***• 1. Imagine the danger of flying with a pilot or riding a public transport (bus, train or taxi), driven by a diabetic under insulin treatment.

• 2. There is no cure for diabetes mellitus — none as of today.

• 3. Diabetics must not be engaged in occupations, which may cause serious hazard to themselves and also to others.

• 4. Patients, their immediate family members and co-workers of diabetics under insulin treatment must be aware of the hazard of hypoglycaemic coma (perilously low levels of blood sugar with coma).

This is the second o/ a series qf three articles an dta bates mriUtus.)

YOU are only 28. For the post several we eks, you have been feeling out of sorts, laxy. in fact weak You have been passing urine several more times, especially at night, than ever before. You have been feeling thirsty and hungry. You are drinking plenty of water and eatiffa a tot more than usual. Even then you keep feeling thirsty and hungry Instead of gaining you seem to be losing weight. You have also dcvel oped some itching of the skin, and a few boils (furuncles) have also cropped up.

Your phyilctan recognizes you have the classic symptoms of diabetes mellitus. The urine contains sugar «♦) and the blood glucose level Is very much raised These tests are repeated and almost the same results are obtained.

The doctor treats you initially with control of your diet He asks you to altogether stop taking refined sugar and ail kinds of sweets and confec-tionertes. He plans your diet so that about 50 per cent of your food is represented by carbohydrates and the remainder by proteins and fats. He asks you to divide equally the entire carbohydrate intake into the three main meals and two small snacks. He also reduces your total food Intake by one third. He follows you for two weeks Although the level of blood sugar has been reduced slightly, it is still quite high. He puts you on oral medicines (oral hypoglycaemlcs) to reduce your blood sugar level. Another two weeks are gone — but the blood sugar has not come down to normal levels as C. You have also been walking about 40 minutes daily.

Now he prescribes regular (fast acting) insulin to be taken before breakfast by injection underneath the skin. The result is dramatic. Urine sample, collected two hours after breakfast, is free of sugar, and the corresponding blood sugar level is normal. Within another two weeks the doctor, with your active cooperation, has worked out a scheme of urine and blood sugar estimations. Insulin injections and diet control for you. He has con eluded that you are a case of Insulin-dependent diabetes mellitus (IDDM) This means you will require treatment with Injections of insulin for the rest of your life. There is no cure for diabetes mclhtus — none aa of today I

Normally enough insulin is secreted by the Beta (B) cells of the islets of Langerhans of the pancreas to take care of the requirements for the utilization of glucose tn the tissues and cells of the body In IDDM there is some damage to the B cells of the Islets, so that not enough Insulin is produced. As a result, glucose ac cumulates in the blood and high levels sre reached (hypcrglycaemia) If the IDDM patient keeps on taking his usual food, and perhaps also an excess of sugars and carbohy drates, a state of diabetic coma may be reached, when the blood glucose level exceeds 400 mg/100 ml blood (22.2 units). This condition is also known as ketoacidotic coma, because of the presence of ketone bodies in the blood (these sre the acidic end products of the burning of fats for fuel for the requirements of the peripheral cells). This leads to a state of acidosis of the blood (normally the blood is mildly alkaline).

Diabetic coma is one of the most serious but avoidable complications of untreated or poorly treated diabetics. The patient in hyperglycaemic coma suffers from "air hunger," as seen by sighing and deep breathing; he also smells of acetone (a sweet smell) in his breath. Very energetic action has to be taken by the doctors to save a patient tn diabetic coma. The diagnosis is made on finding very high levels of blood sugar (400 to 1000 mg or 22.2 to 55.5 units). With some luck, the patient's attendant may provide a history of poorly controlled diabetes, recent bouts of over-eating or of Irregular insulin administration. On physical examination, the patient tn diabetic coma appears severely dehydrated; he has a weak and rapid pulse and tow blood pressure The patient fa treated with a mod erate does of 20 units of regu lar inauhn by intra-muscular or intravenous injection, followed by 4-8 unite per hour there after. Uli a normal level of blood sugar is attained Fluid, have to be administered to restore the water, salt and elec trolyte content of the blood. Reliable laboratory facilities are required for the-frequent determinations of the acid base status of the blood and the levels of the blood glucose, urea and electrolytes. In the event that the patient has to be removed to a better equipped medical centre, ketoacidosis may be partially corrected by the administration of saline (even table salt may be given with boiled water per rectum).

There is another complication associated with the insulin treatment of diabetes mellitus, which can also be pretty serous — hypoglycaemic coma This occurs if an excessive dosage of insulin Is taken, generally mistakenly by the pa tient. Or. if the body's requiremenl (or inauMn has been reduced as a consequence of excessive physical exercise, or starvation for an unduly pro longed period. Thia point will be Illustrated by recalling a recent case

The party was on. The occasion: Ashfaq s third birthday. Daddy Halim had much lo be happy about — hie garment In dustry undertaking had been a great success! We were seated on folding chairs, around the terrace — at least ISO close relatives and friends Kuti bhal was next to me. We were having a great time exchanging pleasantries, under a tastefully decorated shamiana

Soft drinks had been passed around I noticed Kuti bhal did not help himself to one. Dinner was quite late in bring served. Finally It came — biryani and chicken roast, prepared by one of the most celebrated chefs in town 1 had Just had a few mouthfuls, and so had Kuti bhal Then all of a sudden, something seemed to happen to him. First he loot grasp of his plate and then he suddenly went into convulsions and fell on his side Since no one seemed to reckon as to what the matter was. Kuti bhal was hastily removed to a nearby hospital

Laboratory test indicated that Kuti bhal had a very low level of blood sugar With Intra venous injection of a concentrated solution (50 per cent) of glucose, his consciousness was quickly restored. As the doctor had rightly suspected. Kuti bhal was a case of diabetes mellitus under insulin treatment. In fact, he had given himself a shot of Insulin before -coming to the party. Since he was several hours late In hav Ing his dinner, his blood sugar had fallen to a perilously low level. He had therefore developed what is called hypogly-caemic coma. This Is a well known and a potentially serious complication of Insulin treatment. Unrecognized and untreated, the patient may die or suffer permanent brain damage. Patients, thetr Immediate family members and co-workers of diabetics under Insulin treatment must be aware of this hazard and also know bow to recognize the condition soon and what action to take.

Not Infrequently, cases of severe hypoglycaemia may speak Incoherently, behave aggressively and also develop incoordination of movement; they have been charged mistakenly for drunkenness. Symptom. of hypoglycaemia are likely to set in with blood sugar levels below 2.5 units (mmol/lltre) or 45 mg per 100 ml blood. These include hunger, weakness, palpitations. profuse sweating, irritability. confusion, unconsciousness and convulsions. Diagnosed early while the pa tlent remains conscious, mild attacks can be corrected by the ingestion of plain sugar or glucose drinks. Diabetics on fnsuhn treatment are well advised tp carry with them lumps of sugar or packets of glucose (50 grams). Once uncon sciousneas has set tn. the pa tlent requires Intravenous In Stlon of glucose solution.

Is is supplemented by glucose drinks and food after the patient regains consciousness, since recurrences of these episodes are not unlikely to occur, specially in diabetics, who are on regular as well as intermediate acting Insulin. Repeated episodes of hypogly caemla indicates poor control of diabetes and calls for 1m proved monitoring of the treatment .

Imagine the danger of flying with a pilot or riding a public transport (bus. train or taxi), driven by a diabetic under in sulln treatment. No wonder airline pitots are required to undergo medical check-ups at frequent intervals. Can the same be said of the Road Transport bus drivers or the truck drivers plying on the highway? In their own interest. as also that of other*, dia belies must not be engaged in occupations, which may cause serious hazard to others. No wonder Kuti bhai had not shared the information regarding his health status with many of his close relatives and friends. He had captained a passenger let plane for many years until he was grounded recently i