p 95t the g1lduate medical joal160 diabetes and pregnancy, with the record of seven cases in the...

PTHE

95T" G1LDUATEMEDICALJOAL

VOL. VI. JULY, 1931. No. 70.

CONTENTSPAGE

DIABETES AND PREGNANCY WITH THE RECORD OF SEVEN CASES ... ... 159By DAME LOUISE MCILROY, M.D., GLADYS HILL, M.D., AND E. C. PILLMAN-

WILLIAMS, M.A.CANT., M.B., B.S.

THE rREATMENT OF PNEUMONIA ... ... ... ... ... ... ... 170By H. V. MORLOCK, M.C., M.D., M.R.C.P.

POST-GRADUATE NEWS ... ... ... ... ... ... ... 175FELLOWSHIP OF MEDICINE AND POST-GRADUATE MEDICAL, ASSOCIATION.-

SPECIAL COURSES ... ... ... ... ... ... .. .. ... 177

DIABETES ANDPREGNANCY, WITH THE

RECORD OF SEVEN CASES.'3y DAME LOUISE McILROY,GLADYS HILL, M.D.,

AND

E. C. PILLMAN-WILLIAMS,M.A.(CAST.), M.B., B.S.

From the Obstetrical Unit and Bio-Chemical Labora-tory of the Royal Frce Hospital, lUniversity of London.

PART I.-CLINICAL INVESTIGATION.

DIABETES was looked upon as a very seriousdisease in the few cases where it was coin-plicated by pregnancy. Since the discoveryof insulin as a means of treatment the wholeaspect of the condition has changed. Ourviews have, therefore, to be modified as tothe dangers of pregnancy in this disease.The older literature gives records of a com-paratively small number of cases of diabetes

Read at the Obstetrical Section of the RoyalSociety of Medicine, June 19, 1931.

associated with pregnancy and much con-fusion arose as to the accurate diagnosis oftrue diabetes of pancreatic origin. Sugar inthe urine is not infrequently found in preg-nanlt patients. In the majority of womenthis is a glycosuria due to alimentary orrenal causes and usually clears tip on dietiingor soon after parturition is completed.Lactosuria is associated in late pregnancywith mammary function and is of littleclinical importance. The use of insulinand also the investigation of cases of preg-nancy by biochemical methods havedefinitely demarcated true pancreatic dia-betes from benign glycosurias. Co-operationwith the physician and biochemist has giventhe obstetrician a much better understandingof disease whien complicated with pregnancy.Ante-natal supervision, in many cases, hasbeen the means of ascertaining the presenceof disease and of obtaining early andsuccessful treatment.

Sterility.- The explanation of the rarity ofcases of pregnancy in diabetes is given asdue to the inhlibitive influence of the diseaseupon the function of reproduction. Ovula-tion ceases and atrophic changes take place

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160 DIABETES AND PREGNANCY, WITH THE RECORD OF SEVEN CASES

in the ovaries and uterus. These changeslead to irregular menstruation and prolongedperiods of amenorrhoea. Sterility is amarked consequence. Matthews Duncanin 1892 was the first to prove that pregnancycould take place in these cases. He collectedthe records of twenty-two pregnancies, buthe pointed out the grave nature of the com-plication of pregnancy. Stander and Peck-ham state that only about 5 per cent. ofdiabetics become pregnant.

Obesity is associated with diabetes andimpaired endocrine function. Malnutritiondue to impaired carbohydrate metabolism isalso associated with defective genital func-tion. Lambie refers to obesity and thedecline of sexual function in these patients.He considers that menstruation is absent inabout 50 per cent. of diabetics. Treatmentby insulin tends to restore reproductivefunction and to promote conception. Sincethe introduction of insulin, more cases ofdiabetes with pregnancy have been reported.Therefore, it is possible that in the futurethe problem of the cure of sterility in somepatients may be solved by the biochemicalinvestigation of their sugar curves andtreatment by insulin.Pregnancy.-For all practical purposes the

literature before the discovery of insulin isnow out of date. Since the discovery ofinsulin, the two most outstanding papers inthis country are those of Lambie in I926,and of Arnold Walker given to the Obste-trical Section in 1927. The latter has givena very valuable and comprehensive review ofthe literature. He found that in Io,ooo re-corded cases of maternity patients treated inthe Middlesex Hospital, only one patient haddiabetes. The City of London recordsshowed no cases among 24,567 obstetricalpatients. Arnold Walker found only threecases in Britain treated with insulin. Hegave notes of a patient in the MiddlesexHospital under the care of Mr. ComynsBerkeley. Another case from the samehospital is described by Shirley Smith andRoques. The opinion expressed by these

writers is that diabetes is no longer a dangerwhen associated with pregnancy if treatedwith insulin. In his I930 edition, on p. 60I,Whitridge Williams states that diabetes israrely noted in pregnant women and whenfound is ominous for mother and child. Insixty-six cases which he collected from theliterature in I909, 27 per cent. women diedat the time of labour or within two weeks.An additional 23 per cent. died within twoyears. One-eighth of the pregnancies re-sulted in abortion or premature labour, andone-third of the infants born at term weredead. He admits that the most seriouscases were published and compares thefavourable results of the present day in hisClinic as reported by Stander and Peckham.The Mayo Clinic, in I928, contrasts the

doubtful results in patients before insulinand gives the successful issue in two cases.These late records all point to the fact thatthe association of diabetes and pregnancyoccurs more frequently than formerly, andthat the results are much more favourablewhen given appropriate treatment.

CLINICAL RECORD OF SEVEN PATIENTSWITH EIGHT PREGNANCIES IN OB-STETRICAL UNIT.

A large number of patients with glycosurlahave been under observation in the Clinic.

All these patients have been carefullyinvestigated, and only those who showeddefinite diabetic symptoms and blood-sugarfindings have been included in the presentcommunication. The record is for patientsfrom the year I927. The biochemicalinvestigation has been carried out by oneof us-E. C. P.-W.-in the PathologicalDepartment of the Hospital. Many cases ofpotential diabetics were excluded aftercareful consideration as though their curveswere definitely of the diabetic type, they hadno symptoms. A case of diabetes in a con-genital syphilitic was also excluded. Casesof doubtful endocrine origin were alsoexcluded.



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DIABETES AND PREGNANCY, WITH THE RECORD OF SEVEN CASES 161

Age and Parity.-Age seems to have littleinfluence. The patients' ages ranged from26 to 40 years. Shields Warren holdsthe view that diabetes is more serious atpuberty and at the menopause. Middlereproductive life may possibly be morefavourable.None of the cases were primipara. Five

had had one previous pregnancy and theother two each three previous pregnancies.The condition had, however, developed andbeen diagnosed before the onset of thepregnancy under consideration in five ofthe cases. These cases had, therefore,received some treatment for their diabeticcondition for varying periods up to twoyears before they became pregnant.Symptoms.-As the majbrity of the patients

had already been treated for their diabeticcondition, few had marked symptoms. Theyall complained of loss of energy and ofbeing easily tired and breathless on exertion.They, with one exception-a very obesepatient-appeared to be poorly nourished,with flabby muscles. This patient, No. 7,had diabetes and peripheral neuritis beforethe onset of her last pregnancy and walkingwas difficult. She had become lazy in herhabits, and this may account for her obesity.Thirst was a feature in the two untreatedcases, and these cases were passing a highpercentage of sugar in the urine. Head-aches and occasional giddiness occurred inseveral cases. Vomiting was not a markedsymptom in any of the patients. Hydramnioswas not presentin anyof the patients, althoughit seems to be a symptom in those untreatedcases recorded in the literature. Graefedescribes five cases of hydramnios out ofseven of diabetes. Sugar has been found bysome investigators in the amniotic fluid, butnot in the foetal urine. This shows that itis a maternal transudation. Marcel Labb6and Couvelaire report a case where hy-dramnios disappeared on treatment withinsulin. In our cases treatment preventedits occurrence. Frequent estimations of thesugar curves and careful diet kept the

patients well controlled throughout preg-nancy and during delivery.Warren Shields draws attention to the

condition of the heart as a complication indiabetic patients. One patient had slightcardiac enlargement with a presystolic thrill,but no clinical symptoms were present.The heart was normal in the other patients.

DIAGNOSIS.Examination of the urine is carried out

as a routine in all the patients attending theante-natal clinic. Fehling's test is used forsugar. If sugar is present, the patient is sentto the biochemical laboratory for furtherinvestigation. As a rule, patients with benignglycosuria do not suffer from any symptoms.They feel well and do not complain of thirstor wasting. Diet regulation causes disap-pearance of the sugar in most cases. Increaseoccurs after a sugar meal. If renal in origin,sugar may persist in pregnancy and dis-appear after parturition. The diagnosis willbe referred to in detail in Part II.

PROGNOSIS.The prognosis is said to be worse in young

prirtigravidae, better in multiparae in latereproductive life. It is better in the secondhalf of pregnancy, and diabetes occurringduring pregnancy is more favourable fortreatment than when it begins before theonset of pregnancy, as there is less pancreaticloss of function. If diabetes is present anduntreated in early pregnancy, abortion ismore likely to take place. The prognosisdepends upon the early recognition andtreatment of the disease. The diabetes isprobably mild in character when discoveredfor the first time on ante-natal examination.Its incidence may be due to the loweredrenal threshold in pregnancy.Pregnancy should be avoided in women

who are suffering from diabetes. If preg-nancy does take place, the general conditionof the patient and the possibilities of carry-ing out appropriate treatment must be con-



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sidered. Since the advent of insulin, induc-tion of abortion is rarely advised. In noneof the cases in the clinic was it considered.If treatment fails and the condition of thepatient is serious, induction may be unavoid-able. Sepsis is a very dangerous complicationin a diabetic patient. Induction should beperformed by tents and rubber tube and

glycerine, and not by a rapid method. Thepractice formerly was to induce almost everycase of diabetes and, if possible, sterilize thepatient. Now the patient is treated for herdisease, and the pregnancy is, as a rule,allowed to go to term. Induction of labourmay be necessary in cases were the foetus isunduly large, as sometimes takes place.

DIABETES DIAGNOSED DURING PREGNANCY.

No. Age Diagnosed Pregnancies Labour Infant

Case I ... ... 31 20th week 1 child. Weight 10 lb. Spontaneous at 8 lb. 5 oz. SatisfacDied of measles I year term. Normal tory9 months. Long la-bour

Case 2 ... ... 29 22nd week 1 child. 2 years ago. Induced at term 6 lb. 15 oz. Satisfac-Stillborn. Forceps for small pelvis tory

_ _ _ _ _ _ _ __ _ _ _ _ _ _ _ _ _ _ _ .._ _ _ _ _ _ _ _ _ _ - _ _ _ _

PREGNANCY AFTER ONSET OF DIABETES.

No. Age History Pregnancies Labour Infant

Case 2 ... ... 32 Reported only occa- 1st child 5 years ago. Term. P.P.H. ... 7 lb. 12 oz. Stillborn.2nd observed sionallv since last Stillborn Tentorialtears. Pre-pregnancy confinement 2nd, 3 years ago, in cipitate labour

R.F.H. Well

Case 5 ........ 26 Diabetes since birth I child 1 year and 6 Term. Delivered 9 lb. 8 oz. Satisfac-of first child months ago. Died 8 in apother hos- tory

hours after birth. pitalForceps

Case 4 ... ... 29 Diabetes diagnosed 3 children- Term. Spontane- 7 lb. 4 oz. Satisfac-2 months before st --7 years. ous. Some P.P.H. toryonset of pregnancy Stillborn.

2ld-42 years.WVeight 10 lb.

3rd--32 years.Alive.

Case 6 ... ... 27 Diabetes for 1 year Twins 3 years. I alive Term. Spontane- 7 lb. 12 oz. Satis-before pregnancy ous factory

Case 7. ..... 40 Not well for 6 years. 1 child 4 years ago. Term ... ..... 8lb. 1- oz. Nutrition1 year intense thirst. Stillborn. Forceps unsatisfactory. DiedPruritus. Early in a few weeks.peripheral neuritis P.M. Noabnormality

found. Congenitalmental deficient

Case 3 ... ... 35 Under treatment for 3 children alive-- Term. Sponta- 7 lb. 10½ oz. Satis-2 years, from last lst-9 years ago. neous. Slight factorypregnancy Weight 5 lb. P.P.H.

21nd--4 years.Weight 5 lb.

3rd-2 years.Weight 10 lb.



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DIABETES AND PREGNANCY, -WITH THE RECORD OF SEVEN CASES 163

Insulin seems to prevent excessive growthof the foetus.

LABOUR.There were no outstanding features in the

labours of the patients. The average dura-tion was normal. In one case of smallpelvis the labour was precipitate, the infantbeing stillborn. Tentorial tears were foundat post-mortem examination. No prolonga-tion of the third stage was observed. Intwo cases, P.P.H. was slight. Forceps werenot applied in any patient, nor was Czesareansection indicated. Sterilization was notperformed on any of the patients.

Operative interference is to be avoidedowing to the dangers of sepsis. Diabeticpatients tolerate morphia well, it is a usefulsedative for the first stage of labour. Gasand oxygen with ether if required weregiven for delivery. Chloroform is especiallycontra-indicated in diabetes.

The Puerperium.- Infection is frequentamong dietetic patients. Shields Warrenstates that of 300 fatal cases of diabetes with-out pregnancy, 126 died of infection. Hesays on p. 154 "Once a diabetic is infectedhis diabetes becomes more severe . . .

sepsis is the greatest foe of insulin." Thepuerperium was uneventful in all the cases.This is probably due to ante-natal treatmentand to the fact that the majority of thedeliveries were normal. It would seem,therefore, that insulin has a marked prophy-lactic effect upon sepsis. In surgicalpractice this is now recognized and treat-ment is carried out before operations areundertaken. In the ante-natal examinationof diabetic patients, special examinationsshould be made of the teeth and tonsils andappropriate treatment advised.There were no maternal deaths.Infant Mortality.-The table shows the

previous births as compared with thosewhich took place after treatment. Abortiondid not occur in any of the patients under-going treatment. Five infants were born atterm alive and well. One was induced nearterm for small pelvis, alive and well. One

was a precipitate labour, stillborn, with tentorial tears. One was born alive at termbut was very difficult to feed. It seemed tobe mentally deficient. It died a few weekslater of malnutrition. No lesion was foundon the post-mortem examination. Beforethe introduction of insulin, the infants ofdiabetic mothers were sometimes found tobe of excessive weight. All the infants wereof average weight.

Feedintg.-Diabetic mothers have a defi-cient milk supply. Some of the infantswere partially breast-fed for a few days, buteventually had to be artificially fed onhumanized milk and sugar and water.Breast-feeding was entirely given up il allthe cases. It should not be undertaken ifdiabetes is present.The patients as far as possible have been

followed up since their confinements and

sugar estimations made. These will bereferred to in Part II. No patient has givenany evidence of tuberculosis. One infantdied of tuberculosis later, but infection was

supposed to have been got from a particularCOW.

REFERENCES.MATTHEWS DUNCAN. Trans. Obst. Soc. Lond., 1882,

xxiv, 256-285.LAMBIE. Journ. of Obst. and Gyn., B.E.; 1926, xxxiii,

563-606.ARNOLD WALKER. Ibid., B.E., 1928, xxxv, 271-281;

Proc. Roy. Soc. Med., 1928, xxi, 13-21.

SHIRLEY SMITH and ROQUES. Brit. Med. Journ.,1929, i, 66-67.

WHITRIDGE WILLIAMS. ( Obstetrics," 1930.STANDER and PECKHAM, Amer. Journ. Obst.and Gyn., 1927, xiv, 313-321.

PARSONS, RANDALL and WILDER. Mayo ClinicReports, 1928.

SHIELDS WARREN. "The Pathology of Diabetes,"1930.

GRAEFE. Quoted by WHITRIDGE WILLIAMS.

MARCEL LABBE and COUVELAIRE. Bull. Acad. d.

Med., 1925, xciv, 1016-22.See also-

LAURENCE. Quart. Journ. Med., 1929, xxii,191-202; Proc. Roy. Soc. Med., 1927, xxi, 9-16,

MCLEOD. " Monographs on Insulin," 1926.



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PART II.

BIOCHEMICAL FINDINGS.

By E. C. PILLMAN-WILLIAMS.

These seven cases (whose clinical side hasbeen reported above by Professor McIlroyand Dr. G. Hill) from a biochemical viewmust be divided into two classes, severe andmilld.The three severe cases will be considered

first. Case i and Case 2 were kept well

CHART I.

91 Confined IS

l25unitsOlO)(0510I Insulin g 81b6zs_' + 1b '

Insulini ,.reduced

91 bg t22unitMs

BloodSugar / I

iv / l 1\Dieted < / *

wenton'URINE "oliday_________SugarAcetone mo"thpregn" t t otrt+-tro o o o o o o o o

Sept. Oct. Nov. Dec. Jan. Feb. March April May June July Aug. Away1928 1929 GTYarmouth

-* Indicates /n-Patient Hospita/ Treatment.0---l/ndicates Pregnancy a/lues. (Va/ues during Pregnancy).

controlled during pregnancy except forsmall periods of infection such as colds.The third case was more difficult to controlduring the last month of pregnancy and herinsulin had to be almost doubled. On thecharts the blood-sugar findings duringpregnancy are coloured red; the ringedvalues are fasting blood-sugars, whereasall other values were taken at II-II.30 a.m.after ilnsulin and breakfast.

SEVERE CASES.Case I, Chart I.

This patient (multip. i), aged 31, wasreferred to me from the North IslingtonClinic for glycosuria. She complained ofthirst and polyuria. She was four monthspregnant. Her fasting blood-sugar was0o'97 grm. per cent., and the 24-hourlyspecimen of urine contained 6'4 grm. percent. glucose. As she had arranged to gofor a fortnight's holiday the next day, she

was dieted and allowed to go. On return shewas leaking 7'9 grm. per cent. sugar in her24-hourly specimen, and her fasting blood-sugar was o'296 grm. per cent. She wasadmitted to hospital and put on 25 units ofinsulin and diet containing about Ioo grm.carbohydrate. This was later increased to145 grm. of carbohydrate, on which diet shewas practically acetone free. During preg-nancy the blood-sugar level of the patient was



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satisfactory except for the period at the endof December and the beginning of January,when she had a cough and cold (alsoChristmas dinner), but it was difficult to keepher sugar free, as the renal threshold forsugar was low. During the puerperium theinsulin had to be reduced to 20 units, andon discharge from hospital her conditionwas satisfactory.

After delivery the diabetic condition defi-nitely improved temporarily, but it was stillnecessary to give her 20 units of insulin a

CHARI' II.

&3 over4

InsulinUnits 1535 20

I year !4 mths 5 mths2 interval- nteIval inteFraF

Blood Pt did not no Insuin o lin

oAcetone - o o to nsulin

927 Baby 144 at birth 072 1928 9 I9 1930

uar08 next da. lURINE5ugar +;++o + tro o o ooo o -.9s+tr 5/otrotr trtro 5.se 2-3%3z~s .0%

+cetone -9So o o o o o

Jan. Feb. Mar Apr. Ma. Sept. Oct. Nov. Apr May Junei927 Baby '14at bir&h '072 8 19Z9 1930

·108 next day.

day to keep her controlled. The patient is,unfortunately, emotionally unstable, and anyworry (see chart) sends her blood-sugar up.During the last three years her condition hasdeteriorated slightly, and she now needs28 units of insulin per diem to keep her con-trolled on a diet containing about Ioo grm.carbohydrate. The case is unquestionablyone of a moderately severe diabetes.

Case 2, Chart II.First seen by us when twenty-eight weeks

pregnant (sent on from Mothers' Hospital).

She was passing urine loaded with sugarand had a resting blood-sugar of o'I87 grm.per cent. She was admitted and put on abalanced diet and insulin, first I5 units aday, which was later increased to 35 units.The diet contained over Ioo grm. carbo-hydrate, which was later further increased.As is seen by the chart, her blood-sugar

was kept at a reasonable level and theurine sugar and acetone free. The patientwas discharged on the tenth day in a satis-factory condition still on 35 units of insulin.

She reported at intervals for six weeks andthen ceased to attend.A year later, when non-pregnant, the

patient again reported, leaking I-9 grm. percent. sugar in her urine, not having takenany insulin for the year. The fasting blood-sugars were markedly raised (see chart), after20 grm. of glucose the sugar curve was of a

typical diabetic type, starting with a fastinglevel of o'150 grm. per cent., rising at thehour to o'3I5 grm. per cent., and at thesecond hour still being up at 0'2I7 grm. percent. The patient was dieted but only



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attended a few times and was not seen againuntil she was referred by the Mothers'Hospital when six months pregnant (i.e.,two years eight months after first treatment).On this occasion she had a resting sugarof o'I96 grm. per cent., and was leaking 5 grm.per cent. sugar. She was admitted and puton 20 units of insulin and a diet containingI50 grm. carbohydrate and rather reducedfats, as it took some time to get her urineacetone free.This patient was delivered and from a

CHART III.

Insulin O6O45334I..... . ...

AcenooIBlood IF jSugar iGrm%

',o_\ _______ _________

URINESugar ooo --o +-H o o++- ++t-Hi tr++++o00oo t o ++o

Acetone 4 0o0+ 0 -++tr-ooto+ o o ++Dec. Feb. Apr June AugOct. Dec. Feb. June July Aug. Sept. Oct. Nov. Dec. Feb. April.1928 1930 1931

diabetic point of view her condition keptvery satisfactory. The level of her blood-sugar became lower and the insulin wasreduced to i6 units per diem. After fivemonths' interval the patient again returnedquite out of balance, taking no insulin (seechart).Although this patient is very casual and

does not see the necessity of keeping to adiet, she can be kept in a satisfactory con-dition when under observation, and it isnteresting to note here that in the second

pregnancy she was controlled with less in-sulin than during the first pregnancy, andthat after confinement the insulin could beagain reduced. Pregnancy, therefore, con-trary to the normal experience, seems to havehad no deteriorating effect on her diabeticcondition, although in each case she wasonly treated during the latter months.

Case 3, Chart III.This patient, aged 36, with three children,

reported in November, I928; she said she

had not been well since birth of her lastinfant fourteen months previously. Shecomplained of thirst, hunger, polyuria, andpruritus. Her fasting blood-sugar was 0'255grm. per cent., and she was passing urineloaded with sugar and acetone. She wasput on insulin and a balanced diet and onthis was controlled. Eleven months laterthe patient complained of giddiness andamenorrhoea and she was found to bepregnant. From the second to fifth monthsof pregnancy she remained well on 35 units



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of insulin, then she did not report for threemonths, and when she came she was passingmuch sugar and acetone in her urine, andher blood-sugar was 0'297 grm. per cent.She was admitted and it was found necessaryto increase her insulin from 35 to 75 unitsbefore she was controlled (carbohydrate136 gri.), and just before delivery this had tobe raised to 81 units. Soon after delivery theinsulin had to be reduced and her blood-sugar values fell very quickly, until on thefourteenth day she was having 45 units per

MILD CASES.

Case 4, Chart IV.

This patient was referred from MedicalOut-patients to the diabetic clinic for gly-cosuria, November, I927, and was put on adiet and insulin, 15 units, and became sugarand acetone free. There was then an in-terval of three months before she attendedagain, when she reported two and a halfmonths pregnant.During pregnancy this patient's blood-

sugar remained low, but it was very difficult

CHART IV.

4e ^ oo' +c°15 16 15 9

Conf.d-- --------- --

BloodSugarGrm%

Id I

+ + + ++ 00 oAcetone tr -e+ o o + + + + - + +0oo o oo

Nov Dec. Jan. Feb June July Aug. Sept. Oct. Nov Dec. Jan. MarJune1927 1928 1929

diem. This patient had to return home tolook after three children. She was read-mitted recently as her sugar values wereunsatisfactory following an attack of in-flue'nza, and after treatment was dischargedcontrolled with 45 units. This patient isvery difficult to control as her blood-sugarvalues alternate rapidly after insulin and sheis always fluctuating between hypo- andhyperglycaemia. This may partly be ac-counted for by the fact that this patient isslightly hyperthyroidic.

to keep her urine sugar and acetone free.Her carbohydrate was therefore increasedand insulin put up to i6 units.During the puerperium her blood-sugar

remained at a satisfactory level, and shegradually became sugar and acetone free.At the end of three months the insulin wasreduced to 9 units, and three months laterto 3 units a day. She is now doing well,sugar and acetone free, with a balanced dietcontaining Ioo grm. carbohydrate on 3 unitsof insulin daily.



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Case 5, Chart V.This patient, when five months pregnant,

was brought up to me by her sister, Case 4,who diagnosed diabetes on account of thirstand the fact that her urine reduced Bene-dict's solution. She did not wish insulin,but as she continued to pass sugar she wasadmitted, and it was found necessary to giveher 8 units of insulin a day before she wasbalanced. This patient, unfortunately, wasconfined at a hospital near her home, andso for this period we have no figures. She

CHART V.

.3

Insulin8

2 192

*2 Conf 9^ lbsBloodSugar6rm.%

UF1NESugar 4% 25% 4%Z5%2-520%40-7i tr- tr4tr% Z2%

Acetne tr o tr: o ++ ++ + ttr tr o

Nov. Dc. Jan. Feb. March April May June1930 1931

went through her confinement and puer-perium normally. The infant was 91 lb.She now attends hospital occasionally andis not being so strict with her diet, so thatit is probable that her insulin will have tobe increased.Although easily controlled, this patient is

a definite diabetic. A sugar curve done thismonth (four months post-delivery and notbreast-feeding) after 25 grm. of glucose, gavevalues up to 0-304 grm. per cent., and at theend of two hours her blood-sugar was ashigh as 0'240 grm. per cent,

Case 6, Chart VI.This patient reported complaining of

thirst and polyuria for one month. Shewas passing a large quantity of sugar andalso a trace of acetone. Her blood-sugarthree hours after breakfast was 0o297 grm.per cent. She was put on io units of insulinbefore mid-day meal. She was only undertreatment a few weeks before pregnancystarted, and six weeks later she complainedof tremblings three hours after insulin (shewas sugar free). Insulin was therefore re-

duced to 7 units per diem. This dose waslater altered to 4 units twice daily, whichsuited the patient, and on this dose sheremained well.

Delivery and puerperium were norlmal,and on the 8 units of insulin that she hadbeen having before delivery, the patient'sblood-sugar level became too low, so thediet was increased to balance the dose ofinsulin which was kept constant.

She remained well until two weeks ago,when she was sent to a convalescent homefor a holiday. There she developed quinsy,



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CHART VI.

10 7 8

InsulinConf.

71b$.lZozs.

BloodSugar s d irm.% I

URINE _____

5ugar ++++ 0 0 ++o o 0tr 06 trv o 0 +

Acetne tr: tr: o 00 0 o o 0

May June July Aug. Nov. Dec. Jan.9 b.Mbarch April May June1930 1931

CHART VII.

3 Insulin 54

oV IConf.Blood \Sugar IGrm.%

URINE__ _ _-

Sugar -+ooo ooo 3% oo0Acetone trtrooo o+tro ++ o

I , -:July Aug. Oct. Nov. Janr Feb March.19Z 1330 1931



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170 THE TREATMENT OF PNEUMONIA

and consequently returned quite unbalancedwith a blood-sugar of 0-290 grm. per cent.and passing sugar in the urine.This case, though mild, is definitely

diabetic and illustrates well the injuriouseffect of sepsis on the condition.

Case 7, Chart VII.This patient was in a medical ward for

diabetes in July and August, I929. Shecomplained of thirst, pruritus, neuritis andloss of weight. Her resting blood-sugar was0-286 grm. per cent., and her urine wasloaded with sugar and some acetone. Shewas put on a balanced diet and 20 units ofinsulin a day.Her condition and neuritis improved, and

on discharge she could walk with very littledifficulty. Fourteen months later shereported at the maternity department fourmonths pregnant and was admitted. Shewas then found to be sugar and acetonefree and to have a low blood-sugar onI25 grm. carbohydrate a day. The insulinwas reduced and carbohydrate put up to153 grm. Insulin had to be further reducedas the blood-sugar was consistently on thelow side, and finally at the end of ten daysit could be stopped altogether. She was senthome a week later balanced on no insulin anda diet containing 145 grm. carbohydrate.

This patient was admitted later for con-finement, which went off normally, and shewas finally sent out with urine acetoneand sugar free, a normal blood-sugar and onno insulin.Had this patient only been seen during

pregnancy, without knowing the previoushistory the diagnosis of diabetes wouldhave been in doubt; but in her medicalrecord there can be no doubt that she wasa true diabetic, the function of whose pan-creas had improved under efficient insulintreatment.

DISCUSSION.The cases recorded above show that with

adequate treatment by a balanced diet and

suitable doses of insulin, women sufferingfrom diabetes may pass through pregnancywith no injurious effects. The importanceof a sufficient supply of carbohydrate in thediet must be stressed, as all pregnant womenare liable to a mild ketosis, and these patientsparticularly so. In my opinion, 125 to I50grm. of carbohydrate a day is necessary andthe insulin must be adjusted to this intake.The fact that these patients during preg-

nancy frequently pass small or large quan-tities of sugar in the urine, must not be takenas an indication of an increase in severity ofthe condition, as it is largely due to thelowering of the renal threshold for sugarwhich occurs in pregnancy.

In conclusion, it should be noted that inall the cases reported there was an increasein the sugar tolerance, several actually re-quiring less insulin than their pre-confine-ment value; a result, no doubt, of the moreeffective control during pregnancy due tothe fact that the women were more willingto attend regularly during this period.

THE TREATMENT OFPNEUMONIA.

By H. V. MORLOCK,M.C., M.D., M.R.C.P.

LOBAR pneumonia is a self-limited infection;that is to say, within a given time (five toeleven days) the infection has run itscourse, the patient has either overcome theinfection and completely recovered, or theinfection has overwhelmed the patient anddeath has taken place.What then is the deciding factor in the

production of one or other of these results ?This deciding factor is the ability or theinability of the patient to build up sufficientantibodies to overcome the infectingorganism and its toxins.

Therefore in the treatment of pneumonia,



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