MILD AND SEVERE FORMS OF DIABETES 85 



diabetes may occasionally run a mild course, and cases of the other form may 

 sometimes be severe ; this latter course is most frequently seen in the diabetes 

 which occurs after trauma of the brain. 



Not infrequently the symptoms of the accompanying disease (hepatic, 

 nervous, or arterio-sclerotic) are much more prominent than the slight gly- 

 cosuria, and so it happens that the cirrhosis, or the tabes, in spite of the com- 

 plicating diabetes, runs the same course which it would have assumed without 

 the associated condition. In arterio-sclerotic diabetes, as the disease develops, 

 the arterio-sclerosis may become more and more prominent, presenting circu- 

 latory disturbances, cardiac asthma, angina pectoris, dropsy, congested liver 

 and albuminuria; in all of these cases we may note that, as they progress, 

 the glycosuria decreases and finally disappears. 



Although in many of these cases the glycosuria does not become promi- 

 nent, nevertheless, the diabetes and the diabetic disturbances of metabolism 

 usually do not fail to produce evil consequences; on the contrary, there is 

 quite an array of complications and symptoms which appear frequently in 

 mild cases; pruritus pudendorum, vaginitis, vulvitis, balanitis, phimosis, ure- 

 thritis, impotence, fermentation of the urine in the bladder (with pneuma- 

 turia), and as a consequence of this, cystitis and pyelonephritis; itching of 

 the skin, urticaria, eczema, the most manifold ulcerating dermatoses, furun- 

 culosis, carbuncle, lymphangitis, boils, intermittent claudication, gangrene of 

 the toes, necrosis of internal organs, pulmonary gangrene, pulmonary tubercu- 

 losis; also a host of nervous diseases; encephalomalacia, column degeneration 

 of the spinal cord, neuritis, polyneuritis, neuralgia, peripheral paralyses (par- 

 ticularly paralysis of the facial nerve), malperforant, very frequently loss 

 of the patella reflex which occasionally ushers in the remarkable picture of 

 pseudo-tabes diabetica. 



It is impossible to bring this confused array into any systematic arrange- 

 ment; any one of these symptoms, or complications, may appear alone as the 

 first sign of a diabetes, latent up to them ; each of these conditions may remain 

 the only one, or be succeeded in any order by any of the others. 



For some of these conditions diabetes alone cannot be held responsible; 

 thus arterio-sclerosis is the true cause of gangrene of the extremities with its 

 occasional prodrome, claudicatio intermittens, perhaps also of malperforant. 

 This is true, even though these lesions occur during the course of a case of 

 diabetes. In the peripheral paralyses and neuralgias, the neuropathic predis- 

 position doubtless often plays a part, and the diabetics that suffer from poly- 

 neuritis are, as far as I know, all alcoholics. 



Naturally the question next arises whether diabetes has any influence at 

 all in the production of these lesions; for example, in cardiac asthma or in 

 angina pectoris of the diabetic; take the case of an old diabetic, with a 

 glycosuria of from 3 per cent, to 4 per cent., from 50 to 60 grams of sugar 

 per day, suffering from cardiac asthma or angina pectoris; there is slight 

 venous stasis of the liver, occasionally slight albuminuria; nothing abnormal 

 can be detected in the heart. Nevertheless, there is a well-grounded suspicion 

 that a beginning cardiac insufficiency, perhaps due to'myocardiac degenera- 

 tion and perhaps to arterio-sclerosis, is present, Removal of the glycosuria 



