=Definition.=—A nutritional disorder in which there is an abnormal
amount of sugar in the blood, characterized by an excessive urinary
discharge, in which grape sugar is constantly present, and by a
progressive loss of flesh and strength.
=Osteopathic Etiology= and =Pathology=.—Almost invariably there will
be found a posterior dorso-lumbar curvature wherein the spinal column
tissues are much contractured. This condition probably involves the
sympathetics (vasomotor and trophic) to the pancreas, liver and
intestines. Important lesions may also be found as high as the occiput.
Tenderness and congestion over the abdomen, especially the liver, are
frequent. It affects men more frequently than women and is a disease
of adult life, ranging between the ages of thirty and sixty, though
cases have occurred in the very young. It is more serious in the young,
the very young seldom recovering. Hereditary influences are believed
to be a predisposing cause. It affects the better classes principally
and especially those of a neurotic temperament. The Hebrew race is
specially predisposed. The colored race is seldom affected.
Obesity, certain chronic diseases (malaria, gout, syphilis),
occupations taxing the mind, and pregnancy are predisposing influences.
Injury or disease of the spinal cord or brain frequently cause
diabetes, especially any irritation of Bernard’s diabetic center in
the medulla. Derangements of the endocrine system are important.
Injuries to the spine, chiefly in the dorso-lumbar and sacral regions,
and to the abdomen, and diseases of the pancreas or liver are, as
has been stated, oftentimes causes. Lesions to the spine may disturb
the glycogenic function of the liver, the glycolytic ferment of the
pancreas, or produce an alimentary glycosuria. Extirpation of the
pancreas is immediately followed by diabetes, but if a fragment of
the pancreas is left it is not always followed by diabetes. The
normal amount of sugar in the blood is 1-1000 while in diabetes the
amount of sugar is 3 to 4-1000 up to 7 or 8-1000. The healthy kidney
will not excrete sugar when it is at the normal ratio. Concerning
the presence of acetone-bodies von Noorden[70] says: “The excretion
of acetone-bodies may serve, like glycosuria, as a measure of the
intensity of the diabetic disease ... it will be at once understood
that in no other disease do the acetone-bodies occupy so important a
position as in diabetes.” Irritation of the centers of the vasomotor
nerves to the liver or direct stimulus to the liver cells is followed
by glycosuria. Interference with the pneumogastric nerve also
influences diabetes.
=Pathologically=, the liver is enlarged, firmer and darker in color
than normal. Often there is fatty degeneration of the organ. The
pancreas is diseased in about one-half of the cases of diabetes,
especially the islands of Langerhans. The lesions found are granular
atrophy, occlusion of the pancreatic duct, atrophy from pressure,
fat necrosis, and sometimes it is small, soft and anemic. The kidney
changes are those of catarrhal nephritis. In the fatty degeneration
hyalin changes take place. The heart is hypertrophied in a few cases.
Arterial sclerosis is frequently met with. In the lungs bronchitis,
pneumonia and tuberculosis occasionally develop. In the stomach and
intestines catarrh is common. The blood presents an increase of sugar.
In the nervous system are found many lesions, especially congestion,
extravasation and sclerosis of the brain; disturbances of the posterior
part of the cord, and congestion and sclerosis of the sympathetic
ganglia. The bony lesions, however, (almost invariably a posterior
lower dorsal and lumbar) must involve the sympathetics, via the
splanchnics, to the extent of profound metabolic disturbance, for in no
other way can the results of osteopathy be explained. The importance
of specific treatment at this point cannot be over estimated.
=Symptoms.=—The =onset= is gradual; thirst and frequent micturition
being the first symptoms noticed. After an injury or a sudden, severe
nervous shock, diabetes may set in abruptly. As the disease progresses
there will be marked thirst, polyuria, an abnormal appetite, wasting
and debility. The tongue is dry, red and coated. There is constipation
and the skin is dry and harsh. Temperature is often subnormal; pulse
frequent with increased tension.
In some cases the =urine= is not increased in quantity; usually
however, the amount varies from four to five pints to several quarts in
twenty-four hours. It is pale in color, of high specific gravity and
acid reaction. Sugar is present in variable quantities from one or two
per cent to five or ten per cent. Sugar in the urine must be constant
in order that the affection is a true diabetic one. Albumin is often
present; urea is increased and uric acid may be slightly increased.
Acetone-bodies are often found and usually indicate a more serious
condition.
=Diabetic Coma= is the most important and gravest complication.
There is either a sudden or gradual loss of consciousness. This may
occur after some form of exhausting exercise. There may be previous
headache or a feeling of intoxication. It may be preceded by nausea,
vomiting, colicky pains or some local affections, such as pharyngitis
or pulmonary complications. Peripheral neuritis, neuralgia, numbness,
are possible symptoms. Impairment of hearing, cataracts, strabismus,
diabetic retinitis and atrophy of the optic nerve may occur. The sexual
function is lost early in the disease. Eczema, with burning and itching
of the labia and vicinity, (and in men a balanitis), furuncles, boils
and carbuncles are common. Gangrene and edema are not uncommon. Acute
pneumonia, bronchitis and tuberculosis are possible complications.
=Progressive loss of flesh= is a serious indication.
=Diagnosis.=—The diagnosis is easy, as there is no other disease with
which it can be confounded. Careful urinalysis should always be made.
Examination for acetone, diacetic acid and oxybutyric acid is valuable.
=Prognosis.=—Many cases have been cured by osteopathic measures while
nearly all treated have been benefited. If the patient is put upon a
diet free from carbohydrates, in mild cases the sugar will disappear,
while in severe cases it will still be present. Mild cases usually
yield readily to treatment. In cases over forty years of age the
outlook is quite favorable, but in cases under forty, and especially
the young, the prognosis is not so favorable. In cases under puberty
the results are apt to be fatal. Stout persons bear diabetes better
than lean. All cases are liable to complications, which render the
prognosis more serious. It is a disease of long =duration=, although
death has occurred in a few weeks.
=Treatment.=—In nearly all cases of diabetes mellitus examined there
have been found posterior conditions of the lower dorsal and lumbar
regions. The posterior curve has always been fairly well marked and
generally is a symmetrical curve. By that is meant a spinal curve that
is not irregular and the relation of the various vertebræ, one to the
other, is not seriously deranged. Correction of this condition of the
spinal column has almost invariably given satisfactory results and
in the majority of cases the condition of the patient has improved
remarkably, and many entirely cured. To get the best results the
patient should be laid on his side on the operating table and the knees
drawn up so that the thighs are flexed upon the abdomen. The osteopath
standing in front of the patient throws his weight against the flexed
thighs and reaching over upon the spinal column springs the entire
weakened portion of the spine toward its normal position, stretching
the spinal column to separate each vertebra from its neighbor so that
the deranged nerves, as they pass through the intervertebral foramina,
may be released. Meeker[71] reports a case with a marked kyphosis which
was treated two years before enough motion could be had between the
vertebræ to produce any results, but after that they were favorable.
Direct treatment to the abdominal organs to correct liver congestion
and stimulate the pancreas and increase activity of the intestines is
essential.
The nerves affected by the posterior pathological curve of the spine,
mentioned above, and by separate lesions that may exist within the
pathological curvature, are probably the vasomotor nerves to the portal
system, pancreas and the intestines. The vasomotor nerves to the portal
system branches are given off principally from the fifth to the ninth
dorsal vertebræ, although fibres may escape from the cord as low as
the first lumbar vertebra. The nerves to the intestines are given off
principally from about the ninth dorsal to the lower lumbar vertebræ.
Possibly there are nerve fibres direct to the hepatic cell protoplasm.
How lesions in the dorso-lumbar region cause diabetes mellitus is an
important question and is hard to answer. An unnatural acceleration
of the portal circulation may cause an increased quantity of sugar to
pass to the liver, resulting in part of the sugar not being changed
into glycogen and thus passing into the circulation; or a paralysis
of the vasomotor nerves to the liver causes congestion and slowness of
the blood stream. Thus a disturbed circulation of the liver may cause
accumulation of sugar in the liver, so that the blood ferment has time
to act upon the glycogen and transform it into sugar; or there may be
a saccharinity of chyle or blood in the portal vein, due to an impeded
conversion of sugar in the intestines into lactic acid; or there may
be an accelerated absorption of sugar due to an abnormal state of the
intestines; or the nervous control to the pancreatic functions may
be disturbed. Hence, one or many pathological changes may occur and
influence a case of diabetes, due to a disordered dorso-lumbar region.
The center for the hepatic vasomotor nerves, “diabetic center,” is in
the floor of the fourth ventricle at the level of the origin of the
vagi nerves. A lesion of the “diabetic center” or an obstruction to the
pneumogastric anywhere along its course may cause diabetic symptoms;
hence, there may be lesions of the cervical region that would affect
reflexly the diabetic center, or lesions of the pneumogastric may
occur, particularly at the atlas or axis, and cause diabetic symptoms,
or, at least, these may influence the course of a case of diabetes
mellitus. Or the upper cervical lesions may disturb the pituitary gland
which is of importance in carbohydrate metabolism.
There are nerves from the superior and inferior cervical ganglia of
the sympathetic that have considerable influence upon the liver. These
nerves do not pass down the cord to the splanchnics, but pass in the
sympathetic to the celiac and hepatic plexuses and then to the liver.
Stimulation of these nerves causes the hepatic vessels at the periphery
of the liver lobules to become contracted. Possibly in a very few
cases, a stagnation of blood in other vascular regions of the body may
cause the blood ferment to accumulate in the blood to such an extent
that diabetic symptoms occur.
=Dietetic treatment= is essential, but is not so necessary as some
medical authors would have us believe. A regulated diet should be
insisted upon in all cases, but one should not go to extremes in
dieting. A complete elimination of the carbohydrates is no longer
considered the best treatment, as it withdraws too important an element
from the diet, producing weakness without any corresponding return for
good. A patient’s appetite is often inordinate and it will be necessary
to regulate the quantity and character of foods. Proctor[72] mentions a
case which recovered when carbohydrates were restored, as the patient
was too starved to build up. Under osteopathic treatment much more
liberty can be allowed in selection of foods. Von Noorden[73] reported
a number of cases in which excretions of sugar continued upon the
strict anti-diabetic diet, but which were sugar free when they received
a large amount of oatmeal along with some vegetable proteid or white of
egg and butter, other carbohydrates being excluded. It is suggested by
the editor of the Series that the oatmeal may be used alternately with
diabetic diet, and relieve the monotony greatly. It can also be used
as a test of the patient’s digestive and sugar destroying powers. The
following food may be included in the dietary:
Animal Foods.—Meats of every variety, except livers; game, poultry,
fish and eggs.
Vegetables.—Cabbage, cauliflower, celery, lettuce, green string beans,
the green ends of asparagus, tomatoes, spinach, mushrooms, cucumbers,
watercress, young onions, or any other green vegetable.
Bread and Cakes.—Made of gluten flour, bran flour or almond flour;
griddle cakes, biscuits, porridges, etc., may be made of these flours.
Beverages.—Skimmed milk, buttermilk, coffee and tea without sugar, and
carbonated water.
Relishes.—Pickles, cream cheese and nuts of all kinds except chestnuts.
Fruits.—Oranges, lemons, cranberries, cherries, strawberries, all in
moderate quantities.
Other foods may be used, but each case requires a thorough study in
order to determine what is best to do.
Various foods should be tested out and controlled by urinalysis.
The point is to increase metabolism so that the body can store up
considerable carbohydrates without the appearance of sugar in the urine.
In severe cases Allen’s fasting treatment to be followed by a low
diet should be instituted. However, it should be remembered that the
correction of dorsal and upper cervical lesions is invaluable.
Mental excitement and worry should be avoided as much as possible.
Frequent bathing and regulated exercise will be of considerable value.
The diabetic patient should have a well ventilated room and plenty
of rest and sleep; flannels are to be worn next to the skin the year
around.
Various symptoms and =complications= are liable to arise, which the
competent osteopath is prepared to meet by following general rules.
Keep the bowels open. And frequently examine for acetone and diacetic
acid. If there are any symptoms of =coma= fast the patient, and
neutralize the acid intoxication with bicarbonate of soda until the
urine is alkaline.