DIABETES


In such serious cases the urine contains two other components, i.e. acetone and acetone-acetic acid; their presence in the urine we may conclude already from the winy smell of the urine or from the patients breath. If the patients breath has the characteristic unpleasant pomaceous smell, we may be sure that acetone and acetone-acetic acid are not only in the breath, but also in the urine of the patient.


DIABETES MELLITUS usually starts much earlier than the patients becomes aware of it. The first symptoms are vague and general to such a degree that they may be applied to other diseases, especially to diseases of the digestive organs. Consequently we have to examine the urine in all cases whatsoever, before giving any advice or any treatment. Not to do o, I must say, would be an inexcusable mistake.

Diabetes mellitus begins with disorders of the digestive organs. The patient at first complains of uneasiness, painful sensations and tightness in the region of the liver and of the stomach, accompanied by irregular opening of the bowels, sometimes by acid eructation and vomiting of a brownish, very bitter tasting liquid. The patient complains of headache, sleeplessness, intense fatigue, giddiness, buzzing in the ears, weakness of the eyes, palpitation of the heart, burning sensations in the heads and feet; simultaneously the mental condition of the patient gets entirely altered.

Certainly all these symptoms are of an entirely general nature and may be found also in many other diseases. But if the disease progresses, we get confronted with a very characteristic symptoms, i.e. the strikingly increased thirst, especially after eating and during the night.

Naturally the patient is constantly seeking to allay it, and the quantity of liquid consumed is proportional to the amount of urine passed.

According to the increased secretion of urine the patient has to urinate very often, especially during the night, again and again interrupting the patients sleep. As a rule the average quantity of the urine during twenty-four hours amounts to 3-5 pints. But there are cases in which the quantity may be much greater. I remember patients secreting nearly 12 pints urine daily. The urine is usually clear, pale in colour, has a sweet taste and is of high specific gravity (1030 to 1050).

When diabetic urine is boiled with cupric salt, which has a bluish of green color, the latter is reduced to a cuprous salt having a brown or yellow colour, and a process depending upon this chemical reaction from the usual method of recognizing and estimating the amount of sugar present in the urine. The sugar can also be tested by measuring the amount of carbonic acid gas set free on fermentation by yeast and by the extent to which a specimen of the urine rotates the pane of polarized light.

The quantity of sugar passed in twenty-four hours may vary from a few ounces to several pounds, and it is, of course, markedly increased after sugary or starchy food has been taken. In light cases of diabetes the urine contains only 2 to 1 per cent. sugar, in the most serious cases 10 per cent. or even more; in these serious cases there is also albumen in the urine.

In such serious cases the urine contains two other components, i.e. acetone and acetone-acetic acid; their presence in the urine we may conclude already from the winy smell of the urine or from the patients breath. If the patients breath has the characteristic unpleasant pomaceous smell, we may be sure that acetone and acetone-acetic acid are not only in the breath, but also in the urine of the patient. Whoever has repeatedly perceived that smell will always recognize it, hence it is called the acetone-smell.

As a rule the skin of the diabetic patient is dry and harsh with a peculiar papery consistency. Owing to the poor vitality of the tissues, various skin eruptions appear, boils and carbuncles being especially common and, in the fact, sometimes giving the first signs of the presence of the disease.

The sugar deposited from the urine is very liable to cause itching about the groins and eczema of various parts of the body is set up by the presence of sugar in the sweat. There is a special tendency to gangrene of the skin of the feet, commencing with the toes, and this from is a very serious complication of diabetes and a not uncommon from of fatal issue.

Regarding the nervous symptoms I have already mentioned the general symptoms as there are a certain feebleness, exhaustion, dislike of physical or intellectual work, great weakness after the slightest exertion, sensation of formication and numbness in the limbs, headache, depression.

But one symptom of the nervous system is a very characteristic one, i.e. the typical neuralgia, especially frequently affecting the sciatic nerve, usually called ischias or sciatica. Whenever it affects both sides, it may be an early symptom of the diabetes; besides the sciatica there are also cases with neuralgia in the occiput or in the face as well as cases of a specific migraine (sick headache). In other cases of diabetes we find paralysis of the limbs.

The most serious symptom of the disease is the so-called diabetic coma; it usually begins with some slighter general nervous symptoms as there are headache, nausea, a certain unrest, oppression and anguish, very soon increasing and aggravating. the patient gets delirious, jumps out of the bed and gets excited to such a degree that he behaves as raving mad.

As soon as the excitation has passed away, a characteristic enervation and somnolence sets in, aggravating in the most serious cases up to complete unconsciousness and to that deathlike sleep, called coma. The patients breathe extremely deeply and noisily, their faces get bluish red, cyanotic, the pulse is very much accelerated and low, the temperature decreasing.

Such a coma may continue for several days, but in the majority of cases it starts like an apoplexy. In any case the coma always is the most alarming and the most fateful symptom, it is due to a self-poisoning as a result of the absorption of the waste products of metabolism or of the products of decomposition within the intestine. In nearly all cases the coma is the consequence of inappropriate nourishment, especially of too much meat and eggs. The patient overloads the digestive organs with nourishment which cannot be digested, slags remain, poisoning the central nervous system.

Diabetes, as a rule, advance comparatively slowly, except in the case of young people, in whom its progress is apt to be rapid. Indeed, in a general way, it is more serious, the younger the subject of the disease. Various complications arise in its course; some of them I have already mentioned; as one of the most alarming complication I will call attention to the cataract, followed by dimness and loss of sight, furthermore to inflammatory chest affections, of which pulmonary consumption is the most common and is a frequent termination of diabetes.

Occasionally death occurs from exhaustion or from the coma diabeticum spoken of above. But the majority of cases continue suitable diet and treatment for many years without materially getting worse, and in a great number of cases complete cure apparently takes place. The most unfavorable cases are those in children, also cases in which the disease has already become of severe character, and has established before it has been recognized.

There is no other disease in which diet is of such a decisive importance as it is in diabetes. It would be a serious mistake to prescribe schematically the same diabetic diet for all cases; each case has to be treated individually according to the age, weight and activity of the patient as well as to the stage reached by the diabetes.

The amount of energy that must be supplied by the food in order to carry on the vital processes of life, such as body warmth, the action of the heart, he such as body warmth, the action of the heart, the movements of the chest,in breathing, and the chemical activities of the secreting glands, is, for an adult of about 140 lbs. in weight, approximately 1,600 calories daily.

For a patient, lying quietly in bed, little more is needed; for sedentary occupations such a patient requires about 2,000 calories, while if he is doing muscular work, the equivalent of 3,000 calories is needed. I desist from discussing that problem thoroughly, though it is of the greatest importance.

Generally speaking the diabetic diet ought to be composed of albumen. green vegetable and fats. Uncooked food ought to be the main constituent; especially I call the attention to uncooked fermented cabbage, plentifully containing vitamins, mineral salts and an insulin-like body; I usually prescribe 1 to 2 lbs. daily. Furthermore, once or twice weekly, the patient ought to take only fruit, especially berry fruits; owing to their abundance of bases, they alkalize the acids and diminish the demand for albumen.

Green vegetables, especially green beans, salads, onions, horseradish, celery, carrots, radish, potatoes baked in their jackets, fresh cucumbers, nuts, especially walnuts, oatmeal porridge, old and very well toasted rye-bread, cream cheese, fresh butter, daily one to two large spoons of walnut oil and the yolk of an egg, mixed with lemon juice, are of the greatest value for the patients. For, generally speaking, vegetable albumen is more wholesome to the diabetic patient than animal albumen; at least sausage ought to be prohibited.

W. Karo