THEORETICAL CONCLUSIVE CONSIDERATIONS 565 



has been said: In experimental pancreatic diabetes, only the pancreas is absent, 

 all the rest of the manifestations are secondary; in genuine human diabetes there 

 exists, however, a disease of the whole apparatus regulating sugar metabolism 

 (nervous centers in the medulla and brain stem, connecting paths, pancreas, and 

 chromaffin tissue} with insufficiency, but not complete absence, of one part and 

 more or less independent hyper excitability in the other part. 



Through this view, which has been the product of v. Noorden's clinic in 

 recent years, the problem of the pathogenesis of diabetes mellitus has been 

 broadened, but the solution of it seems only to have been thrust back one 

 step further. 



As far as the other glands are concerned in the bringing about of diabetic 

 glycosuria, we may off-hand ascribe with certainty an important role in this 

 direction to only two other glands, the thyroid and the hypophysis. There 

 exists, however, but littler clearness in which way these ductless glands enter 

 into the regulative mechanism of sugar metabolism, and whether they exer- 

 cise this influence chiefly or exclusively by way of the pancreas. In the chap- 

 ter on Basedow's disease we found that hyperthyroidism was not rarely 

 associated with a reduction of the assimilation limits for carbohydrates; in- 

 deed, under circumstances, it could lead to spontaneous glycosuria. The 

 circumstance that the alimentary factor is so prominent in these cases, 

 speaks for the fact that through the hyperthyroidism there is called forth an 

 insufficiency of the pancreas; further, the circumstance that with the suppres- 

 sion of the hyperthyroidism the glycosuria again disappears and eventually 

 there come about normal relations, shows that this insufficiency is actually the 

 result of hyperthyroidism. It appears therefore as has already been amplified 

 in the chapter on Basedow's disease, that hyperthyroidism seems to signify a 

 functional overloading of the pancreas; it is intelligible, from this standpoint, 

 that glycosuria sets in only in individuals predisposed to it. As without such 

 a functional overloading glycosuria would never occur, we are well justified 

 in speaking of a thyrogenic glycosuria in such cases. This also is mostly 

 easily delimited from true diabetes complicated with Basedow's disease. 



As far as the diabetic glycosurias that occur so frequently in acromegaly 

 and gigantism are concerned, it has already been set forth in the correspond- 

 ing chapter that there is present in the great majority of cases an organic 

 disease of the insular apparatus. It was mentioned there that in all conditions 

 of hyperfunction of the glandular hypophysis a period of an abnormal tend- 

 ency to growth is followed by a period of decay, and that the entrance of this 

 decline is different in the various organs and especially so in the various duct- 

 less glands. The insular apparatus appears to be especially sensitive. Be- 

 sides these true diabetic glycosurias there is present in rare cases of acromegaly 

 a similar condition to that observed in true thyrogenic glycosurias; in these 

 cases right at the beginning of the disease there develops a glycosuria, which 

 later disappears and gives place to a normal assimilative ability. Whether 



