Experimental and Clinical Evidence of llie Significance of an Indefinite Fehling Reaction na nn Index of the Pre-glycosuric Stage of Diabetes.
'THE ONSET AND MARCH OF GLYOOSURIA'
AND
THE CAUSE OF TUE PREVALENCE OF DIABETES IN INDIA.
IN a country like India where glycosuria w exceedingly prevalent, the physician lias to be more on his guard, than in European countuatt, when carrying out an ordinary routine urine examination.
The extreme prevaleuce, and its incidence amongst the well-fed classée, of glycosurie may be gauged from a Haying quoted to one of us by a Bengali : ' a man is no gentleman if he does not pass sugar by the age of forty.'
In India, and particularly the Eastern side-Bengal, Orissa, Madra« -glyoosuria more or less takes the place gout occupied in Europe-wheu in the good old days no gentleman counted on going to bed sober. Even in the comparatively young, glycosuria is not uncommon : young adults frequently showing early signs of its probable onset. Flo much indeed in this the case that often, when carrying out investigations with students on sugar tolerance, we have gone into a class-room and selected half a -doeen or so of those present as being probably potential glycosurie». Almost invariably we found that only a small minority could tolerate fifty grammes or so of glucose, many of those selected showing the presence of sugar clinically without the administration of glucose.
Our reason for stating that one has to be more critical in examinm·.' the urins of Bengalis than of Europeans is on account of the large number of oases in which an indefinite Fehling reaction is obtained : sometime* it may only be a simple change of colour on boiling ; sometime« «light reduction may actually take place. Whenever there was any change from normal our experiences show that, in the great majority of case*. the tolerance to sugar and carbohydrates is on a low level.
Hitherto all the evidence we have been able to accumulate pointu to the importance of accepting this indefinite reaction as a warning. If heeded and the individual placed on the proper line nf treatment, umially very satisfactory results are obtained ; if allowed to pass as of little or uo importance, in the majority of cases, there will be a gradual progressive development of events leading through «ucoessiw «tages eventually to parmatient glyoosuria, kidney involvement and death. It is our object in the following pages to trace, an far as possible, this gradual onset and the march of events until glycosuria has become firmly established. In doing ao, we shall avoid, as far as possible, theoretical discussions and rely mainly on the facts, as we have found them from practical analyse« and experiments. Our interpretations may turn out to be wrong but the record of the experimental findings are as accurate as it is possible to expect'.
In section I of this paper we found that the concentration of the sugar of the blood in Bengalis wan distinctly higher than in Europeans ; further, amongst Bengalis, the percentage of migar i« higher in the wellto-do classes than in those not so we 11-fed and who have to perform manual labour.
It was also shown that, as a rale, the better-fed classes sooner or later began to deposit fat and that in the fat-and usually, flabby-the percentage of blood sugar in abnormally high and that the ingestion of glucose causes an increase until, in a large proportion of cases, the threshold stimulus of the kidney Ls overstepped and glyoosuria results. It is usually in thin class that the indefinite Fehling reaction is obtained. A simple tolerance test brings out the cause in its true colours.
In section II of this paper we referred to this class of potential glycosurie and placed him in the category of those in whom the threshold stimulus of the kidney foe excretion of sugar is high. The chain of events we suggest as being something of the following nature :
So long as the energetic period of youth lasts, even though handioappad by a comparatively high glycoemia, the average well-to-do Ihngali, living on a highly carbonaceous diet, is able to burn up and make use of all the sugar that reaches the blood. That is, he is able to fix excess sugar and store it up as glyoogeu and prevent a hyperglycoemia sufficient to call forth glyoosuria.
Once the struggle for food is safely over aud the school boy or student passes on to his office stool or other work, usually of a sedentary nature, still handicappsd by hie high glycaamia he now settles down to a life of ease and comfort. Ho takes little or no exercise and, as prosperity comes to him, he is able to indulge his appetite to a greater extent than in earlier days. Now this is the danger period of his life BO far as glyoosuria is concerned.
The want of exercise, sedentary work, the excessive carbohydrate diet all tend to an increase in the sugar concentration of the blood. So long, however, as the threshold of the kidney remains high enough to prevent glyoosuria, tlu> well-to-do young man uses up the excess sugar of the blood by storing it as fat. This stage may last several years, daring which time there is a gradually increasing deposition of fat. If examined now, it will usually be discovered that the ingestion of 80-50 grammes of glucose causes sugar to appear temporarily in the uriue.
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