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sugar-free, but a secretion of 0-5-0-7 per cent. in the 24-hour specimen could scarcely be avoided in severe cases.A change of colour to pea-green in the Benedict test, butno further, could be ignored. A patient weighing 60 kg.,and of corresponding height and doing light work, neededabout 1800 calories a day. As a rule, it was wise to under-nourish diabetics a little because their weight tended torise under treatment. Dr. Svedberg considered that thestandard diet for a healthy man of 3700 calories a day,recently discussed in England, was unnecessarily highexcept in a few cases of extremely heavy work.The upper limit of the intake of carbohydrates was

governed by the patient’s ability to use them ; the lowerlimit by his needs, by the antiketogenicjketogenic ratioof carbohydrates to fats, and by the stimulating effectof carbohydrates on the insulin mechanism. It was

generally agreed that the dosage of insulin should be keptdown as much as possible ; large amounts of carbohydrateand insulin meant dangerous fluctuations in the blood-sugar. The carbohydrate in a diabetic diet usually didnot exceed 100 g. The protein intake was generally about1 g. per 1 kg. of body-weight, and the upper limit wasset by the facts that fully half the amount of proteintaken meant sugar in the body, that the amino-acidswere, to some extent, ketogenic, and that carbohydrateswere utilised better when the diet was low in protein.Restriction of carbohydrates and protein meant that abouttwo-thirds of the diabetic diet consisted of fat. In 1909the practice was to give diabetics a diet consisting largelyof protein; later, just before the discovery of insulin,the diet was mostly fat. Nowadays we were givinga combination which approximated more closely to anordinary diet, with a reasonable proportion of carbohydrate.Obese patients with mild diabetes did not readily developketosis,’ and could be given relatively more protein andless carbohydrate and fat. They could take about 1-5 g.of protein per 1 kg. of body-weight. Intelligent ’patientscould be given a food table and told that nothing wasforbidden provided they kept within the daily amountallowed of each of the three constituents. It was betterfor them to make liberal use of the vegetables with a

low carbohydrate content and to use bread and potatosparingly. Less intelligent patients preferred to havea diet planned out for them. The aim was to keep theurine sugar-free in such a way that the patient enjoyedlife and used as little insulin as possible. Joslin, inAmerica, claimed that out of 2000 patients under hiscare only ten had 60 units daily.A diabetic did well if he was intelligent, methodical,

and firm ; and if, lacking these qualities, he worshippedhis physician. Most diabetics should be seen quarterlyor oftener. Poverty was a hindrance to insulintreatment. In Denmark the insurance scheme foundthe cost of insulin for all who could not anord it.In Sweden the larger cities provided the cost whennecessary, and in 20 out of 25 provinces the cost wasmet by the central administrative committee ; inthe other five the old-age pension was given in advanceto cover the cost of insulin. Statistics on diabeteswere so far unsatisfactory, but the diabetic mortality-rate had fallen since the discovery of insulin, anddiabetic patients now died at a later age.Dr. CICELY PEAKE recalled Joslin’s dictum that

diabetic children should be given a small dose of insulinat night and wondered whether he still held to it.

Dr. S. R. EASTWOOD had obtained better resultswith obese patients, she thought, by cutting downthe fat in the diet and giving extra carbohydrate.The patient’s sense of well-being seemed to be increased.

Dr. G. H. WAUCHOPE remarked on the sensiblechange which had occurred in the diet of diabeticsduring recent years, their diet approximating as nearlyas possible to that of the normal person. She askedwhether Dr. Svedberg found that her patients everdeveloped hypoglycaemic symptoms.Dr. SVEDBERG replied that she had never used

diets with a very high proportion of carbohydrates.She seldom saw a case of hypoglycaemia.

MEDICAL SOCIETY OF LONDON

AT a meeting of this society on March 12th, SirJOHN THOMSON-WALKER, the president, in the chair,a discussion took place on the

Treatment of Cancer of the Uterus

Mr. VICTOR BONNEY said that up to the end of1928 he had performed Wertheim’s operation forcarcinoma of the cervix 366 times, and achieved afive-year cure rate of 40 per cent. if including, and41 per cent. if not including, cases lost sight of anddying of other disease. Since 10 per cent. of therecurrences took place after the fifth year, a ten-yearfreedom from recurrence was needed before a curecould be justly claimed. His operability rate wasreckoned as 63 per cent. Up to the end of 1923 hehad performed the operation 266 times, with a ten-year cure rate of 30 per cent. or 34 per cent., depend-ing on whether the cases lost sight of and dying ofother disease were or were not included.He thought the results of surgery in cancer of

the cervix were best expressed by saying that theoperation succeeded in keeping cancer-free for fiveyears two out of every five patients who were operatedupon, and one out of every four patients who were seen,and in absolutely curing one out of every three

patients operated upon, and one out of every fivepatients seen. By absolute cure he meant freedomfrom recurrence for ten years. His own results hadnow been constant for many years.

Mr. Bonney threw on the screen tables of figureswhich showed that the prognosis was much betterwhere regional glands removed at the operationwere free of growth. His five-year cure rate forsuch " gland-free " cases was over 50 per cent., ascontrasted with about 20 per cent. for the gland-invaded cases. Over his last 200 operations Mr.Bonney’s operative mortality-rate was 10 per cent.He submitted that in any discussion on the relative

values of operation and radiation, the proper com-parison was, not between the results of treatment byoperation and by radiology, but between the resultsobtained on the one hand by operating on a pro-portion of the cases, and irradiating the remainder;and, on the other hand, the results obtained byirradiating all cases. Of inoperable cases a certainnumber could be salvaged by radium. In assessingthe total achievement this number had to be addedto the number of operative cures. A surgeon whooperated on a proportion of his patients, and irra-diated the remainder, ought to obtain 30 to 31 five-year cures out of every 100 unselected patientspresenting themselves. He himself had no figureswhich bore on that comparison, because, though for20 years he had had most of his inoperable casestreated by radium, he had no record of the resultswhich would be of value to the meeting. He pointedout in 1929 that of every 100 cases presented firsthand to the radiologist, 40 already had malignantinvasion of the regional glands, and these cases

were beyond the scope of radium applied from thevagina. It was in the cases with involved glandsthat surgery more than made up on radium. A

comparison between surgery and radium, foundedon the surgeon’s operability rate, and the numberof so-called "operable" cases (stages I. and II.),treated by the radiologist, was useless, as there wasno similarity between the respective groups. Abetter way, he contended, was to contrast the resultsobtained from similar percentages of the total number

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of patients seen, though inaccuracies arose even insuch a comparison. Probably if we knew enoughcases of carcinoma of the cervix would be dividedinto four classes in which cure could be effected(1) only by operation ; (2) only by radium ; (3) eitherby operation or radium and (4) by neither. When-ever a way was discovered by which invaded glandsand cellular tissue on the pelvic wall could be curedby irradiation, radiological treatment applied to all

patients would give better results than operating ona proportion of them and irradiating the remainder,because the scope of the former method would beenlarged by 60 per cent.Mr. MALCOLM DONALDSON said Mr. Bonney had

referred more than once to the absolute cure-rate,by which the speaker assumed he meant the numberof patients who were symptom-free at the end ofsay ten years, in comparison with the number ofcases seen. He, the speaker, never used the word" cure" in this connexion ; he went further thanMr. Bonney and said a patient could only be saidto be cured when she was dead and the autopsyshowed no growth. Mr. Bonney’s operability figurewas higher than tha,t of most clinics. He contendedthat the mobility of the uterus and the extent ofinvolvement gave the surgeon a good idea whetherthe case was operable or not. He had never hearda surgeon declare, on opening an abdomen, that thedisease was less advanced than he had thought; itwas always the other way about. The five-yearsurvival-rate of cases deemed operable and treatedby irradiation at various clinics were : Stockholm,40-4 per cent. ; Paris, 50-8 per cent. ; Munich,31-5 per cent.; Mayo Clinic, operable, 75 per cent.,borderline, 61-5 per cent. ; and Memorial Hospital,New York, early cases, 44-5 per cent. England didnot at present furnish large masses of statistics ofcarcinoma of the cervix treated by radiotherapy, buta few figures showed considerable promise. Notablythose from the Marie Curie Hospital, UniversityCollege Hospital, and Mount Vernon Hospital.When Dr. Donaldson started to treat cases of carci-noma of the cervix at St. Bartholomew’s Hospitalby radiotherapy he used the interstitial method--i.e.,planting needles round the cervix. Though thiscleared up the local disease, it must be regarded asa failure, as of 113 cases classified as of stages Iand II (operable) only 41 were alive in 1933, or

36.2 per cent. Since 1930 he had, been using a modi-fication of the Heyman technique at Mount Vernon,and had reason to hope for far better results. The

five-year survival-rates from various continentalcentres suggested that the results from radiotherapywere somewhat better than those following Wertheim’shysterectomy, however skilful the surgeon.

Against radiotherapy it was urged by some thatradium applied to the cervix and vagina had only alimited range, not destroying cancerous depositsin internal iliac glands. This seemed the only argu-ment in favour of choosing a Wertheim. Yet 57 percent. of Mr. Bonney’s patients had no glandularmetastases, and, on the other hand, 10-7 per cent.of cases died as a result of the Wertheim. Probablymost of these might have been saved by radiotherapy.Dr. Donaldson considered that radiotherapy wasalready superior to Wertheim’s hysterectomy, andthe problem for the gynaecologist was how to furtherextend the area of efficient irradiation in the pelvisso as to deal with implicated glands. Many methodswith this object had been devised. He envisagedthe time when reliance would be placed on X raytherapy for these outlying secondary deposits. At

present it was very difficult to eradicate carcinomafrom gland tissues by radiotherapy. Until theaction of radium and X rays on malignant diseasewas thoroughly understood, technique could only bebased on empiricism. Carcinoma of the uterusincluded, he said, carcinoma of its body. He would

agree with Mr. Bonney that the treatment for carci-noma of the body was surgical, followed by deepX ray therapy.

DISCUSSION

Mr. VIvIAN GREEN-ARMYTAGE said that the successattained by the flawless skill of Mr. Bonney was notlikely to be approached by less experienced surgeons.The great test in deciding which treatment wouldbe preferred was that which one chose for a nearrelative. A mortality-rate of 15 per cent. from theoperation and a cure-rate of 40 per cent., with monthsof invalidism, would be gravely considered as againstradium treatment, with no immediate mortality, nopain, and an end-result about the same as after aWertheim. In Vienna the Wertheim was beingpractised less and less, radium and X rays havinglargely taken its place.

Mr. STANFORD CADE spoke hopefully of the futureof radium treatment, especially in early cases. The

glands which were the seat of secondary carcino-matous deposits were generally held to be very radio-resistant. In his experience cervical glands withmalignant deposits could be made to shrink underirradiation, and remained free from recurrence forperiods up to 11 years. The Wertheim operationpresented a serious risk to life, certainly in the handsof the average surgeon. A special effort ought to bemade to prevent burns and other accidents fromirradiation. By a combination of X-radiation andy radiation it was possible to effectively dealwith a larger range of patients than by any othermeans.

Dr. J. E. A. LTNHAM spoke of the personal factorin treatment which applied also to radium therapy.In his view there was no serious objection to surgerywhere the disease was essentially local. Cases justbeyond the range of operation, with broad ligaments orpelvic wall involved, or palpable glands, were suitablefor radium treatment. In still more advanced cases,with abdominal glands involved, neither surgery orradium would do great good, but the glands couldbe irradiated. The use of radium and X rayscombined should improve figures.Mr. ARNOLD WALKER had had some experience in

the use of the Stockholm technique in conjunctionwith Mr. Comyns Berkeley; they had been able tosecure results comparable with those followingsurgery, and certainly saved a number of apparentlyhopeless cases. The implication of glands presentedan appalling problem. At the L.C.C. radium centretreatment by combined radium and X rays hadbeen started. He thought the numbers of cases

with gland involvement had been under-estimated.Mr. BONNEY, in reply, said he had never known a

recurrence more than ten years after operation. Ofprivate cases he had operated upon 78 per cent.There was no proper comparison possible betweenthe operability rate of the surgeon and that of theradiotherapeutist, since the latter classification wasonly a matter of opinion. He fully recognisedthat good radium treatment was better than badsurgery.

Mr. DONALDSON, in reply, insisted that the mosthopeful factor in improving the figures for thisdisease was early diagnosis and treatment.