fer from glycosuria. The arteries are
often markedly diseased. In some cases the existence of the glycosuria
is unsuspected before the onset of the gangrene, and it is only on
examining the urine that the cause of the condition is discovered. The
gangrenous process seldom begins as suddenly as that associated with
embolism, and, like senile gangrene, which it may closely simulate in
its early stages, it not infrequently begins after a slight injury to
one of the toes. It but rarely, however, assumes the dry, shrivelling
type, as a rule being attended with swelling, oedema, and dusky redness
of the foot, and severe pain. According to Paget, the dead part remains
warm longer than in other forms of senile gangrene; there is a greater
tendency for patches of skin at some distance from the primary seat of
disease to become gangrenous, and for the death of tissue to extend
upwards in the subcutaneous planes, leaving the overlying skin
unaffected. The low vitality of the tissues favours the growth of
bacteria, and if these gain access, the gangrene assumes the characters
of the moist type and spreads rapidly.

The rules for amputation are the same as those governing the treatment
of senile gangrene, the level at which the limb is removed depending
upon whether the gangrene is of the dry or moist type. The general
treatment for diabetes must, of course, be employed whether amputation
is performed or not. Paget recommended that the dietetic treatment
should not be so rigid as in uncomplicated diabetes, and that opium
should be given freely.

The _prognosis_ even after amputation is unfavourable. In many cases the
patient dies with symptoms of diabetic coma within a few days of the
operation; or, if he survives this, he may eventually succumb to
diabetes. In others there is sloughing of the flaps and death results
from toxaemia. Occasionally the other limb becomes gangrenous. On the
other hand, the glycosuria may diminish or may even disappear after
amputation.

#Gangrene associated with Spasm of Blood Vessels.#--#Raynaud's Disease#,
or symmetrical gangrene, is supposed to be due to spasm of the
arterioles, resulting from peripheral neuritis. It occurs oftenest in
women, between the ages of eighteen and thirty, who are the subjects of
uterine disorders, anaemia, or chlorosis. Cold is an aggravating factor,
as the disease is commonest during the winter months. The digits of both
hands or the toes of both feet are simultaneously