Diabetes Mellitus and Sensory Neuropathies

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The passing of excess urine or polyuria, associated with great thirst, is a condition noted by Aretaeus in the 2nd century A.D. but, according to Adams, neither he or any other ancient writer appears to have known of an association with sweetness of the urine40; this is first attributed to Willis, who wrote:

"A Nobleman in the vigour of his Age, became very prone to an excess of Pissing... in the space of twenty four hours, he voided near a Gallon and a half of clear water, and wonderfully sweet, as though Honey were mixt in it." And "... we need not wonder that the urine of those labouring with the Diabetes is not salt. But why that it is wonderfully sweet like Sugar or hony."4

Sadly, the remedy for diabetics, insulin, the internal secretion of the pancreas,was not isolated before 1922 by Banting and Best.42 Its association with gangrene was probably determined in the 19th century. Lyot wrote in 1896:

"We find a few sparse observations of diabetics with gangrene before 1845, at which time, apparently, Carmichael was the first to establish a relationship between glyco-suria and gangrene."43

Treves, noting the hazards of operating on diabetics in 1895, observed:

"Diabetic gangrene of a limb is determined by many causes, among which especial attention must be given to inflammatory conditions, atheroma of vessels and peripheral neuritis. There was a time when amputation for diabetic gangrene was considered to be absolutely hopeless. Of recent years, however, this operation has been carried out with success.'4

In any event, sugar diabetes is believed to be an ancient ailment and a source of gangrenous complications caused, in younger patients, by loss of protective sensation in the peripheral nerves, especially of the feet, and in those surviving to middle life, to arteriosclerotic changes, or to combinations of the two pathologies. The sensory loss, especially absent pain sensibility, exposes the toes and feet to damage undetected by the victim unless they, or others, observe skin changes and ulceration visually; the broken skin may also become infected, aggravating control of the diabetic state and accelerating local tissue damage.

Modern management with controlled sugar levels, suitable footwear, the use of mirrors by patients to inspect the soles of their feet regularly, and antibiotics may prevent or resolve early tissue damage or limit surgery to toe amputations. Before insulin therapy and even since, severe diabetics with arterial pathology developed irreversible gangrene of the lower limb requiring below-knee amputation, often symmetrically bilateral. Latterly, antibiotics and arterial reconstruction may save some limbs whilst above-knee amputation is less frequently indicated. Outlining these measures, Eastcott concluded:

"... control of infection may be decisive. Diabetic gangrene is a complex condition in which major occlusive arterial disease, lesions in small vessels, and sensory neuropathy may each play an important part."45

Other forms of peripheral neuritis which involve loss of pain sensibility, skin breakdown, infection and bone necrosis include hereditary sensory neuropathy with loss of toes and feet, and leprosy, which may also involve the hands.

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Supplements For Diabetics

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