obstinate itching of the vagina-pruritus of the vagina-which is dependent upon the presence of molds upon the mucous membrane of the vagina. Eczema and furuncles of the labia, and even gangrene, may readily occur. Further, inflammation of the prepuce also readily develops in men, and masses of mold (leptothrix) may collect beneath the part. Among nervous disturbances obstinate neuralgia should first be mentioned. Sciatica occurs with especial frequency, and its diabetic origin should particularly be suspected if it be bilateral in distribution. Occasionally signs of polyneuritis appear. This is attended with abolition of the knee-jerks and with peripheral motor paralysis and cutaneous anesthesia. The symptoms of peripheral pseudotabes develop, as manifested by ataxic gait, tardy pupillary reaction, and swaying when the eyes are closed. Some patients complain of attacks of cramp in the calves. Arteriosclerotic changes in the cerebral arteries occasionally lead to cerebral hemorrhage. At times mental disease is superadded to diabetes. One of the most serious dangers for the diabetic patient consists in diabetic intoxication, generally designated also diabetic coma. This is considered the result of auto-intoxication with abnormal metabolic products. By some 3-oxybutyric acid especially is considered as the toxic agent, and diabetic auto-intoxication is accordingly thought to be an acid intoxication. One can frequently anticipate the advent of diabetic intoxication from the fact that the urine yields a marked ferric-chlorid reaction of Gerhardt, and that the urine and the expired air of the patient occasionally give off so pronounced an aromatic odor of apples or ether that the disease can be recognized by the sense of smell on entering the sick-room. The patients are more or less suddenly seized with coma, frequently breathe loudly and noisily, and exhibit especially unusually deep respiratory movements. Occasionally they attempt to maintain themselves upon their feet, but they stagger about like a drunken person. In some violent delirium occurs, and even maniacal states. Death occurs at times within a few hours amid signs of cerebral or cardiac paralysis, but in other instances only after the lapse of a few days. At times transitory recovery ensues, possibly to be followed in a short time by relapse and a fatal termination. The Diabetes mellitus is generally a chronic disease, whose duration not rarely extends over many years if a rigid diet be observed. Cases that terminate fatally within a few weeks are rare. principal dangers that threaten the diabetic patient consist in pulmonary tuberculosis and pulmonary gangrene, in phlegmons and gangrene of the skin, and in diabetic intoxication. With regard to the relations of diabetes to other diseases it is especially to be mentioned that the obese, the gouty, those suffering from renal and biliary calculi, are frequently attacked by diabetes mellitus. 293 if Diagnosis. The recognition of diabetes mellitus is easy one is competent to make the tests for sugar. In the presence of sugar in the urine the possibility of transitory glycosuria or mellituria is at most to be considered, although this persists for only a few hours, and at longest a few days. At the beginning of diabetes mellitus sugar occasionally appears only at times and in certain portions of the urine-intermittent diabetes mellitus. Under doubtful circumstances the patient should be permitted to take a mid-day meal containing considerable carbohydrates, particularly sugared fruits, sweet farinaceous food and pastry, and the urine passed from four to six hours later examined for sugar. Should the urine then also be found free from sugar the exclusion of diabetes mellitus would be justifiable. It is extremely important to know whether the patient is suffering from diabetes mellitus of slight, or moderate, or profound degree, and this can be determined from the influence of a strictly animal diet upon the elimination of the sugar. In the cases of slight degree the sugar disappears from the urine in from one to three days of an animal diet; while in a case of moderate severity fourteen days will be required; and in a case of profound degree, finally, although the amount diminishes, the sugar does not wholly disappear from the urine. Further, these three gradations cannot always be sharply discriminated from one another, and it may happen that in a case of slight degree transitory periods occur in which symptoms of moderate severity, or of profound degree, appear. The etiologic diagnosis further is important, for when syphilis has been the cause cure has been reported from mercurial treatment. If pseudotabic symptoms predominate care must be taken to avoid confusion with tabes dorsalis. The demonstration of sugar in the urine generally affords a speedy means of differentiation, although diabetes mellitus occasionally occurs as a complication of tabes dorsalis. Anatomic Alterations.-Anatomic alterations distinctive of diabetes mellitus are not known, so that in cases of idiopathic diabetes mellitus no striking peculiarity is found in the body. In cases of symptomatic diabetes mellitus lesions will be found at times in one, and at other times in another organ, in accordance with the causative factors. Attention has for a long time been directed especially to atrophy and other alterations in the pancreas as not rare conditions. On microscopic examination of the riscera alterations in the kidneys are not rarely found. The epithelial cells of the convoluted uriniferous tubules are occasionally involved in fatty degeneration, or they are in a state of coagulation-necrosis, and the epithelial cells of the loops of Henle are converted into swollen, transparent vesicles, involved in hyaline degeneration. The presence in them of glycogen can be demon strated by means of iodin. Deposits of glycogen have also been described in the myocardium. At times the liver-cells also are characterized by the presence of considerable amounts of gly cogen. Opinions are sharply divided as to the pathogenesis of diabetes mellitus. Obviously, elimination of sugar with the urine may take place in consequence of excessive ingestion of carbohydrates, because the liver is incapable of converting all of the sugar into glycogen, and retaining it. Such glycosuria can be experimentally developed in healthy individuals by the administration of more than 200 or 300 grams of grape-sugar-so-called alimentary glycosuria. Saccharine urine will be excreted also if the liver has wholly lost its power of converting even small amounts of ingested sugar into glycogen, for sugar, which, without previous transformation into glycogen, gains entrance directly into the blood, is largely again eliminated with the urine, unused. There results in this way a hepatogenous glycosuria. It is naturally conceivable also that in spite of normal formation of sugar those ferments may be absent from the blood and the tissues that are necessary for the decomposition and utilization of the sugar in the work of the body. The blood in consequence remains unusually rich in sugar, and the resulting hyperglycemia gives rise to diabetes mellitus. Such a condition is one of hematogenous glycosuria. In the development of this variety of glycosuria the pancreas especially is believed to be involved. After complete removal of the pancreas diabetes mellitus has been observed to develop in animals, and this is explained by some physicians on the assumption that one of the functions of the pancreas is to form a glycolytic ferment. Reference to a neurogenous variety of glycosuria should not be omitted. This develops temporarily in animals, among other conditions, after injury to a definite portion of the fourth ventricle, so-called puncture. Possibly it is dependent upon vasomotor disturbances in the liver, induced from the portion of the brain mentioned through the intermediation of the sympathetic nerve. In all probability there are still other causes for glycosuria. Thus the glyco suria that can be developed artificially by the administration of phloridzin has been referred to renal causes-nephrogenous glycosuria, and some clinicians believe in the possibility also of myogenous glycosuria. Especial difficulties will, however, arise in attempting to refer the individual case of diabetes mellitus to its etiologic factors. Prognosis.-Diabetes mellitus is a serious disease, which is but seldom susceptible of permanent cure, and even then will require careful regulation of the diet. The prognosis varies in accordance with the age. Diabetes mellitus is prone to pursue a rapidly fatal course, particularly in children. As. may be understood, the prognosis will be governed by the degree of the diabetes mellitus, and, as a matter of course, the prognosis will be better in cases of the milder grade than in those of moderate severity and of the severe grade. The ferric-chlorid reaction of Gerhardt is of unfavorable prognostic significance, because it frequently precedes diabetic auto-intoxication. Among the complications the prognosis is rendered unfavorable particularly by pulmonary tuberculosis, pulmonary gangrene, and gangrene of the extremities. Treatment.-The indication for causal treatment is but seldom present. If the disease has been preceded by syphilis, a course of treatment with mercurial inunctions and the internal administration of potassium iodid will be prescribed, and recovery has occasionally been reported from such measures. In the symptomatic treatment subordinate and doubtful significance is to be attached to drugs. In any event the greatest importance is to be attached to the diet. The guiding principle in an antidiabetic diet consists in withholding from the patient carbohydrates as largely as possible, but, on the other hand, permitting sufficient animal food and fats to supply the needs of the body in calories. In entering upon an animal diet the transition should not be too rapid and abrupt, as otherwise diabetic intoxication may readily result. Instead of sugar the patient should use saccharin (sulphinid of benzoic acid). The patients tolerate least well the withdrawal of bread, inasmuch as no palatable bread free from starch is as yet known. Generally 100 or even 150 grams of Graham bread may be permitted daily, as a diabetic patient with some sugar in the urine and progressive increase in weight is far better off than one in whom the urine has been freed from sugar, but whose bodily weight is gradually diminishing, and who is threatened by the dangers of diabetic auto-intoxication. An alkaline water, such as that of Selters, Bilin, Giesshübel, Ems, or Vichy, should be used by the diabetic as a beverage. To maintain the skin in good condition two baths (35° C.—25° R.-95° F.) weekly may be recommended. Attention should be directed to the care of the mouth, which should be thoroughly rinsed (solution of aluminum acetate, 1.0: 200-as a mouth-wash) after each meal. The diabetic patient will do well to protect himself from the influence of cold by wearing woollen. underclothing. Wounds and operative measures are to be carefully avoided in consequence of the danger of gangrene, and in any event they should be treated with the most rigid antiseptic precautions. Of late, special sanatoria for the treatment of diabetics have been erected, which have the advantage, among other things, of teaching the patient how to live. A brief consideration of the permitted and the forbidden articles of food may yet be given in this place. There may be permitted': meat of all kinds (fresh meat, smoked meat in the form of ham, sausage, tongue, corned meat, pickled meat, fowl, game, fish, oysters, lobster, and shell-fish), eggs, cheese, unsweetened fruit-juice and gelatin; butter, bacon, cream, cod-liver oil, and olive-oil; green vegetables, such as cauliflower, red cabbage, spinach, green asparagus-tips, green beans, turnip-tops, lettuce, white cabbage, endives, water-cress, radishes, mushrooms; almonds, nuts; alkaline waters, white wine, red wine, unsweetened lemonade from lemons or lactic acid, unsweetened tea and coffee. There are forbidden: honey, ordinary bread, cake, farinaceous food, sago, arrowroot, noodles, maccaroni, oatmeal, barley-grits, whey, chocolate, beer, sweet wine, champagne, alcohol, liqueurs, compot, red beets, onions, radishes, celery, rhubarb, green pease, cucumbers, and chestnuts. Drugs, without rigid restriction of the diet, are without utility. In some cases the amount of sugar in the urine diminishes after the administration of narcotics, as, for instance, opium, 0.02 (grain) thrice daily. Also nervines (arsenic, bromids, antipyrin) have been employed and recommended. Disinfectants (carbolic acid, salicylic acid), if they have any influence whatever in diminishing the amount of sugar in the urine, do so by causing impairment of appetite and restriction in the amount of food taken. Ferments (brewers' yeast, diastase, lab) also have been employed. Recently organotherapy has been resorted to, and pancreatic extract has been administered. Courses of treatment at the springs have been much prescribed, particularly at Carlsbad, Neunahr, and Vichy. I have observed the sugar to disappear from the urine in many cases of diabetes after a course of treatment at Carlsbad, but probably rather in consequence of regulation of the diet than from the effects of the alkaline waters. It is true that generally after a time the sugar reappeared, because the patients lived less carefully at home, and in this way the course of treatment, in some of the cases under my observation, was repeated almost annually with good results. Complications should be treated in the usual manner. For the relief of diabetic intoxication, intravenous infusion of sodium. carbonate (from 3 to 5 per cent.), sodium bicarbonate (5 per cent.), and sodium chlorid (0.6 per cent.) have been recommended, although the results have not as yet been permanent. Occasionally improvement has been observed after the administration of a vigorous laxative. DIABETES INSIPIDUS (POLYURIA). Etiology.-Diabetes insipidus is characterized by two distinctive symptoms-an increased amount of urine of diminished specific gravity and increased thirst. In the same way as with diabetes mellitus, two varieties of diabetes insipidus, idiopathic and symptomatic, may be distinguished. Idiopathic diabetes insipidus occurs in some families as an hereditary disorder. Under such circumstances it has occasionally been observed in alternation with other central neuroses (hysteria, epilepsy, neurasthenia, psychopathy), or, occasionally, also with diabetes mellitus. At times idiopathic diabetes insipidus develops in the sequence of emotional disturbances. Concussion of the body, also, in which the central nervous system participates, may be a cause of the disease. In some cases it has been observed to develop in the sequence of infectious disease, as, for instance, typhoid fever, influenza, and syphilis. The designation toxic diabetes insipidus has been applied to such cases as occasionally develop after the use of digitalis or other diuretics. Alcoholism and saturnism also may be causes of the disease. Symptomatic diabetes insipidus is generally the result of anatomically demonstrable disease of the nervous system. From experiments upon animals it is known that upon the floor of the fourth ventricle, near the point puncture at which is followed |