This extract, from the "The Practitioner's Encyclopaedia of Medical Treatment", Published by Oxford Medical Publications, 1915, describes, in detail, the methods of treatment in the pre-insulin days.

Dr M. Geoffrey Miller, Editor.

 

DIABETES MELLITUS

Corresponding to the age of the patient and the degree of the glycosuria, very different results may be expected in the treatment of diabetes. Generally speaking, the younger the patient, the less amenable will he be. The treatment of ordinary cases is still mainly negative, the aim being to diminish the glycosuria and to prevent the occurrence of acid intoxication, for only exceptionally can we go deeper and attack the origin of the metabolic defect in some definite disease of a ductless gland. With increase in our knowledge of the internal secretions we may look forward to being able to do this more frequently. Naturally, a careful search should be made for evidence of disease of the pancreas, thyroid or hypophysis, and, if found, appropriate treatment should be applied. The first step in the treatment of diabetes was Rollo's discovery that limitation of the carbohydrate intake was followed by diminution of the glycosuria and by relief of symptoms.


For many years the whole aim was to discover an absolutely carbohydrate-free diet and to restrict the patient rigidly to this. This conception was based on inadequate knowledge and ignored the following facts-

1. Proteins contain fractions which can yield sugar and excessive protein diet is so stimulating in its metabolic effect that it causes further breakdown of the tissues, with consequent setting free of more carbohydrate molecules.


2. The failure of a diabetic to metabolise carbohydrates is seldom absolute, and careful search will generally reveal some form in which they can be tolerated to at any rate a limited extent.


3. Assimilation of some carbohydrate is essential to metabolism; in its entire absence the body has to draw on fats which it is unable to oxidise completely without their aid. This results in the formation of abnormal fatty acids. To eliminate these the body has to provide ammonia from its protein and calcium from the tissues generally, thus increasing the wasting.


It will be seen that an absolutely carbohydrate-free diet or a total failure to utilise carbohydrate must result in a metabolic dis aster in which protein, fats and mineral salts alike share. Coma is the clinical expression of such disaster. The craving of the individual for a mixed diet is the unconscious expression of a fundamental physiological fact.


At best, this search for a carbohydrate-free diet was the outcome of a negative ideal and had but a limited aim. The newer conception offers far greater possibilities of permutations and combinations in the diet to suit the metabolic defect in each individual case. Incidentally, it thrusts the drug treatment of diabetes more than ever into the background.


We may summarise the indications for treatment in diabetes thus-

1. Control of the hyperglycaemia, which in volves loss of energy and is the cause of many complications.


2. Increase in the patient's tolerance of carbohydrates.


3. Prevention or control of acidosis.


4. Treatment of complications.

These indications are not independent of each other. thus, increasing sugar tolerance automatically diminishes both hyperglycaemia and acidosis. Before beginning treatment the amount of sugar in a twenty-four hour specimen of the urine is estimated on an ordinary diet. Diacetic acid is also tested for by ferric chloride. If this reagent imparts a claret colour to the urine while the patient is still on an ordinary diet, the case is a severe one, and special caution must be exercised in establishing restrictions.


A sudden restriction of the diet is unjustifiable and involves grave risk of coma. This risk is, moreover, increased by confining the patient to bed during the process of restriction. At first no starch, but all the sugar except that is contained in a pint of milk, is removed from the diet. A mixture of alkalies is prescribed as explained under Acidosis. The urine is tested daily for sugar and diacetic acid; so long as the former falls without the appearance of the latter, restrictions may he steadily increased. Thus only a small amount of milk should be allowed in tea or coffee, and bread should be reduced to 2 oz. at two meals a day. The idea that toast is less injurious than bread is fallacious; the only advantage of it is that, as it requires more mastication, less of it is usually eaten but being drier it contains a higher percentage of carbohydrate.


If the diabetic reaction appears at any stage the diet should not be further restricted for a time, but it need not be relaxed at once until the reaction becomes distinctly more marked, for diacetic acid makes a temporary appearance in any one on a restricted diet. If the case is going on well, sugar will gradually disappear from the urine at some stage in this process. The part played by alcoholic excess in producing glycosuria, usually of an amenable sort, must be remembered. Champagne is particularly apt to excite it in some people. yet, as shown later, moderate amounts of alcohol may help in severe diabetes. It is important to determine as accurately as possible the degree of tolerance of carbohydrate in each case. For this purpose some standard diet of known carbohydrate content is necessary.


The following is the one suggested by Von Noorden-

Breakfast.- Coffee or tea with one or two tablespoonfuls of thick cream, 6 oz. ; hot or cold meat (weighed after cooking), 3 oz.; butter; two eggs with bacon; white bread, 2 oz.


Lunch.-Two eggs (cooked as desired, but without flour); meat, about 6 oz.; vegetables, such as spinach, cabbage, cauliflower, asparagus, prepared with broth, butter or other fat, eggs or cream, but without flour; cheese and butter, 1 oz.; two glasses of light wine; one cup of coffee, with one or two tablespoonfuls of thick cream; white bread, 2 oz.


Dinner.-Clear meat soup (with eggs or vegetables); one or two meat dishes with vegetables, salad of lettuce or tomatoes; wine; no bread.


Drinks.-One or two bottles of aerated waters.


If this diet, which contains about 100 gm. of carbohydrate, does not cause any glycosuria, then the bread is gradually increased until sugar appears. If sugar does appear with this diet, it may be continued for a few days until the sugar is constant and the bread then diminished. If the urine becomes free from sugar on a, restricted diet without diacetic acid making more than a temporary appearance, the restric tions should be maintained for at least a month. Physiological rest allows of at any rate a partial recovery in the sugar-forming apparatus, and as long as abnormal acids do not persist no harm is done to general metabolism. Then a cautious relaxation should be attempted. The following principles must guide us in carrying this out


Wheat flour is often badly tolerated, and the greatest difficulty is to find a satisfactorysubsti tute for bread. Gluten bread was introduced by Bouchardat in 1841; it is prepared by washing away the starch from flour, leaving the more tenacious vegetable protein behind. It is almost impossible to wash away all the starch, and gluten bread nearly always gives a blue colour with iodine. But it is easy to remove enough starch to leave a very unpalatable residue, and, sooner or later the patient revolts against it. I seldom use gluten bread as a routine, employing instead limited quan- tities of ordinary bread if it can be tolerated, or the Brusson-Jeune rolls, which contain less starch than bread and are palatable. Casoid bread or Kalari biscuits taste better than gluten bread, and are free from starch; they should be given a trial. If the patient cannot do with as much starch as is contained in Brusson- Jeune rolls, it is advisable to interpolate days on which gluten, casoid or protene bread is given. Other substitutes for bread are made from aleuronat flour, soya beans or almonds, but, like gluten bread, they are expensive and soon become distasteful. They may be acceptable for a change.


Potatoes are generally tolerated better than bread; in fact, a "potato cure" has been instituted in which they are given largely, but this is not advisable since tolerance for them is limited. On relaxing the diet it is well to add one and then two potatoes of average size (i. e. about 3 oz. each in weight) to the daily food, watching the effect upon the urine.


Of all the forms of carbohydrate, oatmeal is usually best tolerated and is strongly recom mended by Von Noorden; 8 oz. are given in the day, either as gruel, in cases of impending coma, or as porridge or oatcake with eggs on certain days in the course of treatment. I have been favourably impressed by it, and there is a general agreement as to its value.


Fruit sugar (levulose) can often be assimilated up to 50 gm. (rather less than 11 oz.) in a day, cautiously given in doses of not more than 5 dr. at a time. If more is given than can be consumed by the tissues at once, it will be stored as glycogen and subsequently turned into dextrose, which will be excreted. Its cost, however, is prohibitive except for wealthy patients or in emergencies such as threatened coma. I have seen striking benefit from its use. Artichokes are rich in inulin, which breaks down into levulose. This provides a cheaper way of supplying levulose, and I have given moderate amounts of artichokes without increasing glycosuria.


Our object, then, should be to select from potatoes, oatmeal or artichokes the form of carbohydrate which can best be assimilated. If the urine cannot be freed from sugar in this way, the next step is to investigate the effects of various proteins on the glycosuria. Meat proteins may have a distinct influence in main taining it. This, which is insisted upon by Von Noorden, is often overlooked and the patient is allowed to take meat freely. As a matter of fact, he can often take a vegetable diet, which must contain a good deal of carbo hydrate, better than he can manage a carbo- hydrate-free diet with abundant meat. It is not so much that the carbohydrate fraction of the meat protein is not well borne as that the meat has a stimulating effect on the tissue metabolism.


Recent observations of Thompson and Wallace on the increase of glycosuria when meat extracts were given support this view, though I may add that some cases I investigated with Dr Roper did not show intolerance to meat ex tracts. However, when we find that either meat or oatmeal can be tolerated separately, but not when given together, we must conclude that meat proteins diminish the tolerance of the body for carbohydrate in many cases.


Von Noorden finds that the order of tolerance is: meat proteins least, then casein, next cooked eggs, and, finally, vegetable proteins, especially in the form of glidine, best of all. The best scheme seems to be to alternate the days of carbohydrate-free diet with days of oatmeal diet and days on which little but eggs and vegetables are taken. Fast days with rest in bed may also be interpolated, as on Guelpa's plan (see p. 168). But in cases with marked acidosis this is not free from risk.


I will give one or two examples of such schemes, but as every diabetic is a law unto himself, careful investigation is necessary to find a plan which suits each case.


1. Vegetable, egg and oatmeal scheme.

In the course of an ordinary restricted diet a week of the following diet is introduced once in six or eight weeks -

(a) For two days a diet of lettuce, cabbage, spinach, veal broth, three eggs, butter, two lemons for lemonade and coffee. (Personally, I prefer to do without the veal broth, if possible, for reasons already given.)


(b) For three days a diet of 8 oz. of oatmeal as porridge or oatcake, 4 oz. of butter, five eggs, two lemons and coffee.


(c) Two days of (a) again.


2. Three weeks of restricted diet, i.e. no carbohydrate, with the addition of 60 gm. (approximately 2 oz.) of bread. One day of vegetable-egg diet; one fasting day - only weak tea, lemon-squash or whisky-and-soda in suitable cases are allowed, with rest in bed. One day of vegetable-egg diet; four days of carbohydrate free diet. Then the same scheme begins anew. This plan is one recommended recently among others, by von Noorden at the International Medical Congress.

3. Von Noorden records another instance in which a patient kept well for years, exhibiting remarkable energy and remaining free from complications on the following scheme: The

ordinary diet was limited in protein and contained 80 gm. (Approximately 2 Oz.) of bread daily; every fifth day, a vegetable-egg diet was employed, and every second month, a series of vegetable oatmeal days.

4. Marcel Labbe advises the following diet, which may be given for two or three days at a time--300 gm. (about 9 oz.) of leguminous vegetables (peas, broad beans, haricot beans, lentils, soya beans), some green vegetables, 150 gm. (about 41 oz.) of butter, 5 or 6 eggs, 3 to 6 aleurone heads, and a little red wine. A marked increase of tolerance of carbohydrate often follows. I have generally used the first and last of these schemes, and have noted a distinct improvement, the urine becoming quite free from sugar in some cases- at any rate for a time. In any case I am accustomed to recommend entire abstention from meat one day in each week. It is necessary, from time to time, to see how the patient tolerates different carbohydrates. If the urine cannot he rendered free by any means, the best point at which to maintain the patient's metabolism is that to which the intake of carbohydrate can be raised without increasing glycosuria while diminishing the acetonuria.


It is clear that some of these schemes can be carried out much better in a nursing home. It is almost impossible to keep records of the intake and output in the patient's own home, and Cammidge has recently emphasised the importance of quantitative as well as qualitative regulation of the intake. After the food has been regularly weighed for some time, the patient quickly learns to judge with the eye the approximate weight of the food. he is taking, and then the treatment can be continued at home after his tolerance for different forms of carbohydrate has been estimated.


Control of Acidosis.- Recognition of the significance of acidosis has profoundly modified our treatment of diabetes. It is probable that there are never more than traces of acetone in the urine though it may be present in the breath. Hurtley has recently shown that the nitroprusside test, which was thought to be a test for acetonuria, is really a more sensitive test for diacetic acid. In any case, acetone is a mere decomposition product of diaectic acid which, in its turn, is derived from the breaking down of fats that almost always occurs during starvation or even deprivation of carbohydrate.

It naturally follows that the most effective treatment of acidosis is to find a form of carbohydrate which can be assimilated. Then the fall in the amount of both diacetic acid and sugar in the urine is often striking.

Investigations have been made as to the possibility of replacing carbohydrate in metabolism. Citric and glutaric acids do so to a limited extent. Citrates can be added to the alkaline mixture, which should always be given when the diet is being restricted or when acidosis is marked. Alcohol appears to be able to replace carbohydrate rather more satisfactorily. Bearing in mind the dangers of the alcohol habit and that alcoholic excess excites glycosuria, it is nevertheless advisable to give alcohol in acidosis to the extent of about an ounce of the pure spirit in the day. Malt liquor, sweet wines, champagnes and liqueurs must be avoided. Since diacetic acid comes from the breaking down of fats, the question arises as to the advisability of giving fat in food. To do without fat would be to deprive the patient of an important source of energy, and it is a relief to find that the administration of fats in the food does not apparently increase acidosis. The only exceptions to this are the lower, more volatile, fats. Butter, therefore, should be kneaded in water before the diabetic eats it, for in this way the more volatile fats are extracted.


The use of alkali in acidosis is an essential part of the treatment. Spriggs has pointed out that in the normal individual 2 dr. of bicarbonate of soda will render the urine alkaline for twenty-four hours, but if an excess of acids is being formed this is not enough, so that the amount of alkali that can be taken without neutralising the urine is a rough measure of the degree of acidosis. In some cases it is impossible to render the urine alkaline at all, and I have seen a case where, with the fullest doses of alkali (i. e. about 1 oz. every three hours) the acidity of the urine was still twice that of normal. A more accurate measure of acidosis is the amount of ammonia in the urine, which can quickly be estimated by the formalin method. This also has a prognostic value, for a marked rise in the ammonia suggests the risk of coma, though Naunyn's statement that if the ammonia excretion reaches 4 gm. a day nothing can prevent coma is too dogmatic. The normal output of ammonia nitrogen is about 1 gm. a day, and in severe cases of acidosis, may easily reach 3 gm. If the condition improves under treatment, the urine will become alkaline, and the amount of alkali may gradually become diminished without the return of the acid reaction. It is not sufficient to give sodium alone, as is so often done, for other metallic bases are also being drained from the tissues, particularly calcium. Also, if one metallic salt is given out of proportion to the others, it increases the excretion of those others. I employ the following mixture, based upon the relative proportions of the metals normally present in the urine:

Sod. Bicarb. i dr.

Pot. Citrat. gr. xxx

Calcii Lactat. gr. iii

Mag. Carb. gr. iii

Aq. ad. i oz..

This is given three times a day, and increased up to three-hourly doses, according to the severity of the case.


It has been urged against this method that it increases the intensity of the diacetic reaction in the urine, at any rate for a time. But this is merely because the excretion of the acetone bodies is being facilitated, not because their production is being increased. They are now excreted as metallic diacetates instead of in combination with ammonia derived from the breaking down of the proteins of the tissues. This alkaline treatment should never be omitted in severe diabetes. That it is not wore successful shows that we do not yet completely understand the pathology of acidosis. The breakdown of proteins probably plays a larger part in it than is at present realised.


Drug Treatment of Diabetes.-Though alkalis are of distinct value in the treatment of acidosis, drugs have a very limited application to the treatment of glycosuria. Codeia has the greatest reputation in this respect, and apparently helps in some cases. It probably acts by depressing the general metabolism. It is apparently excreted as a glycuronate, and it must be remembered that this substance reduces Fehling's solution. Recently I saw a man who had had glycosuria for some years and who was taking codeia. He still had a small amount of reducing substance in his urine. I did not think it was sugar, and on testing with phenyl hydrazine obtained the osazone of glycuronic acid and not of dextrose, showing that the persistent reducing substance was due to the codeia he was taking. This is a serious source of fallacy which must not be overlooked. In any case, it is quite unnecessary to give codeia when there is merely a trace of sugar in the urine.

Salicylates, also, have some reputation in the treatment of glycosuria. The chief objection to their use is that they mask the ferric chloride reaction for diacetic acid in the urine. They do not mask the nitroprusside reaction, however. As it is probable that salicylates can promote synthesis of purine in the body, there is no inherent improbability that they can help in the synthesis of carbohydrate also, though we have no proof of this. On the whole, I have not been greatly impressed with the action of salicylates in glycosuria. Aspirin has been used, but Von Noorden has observed the onset of nephritis during its administration. It was not certain that the aspirin was responsible, but no other cause could be found.


Arsenic occasionally seems to help, and other drugs such as jambul may diminish glycosuria, at any rate for a time; 5 to 30 gr. of the latter can be given in cachets. Its prolonged use is apt to set up gastric irritation. I have never observed improvement which could be attributed to any other drugs.


After Treatment.-When the urine has been rendered free from sugar, lowered tolerance for sugar and hyperglycaemia will probably persist. Before we can pronounce a patient cured we must know that the sugar tolerance has been restored to normal limits, and that there is no excess of sugar in the blood. In cases of intermittent glycosuria it will generally be found between the attacks that a small quantity of dextrose will produce glycosuria and that there is still an excess of sugar in the blood. All this indicates the advisability of keeping the patient on the same line of treatment for a considerable time after the urine has become free from sugar.


In this connection, reference should be made to those cases of so-called renal diabetes in which there is no excess of sugar in the blood, but rather a diminution. These cases of hypoglycaemia do not show much response to diet and are probably of a comparatively harmless nature. Garrod, however, has reported a case in a boy whose elder sister had typical diabetes. This hardly suggests that renal glycosuria is entirely distinct from ordinary diabetes, and as a precautionary measure we should in such cases prescribe restriction of carbohydrates in the diet, but not their complete absence.


Spa Treatment - For a more detailed account of appropriate spas in the treatment of diabetes, reference should be made to the article on Climatology. In general, it may be said that it is only the milder cases that are amenable to spa treatment. There is considerable risk in sending a thin diabetic, who is passing a good deal of diuetic acid, on a long journey, and I have certainly seen patients made worse in this way. Carlsbad, Marienbad and Neuenabr are not likely to be visited by English patients for many years. The milder r6gime carded out at the Hermitage, Evian, may suit some cases, and there are full facilities there for dietetic treatment to be carried out combined with rwt in pleasant surroundings.

Treatment of Complications

I. Diabetic Coma.-Once coma is thoroughly established nothing more than a temporary rally can be expected, but a good deal can be done in the way of prophylaxis, as has been described in the treatment of acidosis. Carbuncles, overfatigue and constipation are potent factors in provoking coma. On the first suggestion of drowsiness, air-hunger, burning pain in the pharynx or epigastrium, or bilious attacks, the administration of alkalis should be increased and 5 dr. of levulose should be given three times a day. A very extensive relaxation of the diet is probably inadvisable, but 2 pints of milk, though it will increase the glycosuria, may help in impending coma.

If there has been persistent constipation it is a wise measure, which I have found occasionally successful, to have the rectum cleared out and 3 per cent. of bicarbonate of soda with 4 Per cent. of levulose given by drop enema until about a litre of fluid has been given.

When coma has developed despite these measures the case is hopeless and a temporary rally is the most that can be hoped for. This, however, may be of great value in order to enable the patient to sign a will and to recognise his friends. About 30 oz. of normal saline, containing 2 per cent. of sodium bicarbonate, may be run slowly into the median basilic vein at about body temperature. It is well to remove from 7 to I5 oz. of blood first. A similar infusion may be given into the other arm four to six hours later. The temporary improvement is sometimes striking. Stronger solutions are sometimes recommended, such as 5 per cent. of sodium carbonate. The addition of sodium acetate, 1 per cent., has been advised, but I have no personal experience of it. Some authorities believe that normal saline is as effective as the alkaline fluid, but I have not found it so I have added 2 per cent. of laevulose to the fluid, but am not convinced that it is advantageous when the patient is actually comatose.

The treatment of other complications of diabetes resolves itself into the diminution of the glycosuria with the application of ordinary principles to the special lesion. Thus-

2. Diabetic Neuritis, which is apt to occur in all persistent cases to a greater or less extent, soon clears up when the sugar disappears from the urine. The condition sometimes simulates tabes. Aspirin may relieve the pains very considerably. When they can be borne, massage, ionisation and electrical baths are a great help: The complete ophthalmoplegia which sometimes occurs in diabetes is apparently due to neuritis. The prognosis is not bad.

Treatment, in addition to appropriate diet, consists in giving strychnine internally, and electricity. Dr. E. P. Cumberbatch has kindly sent me the following note on this subject : " Electrical treatment may be applied to the orbital muscles when paralysed, but it is difficult to carry out because these muscles lie deeply, and currents that are sufficient to cause them to contract would cause too much pain in the conjunctiva and produce disagreeable sensations by stimulating the retina. Some improvement, however, may follow electrical treatment, and it is not essential that visible contraction of the muscles should be produced. A continuous current should be passed through the orbital cavity, one electrode being a small sponge moistened with 1 per cent. salt solution and placed on the closed lids.


3. Perforating ulcer only occurs when neuritis already exists. Beyond treatment of the neuritis, all pressure must be taken off by complete rest, sodden epithelium removed, the ulcer washed with equal parts of warm water and I0 vol. per cent. of hydrogen peroxide two or three times a day, and then well dusted with equal parts of zinc oxide and starch powder. It may be advisable to use, as a preliminary measure, boroglyceride fomentations, thoroughly wrung out, or a bath containing a little liquor iodi or permanganate of potash.

4. Gangrene if truly diabetic in nature only occurs, like the perforating ulcer, when there is neuritis. But an elderly diabetic seems unusually prone to atheromatous gangrene. In the former condition the knee-jerks will have gone, the gangrene is moist, and diacetic acid is almost certain to be present in the urine; in the latter the knee-jerks may be present, the gangrene is much drier, and there need be no acidosis. The treatment will vary according to which of these two conditions are present. In the former every effort must be made to diminish the hyperglycaemia, which provides the micro-organisms with abundant pabulum. The local treatment may be cai-fied out on the same lines as for perforating ulcer. Early amputation is indicated, as the gangrene tends to spread rapidly. The defective sensibility of the legs in neuritis necessitates caution in the use of hot-water bottles, which may produce gangrene by causing sores. If arteriosclerosis is the cause of the gangrene, vaso-dilators and diffusible stimulants should be given, and the part warmly wrapped up. Here, too, operation will probabiy become necessary, but there is not the same need for haste, as the gangrene does not tend to spread in the same way and a definite line of demarcation will appear. The small ulcerated patches over the internal malleoli are not really perforating ulcers or allied to gangrene. They may appear while the knee-jerks are still present. They originate in the sebaceous glands. They should be treated by cutting a piece of lint to the shape of the patch, moistening it with a stimulating lotion such as 2 gr. of zinc sulphate to an incision into it and scrape out the slough. Dressings with sterile horse serum have been found useful. In chronic cases an appropriate vaccine should be tried. It is of the first importance to support the patient's general condition, which is liable to become profoundly asthenic.

5. Carbuncle,This is a serious complication in diabetes, both on its own account and because it may excite coma. If it is small a ring  of collodion may be painted round it to produce hyperanaemia and prevent its spread. The use of a suction cup after a small incision has been warmly recommended. The suction should always stop short of producing pain. Short repeated applications are better than a single prolonged one. Three to six, applications, last- ing five minutes each, with intervals of three minutes between, are advised by J. M. Graham. Ionisation may be tried with a zinc needle as the positive pole inserted into the middle of the swelling. An old-fashioned remedy is the injection of a drop of pure carbolic acid into the carbuncle. If it does not yield quickly it will probably be necessary to make a free incision into it and scrape out the slough. Dress- ings with sterile horse serum have been found useful. In chronic cases an appropriate vaccine should be tried. It is of the first importance to support the patient's general condition, which is liable to become profoundly asthenic.

6. Pruritus of the vulva is a common complication, and may be the first thing to call attention to the glycosuria. It generally subsides quickly if the glycosuria can be controlled. Of local measures the best is frequent bathing with subsequent application of a lotion composed of glycerine of tannic acid and sulphurous acid, 1/2 to 1 dr. of each in an ounce of distilled water. This prevents fermentative changes in the - saccharine urine which acts up the pruritus. An ointment of 10 gr. of menthol in an ounce of vaseline, or a lotion of 20 min. of chloroform in an ounce of olive oil may help to allay the itching. Pruritus of the glans penis is much less common, and should be treated on similar lines.

7. Eczema should be treated on ordinary lines.

8. Respiratory complications, such as phthisis, bronchopneumonia and gangrene of the lung, must be treated in the usual way. Phthisis generally runs a rapid bronchopneumonic course. The patient must not be too strictly dieted, and the sugar may disappear spontaneously from the urine as the tuberculosis advances.

9. Albuminuria.-The association of albuminuria with glycosuria is common. In some of these the glycosuria is "renal " in nature, that is to say, it is accompanied by hypoglycaemia. In this case treatment should be concentrated on the kidney condition

6. Pruritus of the vulva is a common complication, and may be the first thing to call attention to the glycosuria. It generally subsides quickly if the glycosuria can be controlled. Of local measures the best is frequent bathing with subsequent application of a lotion com- posed of glycerine of tannic acid and sulphurous acid, i to I dr. of each in an ounce of distffled water. This prevents fermentative changes in the -saccharine urine which sets up the pruritus. An ointment of I0 gr. of menthol in an ounce of vaseline, or a lotion of 20 min. of chloroform in an ounce of olive oil may help to allay the itching. Pruritus of the glans penis is much less common, and should be treated on similar lines.

7. Eczema should be treated on ordinary lines. 

8. Respiratory complications, such as phthisis, bronchopneumonia and gangrene of the lung, must be treated in the usual way. Phthisis generally runs a rapid bronchopneumonic course. The patient must not be too strictly dieted, and the sugar may disappear spontaneously from the urine as the tuberculosis advances.

9. Albuminuria.-The association of albuminuria with glycosuria is common. In some of these the giycosuria is "renal " in nature, that is to say, it is accompanied by hypoglycaemia. In this case treatment should be concentrated on the kidney condition, as the glycosuria has not much significance. In others alcoholic excess may be responsible, and if this is corrected the glycosuria soon proves amenable. In one such case I saw, even moderate restriction of the amount of alcohol caused the glycosuria to clear up, only to return with each drinking bout. On the other hand, prolonged glycosuria almost inevitably leads to albuminuria in time, probably from irritation of the kidney. As long as it does not cause raised tension, cardiac hypertrophy and other signs of cardiovascular disease, one need not trouble very much about the albuminuria. The treatment is merely that of the glycosuna.

10. Digestive disturbances are fortunately rare. They may arise from excessive intake of proteins, for which the best thing is a few days of Von Noorden's vegetable, egg and oatmeal diets, or even twenty-four hours practical abstention from food. When digestive symptoms are severe and accompanied by paroxysms of pain it is probable that the glycosuria depends on a definite pancreatic lesion which calls for treatment.

11. Ocular Complications.-Ophthalmoplegia due to neuritis has already been considered. For the treatment of cataract, the most frequent of the ocular complications, reference must be made to works on ophthalmic surgery. Retinitis may occur in simple diabetes, but is more likely to be met with when there is a kidney lesion as well. The treatment is that of the cause. Diabetic amblyopia due to a central scotoma is in my experience only met with in smokers. As the amount of tobacco consumed has sometimes been quite small, I conclude that the symptom is due to the action of combined toxins. Entire abstention from tobacco seems to be necessary in such cases. When tobacco amblyopia occurs in a moderate smoker suspect glycosuria.

I2. Diabetic Collapse--ln some cases the patient may be suddenly attacked with alarming collapse. The extremities and the face become livid and the pulse becomes small and very frequent. The patient becomes drowsy and will probably die within a few hours, but there is no evidence of acetonuria. R. T. Williamson has called attention to the importance of this condition, which is generally attributed to myocardial degeneration, and should be treated on the same lines as acute heart failure from any other cause. The intravenous injection .of a pint of saline containing 1/250 gr. of strophanthin and oxygen inhalations are probably the best methods to adopt.

13. Mental Complications.-Most diabetics are irritable and many are unduly suspicious. Occasionally these, symptoms may be intensified into delusions with suicidal or homicidal impulses, or the patient may become melancholic. Such cases should be treated on the ordinary lines of a toxic insanity. The treatment of the glycosuria must be persisted in.

14. Pregnancy.- Diabetes generally causes amenorrhoea and conception is rare. If it occurs the foetus dies in utero in about two-thirds of the cases, often with hydramnios. The interests of the mother are therefore paramount when they conflict with those of the child. Pregnancy may be allowed to go to full term as long as the mother's condition improves under treatment and the bulk of the uterus is not excessive. But if the glycosuria remains at a high level, if there is hydramnios, or if other unsatisfactory symptoms occur the pregnancy should be terminated, especially if former pregnancies ended by the birth of a dead child. Naturally it must be clear that the glycosuria preceded the pregnancy, and that it is not merely the glycosuria or lactosuria of pregnancy. Even though pregnancy is well borne, the diabetes will probably get worse afterwards; it is therefore best avoided.

W. L. B.

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