The fear of an operation is the more justifiable the weaker the patient is and the more pronounced are other trophic disturbances. Besides the local dangers connected with the operation wound, the narcosis itself is to be feared. In any case chloroform should not be employed as the anmsthetic, since it endangers the integrity of the heart, the resisting powers of which are already greatly depressed in diabetes. It is better to use ether with the previous administration of morphine. Besides the accidents liable to occur during the nar cosis, there seems to be not infrequently a special tendency to coma excited by the antestbetic (Becker ").
In tolerably severe cases the surgeon should not immediately pro ceed with an operation which may be indicated, but should rather, where possible, postpone it until after a two weeks' course of a strict fat-and-flesh diet.
4. Pal»zonary —This complication should not cause any relaxation in the carrying out of the suitable dietetic principles, but rather demands greater strictness and especially the greatest possible increase in the amount of fatty food with the addition of considerable quantities of alcohol. It is advisable that the patients should re side in places where the climate is mild rather than in those lying at high elevations where the air is raw, and treatment in a sanitarium is preferable to a stay in one's own home or in an hotel. Certain hydrotherapeutic measures of a mild character may be cautiously instituted; diabetics with plithisis are individuals demanding the greatest protection against injurious influences. The use of creosote and guaiacol is to be recommended, but tuberculin seems to me, from the results of observations made three years ago, to be of very doubt ful advisability in cases of diabetes. In general the results of treat ment of pulmonary tuberculosis in diabetics are very unsatisfactory. And this offers a still stronger reason for care ou the part of the physician in guarding his patient against infection with tubercle bacilli, on the one hand by removing him from an infected neighbor hood and on the other by maintaining the general nutrition at the highest possible point.
Diabetic many cases there is a prodromic period indi cating the approach of coma; this time is to be employed in taking prophylactic measures which seem often to be successful.
a. The form of nourishment must be varied in different ways ac cording to the nature of the case. If the threatened patient has been taking carbohydrates in considerable quantity, they must be greatly reduced and replaced by added amounts of proteids and fat. On the other hand, if the patient ha's been abstaining strictly from carbo hydrates it will be advisable to permit their use. The mere fact of a change seems to be more important than the direction in which this change is made.
b. Large amounts of alcohol, given in divided closes through the day, are necessary.
c. Constipation must be relieved by mild laxatives, but the use of drastic purgatives is to be condemned.
d. Acting upon a theory, which is doubtful yet worthy of atten tion (acid-intoxication—see p. 95), large doses of alkalies have been recommended; for example, 6 or 8 grams of bicarbonate of sodium a day added to one or two bottles of Vichy or Neueuahr water.
In the actual presence of true coma we are very helpless. Intra venous injections of alkalies, recommended on theoretical grounds, have been found practically to be of no value. I once saw a most surprising result from the recently recommended intravenous injec tion of a litre of a 0.6 per cent. salt solution, in divided closes of 250 grams given at intervals of four hours. The diminished urinary se cretion increased remarkably, and consciousness returned—though only temporarily. I would recommend a further trial of this proce dure, which is certainly rational, having the effect of promoting diure sis and washing out of the system any toxic substances which may be present. After this, injections of camphor and ether give most promise; they are at least indicated by one symptom, which is seldom absent in diabetic coma, namely, weakness of the heart.
Diet Tables.
Concerning the use to be made of these tables enough has been said in the preceding sections (see especially p. 161). We have there seen for what cases and with what object the division of the articles of diet into special groups is necessary. The reader will of course understand that the expressions "allowable," "conditionally allow able," etc., are only relative, and that articles which are "condition ally allowable" in the case of one patient may fall into the division of "unconditionally allowable" in that of another: