The Banting Memorial Lecture 1975

Diabetes and the Alpha Cell

Roger H. linger, M.D., Dallas, Texas

It is appropriate that glucagon should be the subject of a Banting Memorial Lecture, in that Banting
and Best were probably the first to observe the
biologic action of glucagon. In a letter written in
1971 to Dr. Piero Foa, long a leader in the glucagon
field, Dr. Best reminisced about the historic 1921
experiments in which crude pancreatic extracts were
injected into depancreatized dogs. 1 He wrote, "I have
a very clear recollection of the immediate rise in blood
sugar to about 5 to 10 mg.%. This lasted about Vi
hour. As you may know, we thought this might have
been due to epinephrine liberation and, for this
reason, we failed to investigate it thoroughly."
An explanation for their oversight is not necessary.
At that historic moment in medical history, they
could hardly have been expected to concern themselves with the initial upward deflection of the blood
sugar curve when their goal, the discovery of insulin,
was in clear view. However, one year later, Murlin
and Kimball reported that aqueous extracts of pancreas raised blood sugar levels of depancreatized dogs
by 200 mg./lOO ml. or more. 2 They believed that this
was due to a glucoregulatory hormone they named
"glucagon," meaning "glucose-driving."
But, for most of the half century since its discovery,
glucagon was regarded either as a hormone of trivial
importance or as a "nonhormone," an artifact of the
extraction procedure for insulin. The possibility that
it might play a role in human disease was not considered seriously. Ferner was one of the few who believed that glucagon was pathogenically involved in
the metabolic derangements of diabetes mellitus, and
he even proposed that the diabetes caused by total
pancreatectomy was the result of gastrointestinal
Presented at the Thirty-fifth Annual Meeting of the
American Diabetes Association in New York on June 16,
1975.
From the Department of Internal Medicine, Veterans Administration Hospital, and the University of Texas Southwestern
Medical School, Dallas, Texas.
Accepted for publication December 31, 1975.

136

glucagon, 3 but his remarkable ideas were based on

controversial morphologic evidence. The methodologic capabilities essential to test the role of
glucagonfirst, the ability to measure glucagon in
human plasma and, second, the ability to produce a
glucagon-deficiency statehad not yet been developed. Only within the past decade have both become available.
The ability to measure glucagon4 came as the first
"spin-off' of the monumental methodologic breakthrough of Berson and Yalow5 that reshaped biomedical science; that is, it was the second radioimmunoassay to be developed.
In 1957, Anne Eisentraut and I had begun challenging rabbits with glucagon in the hope of producing antibodies for a hemagglutination-inhibition immunoassay for glucagon. It became increasingly obvious that we were wasting our time when, by chance, I
reread the 1956 Berson-Yalow paper describing the
detection of insulin antibodies with 131 I-labeled
insulin. 6 It occurred to me that by labeling the
glucagon molecule with 131 I instead of with a red
blood cell, a far more sensitive and less capricious
immunoassay might result. I telephoned Dr. Berson,
then a total stranger, and explained to him the concept of the radioimmunoassay and its unlimited potential, not just for the assay of glucagon and insulin,
but for other peptide hormones as well. He listened
patiently and politely, but a lack of enthusiasm was
evident. However, he agreed to meet with me.
Some days later, in his office at the Bronx VA
Hospital, I learned the reason for his flat response. He
and Dr. Yalow had already developed a remarkably
sensitive and reproducible radioimmunoassay for insulin. I was elated by this evidence of their achievement
and asked if they would help me develop a similar
assay for glucagon. Dr. Berson advised me not to
waste my timethey had already tried it, and it did
not work because of inability to produce glucagon
antibodies. But, at my insistence, they were kind
enough to teach us the iodination and chromatoelecDIABETES, VOL. 2 5 , NO. 2

ROGER H. UNGER, M.D.

trophoresis technics with which we found that most of

our rabbits already had measurable glucagon antibodies. When I sent this good news to Dr. Berson, 1
received in reply the gracious letter reproduced in
figure 1.
VETERANS ADMINISTRATION
HOSPITAL
ISO WEST KINGSBRIOGC ROA
BRONX 68, NEW YORK

July 2I4, 1959

>5O81/172

Dr. Roger H. Ongor

VA Hospital
li500 S. Uncastor Road
Dallaa 16, Texas
Dew Dr. Unger:
Wo are delighted to hear of your success with the glucagon
antibody. Oar own results In guinea pigs turned out to be
spuriously optimistic. The material migrating with serun
proteins did not Migrate with the garni globulin but
represented damaged fractions. Oulnea pig serum^espedally srC
undilutedtappears to be a particular nuisance In this respect.
I-hope that you hare success on the assay for plasma
glucagon. We hare been doing a lot of work on the plasma
assay of insulin and enclose a manuscript which we submitted
some tine ago. As you probably appreciate^ the assay of plasma
lerels i s considerably more difficult than that of the concentrations of hormones which you can add In Titro. Should
you hare any difficulties we will be pleased to communicate
to you some problems which we encountered in the a*age44&en *2
of plasna insulin and sane of the tricks we hare used to
Increase sensitivity. We are able to assay as l i t t l e as
10 Micro-alcrograns of insulin (l/b \i unit) in plasma.
Rot joins e In sending you our best regards and wishes for
your continued success.
Sincerely yours,

wi K-

Solomon A. Berson, M.D.

Chief, Radioisotope Serrlce
SAB: 88
FIG. 1. A letter from Dr. Berson. (Reprinted with permission of
Metabolism.)

The generous help of Drs. Berson and Yalow were

important factors in the development of the glucagon
assay. As he had warned, the problems of measuring
hormone in plasma were formidable. Although we
published standard curves in 19594 and could measure
changes in endogenous glucagon in the pancreatic
venous effluent in 1961, thus permitting the first
physiologic studies in animals, 7 it was not until 1967
that we could measure glucagon with confidence in
the peripheral blood of animals and man8 and thus
test its physiologic and pathophysiologic roles.9
The second essential capability for the estimation of
glucagon's importance, namely, the production of a
glucagon-deficiency state, was also a spin-off of
another landmark achievementthe discovery,
FEBRUARY, L976

purification, and synthesis of somatostatin in 1973 by

Dr. Roger Guillemin and his colleagues, Drs.
Brazeau, Vale, Rivier, Burgus, and Ling at the Salk
Institute. 10 The unexpected finding by Koerker and
her associates in Seattle11 of dramatic suppression of
plasma glucagon during the infusion of somatostatin
in baboons identified, for the first time, a powerful
glucagon-suppressing agent.
Today, a vast array of data concerning the physiology and pathophysiology of glucagon has been generated by means of these methodologic tools. The fundamental knowledge of the relationships of glucagon
and insulin actions provided by the brilliant in-vitro
studies of Exton and Park 1 2 and of Sokal and
colleagues13 and the more recent in-vivo studies of
Vranic and colleagues14 and of Liljenquist, Chiasson,
Cherrington, Lacy, and Jennings et al., 1 5 has created
a substantial base upon which reasonable concepts of
the function and malfunction of the alpha-beta cell
unit can be constructed.
THE a- AND /3-CELL
AS A FUNCTIONAL UNIT
The idea of a single bihormonal metabolic regulator
was first expressed in 1907, at the very dawn of endocrinology, by M.A. Lane. 16 He reported that certain
islet cells contained alcohol-precipitable granules and
named them alpha cells and called the others beta
cells. He wrote: "One is led to the conviction that the
islets of Langerhans are structures which, in all probability, have a function of producing a two-fold substance which, when poured into the bloodstream, has
an important effect on metabolism." In the early
1950s, Ferner, 3 in Germany, also a morphologist, and
Pincus, 1 7 in the United States, stressed the antagonism of the secretory products of these adjacent
cells. Today, however, the counterbalancing and opposing biologic activities of glucagon and insulin
upon the liver and other common target tissues are
well established. The over-all effects of insulin are
TABLE 1
Demonstrated opposition on common targets: insulin vs. glucagon
Target Cell
Liver

Fat

Effect
Glycogenesis
Glycogenolysis
Glyconeogenesis
Ketogenesis
VLDL secretion
Lysosome formation
Lipolysis

Insulin
*

Glucagon

t
t
t
137

DIABETES AND THE ALPHA CELL

anabolic and promote the biosynthesis of large

molecules, such as glycogen, fat, and protein, while
those of glucagon are catabolic and promote the
breakdown of glycogen and fat into smaller energyyielding components and the use of amino acids for
gluconeogenesis at the expense of protein synthesis
(table 1).
GLUCOREGULATORY FUNCTIONS

The unique biologic opposition of the two hormones endow the alpha-beta cell unit with the ability
NORMAL BASAL
,_^_

GLUCAGON

INSULIN

ECF

4g/hr

LIVERlOg/hr

[GLUCOSE]
6g/hr

80 mg %

LIVER
* FAT
MUSCLE
- BRAIN

B
EXERCISE
|GLUCAGON

__

| INSULIN

MUSCLE
LIVER
BRAIN

to vary glucose flux in a manner physiologically appropriate to the prevailing circumstances while maintaining extracellular glucose concentrations within
remarkably narrow limits, irrespective of those circumstances. This concept is schematized in somewhat
oversimplified form in figure 2. Levine first demonstrated that insulin is the hormone of glucose efflux
from the extracellular space, 18 and although, as Madison showed, insulin also restrains glucose influx, 19
normally glucagon is the dominant regulator of glucose influx. Obviously, if extracellular fluid (ECF)
glucose concentration is to remain unchanged during
wide changes in glucose flux, glucose efflux and influx
must at all times remain approximately equal. This
critical balance appears to be in large part the result of
remarkably precise variation in the insulin-glucagon
mixture. During violent exercise, for example (figure
2B), efflux into muscle is markedly increased. Hypoglycemia is prevented by a proportionate increase in
glucose influx, partly because of a marked increase in
glucagon, and adequate glucose delivery to the central
nervous system thus maintained. Conversely, during a
meal, when exogenous glucose influx is increased (figure 2C), glucose efflux is increased proportionately to
prevent hyperglycemia through increased insulin secretion, glucose efflux rates often approaching the rate
of influx. Consequently, plasma glucose concentration
almost never exceeds 150 mg./lOO ml. in young normal subjects after even the largest carbohydrate meal.
Throughout the life of a normal, healthy individual, ECF glucose concentration is confined within
these narrow limits (figure 2), but whenever a critical
injury or other serious stress is sustained, ECF glucose
must increase promptly for the purpose of maintain-

STRESS
CARBOHYDRATE MEAL
{GLUCAGON

Adrenergic

flNSULIN

5^

[ LIVER

LIVER

ECF

MUSCLE

[ FAT
MEAL

50g/hr

6g/hr

* BRAIN

LIVER

[GLUCOSE]
BRAIN
200 mg %

FIG. 2 .

138

Schematization of the glucoregulatory function of the

alpha cell-beta cell couple in the normal basal state (A),
during extreme exercise (B), and during the influx of ingested glucose (C). The box labeled "ECF" represents the
extracellular-fluid-glucose space.

FIG. 3. Schematization of the glucoregulatory roles of the alpha

cell-beta cell during severe stress. The box labeled "ECF"
represents the extracellular-fluid-glucose space.
DIABETES, VOL. 2 5 , NO. 2

ROGER H. UNGER, M.D.

FIG. 4A.

Distribution of glucagon-producing cells in an islet of

Langerhans from an adult nondiabetic subject determined by the indirect immunofluorescent technic. (X
200)

ing cerebral glucose delivery in the face of a declining

cerebral blood flow (figure 3). To achieve stress
hyperglycemia, insulin secretion declines and
glucagon secretion increases, presumably by means of
adrenergic control of the islets, as the work of Porte et
al. 20 and of Frohman and his colleagues21 indicates,
and stress hyperglycemia continues as long as the
threat to cerebral fuel delivery persists.
The (X and (3 cells of this remarkable and vital
"organ of Langerhans" then serve the nutrient needs of
the far-flung tissues of the body, directing the storage
of nutrients when these are in abundance and retrieving them as required in time of famine, flight, fight,
or injury, always in perfect accord with the needs of
the moment. At all times, hyperglycemia and hypoglycemia, hyperketonemia, and unnecessary nitrogen
losses are successfully avoided.
THE a- AND 0-CELL
AS A STRUCTURAL UNIT
Lacy in this country 22 and Orci and his associates in
Geneva 23 have advanced our understanding of islet
structure and function relationships. At the optic
level, immunofluorescent staining of a human pancreas with specific antiglucagon serum reveals the distribution of a cells in the human islet (figure 4A).
Similar studies using antisomatostatin as well as antiFEBRUARY, 1976

FIG. 4B.

Islet of Langerhans in a chronic juvenile diabetic treated

with the indirect immunofluorescent technic against
glucagon. (X 500)

glucagon and anti-insulin sera reveal in man and in

the rat an outer heterocellular rim containing most of
the a and 5 cells, with the (3 cells in the central
region. 24 At the ultrastructural level Orci has examined intercellular relationships between islet cells.
He has observed junctional complexes of the nexus
type, so-called gap junctions, low-resistance pathways
of intercellular communication, connecting (3 and (3
cells, a and a cells, and (3 and a cells (figures 5 and
6). The same structures have been identified in the
human islet (figures 7 and 8).
Orci has searched for such intercellular communications between heterogeneous endocrine cells in the
anterior pituitary gland; thus far, the a and (3 cells of
the islets are the only endocrine cells with different
secretory products in which such intercellular communications have been observed.25 The possibility
that the islet cells may function as a synctitial network
would help to explain the remarkably precise titration
of the "twofold substance" imagined by Lane some 68
years ago to achieve the balance of glucose efflux and
influx.
Like insulin secretion, glucagon secretion also involves the process of exocytosis; as shown in figure 9,
glucagon granules are extruded into the intercellular
space, and in figure 10 a freeze etching of a Chinese
hamster a-cell provides a three-dimensional view of
such an event. 25
139

V?

.--A

-V

T(k

ROGER H. UNGER, M.D.

FIG. 5A, B.
(opposite
page)

Isolated islets from normal rat stained en bloc with uranyl acetate. The junction between an a- and a /3-cell present in the
framed area of figure 5A is shown at a higher magnification in figure 5B. In the encircled area, the outer leaflets of the
adjacent cell membranes undergo fusion, resulting in a pentalaminar structure, characteristic of a tight junction. (Figure 5A:
X 38,000, figure 5B: X 124,000) (Reprinted with permission of the J. Clin. Invest.)

FIG. 5C.
(opposite
page)

Pancreas treated with lanthanum hydroxide, which delineates the intercellular space in black. The area outlined by the
rectangle is shown at high magnification in the inset. At.places indicated by arrows, the intercellular space between an
a- and fi-ce\\ appears considerably narrowed (presumably a gap junction). (X 31,500; inset: X 102,000) (Reprinted with
permission of the J. Clin. Invest.)

EXTRAPANCREATIC a-CELLS

It is now clear that o:-cells are not confined to the

islets of Langerhans. In 1948, Sutherland and deDuve
reported the presence of glucagon-like biologic activity in the upper gastrointestinal tract of dogs,27 and
Ferner3 believed, on the basis of silver staining, that
he had identified a-cells in a distribution corresponding to that of Sutherland and deDuve's glucagon activity. In 1968, Orci, using electron microscopy, first
described "a-like cells" in the gastrointestinal tract of

FIG. 6A.

the rat.28 More recently, a-cells in the stomach and

duodenum have been carefully studied and found to be
indistinguishable immunohistochemically and ultrastructurally from pancreatic a-cells. Using a specific
antiserum for glucagon, glucagon-immunofluorescent
a-cells have been identified in the oxyntic mucosa of
the dog stomach, both at the optic and ultrastructural 29 levels, and glucagon-immunofluorescent cells have also been observed at the optic level in a human fundus30 (figure 11). Figure 12 reveals
the similarity of the human a-cell in the pancreas

Part of the periphery of an islet showing a poorly granulated /3-cell neighboring two well granulated a-cells. (X 13,000)
(Reprinted with permission of the J. Clin. Invest.)

FEBRUARY, 1976

141

DIABETES AND THE ALPHA CELL

*5

FIG. 6B. Freeze-etch replica of a similar area. The fracture process has split the plasma membrane between two cells
tentatively identified as 0- and a-cells on the basis of
their content in secretory granules. (X 25,000) (Reprinted with permission of they. Clin. Invest.)

FIG. 6C. Higher magnification of the framed area in figure 6B.

One can see the linear ridges of fibrils, characteristic of
tight junctions (TJ), and the aggregates of particles,
characteristic of gap junctions (arrows). (X 92,000) (Reprinted with permission of the /. Clin. Invest.)

and that of the duodenum, an observation reported

previously by Sasagawa et al. 3 1
Moreover, using extracts of hog duodenum provided by Prof. Viktor Mutt, of Karolinska Institute,
Stockholm, we have recently succeeded in separating
from the more abundant glucagon-like immunoreactivity or GLI of hog duodenum a material indistinguishable from pancreatic glucagon with respect to its
molecular weight, isoelectric point, immunometric
ratio, glycogenolytic activity, and binding affinity
and adenylate-cyclase-stimulating activity in isolated
rat liver membranes 3233 (table 2). GLI, by contrast,
differed in all these parameters. The identity of pancreatic and duodenal glucagon seems rather well established.

carbohydrate metabolismin contradistinction to the

traditional unihormonal-deficiency hypothesis, which
attributes all of the metabolic derangements of diabetes to hypofunction of the (3 cell. As shown in figure
13, the "double-trouble" concept ascribes the underutilization of glucose to insulin deficiency but attributes to glucagon excess, either absolute or relative to
the reduced insulin level, most of the glucose overproduction. McGarry and Foster have extended the
bihormonal-abnormality hypothesis to the area of
diabetic ketoacidosis by putting forth evidence that
ketoacidosis requires both an increase in free fatty
acids, the substrate for ketogenesis, and an additional
factor that converts the liver to a "ketogenic mode." 35
Insulin deficiency causes the marked increase in
lipolysis that provides the liver with ketogenic substrate, but it appears that glucagon is essential for the
conversion of the liver into a ketone-producing organ
(figure 14). Their findings are supported at the clinical level by the studies of Gerich et al. 3 6 and of Alberti and his colleagues 3 7 demonstrating that
somatostatin blockade of glucagon secretion can prevent ketoacidosis in insulin-deprived juvenile-type
diabetes.

"DOUBLE-TROUBLE" HYPOTHESIS OF DIABETES:

FUNCTIONAL CONSIDERATIONS

We have recently proposed the bihormonal abnormality hypothesis of the pathogenesis of the metabolic
derangements of diabetes. 34 This theory assigns to
pancreatic and/or extrapancreatic glucagon the role of
an essential comediator of the full-blown disorder in
142

DIABETES, VOL. 25, NO. 2

ROGER H. UNGER, M.D.

FIG. 7A.

The field shows the intercellular space () between a

FIG. 7B.
human insulin-producing cell (/3-cell) and a glucagonproducing cell (a-cell). The intercellular space is narrowed at several points in which the two cell membranes
come into very close vicinity (circles). These regions may
be the site of specialized intercellular junctions of the
tight or gap type. Their exact nature, however, cannot be
clearly determined with this technic. (X 42,000) (Reprinted with permission of the_/. Clin. Endocrinol. Metab.)

The concept of a bicellular abnormality has evolved

very gradually since 1969, when we first reported that
hyperglucagonemia was present in human diabetics, 38
particularly during meals 39 or arginine infusion.9
Assan, 40 Buchanan, 41 Felig, 42 Gerich, 43 Kalkhoff,44
and their associates have made similar observations.
We had also observed hyperglucagonemia in every
known form of experimental diabetes 45 with the exception of totally depancreatized dogs well regulated
with insulin. However, in 1973, Vranic, Pek, and
FEBRUARY, 1976

The freeze-fracture process has exposed a large area in

the plasma membrane of a human islet cell, the cytoplasm of which can be seen in the upper left corner. The
freeze-fractured membrane contains a network of variegated fibrils (TJ) that characterizes the tight junction,
The fibrils delimit various domains in the membrane ().
(X 26,000) (Reprinted with permission of they. Clin.
Endocrinol. Metab.)

Kawamori, 46 Matsuyama and Foa, 47 and Mashiter

and Field and associates48 made the key observation
that levels of circulating immunoreactive glucagon
were high in insulin-deprived depancreatized dogs,
which we subsequently confirmed32 (figure 15). This
meant that hyperglucagonemia was present in every
known form of endogenous hyperglycemia. Moreover,
when the rise in the plasma level of nonpancreatic
glucagon following pancreatectomy was blocked by
somatostatin (figure 16), hyperglycemia was markedly
143

DIABETES A N D THE ALPHA CELL

CLINICAL IMPLICATIONS OF THE

"DOUBLE-TROUBLE" HYPOTHESIS

FIG. 8.

Higher magnification of a freeze-fractured islet cell

plasma membrane. One recognizes the characteristic
network of fibrils of the tight junction (TJ). In addition,
localized domains in the network contain patches of
closely packed globular subunits representing gap junctions (GJ). (X 65,000) (Reprinted with permission of they.
Clin. Endocrinol. Metab.)

In both the adult and the juvenile types, the most

consistent and striking abnormality in a-cell function
is the relative or absolute hyperglucagonemia that occurs during the ingestion of meals or with the infusion
of arginine or alanine. Is this a-cell abnormality in the
inherited forms of human diabetes merely secondary
to insulin lack stemming from the /3-cell disorder, as
it must certainly be in experimental diabetes, or is
there an intrinsic a-cell defect that is independent of
and may, therefore, appear before, after, or simultaneous to the /3-cell abnormality? While there is no
doubt that in human diabetes, just as in the previously nondiabetic laboratory animal, insulin deficiency can cause hyperglucagonemia, the question
that is still unclear pertains to an a-cell defect independent of insulin lack in the diabetic patient. Indeed, when insulin lack is absent or corrected with
exogenous insulin an abnormality in diabetic a-cell
function seems to remain. For example, as shown in
table 3, in fasting human diabetics, glucagon levels
can be lowered significantly by intravenous insulin
infusion in amounts that raise plasma insulin to only
about 30 /u,U. per milliliter, but they do not decline to
the nadir to which glucagon levels of nondiabetics can
be suppressed with a comparable insulin level and

reduced, if not prevented. 3249 It was the finding in

such dogs of a relationship between plasma nonpancreatic glucagon and glucose rise 49 that led us to
propose that glucagon is the principal mediator of the
endogenous hyperglycemia of diabetes mellitus. 34
Similar relationships between hyperglucagonemia and
hyperglycemia have been demonstrated in insulindeprived alloxan-diabetic dogs. 50
Gastrointestinal glucagon may play a role not only
in pancreatic diabetes but also in other forms of diabetes, such as alloxan diabetesat least in the
insulin-deprived state. 51 Simultaneous measurements
of glucagon in the gastric vein, the pancreatic vein,t
and the vena cava in insulin-deprived alloxan-diabetic
dogs reveal large basal glucagon gradients across both
pancreas and stomach. But the administration of insulin promptly turns off gastric glucagon secretion.
Pancreatic glucagon secretion is also reduced by insulin, but only to the normal rate, not to zero. The
lower insulin requirements in diabetes following pancreatectomy may be due to the exquisite sensitivity to
insulin of the gastrointestinal a-cell in the absence of
any pancreatic glucagon secretion.
144

FIG. 9.

Field from an a-cell of rat pancreatic islet stimulated with

arginine. The arrows point to two stages of exocytotic
events of a-granules. (X 42,000)
DIABETES, VOL. 2 5 , NO. 2

ROGER H. UNGER, M.D.

FIG. 10. Freeze-fracture replica of an a-cell from a diabetic (ketotic) Chinese hamster. The arrows point to several exocytotic (emiocytotic)
stomata, three of which show protruding granule cores. For the problem of identification of a-cell in freeze-fracturing technic see
"Morphological characterization of membrane systems in A- and B-cells of the Chinese hamster," by L. Orci, AA. Amherdt, F.
Malaisse-Lagae, A. Perrelet, W . E. Dulin, G . C. Gerritsen, W . Malaisse, and A. E. Renold. Diabetologia 70:529-39, 1974. (X

49,000)

even less marked hyperglycemia.52

In adult-type diabetics the exaggerated glucagon
response to arginine 53 and the abnormal response to
carbohydrate ingestion 54 is not corrected by even supraphysiologic doses of simultaneously infused insulin. This would agree with the report of Aronoff and
associates,55 who found that in diabetic Pima Indians
with endogenous hyperinsulinemia the glucagon response to arginine was as exaggerated as in those with
significant hypoinsulinemiaand significantly greater than in nondiabetic Pima controls, in whom insulin
FEBRUARY, 1976

levels were intermediate between the two diabetic

groups. Further evidence that the o;-cell derangement
is independent of the circulating endogenous insulin
level may be found in demonstrations of abnormal
a-cell function in first-degree relatives of diabetics 56
and in the concordant identical nondiabetic twins of
diabetics. 57
THERAPEUTIC IMPLICATIONS

At the therapeutic level, plasma glucagon and glu145

DIABETES AND THE ALPHA CELL

FIGURE 11
Fundic mucosa of human stomach obtained three hours after death. Positive
immunoperoxidase reaction for antiglucagon 30K is present in several cells (arrows). (X 400)

cose were measured at two-hour intervals for up to 10

days in juvenile-type diabetics during aggressive attempts to achieve "optimal" control with insulin, irrespective of the amount and frequency of the injections. In most such patients, a significant reduction of
plasma glucagon levels was observed as control improved, but this required from 90 to 210 U. of insulin
per daycertainly far more than is secreted by

nondiabetics. 58 Moreover, in most of the juvenile

diabetics, wide-ranging fluctuations in plasma
glucagon were observed during the daytime, probably
related to the meals. Such fluctuations in glucagon
were infrequent in nondiabetic subjects similarly
studied 58 (figure 17). Massive doses of insulin will
ultimately achieve normoglycemia in most such patients but probably by maintaining a disproportion-

FIG. 12A, B. Notice the similarity of the granules of the human pancreatic a-cell and those of human duodenal endocrine cell (arrows).
(X 26,000) (Unpublished document of D. Baetens, P. Loeb, and R. H. Unger, Geneva and Dallas.)

146

DIABETES, VOL. 2 5 , NO. 2

ROGER H. UNGER, M.D.

NORMAL

TABLE 2
Comparison of gastrointestinal glucagon,
GLI, and pancreatic glucagon

M. W.
Isoelectric point
Ratio 78J/30K
Glycogenolytic activity:
per cent of 10 /xg. of glucagon
70 per cent of maximum
adenylate cyclase stimulation
Affinity for rat liver
membranes

Pancreatic
glucagon

GI
glucagon

GLI

3,485
6.2
1.0

3,500
6.2
0.9

2,900
>10
61

100

100

50

1O"8M

10"8M

10"7M

4 x 10' 9

3 x 10' 9 5 x 10"8

KETONES
ately high rate of glucose efflux without appropriate
suppression of glucagon-mediated glucose influx. Inappropriate meal-time hyperglucagonemia, in the
presence of a fixed level of circulating exogenous insulin, may be the cause of the bursts of hyperglycemia
that are commonly observed. The a-cell of the diabetic patient ignores hyperglycemia that lowers the secretory activity of the nondiabetic a-cell and no longer
functions as a glucose sensor guarding the limits of
extracellular fluid on glucose concentration.

DIABETIC KETOACIDOSIS

"DOUBLE-TROUBLE" HYPOTHESIS:
MORPHOLOGIC CONSIDERATIONS

Very little is known about the pathology of diabetes, and modern morphologic technics have only
rarely been applied to man. Drs. Orci, Baetens,
Rufener, Amherdt, Ravazzola, Studer, and
Malaisse-Lagae59 have studied the pancreas of two
juvenile diabetics shortly^ after death, using both immunofluorescent stains and electron microscopy. Islets
were generally sparse, as had been reported by
Gepts, 60 and in addition to a complete absence of
DOUBLE-TROUBLE HYPOTHESIS OF DIABETES
GLUCAGON

I INSULIN

LIVER
BRAIN
6g/hr

FIG. 13. Schematization of abnormal glucoregulation by the

alpha cell and beta cell in diabetes mellitus. The box
labeled "ECF" represents the extracellular-fluid-glucose
space.

FEBRUARY, 1976

KETONES
FIG. 14. Schematization of the ketogenic roles of the alpha and
beta cells under normal circumstances and in diabetic
ketoacidosis according to the hypothesis of McGarry,
Wright, and Foster.35 Upper pane!: Normally the presence of
insulin restrains lipolysis and limits the delivery to the
liver of free fatty acids, the substrate for ketone production. Lower panel: In the absence of insulin, unrestrained
lipolysis provides sufficient free fatty acids for a high
rate of ketone production, but the presence of glucagon is
somehow required to convert the liver into a "ketogenic
mode." Thus, diabetic ketoacidosis also requires the presence of this glucagon as well as the absence of insulin.

insulin-immunofluorescent cells, an increase in both

glucagon-immunofluorescent a-cells, which made up
most of the islet (figure 4B), and somatostatinimmunofluorescent 8-cells was noted. Orci's group
has, therefore, demonstrated by morphologic technics
a relative or absolute a:-cell increase in the islets of the
only two juvenile diabetics studied thus far.
147

DIABETES AND THE ALPHA CELL

Arginine

TABLE 3

HZDmg%
400
200

nlnsulindmU/kg/min.)-*-Glucose

(2mM/kg)

Comparison of mean nadirs of plasma glucagon during intravenous

insulin in:

GLUCOSE

Hyperglycemic

0jull/ml

Juvenile-type
diabetics

(N=5)

Adult-type
diabetics
(N= 10)

39 2

54 1

53 4

nondiabetics
INSULIN

(N=7)

p<0.001

p<0.05
pq/m
300

IMPLICATIONS FOR THE DIABETIC

GLUCAGON
200

100
~

0ng/ml
2.0-

>

GLI

1.00-10 0

20

50

80
110
MINUTES

140

170

200

FIG. 15. Circulating glucagon is present in the plasma of this totally depancreatized, insulin-deprived dog, and increases during the administration of arginine. When insulin is infused, however, circulating glucagon rapidly
declines to unmeasurable levels.

While the complex relationships of the cx-cell and

/3-cell abnormalities in inherited human diabetes to
its clinical manifestations remains to be completely
defined, it is clear that the daily doses of exogenous
insulin do not always reduce the hyperglucagonemia
of human diabetes to normal, even when they exceed
the amounts of insulin secreted in normals, nor do
they achieve normalization of glycemia throughout
the day. On the other hand, glucagon suppression by
somatostatin in such patients, at least in short-term
studies, improves glucoregulation with less insulin.
Elegant studies in juvenile diabetics by Gerich and
Forsham and their colleagues61 have demonstrated
that glucagon suppression by somatostatin results in
marked improvement in hyperglycemia without the
large insulin doses otherwise required, and even prevents the postprandial hyperglucagonemia and
hyperglycemia that is so marked in such patients. One
cannot help, therefore, being impressed with the
therapeutic potential of a safe and practical glucagonsuppressing drug in the control of diabetic hyperglycemia.
The possible long-term benefits of sustained

AROUND THE CLOCK PLASMA GLUCAGON AND GLUCOSE

NORMAL
GLUCAGON

300
PANCREAS
OUT

360

420

480

18hrs

MINUTES

FIG. 16. Plasma glucose in a dog during and after total pancreatectomy, during the continuous intravenous infusion
of somatostatin. Blockade of the rise in plasma glucagon
prevents the development of hyperglycemia despite the
absence of measurable levels of plasma insulin. When
plasma glucagon is elevated after discontinuation of the
somatostatin infusion, hyperglycemia is present.

148

JUVENILE DIABETIC

FIG. 17. A comparison of plasma glucagon levels in blood samples obtained every two hours for three days in a nondiabetic and a juvenile diabetic individual.
DIABETES, VOL. 2 5 , NO. 2

ROGER H. UNGER, M.D.

metabolic normalization of the diabetic cannot be

predicted on the basis of currently available evidence.
However, when science fails us, "biotheologic" inference and common sense may provide the best available
basis for a guess:
A. Nature's efforts are seldom purposeless.
B. Nature makes a substantial effort to avoid
hyperglycemia throughout life.
C. When nature's effort to avoid hyperglycemia is
successful, microangiopathy is rarely, if ever, present.
D. When nature's effort to avoid hyperglycemia
fails, microangiopathy usually develops.
E. Medical efforts to avoid hyperglycemia only
rarely succeed, and only rarely is microangiopathy
prevented.
It would be the height of irresponsibility to suggest
at this time that therapy directed at the hyperglucagonemia, as well as the hypoinsulinemia, would be
more successful than conventional therapeutic
methods of glucoregulation directed only at insulin
delivery. But, on the other hand, it would be the
height of nihilism not to hope so, and the height of
indifference not to find out.

search Physiologist at the Dallas Veterans Administration Hospital).

The author wishes to thank the following persons
for their outstanding technical work: Anna M. Eisentraut, former Chief Technologist; Ms. Virginia Harris, Chief Technologist; Kay McCorkle, Research
Biologist; Nancy Whitten, former Research Biologist;
Margaret Bickham, Biology Technician; Cathy
Mitchell, Biology Technician; Vicki Lupean, Biology
Technician; Shirley Harvey, former Biology Technician; Daniel Sandlin, Biology Technician; Brenda
Tower, former Biology Technician; Ava Marie Jones,
former Biology Technician; Loretta Clendenen, Research Technician.
The morphologic material employed in this review
was generously provided by Prof. Lelio Orci, Chairman of the Institut d'Histologie et Embryologie,
University of Geneva School of Medicine, and his colleagues, Drs. F. Malaisse-Lagae, M. Amherdt, M.
Ravazzola, D. Baetens, and C. Rufener.
The author wishes to express his thanks to his secretaries, Ms. Billie Godfrey and Ms. Carol Tower, for
their help in preparing this manuscript.

ACKNOWLEDGMENTS
REFERENCES

The work was supported by VA Institutional Research Support Grant 549-8000-01; NIH Grant AM
02700-16; Pfizer Laboratories, New York; Bristol
Myers Company, New York; Mead Johnson Center,
Evansville, Ind.; Dr. Karl Thomae GmbH, Germany;
Hoffman-LaRoche, Nutley, N.J.; Hoechst Pharmaceutical Company, Somerville, N.J.; Ciba-Geigy
Corporation, Ardsley, N.Y.; the Upjohn Company,
Kalamazoo, Mich.; Eli Lilly, Indianapolis, Ind.; 30K
Rabbit Fund, and various donors.
The following postdoctoral fellows at the University of Texas Southwestern Medical School performed
the studies upon which this review is based: Drs.
Herman Ketterer, Akira Ohneda, Demetra
Rigopoulou, Isabel Valverde, Eugenio AguilarParada, Jose Marco, Walter Muller, Ingolf Bottger,
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Munoz-Barragan, Hideo Sakurai, Gerald Faloona
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151