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Diabetic Neuropathy

1953; BMJ; Volume: 1; Issue: 4825 Linguagem: Inglês

10.1136/bmj.1.4825.1408

0959-8138

Cedric Hirson, E. L. Feinmann, Henry Wade,

Neurological Disorders and Treatments

degeneration of the posterior columns and anterior horn cells in the spinal cords from three diabetic patients.Similar changes were described by numerous investigators at the turn of the century (Pryce, 1893 ; Nonne, 1896; Marinesco, 1903; Williamson, 1904; Bramwell, 1907).Pathological studies have not been possible on the present series of patients, but there are clinical features which sug- gest that lesions may be present in their spinal cords.Not only is the disturbance limited to motor function but the distribution of the affected muscles is not compatible with the known distribution of peripheral nerves or nerve roots.The presence of extensor plantar'responses in'three, perhaps four, of the patients is unequivocal evidence of a central lesion.It is noteworthy that the plantar responses became extensor while the patients were under observation and were being treated.In Case 1 they became flexor again after some months.It may well be that the cord changes are secondary to atheromatous degeneration of the spinal arteries, but the patients all had normal blood pressures and there was no clinical evidence of arterial degeneration in their fundi or limbs.In this connexion the duration of the diabetes is probably of little importance.In the present series this has varied from six months to three years, calcu- lated on the basis of the length of history of diabetic symp- toms.This method, although obligatory, is probably falla- cious in the case of middle-aged mild diabetics, and the duration of the disease may well be longer in our series (cf.Case 5).It seems to be agreed that the symptoms of the " classical " diabetic neuropathy usually develop in diabetes of long standing (Rundles, 1945), but this is not invariable.In Jordan's (1936) series of 120 diabetic patients with severe " neuritis " the condition preceded the onset of diabetes in 4, was coincident in 7, and in 28 developed within a year of the onset of diabetes.Whatever the nature and cause of the lesion in these patients we feel that the existence of motor disturbances without objective sensory loss in diabetics, as described by Bruns over 60 years ago, is a fact of clinical importance.These patients are being misdiagnosed as suffering from other, often more serious, neurological conditions. SummaryAttention is drawn to a form of diabetic neuropathy previously described 60 years ago but forgotten.The syndrome consists of asymmetrical pain, weakness, muscle-wasting, and arefiexia in the legs, without objec- tive sensory disturbance, in middle-aged patients with diabetes mellitus of relatively short duration.The pro- tein content of the C.S.F. is usually raised.The plantar responses are often extensor and the electromyographic changes in the affected muscles are compatible with a myelopathic lesion.Five new examples of the syndrome are described and the literature is reviewed.