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Diabetes Mellitus.

Synonyms.—Saccharine Diabetes; Glycosuria.

Definition.—A constitutional disorder of nutrition, characterized by the persistent presence of grape sugar in the urine, by polyuria, and progressive loss of flesh and strength.

Etiology.—Predisposing Causes.

Geographical Location.—While diabetes is found in every country it is more prevalent in certain localities, though the reason has not been satisfactorily explained. It is quite common in Southern Italy, India, Sweden, and Germany, and may depend to some extent upon diet, habit, custom, and environments.

Race.—The racial peculiarities of the Hebrews may figure somewhat in their susceptibility to diabetes, though the cause is obscure. We only know that it occurs more frequently among the Jews than any other race.

Sex.—Of thirteen hundred cases reported by Frerichs and Seegen, nine hundred and eighty-eight occurred among males, and three hundred and fifty among females, showing a strong sexual predisposition in favor of males.

Age.—While it has been observed from infancy to old age, its occurrence before puberty is quite rare, and after the age of sixty-five, the most susceptible period being from the age of forty-five to sixty. In women it is apt to occur about the "change of life."

Heredity.—The frequency with which diabetes occurs in certain families makes it apparent that heredity plays some part as an etiological factor, thus "Seegen found it in fourteen per cent of his cases, Schmitz in twenty per cent, and Bouchard in twenty-five per cent." (Von Noorden.)

Social Position and Occupation.—That diabetes occurs far more frequently among the wealthy and cultured, and those who lead a luxurious life, than among the poor and hard-working class, is the observation of all practitioners of experience. That occupation favors the disease is shown by the frequency with which it is seen in those whose work is largely intellectual, as teachers, scientists, poets, statesmen, and those of the learned profession.

Exciting Cause.—The specific cause or causes have not yet been determined and a variety of theories have been advanced as to its origin. Extirpation of the pancreas or loss of function of this organ by disease or morbid growths, results in diabetes, and hence it seems probable that this organ plays some important part as a causal factor.

Whenever the glycogenic function of the liver is disturbed, either by organic disease of the organ or by a disturbance of its innervation by puncturing the floor of the ventricle or section of the pneumogastric, diabetes follows. Tumors of the brain, concussion, hemorrhage, shock, grief, severe mental exertion, or, in fact, whatever produces a disturbance of that portion of the medulla that presides over the glycogenic function, gives rise to diabetes.

Certain drugs produce glycosuria, notably phloridzin, chloroform, and potassium bromide. Obesity and diabetes are so often found in the same person as to suggest a close relation as to cause and effect. An effort has been made to associate the infectious fevers with diabetes, but in all probability such cases are coincidences rather than causes, and the infectious disease, by weakening the system, revealed the diabetic condition that was present previous to the attack. More recently the microbic theory has obtained some support.

Pathology.—Various lesions and degenerations are found in the various organs of the body, but how many are causal and how many the consequence of disordered nutrition would be hard to say. The pancreas is affected in more than half the cases. There may be atrophy, interstitial pancreatitis, and obstruction of the duct, cysts following obstruction from calculi or growths.

The liver is usually enlarged, showing fatty degeneration; sometimes interstitial hepatitis prevails, and again abscesses are observed. The spleen is usually atrophied. The heart is pale, flabby, and there may be fatty degeneration. Pericarditis and endocarditis have been noted, and arteriosclerosis is not a rare condition in diabetes. The lungs share in the general breakdown, and gangrene frequently follows pneumonia. Tuberculosis of the lung is not uncommon. Pleural effusions are sometimes found.

The kidneys are enlarged and show fatty or hyaline degeneration. Interstitial nephritis is frequently present.

Various changes are seen in the brain and cord. There may be softening or thickening of the membranes, but the most constant lesions present are those affecting the medulla or fourth ventricle. The blood contains a larger per cent of sugar than during health. There is generally extreme emaciation, although in some cases the subcutaneous fat is found in considerable quantities. A bronzed condition of the skin is not uncommon.

The eye is usually involved in the advanced stages; cataract attacking by preference young subjects. Of retinal changes, Von Noorden, in "The Twentieth-Century Practice," says: "Those which are dependent upon diabetes occur under three forms: (a) Albuminuric retinitis, accompanying contracted kidney, present as a complication or sequel of diabetes; (b) Retinitis centralis punctata, with characteristic ophthalmoscopic changes (small, shining central spots, usually with hemorrhagic puncta, always bilateral, without involvement of the optic nerves—Leber, Hirshberg); (c) Retinitis hemorrhagica of the ordinary type.

Symptoms.—Two varieties are seen, the acute and the chronic. The general symptoms are very much the same in the two forms, the principal points of difference being in the age of the subject and the method of onset of the disease; the acute, usually occurring in children and young adults, while the chronic form occurs most frequently after the age of fifty. The acute form comes on more rapidly than the chronic form; the latter comes on so slowly and insidiously that the disease is well advanced before the patient is aware that he is its victim. Among the first symptoms that attract the attention of the patient is that he is losing flesh and strength, and that he has frequent calls to void water, and in the morning he is surprised to find so large a quantity in the vessel. There is no pain save a weight in the loins, and the appetite is good; indeed, in many cases, it is voracious. Digestion seems unimpaired, yet the patient continues to grow thin, and prostration is marked; muscular weakness is characteristic.

Thirst is a characteristic symptom, the patient drinking large quantities of water during both day and night. The large quantity of water seems to be necessary to hold the sugar in solution for excretion, the demand for water beginning an hour or two after a meal. The quantity of water consumed has a direct ratio to the quantity eliminated.

The skin may be doughy and relaxed, although usually it is dry, harsh, and constricted. Pruritus is a distressing symptom, and is especially aggravated about the genitals, when the diabetic urine comes in contact with the parts. Boils, carbuncles, and eczematous eruptions are common. The hair becomes dry, and loses its gloss, and the nails become brittle and easily broken.

The tongue is dry, red, and glazed, or covered with dark sordes. The mouth is dry and sticky and the secretion of saliva is diminished.

The urine varies in quantity from four to twenty pints, although in rare cases it may be normal in quantity. It is pale, almost as clear as water, and has a specific gravity, ranging from. 1,025 to 1,050, although in rare cases it may go as low as 1,013. It has a peculiar sweet odor and taste, and an acid reaction. Albumin is sometimes present before sugar appears in the urine, and uric acid is found in excessive quantities.

Tests for Urine.—See Glycosuria.

Pulmonary Complications.—These are not uncommon in the advanced stages, pulmonary tuberculosis being quite frequent, and pneumonia is often seen. The special senses may become impaired; thus the vision becomes disordered, not only by a weakening of the muscles of accommodation, but also in some cases by cataract formation. Otalgia, otitis media, and mastoid affections occur. The senses of taste and smell are also affected in some cases.

Diabetic coma occurs in about half of the fatal cases. It may come on suddenly but a few hours before death, or it may be announced by a peculiar fruity odor of the breath, gastric disturbance, and headache. Emaciation is quite rapid after these symptoms, and death soon follows.

Peripheral neuritis, characterized by neuralgia and a numb, tingling sensation is not uncommon, while diabetic tabes may occur, and is characterized by darting pains, absence of the knee-jerks, and loss of power in the extension of the feet, giving the peculiar tabetic gait—steppage.

The course of the disease varies according to the age of the patient and the form of the disease. Thus in the young, and in the acute form, the disease lasts from a few weeks to two years, while in those past middle life and where the patient is obese, the disease may last for years.

Diagnosis.—The diagnosis is very readily made; muscular weakness without apparent cause, the passage of large quantities of water, itching of the genitalia, loss of flesh and strength, great thirst, hunger, and loss of sexual power, are so characteristic of diabetes that an analysis of the urine will scarcely be necessary for a positive diagnosis.

Prognosis.—Diabetes is a very grave disease, and although some cases recover, a large per cent will terminate fatally. A complication that frequently carries off the patient is pulmonary phthisis.

Treatment.—The treatment may be divided into three parts: Dietetic, hygienic, and medicinal.

Dietetic.—Since the greater portion of glucose that enters the blood is derived from the carbohydrates, sugar and starch, such articles of food as are rich in these substances should be excluded from the patient's diet. Saccharin and glycerin have been recommended as a substitute for sugar, but the taste is so disagreeable to most persons, that it can not be substituted to any great extent. The following articles are to be prohibited: Such fruits and vegetables as are rich in starch and sugar should be restricted, and include the following:

Vegetables—Potatoes, rice, beans, peas, carrots, beets, onions, lentils, turnips, squash, tomatoes, asparagus, parsnips, artichokes, corn, hominy, sago, arrow-root, oatmeal, and cracked wheat.

Fruits—Bananas, pears, grapes, apricots, apples, plums, strawberries, raspberries, gooseberries, sweet cherries, figs, and chestnuts.

Meats—Livers of animals, mollusks (oysters, clams, etc.), and the inside meat of clams and lobsters.

Fluids—Sweet wines, chocolate, and cocoa, if sweetened, lemonade, beer, cider, champagne, and aerated drinks, such as ginger-ale, root-beer, etc., and alcohol.

Foods Permissible.—Vegetables—Cucumbers, water-cresses, lettuce, cabbage, sorrel, mushrooms, spinach, celery, chicory, and various pickles, unless sweet.

Fruits—Lemons, oranges, currants, grape-fruit, and nuts (chestnuts excepted).

Meats—All kinds of fresh meats, poultry, fish, game, bacon, ham, and large quantities of fat, butter, eggs, and cheese.

Bread—The crust, thoroughly toasted, of a French roll and gluten biscuit.

Beverages—Coffee and tea, if not sweetened, sweet milk, buttermilk, plenty of pure water, and the alkaline mineral waters.

By observing a diet of this kind, the sugar is reduced to the minimum and often disappears. We are to remember, however, that the strength of the patient must be maintained, and many times we will have to modify our diet and permit, in moderate quantities, articles on the above-mentioned restricted list. We are not to sacrifice the strength of the patient by a too rigid diet.

Hygienic.—The patient should take light exercise in the open air, and, when too weak to do this, should be well massaged; daily baths, hot or cold, according to the strength and age of the patient should be taken. The sleeping apartment should be well ventilated and flannels worn the entire year. All mental worry and excitement should be avoided, and, where possible, the patient should live in an equable climate.

Medicinal.—The medicinal treatment of this disease has not been very successful. Von Noorden says, "The number of drugs which have been recommended in the treatment of diabetes is legion; the evidence of the small benefit of any individual, one." Of syzygium jambolanum (the bark and seeds of the Java plum) which have been so highly extolled, he says, "I have never seen any results worth mentioning from the use of this drug." The agents most frequently employed are iron, opium, arsenic, nitrate of uranium, creosote, and the bromides.

Lycopus.—In 1873, Dr. D. Ray read a paper before the Yolo County (California) Medical Society, on Diabetes, recommending lycopus. He says of a case, "For weeks I had given her iron, opium, bitter tonics, and astringents, with a host of the remedies recommended by authors, from Dr. Prout down to Flint, and without any benefit, when my attention was called to bugle weed as an agent for diabetes. The administration of fluid extract of bugle weed, a teaspoonful five times a day, soon effected a cure." Since then others have reported favorably upon its use.

Rhus Aromatica.—Dr. Goss in his "Practice of Medicine," speaks highly of this agent in the treatment of diabetes.

Chionanthus.—Dr. Hauss read a paper at the National Association in 1901, extolling the virtues of chionanthus in this stubborn disease. A study of Eclectic remedies promises more in this affection than those so long recommended.

The Eclectic Practice of Medicine, 1907, was written by Rolla L. Thomas, M. S., M. D.

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