or less obsolete, while the duct of Wirsung is the main excretory channel. This suppression of the direct flow of pancreatic juice through the duct of Santorini in favor of the indirect duct of Wirsung shows the importance of the association of the liver secretion to digestive function. The variability of the useful possibilities of the duct of Santorini indicates that this change is a recent evolution.

The liability of the appendix to disease, the wisdom teeth to early decay, and the little toes to corns and callosities, are examples of defects from progressive loss of function. Advancing function also makes for anatomical imperfections, shown in the variability in the length, shape and size of the sigmoid (Finney) as this derivative of the primitive hindgut increases its capacity as a fecal storehouse, and may result in constipation and irregular bowel action. It would appear that the changing digestive function is acting in the same way. The duct association of the pancreas and liver, with its pathological tendencies, shows the instability of short heredity. The gall-bladder, changing from a bile store-house to an organ needed for the relief of tension in