In mild forms of glycosuria and in cases in which the muscular strength, including that of the heart, is good, the most extensive use of muscular exercise should be made. But the physician must be cautious and conservative in this respect just in proportion to the intensity of the glycosuria, the unfavorable nutritive conditions, the difficulty of replacing the material consumed in work by abundant nourishment, the weakened state of the heart, the rapidity with which fatigue ensues, and the tardiness of recovery therefrom.
I would warn the physician especially against allowing himself to be guided in his prescription of severe exercise by the fact that the patient is corpulent. Only when an abundance of adipose tissue is combined with strength of muscle is such a recommendation justifia ble. In all other cases he should proceed with great caution, accus toming the patient by slow steps to increased work.
As regards the kind of exercise, walking and hill-climbing are the most natural and preferable. The exercise is best taken in the morn ing and followed by a long rest. Horseback-riding is also a favorite form of exercise ; it is a passive, exercise which is without doubt good for the circulation and especially promotes regularity of the intestinal functions. However, in regard to corpulent patients, I would say that the belief that riding reduces flesh is entirely wrong; the horse may grow thin, but not the rider. Riding rather favors obesity in that it greatly increases the appetite. Among the sports, any that cause fatigue are to be forbidden, but some when pursued in modera tion are to be highly recommended; unquestionably the most health ful is rowing, then come gymnastics, cycling, and open-air games. When the opportunity for these natural exercises is wanting, or when the patient's strength is insufficient—but only under these conditions —passive movements (medico-mechanical gymnastics), and, if neces sary, massage may be employed. It is the fashion nowadays to overestimate their value; they fail to increase the patient's self-reli ance or to restore tone to his nervous system.
c. Care of the Shin ; Bathing.—The care of the skin holds an im portant place in the treatment of diabetes. Reference has already been made to the evil effects of its neglect (p. 102). When pruritus leads to scratching the danger is especially great, and eczema, acne, or furunculosis may result, or even erysipelas and gangrenous inflam mation. These are all preventable affections, preventable by the ex ercise of cleanliness. Frequent change of underclothing is absolutely necessary. When the patient's instinct of cleanliness is not to be depended upon, the physician must explicitly order regular sponging and at least two tub-baths a week. As regards the temperature of the
sponging and of the baths one must be guided by experience in indi vidual cases, for some bear a low temperature well, others ill (see p. 127). In bathing resorts medicinal baths are given, for the sake of the mental effect upon the patient, in the place of ordinary tub baths, but the kind of bath employed is really of little importance. It does no harm if the water holds in solution a little iron, lithium, bromides, iodides, or sulphur, or if an extract of pine-needles or some medicinal mud is added; the advantage is an imaginary one, but still is one that under certain circumstances is not to be despised. For certain nervous patients with feeble resisting powers weak carbonated salt baths are of special benefit. Strong salt water and cold sea-bath ing are suitable for but few diabetics. In cases of general pruritus the addition of preparations of tar is distinctly beneficial.
d. Treatment of Constipation.—Many diabetics are perfectly regu lar in their bowels, a few have a tendency to diarrhoea, and many again are inclined to be constipated. It is important to combat this tendency to constipation, the more so as a very common experience shows that this condition predisposes to diabetic coma. Inaction of the bowels which has lasted for several days is best met, in these cases as in all others. by a suitable dose of castor oil, calomel, com pound infusion of senna, or the like. These remedies should, however, be employed only in exceptional cases. The aim of the physician should be not to allow the bowels to be confined for several days at a time. Ordinarily this is effected by regulation of the mode of living, bodily exercise, accustoming one's self to a regular time for defecation, a reduced ingestion of carbohydrates, and an abundant supply of fatty food. As an adjuvant may be recommended an occa sional short course of saline, alkaline saline, or alkaline sulphur min eral waters, but when taken at home the efficacy of the latter is soon exhausted. For temporary use (two or three weeks) glycerin lem onade is very beneficial—citric acid 5, glycerin 30, water 1,000; taken in doses of one-half to one litre (oue or two pints) a day. For per manent use a mixture of rhubarb powder with bicarbonate of sodium and sulphur, as much as can be taken on the point of a knife each evening, is preferable to any of the older, and certainly to any of the newer, laxative remedies. Rhubarb may be taken in this form for months at a time without any increase in the dose being necessary. Still there are individual idiosyncrasies, and the physician must take note of them; the same proverb applies in the case of the intestine as in that of the palate : De gustibus non est disputandton.