THE TREATMENT OF DIABETES MELLITUS 

BY ELLIOTT P. JOSLIN, M.D. 

Boston 

RATHER more success is achieved by surgeons in the treatment of general peritonitis than is attained by physicians in the treatment of diabetic coma. In neither condition are the statistics flattering to the profession; but the successes obtained by our surgical colleagues in the prevention of general peritonitis make the failure to prevent coma as a cause of two out of every three diabetic deaths mortifying to say the least. We physicians should begin to regard diabetic coma in the same light as your British brother, Mr. Moynihan, has taught the medical fraternity to look upon the late stages of a neglected gastric ulcer-namely, as an emergency which should not have been allowed to arise. With this issue of the prevention of diabetic coma plainly to the fore as the cardinal point in the treatment of diabetes, it is pertinent to inquire what diabetic patients are most susceptible to coma? And your own experience will enable you to anticipate that the answer, which an analysis of my own fatal cases shows, will be children. Of the sixty-two diabetic children under the age of fifteen who have died under my care, coma was the cause of death in all, and the significance of this melancholy fact is this: that where diabetes appears in its most severe type, as in children, coma is its expression. The propositions are simpler to state than to execute -first, that the best way to avoid coma is to prevent the progress of a case of diabetes from the mild into the severe type, and second, to protect the patient from all those agencies such as infections, anesthetics like chloroform and ether, undue exertion (mental or physical), which tend toward intensifying the severity of the disease. For if the diabetes is kept mild or moderate the coma need not be feared. Next to the children in the frequency of death from coma, strange as it may appear, were those of my cases who succumbed during the first year of the disease. The cause of death in 87 per cent. of these was coma. But diabetes is a chronic disease and the first year of its course should be mild rather than severe, and in mild diabetes coma should find no place.

Diabetes should be sought in the families of diabetic patients and in order to allay anxiety from urinary examinations, it is a good plan to have these made with such frequency that they will become simply a matter of routine. Such individuals should be taught to regulate the quantity of food eaten by the body weight, and never to indulge in unusual quantities of carbohydrate.

Alternate feeding and fasting are adopted when it is found that the glycosuria persists after a preliminary four days' fast. The method which I have found most successful has been to allow, following the first fasting period, 20 to 40 grams carbohydrate not far from half a gram per kilogram body weight-and about one gram of protein per kilogram for two days