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Severe Cases with Ordinary Onset and Course - Complications of Diabetes

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Here nothing definite can be learned of the beginning of the dis ease. The bodily weakness, intellectual relaxation, impotence, and emaciation have come on gradually and almost imperceptibly. The patients look upon themselves as nervous and overworked in body and mind. They therefore give themselves a vacation from time to time, visiting the different watering-places and summer resorts, with out, however, finding the wished-for return of strength. They even consult a physician occasionally, who frequently, through neglect to examine the urine or because of deficient powers of penetration, fails to detect the true cause and agrees with the diagnosis of overwork, neurasthenia, nervous dyspepsia, and the like. At other times disease of some other organ develops (visual disorders, neuralgia, impo tence, pruritus, furunculosis, tuberculosis, etc.) and leads the patient to consult a physician, often a specialist, an ophthalmologist, a der matologist, a neurologist, or the like. The variety of forms under which the disease appears is but too often responsible for the fact that the diagnosis is made only when sad destruction has already been wrought in the body through defective nutrition, or through com plications or sequehe of the primary disease. A more careful exami nation shows that the patients are excreting under the ordinary diet rich in carbohydrates, enormous quantities of sugar-200 to 300 grams or more a day. The tolerance of carbohydrates is at a mini mum or even negative, that is to say, the glycosuria continues for a time, or it may be permanently, despite the withdrawal of carbohy drates from the food.

The further course of the disease varies.

1. In consequence of proper regulation of the diet as to quality and quantity, good nursing, careful treatment of the complications, avoidance of any tax to the mind or body, the nutritive condition be comes better, the patient increases in weight, his strength returns, he becomes able to perform a moderate amount of bodily or mental labor, the complicating organic diseases improve or at least become station ary, and the tolerance of carbohydrates increases slowly, with oscilla lions, to a certain, though usually slight, degree. The patients drag out an anxious existence full of privations for several years, perhaps a decade. The general condition is variable, 11011' good, now bad. Any little careless neglect of the dietetic or other rules which have been established for them is ordinarily followed quickly by a loss of weight and strength. In the mean while complications are no absent;

the old troubles (neuralgia, visual defects, furunculosis) return; new ones (digestive disorders, trophoneuroses, mental disturbances, paral yses, cardiac asthma) declare themselves, and the more serious com plications (acute infectious diseases, tuberculosis, gangrene, heart failure) appear. Finally the patients succumb either because they are unable to take and assimilate sufficient nourishment to maintain the strength, or because they are overcome by some intercurrent dis ease, such as heart failure, tuberculosis, or gangrene, or finally be -cause diabetic coma comes on suddenly and unexpectedly.

2. In contrast to these relatively favorable cases are others with rapidly fatal course. The gravity of the cases is betrayed less by the glycosuria than by the other symptoms. The intensity of the former is doubtless also of great significance in so far as the giving of suitable and sufficient nourishment becomes the more difficult in proportion to the depression of the sugar-consuming function. But the cases which we are now considering present the peculiarity that the swiftly advancing fatality is not turned aside even when the dietetic difficulties are victoriously overcome.

In a certain number of these cases the vulnerability of the diabetic tissues is shown to a fearful degree, or precocious senility declares itself. The patients are attacked by severe complications and sequelce in spite of the best care and of the most painstaking regulations of the mode of living; they suffer from severe forms of neuritis, grave conditions of weak heart, phlegmons, gangrene, and above all tuber culosis. One or other of these complications, or the combined action of several, kills the patient within the short period of one or two years, although in the last stages of the disease the glycosuria may have decreased very considerably and thereby given rise to deceitful hopes of an improvement in the primary affection.

In another proportion of cases the signs of true diabetic intoxica tion declare themselves, sometimes independently of, sometimes in connection with, other complications. Fatal coma appears, either after a long prodromal period (especially a profuse excretion of oxy butyric acid) or without any warning. By far the greater number of patients who are attacked by this malignant form of diabetes, pro gressing inevitably to a fatal termination within one or two years, are young or middle-aged.