In certain cases of severe diabetes, par ticularly when death has been caused by coma, Ebstein has seen a peculiar altera tion in the epithelium of the convoluted tubules in which circumscribed areas alternate with normal portions. Accord ing to Albcrtoni, this lesion is due to the acetone or to the acids which exist in the blood in severe diabetes.
Quite recently, and only in cases in which death occurred during coma, Fichtner has reported a very circum scribed alteration in the cells of the con voluted tubules, which consists of an infiltration of fat at the base of these cells, which is detected by osmic acid. I have also met with this alteration, to which the attention of pathologists should be directed.
In cases of diabetes 644 post-mortem examinations performed. The condition of the kidneys was carefully noted in 241 of these cases. In the remainder they were reported healthy, or only the gross appearances were noted. Of the 241 cases, 68 are reported as hyper trophic; 52 as hyperemic; 94 as the seat of a nephritis; 17 as having fatty degeneration; 7 had epithelial accumula tion; 2 had cysts; and 1 multiple ab scess. Colcord (Kansas Med. Jour., Apr., '91).
Lesions similar to those in Bright's disease rarely occur iu the diabetic kidney.
Several authors have dwelt upon the frequency of cystitis in diabetic subjects.
A complication which is much more rare is pneumaturia, in which the pa tient toward the end of micturition ejects a jet of gas through the urethra. In a patient observed by Mueller, the gas, which was collected under water, was composed as follows: II, from 44 to 57 per cent.; N, from 33 to 35; CO2, from 9 to 19; 0, traces; CH„ traces. Freshly-voided urine contained 1 per cent. of sugar, but sometimes there was no trace of it. There is no doubt that the phenomenon of the fermentation of the sugar is due to the presence of micro organisms in the bladder.
cutaneous complications occurring in diabetes are pruritus, ec zema, and gangrenous lesions. The pruritus may exist without any apprecia ble lesions. It affects the genital organs, especially the glans penis in men. In women it is much more painful, affect ing the vulva. It gives rise to an itch ing, burning sensation, with exacerba tions, which may cause insomnia and various nervous symptoms. Sometimes
it occurs early and forms one of the symptoms revealing the existence of the disease. Diabetic eczema is of two varie ties: either genital, in which case, like the pruritus, it appears to be due to the local irritation caused by the sugar, or general, when it occurs principally in arthritic subjects.
Chronic eczema, located in the genital organs in women, may be pachydermic. (Fournier.) The gangrenous dermatoses have been carefully studied by Marchal, of Calvi, and more recently by Kaposi.
Furuncle and anthrax frequently com plicate diabetes. Anthrax presents a somewhat peculiar type: beginning in sidiously, and with but little pain; the oedema is slight and the febrile reaction is either slight or does not exist. Very frequently the affection is complicated with a phlegmon or with gangrene.
Diabetic gangrene is not nearly so rare as most surgeons suppose. Fourteen cases observed. T. G. Morton (Philadel phia Med. Times. Jan. 1, '89).
Gangrene of diabetes not believed to be due to the presence of sugar in the affected tissues, but to the ill results which follow infective processes in the diabetic. Infection of the skin in these patients is a common accident. There is usually itching and scratching, and by this means pyogenic organisms obtain entrance. Gussenbauer (Wiener med. Plat., Feb. 2, '99).
The gangrene may be primary in dia betics, without any previous phlegmon or anthrax. In this case it is dry or mummified, like senile gangrene. It begins most frequently in the toes, and has been seen to originate simply in a local asphyxia. I have already men tioned the diabetic perforating ulcer (see NErivous ComPmcArrioNs).
Diabetic gangrene is not infrequently the first symptom to attract attention to diabetes in an apparently-healthy person. Hence the necessity of examin ing the urine in cases of gangrene. Roser (Berliner klin. Woch., June 22, '96).
if a gangrenous inflammation occur in comparatively-young persons, the urine should be examined, as diabetics may thus suffer from gangrenous inflamma tions. Diabetic gangrene often arises in the presence of arteriosclerosis; in 9 out of 11 cases observed severe arterioscle rotic changes were present in the small vessels. Koenig (Berliner klin. Woch., June 22, '96).