ritability are usual. The temperature is normal or subnormal. If there is fever, it is due to some complication. Complications.-The complications of diabetes are exceedingly nu merous. The CUTANEOUS COMPLICATIONS.-Furuncles, carbuncles, and suppurative processes following abrasions, injuries, or operations are frequent. Purpura is often present, and gangrene, especially of the feet, is apt to occur. nails are dry and may atrophy or fall out. Herpes zoster and perforating ulcer are occasionally seen accompanying the disease. Profuse sweats may occur. GENITOURINARY SYMPTOMS.-It is seldom that nephritis develops except late in the disease, and then come its symptoms. Albuminuria and adema are not infrequent. Sometimes the first symptoms are irritation and pruritus of the parts where moisture from the urine is likely to exist. In men there may be balanitis, inflammatory phimosis, or paraphimosis. Impotence may be an early symptom. Cystitis is seen from time to time. PULMONARY COMPLICATIONS.-A fruity odor to the breath is the rule. Later in the disease pulmonary complications are very common, and nearly one half of the patients die of pneumonia, tuberculosis of the lungs, or gangrene of the lung. CIRCULATORY SYMPTOMS.-The pulse and the heart are seldom affected until the disease is well advanced, when endarteritis and hypertrophy of the heart may develop. Dilatation of the heart may cause a fatal termination, as may also a fatty heart. Nervous Symptoms.-The nervous symptoms are very important. DIABETIC COMA is one of the most interesting and dreaded symptoms of this disease. It is more likely to occur in the young patients and in those in whom the disease advances rapidly and is associated with rapid emaciation. Before the onset of the coma the urine contains as much sugar as previously, although the amount of urine may be diminished in quantity. Three forms are described: 1. After an unusual bodily or mental exertion, the patient suddenly. becomes prostrated, the heart's action grows rapid and feeble, the skin is cold, stupidity and a comatose condition supervene, and death occurs in a few hours. 2. For a few days (from six to nine) the patient complains of weakness and gastric disturbances, nausea, loss of appetite, constipation, pain in the abdomen, drowsiness, and breathlessness. Some local affection, such as pharyngitis, a phlegmon, or a pulmonary complication, is present. Headache, restlessness, delirium, rapid and labored breathing, cyanosis, a feeble and rapid action of the heart develop, then stupor and coma come on, death occurring in from one to five days. 3. Without previous dyspnoea or prostration, headache may develop suddenly, then vertigo, stupor, and coma, and death occurs in a few hours. Much discussion, theorizing, and painstaking investigation have been in progress for years as to the cause of this coma, but it now seems to be the almost universal opinion that it is due to acid intoxication and that the acid is B-oxybutyric acid, which accumulates in the tissues, circulates in the blood in enormous quantities, and is eliminated in combination with other GLYCOSURIA AND DIABETES MELLITUS 655 elements. Temporary improvement and even cessation of the symptoms of impending coma are not impossible, but they are very exceptional. PERIPHERAL NEURITIS.-There may be mild neuritis in different parts. of the body, giving rise to neuralgic pains, numbness, and tingling. Sciatic pains may be severe. DIABETIC TABES is a name given to the association of severe neuritis with lightning pains in the legs, loss of tendon reflexes, paresis of the extensors of the feet, and the characteristic gait, which is called "steppage." DIABETIC PARAPLEGIA is probably also due to neuritis. Cases are seen where both arms and legs have been paralyzed. MENTAL SYMPTOMS.-Restlessness, headache, dizziness, anxiety, nervousness, and a tendency to melancholia are seen. Occasionally general paralysis develops. Special Senses.-Cataract, particularly in the younger patients, is common. RETINITIS, HÆMORRHAGE into the RETINA, OPTIC ATROPHY, SUDDEN BLINDNESS, and paralysis of the ocular muscles have been observed. OTITIS MEDIA at times seems to be diabetic in origin. Sexual Functions.-Impotence may be a common and early symptom. Abortion is likely to occur, if conception (which is rare) takes place. A diabetic mother may have a healthy child. Pregnancy and delivery aggravate the disease. LARYNGITIS and FURUNCULOSIS of the LARYNX have been noted. Course and Prognosis. In children the disease progresses very rapidly. Most children die within one year. As a rule, the older the patient when the disease begins, the more chronic is the course. The disease is more favorable when the patient has no hereditary dyscrasia, when the disease is concurrent with obesity and gout, when it begins late in life, when the social conditions are favorable and there is freedom from business and financial worry, and when treatment is begun early. The prognosis also depends upon the degree to which treatment is successful in reducing the amount of sugar. In cases supervening after an accident or acute disease the patients sometimes get well rapidly and sometimes slowly. In cases occurring at the climacteric in women the patients are more likely to recover than in any of the other cases. The state of the circulation, indicated by arterial pressure and cardiac impulse, is of great importance in the diagnosis. Complete recovery cannot be expected, but a large number of patients may enjoy fairly good health for a number of years. If it occurs in a person under forty years old, the outlook is bad. Death occurs from heart failure, diabetic coma, pulmonary affections, or nephritis. A few die exhausted and emaciated from the disease alone. The terminal stage of diabetes is that of ethyldiacetic acid poisoning. Treatment of Diabetes.-HYGIENE.-Worry should be avoided. The life should be even and tranquil. A climate where there are the least changes of temperature is preferable. The skin should be kept in the best possible. condition, so that excretion by this channel shall be unobstructed. A lukewarm bath, or a fairly cold bath if the patient can endure it, should be taken each day. An occasional Turkish bath is admissible. Exercise, not too violent, regularly for those who can endure it is important, and massage for those for whom exercise is impossible. Bowling is a good exercise. DIET. After testing the amount of sugar in the urine for several days when the patient is on an ordinary diet, it is well to put him on a strict noncarbohydrate diet to see if the urine can thus be made free from sugar. Such a diet has been planned by von Noorden: Breakfast at 7.30 a.m.-200 c.c. (3vj) of tea or coffee, without milk or sugar; 150 gms. (3v) of beefsteak, mutton chops without bone, or boiled ham; one or two eggs. Luncheon at 12.30 p.m.-200 gms. (3 vj) of cold roast beef; 60 gms. (ij) of celery, fresh cucumbers or tomatoes with vinegar, olive oil, pepper and salt to the taste; 20 c.c. (3v) of whiskey with 400 c.c. (3xiii) of water; 60 c.c. (ij) of coffee without milk or sugar. Dinner at 6 p.m.-200 c.c. of clear bouillon; 250 gms. ( 3 vijss.) of roast beef; 10 gms. (3ijss.) of butter; 80 gms. (3ij) of green salad with 10 gms. of vinegar and 20 gms. of olive oil or three tablespoonfuls of some well cooked green vegetables; three sardines à l'huile; 20 c.c. of whiskey with 400 c.c. of water. Supper at 9 p.m.-Two eggs, raw or cooked; 400 c.c. of water. In many cases the amount of sugar in the urine diminishes so rapidly that in three days none is found. If this is the case, we can gradually add sugar and starch until we see the sugar returning in the urine, and then keep just below the limit. Patients may return to this diet for a short period at intervals of three or four months. Diabetic patients may have the following articles of food: Liquids.Soups: Ox tail, turtle, bouillon, and other clear soups. Lemonade, coffee, tea, chocolate, and cocoa; these to be taken without sugar, but saccharin may be used to sweeten them. Soda water, Apollinaris, Saratoga, Vichy, and milk in moderation may be used. Animal Food. Fish of all sorts, including crabs, lobsters, and oysters; salt and fresh butchers' meat (excepting liver), poultry, and game. Eggs, yolk of eggs, cream, butter, buttermilk, curds, and cream cheese. Bread.-Gluten and brown bread, almond and cocoanut biscuits. Vegetables. Lettuce, tomatoes, spinach, chicory, sorrel, radishes, asparagus, water cress, mustard and cress, cucumbers, celery, and endives. Pickles of various sorts. Fruits.-Lemons and oranges, currants, plums, cherries, pears, apples (tart), melons, raspberries, and strawberries may be taken in moderation. Nuts as a rule are allowable. To aid digestion, 5 drops of dilute hydrochloric acid should be taken after each meal, in water. Among prohibited articles are the following: Thick soups, liver, ordinary bread of all sorts (in quantity), rye, wheaten, brown or white. All farinaceous preparations, such as hominy, rice, tapioca, arrowroot, sago, and vermicelli. Potatoes, turnips, parsnips, squashes, vegetable marrows of all kinds, beets, corn, and artichokes. Liquids.-Beer, sparkling wine of all sorts, and the sweet aerated drinks. SPECIMEN DIET IN DIABETES 657 SPECIMEN DIET FOR ONE WEEK Supper. One half doz. raw oysters, two lamb chops, lettuce, gluten bread and butter, cheese, and a cup of tea. Breakfast. Two soft boiled eggs, gluten bread and butter, and a cup of coffee with cream. Dinner. Bouillon and egg, a piece of steak, oyster plant, salad, gluten bread and butter, and claret wine. One half hour later, a cup of coffee. Supper. Cold turkey, sardines, celery, a piece of cheese cake made with gluten flour and lævulose, and a cup of tea. Breakfast. Two soft boiled eggs, gluten bread and butter, and a cup of coffee with cream. Dinner. Bouillon and egg, roast turkey, gluten bread dressing, celery, cranberries sweetened with lævulose, Mosel wine, and a cup of coffee. Supper.-Turkey salad, celery, cheese, and a cup of tea. Breakfast. Two soft boiled eggs, sardines with lemon juice, and a cup of coffee with cream. Dinner. Bouillon and egg, a piece of steak, gluten bread and butter, cheese, claret, and a cup of coffee. cup Supper. One half dozen raw oysters, milk oyster stew, and tea. and a Dinner. Bouillon and egg, corned beef and cabbage, claret wine, a cup of coffee, and gluten bread and butter. Supper. One boiled fish with butter sauce and celery, gluten bread and butter, and a cup of tea. Breakfast. Ham and scrambled eggs and a cup of coffee with cream. Dinner. Chicken fricassee, celery, spinach, bouillon and egg, a cup of coffee, and bread and cheese. Supper. Smoked salmon, cervelat sausage, gluten bread and cheese, and a cup of tea. Breakfast. Two soft boiled eggs and ham and coffee with cream. Dinner. Bouillon and egg, beefsteak and salad, gluten bread and wine. Four p.m.-One dozen raw oysters. Supper. Steak, celery, bread and butter, cheese, and a cup of tea. In order to avoid monotony, variety in soups, vegetables, flavoring and seasoning substances should be planned. MECHANOTHERAPY IN DIABETES.-All forms of exercise are beneficial in moderation. Vibratory massage over the stomach, liver, pancreas, or the entire abdomen and lumbar region should be employed. ELECTROTHERAPY.-The high frequency current or the static current should be tried. INHALATION.-Ozone inhalations through a static machine attachment or a house ozone generator are useful to combat secondary anæmia. Medicinal and empirical treatment is unsatisfactory. Brewers' yeast is given in tablespoonful doses three times a day. Blueberry leaves in decoction and powder form is a time honored household remedy. Tryptogen, which contains various digestive ferments in combination with gold and arsenic bromide, is given in five grain tablets three times daily. Desiccated glands which furnish internal secretion may be tried in rotation or combination. Improvement sometimes follows the administration of codeine, gr. three times a day, up to gr. vj a day. Morphine, gr. three times a day and upward, or phosphorus may be used. Vichy water with sodium bicarbonate added is the best drink, as alkalies counteract the tendency to coma. The coma which is so much dreaded should always be thought of as a possibility, and long railway journeys, sudden changes of diet, constipation, mental excitement, and worry should be avoided. In coma enteroclysis, with water at 110° F. containing 3j of bicarbonate of sodium to the pint, is indicated. Furuncles, carbuncles, and gangrene require surgical treatment. The increasing number of cases of diabète à deux reported in medical literature would indicate that it is not desirable that a diabetic and a nondiabetic person should share the same bed. OBESITY "The development of fat constitutes a disease when it interferes with the function of some organ or organs. Etiology.-1. Heredity.-In some families there are generations of fat people. These persons seem to grow more and more obese as they grow older, and the treatment is very unsatisfactory unless rigidly carried out. We must not, however, overestimate the hereditary tendency. 2. Modes of Life.-Bad habits of life are probably the most important of all the causes. The habit of overeating, particularly of carbohydrates. and fats combined with alcoholic beverages, especially beer, is most pernicious. With this overeating, a lack of exercise, as is usual in a sedentary life, and oversleep prevent oxidation and fat accumulates. 3. The sexual relations seem to offer a predisposition to fat accumulation. At puberty, at the menopause, and after atrophy or removal of the testes or ovaries we see individuals grow stout. 4. Congenitally small lungs, making a defective oxygenating capacity, have also been mentioned as a cause. As people get adipose they are inclined to be less active and to take less exercise on account of the difficulty in getting about, and the fat accumulates more rapidly. Pathology. We should distinguish between fatty degeneration and fatty infiltration, which is the condition we find in obesity. In fatty infiltration, which is not necessarily a pathological condition, there is simply an excessive deposit of fat in the cells where normally fat is found. As this accumulates we observe the puffy cheeks, the pendulous breasts and abdomen, the massive buttocks and thighs, and the coarse, greasy epithelium which are so unpleasant to see. Within the thorax and abdomen, about the heart and kidneys, and in the omentum this increase in fat may be enormous. Fatty degeneration is a term used to indicate the process of decay, a fatty breaking down of the albuminates within the tissue elements themselves. |