THEORETICAL CONCLUSIVE CONSIDERATIONS 563 



same. Such cases rightly deserve the name pancrcatogenic diabetes. There 

 are further described in detail cases of alterations of the central nervous sys- 

 tem, whose seat makes appear intelligible long continuing irritative mani- 

 festations on the part of the sympathetic centers, which have to do with the 

 regulation of metabolism, or perhaps on the part of the paths that bind these 

 with the chromamn tissue. It is doubtful whether a permanent diabetes 

 may become manifest through such gross anatomical disturbances. In 

 addition there exists' a great many cases in which nothing certain is found in 

 the nervous system and the insular apparatus shows only relatively slight 

 alterations. If we accept the viewpoint of Weichselbaum, however, it seems 

 to me that up to the present there has been in such cases an insufficient agree- 

 ment between the pathologico-anatomical findings and the intensity and 

 acuteness of the clinical manifestations. Especially would this hold true for 

 the juvenile uncontrollably progressive cases of diabetes mellitus. In such 

 cases there lies close the thought of a congenital weakness in the rudiment 

 [Anlage] of the insular apparatus, whereby the hereditary and familial occur- 

 rence may become more intelligible. We can also suppose that in such 

 individuals various deleterious influences infections and intoxications, 

 etc. find a locus resistentiae minoris and damage the insular apparatus; 

 and we can further suppose that the same alterations of the insular apparatus 

 may recuperate, especially if by reason of a corresponding dietetic treatment 

 or prophylaxis the damaged organ is given time and rest for recovery. 



It appears, however, that through these means of consideration alone the 

 problem of human diabetes will not become solved. The nervous factor that, 

 as clinical observation teaches, often occupies the foreground, assigns to the 

 nervous system a much more important role. A disturbance of the regulation 

 of sugar metabolism through the central nervous system is especially to be 

 thought of in two directions. Either the activity of the insular apparatus 

 may be deficient thereby, so that the nervous impulses necessary for a normal 

 function are too weak an insufficiency on a nervous basis, such as we know 

 in the glands with an external secretion in achylia gastrica, for instance. It 

 appears to me, however, that according to that which I have previously set 

 forth concerning the nervous type, this assumption has little a priori to 

 recommend it. Or in the metabolism of sugar there may be an increase in 

 catabolism through an enormous excitation of those centers which regulate 

 the activity of the chromaffin tissue. We can designate this type, then, as 

 nervous or adrenalinogenic. I would only point out especially that in this 

 type the insular apparatus is entirely intact. That such an excitation of the 

 nervous centers leads to a continuous and strong glycosuria, brings into relief 

 a certain weakness of the insular apparatus. In individuals with completely 

 normal pancreas, such excitations as increase the catabolic processes are 

 neutralized by the corresponding counter-regulations. The difficult feature 

 of the question seems much more to lie in the fact that in the nervous type 



