84 DIABETES MELLITUS 



a difference of degree; the nature of the affection depends upon the same 

 process in the mild and in the severe cases, and transitional forms are by no 

 means rare. 



Well developed cases of the mild and of the severe variety resemble one 

 another as little as an epileptic migraine resembles typical severe epilepsy, 

 or even less. When, in a severe case of diabetes, 4 to 15 or more liters of urine 

 are passed with a specific gravity of 1.025 to 1.040, or even 1.060, and a per- 

 centage of sugar from 5 per cent, to 12 per cent, daily (200 to 1,500 grams 

 of sugar daily), it is obvious that there must be an enormously increased 

 intake of nourishment; yet it is easy to understand that in spite of this the 

 patient emaciates, becomes debilitated, and soon perishes. The course of the 

 disease in such cases is necessarily brief. Often vi^ithin a few weeks the body- 

 weight falls to 60 kilograms in a man or 50 kilograms in a woman, and in 

 spite of all endeavors to prevent this, the patient's condition becomes pro- 

 gressively worse; in from one and a half to three years increasing cachexia, 

 diabetic coma, or pulmonary tuberculosis, terminates life. 



Mild cases of diabetes may exist undiscovered for years, even decades, 

 until a complication or an accident leads to the discovery of the glycosuria; 

 so vague may this condition be. In such cases only 10, 30 or 50 grams of 

 sugar are excreted daily, with a normal or slightly increased amount of urine 

 in twenty-four hours, and this state of things may go on indefinitely, although 

 the patient before, as well as after, the discovery of the sugar pays but slight 

 attention to his condition. If he limits the amount of beer, bread and starchy 

 food and gives up sugar and potatoes entirely, this will suffice to keep his 

 glycosuria within the limits above mentioned, whereas, in a severe case, even 

 the strictest diet only brings about an amelioration, and the patient's whole 

 life becomes a combat with glycosuria, a battle for existence. If glycosuria 

 is a symptom in a mild case of diabetes, in a severe case it is the disease, the 

 fatal disease itself. The loss of sugar in the urine, the impossibility of com- 

 pensating for it by an increased nourishment, and the consequences, among 

 which coma is common, are the conditions from which the patient suffers and 

 to which he finally succumbs. 



In the severe cases glycosuria itself is, in a certain sense, the main disease, 

 since usually in cases of " pure " diabetes no disease of any special organ can 

 be found. It is not necessary to discuss the question whether in these cases 

 of " pure " diabetes we are justified in looking upon a disease of some special 

 organ— generally the pancreas— as the cause of the disturbances of metabolism. 

 On account of my own position in regard to pancreatic diabetes I have par- 

 ticularly interested myself in this question; but it is impossible to prove in 

 these severe cases, either from the symptoms and signs present during the 

 life of the patient, or at the autopsy, anything which points to disease of the 

 pancreas or of any other organ. There are, as has already been mentioned, 

 cases of diabetes due to disease of the pancreas, pancreatic calculi, cirrhosis of 

 the pancreas, etc., but they are rare. 



The mild cases rarely belong to the type classified as " pure " diabetes ; 

 more frequently the symptoms point to hepatic diabetes, to nervous diabetes, 

 or to diabetes of the aged (arterio-sclerotic diabetes). Nevertheless, "pure" 



