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Changes in the Nervous System - Complications of Diabetes 1

diabetic, condition, observed, patient, psychoses, coma and tendency

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CHANGES IN THE NERVOUS SYSTEM - COMPLICATIONS OF DIABETES.

1. Psychic Distarbaures.—We have seen in the section on Etiology that a clear insight into the significance of psychoses iu the causation of diabetes is wanting. We know more, however, concerning the psychic disturbances which arise during the course of diabetes, and which are referred to a nutritive disturbance produced by the original disease in the psychic organs. The question of the diabetic psycho: ses originated in France, and it is in that country that most of the work in it has been accomplished. In the first rank among these workers are to be mentioned Mar4c1xal de Calvi and Legrand du The mental changes which are observed in the course of diabetes are characterized by a tendency to improvement running parallel with improvement in the primary disease and especially in the general condition of nutrition; the fully developed psychoses offer, however, an exception to this rule, for the prognosis in such cases is unfavorable. Occasionally the peculiar fact has been observed that the glycosuria has subsided with the appearance of the mental distUrbance and has then remained permanently absent.

The variety and degree of these disturbances vary greatly. Some times the symptoms are the common ones of depression of the intel lectual faculties and a weakness of judgment, memory, and will; very often there is a tendency to deceitfulness and aimless garrulity ; very frequently there are also neurasthenic, less commonly hysterical troubles. The occurrence of actual psychoses is much less common; among these melancholia and hypochondriasis are the first in order of frequency, being observed in all grades of severity from an almost imperceptible degree of mental hebetude to the most pronounced forms of the disorder. Melancholia of diabetic origin frequently presents a homicidal or suicidal tendency. Sometimes there are periodical attacks of somnolence (Ballet, Vergely). Legrand du Saalle has described several cases of " delire de mine" which he re gards as very characteristic of diabetic insanity; the patients believe and maintain without any reason that they are financially ruined and this notion dominates all their thoughts and actions. Cases of this nature have hitherto been described only by French writers.

2. Diabetic Coma."—This condition was first described by Russ maul in 1874. It is now generally attributed to the action of some toxic substance upon the central nervous system. I have spoken

above of the chemical basis of the various theories held, and have there stated that we have to deal with hypotheses only and have no certain knowledge of the subject, and further that all acute ter minations of diabetes associated with loss of consciousness are not. identical with true diabetic coma. We have already referred to the cases of sudden death, due, according to Frerichs' opinion, to paral ysis of the heart, and we must also distinguish the comatose con ditions occurring in diabetes as a consequence of cerebral apoplexy, of the not very uncommon cases of tubercular meningitis, and of other gross anatomical lesions of the brain. Finally many instances of a terminal comatose condition are undoubtedly caused by uraprnic intoxication resulting from the complicating contracted kidney.

After all these complications are excluded there still remain a not inconsiderable number of cases of a peculiar character.

Sometimes suddenly, sometimes after headache, insomnia, rest lessness, anxiety, vertigo, and symptoms resembling those of alco holic intoxication, lasting for a few hours or days, the patients fall into a condition of somnolence which rapidly or more slowly passes into complete coma. The patient now lies quietly in bed without any convulsive movements or at most only slight clonic twitchings. The pupils are dilated, the eyes are half-open or the lids are slowly raised and lowered; the eyeballs seem also to move slowly in differ ent directions. The pulse is small and slightly accelerated; the tem perature may be at first elevated but sinks later far below the norm. Especially characteristic is the deep, long-drawn inspiration, without stridor, followed by a short expiration; the number of respirations is normal or slightly increased. In spite of extensive aeration of the lungs a slight, gradually increasing degree of cyanosis arises—due apparently to obstruction to the peripheral circulation. A sharp acetone odor issues from the mouth of the unconscious patient and makes a diagnosis of his condition possible even at a distance. The urine gives almost constantly a marked reaction with chloride of iron, and contains sugar; still it must be remembered that the urine of a patient in diabetic coma may be free from sugar (see p. 86).

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