562 DISEASES OF THE INSULAR APPARATUS OF THE PANCREAS 



ous manifestations are strongly in the foreground from the beginning. Be- 

 fore everything is the psychic factor, that under circumstances dominates 

 the elimination of sugar from the beginning up to even years, or at least 

 influences it to a marked degree. Especially accentuated does the nervous 

 factor enter into certain psychoses, into traumatic neuroses, into severe 

 attacks of pain, etc. But this can be the case in even uncomplicated cases of 

 human diabetes. In such cases it would perhaps be possible to demonstrate 

 regularly a hyperexcitability of a certain part of the sympathetic system; 

 especially does the glycosuric action of adrenalin always seem in such cases 

 to be distinctly present, indeed under circumstances the entire complex of 

 adrenalin action (vascular and cardiac manifestations, etc.), seems to be very 

 decidedly pronounced. There are all the transitions between this and hyper- 

 tonic diabetes, in which in addition to the hyperexcitability of the sympathetic 

 nervous system, there also occur conditions of permanent hyperexcitability. 



In the much more frequent second type the alimentary factor is in the fore- 

 ground from the beginning. It governs the intensity of the elimination of 

 the sugar, whereas psychical factors have no distinct influence on this. 

 Especially are there no manifestations of hyperexcitability of the sympathetic 

 system, especially that apparatus which has to do with the regulation of 

 sugar metabolism. In the later stages of this type, when it has developed 

 to severe diabetes, there occur a series of symptoms that point to a hyper- 

 excitability of the sympathetic system. Then adrenalin can make the 

 glycosuria distinctly more intense or, if the patient has been rendered sugar- 

 free, may call forth glycosuria. Further there then begins an especial 

 sensitiveness of the renal vessels, in that adrenalin, or similar agents, like 

 pituitrin, then act diuretically. Finally there now shows itself the note- 

 worthy phenomenon that long continued administration of thyroidin raises 

 the blood-pressure, without eliciting any stronger manifestations of hyper- 

 thyroidism than when it is used in non-diabetic individuals. This phenome- 

 non seems to indicate an especial lability of the sympathetic nervous system. 

 To this is added in severe diabetes the known erethism of the vessels, the 

 genesis of which is hard to account for; finally I would like to point out a 

 symptom that seems to me to belong at this place; it is the extraordinary 

 richness in blood of the liver, which we see, as already Klebs mentioned, 

 in the individuals dead from severe diabetes. 



All these manifestations are common to the later stages of both types; 

 I would believe that they are more markedly pronounced in the later stages 

 of the first type. Yet for the corroboration of this is necessary a greater 

 material than has been observed up to the present. 



Let us now investigate how far the pathologico-anatomical findings suffice 

 to explain the clinical observations. No doubt there are cases with gross 

 anatomical disturbances of the pancreas and especially of the insular appara- 

 tus, that without anything else explain a severe disturbance of function of the 



