of the 700 cases just referred to, only two were living at the end of ten years after it had been ascertained that the affection, existed in its fully developed condition.

The incipient or first stage of the disease is, beyond doubt, the most protracted, and, as has been pointed out by Dr. Prout, may extend over several years. Dr. Graves' has recorded a case, obviously a remarkable illustration of the kind, in which the patient had been affected with diabetes more than three years, having frequently during that period been under his observation in hospital. At the time of the last recorded observation (at the end of three years) this patient was daily passing eighteen pints of urine, containing, according to Dr. Graves' estimate, more than a pound and a quarter of solid matter (mostly sugar), but, singular to say, his condition had not become more aggravated. He was not suffering great inconvenience, and did not present any of the other symptoms indicative of the second stage of the malady.

The second stage is much more rapid than the first in its progress, and if not held in check by appropriate treatment, death generally ensues in a few months, or even in a few weeks, after its invasion.

1 Lectures on Clinical Medicine, 2nd edit. vol. ii. p. 268.

It is during this second or advanced stage that the complications or secondary affections are developed, by which the further progress of the malady is so frequently cut short. As has been already stated, when not thus abruptly terminated, death results from emaciation and exhaustion, and is frequently ushered in by coma.

Lung disease, especially phthisis, is by far the most common of the secondary affections with which diabetes becomes complicated, and particularly in subjects below the age of thirty.1 According to the tables of Griesinger 2 pulmonary phthisis produced forty-three per cent., or nearly one half, of the fatal cases which he has analysed. In some instances the chronic lung affection is the ordinary tubercular disease; in others, again, it is the result of inflammatory action, being, in fact, the pneumonic phthisis of Dr. Addison. But whether the disease begins as a genuine tubercular formation or as an inflammatory deposit, it runs much the same course, and is attended by the same symptoms; softening takes place, and lung cavities are formed; a fatal termination being the inevitable result.

Dr. J. H. Bennett, Clinical Lectures on the Principles and Practice of Medicine, 5th edit. p. 908.

2 Op. cit.

It is almost needless to observe that this inflammatory form of phthisis pulmonalis is not peculiar to diabetes, but attacks persons free from this disease. Its incidental development in diabetes must be regarded more as the result of impaired nutrition from an impoverished condition of the blood than as the effect of its saccharine impregnation; and the same may be said of the purely tubercular form. This opinion receives confirmation from the fact that pulmonary phthisis is very seldom observed in the first stage of diabetes when there is malassimilation of starch and sugar only, but when, nevertheless, the blood is strongly impregnated with sugar; its development not taking place until the second stage is somewhat advanced, and when a considerable proportion of the albumen derived from the food also undergoes saccharine transformation, and the function of nutrition is thereby seriously impaired.

Pulmonary phthisis, as a complication of diabetes, generally runs its course very rapidly towards a fatal termination.

Congestion of the lungs and pneumonia, the latter being generally double, are of frequent occurence and of a very fatal character in diabetes; the pneumonia having a tendency to terminate in gangrene. Bronchitis, too, is frequently observed, and

is prone to become chronic. The acute pulmonary affections are generally induced by exposure to cold, which has a powerfully pernicious influence on the debilitated frames of diabetics.

Carbuncles, boils, and inflammation of the subcutaneous areolar tissue, diffuse or circumscribed, are frequent and exceedingly dangerous complications of diabetes.

When carbuncle makes its appearance it is generally located in the nape of the neck or in the back, very rarely in the extremities; boils, on the contrary, are not confined to any particular locality.

The carbuncle incidental to diabetes is usually much less circumscribed than the ordinary form, being surrounded by a diffused inflammation of the adjacent skin and areolar tissue, and, moreover, it is attended with a profuse and very fluid purulent discharge. Another feature of diabetic carbuncles and malignant boils is their strong tendency to terminate in gangrene or sphacelus, either spontaneously or after incisions. In consequence of these peculiarities they are very fatal complications.

Inflammation of the subcutaneous areolar tissue, involving the skin, and generally diffuse, is also a very dangerous complication of diabetes, in consequence of the rapidity with which it passes into

gangrene or sphacelus. It has often been observed, with regard to it, that the period of inflammation preceding the gangrene is generally so brief as to pass almost unperceived.

This low gangrenous form of local inflammation is in some instances developed spontaneously; but in others it is produced by bruises or slight injuries, or by minor surgical operations, more especially by the application of a blister, which consequently, in diabetes, is a procedure to be scrupulously avoided. We have in this local inflammation a significant manifestation of the impaired nutrition and low vitality of the tissues resulting from the morbid condition of the blood in the disease, and the same may be said of the boils and carbuncles.

Dr. Prout has stated that in his experience carbuncles and malignant boils were always found to be associated with diabetes; while other observers, struck with a similar coincidence, have affirmed that all who suffer from carbuncle must also be affected with glucosuria. But it has been shown by others again, that the two morbid conditions are not always associated. Thus Dr. Wagner has given an

1 See abstract of a contribution to Archiv. für patholog. Anat. Band xii. Hefte 4 & 5, in British and Foreign Medico-Chirurg. Review, July, 1858, vol. xxii. p. 259.