the last two months she suffered from several attacks of ague. I had attended the same girl for an attack of acute intestinal haemorrhage which occurred without obvious cause about six months previously, but from which she apparently recovered without leaving any evil effects. On examining the child I found her suffering from what appeared to be general debility, with a certain amount of emaciation?the pulse was small and frequent (105 per minute). But there were no indications of any special malady present. Here was no apparent anaemia, no enlargement of liver or spleen, nor of the lymphatic glands, there was no apparent organic disease of the system of any kind, the appetite was good and the digestion normal ; heart sounds clear and distinct, no murmur audible. Having nothing to guide one, a general tonic regimen was recommended ; rest, with abundance of milk, meat, bread and butter ; as she had a cotton garment, we advised her to wear flannel from head to foot and prescribed Scott's Emulsion, and a mixture containing tonic doses of quinine with a little nux vomica and Wellcome and Burrough's beef and iron wine. I told the mother to put her to bed, as she appeared too weak to knock about, and that I should come over in a day or so and examine her again. On the morning of the 2nd October we called to see the girl and found her in bed breathing rapidly and deeply (66 per minute), with no disease of lungs or heart, &c., to account for this. The nature of the dyspnoea was pathognomonically that of incipient diabetic coma; the mother had noticed polyuria for some days. There was no cough nor fever; we were told that the change in the breathing was only noticed that morning, and as I had seen several cases of this kind the diagnosis was quite evident ; as barring hysteria there is no malady except approaching diabetic coma which causes such a profound alteration in the character of the respiration, together with a complete absence of all other signs of disease of lungs, heart, kidneys, angina pectoris and advanced anaemia. Nothing had happened since I saw the child to cause any material change in the patient. She now complained of great oppression in the chest DIABETIC COMA IN A CHILD. opposite the middle of the sternum and was restless, occasionally sitting up suddenly in bed and Patrick By Surgn.-Capt. Hehir, m.d., f.r.s.e., f.r.c.s.e., then throwing herself back again shortly afterd.p.h., Camb., wards, and then lapsing into a drowsy state. In Lecturer on Medicine and Pathology, Hyderabad, Medical School. fact, the mother asked me if there was anything the mixture she was taking to put her to sleep. in case of diabetic coma is one of The following both for rarity of that affection The breathing was profound, rapid (58 per interest, particular in children, and the circumstances under which it minute), and noisy, in fact typically what is known as diabetic dyspnoea. .occurred. The heart's action was tumultuous and the imM. A. M, an Eurasian girl, set. 9 years, was brought to me by the mother at 11 a.m. on the pulse diffuse and visible through the thin parietes, 29th September 1893, who stated that the child whilst the pulse was small, weak and frequent complained of being very weak and unable to (124 per minute). There was a peculiar sweet move about as usual and was losing flesh. Dur- odour from the breath reminding one of the odour
ing
March
DIABETIC COMA IN A CHILD.
1895.]
from the cup whilst administering chloroform ; indeed this smell pervaded the whole room and arrested my attention at once on entering. The temperature was subnormal (97'2F.) The parents forced a prognosis from me, but would not credit the seriousness of the case. I remained with the child the whole day, making .observations, one of which was upon the microscopic characters of the blood with purely negative results. The change in the colour of the blood was wellmarked it being of a peculiar pinkish hue. At 2 P.M. a two-gallon chamber utensil under the bed was almost full of the urine passed since morning. The child passed urine on an average every 12 minutes and about ? pint was discharged each It was pale, and had all the character time. of diabetic urine, the specific gravity being 1055, and it was calculated from observations made next of sugar was disday that at least 14 ounces The child continued hours. 24 charged in the in this state till 12 noon the following day. We left the patient at 4 P.M. and returned at 9 p.m. to find her in a semi-comatose state, but only for a moment. although easily aroused, to 64 per minute and risen had The respirations was The thready and the pulse were very deep. Aroused to take a drink she extremities cold. into a condition would immediately lapse back The room was now pernarcosis. simulating deep of the breath and vaded with the peculiar odour The latter involuntarily. the passed being urine, child died at 5 A.M. next day without making any one
gets
at rallying. This is the second case of diabetic comma we have the other one being seen in children in Hyderabad, seven years, but his case set. Mussalman of boy that over a period of ran a much slower course, going with a history of associated was it and eleven days, sweets and sugar?the parents a great penchant for eat half a^ pound of sugar at stating that he would to chanced get at it. a time, if he condition has been This profoundly interesting of deal discussion, and up a great the subject of what is the essenknow not do we to the present it. This, however, tial factor operating to produce we consider that the real when is not strange mellitus is still unknown. pathology, if diabetes " The mysterious phenomena of Strumpell says : a diabetes mellitus present problem the solution of which has been most industriously sought postresult has been reached mortem, but no satisfactory he remarks : "As has this and, again, in way*; been said, we know practically nothing of the This is the true causes of diabetes mellitus."f most and scientific the of one popular of verdict
attempt
of
our
We, disease
latest text-books on medicine. of course, know a great deal about the diabetes mellitus, the conditions under
*
Strumpell's
Text-book of Medicine, '
t Op. Git., pp. 911.
n
Oil
Ill
which it occurs, its clinical history, the principles of treatment, &c., but the essential causes of the malady are still obscure. Diabetic coma has been attributed to various special agents circulating in the blood, some stating that these are the products of the decomposition, or rather fermentation of grape-sugar in the blood, others considering this complication to be due to alkaloidal poisoning by a body simulating morphine in its effects. This latter appears to give a clue to the nature of the lethal agent circulating in the blood; it at least gives a clearer explanation than the former ; for the whole clinical history indicates that some poison hasxbeen more or less suddenly formed from a pre-existing substance, manufactured in the system by a perverted metabolism or as the result of an abnormal metamor-
phosis.
Ord in England and Kuhne on the Continent had endeavoured to prove the abnormal product to be acetone, and hence diabetic coma received the appellation of acetonoemia. Recently, however, we have the theory of Jaksch, which considers the phenomeua due to be acid acetic acid as the resulting product of a peculiar fermentative process, whilst others believe it to be due to an excess of one or other of the acids so frequently found in diabetic blood, such as crotonie acid, &c At present no theory stands the test of severe criticism, and none receives universal acceptance. Certain it is that it is impossible to produce this state by the artificial injection of acetone, or any other known agent. Orthodox methods of treatment were adopted, such as the use of salines, alkalis, nitro-glycerine solution, &c., but to no purpose. Personally, I feel convinced that a certain proportion of cases of diabetes mellitus are due to malarial infection, and probably from embolic plugging of the arterial supply of the "diabeticcentre" of Bernard by the Plasmodium malaria), or the disintegrated pigment which is met with in such large quantities in malarial blood. We have proved, by minute examination of the condition of the arterioles of basal ganglia of the cerebrum, that such vessels as the lenticulo-striate arteries of the internal capsules may be completely blocked up in this way, and that such plugging of the smaller arterioles may cause immediate symptoms of paraly-
sis,
or
give origin subsequently
to
miliary
aneu-
rismal dilatations similar to those which Profr. Charcot proved to arise from combined peri-and end-arteritis in the basal ganglia. These small aneurisms rupture in cases of chronic malarial infection and cause attacks of hemiplegia, which are often however temporary in their nature. There is no reason against our conceiving that a similar change may not arise in the arterioles of the diaThere are, of course, betic centre or centres. and diabetes varieties of many causes, but many this is possibly, nay very probably one.
ing
March
DIABETIC COMA IN A CHILD.
1895.]
from the cup whilst administering chloroform ; indeed this smell pervaded the whole room and arrested my attention at once on entering. The temperature was subnormal (97'2F.) The parents forced a prognosis from me, but would not credit the seriousness of the case. I remained with the child the whole day, making .observations, one of which was upon the microscopic characters of the blood with purely negative results. The change in the colour of the blood was wellmarked it being of a peculiar pinkish hue. At 2 P.M. a two-gallon chamber utensil under the bed was almost full of the urine passed since morning. The child passed urine on an average every 12 minutes and about ? pint was discharged each It was pale, and had all the character time. of diabetic urine, the specific gravity being 1055, and it was calculated from observations made next of sugar was disday that at least 14 ounces The child continued hours. 24 charged in the in this state till 12 noon the following day. We left the patient at 4 P.M. and returned at 9 p.m. to find her in a semi-comatose state, but only for a moment. although easily aroused, to 64 per minute and risen had The respirations was The thready and the pulse were very deep. Aroused to take a drink she extremities cold. into a condition would immediately lapse back The room was now pernarcosis. simulating deep of the breath and vaded with the peculiar odour The latter involuntarily. the passed being urine, child died at 5 A.M. next day without making any one
gets
at rallying. This is the second case of diabetic comma we have the other one being seen in children in Hyderabad, seven years, but his case set. Mussalman of boy that over a period of ran a much slower course, going with a history of associated was it and eleven days, sweets and sugar?the parents a great penchant for eat half a^ pound of sugar at stating that he would to chanced get at it. a time, if he condition has been This profoundly interesting of deal discussion, and up a great the subject of what is the essenknow not do we to the present it. This, however, tial factor operating to produce we consider that the real when is not strange mellitus is still unknown. pathology, if diabetes " The mysterious phenomena of Strumpell says : a diabetes mellitus present problem the solution of which has been most industriously sought postresult has been reached mortem, but no satisfactory he remarks : "As has this and, again, in way*; been said, we know practically nothing of the This is the true causes of diabetes mellitus."f most and scientific the of one popular of verdict
attempt
of
our
We, disease
latest text-books on medicine. of course, know a great deal about the diabetes mellitus, the conditions under
*
Strumpell's
Text-book of Medicine, '
t Op. Git., pp. 911.
n
Oil
Ill
which it occurs, its clinical history, the principles of treatment, &c., but the essential causes of the malady are still obscure. Diabetic coma has been attributed to various special agents circulating in the blood, some stating that these are the products of the decomposition, or rather fermentation of grape-sugar in the blood, others considering this complication to be due to alkaloidal poisoning by a body simulating morphine in its effects. This latter appears to give a clue to the nature of the lethal agent circulating in the blood; it at least gives a clearer explanation than the former ; for the whole clinical history indicates that some poison hasxbeen more or less suddenly formed from a pre-existing substance, manufactured in the system by a perverted metabolism or as the result of an abnormal metamor-
phosis.
Ord in England and Kuhne on the Continent had endeavoured to prove the abnormal product to be acetone, and hence diabetic coma received the appellation of acetonoemia. Recently, however, we have the theory of Jaksch, which considers the phenomeua due to be acid acetic acid as the resulting product of a peculiar fermentative process, whilst others believe it to be due to an excess of one or other of the acids so frequently found in diabetic blood, such as crotonie acid, &c At present no theory stands the test of severe criticism, and none receives universal acceptance. Certain it is that it is impossible to produce this state by the artificial injection of acetone, or any other known agent. Orthodox methods of treatment were adopted, such as the use of salines, alkalis, nitro-glycerine solution, &c., but to no purpose. Personally, I feel convinced that a certain proportion of cases of diabetes mellitus are due to malarial infection, and probably from embolic plugging of the arterial supply of the "diabeticcentre" of Bernard by the Plasmodium malaria), or the disintegrated pigment which is met with in such large quantities in malarial blood. We have proved, by minute examination of the condition of the arterioles of basal ganglia of the cerebrum, that such vessels as the lenticulo-striate arteries of the internal capsules may be completely blocked up in this way, and that such plugging of the smaller arterioles may cause immediate symptoms of paraly-
sis,
or
give origin subsequently
to
miliary
aneu-
rismal dilatations similar to those which Profr. Charcot proved to arise from combined peri-and end-arteritis in the basal ganglia. These small aneurisms rupture in cases of chronic malarial infection and cause attacks of hemiplegia, which are often however temporary in their nature. There is no reason against our conceiving that a similar change may not arise in the arterioles of the diaThere are, of course, betic centre or centres. and diabetes varieties of many causes, but many this is possibly, nay very probably one.
