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Cutaneous Complications - Complications of Diabetes 1

skin, pruritus, itching, boils, especially, growth, observed, common and entrance

CUTANEOUS COMPLICATIONS - COMPLICATIONS OF DIABETES.

1. Pruritus is encountered in diabetes under many forms: a. Generalized Pruritus.—This form is found especially in dia betics with marked polyuria and glycosuria, rapid emaciation, and great dryness of the skin. It may be presumed that the dryness of the epidermis irritates the cutaneous nerves passing between the epi thelial cells. Many sufferers from diabetes present generalized pruritus as one of the earliest noticed symptoms of the disease. The phenomenon gradually disappears when the patients are put upon a diet which causes a diminution in the polyuria and glycosuria and with that a lessening of the dryness of the skin.

Besides the view here stated concerning the origin of the pruritus we may mention the theory that the cutaneous nerves are irritated by the sugar circulating in the fluids, and another that there is a cen tral irritation reflected toward the periphery.

b. Pruritus of the Genitalia.—This form is much more common in women than in men, and is not seldom the earliest subject of com plaint by diabetic women. The itching is at first localized on the inner and outer surfaces of the labia majora, extending thence to the neighboring parts (folds of the groin and inner surfaces of the thighs). All be parts indeed which are liable to be wetted by the saccharine urii_ may become the seat of this pruritus. The itching is, as has now been clearly shown, always caused by a growth of hyphomy cetes which partly grow in the form of minute white collections upon the surface of the skin and partly, like the oidium albicans in the mouth, press in between the epithelial cells. Evidently the skin moistened with the saccharine solution offers a most favorable soil for the growth of this fungus (leptothrix and other similar varieties).

Occasionally, perhaps as a result of the fungous growth alone but most frequently and especially in consequence of the irritation from scratching, an inflammation arises which sometimes runs its course as a superficial dermatitis, at other times—when the microbes of suppuration have entered the cracks in the skin—may result in the production of boils and phlegmons.

Pruritus vulvte and its consequences are naturally less frequently encountered in cleanly women than in those who are not. An Eng lish physician recently assured me that he had never observed the symptom among his private patients, but had frequently seen it in hospital practice.

A similar condition is observed in man, but much less it is manifested by itching of the glans penis and prepuce, the forma tion of superficial colonies of the fungus, balanitis, and phimosis. The itching is felt especially at the meatus and may give rise to tenes mus. In other cases the scrotum is the chief seat of the pruritus.

2. Inflammations of the Skin.—The entrance and growth of micro organisms is a necessary condition for the production of furuncles. I have seen pure cultures of the staphylococcus aureus in three cases of furunculosis (ten boils in all). Fiu'iinculosis occurs in mild as well as in severe cases of diabetes, in the early and late stages, when the patient is on an animal diet as well as when he is indulging freely in carbohydrates—on an average in from one-tenth to one-fourth of the cases.

Subcutaneous phlegmons and carbuncles are not so common as boils. They always have their origin in cracks of the skin. The tendency to the gangrenous forms of inflammation, which is so pro nounced in diabetes, is clearly shown in these cases.

While the point of entrance of the infecting germ is usually very readily found in cases of carbuncle and phlegmon, this is not the case with boils. They often appear when the skin is apparently unbroken. It was formerly regarded as certain that furuncles were due to an internal cause, being dependent upon a high percentage of sugar in the blood or else of trophoneurotic origin. The only thing that we can and must admit in this regard to-clay is that the skin in diabetes opposes a less firm resistance to the entrance of microbes, and that for this reason a boil is produced where in healthy persons a small acne papule or only a little hyperemia at the mouth of a follicle would be observed. Doubtless it often happens that pruritus first appears ; the itching part is scratched, little cracks open in the epitheliurn, and through these, either from the scratching finger or from dirty underclothing, microbes enter the skin.

It follows from this that furunculosis is a complication of diabetes which can be prevented by careful attention to the skin, and it would appear that it has become more rare during the last few decades, in which a regard for personal cleanliness has become more universal among civilized people.

3. Tratimata.—Wounds of the skin and also deeper wounds heal more slowly in diabetics; septic germs enter more readily, and gran ulation tissue has a tendency to slough. Although the healing of wounds in diabetics is much better now than it formely was, owing to the application of the principles of antisepsis and asepsis, yet fatal delay in healing and spreading gangrene are still common enough. For this reason surgeons shrink, and justly, from the performance of any avoidable operation in cases of diabetes. Some operations have a particularly bad reputation, especially that for the relief of phimosis.

4. Ioseosible Perspiratiom —See the section on the cutaneous se cretion on page 92.

5. Chemistry of the Sweat.—See page 98.