276 THE DISEASES OF THE HYPOPHYSIS 



extract can hardly be called upon to explain this disease picture. Also the 

 explanation of the disturbance of carbohydrate metabolism so commonly ob- 

 served in acromegaly seems to me to encounter unsurmountable obstacles. 



Rath and later Loeb supposed that in acromegaly the tumor of the hypo- 

 physis pressed on a neighboring sugar center; the diabetes in acromegaly 

 would thus be placed in analogy to the glycosuria sometimes occurring in 

 apoplexy. This view has recently been adopted by Aschner. This author 

 succeeded in demonstrating that a sympathetic center lies in the subthalmic 

 region, the irritation of which causes glycosuria. The glycosuria does not 

 occur after transection of the splanchnic nerves and therefore like that of 

 Claude-Bernard's piqure goes over the chromaffin tissue. In spite of the 

 convincing experiment of Aschner, I cannot agree with his conclusion; it is 

 not clear to me why just in acromegaly, a developing hypophysis tumor 

 should press on this center, while the tumors of the hypophysis without 

 acromegaly, that often lie in the hypophysial duct or even extrasellary, and 

 that give occasion to symptoms of great brain pressure, produce no diabetes; 

 in these cases, on the contrary, as we shall see later, the tolerance limits 

 for carbohydrates are practically always appreciably raised. 



Pineles supposes a correlative affection of the pancreas. Actually 

 Hansemann and Dallemagne have found atrophy of the pancreas in acro- 

 megalic diabetes. It is indeed very probable that in the cases of acromegaly 

 combined with severe diabetes the pancreatic genesis stands in the fore- 

 ground. We see in acromegaly degenerative changes in almost all the organs 

 occur simultaneously with or in the course of the period of increased tendency 

 for growth, and the insular apparatus may rapidly become involved in the 

 process, just as are involved the sensitive glands of generation. 



Schlesinger assumes in acromegaly not only the occurrence of a true 

 pancreatic diabetes but also of a brain-tumor diabetes. Lorand is of the 

 opinion that the glycosuria of acromegaly is thyrogenic as a result of the 

 relationship of the hypophysis to the thyroid gland. The views may be 

 very well true for a part of the cases, namely, that part in which distinct mani- 

 festations of the hyperthyrosis are present. How shall we explain, however, 

 the inclination of alimentary glycosuria or even a spontaneous glycosuria 

 in these cases in which, as in case Ti (Observation XXV) the hyperthyrosis 

 is entirely absent, quite apart from the cases with severe diabetes or diabetes 

 leading to coma? Naunyn and later Borchardt regard the diabetes in acro- 

 megaly as directly hypophysial, that is brought about through the production 

 of an agent that induces glycosuria. The view seems to me to have a 

 certain support in the repeatedly mentioned investigations of Bernstein and 

 myself. I have previously stated in detail that the glandular extract some- 

 how seems to enter in the regulation of the carbohydrate metabolism, but 

 I am not in the position to say anything exact about this action. We are 

 thus evidently guided by opinions, and I would like to be understood as 



