·HIGH BLOOD PRESSURE:
Its Vanations and Control
By JF HALLS DALLY,
MA., MD
Demy Svo Ios, 6d net
British Medical Journal "It com
bines in 1 readable form a great deal of
1aformation with the results of much
practical experiesce As the book
is written 10 an easy and interesting style
it deserves and no doubt will achieve.
populanty
WILLIAM HEINENANN
(MEDICAL BOOKS) LTD
30 Bedford Street, London WC.2.

·INSULIN IN
GENERAL PRACTICE
A CONCISE CLINICAL
GUIDE FOR PRACTITIONERS
BY
A. CLARKE BEGG,
OBE, MD, CHB (Edia ), MB (Lond)
Honorary Physician Swansea Hospital
(
HTH TOUR DIAGRAM)
LONDON
WILLIAM HEINEMAXN
(Alcdical Books) Lad.
1924

·Nade and Printed in Great Britain ·PREFACE This book is based on the experience of over seventy cases of Diabetes which I have had under my care in hospital, or have seen in consultation, since Insulin became available about eight months ago A CLARKE BEGG 74, Walter Road, Swansea

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·CONTENTS 1 DIAGNOSIS CHAP PAGB I IS TEERE GLYCOGURLA? THE EXAMINATION OF THE URINE II ARE THERE CLINICAL SIGNS OF DIABETES? The EXAMINATION OF THE PATIENT 10 III IS THE BLOOD SUGAR NORMAL? 19 EXAMI MATION OF THE BLOOD 18 IV PRINCIPLES OF Dietetics 36 TREAT VENT V DIETETIO TREATMENT 42 VE THE PRINCIPLES OF INSULIN TREATMENT 82 VII SPREME OF THEATMENT FOR A CABE OP MODERATE SEVERITY SECTION 1 BY STANDARD DIET A LOVE 60 SECTION 2 BY STANDARD DIET WITH INSULIN 78 90 96 COMPLICATIONS VIII HYPOGLYCAEXIA IX ACIDOBIS X IMPENDING COMA AND CON XI GANGBESE XII SEPTIC INFECTIONS XIII DISCELLANEOUS NOTES CONCLUSION 101 113 118 121 I DEY 127

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·CONTENTS DIAGFOSIS CHU 1 I IS THERE GLYCOSTRLA? Tgz Eu*CF THE URINE IT ARE THERE CLINICAL $1633 or Due.728? Tal EXAMINATION OF TEIE PATIES III IS THE BLOOD SOGAR NOEXIL? Ter Euc NATION ON THE BLOOD IV PRINCIPLES OF DIZTETICA . TREATJENT V DIETETIC TREATMENT VI Tue PatyciPLES OF INALLY TELITEST VII SCHEME OP TREATMEST FOR A Csiz (T MODERATE BEYERITY SECTION 1 Br STANDARD DIET Awse. SECTION 2 BY STANDARD DIET WITH I SECLIS 78 0 . COMPLICATIONS VIII HYPOGLYCAENIA IX Acidogte X IMPENDING CONA AND COXA XI GANGREXE XII SEPTIC INFECTIONS XIII BISCELLANEOLS NOTES COSCLCSION . for 113 r 118 . 121 INDEX , 127

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·CHAPTER I
I6 THERE GLYCOSURIA?
THE EXAMINATION OF THE URINE.
Although the cardinal sign of diabetes is an
excess of sugar in the blood, attention is usually
first directed to the disease by the appearance of
sugar in the urine The clinical investigation
naturally starts from this point, and the first
question to be decided is whether glycosuria is
actually present.
As it is frequently a matter of chance whether
sugar 18 found in the urine or not, it is very
desirable to have a specimen taken about an hour
after a good meal. If sugar is being passed at
all it is most likely to be present in the urine at
this time.
There are many tests for glucose, but in or.
dinary, qualitative clinical work Fehling's test
$
Ww we want to weler binne 18 wutluer il 13
present in pathological amount. Too delicate a
test is apt to be wisleading.
1

·2 INSULIN IN GENERAL PRACTICE TEHLING'S TEST TEL ith 1. 'l he two solutions for the test should be kept separate Put about 1 inch of No 1 solution into a test tube and add an equal quantity of No 2, mix and boil for two minutes to test the Fehling If it remains clear, add a few drops of urine and boil In the absence of any reaction pour in more urine, until an amount equal to the amount of Fehling has been added Boil again, if no reaction, boil for two minutes and set aside to cool The reaction consists of the appearance of a yellow or yellowish red precipitate which ау come down on the addition of a few drops of urine, or not until the full amount has been added The smaller the amount of urine re quired to produce a reaction the larger the amount of sugar present, so that the test done in this way is to a certain extent quantitative as well as qualitative If, even after standing for a few minutes, the solution remains perfectly clear, one can assume that no pathological amount of glucose 18 present If the quantity of sugar 18 very small, the deposit may be a dirty greenish or dirty blue colour, and difficulty arises with these indefinite reactions There are many more or less elaborate methods for getting rid of "interfering" sub stances in the urine, and go allowing a doubtful reaction to be cleared up, but, without going into

·EXAMINATION OF THE URINE
3
heoretical considerations, attention to the follow
ng points will usually serve to decide the
question -
1 Agcertain whether the patient has been
taking any medicine buch as chloral,
salicylates, carbolic, etc, which may be
responsible for more or less definite
reaction
2 If the specific gravity of the urine 18 very
high, dilute with an equal volume of water
and test again
3 If the specimen examined 19 a fasting one,
have another taken about an hour after a
- 4 An 1 --- + 1-1 - IL LA
amined had been taken soon after a meal,
get a fasting specimen If this gives a
pagsed, but only after meals A still
better and very simple plan 18 to give the
patient about i oz of glucose dissolved in
water, and examine the urine passed an
hour lator A positive reaction will con
1
reaction

·4 INSULIN IN GENERAL PRACTICE 1- AYAT Lactose gives a similar reaction with Fehling's solution, but it occurs only in the urine of women during pregnancy and lactation. Levulose and pentose may give rise to trouble, but they are of rare occurrence. If still in doubt try the formentation test. FERMENTATION TEST. If the urine is not acid, acidify with tartaric acid. Boil for ten minutes, then cool. Take about 50 c.c. of urine and mix with it a small piece of fresh yeast. Fill a Doremus ureometer tube wi all air i tube is be filled and inverteu iu a bman upu i muu... ture.) Set the tube in a warm place for a couple of hours. If glucose be present some gas will have appeared at the top of the tube, if there is no gas one can assume that there is no appreciable amount of glucose. It may be well to put up a control tube containing a solution of glucose and yeast, and another tube containing normal urine and yeast. The former will show whether the yeast is active, while the latter will show whether the yeast itself gives off any gas. Per. formed in this way the test is one of the most reliable for the detection of glucose in the urine. If glucose is present, we want to know how much is being excreted daily. There seems to be a deep-rooted opinion that the specific gravity of a urine gives fair indication of the amount of ·EXAMINATION OF TIL URINE 5 sugar present, but this is very fallacious A high specific grurity may be due to a concentrated urino and contain little angar, wule one of low specific graysty may contain a good deal, the lot specific gravity being due to deficiency of area For a quantitative tost it 18 necessary to get a twenty four hours specimen Instruct the patient to pass urine at say 8 a m, but not to keep what 16 pissod During the bext tronty four hours, up to and including 8 am the following morning, he is to pass all urine into a clean jar or other Sessel lo must measure the total quantity and bring to the doctor an ordinary Medicine bottle full of the mixed urige It 38 worth while in- Brating on the bottlo being thoroughly clean Thers are many methods of doing tho quantı tative test, and it is difficult to say which is the most simple and at the same time fairly reliable I think that the Feliling a methol 18 quito reliable enough for clinical work It has the advantage that the solutions are ways to hand and that no olaborate apparatus is required QUANTITATIVE ESTIMATION OF Starr FEILIG'S STETNOD Placo 10 cc. of Fehlog's solution (5cc No 1 + 5 cc No %) in a small porcelain basın, add wator up to about 50 cc, and bring to the boul over 1 spirit lamp or bunsen NameWhile this 19 beating dilute the urino I n 20,12,5 cc urine to 95 cc water Filla vurette graduated in ces with the diluted urine, and when the I ebling's ·6 INSULIN IN GENER L PRACTICE solution is boiling, run it in blowly Stir the whole time and never add more unlesa the solution 18 boiling vigorously Cuprous oxide is thrown down, and the reaction 18 complete when all the blue colour is discharged from the solution It is when this poir one is able to the dish so tha through a layer of the flaid If a burette 18 not uvailable, the diluted urine may be withdrawn from a 100 cc cylinder by means of a glass pipette and gradually added to the urine If this is done the number of cc used can be calculated by finding how many cc are left in the 100 cc measure when the reaction is complete The calculation is very simple Divide 100 by the number of cc used, which gives the percentage of sugar, or which is the same thing the number of grams in each 100 cc Knowing the total amount of urine, the number of grams of sugar passed in the twenty four hours is easily calculated For example suppose 10 cc of diluted urine has been used, and that the total quantity of urine for the twenty four hours is three pints or 1,700 cc, the calculation will be 100 the urine contains 10 per cent 10 of sugar or 10 grams per 100 cc The total quantity was 1,700 cc and 10 per cent of this = 170, which is the total number of grams of sugar in twenty four hours 10 re,

·EXAMINATION OF THE URINE
7
CARWARDINE & SACCHAROSIETER
inexpensive and may be obtained from any
instrument maker, with full directions
It is a
very convenient clinical method for quantitative
estimation, but is not very accurate
It is convenient at this stage to describe the
tests for acetone and diacetic acid A knowledge
of these tests is essential in the diagnosis and
treatment of diabetes
TEST FOR ACETONE (ROTHERA)
The urine should be as fresh as possible for
both these teste To about 2 inches of urine in a
test tube, add a fow drops of freshly prepared
pared
nitro
Add
with
crystals of ammonium sulphate Invert the tube
soveral times and allow to stand A violet colour,
similar to a permanganate solution, indicates the
presence of acetone A rough estimate of the
amount present may be made by noting the
rapidity with which the colour appears and the
depth of the colour If much 18 present, the
colour appears almost immedintely and is very
deep in a fow minutes If Iittle 18 present, the
colour appears slowly and is little more than a

·8 INSULIN IN GENERAL PRACTICE tinge If there is no colour after fifteen minutes, the test is completely negative The amount present may be roughly recorded by a number of plus signs, thus, acetone + + + means that the colour has appeared within half a minute, acetone + + that it has appeared within two minutes, and acetone + that there is only a later colouration TEST FOR DIACETIC ACID (GERHARDT) Pour about an inch of urine into a test tube, and add drop by drop a solution of weak perchloride of iron Ordinary liquor ferri perchlor diluted three and four times is about right II there is a precipitate ferric phosphate, continue adding until a precipitate ceases to appear The solution turns a deep burgundy colour if diacetic acid is present This colour disappears on boiling, which serves to differentiate it from a somewhat similar colour produced in patients who are taking salicylates, etc It is sometimes advised that the phosphate precipitato should be filtered off before completing the test, but this is seldom necessary There has been much discussion as to the exact significance of these tests It seeins probable that all urines which give a positive reaction for acetone contain diacetic acid also, but not in sufficient amount to give a reaction with perchloride of iron The practical point 18 that a positive Gerhardt s test is of mucli graver significance than a positive Rothera While examining the urine, it 18 always well

·EXAMINATION OF THE URINE
9
to test for albumin, and if present it may be
advisable to look for casts, estimate the amount
of urea and make other investigations to determine
the efficiency of the kidneys
Wo have now established the presence of
glycosuria and have found out how much sugar
18 being passed daily

·CHAPTER II
Are THERE CLINICAL SIGNS OF DIABETES ?
THE EXAMINATION OF THE PATIENT
NEEDLESS to say, the presence of sugar in the
uring does not necessarily indicate diabetes
The history of the case must be gone into and a
thorough clinical examination carried out
The first thing to determine is whether there is
any indication of diseases, other than diabetes,
which may be producing the glycosuria The
principle ones to look out for are
1 Exopthalmic goitre and diseases of tho
thyroid gland Under this heading it
would be well to inquiro whether the
patient 18 taking any preparation con
taining thyroid
2 Cerebral tumour
3 Acromegaly
4 Gall stones
5 New growth affecting the pincreas
These can usually be excluded, but sometimes
present difficulties Recently I had a case under
my care illustrating the difficulties in connection
with new growths
10

·EXAMINATION OF THE PATIENT CABE 1-Wowin, aged_G0 Five years history of indigestion and diabetes las increasing weakness and thirst and has lost much weight Looks ill Passing 45 grams of sugar daily, acetone +, do dincetic acid Traco of albumin Tasting blood sagar, 860 mgr per 100 co. Dietetic trertment not successful, but with tho help of insulin she becamo sugar and acetono frce, had a normal blood sugar, sunod weight and felt well Sho remained rery well for two months, when she was re ndmitted fceling very weak and suffering a great deal If these diseases can bo excluded, the patient is suffering from either true diabetes mellitus or renal glycosuria, and we must look briefly at tho clinical signs and symptoms of the two conditions. DIABETES MELLITUS. The more important clinical signs and symptoms of truo diabetes are : Actiology. Age. No age 18 exempt Speaking gencrally, the younger the age tho more severo is the disease, but this 18 by no means invariable. Sex. Both sexes In my series of cases women preponderate. Ucrcdity. This 18 an important factor. I have had two brothers, both young men, who showed the first symptoms of the disenso at about the gimo time, and in a good many of my cases there was a definito family history in one or other parcnt. very ·12 INSULIN IN GENERAL PRACTICE Race Jews are particularly liable Excessile ingestion of carbohydrates This is usually stated to have no definite influence, but I have had many cases in which it appeared to be an important factor Case 3 is a striking instance The prognosis appears to me to bo decidedly better than usual in these cases Other illnesses and nervous shock, etc I havo seen three cases where the first symptoms followed influenza, and a considerable number where nervous shock and a period of unusual worry appeared to be predisposing causes Symptoms Onset 18 usually gradual, but may be quito sudden More commonly a sudden opset is dus to nervous shock, but Case 17 illustrates a re markably sudden onset without apparent cause Polyura Necessary for the excretion of large quantities of sugar It 18 usually an early symptom Thirst Associated with preceding Pruritus Usually about the vulva in women and about the glans penis in men It is a promi nent symptom in fully 90 per cent of my femalo cases, and is frequently the symptom for which advice is first sought I consider it the most constant single symptom of diabetes in women Loss of weight Almost invariably present and usually an early symptom Jeakness and loss of energy Very common Appetite Usually stated to be greatly in

·EXAMINATION Or TIIE PATIENT
13
crcascd, but I have not found it a common
Bymptom
Sexual funclion Impotence is a common
symptom and frequently an initial one
Physical Signs
General appearance Ofton look pinched, de
pressed and pale
Slin Dry and barsh
Tongue In severe cases dry and red, the bo
called "raw beef tongue
Borrels Apart from complications, invariably
constipated
Cardio vascular system In old standing cases
there are often signs of myocarditis Pulgo
usually rapid Breathlessness and some oedema
common Artorial degeneration 18 very common
in cases of any standing and 18 usually much
1
or absent
Muscles Flabby
Renal Chronic nephritis is very common
18 stated in many toxt books that a traco of
albumin 18 often present, but is of no great
of the urca content of urine and blood, too often
roreale markedly inefficient kidney 8

·INSULIN IN GENERAL PRACTICE The investigation of the urine is discussed fully in the previous chapter. Blood. The question of blood sugar is dealt with in the next chapter. Lipæmia is sometimes found and there is frequently some degree of simple anæmia. Complications. The complications of acidosis, coma, gangrene and infections are discussed in succeeding chapters. Other complications are : Nervous System. Peripheral neuritis, with which the diminution or loss of knee jerk is associated, is very common. It has the usual symptoms of tinglings, numbness, pain, loss of muscular power, etc., and may take the form of the so-called diabetic tabes. Perforating ulcers are not uncommon. Eye. Cataract is very common and usually bilateral. Diabetic retinitis and retrobulbar neuritis also occur. Respiratory System. Pulmonary tuberculosis is prone to occur especially in young patients. It is in this con. nection insulin has a special value, inasmuch as it allows a much more generous diet. Pneumonia may occur and is a very serious compli It must always be remembered that one of the ·EXAMINATION OF THE PATIENT 15 complications may be the first indication of the disease, and that the occurronce of any one of them should lead to an examination of the urino Again, in many cases thero are fot signs or syinptoms, and the dingnosis is made by accident in the course of the routine examination for life insurance or one of the services It should bo an ine in any casc whero thore is ry oxamination Larly unguosis 18 UI TUESDAvio importance RENAL GLYCOSUTIA Aetiology This is unknown It is probably of much more frequent occurrence than 18 generally recognised, as it 18 only by the modern methods of blood examination that it can be diagnosed with certainty Symptoms and physical signs There are no bymptoms except those due to depression and anxiety about their supposcd serious condition Too often thou have been told that they are suffering from diabetes, and put on 7 strict diet which only succeeds in further depressiog their general health I ho condition 18 usually discovered accidentally through routine cxamination of tho urine The solo physical sign is that the urino contains sugar This may occur only after och mcal or may bo constantly present It depends on the ·16 INSULIN IN GENERAL PRACTICE One very the urine height of their "leak point If this is only a little below normal, sugar 18 passed only after meals, if very low it 18 passed continuously The quantity passed is usually small important rule, to which I have not seen any exception, is that there is never any acetone in the trine The appearance of acetone along with sugar would appear to exclude a diagnosis of renal glycosuria The whole subject 18 further discussed in the next chapter Prognosis So far as our present knowledge goes this 18 absolutely favourable The condition does not appear to shorten life or to imprir health The IC diagnosis between ave disease of truo The following case which I saw recently in consultation may be taken as typical of the usual history and the clinical findings CASE aged 84 Complaint diabeteg. History did not know that there was anything wrong Manسه 9 won Tenre Dre dieting depressed rather tht urine contained 16 per cent of glucose elu quantity passed in twenty four hours was 28 grams No acetone or diacetic acid A sugar tolerance test as ·EXAMINATION OF THE PATIENT 17 dopa which shoned that bis blood sugar behaved normally, and I was able to assuro him that thero mas nothing to worry about It will be seen from the above that it may ba possible to differeotiate between renal giz cosuria and diabetes, with a fair degree of certainty, from clinical symptoms zod signs If the patient has been passing sugar, for many years without any deterioration of health, if dieting has little effect on the output of sugar, and if all the other By mptoms and signs of diabetes are absent, if 18 almost certain that he is a case of renal glycosuria On the other hand, if the urine contains acetone or diacetic acid in addition to sugar, it is almost certain to be a case of true diabetes The only certain motkod, however, 16 by oxamination of the blood

·CHAPTER III
IS THE BLOOD SUGAR Normal?
THE EXAMINATION OF THE BLOOD
All the recent advances in the pathology, diag
nosis and treatment of diabetes depend on our
ability to estimate accurately the amount of
sugar present in the blood under varying con
ditions This used to be a difficult and some
what complicated process, necessitating the use
of costly instruments and demanding a moderato
degree of technical skill
The profession owes a debt of gratitude to
Maclean for his simple method of estimating tho
blood sugar Every physician should, of course,
be familiar with it, and the average general
practitioner who is prepared to measure solutions
accurately, and to devote a little time to the
subject, should have no difficulty in carrying out
the test
The time required for the test is from
wenty minutes to half an hour, and I am quito
satisfied after seven or eight months constant use
of it that the test is a very accurate one
Messrs Allen and Hanbury s Ltd supply an
outfit comprising all the apparatus and reagents
equired along with directions for carrying out
The test
18

·EXAMINATION OF THE BLOOD 19 ESTINATION OF BLOOD SUGAR BY MACLEAN'S METHOD General Principle of the Method The preliminary test is to determino the amount of free iodine which is liberated from 2 cc of the special copper iodino solution by excess of sulphuric acid This is done by titration with a standard solution of sodium thosulphato, using starch as the indicator The test proper 18 1 To get rid of protoin in 02 co blood by heating with ncid sodium sulphato solution adding dia lysod iron and Altering through starch frco alter mpor 9 A definito quantity, usually 20 cc, of the clou fitrato is tested quantitatively for sugar 8 This 18 done by adding 2 cc of the special corper 10dino solation, boiling for a certain length of test & The difference between the amount of free iodino now present (ns shown by the amount of thio sulphato solution used) and the amount of free 10dino which tras present in the preliminary test, represents the amount of sugar which was con tained in the deflate quantity of blood fltrato which was taken By mens ot & tablo tho number of milligrams of glacoso per 100 cc of blood, which this figure indicates, is seen at a glance ·20 INSULIN IN GENERAL PRACTICE Apparatus required 1 One special Maclean pipette to contain 09 cc blood ► Two Erlenmeyer flasks of 100 cc crprcity made ol hard, heat resisting glass, one to be provided with a rubber cork with a hole in the centre through which passes a glass tuba narrowed at lower end (This is to minimise eraporation when boiling) 8 Ono 100 cc graduated flask or cylinder 4 One special pipetto to hold 23 8 cc 5 One i cc pipetto graduated in 1/100th c.c. (not essontial) 6 One 1 co ordinary pipette 7 One small filtering funnel 8 Whatman s No 1 filter paper, diameter 11 cras 9 One small cylinder or test tube, marked at 20 cc 10 Ono 20 oc ordinary mpette 11 Two 200 ordinary pipettes 12 One 200 oc fiask 18 One 5oc ordinary pipetto 14 One burette of 25 cc capacity, graduated 10 1/10th Co., with stand 16 Some triangular surgical needleg or preferably & trigger lancet 16 Bunsen burner, tripod stand with wiro gauze Stoch Solutions, etc , required I Some packets of sodium sulphate, each containing 15 grams 2 1 oz pure acetic acid, in drop bottle 8 2 ozs dialysed iron solution 4 4 ozs special alkaline copper iodine solation 5 4 oz8 25 per cent sulphuric acid 6 oze N/10 solution of sodium thosulphato 7 1 oz purc soluble starch powder ·EXAMINATION OF THE BLOOD 21 Solutions for tesc (Which should be mado ap fresh xhon required) 1 Acid sodium sulphate solution Pat about coor 70 cc of distilled water in the 100 co gradu ated flask or cylinder, dissolve in this & packet (16 grams) of sodium sulphate and make up tho volamo with distilled water to 1000. Then ada 01 cc puro acetic acid This can bo dong with piretto (No 6 on list of apparatus) or moro B1mply by keeping tho acctio acid in a drop bottlo ascertain by experiment how many drops are ro quired to mako op 2 or 8 cc, and calculate from this the number of drops in 1/10th of a cc In the drop bottlo which I use 4 drops is the requisite amount 2 N 400 solution of sodium throsulphate Pat somo distilled water into the 200 CO flask, add by means of the ordinary 8 CC pipette, 6 cc of the N/10 Bodium thiosulphato solution and make The dialysed iron solution, tho special alkaline copper iodine solution and the 25 per cent sulphuric acid solution, are ready for use and heep good for months They slould be kept away from the light DIRECTIONS FOR CARLYING OUT TEST Preliminary Test to Standardise Copper Solution In any small clcan flask or beaker pot about 6 c.c acid sodium solpbato solation and add to it exactly 2 cc of tle couper solution by mmDs of ono of the ordinary 2 cc ·20 INSULIN IN G Appara 1 One special Meclca blood. 2 Tso Erlenmeyer il hard, heat resistir with & rubber co through which , lower ead. (TL Then boiling) 8 One 100cc gradu 4 One special purette 5 One 1 c.c. pipette essential) 6 One 1 ac, ordinar 7 One small biterin 8 Wbatsman so I One small cyl nd 10 One 20 cc. ord 11 TO 2 c.c. ordin 19 One 200 cc fle 18, One 5 cc. ord n 24 One burette 1/10th c.c 15 Some trang tngger lant 16. Bunsen barn Stocy 1 Some acl 15 graus 2 1 Oz rure 8 2 azs diri 4 4 ozs 5 5 4 OZS 21 6 8 ozs M/H 7 1 OZ DUE

·EXAMINATION OF THE BLOOD
23
blood The point of Maclean's special pipette is
pinced in the drop or blood, the pipetto itselt leing
held with the distal end inclined downwards, and
the blood flows into it by capillary attraction
assisted by gravity. When the blood reaches the
02 c.c. mark, the pipotte is remorcd, its outside
times till the last traces of blood nro Temored.
Ered with the patto thoroughly clean thero
are sometimes difficulties, and I think the follow.
ing modication has some advantages. After the
finger 14 Driched let the blood drop into a clean
watch glass, and by putting & small rubber teat
on the pipette, such tho blood ap to the mark.
Treniam
121
il te blood has to be taken at the patient's
Lome, it 19 better to withdraw a few ecot blood
from a rein into & test tubo containing a very
littlo finely powdered potassium oxalate. From
thus 02 cc blood can be removed for the tre
This picthod has the advantago that of Anyt
goes wrong with the first test thero is
2
ube ulei out with
Alcohol and ether, and
I tho 09 co mark gets
of A soft lead pencil ) !

·24 INSULIN IN GENERAL PRACTICE 3 After addition of the blood replaco rubber cork and shake to mix thoroughly Heat the flash over the bonsen until the mixture darkens and a few bubbles appear, showing that the fluid 19 approaching boiling point Removo flask and contents of the flask can be poured in at one time The filtrate shonld be water clear 4 By means of the 20 cc pipette exactly 20 cc of the filtrate is transferred to the other small Erlenmeyer flask the one without a cork. To this is added exactly 2 cc of the special copper solution and the mixture boiled in the open flask for exactly six minates from the time that brisk boiling commences The height of flame for this process must be regulated previously For very accurate work Maclean recommends a special apparatus for the purpose, bnt for ordinary clinical work the following method will buffice Put 20 cc acid sodium sulphate solution and 2 cc copper solution into the Erlenmeyer flask and find by experiment what size of flame is necessary to bring the mixture to vigorous boiling in about 1 minute and 40 seconds This is the correct 44 and plunge it up to its neck in a large jug of cold water Thorough cooling is essential 6 To the cooled solution ada 2 cc 25 per cent sul phurio acid and agitate the flask, gently at first

·EXAMINATION OF THE BLOOD
25
and afterwards moro Figorously, tntil about a
minnto after all offervescence has ceased
The borette is filled again with the sodium thio
sulphato solation up to the zero marh, and then
run into the finsk blowly till the yellow colour has
almost gone Add a few drops starch solation,
and go on dropping in the thiosulphate solution
till the blue colour is completely discbarged, as
described in preliminary test When the end
point is reached, rend off the number of cc of
throsulthato solation which has been uscd
7 Calculation of Result The number of cc of thio
sulphato used in the test proper 18 deducted from
tho number of cc nised in tho preliminary test
Look up the resulting namber in the tablo below,
and read of tho number of mgr glucose in 100cc
blood
For example, suppose the preliminary test deod
108 cc sodium thiosulphate eolntion and the test
proper used & c.e, then 108-86 = 22 cc,
and on rclerence to the table it is scen that
thus amount of thiosulphate solution representa
118 mgr per 100 CC of blood
This talle only liolds good when 20 cc of the
2
solution, whild the Atmation of the blood mit
turo 19 in progress

·26 INSULIN IN GENERAL PRACTICE TABLE GIVING THE NUMBER OF MILLIGRAMS OF GLUCOSE Per 100 cc BLOOD EQUIVALENT TO THE AMOUNT OF N/400 SODIUM THOSULPTATE SOLUTION (When 20 cc Blood Filtrate is used) Thiosulphate Ng Glucose pot 100 cc Tblosulphate Mgr. Olacone per 100 C. Thiosulpbato Mor Glucos per 100 cc 218 4 24 4 87 225 с с 012 0 25 088 0 50 0 62 078 086 0 09 1 13 1 26 1 99 153 1 67 1 80 1 91 207 СС 2 22 2 95 2 44 2 61 2 74 2 86 2 99 3 11 18 25 81 37 49 50 56 62 68 75 81 86 93 100 106 112 118 125 191 197 149 160 156 162 168 175 181 187 193 200 206 212 9 24 291 297 249 250 256 262 208 275 281 287 293 800 906 312 4 62 4 74 4 87 4 99 5 12 524 5 87 549 5 62 674 5 87 599 6 12 8 86 3 49 3 61 8 74 3 87 3 99 4 12 fully discussed ) ·EXAMINATION OF THE BLOOD 27 Beforo explaining how the blood oxamination differentiates between true diabetes and renal glycosuria, it 18 necessary to have a general idea of normal carbohydrate metabolism and the alterations which take place in disease All ingested carbohydrates are converted into glacoso and absorbed into the blood A certain amount is used up by the muscles and other ttsgucs, while the remainder accumuintes in the blood up to a certain point, when the surplus rasses to the liver (and to a certain oxtent to the muscles) where it is stored as glycogen As a reguit the blood sugar rapidly returns to tbo normal level When there 18 a further call for Bugar on the part of the muscles for the pro duction of energy the blood sugar tends to be lowered still further, but the glycogen in the layer is reconverted into sugar, passes into the blood, and makes good the deficiency The normal sugar contont of fastıng blood 13 from 80 to 120 mgr per 100 cc After # meal containing carbohydrates tho amount rapidly increases, but in normal persons it rarely grocs higher than 180 mgr before the storage mechanism comes into action, the surplus sugar pagses to the liver and the blood sugar comes duma to the fasting level fairly rapidly No sugar 15 oxcreted, as none passes into the urine until the blood sugar riscs to somewhere beta.con 160 and 200 mgr The cract point at which the kidneys begin to excreto sugar farice, and 18 called the Ical point' In normal persone ·28 INSULIN IN GENERAL PRACTICE therefore, the sugar storage mechanism comes into play before the blood sugar has become high enough to reach the leak point of the kidneys In diabetes, owing to the inability of the tissues to use the blood sugar properly and to the de fective sugar storage mechanism, the level of the blood sugar after a carbohydrate meal goes on increasing until the leak point is reached and glycosuria results In severe, or even moderately severe cases, the blood sugar level may be con stantly above the leak point, so that glycosuria is constant We now know that in most cases this disturbance of carbohydrate metabolism is caused by a diminished supply of insulin, the internal secretion of the islands of Langerhans in the pancreas In renal glycosuriu, carbohydrate metabolism is normal, but the leak point of the kidneys is un usually low If this leak point is about 140 mgt sugar will appear in the urine only after meals, while if the leak point is about 100 mgr glyco surii may be constantly present To impress these facts on my own mind I evolved some rather crude diagrıms, which I hope may help those who are not familiar with the subject to grasp the general principles of the process Dragram 1 illustrates normal carbohydrate metabolism The larger cylinder, graduated in milligrams per 100 cc, represents the blood sugar, while the smaller one represents the liver containing glycogen A pipe (a), in which 18 a

·EXAMINATION OF THE BLOOD
29
tap (b), is shown connecting the tro cylinders
On the other side of the blood sugar cylindia i
an out flow pipe (c) yoha
the kidnoj
sbown an infic
abbume that
the normal faslang ulood sugar level 18 100 mgr
After a carbohydrata mcal sagar 18 poured into
floor
Swear
containing
Glytogon
*
DUONAU I „Normal Carbobjurato Metabolism
the blood from inflow pipo (d), and the level of
the blood sugar in the cylinder conscquently riece
As it does so, howerer, more and more of the
sugar passes along pipo (a), to the urer and is
stored 18 glycogen, so that the level of the blood
sugar noi er riscs biguer than 110 to 150 mg.
Thua llie leak point 18 nerer reached and thoro 18
Do glycosuri? This storage mochanism can only

·30
INSULIN IN GENERAL PRACTICE
take place if there is an adequate supply of
natural insulin available, and insulin may be
regarded as the hand needed to keep tap (6) open,
so that surplus sugar from the blood may pass to
the liver.
Diagram 2 shows the altered carbohydrate
metabolism in diabetes. After a carbohydrate
1200
Blogst.
350
おしまいま
Liver
oontaining
Glycogen
250
DLAGRAM 2.-Carbohydrate Metabolism in Diabetes.
meal, sugar is poured into the blood from inflow
pipe as before, and the level of the blood sugar
rises, but owing to the absence or a diminution in
the supply of insulin, the tap (6) remains more or
less closed. The level of the blood sugar goes
on rising until the leak point of the kidneys is
reached or passed, and sugar is excreted in the
As novinely stated the blood sugar in

·EXAMINATION OF THE BLOOD
diabetes is often constantly above this point, rising
higher immediately after food but never falling
below it, so that glycosuria is constant
Dragram 3 illustrates renal glycosuria Meta
bolism is normal, as there is an adequato supply
of insalın which keeps tap (b), open
The only
departure from normal is that the leak point of
Binod
200
contaming
DLAGRAN 8-Carlohydrato Metabolism in Bopa!
Olycosuria.
the kidnoss (out flow pipe c) 18 abnormally lon
Although the blood sugar norer riscs aboro
normal lorol, there is esther constant or intcr.
mittent gly cosuria
We are now in a position to understand hort
the blood sugar test is used to ditorentiate regal
glycosuria (rom true diabetos A single test may

·CHAPTER IV
PRINCIPLES OF DIETETICS
Food 18 necessary for two purposes
1 To provide material for the growth and
repur of the fabric of the body
2 To provide a supply of potential energy for
conversion into heat and work
All the organic constituents of food may be
roughly divided into three great classes
1 Proteins
2 Carbohydrites
3 Fats
1 Proteins These consist of gluten, myosin,
etc, and may be obtained from either animal or
vegetable foods The manufacture and repair
of the tissues of the body can only be done by
protein, neither carbohydrates nor fats can take
any share in it
On the other hand, protein is able to take the
place of carbobydrates and fats in the production
of heat and energy In other words protein 18
the one indispensable organic constituent of food
Without it repur of the body tissues cannot take
place and hfe would soon cerse
38

·PRINCIPLES OF DIETETICS 2 Carbohydrates These consist mainly of sugar and starches, and are for the most part obtained from vegetable food Along with tho Iats they provide the necessary onergy and hert 3 Fals This group consisting of fat, butter and natural oils se obtained from both animal and vegetablo sources Ints and carbohydrates are more or less complementary to onck other, both are ablo to provide energy and bent whilo both are unable to mako good tissue tristo An ordinary diet should consist of a mixtura of these tlırco great groups, but the actor proportions may ind do vars willan wido limits, depending on raco, climato, the food which 19 77708t really available and least costly The ono Cesential constituent, however, 13 protein, and our next enquiry must be how much of it 18 necessary daily Unfortunately physiologists are unabylo to giro us definite information, and most of our dat? inust be obtuned from the general etperience of mankind, and the average ainount settially found to le consumed by tho aierge min Obviousis the amount necessary deponds to a considerable extant on age, 18 the growing bor us to have Rufficient for growth as well as maintoponce Baly weight would appear to bo a (zetor, as the larger the wody, thio muro matorial for m315 fonanca kuuld appear to be required bo Intount of muscular Fork 18 mother factor, althongli lis gure rise influente nelle amount of protam remred ry still in lorçada The minimum amount of protein require 18 yilen by tarious ·38 INSULIN IN GENERAL PRACTICE man or woman authorities as from gram to 1 gram per kilo grim (22 lbs) of body weight The average amount below which protein should not fall my probably be taken as 2 grams for a child, 15 grams for an adult and I gram for an elderly In round figures the averige minimum amount for a man lending an ordinary life should not be less than 80 grams The amounts of carbohydrate and fat may bo varied within wide lumits, so long as between them they bring the total energy value of the diet up to the necessary standard It must be noted, however, that carbohydrates alone would be very bulky, while too largo a proportion of fat tends to produce disorders of the digestion The usual proportion in an ordinary diet 18 6 of carbohydrate to 1 of fat The standard amount of the constituents of an 21erage diet are given by Hutchinson as follows Carbohydrate 450 grums Protein Fat The amount of potential energy contained in the various ingredients of food is measured by the amount of heat which it produces on complete combustion The standard is the calorie which is the amount of heat required to raise one litre of water 1 C It is estimated roughly that 1 girm of fat produces 9 calories, while 1 gram of carbohydrate or I gram of protein produces only four calories The method of ascertaining 100 75 ·PRINCIPLI S OF DIETETICS 39 the total number of calories in any article of diot 19 very simple Suppose 1 oz of Ontmenl consists of 18 grams carbohydrate, 1 grams protein and 2 grams fat, the calculation of total calories would be as follows — Carbohydrato 18X4 = 72 calories Protein 4X4 = 16 Fat 2x9 = 18 Total 106 The nort question is how many calories are required daily? This is based on the body weight and usual figure given 18 25 to 30 calorics per day for overy kilo of body weight for a man at test I or instanco a man weighing 10 stone (61 kilos) would requiro as a minimum froin 1,000 to 1,900 calories per day whilo nt rest Other uthorities make much more elaborate calculations, taking into account not only weight, but height, ago and sex There elaborato calcu lations are of doubtful practical valuo For ordinary purposes 1 man or womın of avernge physique, doing ordinary sork, requires usually from 2500 to 3,000 calories daily, and the minimum should not como much below the lower [guro Working out the caloric value of the dict of the averago man given above would result as follows Carbobydrato 400 grams x 4 = 1 800 mlones Protein 100 X4 = 100 Tit 75 X9 - 675 Total 2 876 ·38 INSULIN IN GENERAL PRACTICE authorities as from 1 gram to 1 gram per kilo grım (22 lbs) of body weight The average amount below which protein should not fall may probably be taken as 2 grams for a child, 15 grims for an adult and 1 gram for an elderly man or woman In round figures the average minimum amount for a man leading an ordinary life should not be less than 80 grams The amounts of carbohydrate and fat may be varied within wide limits, so long as between them they bring the total energy value of the diet up to the necessary standard It must be noted, however, that carboliy drates alone would be very bulky, while too largo a proportion of fat tends to produce disorders of the digestion The usual proportion in an ordinary diet 18 6 of carbohydrate to 1 of fnt The standard amount of the constituents of an, werage diet are given by Hutchinson as follows Carbohydrate 450 grams Protein Fat 75 The amount of potential energy contained in the various ingredients of food is measured by the amount of heat which it produces on complete combustion The standard is the calorie which 18 the amount of heat required to raise one litre of water 10 It is estimated roughly that I grim of fat produces 9 calories, while 1 gram of carbohydrate or 1 gram of protein produces only four calories The method of ascertaining 100 ·PRINCIPLES OF DIETETICS 39 tho total number of calories in any article of diet 18 very simple Suppose I oz of oatmenl consists of 18 grams carbohydrato, 4 grams protein and 2 grins fat, tho calculation of total calories would be as follows Carbobs dmto 18*4 = 72 calories Protein 4X4 = IG T'at 2x - 18 Total 100 The next question 18 how many calories re requireil daily? This 18 based on the body soight and a usual figure given 18 23 to 30 calorica por day for overy I ulo of body weight for man nt rest For instruce a man weighing 10 stone (0! kilos) would require as a minimum froin 1,600 to 1,000 calories per day whilo nt rest Other authorities make much more elabornto calculations, taking into account not only weight, but height, age and sex These claborate calcu lations aro of doubtful practical riuo t'or ordinary purposes a man or soman of average physique, doing ordinary sork, requires usually from 2,500 to 3000 calories duls, and tho minimun should not corno much below the lower figuro Working out thio caloric value of tho diet of the averago man given aloio would result 18 folloss Carbohsimta 460 gram *4=1800 calones I'rolen 100 X4 - 100 Tit 70 X9 - 070 Total 2675 ·38 INSULIN IN GENERAL PRACTICE authorities as from gram to 1 gram per kilo grin (22 lbs) of body weight The average amount below which protein should not fall may probably be taken as 2 grams for a child, 1} grims for an adult and I gram for an elderly man or woman In round figures the average minimum amount for a man leading an ordiniry life should not be less than 80 grams The amounts of carbohydrate and fat may be varied within wide limits, so long as between them they bring the total energy value of the diet up to the necessary standard It must be noted, hovercr, that carbohydrates alone would be very bully, while too largo a proportion of fat tends to produce disorders of the digestion The usual proportion in an ordinary diet 18 6 of carbohydrate to 1 of fat The standard amount of the constituents of an average diet are given by Hutchinson as follows - Carbohydrate 450 grams Protein 100 Fat The amount of potential energy contuned in the various ingredients of food is measured by the amount of heat which it produces on complete combustion The standard is the calorie which is the amount of heat required to ruise one litre of water iC It is estimated roughly that 1 gram of fat produces 9 calories, while I grim of carbohydrate or 1 gram of protein produces only four calories The method of ascertaining . 75 ·I'RINCIPLLS OF DIETŁTICS 39 the total number of calories in any articlo of dict 18 very simple Supposo 1 oz of ontmoal consists of 18 grams carbohydrato, grams protein and 2 grams fat, tho calculation of total calories would be ns follow Carbohydrato 18 x 4 = 72 calories Trotein 4x4 = 16 Fat 2X9 18 PE Total 106 The next question is how many calories are requru duly? This is based on the body weight and a usual figuro gnen 18 20 to 30 calorics por day for overy kilo of body weight for amin at ront For instanco a man weighing 10 atono (61 kilos) would requiro as a minimum fron 1,600 to 1,900 calories por day while at rest Other authorities maho nuch more claborato calculations, taking into account not only weight, but height, ago and sex Thero clnborato calcu lations no of doubtful practical valuo l'or ordinary purposes 1 non or woman of averngo physiquc, doing ordinary work, requires usunli from 2,600 to 3000 calorios daily, and thc ue of 10 TCSUL as tollows Carbohydrto Protein Iat 450 grms*4=1 100 - 400 X9 - 675 Total 2 875 11 ·50 INSULIN IN GENERAL PRACTICE to follow his ordinary occupation. The following case illustrates this Has always been a small eater, and not food of sugar and sta sugar, 1 hours. The fas CC. I was of opinion that he was a moderately severe case, and would require insulin, but advised his doctor to put him on the standard diet first and be the effect In two days he was sugar free, and up till now (six weeks later) has remained both sugar and acetone free, is gaining weight and feels well Blood sugar not examined Bince Where the standard diet is successful, it is a good plan to make the patient have a fast day or semi-fast day once a week to rest the pancreatic cells. When a man is employed during the week, Sunday is the most convenient day for the purpose, as it is undesirable and impracticable to ask anyone to fast on a day when engaged in any active occupation. The schemes of diatet which are available, apart from the may be summarised. At the present time i to' ing the use of "ladı? ace ar tolerance 3 {

·DIETETIO TRCATVENT
51
renched with the "standard' diet Agust
th18, lowovor, tho "ladder diet' involves at
least one month in bed in a hospital or similar
institution, and another month of work and if
ultimately the case is found to bo unsuitable for
dietetic treatment alono, much valuablo time
has been lost The standard' diet bas the
advantngo that, in mild or modorate cases it inay
be used while the paticnt is following his ordinary
occupation, and in moro beroro cases where lsing
up is required, less strict supervision suffices
and a much shortor trmo is necessary to decido
whether insulin is required or not
For these reasons I adviso that cascs blould
first be triod on the "standard diet oxcopt those
who havo marked denutrition or acidosis Tho
latter should bo put on insulin treatment at once

·CHAPTER VI
T1
THE PRINCIPLES OF INSULIN TREATMENT
IT 18 unnecessary to go into tho well known
history of the discovery of insulin by Dr Banting,
of Toronto
For a good many years it has been known that
normal carbohydrate metabolism depended on
the presence in the blood of the internal secretion
of the cells i
pancreas
and their
absent The actual cause of the degeneration 18
not known, and possibly is not the same in all
Diabetes is therefore a deficiency
disease, the deficiency being the absence of the
internal secretion of these islet cells of the
pancreas, in the same way that myrodem? is due
to deficiency of the internal secretion of the cells
of the thyroid gland Various attempts were
made to treat diabetes by the oral administration
of pracreatic extracts, but without success Until
1922 all attempts to isolate the active principle of
the internal secretion were also unsuccessful In
that year Dr Binting and his co vorhers, while
not succeeding in isolating the activo principle,
were able to produce a preparation which con
cases

·PRINCIPLES OF INSULIN TREATIENT $3 tarncd the active principlo in a modorately puro Blato. This preparation 19 called 10solm. The method of administration is by subcutaneous in jection After a preliminary trial on samals 16 krag ubod on human drabetics with strikingly beneficial results Glycosuria nas leasedod or abolished, blood sugar was lowered and thero tras Wonderfal clinical improvement These results have been amply confirmed by physicians in all parts of tho world, and there is no doubt that a non era bas begun in tho treatment of diabetes The troatment is still in the oxperimental atago Tho amount required, the best apaciog of dogca, the regulation of the diet during treatment and many other points are still unbottled Much of the recent literaturo is moro calculated to confuso than enlighten tho ordinary practitioner First and foremost, ono most impress on the palicnt the fact that troalmont with insulin involves drotary sestrictions and that these re strictions, whilo pot nearly so sovers as in tho pro 10sulin daya, muat bo carried out conscien. tiously and accurately Oming largely to tho domowhat misleading accounia which haro appoarod in the la; press, many peoplo imagine that a low doses of insulin will not only curo diabetes, but will allow them to haro a practically un restricted diet It is only fair that tho limitations of the treatment should bo explained to patients, and that they should be told quito firmls that if they are not prepared to follow directions implicitly that it is uscless to start on the treatment ·54 INSULIN IN GENERAL PRACTICE It should also be explained to them that, so far as our present knowledge goes, insulin 18 not really a cure for diabetes, but that the daily use of it, combined with dietary restrictions, will enable them to keep the disease in abegance The next question to decide is whether the patient must remain in bed for a time at the beginning of the treatment Most of the author ities say that it is essential, and undoubtedly at 18 the ideal plan, but what the ordinary practitioner wants to know in the treatment of this disease 18 not what are the ideal conditions, but what are the minimum conditions necessary to allow the patient to have the advantage of the new treat ment Where the patient's circumstances are easy, and no great hardship is involved by a stny of three to four weeks at home or in hospital, it better that he should do so Again, if the patient has marhed denutrition, or much acidosis, he should rertainly be in bed In a mild or moderate case, however, where it 18 very difficult for a patient to lie up, and where his occupation is not very arduous, I sce no reason why he should not have treatment while following his usual occupation One advantage claimed for having the patient in bed is that there is more control over his diet While, to a certain extent, this is true, my ex perience shows that an intelligent and strong minded patient will follow the prescribed diet whether he is out of sight or not, but nothing ·PRINCIPLES OF INSULIN TREATMENT aliort of solitary confincmont will keep a stupid or weak willed patient on the right road Before describing the scheme which commend for the treatment of cascs in gesoral practice, I shall shortly describe the asual or thodox treatment of a case of medium saverits in I ospital under ideal conditions "Ibo patient s kopt strictly in bed The amount of sugar in a twenty four hours specimen of urine, while on ordmary diet, 18 ascertained and also bethor acotone or diacetic acid is present. The amount of blood sugar four to five hours after a meal 8 estimated I he bowels are woll opened and he is fasted for ono das trom his hought and treight the aurlace area of h18 body is found by means of a table, and from another table, with age and sex taken into con sideration 18 estimated the total food calories required for the basal maintenanco diet The ett step is to work out tlic proper constitution of a dict which will produco the required number of calories In doing so the first step is to fix tho am unt of protein which 18 mien by vanous not ontres, at ditierent amounts ranging from 3 gram ti gram for each kilogrım of body weight The next step is to calculate the amount of carbohydrate and lat, wbrch with the aid of tlo protein will produce the required number of mal 1308 At the same time the carbohydrate and fwleutial curbohydrate contained in the protein martino in proper proportion to the fat Didierent authorities and various complicated and grently ·56 INSULIN IN GENERAL PRACTICE divergent formule for working out the correct proportions Having selected one of these many formulæ, you proceed to work out the exact amounts of carbohydrato, protein and fat, and this diet is called the "basal maintenance diet It is supposed to be exactly sufficient to maintain the patient while at rest in bed and at the samo time to prevent acidosis Following the fast day, he is given thıs basal maintenance diet If after three days there is still glycosuria another fast day 18 given, followed by a half rition day In a mild case there should then be no sugar or acetone in the urine, and the carbohydrate is gradually increased, leaving the protein and fat constant, until the 18 Just 7 constant trace of sugar in the urine The total sugar value of the diet at this stage, estimated by adding together all the carbohydrate, 58 por cent of the protein and 10 per cent of the fat, T funny anco 18 sirable * wluch can be obtained with each unit of insulin is estimated tolerance the tolerar raised to 140gm , provided the proper relationship of carbohydrate, protein and fat were maintuned If all goes well, the diet and insulin remun constant The tolerance, however, may increase or diminish, if the former, either the carbohydrate ·PRINCIPLES OF ISVLIN TREATALENT 58 increased or the insulin diminished, if the lattor, the insulin 13 incrcased or tho carbohydrate diminished Such a short sketch of the usual treatment with meulin 18 carried out in liospital, where the patient is under constant observation and all facilities are seady to hand it 18 a satisfactors method and is undoubtedly cry scientific, perhaps allra scientific, as the trorking out of laborato embles and calculation to decimal points is scarcely justifically our very imperfect knowledge of the variations of the metabolic processer af the human Lunds Ti bilo fully approring of the use of the80 metoda in hospitals, for it is by each means that Turther knonkdge 18 gained, I am convinced that in the ordinars caso one cas oltain equally good results with much mare simple methods, and that beso methods are nailable in general practice and without spccral rasutus ne After all clero are many fallacies in the data used in there highly scientific methods lor anutence, it is certain that tho x847l statement that ench unt of pirulin will alloir a raticat to usasoanertragu o carlxhydrate is innccurate It may recantinally do more, but in the great Inujority of cgeg at will do less The calculation of ile ortra carboidrato vluch a patient can USD on a giren dose of insulin is consequently nied For instaneI had a patient who, Trità 5) NB If moulin du could only mehuoliso a dict conting 10 grins of total sugar value II RC accept the rulo turi ono unit of insula A.

·68 INSULIN IN GENERAL TREATMENT always metabolise two grams of carbohydrate, it would appear that this patient's pincreas was actually a minus quantity! Take again the proportion of carbohydrate to fat, the authorities differ very widely and they cannot all be right. As a matter of fact practical experience shows that there can be no invariable rule A ratio which prevents acidosis in one case may fail to do so in another Again, even if the basal maintenance diet can be estimated accurately from the various factors, of height, weight, age and sex, it is certain that there is no constant relationship between this basal maintenance diet and the adequate diet, that is the diet necessary to enable the patrent to carry on a fairly normal life, which is the diet we wish to ascertain If with or without the aid of insulin, he cannot utilise an adequate diet, we must certainly fall back on a lower standard wluch 18 within his powers, but this means a life of semi in alıdısm Some writers appear to regard an adequate diet as a "luxury' diet, but surely our object is to restore the patient to a fair degree of herith and strength Merely keeping him alıve, though better than letting lim die, is very far removed from a successful result In all nety discoveries it seems difficult to rid our minds of preconceived ideas Just as our ancestors in the early days of the railway train continued to carry their luggage outside on tho roof of the railway carriage, because they had been accustomed to do so when travelling by ·PRINCIPLES OF INSULIN TREATMENT stage coach, bo to aro inclined to adhere to many ideas of dietetic treatment which the discovery of insulin bas rendered obsolete Looking at the problem from a common sense puiat of vow, it is a fairly simple one. Here is a patient with diabetes ile is pot utilising or storing sugar normalls, and his metabolism for other lood Atulis, especially fat, 18 albo dieordered. We know that his disability is due to impairment of tho pancreatic colls, with consequent diminption of tho natural supply of insulin, but we do not koor whether thia impairmont 18 functional or organic, or whether the supply of qsulin is absoldioly or only relatively deficient. It may be that the diet br been unsuitable in quantity or quality, and that the supply of insulin, whila unablo to meet these excessive demande, is sufficient to metalulise as adequate and properly balanced dict This re can determino only by experiment, and the simiplest means of doing 50 is to put the patient on an adequate diet, keeping the carboby drato as low 18 18 compatible wita safety If he is able to utsliso this diet, that is i gli cosuria coases, the blood sugar is normal, thero ia no acidosis, and be maintains proper neight and strength good and well. It not he must be giren enough insulin daily to enablo han to do so The quantity of insulin necessary IM found by giving gradually tocreasiog amodnie winto the dici is kept constant.

·CHAPTER VII
SCIIEME OF TREATBIENT FOR A CASE OF
MODEPATE SEVERITY WIIERE THERE IS NEITHER
MUCH DENU FRITION OR ACIDODSIS
SECTION I By STANDARD DIET ALONE
Ix his work is not very arduous, ho can go about
his usual occupation The case is investigated
as described in the previous chapters A caro
ful history should be taken of the date of onset,
the order of appearance of symptoms, such as
na linorenn
papanol
11
nta
P
to alcohol, etc Family history, whethier any
cases of diabetes A 24 hour specimen of the
urine is obtained while on usunl diet The
amonnt of sugar is estimated, and acetone and
diacetic acid tested for The specific grayity is
of comparatively little importance, though?
specific gravity relatively low to the amount of
sugar found is suggestive of a lov urea content
and would suggest a searching examination into
the officiency of the kidneys A systematic
search for septic foci should be made, special
attention being directed to the state of tho teeth
If any dental treatment is required
and gums
60

·STANDARD DIET ALONE 61 It should be carried out at once All the other syatarne should be thoroughly infcstigated and reaulte noted Tha alightest cough necessitates a painstaking and mainuto examination of the chest and tho microscopic examination of any sputum Blood sugar The most frequent question asked mo by practitioners 15 whether an estimate of bo blood sugar is essential before commencing insulin treatment in all casca it is scry desirablc, but it may bo omitted when there are markod clinical Bigo8 of truo diabetos especially whero there is acetono or diacetic acid in the gripe This precaution would generally serve to prerent tho 280 of snaulin propal glycosuria or other con ditions whero sis employment would bo dangerous or ueclosb Wherever circumstances permit, howorer, iho amount of blood sugar foar to five hours after tho last meal should be ascertarned In the great majority of cases this 18 sufficient, lot of the resalt is equs socal & Ruger tolerance tcet should be dono If the practitioner door not do tbo test himselt ho can drase of a law ca's of blood from a rein into a tubo containing a little potaessum oxalatc, adding ono drop of 40 por ccnt forinalın as a preservativo (Graham), and Bend mithout delay either to a physician or to a laborators From A consideration of his prarious eight and from one of the ordinary tables of averago peight for height, an idea con la formed whether ibo patieat's weight is a fair ono or whether an increase or a dccrcaso woald be denrablo ·62 INSULIN IN GENERAL PRACTICE 66 1 The next step 18 to prescribe a diet which will be adequate without being excessive For reasons given in a previo I do not think that in practice there is relationship between the weight of t the caloric value of necessary food * of a large number of for most adult patients a tc produce about 2,300 ono to begin on This diet has y d something on the lines in a simplified form First fix the amount of of protein necessary for an a matter of dispute As constituent of the diet, and repair cannot be carried on, on the side of giving too and this applies with special peoplo where growth as well as provided for For the same can do with less and it is al give any considerable excess ronal inefficiency To do so w unnecessary strain on the k there is often a tendency to renal inefficiency Another consideration has to be namely, that it is impossible acceptable diet from ordinary I protein factor 18 very losy Hutchison, in his fascinating bo 3 LC ·STANDARD DIFT ALONE 63 after reviewing the whole subject, thinks that an averago min doing moderato work requires from 100 to 120 gms protein per day and that at the {cast be should base 80 gms of which a con Riderable portion should be animal protein Probably a far working rule is to allow 2 g138 por kilo of body weight for young patiente, 1 gm per kilo for elderly patients and it yms per kilo for thoso of middle age Still more simply, one 18 not far wrong in allowing about 80 gms protoia daily for the average adult leading an ordinary life llaving fired tho amount of protein we must now work out the annunt of carbohydrate and fat which, along with the process, will give a diet of 2,300 calories Inothings must be borno in mind, first, that each grammo of carbohydrato or proten produces i caloris ssd that each grammo ol fat produces 9 calories, and secondly, that the amount of fat should not bo in too great cxcc88 Tho reason, as expued before, is that a certain pro portion of carbobydrato is necessary for the proper metabolism of fat and the provention of acidosis a good working rule for the right proportion 18 that girev bs Woolyatt 17 that tho fat should not exceed twice the total carbohydrate plas ball the protein For example, the amount of proton is fixed at 80 grams, the maximum amouni ol fat allowed would be 186 grams, while tho carbohydrato youll by 73 grams if to wish to baro a diet at about 2,500 calorio.

·68 INSULIN IN GENERAL PRACTICE Saccharine, to the extent of a fer tablets a day, appears to do no harm, but it is more desirable that the patient should lose the taste for sweet things, which he speedily does. For a special occasion jellies may be given if made of gelatine, flavoured with orange or lemon juice and slightly sweetened with saccharine. 1 Bt Ozs. rather expensive, owing to the quantity of agar. agar required. This can be greatly reduced if the white of one egg is added. Recipe for Bran Biscuts. Brun (the variety used for feeding cattle) 2 ozs Agar agar, nowdered. oz One thite of egs. Pinch of salt Cold water. The bran is tied in cheese cloth and hung under the cold water tap to wash. It is squeezed repeatedly until the water runs through clear, which takes about half an lour. The agar is mixed in 34 ozs. cold water and brought to the boil. The white of egg is slightly beaten up and mixed with the bran. The hot agar solution is next added, and the mixture is moulded into eight thin biscuits. When firm and cold, these are baked until dry and crisp. If only two or three biscuits are allowed in tho day, the quantity of both carbohydrate and protein is negligible.

·STANDARD DIET ALONE 69 No patent food of any kind should be used unless the makers furnish a certified analysis of the amount of the carbohydrate, protein and fat that it contains, In framing a diet, several things haro to be borne in mind. While there is no very great alteration in the amount of protein from that contained in an ordinary diet, the wholo relationship of carbohydrate to fat 18 altered In an ordinary dict there 18 roughly six times as much car. bohydrato as fat, whilo in a diabetic diet thero may bo thrro timos as much fat as carbohydrato. This is a cry great difference, and in anything but a mild caso with little or no acidosis it 18 a good plan to make the change a gradual ono The easiest way to do tlus is to prescribo the diet on tho lincs given above, but instruct the patient to begin with a daily allowance of 3 to 4 extra oze of broad, and reduce this by 1 oz. or more a day until tho proscribed amount 18 reached. I'atients misg tho bulk of dict they are accustoined to, henco the necessity of always repletion. 'Thcro 18 often difficulty in getting the requisito Amount of fat presented iu an appetising form. In tbcso cases ono must ring tho changes betweun ·68 INSULIN IN GENERAL PRACTICE 1 Siccharine, to the extent of a few tablets a day, appears to do no harm, but it 18 more desirable thit the patient should lose the taste for sweet things, which he speedily does For a special occasion jellies may be given if made of gelatine, flavoured with orange or lemon juice and slightly sweetened with saccharine ? the place E these are they are rather expensive, owing to the quantity of agar agar required This can be greatly reduced if the white of one egg is added Recipe for Bran Brscurts Bran (the variety used for fecding cattle) 2 ozg Agar agar powdered One white of e66 Pinch of salt Cold water 8t ozs The bran is tied in cheese cloth and hung under the cold water tap to wash It is squeezed repeatedly until the water runs through clear, which takes about half an hour The agar is mixed in 37 ozg cold water and brought to the boil The white of egg 18 slightly beaten up and mixed with the bran The hot agar solution 18 next added, and the mixture is moulded into eight thin biscuits When firm and cold, these are baked until dry and crisp If only two or three biscuits are allowed in the day, the quantity of both carbohydrate and protein 18 negligible 1 oz ·STANDARD DIET ALONE 69 No patent food of any kind should be used unless the makers furnish a certified analysis of the amount of the carbohydrate, protein and fat that it contains In framing a diet, several things have to be borne in mind While there 18 no very great diet there is roughly six times as much car bohydrate as fat, while in a diabetic diet there Carbohydrate in anything cidosis it 18 a good plan to make the change a gradual one 'I ho easiest way to do this is to prescribe the diet on the lines given above, but instruct the patient to begin with a daily allowance of 3 to 4 extra ozs of bread, and reduce this by 1 oz or more a day until tho prescribed amount 18 reached At the same time ho begins with about half the amount of fat prescribed in the diet, and increases this daily till the full allowanco 18 reached Patients miss the bulk of diet they are accustomed to, hence the necessity of always making green vegetables an important item in the diet list Thoy contain very little carbohydrate, but from their bulk give an agreeable feeling of repletion There 18 often difficulty in getting the requisito mount of fat presented in an appetising form In theso cases one must ring the changes between ·70 INSULIN IN GENERAL PRACTICE bicon, butter, cream, etc, and serve them up in as many different ways as possible If olive oil or sardines can be taken, they are a great stand by Walnuts are useful, but somewhat in digestible One cannot emphasise too much the necessity of having the food cooked and served as nicely as possible, and with as great a variety It makes all the difference to a healthy person, and much more to a patient who is chafing against all the restrictions of his diet All the weights given in the above table aro those of the cooked article The reason for this is that where a patient 18 a member of a house hold, it is often impossible for him to have his ration cooked separately There may be a family joint, or in the case of porridge it would be very difficult to make, siy, four o inces of porridge by itself Again in the case of fish, there 18 so much waste material in small fish that the weight in a raw state 18 little guide to what is actually con sumed How then should the food be weighed without interfering with tasteful service ? A small scale, like a large letter scale, should be obtained and kept on the table It is a con venience to use a similar plate for weighing everything, and to have a disc of lead to act as an exact counterpoise on the other side of the scale For weighing hot food the disc to balance tho plate, plus the requisite weights, are placed on nno side of the scale and a hot plat dopo other Porridge, or whatever 18 quickly put on the plate ·Segg ܗ ܗܘ ܤ ܫ STANDARD DIET ALONE and served immediately Similarly for hot liquids the same cup or bowl of Inown capacity can be used, instead of having to translor each time to a mcasure and back again A daily diet list of about 2,300 Calories may be made up as follows Cubotsd u Prodela (prites) (TU) (ms) 18 18 8 ozs butter 72 10 ozs vegetables (5 per cent) 10 8 OZ micat 91 2 oze ham 12 16 2 ozs brcon SO 6 ozs mult 6 5 5 1 oz ortmeal 18 2 1) ors patato 9 2 ozs broren brend 26 8 1 oz olive oil az chocse 3 70 81 183 If the patient is not very intelligent, or bas po knowledge of cooking and the arrangement of meals, it is desirable to give him, in addition to the daily ration list, a few specimen menus of ibo different moals of the day The following menus will illustrate the way this can be done with tho 9,300 Calories " standard" daily ration Whon the patient is rell of it 18 easy to get tery considerable variety, but it is by no means. 80 easy whon mcins are limited It 18 obvious that 1 dubenic diet is an expengte diet, especially in winter, slien grecu vegetables and cggs are scarco and dear There are physiological reasons 15 ·72 INSULIN IN GENERAL PRACTICE wby, in an ordinary diet, carbohydrate should largely predominate over fat, but there is the economic reason also, viz , carbohydrates are much cheaper than fats The reversal of this proportion in the diet of a diabetic means a great increase in cost INEXPENSIVE MENU FOR ONE DAY Breakfast 4 oz porridge (1 oz oatmeal) 2 oz milk Tea and toz milk. 1 ess 2 oz bacon 1 oz brown bread oz butter Dinner 1 cup beef tea 3 oz meat (beet or mutton) 5 oz cabbage cooked with 1 oz butter 14 oz potato 1 bran biscuit oz butter 1 oz cheese Tea Tea withoz milk 1 oz brown bread oz. butter 2 oz lettuce, tomato or cucumber Supper Coffeo with 2 oz hot milk 2 boiled eggs 2 oz cold him 3 oz salad with oz olive oil 1 bran biscoit. oz butter ·STANDARD DIET ALONE 73 INEXPENSIVE MENU FOR WORKMEN AND OTHERS WHO KAYE TO TAKE TEEIR LUNCH OUT WITH THEN Breakfast 4 oz porridge (1 oz oatmcal) 14 oz milk Tea with } oz milk 2 oz herrings fried with #oz butter 1 oz brown bread oz butter Lunch Eot coffee in thermos flask, mudo with 2 oz mulk 1 oz brown bread 1 oz butter 1 oz cheese 2 hard boiled eggs (or 2 oz tunned salmon or sardines) 2 oz cold ham S oz salad toz olive oil Dinner 1 cup beef toa 2 oz tripe browned in oz batter and stowed slowly 2 oz onions fried in oz dripping 4 oz greens 11 oz rotato mashed with oz milk, 1 poached egg Supper Cup of tea with 1 oz milk 2 brin biscuits oz batter ·INSULIN IN GENERAL PRACTICE MORE EXPENSIVE MENU (1) Breakfast 8 oz grape fruit Coffee made pith 2 oz mulk, 2 oz bacon with 2 oz tomato, grilled 1 boiled egs 1 oz brown bread oz butter Lunch 1 cup beef tea 2 stuffed eggs (hard boiled eggs cat in hall, pound the yolks with 1 oz butter, and a flavouring of ancbary) Serse cold with 8 oz salad 2 oz cold ham 1 bran biscuit oz butter Tea Ten with | oz cream (thin) 1 oz brown bread 1 oz butter 2 oz banana Dinner 2 oz salmon with 1 oz cucumber 2 oz beef steak grilled with 2 Oz onion 1 oz rotato 5 oz French beans or stewed celery 3 oz walnuts Coffee with oz milk MORE EXPENSIVE MCYU (2) Breakfast 2 oz grape fruit Coffee with 2 oz milk 1 egg 2 oz bacon 1 oz brown brend oz butter ·STANDARD DIET ALONE 75 Lunch 1 cup bcef tea 2 oz cold ham S oz salad with 1 oz olivo oil 2 bran biscuits oz butter oz cheese 8 oz banana Tea Tea with $ oz milk 1 oz brown brend oz buttor Dinner 2 oz fish (white), 2 oz cucumber or tomato 2 oz meat (boef or mutton) 5 oz leeks or cabbage, boiled and flavoured with bovni Savoury omelette made with 2 1 oz butter and oz cheese, pepper and salt to tisto 2 oz walnuts Coffee made with 2 oz milk MORE EXPENSIVE MENU (8) Breakfast Tea with $ oz milk 1 oz brown bread oz batter 1 egg scrambed with oz mulk toz butter 2 oz grilled bacon Lunch 8 ray oysters 2 oz cola ham with 4 oz grilled with 4 oz tomato. 1 brun biscuit az butter 1 oz cheesc

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·STANDARD DIET ALONE can be camed out sufficiently to stop the loss in weight and restore a fair amount of energy with out this symptom appearing, all 18 well If not, the amount of carbohydrate may be cautiously increased, and the same good result obtained, but if the addition of carbohydrate gives rise to glycosuria, the attempt rust be abandoned and insulin treatment begun When there is no glycosuria, an occasional blood examination is desirable to make certain that the blood sugar 18 keeping within normal limits The leak point of the kidneys in some cases may be so high that although there is no glycosuria, the blood sugar may be considerably above the normal level General directions are given, the details of which must depend on the circumstances of the patient. The bowels should be kept wel open, and for this purpose an early morning draught of a mild saline, such as Carlsbad salts in a tomblerful of hot water, is useful Water or soda water should be taken freely between meals Warm clothing should be porn Ladies' fashions at the present time apparently make it difficult for them to wear adequato under garments There is not much difficalty with men, but, avoidance of worry and adequate rest are very important Even if % patient 18 following his usual Occupation, he should rest as much as possiblo in his spare time and go to bed earts It is useless to spend time arranging a diet calculated to produce enough heat and energy ·82 INSULIN IN GENERAL PRACTICE The increase may be made every day or every second day at first, but at longer intervals as the larger doses are reached Any case which requires more than 40 units a day should be in a nursing home or hospital till the correct dose is found, as constant supervision should be available during this period CONTROL OF Dosage This is 1 most important question If constant blood sugar estimations are essential, the treat ment must be largely confined to physicians working in special institutions, while if dosage can be controlled by urinary examination the treat ment cîn be carried out by the general practitioner in his ordinary practice In the majority of cases the urinary examination 18 quite sufficient, and if the practitioner is prepared to study the elementary principles of dietetics and is able to devote a little time and thought to his cases, there 18 no reason whatever why he should not employ insulin in his diabetic cases The ideal aim of treatment is to keep the blood sugar constantly within normal limits, and the only danger in attempting to do 60 18 that the blood sugar may at some period of the day be so much reduced below these limits One as to cause hypoglycæmic reaction would imagine that as the danger arises from lowered blood sugar frequent blood examin atrons would obviate the risks No doubt it 18 the best method, but even daily examinations,

·STANDARD DIET WITH INSULIN 83
and this 18 scarcely practicable, do not entirely
do so
Somo months ago I had a patient under treat
ment in hospital who was getting on well with
moderate doses of insulin One afternoon he had
a definite hypoglycemic reaction although his
blood sugar, which happened to have been esta
mated that morning bad been 155 mgr and he
MY
risk of hypoglycemia in the vast majority of
cases however so long as there 18 a trace of
ench day, and that this is undesirable as it in
volves overwork of the pancreatic cells that, as
the urine should be kept quite sugar free tho
only method of controlling dosage is frequent
blood sugar estimations This objection may bo
truo in theory, but practically control lwy urinary
examination alone works very well and, if tho
dosage of insulin is only gradually increased, is
possible, and cien dangerous, to give vaccines
witl out opsonic control that to do so was to
intite disaster from a negative puato Non

·84 INSULIN IN GENERAL PRACTICE vaccines are given freely by all practitioners, and I imagine that the estimation of an opsonic index is a rare event In both cases the examination of the blood was essential in the initial experiments, but can be more or less dispensed with as experience is guned At the beginning of treatment, both an evening (1 hour after supper) and a morning (before breakfast) specimen of urine should be examined daily These are convenient times for a patient to get specimens, and both can be brought to the doctor in the morning That one expects to find depends on whether the patient is a mild case who is having only a single morning dose of insulin, or whether he is a more severe case who is having two doses, one in the morning and one before tea In the former, who has fair sugar tolerance, the effect of the morning dose of insulin lasts all day, but is becoming exhausted by the evening, with the result that he has no glycosuria during the day but a trace appears The night's fast abolishes this again, so that the morning specimen 18 sugar-free In the latter, where the tolerance 18 not so good, the effect of the morning dose is passing off by the afternoon, but the second dose reinforces the effect. There is no glycosuria till early the next morning The dose of insulin should be increased until there is just the faintest trace of sugar in either of the specimens After the treatment is esta! lished, an intelligent patient can regulate thed after supper ·STANDARD DIET WITH INSULIN 85 himself and safely keep hıs urine entirely sugar frec The examination of the urine shows him if he is having too little insulin, and his own h acetone 3 only a small quantity of the former and none of the latter, no anxiety need be felt and no change indicated If, however, there is much acetone (as shown by the nitro prusside test giving a distinct colour within half a minute), or if the ferrı perchlor test is definitely positive, the fat in the diet is diminished and the carbohydrate increased ML 1 vrnen the necessary dose of insalın has been ascertained and the proportions of carbohydrate and fat adjusted, the further regulation of the diet, if any is required, is made on the lines described previously, where the patient has been rendered sugar and acetone free without the use of insulin In the unlikely event of the diet of minnanlauh riant he shown herodlarn ---La it it does, the carbohydrate must be increased and tho dosago of insulin also increased if necessary ·86 INSULIN IN GENERAL PRACTICE ones After the initial stages of treatment, patients of average intelligence may usually be trusted to examine their own urine This is not only a great saving of time to the doctor, but impresses on patients the necessity of adhering to the pre scribed diet I have always found that patients who test their own urines are the most satisfactory The evil of any surreptitious addition to the diet is forcibly brought home to them and they do not offend again All they require is a spirit lamp, some Fehling's solution, some dilute lıq ferri perchlor and some test tubes There is a practical point with regard to the latter See that they are provided with small test tubes, about inch, instead of the usual large ones This allows a great saving of Fehling s solution, which is quite a consideration to people of moderate means, when frequent examinations are being done They should enter the results in a book daily, which is shown to the doctor when they report themselves Who 18 to administer the insulin ? In the vast majority of cases it is impossible for the doctor to do 50 The exigencies of his work made it out of the question to see a patient twice, or even once daily at a specified time, and that usually an inconvenient one Even if he could do so, the cost to the patient would be prohibitive Some times it is possible to arrange that a nurse should give the injections, and district nurses have been hind enough to do it for some of my hospital patients when they left the institution Usually ·STANDARD PIET VITI INSULIN 87 the patient has got to learn to inject himself, and, as a rule, there is no dificulty in teaching bim bow to do it antıæptically One has to Ho 18 with some tincturs of nodine, a little lyso), and some cotton wool A small quantity of ether 18 poured into a clean egg cup After taking the wire ont of tho needle, it is put on to the syringe, which 18 filled and emptied of ether several times, taking care that the neodle 18 quite submerged so the ether Tho piston 18 worked up and down several times to get rid of all the other After putting a drop of lysol on the rubber stopper of the insulin bottle, the needle 18 inserted, and the requisito amount of insulin drawn up into the syringe Tho area selected for the injection is then rubbed with a small piece of cotton wool soaked in the with ether, dned again, and the wire inserted in the needle The reason for advising & minim By ringe, instead of one graduated in c C8, 18 that minims better cs into minis 9m, practically vse will it in m 'l hen, if you wish the patient to have 10 units, the dose 19 05cc or 8 m The site of injection is immaterial For paliests who are injecting themselres, the upper ·88 INSULIN IN GENERAL PRACTICE part of the chest in men and the outer side of the thigh in women are sometimes found more con venient than the arm At first I was very doubtful of allowing patients to inject themselves in case they would get septic arms, but, after six months experience of about forty patients in jecting themselves once or twice daily, there has not been the slightest trouble Occasionally, after injection, there 19 said to be some redness and swelling due to protein reaction, but I have not seen at Expense In spite of the recent reduction, the price of insulin 18 very high The 5 cc bottle containing 100 units, costs 128 6d, which works out at about 11d per unit Employed men and women are all right, as insured persons are entitled to have insulin supplied free under the National Health Insurance Act Incidentally, all panel practitioners should know that the cost of this and similar preparations is kept in a that thorn ennrol of being The case or very moderate means, or the wives of working men, is very different While the cost of a small daily dose, such as 10 units (18 3d ), may be managed, it 18 impossible for them to afford, say 30 units, costing 38 9d per day, especially as the necessary diet is more expensive than an ordinary one The Swansea hospital authorities are generously supplying with insulin, on leaving the hospital, all in patients not being insured persons, who are ·STANDARD DIET TITH INSULIN 89 cortified by the physician in charge as being suitable cases, provided they report themselves at the hospital at prescribed times (usually every two wecks), so that blood or other examinations can can bo made as required. The preliminary stay in hospital weeds out patients who are not propared to submit to dietary restrictions, and those who have not sufficient intelligence to carry on the treatment outside. This still leaves untouched the problem of the middle class patient, and I

·CHAPTER VIII
HYPOGLYCAMIA
The normal fasting blood sugar, as we have seen
in a previous chapter, is from 80 to 120 mgr per
100 CC
The essential action of insulin is to
lower the blood sugar, and, if by excessire dose
or by the administration of an ordinary dose not
followed by a meal, the blood sugar
unduly
lowered, a condition of hypoglycemia results
Nothing much happens until the blood sugar 18
reduced to about 60 mgr At this point a train
of symptoms appear, to which has been given the
name of hypoglycæmic reaction The time of
occurrence is variable If the insulin has not
been followed by food, the reaction may appear
in half an hour, if it has been followed by food,
the reaction may not appear till some hours later
ness of vision, tremor, and nearly always profuse
perspiration if no treatment is given, spontaneous
recovery may take place, or the patient may pass
into a state of coma and death Fortunately,
prompt recovery takes place, when 10 to 20
grammes (1 oz) of glucose is given by the mouth
90

·HYPOGLYOÆJIA
91
If this 18 not available, a fow ounces of orage
Juice, ordinary cane sugar, or eren milk does
well For slight symptoms, a cup of tea with two
or three lumps of sugar does very well If coma
has developed so far that en allowing 18 impossibe,
about 200 cc of a 5 per cent solution of glucose
should be given subcutaneously or intravenously
A similar solution may be given rectally, while
the apparntus for subcutaneous or intravenous
injection is being prepared, and may be effective
In a comatose case, i cc of 1 in 1000 solution
of adrenalin should be given intramuscularly
Adrenalın causes any reserve of glycogen in the
liver to pass into the blood as sugar Even if it
18 effectivo in rousing the patient, sugar should be
given 18 soon as possible
All patients should be varned of the danger of
obtai
that they know what to look out
I ho actunl cause of the 1
18 probably the inabihty of tho
normal supply of sugar
blood sugar is reduced
In the early days of
alarming experiences of
as Blown in the fol'
1,

·92 INSULIN IN GENERAL PRACTICE case, inısmuch as the patient experienced both diabetic coma, and later on hypoglycemic re action CASE 6-A woman, aged 88, with two yerrs history of diabetes Has lost 5 stones in weight Double diabetio cataract causing total blindness Looks wretchedly ill depressed and emaciated Passing 82 gms sugar daily Acetone and diacetic acid Her case is described fully in connection with drabetic com She was on 30 units of insulin daily without much effect on the urine and blood sugar, when the dose was increased to 60 units in three doses of 20 units each At the end of the first day she was sugar and acetone free The same treatment was continued the following day, but about 9pm she became rather drowsy, and at 10 p in become almost complete comatose, and was sweating profusely Urine drawn off by catheter con tained no sugar, acetone or diacetic acid The blood sugar was 60 mgr Fifty grms of glucose were given with great difficulty by the mouth, and in 15 minutes tho patient had completely recovered. This alarming experience should have been avoided first by increasing the dose of insulin more slowly, and secondly by lessening the dose on the second day, when the urine was sugar free, or by examining the blood to Nscertain how far the sagar content had plats Another case is of interest, is sf very small dose of insulin mu, glycemia momentin CASE aged 6l three diabetes 43 gms of the urin trace of fasting was not doing dietotio was given 10 each day The urinary to & trace, abont 2 . $

·HYPOGLYOÆVILA
93
breakfast, bo got & definite though not severe hyro
glycemio reaction which was promptly relieved by the
administration of sugar I do not see how even a blood
Bugar examination thnt morning could have avoided this
reaction as there was a trace of sogar in the urine, and
bis leak point was not low
It can be readily understood that the greatest
danger from hypoglycemia would occur when the
reaction took place at night A patient might
pass from ordinary sleep to a state of coma and
death, so that there would be no opportunity of
treatment I do not know that any such catas
tropho has actually happened, but the possibility
emphasises the necessity of never giving insulin
ncar bed timo
Again, the danger of a reaction 18 much greater
during the first few weeks of treatment than at a
later dato Tho reason for this is that in the
carls stages there may be very littlo resero of
glycogen in the liver and muscles for the blood to
draw on, as its own sugar content falls, whereas
later on 1 reservo b18 been built up
Out of
somo forty hospital cases, who sinco discharge
forgot all about le tez until reminded of it by
tho onset of hypoglycumic symptoms As he
had nlready had ono reaction while in hospital,
ho recognisod tho symptoms at oncc, a wallowed

·100 INSULIN IN GENERAL PRACTICE 20 grams of fat and will produce about 1,200 calories The patient being in bed these calories are sufficient Insulin should be given in doses of from 10 to 40 units daily, the actual amount depending on blood sugar and the effect on the urine It must be constantly remembered that what we are treating now 18 acidosis, ? e, we want to get rid of the di acetic acid in tho urine The amount of sugar which is being excreted does not at the moment trouble us There is no need to give too much carbohydrate, but so long as there is diacetic acid, our aim is to have at least a good trace of sugar present in the urine, so that we are certain of having enough sugar in the system for the insulin to work on, and so permit the proper metabolism of fat In short the insulin is pushed until the urine is acetone and diacetic acid free, while enough carbohydrate is given blood sugar above normal This can be ascertained either by blood sugar examination or more simply by keeping a constant trace of sugar in the urine This insulin treatment of acidosis 18 wonderfully successful When cases are got at this stage I have never seen it fail to bring about striking and rapid improvement TVhen the acidosis has been cleared up, the diet is gradually readjusted and treatment of the underlying diabetic condition instituted keep the

·CHAPTER X
IurEYDING COSA AND Cous.
1 OEDIYAET TIRE Or Cox AEROCLATED WITH
ACIDOSIS
THERE IS DO hard and last line between this
and the last group of cases. There is often a
gradual progression from acidosis to impending
coma and complete coma Occasionally, however,
the onset of coma 18 quite badden. The patient
without previous warning, and perhaps without
any knowledge that he is suffering from any
disense, is suddenly attacked with weaknees,
10
constant attention and to have skilled nursing
188istance As, boterer, there is often m
opportunity to get the patient removed without
tho loss of valuable time it is very necessary that
all practitioners should be familiar with the
symptoms of the condition and the best line of
treatment
Symptoms
The first warning symplom is often anorexia
with gastrie discomfort or pain, followed ty
101
L

·100
INSULIN IN GENERAL PRACTICE
20 grams of fat and will produce about 1,200
calories. The patient being in bed these calories
are sufficient,
Ingulin phania ha miwan in Ancag of from 10 to 40
blood
• 18t be
constantly remembered that what we are treating
now is acidosis, i.e., we want to get rid of the
diacetic acid in the urine. The amount of sugar
which is being excreted does not at the moment
trouble us. There is no need to give too much
carbohydrate, but so long as there is diacetic acid,
our aim is to have at least a good trace of sugar
present in the urine, so that we are certain of
having enough sugar in the system for the
insulin to work on, and so permit tho proper
metabolism of fat. In short the insulin is pushed
until the urine is acetone and diacetic acid freo,
while enough carbohydrate is given to keep the
blood sugar above normal. This can be ascertained
either by blood sugar examination or more simply
by keeping a constant trace of sugar in the urine.
.:----ndaufully
rapid improvemer
cleared up, the
treatment of the
instituted.

·CHAPTER X
IMPENDING CONTA AND COMA
1 ORDINARY TYPE OF COSA ABSOCIATED WITII
ACIDOBIB
TICRE IS no hard and fast line between this
and the last group of cases
There 18 often a
gradual progression from acidosis to impending
coma and complete coma Occasionally, however,
the onset of coma is quite sudden
The patient
without previous warning, and perhaps without
any knowledge that he is suffering from any
disenge, 18 saddenly attached with weakness,
handann mann and conduell Anonen
the practitioner is ablo to give them close and
constant attention and to have skilled nursing
assistance As, however, there 18 often no
opportunity to get the patient removed without
tho loss of alunblo time it 18 very necessary that
all practitioners should bo familiar with the
symptoms of the condition and the best line of
treatment
Symptoms
The first waruing symptom is often anorexia
with gastric discomfort or pain, followed by
101

·100
INSULIN IN GENERAL PRACTICE
20 grams of fat and will produce about 1,200
calories The patient being in bed these calories
are sufficient
Insulin should be given in doses of from 10 to 40
units daily, the actual amount depending on blood
sugar and the effect on the urine It must be
constantly remembered that what we are treating
nov 18 acidosis, i e, we want to get rid of the
diacetic acid in the urine The amount of sugar
which is being excreted does not at the moment
trouble us There is no need to give too much
carbohydrate, but so long as there 18 diacetic acid,
our aim is to have at least a good trace of sugar
present in the urine, so that we are certain of
having enough sugar in the system for the
insulin to work on, and so permit the proper
metabolism of fat In short the insulin is pushed
until the urine is acetone and diacetic acid frco,
while enough carbohydrate is given to keep the
blood sugar above normal This can be ascertained
either by blood sugar examination or more simply
mantha urina
1.
innt donna nfo
treatment of the underlying diabetic condition
instituted

·CHAPTER X
IMPENDING COMA AND CONA
1 ORDINARY TYPE OF COMA A ESOCIATED WITH
ACIDOSIS
Therf 16 no hard and fast line between this
and the last group of cases There is often a
gradual progression from acidosis to impending
comn and completo com
Occasionally, however,
the onset of coma is quite sudden Tho patient
without previous warning, and perhaps without
any knowledge that ho 18 suffering from any
d18e96c, 18 suddenly attacked with weakness,
1
constant hention and to have skilled nursing
assistance As, howerer, there 18 often no
opportunity to get the patient removed witbout
the loss of ralunble time it is very necessary that
all practitioners should be familiar with the
symptoms of tho condition and the best line of
trentment
Symiptoms
The first ning symptom is often anorexia
with gastric discomfort or pain, ſollowed by
101

·100 INSULIN IN GENERAL PRACTICE 20 grams of fat and will produce about 1,200 calories The patient being in bed these calories are sufficient 10 1 111 102 je constantly remembered that what we are treating now 18 audosis, 1 e, we want to get rid of the diacetic acid in the urine The amount of sugar which is being excreted does not at the moment trouble us There is no need to give too much carbohydrate, but so long as there is diacetic acid, our aim is to have at least a good trace of sugar present in the urine, so that we are certain of having enough sugar in the system for the insulin to work on, and so permit the proper metabolism of fat In ghort the insulin is pushed until the urine 18 acetone and diacetic acid free, on to keen the ܘܐܝܕܐ ܬ ܬ by keeping a constant trace of sugar in the urine This insulin treatment of acidosis 18 wonderfully Buccessful When cases are got at this stage ii.I am and 1 1 treatment of the underlying diabetic condition instituted ·IBIPENDING COMA AND COBLA 103 glucoso is wvailable give 15 grams (t oz ) dissols ed in hot water, if not, give the juice of large oneet orange which contains about the samo amount of glucose Failiog these, give a cup of hot weal tea containing a tablespoonful of ordinary Alar1 h moro sugar The dose of insulin will depend on whether thero has been improvement in the clinical picturo or in the urine If littlo or no improvement givo another 15 to 20 umts, whulol there is decided improvement 6 to 10 may bo bufficient The urine 18 examined again every two or three hours and a dose of insulin, followed by sugar, continued until the urine is free of diacetic acid It 18 difficult to say exactly how much sugar should be given, but the urino should nover bo allowed to become sugar freo until the patient 18 wall out of danger During this time other measures are being cmployed The patient should have complete rest in bed witli plenty of blankets and hot water bottles The borrels are clenred out with an onoma He should be given hot water, weak tea or coffee, bourl (but not milk on account of the fnt it contains) The administration of fluid must not be overdone, the usual allostance being ono pint every three hours for an adult, and half this wount for a child if the pulse is unsatisfactory, digtalın or stropanthin should be given lypo dernicalls Since the advent of insulin thero ·102 INSULIN IN GENERAL PRACTICE nausea and vomiting Sometimes the character istic heavy sweetish odour of the breath, sud to be due to acetone, is the first thing noticed Other symptoms are pain in the back and legs with muscular weakness, restlessness, headache and drowsiness, flushed cheeks, dry tongue, feeble pulse If unrelieved the drowsiness passes into complete coma, which is characterised by the abnormal type of breathing The respiration is slow and deep, the so called "air hunger of Kussmaul Examination of the urine shows that it is full of tone lacetic acid with a larger or smaller quantity of sugar Contrary to what one might expect, the blood sugar is often not very high, perhaps round about 200 ingr Dragnosis In the later stages this is usually obvious If a case is seen for the first time in coma and the diagnosis is in doubt, draw off a specimen of tho urine If sugar and acetone or diacetic acid 18 found, treat at once as diabetic coma Treatment This depends on whether it is a case of impending or of complete coma when the patient 18 unable to swallow In erther case the first thing to be done is to give an injection of 25 to 30 units of insulin (a) Impending As soon as y injected, give f 11 n ·RAU TAIPENDING COU4 AND COMA 103 her lett ega and gave her very good neion Sho is still la tair health, sugar and setons fro and mth a nearly normal blood sugar. She 18 able to tako modcrata diet, about 1,800 calories, but requires 30 to 60 volts o! Insulin Jaily Ler tolerance 18 apparently decreasing 6 at one time sho conld take A Buonar diet with 10 onits dalis, CABE B.Man, aged 62 Elas had Asabetes for eight years, latterly cataract both 38 Looks wenk and ul. Unino contolas 88 grung sugar dasly Acetono present in largo qanotity but no diacetic acid Fasting blood sugar 200 mgr Treatment by Grabum's ladder det ma kogun, but on the 7th day be developed severo acidosis. He was very drotey rod cowted, and boil tha chowistio brostb. Qero similar tonna g case, and a ab Anå rosu! Oas ".. ugen 25, kdaitted to bosques ou 25th April, 1949 Ono scar's history of diabetes with sound symptoms of polyuria, turbt, weakness and loss of weight (two stones) Looks rery ill, drowsy, has adema of Ankles and soptic spats all over body No Inco jerks Parsing 118 grama sagat daily with mach acetono and dvacetic acid. Fasting blood sugar B90 grams Ordinary ruotinent by alvacutary teet ete, tried for a low dare but ho becamo wonse Tlc breath smelt atrongly of acetono, there was nach second and duscetic acid in urino, bo ras becoming rery drowsy and slightly cynnosed. Similar tregtment was given and tbe acidosis quickly raulshed and be locked a different math tre got him up to diet of 1,800 calonen hilo romaalaing ugar and acetose (res and with a fasting bloom 100 to 120 mgr bus to do ne bo of kosulin duls bis 66.50 19 of ho luns loco able to asimulate a With 80 gaita dalls although #ork which shows ·104 INSULIN IN GENERAL PRACTICE has been much discussion as to the advisability of giving sodium bicarbonate or other alkalıs Some authorities say they help, while some affirm that they are actually harmful As I never say any result from alkalis in cases of coma before the days of insulin, I think they are just as well omitted. The treatment at this stage is usually success ful I have had three cases who all recovered and did well afterwards The following one may be taken as typical CABE 6 - Woman, aged 88, with two years history of diabetes Has lost 6 stones in weight and had double cataract, causing total blindness Looled wretchedly ill, depressed and emaciated Passing 82 grams sugar 1 strongly of acetone and she was very drowsy Sho was put on insulin, 10 units every two hours at first, and Bubsequently at longer intervals, 10 grams of glucose or 1 oz of bread with some sweet tes being given after each dose It was three days before the acetone had completely disappeared from the orine, but the patient's condition soon changed marvellously From being drowsy, dull and depressed, she became bright and cheerful Shortly after dietetic treatment on Graham's plan was tried but without success Ler tolerance for carbohydrate appeared to be practically nil She was then pat on insulin 10 units three times a day but, with a Fery moderato diet, still had mach glycosura Acetonaria and a high blood sugar The insulin was raised to 20 units three times a day which cleared everything up but caused a sercre hypoglycemic reaction which was described on rage 92 Tho cataract was removed from ·IMPENDING COJIA AND COS1 107 proviously cleansed with other and rodine, the reservoir raised to about ? fect and the requisito amount run slowly in I 16 does not run in well another place can be tried If the patient 18 80 all that it is doubtful whether fluids will bo absorbed from tho subcutaneous tissues, the glucoso solution of tho same strongth may bo gricn intravenously and the pealın by tho samo route and at the same time In three houre or parlier in the absonco of impros ement, tho urine 18 draton off, and if it contains acctono or diacetic acid a further 10 to 20 units 18 giren Collored by tho samo amount of sugar This process 18 TO peated about every three hours till tho acidosis is controlled The insulin must be pushed but soser sufficients pushed in relation to the sugar, 28 to render the urine sugar free It sa}} bo roadıly understood that if the roro allowed tho I lood sugar might drop to such an outent as to causo a lypoglycemic reaction It 18 no uso $7ing patient from diabolic coma to plongo luim intotko coma of 13 poglycuma Blood sugar exanınation is a great help in controlling tho amount of moulin and sugar required, but tho periodic examination of the urino as detailed abovo 18 generally sufficient to aroul danger It may seem una armful, to administer gl 18 alrcady ing into theorctica Oxrerin paulia food sugar ·106 INSULIN IN GENERAL PRACTICE (6) Complete Coma The initial indication is the same as in im pending coma, but here it is advisable to give 30 units of insulin at once The difficulty 18 that the patient cannot take anything by the mouth so the necessary sugar must be introduced per rectum or by subcutaneous or intravenous in Jection If the lower bowel is empty a 300 cc (about half a pint) of a 5 per cent solution of glucose can be given slowly by this route If it is not retained, or if the appliances are ready to hand, it is better to proceed at once to give a subcutaneous injection In this case, the strength and quantity of the glucose solution is the same but of course strict antiseptic precautions must be taken The simplest plan is to use one of the glucose tubes supplied by the various drug houses The contents of one tube are diluted to one pint with boiled water which makes a sterile 5 per cent solution If one of these tubes is not to hand, though it is a very useful thing to keep for emergencies, a solution must be made up from pure glucose and boiled water, the pro portions being 1 oz to a pint An outôt such as 18 usually carried in a midwifery bag does very well or an ordinary aspirator needle attached to about three feet of rubber tubing with a suitable glass reservoir above The barrel of an all glass 10 or 20 cc syringe will do in an emergency The whole outfit is boiled and filled with the sterilised glucose solution The needle is inserted under the skin of the chest, the skin having been ·IMPENDING COJIA AND COJIA 107 proviously cleansed muh ether and iodine, tho reson or raised to about 2 feet and the requisito amount run slowly in If it does not run ia voll anothor placo can be tried If the patient 13 ao all that it 18 doubtful whether fluids will bo absorbod from the subcutaneous tissues, the glucosa solution of the sime strength may bo grcn intrar cnously, and the insulin by the same routo and at the same time In threo hours or earlier in tho absenco of improvement, the urine 18 drawn off, and if it contains acotono or diacetic acid a further 10 to 20 units 18 giren followed by tho samo amount of sugar This proccas 18 TO peated about overy thrco hours tull tho acidosis is controlled be insulin must be pushed but never sufliciontis puslied in rolation to the sugar, as to rendor the urine sugar free It will bo readily understood that if this svors allowed, tho I lood sugar might drop to auch an extent as to cubo a hypoglycemic reaction It 18 no uso $1919g pzioni from diabotic coma to plungo hem into the com, of hypoglycemia Blood sugar examination 18 great help in controlling the amount of inguim and sugar required, but tha poriodic examination of the urino 28 detailed aboso 18 generally sullicient to avoid danger It my sem unnecessary, and indeed barmful, to administer glucose to a patient whos blood sogar 18 already excessivo but, without going into theoretical considerations it has been found lv cafenienco that coma patients do better with insula and sugar than itk lusul alone ·108 INSULIN IN GENERAL PRACTICE Especially when blood sugar estimation 18 not available, it is much better to err on the side of giving too much sugar than giving too little The same general directions apply as in the case of impending coma The patient is of course in bed and kept warm with blankets and hot water bottles Unless the initial dose of glucose 18 being given per rectum the bowel is emptied with a soap and water enema, and the heart is supported with digitalın, etc A certain amount of fluid 18 being given with the glucose, but a total amount of one pint every three hours should be aimed at in an adult This can be made up by rectal, subcutaneous or in extreme cises in travenous injections of normal saline In hospital continuous rectal administration by the thermos flask and drop method of either normal salme, or normal salıne and glucose 18 of great value Just before insulin became available I had three cases of diabetic com1 all of whom died Since then, although I have had a good many rases of impending coma, I have had only one ase of frank diabetic coma, and this case was admitted in a moribund condition CASE 10–Girl aged 20 History of diabetes for como nonths She had gone into a state of coma sixteen hours cfore admission On admission she was wasted to lmost Interally skin and bone she was deeply un onscious, breath smelling of acctone and the urino rawn off with the entheter contained much sugar, cetone and dincetic acid Thirty units of insulin woro iven subcutaneously and glucose and saline giren atravenously by the sapbenous yein Ns it was impossibic ·ISIPEWDING COMA AND CONI to Ind Ebo re ne in the arm Sho derer corcred con sciousness and died sborily niter admission Howosor, thero are a good many cases on record of completo reorers Alter oren conpleto coma of this type, so that hope should never lo abandoned i ho koynota of treatment & im medunto, large and repeated doses of insulin “ballered as the Americans say, by adequate doses of glucose 2 COMA OF THE 'ost OPERATITE TYPE The second group of cour cases characterised Roy abundant gls cosuria very lug! blood sugar but little or no acidosis aro not nearly so nmen ablo to trustment Pathology Winto the consensus of opinion is that ordinary diabetic comz ith acidosis 18 caused by the toxic clect on the brain of tho ory butyric acid in the circulating blood, there does not appear to bo any satisfactory explanation of the cause of the coma in the group of cases which sro aro non con andering Thero is littlo or no audosis and presumably there can bo no great excess of Oxybutyric acid in the circulating blood The mero ercess of blood sugar cannot be tho canse, ng at mny Tiso to the samo bought without causing on; symptoms of com? Again it taigutloargued that although sugır 13 present in excess in the blood, tho bram cells aro no longer able to use it, and that coma really results from a deficiency of Quaslavlo sugar 1 bss scams unlicly as the ·116 INSULIN IN GENERAL PRAOTICE the left great toe was black, fairly dry, and with a fairly definito line of demarcation, but the dorsum of foot Bhowed some lines of inflammation and was somewhat tender There was also a black bleb at inner surface of right great toe He was passing 172 grams of sugar daily and the urine contained a small quantity of acetone but no diacetic acid Blood sugar 998 mgr General condition fairly good (Urine slight trace of albumen) He was kept in bed, the toes kent dry and clean and given a diet containing 75 grams of carbohydrate and a total calorio value, with a daily allowance of 2 oz of alcohol, of 2,400 calories Insulin was given in gradually increasing quantity, but it ms not until a dose of 80 units twice daily was reached that the orine became practically sugar free and the blood sugar became redaced to 180 mgr The gangrene did not spread and now five months after onset of gangrene, tho right toe hrs healed up after the seraration of a small slough while the left great toe sloughed off at the original line of demarcation and has almost healed. CASE 16-Man, aged 58 History of diabetes for cloven years Nine months previously had dry gangrene of little toe of right foot which sloughed off, and lie recovered Kept pretty well til three weeks before I saw him, when he had got a small patch of gangrene below ball of right great toe, which was now moist and tending to spread along sole of foot Urine contained 45 per cent of sugar, acetone but no diacetic acid er I hart but the gangrene continued to spread The leg was amputated above the knee but there was a large slough f

·GANGREVE
The other case 1913 gangrene of a toc following
tho opening of a small 168cers He was feeling
all when admitted to hospital but was so much
botter after a week or so on insulia with suitable
dict, that he insisted on leaving hospital, and I
have been unable to trace him
Theso are by no means brilliant results and I
am not convinced that thoy are any better than
they would have been without insulm
Vibero insulin kas very definitely improved, the
prognosis is that it gives the patient a much better
clanco to stand operation if amputation is required
It seems quite probable that if these patients
had been baving naulin (or thorough dietetic
trcalment if that by itself was enough) previous
to the onset of gangreno, that tho gangreno might
havo been provonted Better still rould bo
carlier treatment to prevent the occurrence of the
arterial degeneration without which gangreno
would not tako place at all

·CHAPTER XII
1 m
U
SEPTIC INFECTIONS
It has long been known that diabetes may be
greatly aggravated by infection, and that on the
other hand dıbetics are particularly susceptible
to at least some infections Perhaps this is most
clearly shown in their lack of resistance to the
staphylococcus, the causative organisn of both
boils and carbuncles So prone are some cases
to infection
injection
Every time
with strict antiseptic precautions, the skin being
rubbed with ether and then nodine, he developed
a large septic spot at the point of puncture 1 be
arms became so painful that it was a problem how
to carry on By way of experiment I instructed
the sister to give the injection in the way I learned
froin Sır Almroth Wright, viz, by putting a drop
of pure lysol on the skin and inserting the needle
through the drop We had no more trouble, and
the bint may be useful to anyone who comes
across a similar cise
Carbuncles and boils are by far the commonest
infective conditions complicating diabetes The
latter are seldom dangerous, and indeed they are

·SEPTIO INFECTIONS 119 often useful in drawing attention to the necessity of a urinary examination The ordinary treat. ment of diabetes usually clears up the condition, but it may be supplimented by vaccines Carbuncle on the other hand 18 a very senous complication, and must be tho immediate cause of death in many diabetics Unless treated energetically the patient 18 apt to go into a stato of coma, and as the coma 18 usually of tho post operatiro type there is little chance of recorory The treatment 18 the ordinary one of tonics and stimulanta, free opening and scraping away of aloughs The diet should be an easily digested one and contain a fair amount of carbohydrato, trilo insulin is given in substantial doses, Bay, 20 units three times a day, controlled as before by the oxamination of the urine and tho blood Enough should be given to bring the urinary sugar down to a good inco, and to bring the blood sugar to a little under 200 mgr, and to get rid of Any acidosis II there is much acıdagis it 18 sometimes well to wait for twenty four or thirty 813 hours before incision and scraping so as to got the patient into better condition in a caso recently under my caro mo did this, and at tho end of the timo found the patient go much better, and the carbuncle breaking down and dischnrging 60 frecly that no operation mas required Thoro is no doubt that tho intensivo 280 of maulin in this condition hasiebs resolution and minimises the risk of coma With regard to thoadministration of anæstlctics

·120
INSULIN IN GENERAL PRACTICE
in diabetic cases Nitrous Oxide, either alone or
with oxygen should be chosen I have never
seen harm result from its use even when given
early in treatment

·CHAPTER XNI
MISCELLANEOUS Notes CONCLUBION.
Utmato Effect of Insulin Treatment on Sugar
Tolerance.
Tae time that has elapsed since the introduction
of rnsulin is much too short to say whether patienta
so havo been restored to health by its means
will keep well and live out tho allotted span, and
if so, wober tho dost can romain stationary,
whether it will bave to be increascd, or whether
it can be gradually seducod and anally dispensed
mth In other words will their sogar foloranco
remain stationary, diminish or increase. So far
as my cerses of casce goes the great majority
reqaro to kecp up the sams doso, a fair nombor
karo been able to decrease it and only one, Caso
&, has had to increase it materially. In addition
to Case 9 which has been already mentioned, tho
following caso is another sllustration of greatly
increased tolerance and incidentally shows the
wonderful effects of insulin
Casa 17-Boy, nged 17 Ilustory of eodden onset at
diabetes thru Focks before admission. Previously bo
en in good health but one day he thirsty and celf limi
od tbe tallossox day was too s to go to work. Condition
be mpuh OrB6 so pito of dietetic treatment,
On aimision, bo was thio, pacbe), anemic and
miscrablo looking Tho urbe containod 8 percent sugar,

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·INDEX. Acetone in ande, 16, 46,85, Carbohydrater, 37, 39 103 excente lojestion of, 1% test los, 7 metabolism, 28, 40 Acidoxin, 41, 96, 119 proportsons, 68 CANAL of, 85 Carboucles, 118 insultu treatment of, 100 Cardio vascular syatem, 13 moderately sovero, 07 Carwardine's sccharometer, trustment of, 99 7 Adrenalin, administration of, Checse, food valao of, 68, 71 Clupcrl ages of diabotca, 30 Atr-bonger of Kutsmaal, 102 Clothing, 77 Alcohol, ass ol, 67, 116 Con, complete, 106 Allen treatment, 44 habetic, 102, 108 Anesthetics, 113 tmpending, 101, 102 Arterial degeneration, 114, insulis treatment, 107 117 pont operative type, 109 prognosis of, 113 Bacon, food value of, 65, 70 symptoms of, 101 Buscing'• work, 82, 195 tendency to, 90, 93, 06 Fleet tou, fool value of, 67 treatment ol, 102, 110 Blood, ramination of, 18 Complications of diabetes, caget in, 18, 27, 29, 61,105 14,00 Muebra't lent, 19 Creara, toad ralad , 68, 70 Baly weight, 37 Toit, 118 Denutrition treatment, 46 Bran bucata, 68 Diabeter, clinical rigos of, Irene ford rulue of, 65, 71 Batter, food rules of, 65, 71 complication of, 14,90 diagnosis of, 1, 10, 18 Calories, calculation of, 3B, dietetic treatment, 42, 44 etiology of, 11 of Handard sstiot, Tt okolia in, 53, 79, 83, 86 require), 59, 63, 103, 116 10

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·7 INDEX, Acetone in trine, 16, 46,85, Carbobydrates, 37, 39 excessite injestion of, 12 test lor, 7 metabolism, 28, 40 Aerdosis, 11, 96, 119 proport10n3, 58 causes of 85 Carboncies, 118 lasaliu tresturnt of, 100 Cardio Fakcolas syaten, 13 moderately kevere, 97 Carwordise's saccharometes, treatment of, 99 Adrenalın, aministration of Cheese, food tslae of, 65, 71 91 Cluascal signs of diabetes, 10 Air banger of Kugemaul, 102 Clothing, 17 Alcohol, uso ol, 67, 116 Coran, complete, 106 Allen treatment, 49 dus hetic, 102, 103 Anesthetics, 119 imperdag, 101, 102 Arterial degeneration, 114, toalin treatment, 107 117 post operatite tye, 102 Protoeus oł, 112 Bacon, food valdo of, G5,70 symptomu of, 101 Lanting's work, 02, 125 tendency tn, 90, 99, 95 Teem te food value of, 67 treatment of, 102, 110 Blood, cxamination of, 18 Complications of dalam Hogaria, 18, 27, 29, 62,103 14,30 Macbrar o test, 19 Crean, forud valde ses, 70 Body weight 37 Deputrition tresment, Brooksevits 68 Thaketes, elleslegs of Brend, ford calce ok, 63, TL 10 Batter, food relaç ol, 65, 71 com placations of, 14,30 thagnoruo, 1, 10,1% Calories, esleulation of, 33, dietetic treatment, 12,4 dstanderd ralios, 71 etiology of, 11 insulia 24, 53, 79, 83, 86 magasred], 39, 65, 105, 116 Doin, 13% 113 ·128 INSULIN IN GENERAL PRACTICE Diabetes, prevention of, 123 Food, values of common nop pancreatic, 123 articles of diet, 65, 71 treatment of, 42 weighing of, 70 types of, 122 Foot, gangrene of, 113 Diacetic acid, 85, 103 Fredericia's apparatus, 98 test for, 8 Fruits, food value of, 66 Diagnosis, differential, 10, 27 Gangrene, pathology of, 114 of diabetes, 1, 27 symptoms of, 113 of glycosuria, 1 treatment of 114 Diet, allowed and forbidden, Gerhardt's test, 8 43 Glucose, administration of, basal maintenance, 55 91, 103 control of, 76 percentage table, 26 food values of common tests for, 1 articles of, 65, 71 tolerance, 32, 56, 121 Graham's "ladder," 44 Glycosuria, 1, 10, 15, 27, 42 mixed, 37 diagnosis of, 1 restricted with insulin, diseases other than dia 53 betes producing, 10 standard, 48, 60 renal, 15, 27, 77 Dietetic treatment, 42, 44 Graham 8 "Jadder diet," 44 Dietetics, principles of, 36 Dosage of insulin, 79, 80, 81 Heredity, factor of, 11 Hypoglycæmic reaction, 83 Eggs, food value of, 65, 71 90, 92, 94 Examination of patient, 10 Insulin, 42, 48 of urine by patient, 86 administration of, 79 control of dosage, 82 Fat metabolism, 40 cost of, 88 Fats, 37, 39 dietary restrictions with, Fehling & test, 1, 5 53 Fermentation test, 4 dosage of, 79, 85, 87, 103 Fibh, food value of, 65, 70 hypoglycæmic reaction Food, allowed and forbidden, and, 83, 90, 92, 94 43 increase of dose, 81 organic constituents, 36 injections of, procedure, patent, 69 86 ·INDEX 199 Ianulia, latcrane ose el, 119 Oatmeal, food relac of, 66, limitations of, 121 preparations available, 790, olive, food ralue of, 66. spacing of dones, 80 Atandard dict with, 78 Ogsters, food sale of, 66 treatment of acidosis by, 100 Pancreatic extracts, 32 treatment, principle, of, Patiept, examination of, 10 83 ERBUATLON of arias by. ultimate Blect on nogar 86 tolerance, 121 Potato, food value of, 66, 71 Islands of Langenhaas, 52 Pregnancy, brine during, Prognosis of coma, 112 Jews and diabetes, 13 of renal glycosuria, 16 Proteio, Amount requisite Ketosis. 43.96 63, 64 Kiiveys, Icak polat of, 16, Proteros, 36, 39 28,77 Pristus in diabetes, 13 Lactose, test for, 4 Quantitative estimation of Lysol, antiseptic, 118 Maclean's withol of exti. Ilonal Riscoruna, 15, 27,17 Rectal Injection of rogar, 106 mation, 19 Healy, for spesiye mend, 73 Respiratory system la du Leteo, 14 more expensive meat, 74, Rest, question of, 77 73 Bre, foul value of, 65,11 Metaboliena, 28, 40 Saccharine, 68 tarbohydrate, 28, 40 Bacchsroteier, Cerrar Parution, 37 dian', 7 31:13, food salve of, 63, 71 Sellende test, 9% Septic infortino, 114 Budism birsalmus, Nephritis in dithete, 13 07, 9, 396 Serious system ia diabetes blonolitos pripa-81 lott, foot raide of. GO, 10 ? *ugar, 3 2

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