USA > Ohio > Hancock County > Findlay > Twentieth Century History of Findlay and Hancock County, Ohio, and Representative Citizens > Part 116
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childhood. These individuals were naturally very heavy, bu: - nevertheless the tolerance in terms of body weight was abore normal. In the first case it was 2.2 gms. per kilo; in the second and third it could not be established, but was shown to be something over 2.6 gms. per kilo.
CASE VIII .- No. 26068. June 8, 1910. (Acromegaly.) Male, aged 42, weight 90 kilos (200 lbs.).
June 9, 10 and 11 .- Glucose in 100 gm., 150 gm. and 175 gz. doses respectively gave no glycosuria.
June 13 .- Glucose 200 gms. gave a positive reduction of 0.4 per cent by the polariscope.
CASE IX .- No. 27045. December 10, 1910. (Acromegalic giant.) Male, aged 35, weight 116 kilos (257 lbs.), height 197 cm. (6 ft 6 in.)
December 12 .- Glucose 200 gms. negative.
December 14 .- Glucose 200 gms. with 0.2 gm. ant. lobe ext. sub cutaneously, negative.
December 15 .- Glucose 300 gms. with 0.4 gm. ant, lobe ext. sub- cutaneously, negative.
December 16, et seq. Patient unable to retain amounts over 30) gms. Tolerance not established. Lævulose not tried. An increase of five pounds in weight during the 5 days of sugar feeding.
CASE X .- No. 25947. May 15, 1910. (Gigantism.) Male, aged 3%, weight 134 kilos (276 lbs.), height estimated at 7 ft. 6 in.
May 20, 23, 28 and 30 .- Glucose 100 gms., 200 gms., 275 gms. and 300 gms. respectively gave no glycosuria. Subsequent trials with amounts over 300 gms. were vomited. Actual assimilation limit for glucose not reached. Lævulose not tried.
June 12 .- Glucose 175 gms. with 0.1 gm. post. lobe ext. suber- taneously gave no reduction.
June 13 .- Glucose 250 gms. with 0.1 gm. post. lobe ext. subcu- taneously gave no reduction.
Further tests omitted owing to discomfort from the injections.
These 10 examples, therefore, of outspoken acromegaly of gigantism, representing conditions which we attribute 0) primary anterior lobe hyperplasias, have shown gradations ir. tolerance varying from something below 100 gms. of ingesta! glucose to amounts possibly far in excess of 400 gms. Ha2 we been fortunate enough to have observed a patient in the very early stage to which, presumably, spontaneous glycosuria is largely confined, the series, from the standpoint of sugar tolerance, would have been complete. Assuming as we do a: present that the disturbed limits for sugar assimilation ane associated in large part, if not solely, with posterior lobe lesions, it is conceivable that the malady might run its course without seriously disturbing the carbohydrate tolerance-in other words, without inciting the primary increase and sub- sequent decline of posterior lobe activity.
Step by step with the acquired increase of sugar tolerance shown by these patients, other symptoms which we attribute to deficiency of glandular activity become more or less promi- nent-general weakness and drowsiness, a subnormal tempera- ture, a low blood pressure, amenorrhoea or impotence. and. above all, the adiposity already commented upon. The a- quired power of storing carbohydrates is, in other words. merely one of many clinical manifestations of glandular (posterior lobe) insufficiency, but it furnishes a clinical test by means of which it is possible to estimate in a measure the stage at which the malady has arrived, and it may therefore
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Tolerance in States of Primary Hypopituitarism .- Of more nterest than the foregoing group of cases are those in which there has been from the outset a deficiency of posterior lobe ictivity. They are of greater moment also, for they have been videly overlooked. In their most striking form these various conditions of hypopituitarism are brought about (1) by direct pressure upon the infundibular stalk by interpeduncular umors, often having a congenital anlage; (2) by direct in- 'olvement of the posterior lobe in a growth originating in the fland itself, or (3) by the distant effect of a tumor causing an obstructive hydrocephalus and thus damming back the fluid nedium carrying the posterior lobe secretion.10
As the following data abstracted from our case histories will show, we have had numerous opportunities for testing he sugar tolerance of patients afflicted with the lesions com- rised in the first two of these three subdivisions. The same ymptoms of hypopituitarism that we have recounted above as occurring late in acromegaly, under these circumstances ap- ear as the primary manifestations of the malady-adiposity being one of the most striking features. The presence of an nterpeduncular or pituitary tumor in many of these 11 cases o be recorded was certified by operation or autopsy or else by he existence of definite neighborhood symptoms which, aided y the X-ray rendered the diagnosis beyond dispute.
Only one of these patients showed a subnormal assimilation imit. This was a mixed case in which a large infundibular umor was associated with suggestive acromegalic changes in he bones of the hands, marked adiposity (the weight being 13 lbs.), and a low tolerance for ingested glucose, on a single est 100 gms. giving a positive glycosuria. The condition was ne for which no adequate explanation offered itself, except n the basis of an overactive anterior lobe combined with an nderactive posterior lobe. At autopsy a year later the gland, hough intact, was found to be somewhat compressed by the rowth, which had greatly elongated the stalk and had doubt- 'ss obstructed the posterior lobe secretion.
The typical cases of primary hypophyseal tumor showing no 'ace of acromegaly which have occurred in our series and hich have had their sugar tolerance estimated are as fol- ws. In the first two cases the tolerance for ingested glucose one was determined. Both were patients with pronounced ighborhood symptoms. The assimilation limit of 400 gms. the second case was particularly high, in view of the body eight, namely 5.7 gms. per kilo.
" These matters have been fully discussed by one of us in a de- iled description, as yet unpublished, of the clinical aspects of ese states (Cushing: Clinical aspects of dyspituitarism. Lec- re before the Harvey Society, New York, December, 1910).
It has been found by Cushing and Jacobson that the cerebro- inal fluid, particularly in cases of obstructive hydrocephalus, s the same power in reducing the assimilation limit of the dog d rabbit that is possessed by the extract of the posterior lobe elf, another indication, in addition to these recorded by Cush- and Goetsch, that the cerebrospinal fluid is the medium which tries the products of posterior lobe secretion.
noma.") Male, aged 36, weight 88 kilos (195 lbs.).
April 26 .- Glucose 100 gms. negative.
April 27 .- Glucose 200 gms. positive; 1.2 per cent dext. rotatory. April 29 .- Glucose 100 gms. with 0.1 gm. post. lobe ext. gave gly- cosuria.
May 1. Operation .- Partial tumor extirpation. Subsequent in- crease in weight.
May 23, June 4. June 5, June 7, June 8 .- Glucose in doses of 100 gms., 150 gms., 175 gms., 200 gms. and 225 gms. respectively gave no glycosuria. Larger doses were not retained by the stomach, so that the ultimate tolerance was only roughly estimated at some- thing over 2.6 gms. glucose per kilo of body weight.
CASE XII .- No. 26634. September 26. 1910. (Hypophyseal tumor.) Male, aged 32, weight 70 kilos (157 lbs.).
September 29, 30 and October 1 .- Glucose in 200, 300 and 400 gm. amounts retained. No glycosuria.
October 6 .- 0.1 gm. post. lobe injection without sugar feeding gave no glycosuria.
October 7 .- 0.2 gm. post. lobe injection without sugar feeding gave no glycosuria.
October 11. Operation .- Sellar decompression. No post-opera- tive glycosuria. No further feedings.
In the following case sugar was well taken and it was possi- ble to make comparative tests of the tolerance for ingested glucose and lævulose, it being shown that the assimilation limit for glucose was by weight of sugar about twice that for lævulose. The tolerance for glucose was 4.9 gms. per kilo of body weight; for lævulose it was 2.3 gms. per kilo. A gain of 5 lbs. in weight occurred during the sugar feeding. The case is important also in that it was the first of our series in which a definite therapeutic dosage for ingested extract was estab- lished on the basis of giving enough gland to produce a tran- sient lævulosuria, with an amount of lævulose which would have represented the assimilation limit of a normal individual of an equal body weight. This was about 30 gms. below her estimated limit.
CASE XIII .- No. 27619. April 12, 1911. (Hypophyseal " ade- noma.") Female, aged 30, weight 71 kilos (158 1bs.).
April 13 .- Lævulose 150 gms. gave a suggestive reduction.
April 14 and 15 .- Glucose in 200 and 250 gm. doses was negative. April 16 .- Glucose 300 gms. gave a suspicious reduction.
April 18 .- Glucose 350 gms. positive. Estimated limit 325.
April 19 .- Lævulose 160 gms. positive. Estimated limit 150.
April 20. Operation .- Removal of a large portion of the tumor (or hyperplastic gland) by the usual infralabial approach. Good recovery.
May 3 .- Treatment with whole gland feeding instituted in 0.2 gm. doses three times a day. Marked subjective improvement. No spontaneous glycosuria.
To determine a more accurate basis for the glandular therapy the following tests were made with increasing amounts of gland- ular extract ingested while the sugar amounts remained stationary.
May 10 .- Lævulose 120 gms. with 0.6 gm. of whole gland extract divided in three doses during the day. No reducing substance in urine.
May 11 .- Lævulose 120 gms. with 1.2 gm. divided in three doses during the day. Positive reduction in specimen on evening of this day. Positive Seliwanoff test for lævulose. Estimated therapeutic dosage, therefore, 0.4 gm. of the whole gland extract three times a day.
Judging from the estimates given by the preceding record on the lævulose basis alone, the three following cases show an
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enormous increase in the assimilation limit for sugars-in Case XIV 200 gms., or 2.8 gms. per kilo; in Case XV 300 gms., or 4.3 gms. per kilo, and in Case XVI also 4.3 gms. per kilo. If we are to multiply these figures for weight of in- gested lævulose by two, the amount of glucose necessary to reach the limit of tolerance would in many cases easily ex- ceed the individual's capacity of its retention.
CASE XIV .- No. 27419. March 13, 1911. (Hypophyseal “ ade- noma.") Female, aged 34, weight 72 kilos (160 lbs.).
March 14 .- Lævulose 150 gms., atypical reduction.
March 15 .- Lævulose 200 gms., a slight but definite reduction. Estimated limit.
CASE XV .- No. 27156. January 1, 1911. (Infundibular tumor.) Female, aged 40, weight 69 kilos (154 lbs.).
January 3 and 4 .- Lævulose 100 gms. and 200 gms., both nega- tive.
January 5 .- Lævulose 300 gms. gave a slight reduction on the third specimen. Established limit.
CASE XVI .- No. 26250. July 16, 1910. (Hypophyseal tumor.) Male, aged 27, weight 69.7 kilos (155 lbs.).
July 18, 19, 20, 22 .- Glucose in increasing doses of 150, 200, 250 and 300 gms. caused no glycosuria. An increase in weight of 1.6 kilos (3.5 lbs.) occurred during these feedings.
July 24 .- Glucose 350 gms. vomited.
July 26 .- Glucose 200 gms. with 0.1 gm. post. lobe ext. gave glycosuria with 0.4 per cent dext. rotation.
August 3. Operation .- Sellar decompression.
August 23 .- Glucose 200 gms. negative.
August 25 .- Glucose 300 gms. positive, a post-operative lowering of the limit, presumably from liberation of post. lobe from pres- sure. Tolerance for ingested glucose estimated at 4.3 gms. per kilo.
April 20, 1911 .- Returned for observation, with an advance in adiposity, etc.
April 21, 26, 28 .- Lævulose in 150, 160 and 200 gm. doses gave no reduction.
April 29 .- Lævulose 250 gms. gave a slight reduction in the first specimen.
May 5 .- Lævulose 250 gms. gave an atypical reduction.
May 6 .- Lævulose 300 gms. gave a positive lævulosuria by Seliwanoff's test. (Compare Case XXI.)
There remain in this series of patients subjected to the sugar tests several in whom the symptoms of glandular in- sufficiency were equally outspoken, though the neighborhood pressure disturbances were relatively insignificant. Altera- tions in the sella turcica, however, were present in many of them. Thus in Cases XVI and XVII, the latter a typical in- stance of Fröhlich's syndrome, the glandular fossa was ex- ceedingly small. That a condition of glandular insufficiency need not depend upon the presence of a tumor needs no com- ment. Indeed in all probability a primary glandular hypo- plasia is just as common a starting point for hypopituitarism as it is for hypothyroidism and the clinical states arising from disturbances of one or the other of these glands are in all probability equally frequent.
In the following case, as in Case XIII, sugar was well borne so that comparative estimates for lævulose and glucose could be roughly established at 4.7 gms. of glucose per kilo. and 2.9 gins. of lævulose per kilo.
CASE XVI .- No. 27140. December 29, 1910. (Sexual infantilism with painful adiposity.) Female, aged 23, weight 59 kilos (13) lbs.)
December 30 .- Glucose 200 gms. negative.
January 1, 1911 .- Glucose 300 gms., slight reduction. Estino- ted limit 280.
July 12 .- Lævulose 150 gms. negative.
July 15 .- Lævulose 200 gms. positive. Estimated limit 175.
The next case was a typical example of infantilism of the typus Fröhlich. The assimilation limit for lævulose was 150 gms., or 2.8 gms. per kilo.
CASE XVII .- No. 27421. November 13, 1910. ("Dystrophia adiposo genitalis.") Male, aged 9, weight 54 kilos (120 1bs.). November 12 .- Levulose 100 gms., negative.
November 15 .- Lævulose 150 gms., positive on first specimen. Established limit.
The two succeeding cases are similar ones, with adiposity and amenorrhoea. The first patient showed definite neigh- borhood symptoms and was epileptic. Her tolerance for glu- cose was about 200 gms., 3.3 gms. per kilo. The second pa- tient assimilated glucose up to 275 gms., 2.7 gms. per kilo.
CASE XVIII .- No. 25715. April 4, 1910. (Hypophyseal adiposity with infantilism.) Female, aged 14, weight 61 kilos (136 lbs.).
April 6, 11, and May 6 .- Glucose in 50, 100 and 150 gm. amounts was negative.
May 9 .- Glucose 200 gms. positive, 0.4 per cent dext. rotation. Established limit.
May 14 .- Glucose 100 gms. with 0.1 gm. post. lobe ext., negative. May 17 .- Glucose 150 gms. with 0.1 gm. post. lobe ext., negative May 23 .- Glucose 175 gms. negative.
May 28 .- Glucose 175 gms. with 0.1 gm. post. lobe ext. positive, 0.6 per cent dext. rotation.
CASE XIX .- No. 25694. March 31, 1910. (Hypophysea] adi- posity.) Female, aged 15, weight 103 kilos (230 lbs.).
April 8, 15, 20, 29 .- Glucose in amounts of 50, 100, 150 and 200 gms. was negative.
June 4, 5 .- Glucose 225 gms. and 250 gms. respectively, nega- tive.
June 6 .- Glucose 275 gms. not retained.
June 7 .- Glucose 275 gms. retained and gave glycosuria, 0.6 per cent. dext. rotation. Established limit.
June 10 .- Glucose 200 gms. with 0.1 gm. post. lobe ext., negative
Both of the following patients would have been regarded as typical instances of "adiposis dolorosa " with amenorrhea, and their association with a pituitary lesion might have been overlooked had it not been for the fact that both showed defi- nite symptoms-an early hemianopsia in one case and an en- larged sella, with pituitary headaches, in the other. Both showed a high tolerance, which, however, is less striking in relation to the body weight, owing to the extreme adiposity. In the first case the tolerance for glucose at 400 gms. repre .. sented a little over 3 gms. per kilo.
CASE XX .- Surgical No. 26679. October 4, 1910. (" Adiposis dolorosa " with neighborhood symptoms.) Female, aged 55, weight 123 kilos (273 lbs.).
October 25. Operation .- Sellar decompression. November 1 .- Hypophyseal therapy (9 grains daily of the whole gland extract) caused polyuria. November 12 .- Glucose 300 gms. negative.
November 14 .- Glucose 400 gms., faint reduction. Limit.
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uwvut Aro gis., or 3.4 gms. per kilo. On readmission six months later there had been an increase in weight and a marked advance in the assimilation limit for glucose beyond the patient's capability to retain it. Her assimilation limit for lævulose had come to exceed the former limit for glucose by weight of sugar, namely, about 320 gms., or 3.6 gms. per kilo of existing body weight. (Compare Case XVI.)
CASE XXI .- No. 26225. July 10, 1910. (Hypophyseal adiposity.) Female, aged 24. Weight 81 kilos (181 lbs.).
July 10 .- Glucose 150 gms. negative.
July 11 .- Glucose 250 gms. atypical reduction.
July 13 .- Glucose 300 gms. not retained.
July 14 .- Glucose 300 gms. retained. Urine showed heavy re- duction (not polarized). Estimated limit 275.
January 11, 1911. Readmission .- Gain in weight of 6.7 kilo. Glucose not retained in early tests.
January 22 and 23 .- Lævulose 10 and 200 gms. negative.
January 24 .- Lævulose 300 gms. gave an atypical reduction after
9 hours. Estimated limit 320. -
January 28 .- Lævulose 200 gms. with 0.4 gm. post. lobe ext. gave a positive reduction with Fehling's.
Summary of Clinical Data .- These bare records of the car- bohydrate tolerance as it has been observed in the clinical cases of dyspituitarism suffice to show a striking parallelism with the protocols which we have given of the experimentally induced states of hypophyseal insufficiency. Their similarity is at all events enough to justify the assumption that here too we are dealing with a condition of altered activity of the pos- terior lobe.
Under both circumstances, apparently regardless of the in- fluence of the pars anterior, the acquirement of a high car- bohydrate assimilation limit goes hand in hand with other features which we are inclined to attribute to posterior lobe in- sufficiency and which appear to indicate a lowering of me- tabolic activity-notably a subnormal temperature, a dry skin, a low blood pressure, a large appetite (especially for carbohy- drates), and marked deposition of fat throughout the body.
In these conditions then of primary or secondary involve- ment of the hypophysis, interfering with the normal produc- tion of glandular secretion and producing, among other things, a marked rise of the carbohydrate tolerance, glandular therapy should be instituted, perhaps taking the tolerance as an index for the amount of glandular extract to be given.
We are merely on the threshold of these carbohydrate studies n clinical cases, and fully recognize that the observations have ›een crudely made. They will necessitate quantitative deter- ninations and better methods both of sugar administration end of giving the extracts. The latter problem is particularly mportant, if we are to advance the therapy of these condi- ions at least to the point where thyroid therapy now stands.11
GLANDS IN GENERAL AND TO THE HYPOPHYSIS IN PAR- TICULAR.
Glycosuria in its relation to lesions of the central nervous system received abundant attention after the first impulse given to the subject by Claude Bernard's discovery. The ex- act location, however, of his so-called sugar center seems never to have been precisely determined, and we have experimental evidence that glycosuria may likewise be produced by a piqure or other injury of the brain stem anterior to the medulla.
On the clinical side it was noted by several of the earlier writers that glycosuria was not infrequent in cases of basal brain tumor. Curiously enough, however, this proved to be more true of growths situated in the interpeduncular neigh- borhood than of those involving the hind-brain. Indeed Loeb " pointed out that it was actually a more frequent mani- festation of tumors in the region of the hypophysis than of those supposedly in the neighborhood of Bernard's "center "; and more recently Stern and Josefson, to quote from Messe- daglia," have shown that clinical mellituria has been the ex- ception (3 cases only) in the 36 reported cases of cysticercus of the fourth ventricle.
In explanation of the occurrence of diabetes with certain hypophyseal tumors Rath " in 1888 offered the suggestion that alterations might have taken place in the composition of the cerebrospinal fluid which caused it to act as an irritant upon the nervous structures-an interesting assumption, in view of our recent demonstration that the posterior lobe actually discharges its secretion into the cerebrospinal fluid. Others as Pineles 15 and Strumpel 1 explained the condition as
was given sugar in this amount on consecutive days. Meanwhile the amount of extract was increased until a positive transient mellituria followed the sugar administration. This established the amount of extract at 0.4 gm. (6 grains) three times a day as the therapeutic dose. It is to be noted that we are here speaking of "whole gland " feeding with the realization that it is the pos- terior lobe extract which the preparation contains that is the essential element. Though we have worked with isolated pos- terior lobe preparations in the experiments in the laboratory, they are as yet too expensive for prolonged administration such as these individuals need.
12 M. Loeb. Hypophysis Cerebri and Diabetes Mellitus. Cen- tralbl. f. innere Med., 1898, XIX, p. 893.
13 Messedaglia. Lesioni dell' ipofisi e glicosuria. (Reprint.) Reviste Sintetiche, Milan, No. 30, 1903.
14 Rath: Ein Beitrag zur Kasuistik der Hypophysistumoren. Inaug. Diss. Göttingen, 1888.
15 Pineles. Ueber die Beziehung der Akromegalie zum Diabetes Mellitus. Jahrb. d. Weiner k. k. Krankenanst., 1895, IV, Part II, p. 27.
" Strümpel. Ein Beitrag zur Pathologie und pathologischen Anatomie der Akromegalie. Deutsche Ztschr. f. Nervenheilk., 1897, XI, p. 51. In his interesting detailed report of a case Strümpel makes the following deduction: "Den Hypophysistu- mor als Ursache der Glycosurie anzunehmen, ist unmöglich, da Hypophsistumoren auch ohne Glykosurie vorkommen." A simi- lar deduction has misled others into the statement that because tumors of the hypophysis are found without acromegaly there- fore this malady cannot be attributed to the tumors which have been found present in certain cases.
" In this connection the observation in Case XIII is particularly worthy of note, as giving some lead as to the dosage essential to he individual case on the basis of the carbohydrate tolerance. he patient weighed 71 kilos and showed an overtolerance for evulose, the limit being estimated at 150 gms. Judging that her ormal tolerance for lævulose would have been about 120 gms. she
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possible only on the basis of a concomitant pancreatic lesion, and still others hypothecated the existence of centers, other than that of Bernard's, which presided over the glycogenic function. Such centers were postulated for the pons, for the optic thalamus, the cerebellar and cerebral peduncles, and finally Loeb offered the interesting suggestion, which was sup- ported by Caselli and accepted by a number of subsequent writers, that the tuber cinereum (the cortical tissue around and including the infundibulum) might be a sugar center.
In more recent years a furtherance of our knowledge of these glycosurias of supposedly encephalic origin has come about indirectly through the many investigations upon the rôle played in carbohydrate assimilation by the functional activity of the various glands of internal secretion.17
The relationship of the pancreatic islets to the more com- mon and more persistent forms of clinical diabetes was clearly shown by the important studies of Opie and others, but only of late has the attention which they deserve been given to other ductless glands in so far as their activities influence carbohydrate metabolism. It has become evident that all of the glands, either by their primary action or through interre- lation with other members of the series, play a part in sugar metabolism. It is known, for example, that experimentally induced thyroid insufficiency leads to an increased tolerance for sugars," while the studies of Eppinger, Falta and Rudin- ger " have indicated that removal of the parathyroid bodies has a contrary effect, namely, a lowering of the carbohydrate assimilation limit. Furthermore, experimental hyperglycæ- mia and glycosuria have been produced by injections of epine- phrin, which apparently exercises its influence through the splanchnic control of the glycogenic function of the liver.20
Clinical corroboration of these laboratory findings have been many. Thus the carbohydrate tolerance in hypothyroidism (myxœdema) has been found in many clinical cases to be high and, contrariwise, in hyperthyroidism-a condition which as yet has not been experimentally reproduced-it is known that the assimilation limit is below the normal. In- deed, in extreme grades of exophthalmic goitre spontaneous glycosuria may occur, and it has been observed that the ad- ministration of thyroid extract in adequate dosage may pre- cipitate an actual glycosuria in the patients with exophthal- mic goitre in whom it does not spontaneously occur.21
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