This is to be especially emphasized as we must regard progressive diabetes in childhood as pancreatogenous with at least the same certainty as ordinary diabetes. The examination of the pancreas macroscopically and microscopically reveals so few anatomical changes that in many of the older autopsy records it was not deemed necessary to mention its condition. In the last two decades attention has been directed to the pancreas. The small size and relaxed condition of that organ has been given as a frequent finding. I myself have noted the latter condition, although no changes were discovered in the islands of Langerhans. It is of interest and deserves further observation that some of the children treated by me for diabetes had syphilitic fathers and that that disease was not completely cured at the time of the pro creation of the child. In such cases it is possible that there might be a functional weakness of the pancreas clue to the syphilitic virus. I have thought of this only recently and cannot fortify it with any great amount of clinical material.
of the writings upon diabetes in childhood, the impression is frequently gained that the onset of the disease is usually quite sudden and that the disease begins at once as a severe type of glycosuria. My experience does not agree with this opinion since in the majority of my little patients there were periods of months or even years during which the glycosuria was of a mild type and imme diately modified by the exclusion or even moderate limitation of carbo hydrates. This knowledge has been gained by the fact that the urine of small children is tested for sugar more frequently than formerly. Cases which are regarded as severe directly after the detection of the disease, have probably not been observed in the early stages. The passage from a mild form to a severe type is therefore apparently much more rapid in children than in adults. So long as the disease is mild, there is little evidence of illness. The thirst may betray it or the flecks of sugar on the underclothes may attract the mother's attention. Com plications such as disorders of the skin, diseases of the eye, neuralgias, etc., which in adults so often give the first diagnostic hint are practi cally unknown in the diabetes of childhood. When the diet is regu lated, the thirst disappears and the children develop satisfactorily in their physical and mental growth.
After months or years the tolerance for carbohydrates fails. This is often induced by some foolish lapse in diet or oftener by an inter current febrile disease (tonsillitis, diphtheria, pneumonia, influenza, etc.), which so often even in the diabetes of adults produces a rapidly incurable change. Even when such causes are absent the lessened tolerance is only postponed, not removed and the diminution quickly changes into complete loss. A period of a few months, often but several weeks may elapse between a tolerance for SO-100 grams of bread and the complete development of a severe type of glycosuria, no longer modified by the withdrawal of carbohydrates. As soon as the loss of tolerance appears,
the vivacity of the child with the physical and mental activity disap pears. They do not want to play with other children, become easily exhausted, complain of pains in the joints after every exertion and rapidly emaciate. A carefully selected dietary and good nursing may possibly coax back the old vigor but it is never more than a coaxing.
In the meanwhile thirst, which had for a time been in abeyance. reappears and the quantity of urine increases two to four times the nor mal. The urine contains large amounts of acetone, diacetic and oxy butyric acids and ammonia and the breath has the odor of acetone exactly the same as in adults. The fully developed picture of diabetic autointoxication (diabetic acidosis) is now evident. The urine is rarely free from albumin although the quantity is small. Under the micro scope the so-called coma casts are seen soon after the first appearance of the iron chloride reaction and their number markedly increases toward the end of life. I found the largest amounts of pathological acid, meta bolic products among children under seven years of age in a boy of four years, 4.2 grains of acetone, 38.5 grams of oxybutyric acid and the urine contained 4.5 grams of ammonia in an excretion of 10.2 grams of urea. In this patient I determined the finding, repeated in other cases, that the uric acid was abnormally abundant on an absolutely purin free diet (eggs, vegetables, butter, cream, oatmeal): 0.6-0.87 grams per day while the nitrogen excretion balanced the intake. This indicated an enormous nuclear destruction as the nuclein is the progenitor of uric acid and the other purin bodies.
The termination of diabetes in childhood, when an intercurrent infectious disease does not complicate it, is without exception death by coma. Its approach is usually made manifest by gastric disorders such as loss of appetite, nausea, vomiting, pain in stomach, spontaneous or on pressure. Increasing nervous irritability alternating with rapid relaxation, sleeplessness, and great muscular weakness are further symptoms. They often continue for weeks although commonly the dis ease runs a rapid course. No mention need be made of the complicating organic diseases occurring with diabetes and so common in the adult type since they are only suggested. Some cases have been found asso ciated with an unknown functional change in the pancreas and disorder of the intestinal secretion (calculus formation in the duct of Wirsung with resulting cyst and destruction of gland). Severe disorders in the digestion especially steatorrhcea and azoto•rhoea follow.