However, when, as has been remarked by _Bernard and Fere, an improvement in the mental condition occurs during the antidiabetic treatment, one would be inclined to achnit a certain relation be tween mental symptoms and the diabetic dyscrasia. The same conclusion is reached when the glycosuria and mani acal symptoms alternate. Cases of this kind have been reported.
Vascular Systent.—The lesions of the heart have been indifferently studied until of late. Among 380 diabetics Mayer has observed cardiac complica tions in 82.
Of 380 cases, 337 were in the first stage of diabetes and 47 in the second stage; of the latter 20 were under observation (hiring both stages. Increa,sed cardiac volume, either from hypertrophy or dila tation, is nmeh more frequent in dia betes than one would suppose from the literature, it being fonnd without other anatomical lesions in S2 of the 3S0 cases. J. Mayer (Zeit. f. B. 14, II. 3, 'SS).
These patients are either of very deli cate constitutions, with the heart weak and irregular, or they are obese diabetics, with the face red or cyanosed, who pre sent a strong cardiac impulse, and signs of dilatation of the heart, either with or without atrophy. These patients are liable to die suddenly. Such cases should not be confounded with the true diabetic coma; moreover, they differ from the latter by the absence of ace tonuria and by the suddenness of death. Very often it is after a voyage or fatigue of some kind that these patients fall into a state of collapse, with cold ex tremities; small, feeble pulse; a loss of consciousness, more or less rapid; and death in a few hours.
Five cases of diabetic angina pectoris; in one sudden death during attack. Vergely (Jonr. de MM. de Bordeaux, '94), There are also mixed cases, where, with a weak heart, there is, at the same time, autointoxication. I have myself observed three such cases. The ical examination of the heart shows the myocardium rather atrophied and pale.
Virehow's necropsy the heart was enlarged in nine cases out of sixty-nine, and exclusive of those in which there was enlargement from anatomical causes (vascular, valvular, or renal disease), a percentage of 13. Mayer (Zeit. f. klin. Med., B. 14, H. 3, 'SS).
Of the patients who (lied of diabetes at the Berlin Charite 10 per cent. had
cardiac enlargements without valvular or arterial lesions or renal disease. O. Israel (Annual, '89).
Arteriosclerosis is exceedingly com mon in diabetics. Ferraro dwells par ticularly upon generalized endarteritis.
According to him, the atrophic and crotic lesions reported in various organs are due to this endarteritis.
In the last 11 years there have been 26 eases of diabetic gangrene admitted to the wards of St. Thomas's Hospital. From a study of these eases the follow ing conclusions may be noted: 1. That it yet remains to be proved that true gangrene (excluding death from acute specific processes, which may occur in any subjects and at any age) occurs in diabetic patients unaccompanied by such arterial disease as would of itself produce the gangrene. 2. That the glycosuria may or may not precede the gangrene, but is not usually accompanied by other signs of diabetes. 3. That septic wounds may produce a glyeosuria, which van ishes when the septic process is removed. 4. That individuals snlIering from sep tic processes a,re often on the border-land of glycosuria. 5. That gangrene may aggravate a pre-existing glycosuria. 6. That thc arterial disease is sometimes that Nvhich accompanies, or is produced by, chronic renal disease. 7. That it has yet to bc proved that neuritis can pro duce any gangrene comparable to that of the so-called diabetic gangrene. S. That the best chance of recovery is offered by removal of the limb near the trunk, and that this measure should be under taken before the patient is reduced by septic absorption. 9. That the presence of glycosuria may be an indication, in stead of a contra-indication, for opera tion. C. S. Wallace (Lancet, Dec. 23, '99).
(Edema, which is quite common in diabetes, is not always symptomatic of an affection of the heart. It may pos sibly be due to a complication of Bright's disease of the kidneys, but this is extremely rare; to a venous throm bosis, of which examples have been re ported by Pavy, Gull, Dionis des Car rieres, Leudet, Potain, and others. Sometimes there appear to be active tumefaction and other inflammatory phenomena that are apparently due to vasomotor disturbances. In many cases the cedema depends upon the impaired nutrition of the vessels caused by the dyscrasia.