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Thomas Grainger Stewart, M.D., F.R.S.E.,

PHYSICIAX IN ORDINARY TO HER MAJESTY THE QUEEN FOR SCOT-
LAND, PRESIDENT OF THE ROYAL COLLEGE OP PHYSICIANS
OF EDINBURGH, PROFESSOR OF PRACTICE OF PHYSIC
AND OF CLINICAL MEDICINE, UNIVERSITY
OF EDINBURGH,

AS A TOKEN OP
HIGH PERSONAL ESTEEM

AND IN

REMEMBRANCE OF NUMEROUS PROFESSIONAL FAVORS
AND PERSONAL KINDNESSES,

THE FOLLOWING PAGES ARE INSGRIBED BY

THE AUTHOR.

No. 8 IN THE PHYSICIANS' AND STUDENTS' READY
REFERENCE SERIES.

DIABETES:

Its Causes, Symptoms, and Treatment.

CHARLES Wr PURDY, M.D.,

queen's university.

Honorary Fellow of the Royal College of Physicians and Surgeons, Kingston ; Member of

the College of Physicians and Surgeons of Ontario ; Author of " Bright's Disease

and Allied Affections of the Kidneys;'* Member of the Association of

American Physicians, of the American Medical Association, of

the Chicago Academy of Sciences, of the llUaois

State Microscopical Society, etOv fltc.

■WITH CLi3JTiaA.3u ir*iuxjSTri.«LTio3srs.

Philadelphia and London :

F. A. DAVIS, PUBLISHER.
1890.

Entered according to Act of Congress, in the year 1890, by

F. A. DAVIS,

In the Office of the Librarian of Congress at Washington, D. C, U. S. A.

Philadelphia:

The Medical Bulletin Printing House,

1231 Filbert Street.

PREFACE.

The object of this volume is to furnish the physician
and student with the present status of our knowledge
on the subject of diabetes in such practical and concise
form as shall best meet the daily requirements of prac-
tice, as they seem to me from a careful study and re-
corded observation of the disease extending over a
period of twenty-one years.

I have dwelt with some minuteness upon the treat-
ment, more especially in matters of diet, well knowing
that a disregard of these details constitutes the most
frequent cause of failure in controlling the disease.
In order to further elucidate this part of the subject, I
have illustrated the various forms of the disease with
their appropriate treatment from cases in actual prac-
tice, selected from my clinical records.

Finally, I have endeavored to bring out prominently

the leading features of diabetes as it occurs in the

United States, together with the natural resources of

the country best suited to the disease, as the waters,

foods, and climate, since the very extensive range of

these entitles them to rank in point of efficiency for the

relief of the diabetic patient as at least equal to those

in any other land or clime.

The Author.

163 State Strekt,

September, 1890.

(V)

CONTENTS.

SECTION I.

Historical, Geographical, and Climatological

Considerations of Diabetes Mellitus, . 1

Early history of diabetes. Geographical distribution : Europe,
Asia, Australia, Central America, West Indies, South
America, Pacific Islands, United States. Climatology of
diabetes mellitus: Cold, moisture, altitude, warmth, etc.
Mortality : By States ; in cities and towns ; in rural dis-
tricts ; increasing death-rate in United States.

SECTION II.

Physiological and Pathological Considerations

op Diabetes Mellitus, 19

The liver : Physiological disorder ; glycogenic function of.
Formation of sugar : Its source. Carbohydrate foods :
Their destination in health ; perversion of, in diabetes mel-
litus. Nervous system in diabetes : Medulla ; the vagi.
Artificial glycosuria : Caused by traumatisms ; poisoning by
strychnia, chloroform, and curare. Pancreatic diabetes.

SECTION III
Etiology of Diabetes Mellitus, .... 31

Predisposing influences : Heredity ; race influences ; sex ; age ;
climate. Exciting causes : Mental emotion ; brain dis-
orders ; excessive eating ; malaria ; alcoholism ; sexual
excesses, etc.

SECTION IV.

Morbid Anatomy of Diabetes Mellitus, . . 41

The liver : Enlargement ; hyperaemia, etc. Lungs : Phthisical
changes ; cheesy deposits ; cavity formation ; pneumonic
changes. Pancreas : Fibrosis ; fatty degeneration ; cancer ;
calculovis concretions, etc. Kidneys : Enlargement ; hy-
peraemia ; tubular changes. Heart : Hypertrophy. Brain:
Alleged changes in. The blood : Chemical changes ; physio-
logical cliauges.

(vii)

viii Contents,

SECTION y.
Symptomatology op Diabetes Mellitus, . . 4t

Classification of diabetes mellitus. Classical features. Diges-
tive symptoms. Circulatory symptoms. Nervous symp-
toms. Cutaneous symptoms. Muscular symptoms. Urinary
symptoms : Diuresis ; sugar ; urea ; albuminuria. Com-
plications : Coma ; pulmonary affections ; ocular disorders ;
phlegmon and gangrene ; albuminuria. Course and dura-
tion. Diagnosis. Examination of urine : Fehling's test for
sugar; Haines's test for sugar; phenylhydrazin test; the
author's quantitative test for sugar ; approximate method.
Prognosis: Age ; pancreatic complication ; patellar reflexes,
etc.

SECTION YI.
Treatment op Diabetes Mellitus, . . .81

Prophylaxis. General dietetic considerations : Breads ; farina-
ceae ; green vegetables ; milk ; meats, etc. Beverages : Al-
coholics ; mineral waters. List of foods permitted. List
of foods prohibited. Systematic method of dieting. Medi-
cinal treatment : Opium ; antipyrm ; bromides ; ergot ; ar-
senic ; iodoform ; jambul ; oxygen gas ; alkalies. Treatment
of complications : Constipation ; dyspepsia ; furuncles ;
coma. Hygienic treatment : Clothing ; ventilation ; baths ;
exercise ; sleep, etc.

SECTION VII.
Clinical Illustrations op Diabetes Mellitus, . 115

Cases of severe type in young subjects. Mild form after middle
age. Case of exceptional severity in aged subject. Case of
malarial origin. Cases illustrating mild type in Hebrew
race. Case in childhood. Cases illustrating oxygen treat-
ment.

SECTION YIII.

Diabetes Insipidus, 161

Classification. Etiology. Pathology. Symptoms and course.
Duration. Diagnosis. Prognosis, Treatment.

Bibliography, 173

DIABETES.

SECTION I.
Diabetes Mellitus.

HISTORICAL, GEOGRAPHICAL, AND CLIMATOLOGICAL
CONSIDERATIONS.

We have reasons to believe that diabetes was known
in periods of remote antiquity. The earliest records of
the disease come from India. In the Ayur Yeda of
Susruta is to be found the following passage* : " Mellita
urina laborantem quem medicus indicat, ille etiam in-
curabilis d ictus est." The presence of the disease in
various parts of Europe and Asia during very remote
periods is referred to by numerous writers, although
nothing definite upon the subject is to be found in the
extensive writings of Hippocrates. Celsus, who lived
nineteen hundred years ago, wrote : " If the quantity
of urine which is passed is larger than the quantity of
liquids imbibed .... emaciation is caused, and
life is endangered."

Both Galen and Aretseus speak of the disease in
seA'^eral passages, but the latter especially has described
it minutely, and was one of the first to use the name
"diabetes." He wrote : "The patients urinate unceas-
ingly .... the}^ are tortured by an unquenchable
thirst ; they never cease drinking and urinating . .
. . the integuments of the abdomen become wrinkled,
and the whole body wastes awa}-."

*Hirscli's Hand-book of Historical Pathology, vol. ii, p. 643.
1 A (1)

2 Diabetes Mellitus.

During the middle ages writers have made repeated
mention of a disease characterized by excessive flow of
urine, thirst, and wasting, which must have referred to
diabetes ; but none of them speak of the sweet proper-
ties of the urine. This peculiarity of the urine, if known ,
seems to have escaped notice until about two hundred
years ago, when Thomas Willis first called attention
to it.* It was not, however, until one hundred years
later (1775) that Dobsonf first showed that the peculiar
taste of diabetic urine depended upon sugar, which he
demonstrated by evaporating the urine and producing
the sugar in crystals. About twenty years later John
Rollo published a systematic essay on diabetes, minutely
describing a number of cases, and his thorough discus-
sion of the subject laid the foundation of its subsequent
literature.

The geographical distribution of diabetes embraces
the widest possible range, with few exceptions, including
every land and clime. The records show a greater fre-
quency of the disease in certain locations than in others,
but precisely how much this depends upon climatic con-
ditions has, up to the present time, been undetermined
by systematic observation.

The disease appears to be rare in St. Petersburg, as
attested by Attenhofer and Lefevre, the former not
having seen a case in his practice, or heard of one in
that of his colleagues, for six j^ears. Similar accounts
come from Copenhagen, where no records of death from
diabetes occur in the mortalit}^ tables from 1835 to 1838.
We have records of cases from Turkey and Egypt, and
in Morocco the disease is not uncommon. No mention
of the disease is made by the English or French phy-

* Pharmaceutice Rationalis, sec. iv, chap, iii, p. 64.
t Med. Observer and Inquirer, London, 1776, v, 296.

Geographical and other Considerations.

sicians in their practice on tlie Coast of Guinea. On
the other hand, the disease is remarkably common in
Ceylon and in some parts of India, notably in Bengal.
From China, Japan, Australia, and the islands of the
Pacific we have no authoritative records of the disease ;
and the same may be said of Central America and the
West Indies. Blair declares that in Guiana it is abso-
lutely unknown. In Mexico it is met with quite often,
but in Brazil it seems to be little known.

The following table, the data of which is taken from
"Hirsch's Hand-book," gives in an incomplete way the
distribution of diabetes throughout Europe: —
Table I.

Location.

England

Ireland

Sclileswig Holstein . .

Berlin

Chemnitz

Frankfort-on-the-Main

Wurzburg

Brussels

Deaths from

Period.

Diabetes per

1000 Deaths.

1852 to 1869

1.25

1841

.74

1871 to 1879

.65

1877 to 1879

.94

1871 to 1874

1.00

1865 to 1880

1.60

1852 to 1855

1.20

1864 to 1880

.60

With regard to the climatology of diabetes, Dr.
Dickinson, who has studied the subject closely in Great
Britain, concludes that the disease is more common in
the colder counties of the kingdom than in the warmer
ones.

It has seemed to me that our own country offers
exceptional advantages for climatic study of diabetes.
The United States comprises a territory of about 3000
miles in length by about 2000 miles in width. Its area
is over three and a half millions of square miles —
nearly equal to the whole continent of Europe — or

4 Diabetes Mellitus.

twenty-nine times larger than Great Britain and Ireland.
It possesses all ranges of mean temperatures for the
year, from 35° F. in Vermont, to 75° F. on the Gulf
coast; all elevations from the sea-level to an altitude
of 10,000 feet and over; all ranges of rain-fall for the
year from 10 to 60 inches. It will be readily perceived,
therefore, that such a wide range of geographical and
climatic features enable us to give an emphatic answer
to many questions relating to the influence of climate
over disease, which has proved to be exceedingly baffling
in those countries possessing a more limited area and
range of climate.

In attempting a systematic study of the climatology
of diabetes in our own country, I was first met by tlie
unfortunate fact, that the United States, unlike all other
civilized nations, has no system of registration of vital
statistics. The data afforded by the census is, therefore,
the chief source from which even an approximate esti-
mate can be made of liability to particular forms of dis-
ease in different parts of the country. Fortunately, an
effort has been made in the last census (1880) to obtain
more complete and accurate returns of deaths than have
before been furnished, and likewise to make the returns
more accurate as regards the causes of death. With re-
gard to diabetes, the deaths have been reported under
the head of " glycosuria," and, therefore, cases of non-
saccliarine urine — diabetes insipidus — do not vitiate the
records.

In order to insure greater accuracy in calculations, I
have excluded from my records and tables all States and
Territories furnishing a total death-list of less than 5000 ;
because the comparatively low mortality from diabetes —
.5 to 6. per 1000 deaths — renders estimates on a lower
basis necessarily very faulty. I have compiled the fol-

Geographical and other Considerations.

lowing table (No. II) chiefly from the mortalit}^ reports
of the tenth census of the United States, ending with the
month of May, 1880 :—

Table II. — Deaths Jrom Diabetes per 1000 Deaths in each State in the
United States in 1880.

State.

Total
Deaths.

Deaths

from

Diabetes.

Ratep
1000.

17,929

10.

.55

14,812

11.

.70

11,530

23.

1.99

9,179

31.

3.37

21,549

24.

1.11

45,017

98.

2.11

31,213

85.

2.72

19,377

47.

2.42

15,160

24.

1.58

23,718

41.

1.31

14,514

15.

1.08

9,523

42.

4.41

16,919

19.

1.12

31,149

65.

1.96

19,743

53.

2.68

9,037

16.

1.99

14,583

13.

.88

36,615

52.

1.42

5,930

10.

1.68

8,474

10.

1.18

88,332

195.

2.20

21,547

25.

1.11

42,610

139.

3.23

63,881

116.

1.81

15,728

10.

.63

25,919

44.

1.69

24,735

19.

.76

5,024

32.

6.36

24,681

29.

1.13

16,011

45.

2.81

Alabama . . .
Arkansas . ,
California . ,
Connecticut . .
Georgia . . ,
Illinois . . .
Indiana . . ,
Iowa . . . ,
Kansas . . ,
Kentucky . ,
Louisiana . ,
Maine . . . ,
Maryland . ,
Massachusetts ,
Michigan . .
Minnesota .
Mississippi . .
Missouri . .
Nebraska . ,
New Jersey .
New York .
North Carolina
Ohio ...
Pennsylvania
South Carolina
Tennessee . .
Texas . . .
Vermont . .
Virginia . .
Wisconsin .

It may first be noted that the mortality reports of
the United States census for 1880 give a total mortality
for the country from all causes of 156,893. Of these,
1443 were returned under the head of glycosuria. This
gives an average ratio of deaths from diabetes for tlie
whole country of 1.90 per 1000 deaths.

• Diabetes Mellitus.

The most notable feature brought out by Table II
is the comparatively enormous mortality from diabetes
in the State of Vermont— 6.36 per 1000 deaths,— so far
as I am aware, the highest ratio of any place in the
world. Now, the chief features of the climate of Ver-
mont are the long-continued and severe winters. The
snow remains on the ground from five to six months of
the 3'ear, and the mean range of temperature is only
about 35° F. The State of Maine, which adjoins Ver-
mont on the nortli and east, and the climate of which is
little, if any, less severe than that of the latter, furnishes
the next highest mortality from diabetes in the United
States— 4.41 per 1000. While there can be little doubt
that the severitj^ of the climate in these two northeastern
States is chiefly responsible for the high mortalitv from
diabetes, it 3'et remains to account for the difference in
the mortality between these two States lying side by
side. It is true that Maine borders on the sea, but
three-fourths of tlie State is as far removed from the
sea as Vermont. What, then, determines the difference
in the mortalit}" from diabetes between these two States?
I have no doubt, as I shall hereafter endeavor to show
by numerous illustrations, that it is largely, if not
soleljT^, determined by altitude. It is perfectl^^ clear to
me that diabetes is a more fatal disease in higher alti-
tudes, and this holds true in any latitude. Under di-
minished atmospheric pressure oxidation is greatl}^ im-
peded, and under such circumstances the disease will
prove more fatal. It must not be forgotten that the
amount of oxygen in the system, and consequently the
activit}'^ of oxidation in the economy, depends not upon
the quantity of oxygen in the atmosphere, but directly
upon the degree of atmospheric pressure. Thus, De-
marqua}^ has shown that the blood of people who dwell

Geographical and other Considerations.

in n locality where the atmospheric pressure is onl}" 380
millimetres contains but one-half as much oxygen as
the blood of those who live at the sea-board, where the
atmospheric pressure is 760 millimetres. Now, the effect
of increased oxidation in the system is undoubtedly a
favorable one in diabetic conditions, whether it be
brought about by increased atmospheric pressure through
residence near the se->-level. or by the more direct way
of inhalations of oxygen gas ; indeed, the latter has re-
duced remarkablj^ — one-half — the quantity of sugar in
the urine of diabetics without any associated change of
diet.

The State of Vermont, in addition to being one of
the coldest States in the Union, has for the most part
an elevation above the sea of from 3000 to 5000 feet,
wiiile its neighbor, Maine, lies comparatively low. It is
true that Maine is largely hilly and broken country, but
only a comparatively small part of the State in the west
and north rises into mountains.

It may then be safel}^ assumed that cold and altitude
are the chief climatic features that determine high mor-
tality from diabetes. If we pass to the south sufficiently
far to reach the highest mean annual temperature of the
country, — say 75° F., — and select a State at or near the
sea-level, such as Alabama, we find that the mortality
from diabetes sinks to the lowest ratio in the country —
.55 per 1000 deaths.

In order, however, to reach more accurate conclu-
sions as to climatic influences over diabetes, it is better
to group together certain tracts of country whose
climatic features in each group are as nearly alike as
possible. With this end in view I have adopted the
grouping of Mr. Gannott, the geographer of the Census
Office, since it seems to me altojirether the best that has

Diabetes Mellihis.

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Oeographical and other Considerations. 9

been attempted. With this us tlie basis I have, from
various sources, worked out Table III, which gives the
death-rate from diabetes per 1000 deaths, the mean
annual temperature, tlie mean elevation, and the popula-
tion of each group. The topography of these groups is
given below : —

"North Atlantic Coast Region comprises a strip of land
from 50 to 75 miles wide, along the coast of Maine, New Hampshire,
Massachusetts, Rhode Island, and Connecticut. The surface is mainly
undulating and hilly, becoming less varied toward the south. The
coast is bold and rocky in Maine, but mostly sandy and low in Massa-
chusetts, Rhode Island, and Connecticut. There is little swamp or
undrained land. The elevation is from 100 to 600 feet.

"The Middle Atlantic Coast Region includes a strip of land
comprising the coast counties of New York, New Jersey, Delaware,
Maryland, and Virginia. The surface is low and sandy, and along the
New Jersey coast we find sandy reefs, shoreward from which are
lagoons succeeded by extensive areas of swamp. The country is low,
nowhere rising above 100 feet above the sea-level.

"The South Atlantic Coast Region includes the coast coun-
ties of North Carolina, South Carolina, and Georgia, with extensive
reefs, inclosing large bays and sounds. A large proportion of the area
is low and swampy. The average elevation above the sea is less than
100 feet.

" The Gulf Coast Region includes the entire State of Florida and
the coast counties of Alabama, Mississippi, Louisiana, and Texas. In
Florida and Louisiana a large portion is uninhabited swamp land. The
elevation is less than 100 feet.

" The Northeastern Hills and Plateaus include all that
portion of Maine, New Hampshire, ^lassachusetts, and Connecticut
not comprised in the coast strip, with all of Vermont and the northern
portion of New York State, including the Adirondacks. The area is
not all, strictly speaking, mountainous It includes a large amount of
hills and broken country. It was originally covered with dense forests,
which have in the settled portion been cut away. The elevation is
mostly above 500 feet, and in considerable parts rises to mountains
from 3000 to 6000 feet above the sea.

"The Central Appalachian Region comprises the Catskill
region of southeastern New York, the central portion of Pennsylvania,
and the western part of Marjiand, and chiefly consists of narrow, par-
allel ridges, with singularly uniform crests, broken by few gaps, and

10 Diabetes Mellitus.

rising- from 1000 to 2000 feet above the narrow valleys separating them,
which ill their turn are from 500 to 1000 feet above the sea.

" The Nokthern Lake Region comprises those parts of New
York, Ohio, Indiana, Illinois, Michigan, and Wisconsin which border
on the great lakes. These large bodies of fresh water exert a consider-
able influence upon the climate, in moderating the extremes and in
rendering the atmosphere humid. The mean elevation is about 300
feet above the sea.

" The Interior Plateau comprises that portion of the plain from
the base of the Appalachians eastward, which includes parts of Penn-
sylvania, Virginia, and North Carolina; and also on the west side of
the Appalachians, the plateau country of central New York, and western
Pennsylvania, Tne surface is broken and hilly, but now here rises into
mountains. It was upland countiy originally, covered with forests,
which have been largely cleared away. It contains comparatively
little water surface or swamp land.

" The Southern Central Appalachian Region includes por-
tions of Virginia, West Virginia, the Carolinas, Kentucky, Tennessee,
Georgia, and Alabama. This is largely a mountainous region, 5000 to
6000 feet in height on the north, gradually diminishing in the south to
1000 feet or below. This region is largely covered, especially in the
south, with heavy forests of pine and hard wood.

" The Ohio River Belt includes those parts of Ohio, Indiana,
Kentucky, and West Virginia which border on the Ohio River. It is
broken country, more and more diversified in the upper part of the
river. For the most part the rivers flow in deep, narrow valleys, bor-
dered by high blufis and broken hills. Elevation, 500 to 1000 feet.

"The Southern Interior Plateau includes the secticnof the
Atlantic plain which extends across South Carolina, Georgia, with the
region in central Alabama and Mississippi lying between the Appa-
lachian region and the Gulf-coast belt. It is mostly level and heavily
timbered, principally with pine, a large part of which being what is
popularly known as " pine barrens." It is a warm climate, the tem-
perature rising higher than on the coast. Elevation, below 1000 feet.

" The Northern Mississippi River Belt extends from the moutli
of the Ohio River to the head of the Mississippi River, including portions
of Missouri, Iowa, and Minnesota on the western, and of Illinois and
Wisconsin on the eastern, bank. Elevation, 500 to 1000 feet

"The Southwest Central Region includes the northwestern
part of Louisiana, the southern part of Missouri, all of Arkansas
except that belonging to the south Mississippi River belt and central
Texas. It is mainly upland, and, except parts of Texas, is heavily
timbered. Elevation, 100 to 500 feet.

Geographical and other Considerations. 11

" The Prairie Region comprises most of the State of Illinois, the
southern part of Wisconsin, nearly all of Iowa, southern Minnesota,
the northern part of Missouri, the eastern half of Kansas, a consider-
able portion of Nebraska, and part of Dakota. The surface is nearly
level, except where cut by streams. Forests cover but a small portion
of the area. The soil is deep, extremely fertile, and generally very
retentive of moisture. The elevation is from 500 to 1000 feet on the
eastern portion, gradually rising to from 2000 to 3000 feet in the west.

" The Northwestern Region comprises parts of Minnesota, Wis-
consin, and Michigan. It is heavily timbered and well watered, con-
taining large numbers of small lakes and considerable areas of swamp.
This large water surface, together with dense forests, tends to give
this region a moist atmosphere, although the rain-fall is not great.
The elevation is from 1000 to 1500 feet.

" The Pacific Coast Region comprises the coast regions of Wash-
ington and Oregon Territories and California lying between the Cas-
cades and Sierra Nevada and the Pacific coast. The surface consists
of a complex range of mountains, known as the coast range, running
parallel to the coast, east of which is a great valley extending from
Puget Sound to the southern part of California. The elevation varies
from the coast-line to 3000 feet."

If, now, we examine Table III, we find the highest
mortality from diabetes in the United States is reached
in the Northeastern Hills and Plateans. The mean tem-
perature for this region is from 35° to 45° F., and the
mean elevation is about 1500 feet, — the coldest and one
of the most elevated regions in the countr3\ We there-
fore find that, whether we take the State as a nnit, or a
group of States, the territory which furnishes the lowest
mean temperature and the highest altitude also furnishes
the highest mortality from the disease under consider-
ation. The Pacific Coast Region furnishes the next
highest mortality- from diabetes of the State groups in
the country. The mean temperature of this region is
about 55° F., and the average elevation is about 1000
feet. The temperature, as will be observed, is not sufli-
ciently low to explain the very high mortalitj^ of the
disease in this region, although the altitude is such as

12 Diabetes Mellitus.

to partly counterbalance the higher temperature. But,
comparing both the temperature and altitude of this
region with some others, — such, for instance, as the
Southern Central Appalachian Region, — we still find the
mortality from diabetes in the Pacific Coast Region un-
duly high. After a careful consideration of all the con-
ditions of this region, I have no doubt that tlie unduly
high mortality from diabetes here is more apparent than
real, as it is with other diseases, such as consumption.
In other words, the salubrious climate of the Pacific
coast attracts many invalids suffering from diabetes,
who there die, and thus unduly swell the records.

In the Northwestern Region we note a very high ratio
of mortality from the disease. The mean temperature
for this region is ver^^ low, — about 45° P., — and the ele-
vation is high — 1500 feet.

If, now, we pass to the extreme opposite conditions
of temperature and altitude — such as the Gulf Coast and
Southern Interior Plateau — where the mean tempera-
ture range is from 60° F. to 75° F.,and the altitude for
the most part is below 100 feet, we find the lowest mor-
tality from diabetes in the country.

The Ohio River Belt, the Northern Mississippi River
Belt, and the Prairie Region all furnish compara-
tively high ratios of mortality from diabetes ; their
mean temperatures are comparatively low, and their
altitudes are comparatively high. Tlius, from whatever
stand-point we view the subject, we must conclude that,
in the United States, diabetes attains its liighest mor-
tality in the lowest range of temperature in conjunction
with the higher altitudes, and vice versa.

I have thus far said nothing as to the eff'ects of
moisture over diabetes, because the evidence upon this
point seems rather contradictory. As a rule, the more

Geographical and other Considerations. 13

humid climates — if we measure the humidity by the
mean rain-fall — are those in which the temperature range
is the highest; and since, as already shown, the tempera-
ture is the strongest determining influence over the
mortality ratio, it follows, as a rule, that the lower mor-
tality is attained in the more humid climates, not, how-
ever, as a result of the greater humidity, but as a result
of the accompanying high temperature. Thus it will be
observed, upon examination of Table III, that in the
South Atlantic Coast Region and Southern Interior
Plateau the mean rain-fall is the highest in the country.
These regions, as alreadj^ noted, furnish the very lowest
ratios of mortality from diabetes in the country — .76 and
.86 per 1000 deaths. This has already been shown to be
due to the liigh temperature, combined with the low alti-
tude, and therefore not to humidity of the atmosphere.
But, notwithstanding all this, I am inclined to believe
that a moist atmosphere, even in warm climates, has an
appreciably unfavorable influence over diabetes ; and
that in northern climates it has a still more unfavor-
able influence. Thus, directly on the Gulf coast the
mortality from diabetes is slightly higher than it is a
few miles in the interior, and this holds true from
Florida to Texas inclusive. In the North Atlantic
Coast Region — one of the most humid in the country —
although the altitude is low, yet the mortality from dia-
betes is moderately high — 2.91. Again, take the North-
western Region, where, although the mean rain-fall is not
high (30 to 40 inches), yet in consequence of the numer-
ous lakes scattered over the region the atmosphere is
moist. The mean temperature is but moderately low,
and nearly the whole tract is protected b}^ dense forests,
yet the mortalit}^ from diabetes is decidedly high — 2.74.
On the whole, it therefore seems probable that a moist

14 Diabetes Mellitus.

atmosphere sliglitl}^ modifies the favorable influence of
high temperature over diabetes, and that it emphasizes
the pernicious effects of cold over the disease.

From all that has been said, it will be seen that the
most favorable location for residence for diabetic patients,
in the United States, is within the area of territory
bounded on the east and including the South Atlantic
coast, and from thence extending westward and including
the Southern Interior Plateau and the Southwest Cen-
tral Region. It includes, in part or in whole, the States
of North Carolina, South Carolina, Georgia, Alabama,
Mississippi, Louisiana, Arkansas, and Texas. In addi-
tion to the climatic advantages of the territory just
named, it possesses another, — and one of no mean impor-
tance to diabetic patients, — viz., the almost perennial
supply of those foods which, as will be later shown, are
most suitable to their condition. On the whole, prob-
ably no place on the inhabited globe is better suited for
a residence for diabetic patients than the belt of country
embracing the States above named.

By no means the least interesting feature occurring
to me, in the course of these investigations, was the de-
velopment of the fact that the territories furnishing the
highest mortality from diabetes in the United States
coincide very closely with those furnishing the highest
mortality from consumption. The very frequent termi-
nation of diabetes in consumption, as will be shown
later on, lends significance to this fact.

The next question claiming attention in the clima-
tology of diabetes is tlie comparative mortality of the dis-
ease in the rural and urban population. Dickinson holds
the view that the mortality from diabetes is higher in rural
than in urban populations ; while Sir William Koberts has
arrived at directly the opposite conclusion. Here, again,

Geographical and other Considerations. 15

our own country offers exceptional facilities for solving
climatic features of the disease, which I have endeavored
to bring forward. It will be remembered that while the
population of Great Britain is about 268 to the square
mile, that of the United States averages only about 14.
The density of population in our own country is, there-
fore, such as to render the contrast between urban and
rural life much stronger than in Great Britain.

I have in Table IV selected twelve regions of the
country, and carefully tabulated the ratio of mortality
from diabetes in the rural and urban population in each
region. As near as possible I have selected examples
of the typical climates of the country, the regions of
which at the same time contain sufficient number of
large towns and cities to make the contrast between
rural and urban life as strong as possible.

Table IV. — Showing Ratio of Death from Diabetes in Rural and Urban
Popidations in the United States in 1880, by Regions.

Regions.

Deaths from

Diabetes per

1000 Deaths.

Rural.

Urban.

1. North Atlantic Coast Region

2. Middle Atlantic Coast Region

3. South Atlantic Coast Region

4. Gulf Coast Region

3..55
1.27
.70
.49
3.98
2.51
3.47
2.51
2.96
2.09
3.30
2.69

1.76

.88
1.15
1.56

5. Northeastern Hills and Plateaus ....

6. Central Appalachian Rcgic:i

7. Northern Lake Region

8. The Interior Plateau

9. The Ohio River Belt ........

10. Northern Mississippi River Belt ....

11. Central Regions (Plains)

12. Pacific Coast Region

2.43
1.35
1.15
1.42

.82
1.84

.64
2.53

An examination of Table lY discloses the fact that
in the northern regions of the country, such as the

16 Diabetes Mellitus.

North Atlantic Coast, the Northern Hills and Plateaus,
and the Northern Lake Regions, the mortality from dia-
betes in the rural population greatly exceeds that in the
towns and cities, — in fact, it nearly trebles the latter. It
is further remarkable that in the Central Region of Plains
and Prairies the rural mortality from the disease is more
than five times greater than that in the' towns and cities.
The mean temperature of the latter region is about 55°
F., and the elevation is about 1000 feet above the sea.
The country for the most part is a level and exposed
plain, the little timber which occupied it having been
cleared away. The winds are, therefore, unobstructed,
and for much of the year are cold and severe. No
stronger argument could possibly be brought forward
than the conditions in this region, to prove that exposure
in northern climates greatly increases the mortality from
diabetes in the rural over that in the urban populations.
In further examination of Table lY, however, we meet
with the curious fact that in the warmer climates the
conditions as to mortality are directly reversed. In the
South Atlantic and Gulf Coast Regions, the mortality
from diabetes in the towns and cities greatly exceeds
that in the country, — in fact, it is more than double the
latter. It will, therefore, be perceived that the relative
mortality of diabetes in rural and urban populations is
chiefly determined by temperature, in the colder re-
gions the mortality being decidedly higher in the
country, while in the warmer regions it is higher in
the cities. The explanation of these facts appears to
me to be as follows: Cold, as already shown, greatly
increases the mortality from diabetes. In cold climates,
those who are best sheltered from exposure sufler least
from the disease. This fact is brought out in strong
contrast in the United States, because there the houses

Geographical and other Considerations. It

are constructed with a view to greater warmth and com-
fort than in Europe. In the warmer climates of the South
the evil effects of cold no longer operate, and the atmos-
pheric conditions affecting the disease are chiefly those
of purity. The country people are able to live in the open
air the 3^ear round without exposure to cold or chill, and
oxidation attains its greatest activity. In the cities
more or less confinement and impurity of atmosphere is
inevitable, which tends to impede oxidation and give
greater impetus to tlie disease.

It is a remarkable fact that the mortality reports
of the United States census for 1880 do not furnish a
single death from diabetes in either the Indian or Chinese
population of the country. With regard to the Indian
population this, perhaps, does not seem so surprising, con-
sidering the habits of this race as to eating, since, as a
rule, they are spare eaters, and subsist almost exclu-
sively upon nitrogenous foods. With regard to the Chi-
nese population, the explanation is by no means so easy.
It may be observed, however, that the reports bear out
the records from their native land, where, as already
stated, we have no reports of the disease. The exemp-
tion from the disease enjoyed by the Chinese is, there-
fore, in all probability due to a race peculiarity.

From a comparison of the mortality records of the
four last United States census reports, I have been able
to ascertain that the relative mortality from diabetes in
this country has been very decidedly on the increase
during the last forty years. Thus, the census reports
for 1850 give a death-rate from diabetes in the United
States of 72 per 100,000 deaths ; that for 1860 shows 98
per 100,000 deaths; that for 1870 shows 170 per 100,000
deaths; and that for 1880 shows 191 per 100,000 deaths.
It will, therefore, be seen that the death ratio from dia-

18 Diabetes Mellitus.

betes in the United States has increased 150 per cent.
within the forty years ending in 1880.

Table V. — Ratio of Deaths from Diabetes in tJie Umted States from 1850
to 1880j Incltisive.

Year.

Ratio.

1850 . .
1860 . .
1870 . .

72 i^er 100,000 deaths.

98 " " "
170 " " "

1880

191 " " "

It will be observed, upon examination of these rec-
ords, that the increase of the death ratio from diabetes
during the first period of ten 3'ears — from 1850 to 1860
— was about 30 per cent. Between 1860 and 1870 the
death-rate increased to the enormous proportion of
nearly 100 per cent. In the last decade, from 18Y0 to
1880, the rate of increase has only been about 8 per
cent. I can assign but one cause for tlie enormous in-
crease of the death-rate from diabetes during the period
from 1860 to I8TO, viz., the decided change in the habits
of the nation in living, cousequent upon the civil war.
Previous to 1860, the inhabitants of tlie United States
were a frugal and economical people, enjoying but mod-
erate luxuries in living. With the war of 1860 came
inflation of the currency and hitherto unknown abund-
ance of money. The consequence, as is well known,
was that the people entered upon a career of luxurious
living, which has earned for them the reputation of
being the most extravagant nation in the world. It
seems altogether probable, therefore, that such marked
and sudden changes of life, from those of frugalit}^ to
luxury, which extended even to the hitherto poorer
classes of the people, largeh^ accounts for the decided
impetus given to the disease during the period named.

SECTION II.

PHYSIOLOGICAL AND PATHOLOGICAL CONSIDERATIONS.

Diabetes MELLiTUsmay be defined as a disease charac-
terized hy a perverted elaboration in the economy of
the food products whereby cliiefly, though not exclu-
sivel}^, the carbohydrates become converted into sugar ;
and the efforts of the system to eliminate the latter give
rise to certain symptoms and disturbances which will
be described later in detail. Viewed from whatever
etiological stand-point we choose, — whether we accept
the nervous, the muscular, or the hepatic theory of its
origin, — the essential features of the disease consist of
a perversion of the elaborating mechanism of the organ-
ism. Our present knowledge of ph^^siological chemistry
renders it more than probable that this disturbance is
chiefly seated in the liver; and for the last fifty years
the most earnest efforts have been put forth in attempts
to unravel the nature of this morbid process.

Bernard laid the foundation of subsequent research
by demonstrating that one of the functions of the liver
in health is the formation and storing up of glycogen, or
animal dextrine, — a substance chemically identical with
starch. Bernard showed that when an animal is recently
killed and the liver is removed and placed in a warm
place, it soon becomes charged with sugar by the con-
version of part of this glycogen into glucose. If next
all the sugar be washed out of the liver by means of a
stream of water, and the organ be permitted again to
remain in a w^arm place for twent3'-four hours, it becomes
abundantly charged again with sugar. This may be

(19)

20 Diabetes Mellitus.

repeated again and again until finally all the glycogen
contained in the liver is converted into sugar. Since
the sugar obtained from glycogen or animal dextrine in
the liver is identical in all respects with the glucose
found in diabetic urine, it cannot be doubted that the
source of diabetic sugar is the liver.

It has just been stated that gl3^cogen is chemically
identical with starch. Thej^ are both convertible into
glucose by contact with saliva, pancreatic juice, or dias-
tase. They possess one important difference, however,
viz., glycogen is couA^erted into glucose by contact with
arterial blood, while starch remains unchanged by the
latter. The blood, therefore, contains a peculiar ferment,
capable of converting animal dextrine into sugar; as
jQi this ferment has not been isolated.

Schiff has shown that this ferment totally disappears
from the blood of frogs during the second half of the
winter and the early spring months. During this time,
although the liver is as full as usual of glycogen, no
production of sugar occurs when the liver is isolated ;
and, moreover, artificial glj^cosuria cannot be induced in
these animals at such times. It is important in this
connection to note that animal dextrine, altliough always
present in the livers of all healthy animals, yet under a
variety of diseased and unnatural conditions it quicldy
and entirely disappears. This explains why it is rarely
to be found if souglit for post-mortem.

Before it be possible to comprehend the part tnat
glj^cogen plays in the production of diabetes, it is first
necessary to inquire into its source, formation, and des-
tination in the organism in health. Great divergence of
opinion prevails among physiologists upon this ques-
tion, most of whom, however, at present adhere to one
of two theories. Bernard believed that a continual con-

Physiological and Pathological Considerations. 21

Aversion of this gl3^cogen into sugar is going on in the
liver during health, and that sugar is being constantly
poured into the portal vein and distributed in the circula-
tion to be consumed in the lungs and muscles. In other
words, Bernard's view is that the liver in health is a
sugar-forming organ, and that gl3'cosi»ria only results
from failure of the system to appropriate the sugar
formed in the liver.

On the other hand, Dr. Pavy holds that in health
there is no conversion of glycogen into sugar going on
in the liver, nor any stream of sugar flowing into the
circulation throngh the hepatic vein, and that when such
does take place it is the result of diseased conditions,
similar to diabetes, or the result of post-mortem changes.
To use his own words, " Instead of the liver being
essentially a sugar-forming, it is a sugar-assimilating
organ. Its great function in relation to sugar is to pre-
vent this principle reaching the circulation to any
material extent."

The chief evidence in favor of Bernard's theory rests
upon his assumption that in recently-killed animals the
blood in the hepatic veins contains considerably more
sugar than does the blood of other parts of the body. Dr.
Pavy considers the results obtained by Bernard's experi-
ments due to rapid changes which occurred during the
experiments. He varied these experiments with the
view of avoiding these changes, and obtained an alto-
gether different result. By catheterizing the right heart,
and introducing a tube along the jugular vein, he was
able to obtain the blood of the hepatic veins in its
normal condition. Thus obtained, the blood was found
to contain only the normal traces of sugar which are
common to all parts of the circulation.

With regard to diabetic conditions, Bernard and his

22 Diabetes Mellitus.

school take the ground that glycogen has its normal
seat in some hepatic cells, while the ferment which is
capable of converting it into sugar resides in other cells,
the union or separation of these two substances being
determined by the nervous system. In proof of his
position Bernarc^ pointed out that injuries to that part
of the medulla which includes the vasomotor centre for
the liver — floor of the fourth ventricle and vicinit}^ —
produce artificial gl^xosuria in perfectly healthy
animals.

Dr. Pavy admits the nervous influence so far as the
production of hyperaemia of the liver through vaso-
motor paral3'sis; but he considers the diabetic condition
as one of chemico-physiological derangement of the
liver. In other words, he considers that the carbo-
hydrates in healthy digestion are changed into maltose,
dextrine being an intermediate product. When glucose
is ingested it is converted in the stomach and intestines
by means of the glucose ferment into maltose, and the
maltose, from either source, under the influence of a
good venous blood, becomes absorbed and assimilated.
In the diabetic condition, in consequence of the vaso-
motor paral3^sis, great dilatation of the vessels of tlie
chylopoetic viscera occurs, and the blood, entering the
liver in an imperfectly deox3'genated state, gives rise to
a glucose-forming ferment. Since the glucose thus
formed is not assimilated, it passes into the circulation
and appears in the urine.

Without entering into a minute consideration of the
numerous experiments and arguments which have been
brought forward in support of either of the above doc-
trines, it seems to me altogether probable that the ex-
planations of Dr. Pavy, both as to the phj^siological
function of the liver in relation to glucose, as well as

Physiological and Pathological Considerations. 23

the production of diabetes, is more nearly the correct
one.

Our present knowledge strongly indicates the view
that the ultimate destination of the carboh3'drate foods
in the economy is the formation of fats. Now, almost
the first step in pronounced diabetes is that of rapid
emaciation, without any increase of temperature or loss
of appetite ; on the contrar}-, the temi)erature becomes
lower than normal, and the appetite becomes increased.
It is eA'ident that the emaciation in diabetes means that
the elements which normally go to make up fat do not
reach their destination in the economy, but are turned
aside during some step in the metamorphosis, and con-
stitute the waste. That this defect occurs in the liver
there can be little doubt. If this be the correct expla-
nation of the pathological processes in diabetes it would
seem to harmonize best with the varied and uncertain
lesions found, the multiple methods by which it may be
artificially induced, and the many gradations of its
intensity.

If w^e accept the explanation of Bernard we must
assume that considerable quantities of sugar circulate
in tlie normal blood. If we attempt to trace it to its
destination in this fluid, we find the theory that it is
oxidized in the lungs is an untenable one ; for the blood
in tlie right side of the heart is found to contain no more
sugar than that in the left side. It has been assumed
that in health the sugar is converted in the muscles into
lactic acid by means of a ferment, and that lack of this
ferment permits the sugar to remain unchanged when it
accumulates, and escapes by the urine. Experiments
npon animals, however, demonstrate that when they are
frozen to death — a process which arrests fermentation —
no glycosuria results. In addition to this no anteccr

24 Diabetes Mellitus.

dent changes in the muscular system are present in
diabetes that are observable — certainly no grave nutri-
tional alterations, such as must necessarily follow the
diversion of so large an amount of the normal pabulum.

It has already been stated that the carbohydrate
foods are the chief source of sugar in the economy, but
it must not be forgotten that they are not the exclusive
source of that product. Dr. Pavy found by experi-
ments upon dogs that, when fed exclusively upon animal
food, the average proportion of gl3^cogen in their livers
was T.19 per cent. Upon vegetable food, including
potatoes, barley-meal, and bread, the average percentage
of glycogen reached 17.23. Dr. McDonald* extended
these observations to other animals, and obtained results
which show that glycogen reaches its greatest amount
under the ingestion of starch and sugar ; that it is still
formed, though scantily, upon a diet of albumin, fibrin,
and glutin ; while upon a diet of animal oil or fat, vege-
table oil, and gelatin, gl^^cogen almost entirely disap-
pears from the liver. With regard to the formation of
sugar upon a purely nitrogenous diet, Professor Hough-
ton has suggestedf that the nitrogenous elements may
be split up in the liver into glycogen and urea. Albumin
closely corresponds chemicall}^ to a combination of these
two products, — the nitrogen corresponding to the urea,
the hydrogen and carbon to the glycogen. It will be
observed that in diabetes the sugar and urea in the urine
usually increase and diminish together, which strongly
indicates their common origin.

We have next to consider the part played by the
nervous system in the production of glycosuria. Bernard

* McDonald on Functions of the Liver, p. 14.

t Houghton on Diabetes Mellitus, Dublin Quarterly Jour., November,
1861, p. 269.

Physiological and Pathological Considerations. 25

demonstrated that puncture of the floor of the fourth
ventricle of the brain is immediately followed by glyco-
suria. It was at first supposed that the glycosuria
thus induced was brought about through irritation of
the pneumogastric nerves, but subsequent experiments
showed that puncture of the medulla caused the urine
to become saccharine, even when the vagi were divided.
It was further proved that the glycosuric influence was
not conveyed from the brain to the liver through the
vagi by the following experiments : Without puncture
of the medulla, the vagi having been divided, the cut
end connected with the liver was subjected to galvanism
without inducing glycosuria; when, however, the cere-
bral end of the nerves were galvanized, glycosuria at
once resulted. The vagi, therefore, are capable of con-
ducting the gl3^cosuric irritation to the nerve-centres,
but not toward the liver.

It would occupy too much space here to detail the
numerous, though interesting, experiments conducted by
Schifl", Pavy, Eckhard, Aladoft', and others, with the
object of defining the route of the so-called gl3^cosuric
influence from the vasomotor centre in the medulla to
the liver. It may, however, be stated that, starting with
the suggestion of Bernard that the route probably lay
along the spinal cord and splanchnic nerves to the liver,
experimenters have succeeded in mapping out this course
with a reasonable degree of certainty, as follows : Begin-
ning at the glycosuric tract, which, broadly speaking,
comprises that part of the cerebro-spinal axis which is
included between the optic thalami and the lower end of
the cervical enlargement, the glycosuric influence passes
into the spinal cord ; then by filaments of the sympathetic,
which accompany the vertebral artery into the lower
cervical ganglion ; then through the annulus Yieussens

2 B

26 Diabetes Mellitus.

into the first dorsal gfinglion ; from thence through the
prevertebral cord of t^e sympathetic and branches to
the liver.

Artificial glycosuria may be brought about by numer-
ous traumatisms and influences more or less profoundly
affecting this nervous mechanism, by cutting or punctur-
ing various parts of the nerve-centres, or the nerves
leading therefrom ; by drugs which act powerfully upon
the nervous mechanism, either directly upon the vaso-
motor centre, or indirectly by reflex action through the
sympathetic S3'stem. Thus, glycosuria has been induced
by poisonous doses of strychnia and curare; by in-
halations of chloroform and ether; by wounding the
liver by means of needles, or injecting acids or stimu-
lants into the hepatic veins ; by violently irritating some
sensory nerve, and by injecting arterial blood into the
portal vein, etc. It is probable that most, if not all, of
these injuries act in a similar way, — paradoxical though
this may seem, — viz., by irritating the vasomotor centre,
either directl}^ or indirectly', resulting in dilatation of the
vessels of the liver and consequent hyperaemia of the
organ and its attendant glj^cosuria. Artificial glycosuria, ^
however brought about, — except through lesions of the
pancreas, — passes away in a short time, rarely lasting
longer than twenty-four hours, and this stronglj^ suggests
that the nature of the cause is one of irritation.

On the other hand, in permanent diabetes the con-
dition of the vasomotor apparatus is one of paral3'sis,
and, although our knowledge has not yet reached precise
data as to pathological causes, our researches in artificial
glycosuria have paved the way to their very threshold.

Finally, in addition to the diabetes of nervous origin,
recently-ascertained facts render it strongly probable, if
indeed not certain, that diabetes sometimes arises in an

Physiological and Pathological Considerations. 2t

entirely" different way, originating, as Lancereaux long
ago maintained, from lesions of the pancreas. Yon
Mering has shown in the most conclusive manner that
complete ablation of the pancreas in the dog is followed
by more or less intense diabetes, which iisuall}^ lasts
until the death of the animal. Lepine hasrecentlj' pub-
lished the results of four such experiments, which are
both interesting and instructive. In the first case no
diabetes resulted from the experiment, there being peri-
tonitis from perforation caused by gangrene of the
duodenum.* The second dog presented no glycosuria
during the whole time it lived after the removal of the
pancreas ; but at the autopsy it was found that part of
the pancreas remained. The fragment remaining had
no connection with the duodenum. This dog, although
he had no glycosuria, 5^et according to analysis he had
h3^pergl3^C8emia, — about 2 grammes of sugar per kilo-
gramme of blood. The third dog, after the removal of
the pancreas, had no gl3'Cosuria during the first three
da3's ; then after having been fed there appeared 5
grammes of sugar to the litre of urine. Two hundred
grammes of glucose were then administered, and the
following day the urine contained 50 grammes of sugar
to the litre, — about 25 grains to the ounce. This intense
diabetes persisted until the death of the animal. The
fourth dog survived twelve days, and during all this
time it was diabetic, passing from 40 to 80 grammes of
sugar daily. Examination of the blood of this fourth
animal showed intense hyperglycaemia, the arterial
blood containing 8 grammes of sugar per litre. f

Lepine has suggested two hypotheses in explanation
of diabetes of pancreatic origin. The first suggests that

* It win be remembered that febrile and inflammatory processes at
once arrest the excretion of sugar in the urine of diabetics.
t Lyon Medicale, December 29, 1889.

28 Diabetes Mcllilus.

in the normal state a part of the pancreatic ferment is
re-absorbed and contributes to the destruction of
glucose. This is supported by the known action of
the diastatic ferment of the pancreas. The second
hjq^othesis suggests that, as is now known, the contact
of diastase with starch does not result in the formation
of glucose, but of maltose ; so the diastatic ferments of
the saliva and of the pancreatic juice in contact with
gl3'COgen furnish a sugar which is likewise identical with
maltose. It thus results that the presence of the pan-
creatic ferment is necessar3^ to transform glycogen into
glucose ; and if this ferment be wanting the hepatic
sugar will not be normal glucose, but some other form
of sugar incapable of appropriation by the S3^stem, which
is eliminated by the kidneys. Thus, in health, the pan-
creas and liver are both concerned in the elaboration of
normal glucose. Therefore, according to Lepine,
*' whichever of these hypotheses be accepted, pancreatic
diabetes will be the result of the withdrawal of the pan-
creatic ferment, and diabetes will thus result from a
relative reduction of the ferment in relation to the quan-
tity of the carbohydrates to be destroyed." *

The above experiments and suggestions are of
undoubted value in furnishing a possible solution of
the nature of that form of diabetes which, as will here-
after be shown, so frequentl}' follows upon disease of the
pancreas.

In concluding this subject, it may be stated that,
while our knowledge at present can scarcely be said to
have attained exact data with regard to all the physio-
logical and pathological phenomena of diabetes, the
most recent advances upon the subject seem to fore-
shadow the following conclusions : —

* Therapeutic Gazette, March, 1890, p. 122.

Physiological and Pathological Considerations. 29

{a) That the essential feature of diabetes consists of
a more or less profound disturbance of the glj^cogenic
function of the liver.

(6) That the chemico-physiological changes in dia-
betes result in arrest of the elaboration of certain foods
in their course toward their ultimate destination in the
organism, — probably as fats, — and the intermediate
product, passing into the general circulation, escapes
from the system, chiefly by way of the kidnej^s, in the
form of sugar.

(c) That the disease is accompanied by a hypergemic
condition of the liver, and a more or less engorged state
of the ch}' lopoetic viscera.

{d) That recently-ascertained facts indicate that, in
addition to the liver, the pancreas also is concerned in
the production of sugar in the organism, — or, to speak
more accurately, in preventing the production of sugar
in the organism, — and consequently diseases of the
latter organ are liable to induce diabetes.

(e) That diabetes may be brought about by diseases
which involve the central ganglia that preside over the
A'asomotor nerves of the liver, by diseases affecting the
peripheral distribution of these nerves, and probably
also by disorders involving inhibitory reflex action of
the sympathetic nervous system.

SECTION III.

ETIOLOGY.

Predisposing Influences. — The most prominent feature
of the disease to be noted in this connection is its
strongl3'-stamped heredity ; probably 30 per cent, of the
cases may be traced to this source. That the disease is
much inclined to run in families must be apparent to all
careful observers whose experience has brought them
much in contact with it. Numerous and interesting are
the instances recorded by various authors, showing its
marked family preferences, sometimes extending through
several generations. Dr. Ralfe has recorded an instance
which came under his observation in which the disease
attacked successive members of a family extending over
a period of nearl}^ a centur^^, and including four genera-
tions. Sir H. Marsh also refers to a family in which he
traced the disease through four generations. It is not
uncommon to observe periods of culmination of this
tendency in certain generations, in which the disease
becomes almost a family plague, so many are the mem-
bers who succumb to it. Sir Wm. Roberts speaks of a
family consisting of eight children, every one of whom
became diabetic. Dr. Pavy refers to a family of seven,
four of whom were diabetic ; also to another, in which
three brothers became subjects of the disease. Dia-
betes sometimes maintains this strongly-marked fatality
through two or more generations uninterruptedl}^ One
of m}' recent cases is the seventh subject of diabetes in
the same family, all of whom became affected with the
disease during two generations. Sometimes the disease,
like tuberculosis, shows a maiked proclivity for certain

(31)

32 Diabetes Mellitus.

families for a certain period, and then skips a generation,
to re-appear after a period of exemption. It is altogetlier
likely that, if a more careful system of interrogating
patients were practiced as regards family history, a
much higher percentage of hereditary causation would
be revealed. In the consultation-room patients are pro-
verbially inclined to present the best side of their family
histories. Family tradition, in such matters, is feebly
cherished, apparently, and easily slips from the memory.
In one of my cases direct inquiry at the first visit failed
to elicit any family history of the disease. Subsequent
circumstances disclosed the fact that both the father and
mother of the patient were diabetic.

Whatever be the determining influences of diabetes,
they strongly leave their stamp upon the offspring, as,
indeed, do most diseases which involve the integrity of
the liver or nervous S3^stem. In certain families it is
not uncommon to note the effects of transmitted hepatic
defect, carrying with it a legacy of gout which the off-
spring is unable to silence by the most abstemious course
of living. So, too, with regard to the nervous system ;
to record its transmitted defects would entail rewriting
a large portion of the literature of the subject, so widely
distributed are these influences. It has furthermore
seemed to me, indeed, remarkable how frequent are
nervous disorders in families of diabetic parentage. In
this connection it may be noted that diabetes is alleged
to be unusually frequent in the Hebrew race. My own
experience confirms this observation to a somewhat re-
markable degree. I have, at the present writing, six
Jewish patients under treatment for diabetes, and my
records show nearly a score of cases of the disease
among Hebrews within the past three years. In addi-
tion to these, several cases have come within my notice

Etiology. 33

in the practice of my colleagues within the same period.
I can also attest, so far as my own experience is con-
cerned, to the almost universally mild character of
diabetes among this people. As a single illustration I
would mention the case of a 3'oung Hebrew woman, 29
years of age, who has been under my care for the past
two years. During all this period the disease has been
kept under control by moderate limitations of diet, only
occasional traces of sugar having been present in the
urine. I have rarely, if ever, met with diabetes in so
young a subject, save in the more pronounced form.

I have closely interrogated a number of Hebrew
patients with the hope of eliciting a cause especial to
this race. The only probable explanation derived from
these investigations seems to be connected with habits
of overingestion of food. I have been assured, by a
highly intelligent Jewish member of the medical profes-
sion, that, as a class, Hebrews " are very large eaters."
In chronic Bright's disease and gout the subjects, as a
rule, are large eaters, and I have assuredly traced gly-
cosuria to the same source, as will be hereafter shown.
When diabetes is brought about by habits of excessive
eating, I have usually found the disease mild in form
and easily controlled. Precisely these conditions obtain
in the Hebrew race.

Sex. — Exactly one-third of my recorded cases of
diabetes to date have been females and two-thirds males.
Of 380 deaths from diabetes reported in the State of
Illinois from 1880 to 1888, 131 were females and 249
were males. In 1880 the number of deaths from diabetes
in the United States, as shown by the mortality reports
of the census, were 1443. Of these, 422 were females
and 1021 were males. For the ten years ending in 1870
the deaths from diabetes reported in England and Wales

34 Diabetes Mellitus.

numbered 6494. Of these, 2223 were females and 42Y1
were males. It will, therefore, be observed that in
England and Wales diabetes is about twice as fatal
among males as females ; while in the United States the
disease is nearly two and one-half times more fatal
among males than females.

Age. — Diabetes is infrequent in the two extremes of
life. The youngest patient whom I have treated for
the disease was 3 years and 4 months old, although a
case came within my personal knowledge in which the
disease began in infancy and terminated with the life of
the patient seven years later. At the other extreme of
life I have met with but few cases, the oldest patient I
have treated for diabetes being 66. Statistics on a large
scale indicate that diabetes, from comparative infre-
quency in childhood, gradually increases and attains its
maximum at about 25 years of age; from thence until
about the age of 65 years it maintains a pretty constant
uniformity ; and after 65 its frequency gradually declines
until extreme old age, when it again becomes rare.

Climate. — Up to the present time some difference of
opinion has prevailed as to the influence of climate over
diabetes; and, indeed, the records of the disease —
doubtless very imperfect — from various parts of the
world render it somewhat confusing in attempting to
draw accurate conclusions, owing to their apparently
contradictory character. Thus, in Russia, which pos-
sesses a typically cold climate, the disease is said to be
rare. On the other hand, in Ce3don, which is almost
under the equator, and consequently possessing a typi-
cally warm climate, diabetes is said to be quite frequent.
Notwithstanding all this, I have endeavored to demon-
strate, by a careful consideration of the climatic condi-
tions in the United States, that diabetes, at least in our

Etiology. 35

country, is directly and decided!}^ increased by cold and
high altitudes, while it is as directly diminished by the
opposite conditions. See Section II.

I have had but limited opportunities for studying the
influence of climate over diabetes outside of the United
States ; but if my observations and deductions be cor-
rect, there seems no good reason why different results
should follow similar conditions of climate in other
countries, unless some outside influences prevail which
to me are unknown. I strongly suspect, therefore, that,
in those countries where the disease is reported as
greatly at variance with the climatic conditions which
determine its relative frequency in the United States,
the apparent discrepancy is due — if the records be
not defective — to some other influence than that of
climate, such, perhaps, as the life or habits of the people.
We have indeed seen, even in the United States, that the
race peculiarities of people very profoundly modify the
effects of climate over diabetes ; for, as was noted in
Section I, among the natives of the country, — the In-
dians,— diabetes is unknown where in the same latitudes
in the white population it is frequent. In Ceylon,
where, as has been stated, diabetes is frequent, it is cer-
tain that the undue frequenc}^ is determined by some in-
fluence other than climate, for in other climates closely
corresponding in most respects with that of Ceylon, such
as China, some parts of the African coast. Central
America, some of the Pacific Islands, and the West
Indies, the disease is rare. The United States combines
the largest tract of territory in the world, with the
widest range of climate in which the life-habits of the
people * are practically identical, and therefore the

* Excluding the relatively small populations of the native Indians and
the Chinese.

36 Diabetes Mellitus.

genuine influence of climate over diabetes, as shown by
our mortality records, must be considered as conclusive
as are obtainable. It only remains, then, to repeat that
which has already been shown in Section I, viz., that
cold climates and high altitudes very markedly increase
the mortality from diabetes, and vice versa.

Exciting Causes. — When we consider that almost any
influence or agency which profoundly disturbs the vaso-
motor mechanism of the central nervous system, or very
seriously impairs the physiological action of the liver, is
capable of bringing about gl3^cosuria, it no longer
appears a matter of surprise tliat the exciting causes of
diabetes comprise a wide range of agencies, — so wide,
indeed, that it is altogether likely that many remain as
yet undetermined.

3fental emotion is undoubtedly the most fruitful
exciting cause of the disease. Willis traced the disease
to " sadness and long sorrow," and since then numerous
observers have recorded cases originating in grief, anger,
anxiety, overmental toil, and various forms of mental
strain and shock. Rayer mentions a case that followed
upon a violent fit of passion. Roberts cites a case which
"followed on distress of mind caused by unjust sus-
picion of theft ; in another it followed tlie burning down
of his place of business ; in a tliird it was attributed to
anxiety attendant on a Cliancer}^ suit."

Dickinson has recorded the case of a woman, who
seven months after the death of her husband became
diabetic, apparently brought on by inordinate grief.
Another, in which " a child fell from a third-floor win-
dow, and was smashed upon the pavement to all appear-
ances hopelessly. But the accident was more fatal to
its mother than itself. The child survived. The mother
never recovered from the shock. For three weeks she

. Etiology. 37

could neither eat nor sleep. Within two months she be-
came much emaciated under diabetes, and died of the
disease within ten months of the occurrence upon which
it had succeeded."

Dr. Garrod has recorded the following instance :
"Two gentlemen fought a duel in Holland; after the
first had fired he remained for some time in a state of
suspense from his adversary's pistol once or twice miss^
ing fire. He was uninjured, but a day or so after be-
came diabetic." In the United States, where commercial
competition is very keen, and the possibilities of rapid
accumulation of fortune spurs men on to overmental
exertion, I am satisfied that diabetes more frequently
results than in some of the older communities, where
business is conducted under more settled and tran-
quil conditions, coupled witli longer periods of re-
laxation and rest. Here in the West, where the former
conditions prevail so prominently, cases of diabetes very
frequently present themselves for treatment from the
ranks of the more active business pursuits, which are
clearly traceable to the pressure and excitement of
business life. As an example, I might mention the
case of a bright 3^oung man, aged 29, whose diabetes
without doubt originated in overanxiety in conduct-
ing extensive transactions on the produce exchange.
He accumulated a large fortune at the expense of
contracting diabetes, which killed him within a j'ear
of its onset. In another case, the patient was a man of
somewhat large business interests which, becoming com^
plicated, gave him much anxiety and worr}^ He became
very markedly diabetic, and I sent him to the South
Atlantic coast for complete rest, where he recovered.

The vasomotor meclianism is, indeed, keenly sensitive
to mental influences, and the diabetic condition may be

38 Diabetes Mellitus.

brought about through this channel in various ways, from
too prolonged taxation to the more violent agency of
direct shock, or both combined.

Disease and traumatisms of tlie brain are frequent
exciting causes of diabetes, and an almost endless list
of examples might be brought forward in illustration.
Richardson has recorded a case of diabetes, the autops}-
of which revealed an osseous tumor pressing upon the
pons Varolii, and an abscess in the posterior cerebral
lobes. Dompeling* records a case of diabetes caused un-
doubtedly by a tumor " as large as anut," which was found
after death occupying the whole right half of the medulla
oblongata. Fritz has collected a whole series of cases
of diabetes associated with various diseases of the brain
and cord. As to traumatisms, blows and falls upon the
forehead, vertex, or occiput are the most frequent causes
in this class. In the case of the child I have already
referred to, the cause seemed to arise from a fall upon
the floor of a car, which caused a violent blow upon the
occiput. The cliild became diabetic very soon after, and
died of coma within eighteen months.

Fischer has recorded 21 cases of diabetes which were
brought about by blows and falls upon the head, — some
with and some without cranial fracture. The same ob-
server has recorded over 20 additional cases of diabetes
which were brought about by blows on the face, loins,
thorax, and abdomen, together with fracture of the ver-
tebra, contusions of the kidney, liver, etc. The disease
brought about by these injuries comprises all grades of
severity, from slight glycosuria to the most severe t3'pe,
leading more or less rapidly to death. Freirichs traced
75 of 165 cases of diabetes to some form of nervous
lesion, consisting of organic diseases of the brain, mental

* Arch. Gen., May, 1869.

Etiology. , 39

disorders, peripheral nervous disturbances, concussion,
blows, and mental strain. In this connection, it may be
noted that glycosuria is common in certain types of
insanity.

Various other causes are ascribed for diabetes, such
as gout, malaria, alcoholism, sexual excesses ; and re-
cently Schnee has insisted that inherited syphilis is the
most frequent of all causes. I do not agree with the
above-named author, since in my experience the effects
of inherited syphilis are developed, as a rule, at an
earlier period of life than is diabetes.

I have no doubt, as before stated, that overeating
frequently induces glycosuria, and in people predisposed
to diabetes it sometimes leads to that disease. This
result is more likely to follow from overingestion of
starchy foods. In such cases the disease seems to be
brought about by supernutrition of the portal system.

SECTION lY.

MORBID ANATOMY.

The liver is frequently found to be enlarged in sub-
jects who have died of diabetes. This change, however,
is not a constant one ; in fact, some authors deny that
it is anything more than an accidental occurrence. More
recent and extensive post-mortem researches, however,
plainly demonstrate its frequency, if not usual associ-
ation with the disease. Sometimes the enlargement is
slight ; at other times it is very marked, the organ reach-
ing two or three times the normal size. With the
enlargement the organ is usually darker in color than
normal, and somewhat harder in consistence. The
essential and most constant changes found are marked
dilatation of the hepatic capillaries, hyaline thickening
of the walls of the latter, and slight interstitial over-
growth surrounding the hepatic cells, either individually
or in clusters, and extending along the walls of the
interlobular plexuses. In addition to this, the vessels
are distended and enlarged ; the liver-cells swollen, some-
what granular, and indistinct in their outlines, with a
diminished amount or absence of the normal fat contents.

The lungs exhibit very constant lesions at the au-
topsy of diabetic patients. These are partly phthisi-
cal and partly pneumonic in character, — hepatization,
caseation, and excavation being the leading features.
It has been questioned by some authors if true tuber-
culosis of the lungs is associated with diabetes at
all ; and Dickinson even asserts that diabetic patients
enjo}^ exceptional immunity from that formation. The

^' (41)

42 Diabetes Mellitus.

cheesy deposits of diabetes mellitus are claimed by
this author to differ from those of tuberculosis in the
tendencj' of the former to more rapid excavation, and
also to become located in the lower part of the upper
lobes, while the tubercular disease nearly alwaj^s begins
at the apex. Notwithstanding all this, with the aid of
recent and more exact methods it has been established
that, for the most part, these lung-lesions in diabetes are
tubercular. Leyden, Rutmeyer, Rugel, and many others
have demonstrated the presence of the bacillus of Koch
in the expectoration, the pus of the cavities, and the
necrotic portions of the lungs in these cases. It ma}'^ be
true that the bacillus tuberculosis is not always found
in the sputum in these cases ; but the same may be said
of tuberculosis in other than diabetic patients. The
geographical distribution of diabetes in the United
States, as I have already shown in Section I, closely
corresponds with the consumption-belt; and the clinical
symptoms of tubercular phthisis are practically identical
with those of diabetic phthisis, perhaps onl}'^ modified in
the latter case by more pronounced localized pneumonic
symptoms. It may be concluded, therefore, that the
phthisis of diabetes is identical with tuberculous phthisis,
modified, of course, as it must be, by the presence of
anotlier disease scarcely less serious than itself.

Besides the cavities found in the lungs in diabetics,
the autopsy also reveals the presence of caseous nodules,
which are impossible to distinguish by the naked eye
from those of tubercular origin. Evidences of circum-
scribed areas of pneumonia may be noted, such as red
and gray hepatization, tending to necrosis and cavity
formation.

The pancreas is so frequently found to be the subject
of anatomical change in diabetes as to suggest the

Morbid Anatomy. 43

probability of causal relationship. In addition to this
recent experiments upon animals, consisting of ablation
of the pancreas, has been found to be followed almost
invariably by diabetes, as was shown in Section II.
Senator believes that disease of the pancreas is present
in one-half of all cases of diabetes. Lancereaux has
reported 14 cases of diabetes associated with lesions of
the pancreas. Depierre has recently confirmed these
observations of Lancereaux, and cited a number of
similar cases. The most common lesions of the pancreas
observed at the autopsj^ in diabetic subjects are fibrosis
or hyperplasia of the connective tissue, fatty degener-
ation of the gland-cells, cancer, calculous concretions in
the ducts, with or without obstruction, and in the latter
case atrophy or cystic dilatation.

The kidneys are subject to more or less marked ana-
tomical changes, depending chiefly upon the length of
time the disease existed before death. The increased
demand made upon the kidneys in diabetes, together
with the irritating effects of the foreign matter (sugar)
which is eliminated in such large quantities, give rise to
congestive changes of all grades, from mere hyperaemia
up to pronounced swelling and degenerative changes in
the excretory structure of the gland. In well-marked
cases of diabetes, which have long continued, the autopsy
usually discloses considerable enlargement of the kid-
ne3's. The surfaces of the organs are smooth, and the
capsules non-adherent. The kidneys are overfilled with
blood. The tubular epithelium is swollen, granular, and
in some cases fatty. Interstitial changes are infrequent
unless the disease be associated with Bright's disease.
A peculiar " dropsical degeneration " has been described
by Can tani, which is confined to the large medullar}^ tubes.
The cells become swollen and clear, and almost indistinct.

44 Diabetes Mellitus.

The heart is the subject of anatomical changes in a
considerable percentage of cases, — about 15 per cent.,
according to recent statistics. Jacques Mayer, whose
experience with the disease at Carlsbad has been con-
siderable, has given this subject special attention. In
his observations of 380 cases of diabetes, cardiac changes
were found in 64 of them. The essential features of the
heart-lesions in diabetes, as revealed at the autops}',
seems to be enlargement of the organ without valvular
changes. The enlargement is chiefly of the left ventricle,
and may consist of thickening of the muscular wall or
of dilatation. It has long since been observed that
fatty changes in the heart are common in diabetic sub-
jects. Mayer holds the view that the cardiac changes
in these cases is due to the irritating effects of sugar
and urea in the circulation. Israel has found hyper-
trophy of the heart in 10 per cent, of the diabetics in
the Charite hospital, at Berlin.

In 1885 I published the results of some studies*
upon the circulation in diabetes, showing that in a large
percentage of the cases there is increased vascular ten-
sion, as indicated by the sphygmograph, similar to those
in chronic Bright's disease. It would seem that, as in
Bright 's disease, so in diabetes, an extra demand is made
upon the heart, and the regular sequence in all such
cases is primarily hypertrophy of the left ventricle, ulti-
mately tending to degenerative changes in the cardiac
muscle and dilatation of the ventricle.

The brain, which is believed to be the main-spring of
the morbid changes in diabetes, has been most minutel}^
studied by numerous observers in search of anatomical
changes which would explain the cause of the disease.
Thus far, however, it must be admitted that the results
* Jour, of Am. Med. Association, September 12, 1885.

Morbid Anatomy. 45

have been far from uniform or satisfactory. Dickinson,
who seems to have been the most industrious investi-
gator in this field, claims that certain minute anatomical
changes are characteristic of the disease, although he
admits that "the brain of diabetics is almost invariably
free from tangible disease, and to rough examination
natural." Minute examination, however, he claims, will
reveal a fine cribriform or porous condition of the white
matter, as if studded with pin-holes, each of the punc-
tures containing a small vessel. The favorite seats of
these changes are the corpora striata, optic thalami, pons,
medulla, and cerebellum. The fluid in and around the
brain is claimed to be slightly in excess, as has been
termed a " wet brain " — not uncommon in other condi-
tions. The fluid in the ventricles and beneath the
arachnoid is colorless and limpid. A peculiar condition
of the spinal cord described, although not claimed to be
always present, is dilatation of the central canal, espe-
cially in the dorsal and lumbar regions.

These changes are perivascular in nature, and accom-
panied b}^ minute haemorrhages or extravasations of
blood, apparently occurring rather by transudation than
by rupture. These extravasations are said to be most
pronounced in connection with the larger perivascular
canals, notably between the base and ventricles.

Numerous observers have sought for these changes
in connection with diabetes, but without confirming Dr.
Dickinson's observations. As Sir William Roberts truly
says, " It certainly seems strange, if this wide-spread
destruction of nervous matter really occurs in diabetes,
that mental aberration and paralytic accidents should
usually be so conspicuously absent from the clinical
histor}^ of idiopathic diabetes." A committee of the
London Pathological Societ}^, appointed to investigate

46 Diabetes Mellitus.

this subject in 1882, reported that they failed to find in
the brain " any changes which could be regarded as ex-
clusively or constantly associated with diabetes."

The blood in diabetes, as might be expected, is ab-
normally charged with sugar, often reaching one-fourth
to one-half of 1 per cent. In addition to this, an abnor-
mal amount of fat is present, in some cases sufficient to
give the blood a milky appearance. Gamgee has given
an analysis of diabetic blood in one case which showed
13 parts of fat in each 1000 parts (the normal being 2).

The blood suffers some impoverishment in diabetes ;
there is an increase in the proportion of water, and a
reduction in the total solids, especially of the corpuscles ;
and the alkalinity of the blood is markedly diminished.

Such are the chief features of our present knowledge
of the morbid anatomy of diabetes. It will be perceived
that the disease has not yet given us anything very tan-
gible in explanation of its very remarkable phenomena
through the source of pathological anatomy. It has,
indeed, been truly said that this " is the most unsatis-
factory chapter in our knowledge of the disease." Most,
if not all, of the lesions actually present are only found
after the disease has been in progress some time, the
morbid anatomy of recent diabetes being practically nil.
These facts strongly suggest that the changes thus far
observed are secondary rather than primary, and their
nature, for the most part, bears out this suggestion.

SECTION Y.

SYMPTOMATOLOGY.

Before entering into a description of the sj^mptoms
of diabetes mellitus, it is proper to note that nearly all
authors recognize two distinct forms of mellituria. First,
a milder disorder in which but small quantities of sugar
appear in the urine, and these intermittently, the general
health of the patient suffering but slight, if any, disturb-
ance ; by common consent this form has been termed
glycosuria. Second, a more pronounced form of dis-
order characterized by the excretion of large quantities
of excessively saccharine urine, by thirst, morbid appe-
tite, general wasting, and more or less profound disturb-
ance of the general health.

Since glycosuria is a transient condition of no grave
import, capable of being brought about by a multitude
of agencies, most of which are accidental or artificial, it
is of more interest to the experimental physiologist
than to the therapeutist. It will, therefore, be chiefly
with the second form of the disorder that we shall have
to do in the following pages.

By some the second form, or true diabetes, is divided
into a mild and severe type, and such division will serve
practical purposes if it be not forgotten that these two
types may pass indifferently from one to the other in
the same subject at any time during the course of the
disease.

Thirst, polyuria, lowered temperature, emaciation,
and certain nervous disturbances may be considered the
classical features of diabetes ; but a more minute con-

(47)

48 Diabetes Mellitus.

sideration of these will be greatly facilitated by a 33^8-
tematic review of the effects of the disease upon each of
the great divisions of the economy.

The Digestive System. — The effects of diabetes are
prominently noted here through more or less pronounced
thirst. This, indeed, is often the first symptom to
attract the patient's attention ; he observes an in-
creased and increasing desire for water. In the mild
form of the disease the thirst is not so prominent, and
may attract little or no attention, but in the severe type
the thirst sometimes becomes enormous, especially in
young subjects. I have known a diabetic child to call
for water on an average every half-hour, and the amount
consumed seemed prodigious. As a rule, diabetic patients
will drink from 10 to 12 pints of water daily, but they
have been known to drink 30 and even 35 pints per day.
Notwithstanding this enormous ingestion of water, the
thirst remains unquenched and seemingly unquenchable,
for the mouth and throat remain dry and parched.
Together with this inordinate thirst, there is usually a
morbidly-acute appetite. In the early but well-formed
stages of the disease this symptom is specially promi-
nent, the appetite becoming indeed so ravenous that
the patient often finds it difficult to satisfy his hunger.
As might be expected, the result of such overingestion
of food sooner or later tells seriously upon the digestive
organs, and, consequently, in the later stages of the dis-
ease the patient becomes a prey to various gastro-intes-
tinal disorders. The appetite fails ; indeed, often com-
plete anorexia and loathing for all food sets in ; gastric
pains are likely to follow tlie latter, becoming more es-
pecially prominent upon the approach of a fatal termi-
nation. Constipation of the bowels is the general rule
throughout, although, in that form of the disease asso-

Symptomatology. 49

ciated with pancreatic lesions, an obstinate diarrhoea
usually sets in, which baffles the most skillful treatment.

In the more pronounced form of the disease, the
mouth, tongue, and fauces present a reddish, congested
appearance, not unlike that which is common to invet-
erate tobacco-smokers. The tongue especially is red
and glazed, although sometimes it becomes quite thickly
coated with white fur. The whole mouth and throat in
severe cases becomes dry, parched, and distressingly
uncomfortable. The gums become more or less tender,
and their margins frequently become sore and shrink
from the teeth, to the extent in some cases that the latter
loosen and fall out.

In some cases a more or less constant sweet taste in
the mouth is experienced by the patient. This symptom
does not seem to bear any relation to the severity of the
disease, for in one of my cases the patient was annoyed
by it exceedingly when but 1 or 2 grains of sugar to the
ounce were present in his urine, and it only disappeared
when his urine became non-saccharine. As a rule, the
thirst, hunger, and indeed all the digestive disorders
become aggravated by the ingestion of starchy and
saccharine foods.

The Circulatopy System. — In the early course of the
disease, the most prominent feature in connection with
the circulation seems to be that of lowered bodily tem-
perature. The usual range is 97° F. to 96° F., although
it has been known to sink as low as 93° F. Consequent
upon this subnormal temperature, the patient is annoyed
by more or less chilly feelings, and he instinctively
seeks artificial heat by means of extra clothing, or by
remaining more than usual indoors. Diabetic patients
are proverbially susceptible to colds upon slight expos-
ure, in consequence of their lowered bodily temperature.

8 C

50 Diabetes Mellitus.

Anaemia is not uncommon, especially in advanced
stages of the disease, although this is by no means
invariably the case. I have elsewhere noted that
increased arterial tension, as shown by the sphygmo-
graph, is exceeedingly common in diabetic patients. In
pronounced cases I have found this to be the rule, rather
than the exception. This is probabl}^ in close relation-
ship with cardiac h3^pertroph3", which is now known to
be very frequent in diabetes. Extension of the area of
cardiac dullness below and to the left, with accentuation
of the second sound of the heart in the second right
costo-sternal interspace, and increased tension of the
pulse, indicate lij-pertroph}^ of the left ventricle, which
is frequent in the middle stages of the disease. In late
stages the pulse often loses its tension, and cAidences of
weakened circulation supervene, — such as dropsy and
dyspnoea, more or less pronounced. These symptoms
are usually associated with fatty changes in the cardiac
muscle, with or without dilatation of the ventricle.

The Nervous System. — It is rare to meet with a case
of diabetes in which there is not more or less nervous
disturbance. Periods of wakefulness are very common,
which, unless overcome by the use of narcotics, oc-
casion great loss of sleep. Diabetic patients are usually
" nervous " in the popular sense of the term. The more
marked the disease, the more pronounced are these
symptoms. Neuralgic pains and cutaneous hyperses-
thesia are frequent. Sensations of abnormal bodily heat
are often complained of. Sudden spells of perspiration
are common, sometimes unilateral and sometimes more
localized still, affecting only the hands or extremities.
The intellectual faculties for the most part remain clear,
although as the disease becomes advanced the patient
often becomes irritable and fretful, and loses much of

Symptomatology. 51

his strength of character. Not infrequentl}^ the pa-
tient becomes cunning and deceitful in minor matters,
especially those relating to Jiis food, resorting to all
sorts of ruses to obtain prohibited articles of diet.
Finally, as Dr. Dickinson aptly says, " The mind dete-
riorates morally and intellectually, and the disease, like
advancing age, supplies fears to the brave and follies to
the wise." The strong, well-balanced mind becomes
weak, vascillating, and morose, and the normal equa-
bility of temper gives way to frequent spells of irri-
tation, or outbursts of passion. The sexual power
deteriorates early in the disease, and later on it becomes
abolished, — failure of the power of erection results in
complete impotence. Yirility may, however, return if
the disease passes away. Finall}^, the late stages of the
disease often terminate in gradually-developed stupor,
which is followed by profound coma and death. The
nature and symptoms of diabetic coma will be fully con-
sidered later, under the head of Complications of the
Disease, to which it more properly belongs.

The Cutaneous System. — For the most part the skin
of diabetic patients is dry, harsh, and unperspirable.
The wasting of subcutaneous areolar tissue causes the
skin to become wrinkled and loose, which gives the
patient, in marked cases, a prematurely-aged appearance.
The hands rub together with a harsh, parchment-like
sound, and the surface of the skin may often be seen,
upon close inspection, to be covered with scurfy-white
dust (Pavy).

Itching over the whole cutaneous surface is liable to
arise at times, and greatly annoy the patient, especially
at night. A case of this kind recently came under my
care, which for a time proved very obstinate and rebel-
lious to the usual methods of treatment. More frequent,

52 Diabetes Mellitus.

however, are the local skin irritations which arise in
tliese cases, especially those at the meatus urinarius in
the male, and about the vulva in the female. These dis-
tressing local irritations, which may be of all grades of
severity, from simple er3'thema to pronounced eczema,
are doubtless caused by the local effects of sugar in the
urine, for we find that, wherever the cutaneous surface
be bathed with saccharine urine, local irritation ensues.
In diabetic children, who are not carefully attended to
by the nurse, it is not uncommon to find quite exten-
sive patches of eczema on the inner sides of the thighs
and legs, consequent upon the frequent contact of urine
with these parts.

Eczema, lichen, and psoriasis are frequent localized
accompaniments of diabetes.

The Muscular System. — The chief feature of the dis-
ease which claims attention in this connection is wasting.
No more constant S3'^mptom of diabetes is present
than general muscular falling away. In marked cases
this wasting is sometimes alarmingly rapid. I have
seen patients afflicted with diabetes lose from 40 to 60
pounds in weight within a few weeks. The emaciation
usually corresponds with the degree to which the urine
becomes saccharine, and is most marked when polyuria
and thirst are most prominent. If the excretion of
sugar be reduced to the minimum the progressive ema-
ciation becomes staj^ed, but in pronounced forms of
diabetes it is rarely that the loss of flesh can be restored,
chiefly because the necessary restrictions of diet do not
favor the increase of weight. Occasionally it happens
that diabetic patients do not emaciate, notwithstanding
very pronounced polyuria and the excretion of large
quantities of sugar. Roberts mentions the case of a
diabetic who, although he passed 12 pints of highly

Symptomatology. 53

saccharine urine daily for some months, still maintained
the very generous weight of 210 pounds. A few similar
examples have been recorded, but they must be looked
upon as exceptional cases.

Muscular cramps are sometimes complained of by
these patients, especially in the legs. They are, proba-
bly, reflexes from gastric disturbances, as they often are
when unassociated with diabetes, and, therefore, they
do not merit special attention here.

Aside from the weakness of the muscular system
consequent upon the exhausting effects of the disease, I
would call especial attention to a peculiar sensation of
weariness in the muscles, which I have never failed to
observe when the urine is highly saccharine. In prac-
tice I often teach my patients the significance of this
indication, since it enables them to present themselves
for examination upon any return of the urine to a sac-
charine condition, after a period of exemption from the
latter. The urine may be saccharine in some cases
without the patient having noticeable thirst or polyuria,
but the condition above noted will rarely be absent if the
urine be saccharine. This peculiar feeling is one of
fatigue, or weariness, rather than actual pain, and it is
most prominent in the muscles of the legs and arms.
From the fact that this symptom so uniformly appears
and disappears with the presence or absence of sugar in
the urine, it seems altogether likely that it is due to
some deleterious effects of sugar upon the muscular
fibres, as it circulates in the blood.

Muscular movements become laborious and fatiguing
in pronounced diabetes, and consequently these patients
are disinclined to exercise ; especially is this the case
with regard to active exertion, such as walking.

The Urine. — Very remarkable changes occur in the

64 Diabetes MelUlus.

urinary secretion in diabetes, both as regards its physi-
cal and chemical characters. The physical appearance
of the urine is quite cliaracteristic to the practiced eye.
It loses its normal depth of yellowness by two or three
shades, and becomes of a decidedly greenish hue. When
passed in a vessel, it froths much more than does normal
urine. It loses none of its normal transparency, but re-
mains perfectly clear in uncomplicated cases. The specific
gravitj^ of the urine becomes decidedly increased, and
it usually fluctuates between 1030 and 1045, although it
may rise to 1074 or sink to 1015. I have usually found,
if the specific gravity of diabetic urine habitually sinks
much below 1020, that the disease is associated witli
contracting kidney. The chemical reaction of the urine
is usually pronouncedl}^ acid, and it remains so unusually
long when exposed to the atmosphere.

The quantity of urine becomes remarkably increased
in diabetes, the increase usually keeping pretty accurate
pace with the quantity of sugar excreted. Diabetic
patients usually void from 6 to 12 pints of urine a day ;
but in some cases the enormous quantitj^ of 25 and 30
pints have been voided. The daily quantit}^ of the urine
varies exceedingly in diff'erent cases ; it also fluctuates
much from time to time in the same case. The chief
causes of fluctuation are the character and quantit}^ of
food ingested, and the amount of fluids imbibed. It is
probable, also, that certain conditions of the sj'stem in-
fluence the quantity of urine excreted. We know, for
instance, that intercurrent febrile conditions cause a
decided diminution, both in the quantity of urine and
sugar ; and the}^ sometimes even cause a temporary dis-
appearance of the latter.

With regard to the chemical changes in the urine in
diabetes : The most marked and remarkable of these is

Symptomatology. 55

the presence of sugar. The quantity of sugar present
ranges from 1 to 8 or 10 per cent., the average in well-
marked cases being about 4 or 5 per cent., — 20 to 25
grains per fluidounce. It will be perceived that with the
great augmentation of the volume of urine, heavily
charged as it is with sugar, a very considerable amount
of the latter is eliminated from the system in marked
cases. A pound and a half to 2 pounds may be consid-
ered the highest daily range in the most severe cases ;
and from this it may mark all grades in quantity, down
to an ounce or less in the milder forms of the disease.
As an example ot* the enormous possibilities of some
cases in this direction, Dickinson has recorded the case
of one of his patients, who passed 50 ounces of sugar in
twenty-four hours, and, he sagely adds, " at which rate
he would have made his own weight of sugar within the
ecclesiastical period of forty da3's."

The quantity of sugar in the urine fluctuates con-
siderably during the daily C3^cle of twenty-four hours,
reachino^ its highest ranoje from three to four hours after
meals, and attaining its minimum range during the
hours of longest fast — as before breakfast. The quantity
sometimes greatly diminishes and, indeed, may disappear
upon the approach of a fatal termination of the disease.

The amount of urea in the urine is usually increased
in diabetes, the degree of increase corresponding with
the severity of the disease. Ordinarily double or treble
the normal amount is excreted, but it may reach five or
six times more than the healthy standard. It has been
claimed that the diet of diabetic patients accounts for
the excess of urea in the urine, but this explanation
does not accord with facts. The urea maintains even a
higher range when the diet is unrestricted than when
largely limited to nitrogenous elements ; indeed, when

56 Diabetes Mellitus.

patients are put upon an almost exclusively animal diet,
both the sugar and urea in the urine are dminished, not
only proportionately, but absolutely. It will usually be
found that the greatest excretion of urea corresponds
with the degree of rapidity in which emaciation pro-
gresses, and this strongly suggests its source, viz., the
albuminoids of the system.

Professor Houghton has shown, as already stated, that
if albumin be split up its radicals correspond to the sugar
and urea, the hydrogen and carbon corresponding to the
sugar and the nitrogen to urea, and this is probably the
nature of the retrograde metamorphosis going on in the
diabetic process. Strong support is lent to this view by
the fact already mentioned, that the amount of sugar and
urea in the urine increases and decreases simultaneously.
Diabetic urine usually contains acetone, or an acetone-
yielding substance — aceto-acetic acid. These, probably,
do not exist in the urine in a free state, but in combina-
tion with some base which is the product of the break-
ing up of sugar in the blood. Acetone may be recog-
nized by its quality of changing the color of a solution
of chloride of iron to a mahogany red. A better test,
however, consists of adding a solution of nitro-prusside
of sodium and ammonium to the fluid suspected to con-
tain acetone, and, upon shaking well, a rose-violet color
is produced, if acetone be i:«*esent.

The most important morbid chemical product in the
urine in diabetes which remains to be considered is the
occasional presence of albumin. For the most part,
albuminuria is confined to the late stages of the disease,
and it is doubtless associated with damage of the
kidneys, brought about b3'^ long-continued excretion of
highl3'-saccharine urine. Tiie degree of albuminuria is
usually slight, rarely exceeding 4 or ^ gramme to the

Symptomatology. 57

litre. In cases in which it much exceeds this amount,
in all probability some independent renal disease co-
exists. Thus, I have seen associated with diabetes a
high degree of albuminuria, — 4 grammes to the litre,
— the origin of the albumin being due to co-existing
amyloid disease of the kidneys. When albuminuria
arises consequent to, and in the early stages of, diabetes,
it is likely to pass away, if the urine becomes perma-
nently free from sugar.

Complications. — One of the most frequent, and cer-
tainly the most fatal, of all the complications of diabetes,
is a peculiar form of coma — Kussmaul'scoma — sometimes
termed acetonsemia. Among the younger subjects of
the disease this complication is the most frequent cause
of death. Few well-marked cases of diabetic coma
have thus far been known to recover; the patients
usually succumb within two or three days, sometimes
even more suddenly.

Two forms of diabetic coma have been described by
writers, and, as t3^pical illustrations of each form, I will
describe two cases that came under my observation.

In the first case the bowels became constipated for
two or three days ; the appetite for food almost ceased,
and the patient became weak and listless. I was called
after these prodromal S3^mptoms, and found the patient
complaining much of pain in the stomach and bowels.
The respirations were quickened, shallow, and panting,
and numbered about 30 per minute. The patient was
rather drowsy, and frequently dozed off to sleep in the
intervals between the pains. The pulse was small,
thready, and increased in frequency to about 100 beats
per minute. The patient was seen about eight hours later,
when the S3^mptoms were all more pronounced, except
the intestisal pain, which was less complained of. The

3»

58 Diabetes Mellitus.

following day the patient was constantly drows}^, and
slept most of the time without narcotics. He could be
easily aroused, but lapsed into sleep again in a few
seconds if undisturbed. The respirations had increased
in number to 40 per minute, and the pulse had risen to
120 beats per minute. In the evening he was found
completely comatose ; his respirations were 45 per min-
ute ; his pulse was 130 per minute, weak, and intermit-
tent. No food had been taken during the day. During
the night he sank rapidly, becoming more profoundly
comatose, and died before morning — about forty-eight
hours after the first alarming S3'mptoms.

In the second case — that of a young woman 23 j^ears
of age — after unusual weakness and malaise for two or
three days, she was attacked suddenly during the night
with severe pain in her stomach, which was followed by
vomiting. Succeeding these symptoms was intense
gasping dyspnoea, causing the patient to sit up and lean
forward, in the typical asthmatic position. She was
evidently in great distress, and expressed the fear that
she w'ould " choke to death." The pulse became feeble
and rapid, the extremities cold ; and pronounced symp-
toms of collapse succeeded, from which, to some extent,
she rallied by morning ; but in the meantime she gradu-
ally became drowsy, with intervals of marked delirium.
During the day she became more and more unconscious;
the pulse became more feeble and rapid, reaching 150
beats per minute. The respirations were labored and
shallow, but not panting or frequent (as in the former
case), numbering only 18 or 20 per minute. The patient
died in the evening, in a state of coma and collapse.

Other s3'mptoms are not uncommon in diabetic coma,
such as a peculiar fruit}^ odor of the breath and urine,
the presence of acetone in the urine, and in some cases

Symptomatology. 59

tonic convulsions supervene. The chief features of
the complication are gastro-intestinal pain, dj'spncea,
and more or less rapidl}' -developed coma and collapse.
Diabetic coma may be brought about by fatigue, mental
emotion, or some trivial intercurrent illness which under
ordinary circumstances would but little disturb the gen-
eral health. In the case of the young woman just
narrated, no especial cause for alarm was present until
she contracted epidemic influenza {la grippe)^ which
probably precipitated the diabetic coma and caused her
death. A highlj-acid state of the urine, the presence
of acetone in the latter, and constipation of the bowels
are usually the preludes to the comatose complication.
As to the cause of diabetic coma : The sj-mptoms
certainly indicate that tlie comatose state is brought
about by some toxic agent in the blood, and that this
agent is the result of alcholic fermentation of sugar in
the blood has thus far been largely accepted as the true
explanation. Dr. Ralfe, who has studied tliis subject
closely, holds that the toxic agent is acetone, or an
acetone-fielding agent ; that when the quantity formed
is not excessive, and the kidneys maintain their func-
tional activity, the acetone is eliminated without causing
any systemic disturbance ; for experiments upon animals
prove that considerable quantities of acetone can be
ingested without serious consequences. When, how-
ever, excessive quantities are liberated in the blood, or
wiien the renal function fails, an excessive quantity is
suddenly accumulated in the blood, and then toxic
symptoms are at once set up. The frequent appearance
of acetone in the urine just previous to the outbreak of
diabetic coma, and the persistently diminished alkalinity
of the blood in this condition, even when large quanti-
ties of alkalies are administered, form the strongest

60 Diabetes Mellitus.

arguments in favor of the acetone theory of the cause
of diabetic coma.

I am inclined to believe, however, that the toxic
agent or agents which bring about the coma of diabetes,
with its associated phenomena, is nothing more nor less
than ptomaines. The extensive retrograde metamor-
phosis of albuminoid substances constantly going on in
high grades of the disease, and the diminislied alkalinity
of the blood, which entails its diminished oxidizing
power, certainly combine the most favorable conditions
for originating these toxic agents. In addition to this,
the prodromal symptoms of the coma, such as diminu-
tion of the urine and constipation of the bowels, by
diminishing the avenues of escape, tend to cause accumu-
lation of any toxic agents that may be generated in the
system; while some intercurrent disorder or overfatigue,
such as usually precedes the attack, disturbs the normal
resisting power of the organism to the poison, completes
the chain of causative factors, and precipitates the com-
plication, the symptoms of which strongly indicate the
nature of the cause.

Pulmonary Complications. — Tubercular phthisis is a
very frequent complication of diabetes. It attacks,
perhaps, the majority of patients in whom the disease
has lasted beyond two or three years. In some respects
the symptoms differ from those of ordinary phthisis ;
the cough is often dry, the expectoration less profuse,
haemoptysis is uncommon, and the temperature is usually
below 100° F. Sometimes pneumonia is lighted up in
the progress of this complication, or, wliat is quite as
common, the phthisical s^^mptoms begin with bron-
chitis. The sugar in the urine usually diminishes, and
sometimes disappears in the course of the lung compli-
cation, probably in consequence of pyrexia, for it

Symptomatology, 61

increases and decreases with the rise and fall of the
bodily temperature.

Ocular Complications. — Amblyopia is said to occur
in about 20 per cent, of the cases of diabetes. Tem-
porary dimness of vision is not uncommon to the dis-
ease, and is probably due to defect of adjusting power
in the ciliar}^ muscles. More pronounced and often per-
manent amblyopia is common, and may be brought
about by retinal haemorrhage, atroph}^ fatty changes in
the retina, or retinitis, and neuro-retinitis ; in short,
very similar changes to those met with in chronic
Bright's disease. These conditions are chiefly met
with in chronic cases. The most interesting ocular
complication of diabetes, however, as well as one of the
most frequent, is that of cataract. Griesinger noted the
appearance of cataract in a collection of 225 diabetics
twenty times, or nearly one in every 10 cases. It
usually affects both eyes, though not always simul-
taneously, and by preference the riglit eye first. It
may appear without previous defect of vision, or after
one or more attacks of ambl3'opia. Occasionally, it
pursues a very rapid course, causing complete loss of
vision in one or two weeks. More often, however, it
takes several weeks or even months before the vision is
destroyed. The cataract is usually of the soft variety,-
but occasionally it may be firm, especially in aged sub-
jects. Dr. Mitchell has shown that the administration
of sugar to frogs causes their lenses to become opaque,
the opacity passing away after the animals have been for
a time in water. He also found that the lenses could be
rendered opaque after removal from the animals b}'' soak-
ing them in syrup. It was thought that these experi-
ments explained the formation of diabetic cataract ; but
more recent observations have thrown considerable

62 Diabetes Mellitus.

doubt upon the subject. Hepp has failed to find sugar
in the lenses of diabetic patients suffering from cataract.
Fischer records similar negative results. In addition to
this, diabetic cataract is a permanent condition, and does
not improve, even when the urine of the patient ceases
to be saccharine, and so remains. Moreover, diabetic
cataract nearly always arises in chronic cases, after the
disease has lasted two or three years, and this strongly
suggests that it is one of the degenerative changes com-
mon to the last stages of the disease. As a rule, opera-
tions for diabetic cataract are not advisable, for they
generally fail owing to almost invariable suppuration
of the eye. Wounds in diabetic patients are attended
by unusual danger, owing to their proneness to obsti-
nate suppuration, and operations for cataract form no
exception to the rule.

Phlegmonous and Gangrenous Processes are fre-
quently the result of diabetic conditions. Perhaps the
most frequent of these are multiple boils, which some-
times occur in sufficient numbers to cover the whole
surface of the back and shoulders, and even to extend
over the extremities. Thej^ may be small and confluent,
or they may be large and scattered, but in all cases they
are phlegmonous and obstinate in their course, often
lasting for months b}^ successions of new crops. Prout
went so far as to assert that " carbuncles, and malignant
boils and abscesses allied to carbuncles," were always
accompanied by sugar in the urine. In diabetic condi-
tions they certainly hold some relationship to sugar in
the organism, since the surest way of relief from them
is to eliminate the sugar from the urine. Max Schuller,
who has studied this subject, concludes that they are
not due to the specific action of sugar upon the tissues,
but are caused by infection, as are other phlegmons.

Symptomatology. 63

He thinks it is not even probable that they are due to
any special micro-organism peculiar to diabetes, since
he has found in them only the round diplococci and
streptococci found in ordinary phlegmonous suppura-
tions. We may, perhaps, infer that the presence of
sugar in the circulation lessens the resisting power of
the tissues to the micro-organisms of phlegmonous sup-
puration, probably through nutritional changes which it
brings about.

Gangrene is an undoubted though not very frequent
complication of diabetes. From its preference for the
lower extremities, beginning usually in the great toe, as
well as from its slow course, it has been described as
allied to gangrene of old age. The character and course
of the process are largely modified by the nature of the
tissues attacked. Dr. Hunt, of Philadelphia, has studied
this subject closely, and reviewed 64 cases. He records
the locations attacked as follows : The leg below the
knee, including the foot, 3t ; the thigh and buttock, 2 ;
nucha (not ordinary carbuncle), 1 ; external genitals in
females, 1 ; lungs, 3 ; fingers, 3 ; back, 1 ; eyes, 1. As
to the nature of the process, he concludes that " when
the tissues are succulent the gangrene will also be of
that character; when they are composed mostly of skin,
tendon, and bone, they will approach the senile gangrenes
in appearance." It is also claimed that diabetic gan-
grene " never presents the clear-cut line of demarcation
between the dead and living parts that is characteristic
of the senile variety, and, moreover, there is a lack in
the diabetic form of the decided dryness and shrinking
of the senile gangrene." Like most complications of dia-
betes, gangrene is a late accompaniment of the disease.

Albuminuria must be considered a frequent complica-
tion of the late stages of diabetes ; in fact, it is the

64 Diabetes Mellitus.

rule, rather than the exception. If the patient be under
40 years of age, the albuminuria is usually unaccom-
panied by primary lesions of the kidneys, and, as a rule,
need not excite any special alarm. The kidneys, in such
cases, are doubtless considerably congested, and in some
cases enlarged, with slight tubular changes in progress.
It is rare, however, for nephritis to assume a sufficiently
acute form in these cases to threaten the life of the
patient, or to outrun the primary disease. The amount
of albumin in the urine is usually small, — J gramme or
less to the litre.

In patients beyond middle age, however, especially
those who are well nourished and have been large eaters,
if albuminuria be present, it is well to bear in mind the
fact that granular atrophy of the kidneys — interstitial
nephritis — is frequent, under such circumstances. Such
patients will usually be found to have hypertrophy of
the left heart ; abnormal tension in their arteries ; while
the urine will usually be found of low specific gravity,
containing a small percentage of albumin ; and a few
perfectly-clear hyaline casts may usually be found, if the
urinary sediment be carefully collected and placed under
the microscope.

The following illustration from my records of practice
will, perhaps, emphasize the practical importance of
being on the alert in such cases. Three years ago a
gentleman from an adjoining State came to consult me
in reference to sugar in his urine, which he said he dis-
covered a year or so before. His " age was 58 years ; he
had been a * generous liver,' always had a good appetite,
and he was well nourished ; in fact, robust. Analysis
of his urine showed it to contain 8 grains of sugar to
the ounce, and a mere trace of albumin. He was given
some directions as to diet, which related more to his

Symptomatology, 65

diabetic condition than to his albuminuria. Three
months after I was summoned to his home, to find him
in the last stage of uraemia, which terminated in death
four hours after my arrival." As the sequel showed,
his greater danger lurked beneath a faint degree of
albuminuria, the result of contracting kidneys; while
his greatest fears were aroused by a mild and — in men
of his age — comparatively harmless form of diabetes.

It is in such cases that a low specific gravity of urine
is sometimes met with. The cirrhotic kidney is unable
to excrete the normal amount of solids, and the polyuria
still further lowers the proportion of the latter, so that
considerable sugar may be present while the specific
gravity of the urine remains low, — a seeming paradox
in true diabetic conditions. Amyloid degeneration of
the kidney occasionally complicates diabetes, though
rather by accident than otherwise. A chronic necrosis
or suppurative process may be in progress, and the
system may withstand the drain for months or years
until diabetes sets in, which further impairs nutrition
and precipitates the amyloid disease. An illustration
will be found among the clinical cases in Section YII
of this volume.* When amyloid disease of the kidneys
complicates diabetes, the urine becomes highly albu-
minous— 2 to 6 grammes to the litre ; digestive disorders
and diarrhoea follow, and the patient becomes decidedly
dropsical.

Course and Duration of the Disease. — In most cases
diabetes begins gradually, if, indeed, not insidiously,
and it may exist in a latent form for some time. Sooner
or later, however, unusual thirst or weakness, and, per-
haps, increasing desire to urinate arouses the sus-
picions of the patient to the fact that he is not well.

* Case 102, J. W., Section VIL
C*

66 Diabetes Mellitus,

An increased appetite, however, frequently lulls his sus-
picions, and he may continue for some weeks in the belief
that with good digestion he must obviously be all right.
His increased appetite, however, but quickens the pace
of his disease, hy causing an increased ingestion of
sugar-forming foods. Increasing thirst, more frequent
calls to urinate, and advancing weakness compel him at
length to seek advice, which leads to the discovery of
his true condition.

Sometimes the disease begins much more abruptly,
so much so that the patient is able to fix upon the very
day in which it began. His thirst and polyuria make
such frequent demands upon his time and attention that
it is impossible to overlook them.

The disease may assume still another form of onset,
in which nearly all the sj^mptoms remain latent for a
lengthy period of time. Slight traces of sugar in the
urine may constitute all that is discoA^erable to indicate
any abnormal condition ; thirst, polyuria, and wasting
being absent. In elderly people especially, the disease
often thus begins and continues for a 3- ear or more.

The course of the disease, after it has become fully
developed, depends upon several circumstances, such as
the age of the patient and the character of the treat-
ment employed. In young subjects the disease is usu-
ally progressive toward a fatal termination; and the
younger the patient, the more certain does this hold true.
In patients under 30 years of age the disease usually
advances with a steady and decided march in its most
pronounced form. The thirst and polyuria are promi-
nent ; weakness and emaciation become more and more
pronounced ; the appetite fails ; and the patient, in his
reduced state, becomes a pre}^ to various nervous dis-
turbances, especially that of insomnia. Dropsj^ may or

Symptomatology 67

ma}'^ not appear near the end ; but finally one or more
of the complications already described — usually coma —
closes the struggle, the patient rarely succumbing to the
direct prostrating effects of the disease.

If judicious treatment be emplo^^ed, the symptoms
may be considerably modified. Thus the thirst and
polyuria may be largely controlled, and even the quan-
tity of sugar in the urine may be reduced to 1 or 2 per
cent. But in this especial class of cases, notwithstand-
ing these indications of apparent improvement, the
increased emaciation points to the progressive character
of the disease. However favorable the aspect of the
disease at times may appear, these patients can rarely
be made to increase in weight to any material degree ;
and sooner or later some intercurrent disorder disturbs
the balance of resistance, and the disease redoubles its
force and carries the patient farther from the line of
health. A chance exposure lights up an intractable
bronchitis, or a localized pneumonia may be the result,
to which phthisis may soon after form the sequel. A
score or more of disorders apparently lie in wait for the
young diabetic patient, while rarel}^ does the avenue to
recovery cross his course. The result, consequently,
however long dela3'ed, is pretty surely a fatal one.

Sometimes, as Dr. Pavy has pointed out, the disease
advances by a succession of short bounds or leaps, the
treatment seeming at times to check its progress ; but
relapse after relapse at length bring the patient to a
condition of extreme marasmus, ending in death.

The disease sometimes pursues still another course ;
beginning with the most pronounced and even violent
symptoms, and after thus continuing for a few weeks, it
suddenly assumes a milder form, and so remains, or
even passes away. As an illustration of this form of

68 Diabetes Mellitus.

the disease, a lady from St. Louis two years ago placed
herself under my care, who had for six weeks suflered
from the usual symptoms of the disease in the most
severe form. She had lost 40 pounds in weight within
the time above named. She was put upon treatment —
chiefly dietetic — and soon her urine ceased to be saccha-
rine, and so far as I know it has so remained. She had
regained much of her lost weight before passing from my
immediate observation.

The course of diabetes in patients beyond middle
age is more variable ; but ■ on the whole its progress is
more tardy and its symptoms are much less violent. It
is not uncommon, indeed, for elderly people to have
sugar in their urine almost constantly, without suffering
from any marked or disturbing symptoms whatever.
Neither thirst, polyuria, nor wasting are present, and
the patients are in no way incapacitated for their usual
business and social duties. In other cases the disease,
while natural!}" more pronounced, yet a few restrictions
of diet hold it well under control, and the patients, by
following a few rules as to eating, continue without dis-
comfort from the disease for years, without any apparent
progress of the latter.

Exceptionally, even in those well on in j^ears, the dis-
ease assumes the more severe type common to j^outh, as
in the case of a woman at present under my care (Case
185, Section YII). The patient, although 50 years of
age, suffers from diabetes in its decided and progressive
form, notwithstanding the most careful observance of
all details of well-directed treatment.

"With reference to the duration of the disease, it may
be stated that diabetes is essentially a chronic affection,
and its course is marked by a compass of years rather
than by that of weeks. It is true that occasionally the

Symptomatology. 69

disease quickly proves fatal. Dr. Roberts has recorded
a case which succumbed in nine days ; but such
instances are very exceptional.

In younger subjects the usual duration of diabetes is
from one to three years, the largest number of deaths
recorded being those in the second j^ear. It is not
uncommon to meet with cases, in subjects bej^ond mid-
dle age, which survive from five to ten years. Finally,
it must not be overlooked that cases are on record in
which the urine has been continuously saccharine for
over twenty years.

Owing to the somewhat irregular course of diabetes
and its susceptibility to modification by treatment, it is
impossible to assign a definite duration to any given
case.

Diagnosis, including Examination of Urine.^-The diag-
nosis of diabetes presents no difficulties, if attention be
directed to the urine. In typical cases, it is almost im-
possible for the pli3^sician either to overlook the disease
or to confound it with other conditions. Thirst, dryness,
of the mouth, polyuria, muscular weakness, and emacia-
tion are likely to lead to an examination of the urine
and the discovery of sugar. It is necessar}'^, as a matter
of accuracy, to observe the case for some time, in order
to ascertain if sugar be constantly or only occasionally
present in the urine, — thus to distinguish between dia-
betes and glycosuria. In less pronounced forms of the
disease, the presence of sugar in the urine may be over-
looked, owing to absence of such symptoms as are likely
to lead to an examination of the latter. The more rou-
tine practice of urinalysis now in vogue renders this
error less common than heretofore ; especially is this
the case in hospital practice.

As the diagnosis of diabetes hinges so largely upon

TO Diabetes Mellitus.

the examination of tlie urine, I will briefly review the
most practical features of testing the urine for sugar
which will best serve the convenience of the general
practitioner, without an attempt to include all the tests
for sugar which have been brought forward from time
to time, many of which I have found too complicated
and unsatisfactory for routine work.

Among the numerous qualitative tests for sugar in
the urine which have been brought forward to date, the
most popular, perhaps, has been that form of the copper
test known as Fehling's solution. The original formula
for this solution is as follows : Dissolve 34.639 grammes
of sulphate of copper in 200 grammes of distilled water ;
1*13 grammes of pure crystallized neutral sodic tartrate
are dissolved in 500 or 600 grammes solution of caustic
soda (specific gravity 1.12), and into this basic solution
the copper solution is poured, a little at a time. The
clear, mixed fluid is diluted to one litre. The above
solution is very unstable, so much so that it must be
freshly prepared in order to be depended upon. With
the view of rendering Feliling's solution more stable,
Schmiedeburg proposed substituting manuite for the
sodic tartrate, which I have found to answer the purpose
very well. The formula for the preparation of Fehling's
solution, improved as 1 am in the habit of using it, is as
follows : 34.639 grammes of pure copper sulphate are
dissolved in 200 grammes of distilled water, to which
are added 15 grammes of pure mannite ; 500 or 600
grammes of solution of caustic soda are added to the
first solution, little by little ; finall}'^ the whole is brought
with distilled water to the volume of 1 litre.

In applying this test, 1 drachm should be diluted with
an equal bulk of distilled water in a test-tube, and gently
boiled for a few seconds. If it remain clear, add the

Symptomatology. Yi

suspected urine, drop by drop, and if sugar be present
the first few drops will usually cause a yellow precipi-
tate. If no precipitate occur, continue dropping until
1 draclim — not more — of urine be added, re-appljdng the
heat occasionally. If no precipitate occur, sugar is —
clinicall}'^ speaking — absent.

As above prepared, Fehling's solution is entirely
stable, and will keep indefinitel3^ One drachm of the
solution responds to ^^ to yj^ grain of sugar.

Fro/. Haines^s Test. — On the whole, the most satisfac-
tory qualitative test for sugar in the urine, in my experi-
ence, is that prepared after the formula devised by Prof.
Walter S. Haines, of Chicago. Its construction is very
simple, as follows : Take of pure sulphate of copper, 30
grains ; pure water, ^ fluidounce ; make a perfect solu-
tion, and add pure glycerin,^ ounce ; mix thoroughly,
and add 5 ounces of liquor potassse. A perfectly-clear,
transparent, dark-blue liquid results, which, being per-
fectly stable, may be set aside indefinitely for use. In
testing with this solution, take about 1 fluidrachm of
the test, and gently boil, when no change should take
place ; now add 6 or 8 drops — not more — of the sus-
pected urine, and again boil. If sugar be present, an
abundant j'ellow or yellowish-red precipitate is thrown
down ; if no such precipitate appear, sugar is absent.
The white, flocculent deposit thrown down, when non-
saccharine urine is added, consists of the phosphates of
calcium and magnesium of the urine, which the alkaline
character of the test-liquid has precipitated, and it
should not be mistaken for an indication of the presence
of sugar.

The above test has given me most satisfactory quali-
tative results in daily work during a continued use of
six years. By comparative experimentation I find that

72 Diabetes Mellitus.

1 drachm of Professor Haines's test responds to t^I^
grain of grape-sugar.

It is well to bear in mind the fact that the copper
tests are liable occasionally — though in reality very
rarely — to lead to erroneous conclusions as to the pres-
ence of sugar in the urine. Certain normal constituents
of the urine — ^notably uric acid, urates, creatinin, mucus,
and pyrocatechin ; as well as certain occasional constitu-
ents, as oxybutyric acid, urochloralic acid, uroleucic acid,
and uroxanthic acid; as well as such drugs as tannin,
morphine, salicylic acid, carbolic acid, cubebs, etc. — pos-
sess more or less reducing power over the copper tests.
The normal elements of the urine possess, for the most
part, but feeble reducing powers over these tests, and
therefore the errors spoken of are actually encountered
but rarely. Nevertheless, since such errors are possible,
it is well, in cases of doubt, to appeal to such methods
as may be considered absolute. Fortunately, we have,
in the phenylhydrazin test, introduced by Fischer, one
that is entitled to be considered positive in its capa-
bility of detecting sugar.

The Phenylhydrazin Test. — This is best conducted
as follows : First, introduce in the bottom of an ordinary
test-tube a layer of phenylhydrazin — say ^ to ^ inch
in thickness ; upon tliis place another J to ^ inch of
pulverized sodium acetate ; next, add water to one-fourth
the capacity of the tube; and, lastly, add suflacient of
the suspected urine to half-fill the test-tube. Gradu-
ally bring the whole to the boiling-point, and boil for
about one minute, and then decant into a conical glass
vessel, and set aside to cool. In from three to twelve
hours take up a few drops of the sediment from the
bottom of the glass vessel with a pipette, and place
them under a microscope. If sugar be present in the

Symptomatology. 73

urine, very peculiar, yellow, acicular crystals will be
readily seen — phenylglucosazone — which are altogether
characteristic. They have a marked tendency to crys-
tallize in stellate or rosette form, or in bundles, like
sheaves of wheat.

The phenylglucosazone crystals ma}^ frequently be
seen in half an hour after the boiling ; but if none are
found after the test has stood twelve hours it may be
confidently stated that the urine is free from sugar.

So far as at present known, this test reacts only with
glucose, maltose, and lactose.

The above tests leave little, if anything, to be desired
in the way of qualitative analysis of urine for sugar.
Having once determined the presence of sugar in the
urine, it becomes all-important to know, with some degree
of accuracy, the quantit}^ thereof, in order to be able to
estimate the degree of severity of the disease, as well
as to gain some knowledge of its course from day to
day.

Now, most of the quantitative tests for sugar in the
urine, if, indeed, not all of them brought forward to
date, are either complicated, time-consuming, unstable,
or inaccurate, and therefore far from satisfactory for
practical purposes. The fermentation-test of Roberts
requires twent3^-four hours' time to reach results which
are by no means accurate when obtained. Fehling's
solution, perhaps the one most generally depended upon,
has been by no means satisfactory in my hands. In
view of these facts, I have constructed a formula for a
solution which, I trust, will prove as satisfactory in gen-
eral practice as it has in my laboratory work, where it
has answered all tliat could be desired.

The Author^s Quantitative Method. — The formula for
this test is as follows : —

4 D

T4 Diabetes Mel lit us.

U Cupric sulphate (pure), . . . 4.15 grammes.
Caustic potash, " . . .20.4 "

Strong ammonia (sp. gr. 0.9), . . 350 c. cm.

Pure glycerin, 50 "

Aquae destill., .... ad 1 litre.

The solution is prepared by dissolving the copper
sulphate in part of the water and adding the glycerin.
In another portion of the water dissove the caustic
potash. Mix the two solutions and add the ammonia.
Finally with distilled water bring the volume of the
whole to 1 litre and filter.

If it be desired to use the English weights and meas-
ures in preparing this test, the formula is as follows: —

R Pure sulphate of copper, . . . K drachm.

Caustic potash (pure), .... 2}^ drachms.

Strong ammonia, 5}4 Afi- ounces.

Pure glycerin, 6 fld. drachms.

Distilled water, ... to 1 pint.

The principle upon which the application of this test
depends is the fact that a definite quantity of the solu-
tion is reduced upon boiling with a definite quantit}^ of
grape-sugar, causing the complete disappearance of the
beautiful blue color, and leaving a perfectly clear and
colorless fluid as the result. Thus, 30 cubic centimetres
of this solution are reduced, upon boiling, by ^ grain of
grape-sugar.

The test should be applied as follows : Into a 4-
ounce glass flask pour 30 cubic centimetres (about f^j)
of the test-solution, to which should be added an equal
volume of distilled or soft water ^ and bring the whole
to the boiling-point over a spirit-lamp. A pipette, gradu-
ated in minims and holding not less than J drachm,
is now filled with the saccharine urine to be tested, and
while the solution is boiling the urine is slowly dis-
charged from the pipette, drop by drop, into the test-

Symptomatology. 75

solution, until the blue color completely vanishes and
leaves the solution perfectly colorless and clear. The
number of minims it takes to discharge the blue color
of the solution contain just J grain of sugar. By multi-
plying this number of minims until the product is 480,
the multiple thereof represents the number of quarter-
grains of sugar to the ounce, which, if divided by four,
gives the number of grains of sugar in each ounce of
the urine tested.

The accuracy of this test may be readily proved as
follows : Bring 30 cubic centimetres of the solution, in
an equal volume of distilled water, to the boiling-point
in a glass flask. Then fill the pipette with a solution of
grape-sugar of known strength in water (better still, in
urine), — say 8 grains to the ounce, — and, as the test-
solution is boiling, discharge the sugar solution from the
pipette into the boiling fluid, drop by drop, when it will
be seen that exactl}^ 15 minims of the sugar solution (or
urine) completely discharges the blue color : therefore,
15 minims of the solution contained \ grain of sugar,
— the exact proportion of a solution of the strength of
8 grains to the ounce.

In testing, the solution should be raised to the boil-
ing-point, and kept slowly boiling ; and the urine to be
tested should be slowly discharged from the pipette,
two or three seconds elapsing after each drop, until
the blue color begins to fade ; then the drops should be
added still more slowl}', about ten or twelve seconds
elapsing after each drop. By this means the precise
quantity of urine may be determined which completely
eliminates the blue color of the test-solution, and the
most accurate results are obtained.

It maj^ be noted after testing, that, upon cooling, the
test-solution slowly resumes its blue color, owing to

76 Diabetes Mellitus.

absorption of oxygen from the atmosphere and reform-
ing the blue protoxide of copper from the suboxide held
in solution by the ammonia.

B}'^ means of the above test the quantity of sugar in
a given sample of urine may be determined accurately
within five minutes ; the solution is entirely stable and
will keep indefinitely ; it is perfectly- cleanly and simple
in application ; no copper products cling to the utensils
or obscure the chemical reactions from view.*

Finally, this solution may be used in an ordinary
test-tube, and remarkably accurate results obtained
by attention to the following details : Measure accu-
rately 1 drachm of the test-solution in an ordinary test-
tube and raise it to the boiling-point over a spirit-
lamp. Dilute the urine to be tested with an equal
volume of water. With a minim pipette, or one the
point of which is suflSciently large to drop minims, dis-
charge the diluted urine, drop by drop, into the boiling
test-solution until the blue color is completely dis-
charged. If 1 minim of the diluted urine discharges
the blue color of the test, the urine contains 30 grains
of sugar to the ounce, or over. If it requires 2 drops
to discliarge the blue color, the urine contains between
15 and 30 grains to the ounce. If it takes 3 drops to
eliminate the blue, there are between 10 and 15 grains
of sugar to the ounce. If it requires 4 drops of the
diluted urine to reduce the blue color, there are between
1^ and 10 grains of sugar to the ounce. If 5 drops, there
are between 6 and T^ grains to the ounce. If 6 drops
are required, there are from 5 to 6 grains to the ounce.
If 8 drops are required, there are from 4 to 5 grains to

* All the copper tests here described are prepared for me and kept in
stock by Messrs. Gale & Blocki, 44 and 46 Monroe Street, from whom they
may be procured at any time.

Symptomatology. 77

the ounce. If 10 drops are required, there are from 3 to

4 grains to the ounce. If 15 drops are required, the
urine contains from 2 to 3 grains to the ounce ; but if
the bhie color fails to yield to 15 minims, the urine con-
tains less than 2 grains of sugar to the ounce. Thus,
the relations may be seen at a glance by the table
below : —

One Drachm of Test-solution.
If reduced by 1 minim of diluted urine, it contains over 30 grains to

1 ounce.
If reduced by 2 minims of diluted urine, it contains between 15 and 30

grains to 1 ounce.
If reduced by 3 minims of diluted urine, it contains between 10 and 15

grains to 1 ounce.
If reduced by 4 minims of diluted urine, it contains between 7}4 and 10

grains to 1 ounce.
If reduced by 5 minims of diluted urine, it contains between 6 and 7}4

grains to 1 ounce.
If reduced by 6 minims of diluted urine, it contains between 5 and 6

grains to 1 ounce.
If reduced by 8 minims of diluted urine, it contains between 4 and 5

grains to 1 ounce.
If reduced by 10 minims of diluted urine, it contains between 3 and 4

grains to 1 ounce.
If reduced by 15 minims of diluted urine, it contains between 2 and 3

grains to 1 ounce.

In making the above approximate analysis, the first

5 drops of urine should be slowlj^ added, about five
seconds elapsing after each drop, during which the solu-
tion should be gently boiled ; after 5 or 6 drops have
been added, the solution may be kept slowly boiling and
the urine added, drop by drop, continuously, but slowly,
until the blue color completel}^ fades, or till 15 minims
of the diluted urine be added.

The above tests seem to me all that are required for
practical purposes. Those who desire to make them-
selves acquainted with the other tests for sugar in the

78 Diabetes Mellitus.

nrine which have been brought forward are referred to
Dr. Tyson's excellent little hand-book on " Practical
Examination of Urine."

If, then, upon chemical examination of the nrine as
described, it be found that sugar is present to the extent
of 5 to 10 or more grains to the ounce, it is strongly
probable that the case is one of diabetes ; if repeated
examinations be made, extending over some time, with
the same result, the probabilit}^ becomes a certainty, and
the diagnosis of diabetes mellitus is complete.

Prognosis. — The prognosis in a given case of diabetes
depends upon a number of circumstances, the most im-
portant of which, perhaps, is the age of the patient.
Under 20 years of age the disease is ver^^ fatal ; indeed,
under such circumstances few recoveries are recorded.
From 20 to 45 years of age the outlook is more hopeful,
the disease being somewhat more amenable to treatment.
At the same time, it must not be overlooked that up to
45 3'ears of age diabetes is a very fatal disease, and
causes the death of the majority of those who become
the subjects of it.

After middle age — sa}^ after 50 — the outlook is de-
cidedly more favorable, as the disease then, for the most
part, assumes a mild course, and not unfrequently termi-
nates in recovery.

It may be laid down as a general rule that the danger
to life from diabetes is in inverse ratio to the age of the
patient, thus forming a prominent exception to the usual
rule of increasing mortality with increasing age, which
is the sequence in most diseases.

The cause of the disease influences the prognosis.
Thus, cases traceable to mental anxiety and overmental
toil are of more hopeful outlook, especially if the cause
be removable. When the disease arises from trauma-

Symptomatology. 7^

tisms the prognosis is generally more favorable. On the
other hand, as Lancereaux has pointed out, when the
disease is traceable to diseases of the pancreas, the prog-
nosis is especially gloomy. The length of time the dis-
ease has been in progress and the urgency of the S3^mp-
toms have an important bearing on the prognosis. Cases
in which the disease has become confirmed and the ema-
ciation pronounced give little encouragement or hope
for the future. On the other hand, if the disease be
discovered early, and but little inroads have been made
upon the flesh and strength, the general prognosis is
always more hopeful.

It is a somewhat remarkable fact, as bearing on the
prognosis, that diabetes in stout people is much less
serious than in spare people. The development of cata-
ract is usually regarded as very unfavorable in these
cases, indicating an early fatal termination. Such cases
are said to usually end in death within from six to twelve
months ; and, although some of them may survive longer,
they may be considered as essentiall}'' incurable cases.
Finally, absence of the patellar reflexes is believed to
prevail only in unfavorable cases.

Complications of tlie disease and intercurrent con-
ditions always render the prognosis grave, and this ap-
plies to the most trivial maladies as well as to the more
serious. Thus, it is not uncommon for some slight ail-
ment, such as a cold or diarrhoea, to precipitate the
more serious features of the disease which before
gave no occasion for immediate alarm. Such compli-
cations as gangrene, pulmonary tuberculosis, and es-
peciall}^ diabetic coma render the prognosis at once
unfavorable.

Lastly, the results of treatment enable one, in a
measure, to estimate the gravity of the case. Thus, if

80 Diabetes Mellitus.

the urine become free from sugar upon a restricted diet,
we are justified in forming a favorable prognosis ; while,
if the disease fail to yield to strict dietary measures, and
the urine continues heavily laden with sugar, the outlook
must be considered unfavorable.

SECTION YI.

TREATMENT.

Prophylactic measures are advisable for people of
diabetic parentage, or for those whose families present
marked tendencies to the disease. In such cases it is
wise to adopt a system of diet which limits the use of
starchy and saccharine foods to the most moderate pro-
portions. Occupations should be selected which entail
the least possible mental pressure and excitement; and,
if practicable, a residence should be chosen as near the
sea-level as possible, with a mean temperature range of
about 70° F. The observance of the above conditions
will insure the individual the best chances of avoiding
the disease.

The treatment of diabetes proper may be most sys-
tematically considered under three divisions, — dietetic,
medicinal, and h3^gienic.

General Dietetic Considerations. — Until future in-
vestigation shall have revealed some agency through
which we are able to check the excessive formation of
sugar in the liver, our chief resource against the disease
must consist in withholding from the system that which
it is capable of converting into sugar, and in supplying
that which it is capable of assimilating as nourishment.
The accomplishment of this object is the essential aim
of the dietetic treatment of diabetes.

Ph} siological chemistry as wxU as experience have
shown us that the chief source of sugar-production in
the system is the carboh3'drate foods, more especially
starches and sugar. In nearly all mild cases of diabetes,

4* (81)

82 Diabetes Mellitus.

and in most cases of recent origin, the avoidance of
these foods arrests the excretion of sugar, as well as the
more prominent symptoms of the disease.

It has just been stated that the chief source of sugar
in the organism is the carbohydrate foods ; but, unfor-
tunately, while they are the chief, they are not alwa3^s
the only, source. Experimental investigation has shown
tliat when animals are fed upon purely nitrogenous foods
— even for lengthy periods of time — a small amount of
glycogen still continues to be present in their livers. In
the graver forms of diabetes the " sugar-forming vice "
of the organism becomes so strong that the liver is
capable of splitting up a portion of the nitrogenous
foods, and probably even the albuminoids of the tissues,
and of transforming a part of these into sugar. In such
cases, while the dietetic treatment is able to modify the
excretion of sugar, as well as most of the symptoms, it
is not able to entirely arrest the progress of the disease.
Fortunately, such cases form a minority of those who
become subjects of the disease, and are in nearly all
cases very young people, or long-neglected and advanced
cases.

The sugar-forming powers of the organism in diabetes
are feeblest in their operation upon nitrogenous materials,
and therefore animal foods are the least susceptible of
conversion into sugar. Next in order rank the green
parts of certain vegetables, which quite strongly resist
sugar transformation. Finally, the starchy and sac-
charine members of the carbohydrate group are the
most easily transformed into sugar of all, and are there-
fore the most dangerous for use. Practically, then, the
more completely we are able to eliminate the starchy
and saccharine foods from the diet, the more completely
we are able to hold the disease under control. At first

Treatment. 83

sight this might seem to be a very simple matter ; but
when we come to furnish a diet-list that strictly con-
forms to the above principle, it will be found a most
difficult problem to solve, owing to the very wide
diffusion of starch and sugar throughout the organic
world.

It lias recently been claimed by Eickhorst, and
others, that an exclusively nitrogenous diet is damaging
to the organism in diabetes, and that the safer course is
to permit a variety of foods, which includes the carbo-
hydrates. Except in special cases, in which some organ
is crippled by organic disease, such as the kidney, there
is not a particle of evidence to support such assertion.
It is well known that wliole tribes of men live uninter-
ruptedly upon an exclusive meat diet, and enjoy the
most robust health, as well as a muscular and mental
vigor that will compare favorably with those who live
upon a mixed diet. Besides such examples upon a large
scale, it has been demonstrated in private practice and
experimental investigation, repeatedly, that a thoroughly
nourishing and sustaining diet can be furnished, exclusive
of the carbohydrates, upon which diabetic patients can
live, not only without damage, but with uniformly bene-
ficial results. In comparison with the damaging effects
of sugar in the circulation, which is sure to result
from the ingestion of starchy foods, the fancied damage
due to the exclusive use of animal diet sinks into in-
significance. We know that when the blood is charged
with large quantities of sugar, it not only gravely alters
the nutritive qualities of the former, but it is also liable
to induce chemico-toxic changes in that fluid, which are
dangerous to life. We know that the perverted elabora-
tion of food (chiefly the carbohydrates), the saturation
of the tissues with the resulting morbid products, and

84 Diabetes Mellitus,

the necessary efforts at their elimination, lead with cer-
tainty to altered nutrition, emaciation, wasting of the
vital forces of the economy, secondary disease of im-
portant organs, and, in short, to that complex of morbid
changes which in diabetes bring about exhaustion and
death.

First in importance ranks the question of bread in
the construction of any diabetic diet-list. The with-
drawal of this article from the list is usually the most
serious deprivation the patient has to encounter. In
consequence of this fact, an almost endless number
of breads have been placed upon the market, which are
claimed to be free, or nearly free, from starch, and are
hence named diabetic breads. Now, I do not hesitate to
say that most breads which have been put upon the
market with such claims are " a snare and a delusion,"
and have unquestionably shortened the lives of hundreds
of diabetic patients. Most samples of so-called "diabetic
flour," from which the starch is claimed to have been
eliminated, "or nearly so," contain from 30 to TO per
cent, of that article. Some time ago I became very
skeptical of these preparations, in consequence of find-
ing, upon analysis of a sample coming from a prominent
firm, that it contained about 60 per cent, of starch.
But Dr. Chas. Harrington, of Boston, has rendered us
under perpetual obligations to him for fearlesslj^ ex-
posing the most of these deceptions, by publishing a
careful analysis of most of them in detail. It may first
be noted that his analysis of home-made bread gives the
proportion of contained starch as 44.99 per cent. The
Graham wafer, made of Graham flour, contains 68.45
per cent, of starch. The gluten flour, of Farwell &
Rhines, of Watertown, N. Y., contains 67.17 per cent,
of starch. The special diabetic foods of these makers

Treatment. 85

contain 68.18 per cent, of starch; and the bread made
of this flour would contain 36 per cent, thereof. The
gluten flour of the New York Health Food Company
contains 66.18 per cent, of starch. Bread made of this
flour would contain 35 per cent, of starch. The gluten
wafers of the same company contain 66.96 per cent, of
starch. Dr. Johnson's *' Educators," a biscuit said by
the seller to be " absolutely free from starch," contain
of the latter 11.42 per cent. The Boston Health Food
Company's diabetic flour, No. 1, sold as absolutely
non-starchy, contains 62.94 per cent, of starch. Bread
made of this flour would contain 30 per cent, of starch.
In view of the above facts, there seems but one
course to pursue with reference to bread if we expect to
cure our diabetic patients, and that is to limit or curtail
its use in all forms. By simply reducing the ordinary
allowance of common bread to one-half the daily amount,
we have it in our power still to furnish bread to the pa-
tient which gives him a less quantity of starch than
does the use ad libitum of most diabetic foods in the
market. After varied and laborious experiments with
substitutes for bread, I have found the following method
the most satisfactory : Permit the patient to use his own
regular table-bread, but limit the allowance to one-half
the usual daily use. If sugar still appear in his urine,
reduce the allowance to one-quarter the ordinary amount.
If sugar still appear in his urine, curtail the use of
bread completely. The advantages of this method are
that we know, with some degree of certainty, the amount
of starch that the patient is getting in his bread-supply.
The article supplied is, at least, digestible, which is
more than can be said of most of the substitutes. In
my experience, if the patient cannot assimilate one-half
to one-quarter the usual amount of ordinary bread —

86 Diabetes Mellitus,

2 to 3 ounces daily — without excreting sugar in the
urine, he cannot assimilate any substitute therefor,
and, under such circumstances, the sooner all bread is
stricken from his diet-list the better. When bread is
permitted it should be as fresh as possible, and it is
better cut in thin slices and well toasted on both sides.
The daily allowance of bread will be better assimilated
by diabetic patients if taken but twice a day, — at the
morning and evening meals; the long intervals between
its introduction into the stomach insure its more thor-
ough disposal in the normal way.

Of the other foods derivable from the vegetable king-
dom, the cereals and seme of the tubers are the most
dangerous. Potatoes, beets, parsnips, carrots, among
the latter; and, of the former, rice, sago, oatmeal,
cornmeal, buckwheat, rye, barley, peas, and beans,
should be prohibited without compromise in most, if
not in all, cases. In the strict form of dieting we are
obliged to avoid the whole list. In cases of moderate
severity we may, however, draw upon one class of
vegetables — greens. Green vegetables consist mostly
of cellulose, and contain little, sometimes almost no,
starch. They are rendered still less objectionable if
boiled before being eaten, as the hot water dissolves out
much of the remaining starch and sugar. The starch
and sugar contents of vegetables vary considerably,
according to the degree of cultivation and the nature of
the soil and climate in which the}^ are grown. As a rule,
a high degree of domestic cultivation favors an increase
of the starch and sugar, while high temperature and
sunny skies have an opposite tendency. Among the
least objectionable vegetables may be mentioned lettuce,
cucumbers, olives, mushrooms, brussells-sprouts, cab-
bage, spinach, and water-cresses.

Treatment. 87

Sojaj or Japanese bean, owing to its high nutritive
properties and its low percentage of starch, is likely to
enter largely into the diabetic diet of the future. It has
recently been much cultivated in some parts of Europe,
especially in Hungar3\ Its composition is as follows :
Nitrogen, 36.6 per cent.; fatty matter, 17 per cent.;
starchy matter, 6.4 per cent.

A sauce is made from soja which bears the name of
stiso and soju. A kind of cheese is made from it, and
very much prized in Japan as a table-luxury.*

In Europe the soja has already been utilized for food
of men and animals, and recently the attempt has been
made to make bread of it. This is very difficult because
of the large proportion of oil which it contains. This
oil is very purgative, and hence it becomes necessary to
rid the meal of it in order to render it fit for domestic
usages. Lecerf in Paris and Bourdin in Rheims have
succeeded in rendering the bread made from this meal
very well supported by the stomach.

This bean, which, as the analysis shows, is more nu-
tritive than meat, serves for nourishment to a great
country like Japan, under the forms of sauce, of cheese,
of farina, and even of real artificial milk.f

Most nuts except chestnuts may be permitted, the
list including almonds, walnuts, Brazil nuts, filberts,
butternuts, and cocoanuts.

Great differences prevail in practice with regard to
the use of fruits in diabetic conditions, some authorities
allowing them freel}', while others curtail them. Some
fruits, such as apples and strawberries, really contain
very little sugar, and in the case of apples the sugar is

* See article of Egasse, on Economic and Therapeutic Applications o|
Soja, in RuUetin de Therapeutique, vol. cxv, p. 133.
t Therapeutic Gazette, March 15, 1890, p. 150.

88 Diabetes Mellitus,

in such form that it is often well assimilated by diabetics.
The truth is that it is more difficult to make a rule
which will apply universally with regard to the use of
fruits than with any other class of foods in these cases ;
and therefore it must to some extent be a matter of
experiment in each individual case. It may be stated,
however, in a general way, that mild cases will bear a
moderate use of such fruits as apples, tomatoes, and
strawberries ; but in severe cases it is best to prohibit
their use without exception.

With regard to foods of animal origin, fortunately
but three articles are open to question as appropriate
for use, viz., honey, liver, and milk. The first of these
requires no comment further than to say that its highly-
saccharine composition excludes it without exception
from use in all cases. Liver contains a varying per-
centage of sugar, besides large quantities of glycogen,
which is readily convertible into sugar, and therefore it
is objectionable in strict dieting. Oysters must be in-
cluded in this restriction, owing to their proportionately
enormous livers.

With regard to the proprietj' of the use of milk,
authorities differ very greatly. Dr. Donkin, the most
enthusiastic advocate in its favor, published a book in
London, in 1871, upon the exclusive use of skim-milk as
a cure for both diabetes and Bright's disease, and since
then the " milk cure " has attracted considerable atten-
tion. Dr. Donkin's method of treating diabetes by a
milk diet, however, has met with but feeble indorsement
by his own countrymen, most of whom either limit or
exclude it from use. On the other hand. Dr. Tyson, of
Philadelphia, whose experience has been very large in
these cases, very strongly indorses the milk cure. My
own experience with the use of milk in the treatment of

Treatment. 80

diabetes began nine years ago, since whicli time I have
made thorough and varied trials of it. My conclusions
are that a milk diet is successful, chiefly, in milder forms
of the disease. Such cases are, as a rule, controlable by
moderate limitations of diet, which ofl'er a greater range
and nutritive power than does milk. I believe that the
milk treatment, therefore, finds its most appropriate
range of application in cases of children, and those cases
which are complicated by renal lesions — albuminuria.

I have searched in vain, among the published cases
which Dr. Donkin has treated by skim-milk diet, for a
single record of cure ; nor have I found any result that
could be called at all remarkable, as compared with those
treated by an animal diet. Dr. Donkin's " Case I, J. G.,
complete recover}^," so called, must be considered the
best result obtained. This was a case in which, upon
skim-milk diet, the urine became free from sugar, and so
remained thirteen months ; but here the record ends
without the patient ever having returned to a mixed
diet, save the addition of meat. Now, when we consider
that J. G. was " a large, robust man, 58 j^ears of age," we
would at once expect that a ver}^ moderate restriction of
carbohydrate foods would eliminate the sugar from his
urine. Certainly, as a rule, we can readily eliminate the
sugar from the urine, in cases of that age and type, by very
moderate restrictions of diet. Dr. Donkin's young dia-
betic patients, according to his own records, without
exception, ultimately died from sometj'pical complication
of the disease, as pneumonia, phthisis, or bronchitis, — as
did his cases III, lY, and YI ; and moreover, as a rule,
they continued to excrete more or less sugar with their
urine, although he speaks of these cases as examples of
" rapid and complete recovery," " immediate relief and
arrest of the disease," etc.

90 Diabetes Mellitus.

The facts appear to be, with regard to milk, that it
acts by reducing — not curtailing — the sugar-convertible
food. Milk contains about ^ ounce to each pint of lac-
tine (milk-sugar), an animal hj'drocarbon, which I do not
doubt, as Dr. Pavy sa^'s,*' comports itself in the intestinal
canal precisely as does grape-sugar." It has been claimed
that lactine is changed in the stomach into lactic acid,
and thus escapes sugar transformation ; but the fallacy
of this doctrine may be readily proved by administering
lactine to patients aifected with pronounced diabetes,
when without exception it will be found to quickly in-
crease the excretion of sugar by the kidneys. The oft-
repeated statement that milk-sugar is well assimilated by
diabetics, in my experience, only holds true in mild cases.
In the more severe tj^pe of the disease an exclusive or
even adjunct diet of milk has invariably been attended
by unsatisfactory results.

In the matter of beverages, I am satisfied that dia-
betic patients are usually permitted greater liberties
than is good for them ; indeed, I do not doubt that the
excessive use of the highly-saccharine wines often has
much to do in bringing on the disease.

Until very recently, when I took the pains to analyze
most of the beverages in domestic use, I was in the
habit of permitting the usual stereotyped list. I find,
however, that many of them which are usuall}^ allowed
contain very considerable amounts of sugar, and I now
exclude them from use, with perceptivel}^ good results
to my patients. Thus, coffee is permitted in all the
diabetic diet-lists I have seen, and 3^et the best grades of
Java and Mocha contain at least 10 per cent, of sugar.
B}^ taking ^ ounce of Java coffee commonly sold in
the markets, and with a cup of boiling water I have
made the usual cup of coffee in domestic use. Analysis

Treatment. 91

of this cup of coffee demonstrated that it contained 1.5
per cent, of sugar — about tj grains to the fluidounce.
Analysis of Mocha gave closely corresponding results.
With regard to alcoholic beverages, it is doubtful if
their temperate use is harmful to diabetic patients, pro-
vided they be free from sugar. The importance, how-
ever, of the last-named point cannot be too strongly
insisted upon, and, since I have carefully analyzed most
of the list, the following results are subjoined as a guide
in practice :—

Sugar Contents of Leading Alcoholic Beverages, According
TO the Author's Analysis.

native AMERICAN WINES.

■rr -nwT ^ ,-., ^ -..^ . CONTEXTS OF SUGAR

Ja. W. Crabb's California. in each fl. ounce.

Chablis, 1 grain.

Rislings, 1 "

Sauterae, 1.3 grains.

Old Grape-Brandy, 4 **

Burgundy, 3-4 "

Cabernet, ^

Medoc, > Clarets, 2-3 "

Beclan, )

Sherry, Old Dry, 10 "

Marsala, 10 "

Madeira, 24 "

Port, Old, 34 "

Tokay, 48 "

Muscatel, 80 "

Malaga, 40 "

Angelica, 50 *'

Steuben County Wine Co.'s Wines.

New York Catawba, 1 grain.

Ohio Catawba, 1 "

Ohio Delaware, 3 grains.

Norton's Virginia Seedlings, .... 4-5 "

Burgundy, 5-6 "

Extra Family Claret, 3-4 ''

Walters' Sherry, Dry, 8 "

P. J. Port, Dry, 24 "

Gold Cross Champagne, . . . . , 30 "

Diabetes Mellitus.

CONTENTS OF SUGAR
IN EACH FL. OUNCE.

IMPORTED WINES.

Port, Oporto, 30 grains.

Sherry, Vino de Pasto, 12 "

Malaga, 140 "

Madeira, 45 "

St. Julien, 2-3 "

Pontet Canet, 4-5 "

Chateau Larose, 4-5 "

Budai Imperial* (L. Reich, N. T.), . . . None.
Diatetischer Rothweiu* (Schreiber's), . , "

Rhine and Moselle Wines.

Deinheimer, 1 grain.

Niersteiner,

Geisenheimer,

Gardens,

Laubenheimer,

Liebfraumilch,

Marcobruner,

Johannisberger, . 1.5 grains.

grains.

Sauternes.

Graves, 12

Haut Sauternes, 10

Sauternes, 20 "

Barsac, 17 "

Burgundy Wines.

Beaujolais, ........ 4-5 grains.

Chambertin, . . . 4-5 "

Pommard, 5-5.5 **

Champagnes.

Pomery See, 30 grains.

G. H. Mum's Extra Dry, 30 "

Veuve Clicquot, 30 "

Ruinart, Extra Dry, 12 "

Ruinart, Brftt, 10 "

Moet & Chandon's Imperial BrM, ... 15 *'

Piper Heidsieck, Sec, 30 "

Roederer, Carte Blanche, 48 "

Monopole Club, Dry, 20 "

* The Budai Imperial of L. Reich, New York, and the Diatetischer

Rothweiu of Loeb & Co., 55 Warren Street, N. Y., are the only wines I
have found absolutely free from sugar in the market.

Treatment.

CONTENTS OP SUGAR

IN EACH FL. OUNCE.

DrpMonopole, ....... 30 grains.

Delbeck, Extra Dry, .

. 8 "

Delbeck, Brftt,

. 10 "

Perier Jou6t, Special, .

. 34 "

Jules Mum's Grand Sec,

. 40 "

SPIRITS.

Jamaica Rum, ....

7.5 grains.

St. Croix Rum, .

. None.

Medford Rum,

Gin, Old Tom, .

Gin, Holland,

((

Brandy, Hennesy,

2.5 grains.

Brandy, Reno,

4 "

Whisky, Scotch, .

None.

Whisky, Bourbon,

({

Whisky, Rye,

Whisky, Irish, .

((

Arrack,

((

Tequila (Mexican), .

24 grains.

BEEBS, ALES, AND POBTEBS.

domestic Beers.

Schlitz's Pilsener, 4 grains.

Schlitz's Extra Pale, 4 "

Schlitz's Export, 4 "

Schlitz's Porter, 7.5 "

Blatz's Export Beer, 4 "

PabstBeer, 5 "

Schoenhofen Beer, 4.6 "

U. S. Brewing Co.'s Beer, 5 "

Imported Beers.

Pilsener, Light, . 3 grains.

Erlanger, Dark, 6 *'

Liebotschaner (Bohemian beer), . . . .2 *♦

Capuziner, , , 4 "

Augustiner, 6 "

Wurzburger, 5 "

Culmbacher, 6 "

Tivoli, 5 "

Budweiser, 5.8 "

Kaiser, 2 "

94 Diabetes Mellitus.

Alp,, CONTENTS OP SUGAR

"^''^*' IN EACH FL. OUNCE.

Bass, 2 grains.

AUsop's, 2.5 "

Dow's, ......... 3 "

Porter.
Guinuess's stout, 6 grains.

It will be seen, from an examination of the foregoing
list of alcoholics, that, of the wines, the Rhine and Mo-
selle type is the most suitable for the use of diabetic
patients on account of the very low percentage of sugar
which they contain, — only 1 to 1.5 grains to the fluid-
ounce. Special attention is called to the fact that a
number of native American wines of this type — notably
Chablis and Rislings of California, and the catawbas of
New York and Ohio — are nowise inferior in this respect
to the very best brands of imported wines ; indeed, they
are considerably superior to some of the most expensive
Rhine wines, such, for instance, as Johannisberger. For
the plethoric diabetic patient, therefore, the American
wines just named may be considered very suitable. On
the other hand, in the spare and anaemic class of patients
a red wine is more suitable, and in this class no wines
approach the Budai Imperial and Diatetischer Roth-
wein, since they are probably the only clarets in our
market that are free from sugar.

Of the various spirits, rum should be avoided, as
probably most brands contain more or less cane-sugar,
and in the case of Jamaica rum a very considerable per-
centage of grape-sugar is also present. Brandy contains
a varying amount of sugar, as usually found in the
markets, ordinarily from 2 to 5 grains to the ounce. It
should therefore be used but sparingly. Whiskies are
free from sugar.

With regard to beer, ale, etc., the grape-sugar added

Treatment. 95

in mannfacture for fermentative purposes is never thor-
oughly removed by the latter process. Bass's pale ale
and the pale Bavarian beers contain the least amount of
sugar of this class — about 2 grains to the ounce. The
quantity of these beverages usually drunk quite makes
up for the quality, and therefore, on the whole, they are
best used but sparingly by diabetic patients, or alto-
gether avoided.

Champagnes, sauternes, and sweet wines — either
native or imported — are altogether unsuitable for the
use of diabetic patients, as will be readily seen upon ex-
amination of the list.

All mineral waters are permissible as beverages, and
some of them are curative, especially the alkaline waters.

Among the American waters, those of Waukesha,
and especially the Bethesda Spring, stand at the head of
the list. The best results are derived from these waters
by drinking them at the springs for a few weeks, where
I have invariably found them to be beneficial to diabetic
patients. The Saratoga Yichy is also an excellent water ;
its alkalinity renders it especially suitable in these cases.
Finally, the Idaho Springs, near Denver, especially the
Bath Spring, deserves mention as approaching closely
in composition the Carlsbad waters in Bohemia, though
of somewhat lower temperature.* With such excellent
and appropriate waters at home, it seems not only foolish
but hazardous that so many of our countrymen should
undertake the risks, inconveniences, and expense of long
pilgrimages to European springs, for it is well known
that such long, fatiguing journeys are peculiarly dan-
gerous to diabetic patients.

Having, in a general way, reviewed the leading

* Unfortunately, the liigh altitude of the Idaho Springs renders that
location unsuitable for lengthy visits by diabetic patients.

96 Diabetes Mellitus.

features of the dietetics of the disease, a list of appro-
priate foods is here appended as a more minute guide,
followed hy a list of those which should be prohibited.

Foods Pepmitted. — Meats of all kinds except livers, —
beef, mutton, pork, poultry, game ; either fresh, roasted,
broiled, dried, smoked, cured, potted, or prepared in any
way except with sugar, flour, or prohibited vegetables.
Soups made from meats without flour and excluded vege-
tables. Fish of all kinds except oysters and the inner
parts of crabs and lobsters. Eggs, butter, cheese, and
oils. Jellies made from Cox's gelatin, unsweetened ex-
cept with saccharin. Spinach, lettuce, olives, cucumbers,
summer cabbage, mushrooms, brussells-sprouts, and
water-cress. Almonds, filberts, walnuts, cocoanuts, and
Brazil nuts.

Beverages. — Water, including all mineral waters,
Rhine wine, California Rislings and Chablis, New York
and Ohio catawbas, Budai Imperial, Schreiber's " dietetic
wine," whisky, and gin.

Foods Prohibited. — Common bread, except as speci-
fied below ; biscuits, crackers, and cakes. Farinaceous
articles, such as potatoes, rice, sago, tapioca, macaroni,
vermacelli, common flour, oatmeal, cornmeal, buckwheat-
flour, barley-meal. The liver of all animals, oysters, and
sugar. Saccharine vegetables, as turnips, carrots, pars-
nips, peas, beans, beets, onions, and rhubarb. Blanched
vegetables, as celery, seakale, endive, radishes, and all
roots, fruits, and chestnuts.

Beverages. — Tea, coffee, milk, whey, buttermilk,
skimmed milk, chocolate, cocoa, malt liquors, cider,
champagne, sauternes, sherry, port wine, Madeira, and
all sweet wines and liquors.

The discovery of saccharin has furnished us a sub-
stitute for sugar which has a sweetening power of nearly

Treatment. 9T

three hundred times greater than the latter. The tablet
form in which saccharin is now put up is very convenient
for sweetening beverages. My patients have usually
found that food and beverages flavored with saccharin,
if not oversweetened, are quite as agreeable and pleasant
as when flavored with sugar.

Systematic Method of Dieting. — A systematic method
of dieting diabetic patients is of no less importance than
the quality of the diet emplo3'ed. In order to determine
accurately the effects of certain foods upon the disease,
no specific medication should be employed until the
sugar excretion is reduced as far as possible by diet
alone. This method enables the physician to distinguish
how far improvement is due to diet and how far to the
medication, the practical importance of which will be
readily perceived.

When a case first comes under observation, it is a
useful plan to permit the patient to eat and drink what-
ever he chooses for the first twenty-four or forty-eight
hours, in order to gauge the character of the disease.
At the end of that time careful note should be taken of
the quantity and specific gravity of the urine, as well as
the percentage of sugar. In beginning treatment, an
abrupt change to a strict diabetic diet would carry with
it more or less danger, and therefore such course is not
advisable, but rather a gradual change should be brought
about. Step by step the more objectionable foods
sliould be limited or cut off" until sugar ceases to appear
in the urine, or until we reach an exclusivel}'' animal diet.

The first step should consist in excluding the use of
potatoes, sugar, and farinaceous foods, and reducing the
bread-allowance to one-half the usual amount eaten b}'' the
patient — 3J to 4 ounces daily. With these restrictions
the patient may continue without other changes for about

5 E

98 Diabetes 31ellitus,

two weeks. In the milder cases this " first step " in diet-
ing will have caused a reduction of the sugar in the urine
to relatively small proportions ; indeed, in many cases it
will disappear. If, however, at the end of two weeks
sugar still appear in the urine under close observance of
the above restrictions, we may know that the disease is
at least of fairly severe type, and we should proceed to
the next step in dieting. This should consist in the ex-
clusion of milk and all vegetables except the green ones
enumerated in the permissible list. Greater care should
be exercised in the use of bread ; not more than one small
slice should be permitted at the morning and evening
meals, — 2 ounces daily. Perhaps one apple a day, if not
sweet, may be allowed ; one tomato, or, in place of the
latter, a few strawberries. The urine should be examined
from time to time, and if sugar does not disappear the
restrictions should be increased until the patient is living
upon meats, a few greens, and some nuts, and but 1
ounce of bread daily, with water and the permissible
alcoholics as beverages.*

After three or four weeks' adherence to the above
restrictions, if sugar still appear in the urine, we may
be sure that we have to deal with the disease in its most
severe type, and, accordingly, we must bring to bear
against it all our resources of diet in the strictest form.
Everything containing starch or sugar that can be
avoided should be strictly prohibited; in short, the
patient should be reduced to an absolute animal diet.
Meats, gelatin, eggs, and fish should constitute exclu-
sively the food, while water and a little spirits should be
the limit of beverages.

It will be found that a strictly animal diet will often

* It will be found that a slice of freshly-inade table-bread % inch
thick and 3 inches in diameter, if nearly circular, will weigh about 1 ounce.

Treatment. 99

remove the last traces of sugar from the urine ; and after
continuing it for a few weeks or months, a reversion to
some of the less objectionable articles of the vegetable
order will cause no re-appearance of sugar in the urine.

It must not be supposed that it is always an easy
matter to place patients upon an absolute animal diet.
Aside from the difficulties of securing the thorough
accord and assistance of the patient, those especially
with weak digestive powers frequently suffer from gas-
tric disturbances and diarrhoea. When such compli-
cations arise the diet must be relaxed a little, and the
patient should be brought more gradually under restric-
tions. Time and patience will, in the majority of cases,
overcome all obstacles. I once labored with a young
diabetic patient for about four months in accustoming
his stomach to an animal diet, upon which he now lives
in perfect contentment and excellent health, with his
urine free from sugar, now considerably over a 3'ear.

In accustoming patients to a diabetic diet, care
should be exercised not to permit the stomach to be
overloaded with food, light meals being the better rule
to follow. The beneficial effects of temperate eating in
diabetes were prominently illustrated during the siege
of Paris, as Bouchard tells us that sugar entirely dis-
appeared from the urine of diabetics in whom up to that
time it had persisted, even though they had been living
on a carefully-regulated diet. The diminution in the
quantity of food, occasioned by its great scarcity during
the siege, effected that which alteration in quality had
failed to accomplish.

In stout, overnourished diabetics of middle age and
over, the disease often yields completeh^ to habits of
moderate or spare eating. The disease in such cases is
doubtless brought about by overeating, for, as a rule,

100 Diabetes Mellitus.

such patients are large eaters. If in these cases the
amount of food be reduced to a limit which the S3'stem
can appropriate, without even altering the qualit}^ there-
of, the disease will pass away ; and, moreover, if habits
of temperance in eating and drinking be continued, the
cure will usually be permanent.

About two years ago a patient withdrew from my
care because I did not give him medicine to remove
the sugar from his urine. The percentage of sugar in
his urine was small, and was due to intemperate habits
of eating and drinking, which he could not be induced to
correct. It was no uncommon occurrence for him to
eat all the luxuries and delicacies within the range of a
well-appointed table, and to imbibe therewith a quart
or two of champagne, and finally to finish the day
with a plebeian potation of eight or ten glasses of lager
beer. He has since made one or two trips to Carlsbad,
but without essentially altering his habits, and it is
needless to add that he still has his diabetes. Like too
man}^ wealthy men, he evidently lives up to the belief
that his mone3^ should procure him not only all the
luxuries of life, but also exemption from the ills of
" the world, the flesh, and the devil."

With regard to the use of water b}^ diabetics, I have
usually placed no limit upon the quantit3^ allowed, per-
mitting the patient to follow his own inclinations in this
respect, only stipulating that it should not be drunk
ice cold. The increased thirst of diabetics points to
dehydration of the blood and tissues, and it is more than
probable that the liberal use of water serves a useful
purpose in taking up and carrying sugar from the S3'steni,
which might otherwise accumulate suflficiently to give
rise to serious consequences.

The dietetic treatment of diabetes has been dwelt

Treatment. 101

upon at considerable length because, with our present
knowledge, it undoubtedly holds the key to the most
successful management of the disease. In concluding
this review of dietetics, the importance of at first sepa-
rating this from the medicinal treatment cannot again be
too strongly insisted upon, since, as already shown, when
a system of diet and medication are employed simultane-
ously from the beginning, it is impossible to estimate,
with any degree of accuracy, the beneficial effects of
either the one or the other. When we have accomplished
all that seems possible with the aid of diet, if sugar
still remain in the urine, then^ and only then, should we
have recourse to drugs, unless it be to combat special
symptoms.

Medicinal Treatment. — It remains next to speak of
the medicinal treatment of diabetes, and, of the extended
list of drugs which have been from time to time extolled
for their curative powers over the disease, only those
will be considered which have met with suflficient indorse-
ment to entitle them to notice.

Opium. — Considering the decided nervous element
in the causation of diabetes, it would natnrall}' be ex-
pected that nervous sedatives would have some con-
trolling influence over the disease. To some extent
these anticipations have been realized, since opium, as
the representative of this class of drugs, tends to re-
strain the excretion of sugar; indeed, of the various
drugs that have been recommended, opium maintains its
reputation best. To be eflTective, opium must be em-
ployed in full doses, and therefore it is fortunate that
diabetic patients, as a rule, are remarkably tolerant of
the drug.

The indications for the employment of opium are a
continued high percentage of sugar in the urine, which

102 Diabetes Mellitus.

fails to yield to strict dietetic measures. In such cases
it may be administered in gradually increasing doses
until the sugar disappears from the urine, or until no
further reduction in the percentage of sugar seems to be
obtainable. As to the method of administration, I be-
lieve Dr. Ralfe's practice, of giving one sufficient daily
dose at bed-time, to be the most useful. This is least
likely to disturb the digestion, or to cause the patient
headache and other dis1;urbances. Of the various prep-
arations of opium, codeine is probabl}^ the most useful,
as it is less likely to induce constipation than the crude
drug, and, moreover, it is much better borne b}^ the
stomach. The dose, to begin with, should be :J to |-
grain, which may be gradually increased to from 5 to 15
grains per da}^ Morphine, or, better still, the bimeco-
nate of morphine, may be employed if codeine be not
obtainable.

It must not be forgotten, however, that in opium we
have an agent capable of doing much harm if recklessly
emploj'ed. Its prolonged use is liable to induce the
opium habit, and, although the danger of the latter is
said to be diminished in diabetics, it is still a danger
which no condition confers complete immunity from;
and this applies both to opium and its preparations.
The dose required to control the excretion of sugar is
usually so large that, sooner or later, in my experience,
the druof has to be abandoned on account of its damas;-
ing effects upon nutrition. Tlie exceptions to this rule,
I am satisfied, are so few that the opium treatment
should be reserved, for the most part, for failures by
other methods.

Antipyrin. — Somewhat allied to opium may be classed
the recently introduced agents of the phenol and aromatic
series,-— antipyrin, phenacetiu, salol, acetaniiid, exalgin,

Treatment. 103

etc. Antipyriii, the most powerful and most popular of
these, has been heralded as almost a specific for diabetes.
Like so many alleged specifics for diabetes in the past,
it is likely to enjoy a season of popularity and then
pass into merited oblivion. The first case that I treated
with antipyrin was one of typical severity, in a young
subject in whom careful dieting had kept the urine down
to an average of 4 pints daily, and a varying percentage
of sugar of from 2 to 5 grains to the ounce for many
months. All restrictions of diet were thrown off", and
the patient was put upon 45 grains of antipyrin a day.
The quantity of urine and tlie percentage of sugar
steadily increased from the beginning. At the end of
ten days the sugar had reached about 15 grains to the
ounce, and three daj^s later the patient passed into typi-
cal diabetic coma and rapidly succumbed.

The second case was quite as typical, although in an
older subject. The sugar had been reduced to 1 per
cent, or under by careful dieting for two years. Die-
tetic restrictions were only partly relaxed, and under 45
grains of antipyrin a da}^ the quantity of sugar doubled,
as did also the volume of urine, by the end of one week.
The third case was one of glycosuria, in which, upon a
strict diet, the urine was usually free from sugar. Upon
relaxation of diet rules, sugar appeared in the urine to
the extent of 2 or 3 grains to the ounce, which antip3a'in
failed to eliminate at tlie end of a week.

Antipyrin is unsuitable for lengthy periods of ad-
ministration in doses of 45 grains per day, and in smaller
doses it is not claimed to modify the disease. Moreover,
it is liable to cause albuminuria, and therefore it cannot
be considered a safe agent for use in these cases.

The bromides have long been used in the treatment
of diabetes. They are excellent remedies for many ner-

104 Diabetes Mellitus.

vous conditions which so often accompany the disease;
but I have never been able to trace any reduction of
sugar in the urine to their use. It is possible, however,
that they may indirectly contribute toward a lessened
degree of sugar excretion by inducing a more tranquil
nervous state. The bromides of sodium and lithium are
preferable to the potassium salt, being more acceptable
to the stomach. The bromide of sodium is given in 15-
to 20-grain doses, and the lithium salt in 5-grain doses,
well diluted, and the dose may be repeated several times
a day.

Ergot has enjoyed a popularity in the treatment of
diabetes second only to that of opium, and probably
not without some slight merit. Its vaso-constrictor
action upon the portal circulation doubtless accounts for
its beneficial effects in these cases. Its controlling
power over typical diabetes, however, is feeble ; but in
mild cases it often sensibly diminishes the sugar excre-
tion. Ergot is, therefore, best suited to mild cases, and
especially those in which the patient has good digestive
powers. The drug is best administered in the form of
ergotine, or the fluid extract of ergot prepared by
Squibb. The latter may be given in ^-drachm doses,
gradually increased according to the tolerance of the
I stomach.

Arsenic has long been used in the treatment of
diabetes. Its use was first suggested from the fact
noted by Salkowsky, that when animals were given
large doses of arsenic, glycogen greatly diminished in
their livers. More recently bromide of arsenic has
been strongly recommended in doses of -^^ grain, which
may be increased to -^^ grain, or more, if no toxic
symptoms are observed. There are two standard solu-
tions of bromide of arsenic in the market, — Giliford's,

Treatment. 105

of which the dose is 10 drops to begin with, which may
be increased to 20 drops, or over ; and Clemen's solu-
tion, which is considerably stronger, and the dose of
the latter, to begin with, should not be over 5 drops.
A few 3'^ears ago it was thought that bromide of arsenic
promised brilliant results in diabetes, but it must be
confessed that it has disappointed expectations. In one
of my cases Giliford's solution was given for a long
time, in 25-drop doses three times a day, but during all
this time the patient continued to excrete urine that
contained 30 grains of sugar to tlie ounce. Upon witli-
drawing the bromide of arsenic, and placing the patient
upon a restricted diet, I had the satisfaction of seeing
the sugar speedily reduced to 2 or 3 grains to the ounce.
I have given the bromide of arsenic treatment a thorough
trial, in at least 10 or 12 other cases, without obtaining
any result which could be called satisfactory ; certainly,
it has not materially lowered the percentage of sugar in
the urine. In conjunction with lithium, as suggested
by Rouget, arsenic has attained some popularity, being
especially lauded hy Martineau, who claims to have
cured 67 out of 70 cases of diabetes by this treatment.
In other hands, however, this treatment has not been
attended by appreciable benefit ; at least, such is the
report from Bordeaux, where opportunities for trying
it on a large scale have been carried out. The chief
benefits I have obtained from the use of arsenical prep-
arations in diabetes have been from arsenite of iron,
in cases complicated by anaemia or malaria. In such
cases I often employ the latter, in pill form, beginning
with jV gr^iiij ^"d gradually increasing the dose to ^
or \ grain.

Iodoform was recommended by Moleschott, about
ten years since, as a remedy for diabetes. Since then

106 Diabetes Mellitus.

it has been used considerably, and with somewliat
favorable results, seeming to cause a diminution of
thirst, pol3^uria, and the excretion of sugar in the urine.
Its well-known tendency to produce toxic symptoms
renders great care necessary in its administration. Its
use should, therefore, not be continued beyond two
weeks at a time ; but after two weeks' interruption it
may again be resumed for another two weeks. Iodoform
may be given in doses of 1 to 3 grains, repeated three
times a day ; or one sutficient dose ma}'^ be administered
at bed-time, which is probably the least unpleasant
method. Moleschott's formula, which is claimed to
disguise the unpleasant odor of the drug, is as follows:
Iodoform, gr. xv; ext. lactucari sat., gr. xv; cumarin,
gr. iss ; to be made into 20 pills.

Jambul. — The seeds of the Syzygium jambolanum are
highly extolled bj^ the natives of India as a remedy for
diabetes. The jambul treatment was introduced into
Europe about five years ago, and has met with varying
success. The drug appears to be very uncertain in its
action as obtained here, occasionally giving very good
results, or apparently so, while at other times it seems
to exert no favorable influence over the disease. I
have certainly observed marked benefit from it in one
chronic case, as it completely eliminated the sugar from
the urine, while the patient was on a non-restricted diet.
I have since used it in a number of other cases, but
with much less satisfactory results. The dose of the
powdered seeds is from 3 to 5 grains. A fluid extract
of jambul is prepared, the dose of which is from 6 to
8 drops.

Oxygen. — Inhalations of oxygen gas have been
strongly recommended for diabetes by Bouchard, Day,
Demarquay, Wallian, and others. My own experience

Treatment.

107

with this agent has led me to think very favorably of its
use in these cases. I have already shown that diabetes is
a much less fatal disease in low altitudes, and, moreover,
the evidence may be considered conclusive that the
increased oxidizing power of the blood consequent to
low altitudes is the chief cause of this favorable influence
over diabetes. By the systematic employment of
oxygen inhalations we may secure the same beneficial
results to our patients at home which are afforded by a
residence at or near the sea-level. In my hands, the
best results in these cases have followed upon the inha-

lation of from 3 to 5 gallons of oxygen twice daily, —
morning and afternoon. The gas may be more economi-
call^', as well as more effectually, administered by
diluting it with about an equal volume of atmospheric
air, and inhaled slowly and deeply, half a minute or so
elapsing between the inhalations.

Various appliances have been devised for the genera-
tion and administration of oxygen, but for the use of
those in general practice the apparatus furnished by the
American Oxygen Association of New York, under the
name of No. 1 (see cut, above), is, altogether, the best

108 Diabetes Mellitus.

in the market. This apparatus has a capacity of 8 to 10
gallons in ten minutes,— ^sufficient for 2 doses, — and the
oxygen furnished is remarkably pure. The instrument
is as portable as an ordinary hand electric battery, and
may, therefore, be used in the office or at the home of
the patient.

Another, though far less efficient, means of obtaining
the benefits of oxygen is by the administration of dioxide
of hydrogen, or so-called peroxide of hydrogen. The
dioxide of hydrogen is usually administered in the form
of a 3-per-cent. solution, — preferably Marchand's, — the
dose of wliich is from 1 to 2 teaspoonfuls, largely diluted
with water. A better article still is the glycozone of
the same manufacturer. Those who desire to make
themselves more thoroughly acquainted with recent
methods in the use of ox3'gen are referred to the excel-
lent work of Demarquay, on " Medical Pneumatology,"
recently translated, with valuable additions, by Dr.
Wallian.

Alkalies. — Finally, the beneficial eff'ects of the ad-
ministration of alkalies in diabetes deserves mention
here. The blood in diabetes becomes greatly reduced
in its alkalinity, and, as a consequence, its ox3^gen-hold-
ing powers are greatly weakened. It follows, therefore,
that the use of alkalies are very appropriate in these
conditions, and experience has amply demonstrated
their usefulness.

A number of other drugs have been more or less
highly extolled for their alleged specific influence over
diabetes. Among these may be mentioned : Sodium
phosphate, nitrate of uranium^ salicylic acid, picric acid,
calabar-bean, potassium iodide, iodine tincture, lactic
acid, codliver-oil, belladonna, valej'ian, and phosphorus.
There does not appear to be sufficient evidence in favor

Treatment, 109

of any of these to entitle them to any degree of confi-
dence. Carefully discrimmated from the benefits derived
from dieting, these drugs are probably nearly inert, so
far as their influence over diabetes is concerned.

Treatment of Complications and Special Symptoms. —
It remains next to consider the treatment of the special
symptoms and complications of the disease. Those
referable to the stomach command special attention,
since disordered digestion is so frequent an accom-
paniment of diabetes that it may be considered the rule,
after the disease has become thoroughlj'^ established.
The digestive and assimilative functions should, there-
fore, receive special support, through such agents as
general experience has taught us prove the most eflScient.
Among these may be mentioned pepsin, the vegetable
bitters, — especially str3'chnia, — and the mineral acids.

Constipation of the bowels, so frequently accom-
panjdng the disease, should be especially guarded
against, as this condition reacts very markedl}', in
enfeebling the digestive and assimilative powers. In
addition to this, it is beUeved that constipation often
tends to precipitate diabetic coma. I have an especial
preference for the natural alkaline purgative waters to
meet the requirements in such conditions, since they
relieve the overacid state of the intestinal canal, so
common to the disease. Freidrichshall water; or the
recently-introduced Spanish Rubinat Condal water,
given before breakfast, are very appropriate ; or 1 or 2
teaspoon fuls of Sprudel salt may be taken in a glass of
hot water, upon rising in the morning. In middle-aged
people inclined to stoutness and overeating, a course of
purgation by either of the above-named agents often
proves highly beneficial.

An occasional purgative dose of blue mass (10 grains)

110 Diabetes Melliius.

has an admirable effect at times. The continued action
of small doses of mercurials is justly open to question
in these cases ; but when an occasional decided dose is
given, the liver is stimulated to clear away the effete
bile products, and the assimilative powers of the in-
testinal tract are improved by the relief afforded to the
sluggish portal circulation.

The pneumonic and inflammatory bronchial complica-
tions are best met by such agents as ergot, combined
with digitalis and muriate of ammonia.

Furuncles. — The complication of multiple boils some-
times yields to quinine, when given to the extent of 10 or
12 grains daily. They are sometimes very chronic and
rebellious to treatment, however, in which case the only
certain relief to be obtained is by eliminating the sugar
from the urine, and every effort should be made in that
direction.

Diabetic Coma. — The most dangerous, and certainly
the most rapidlj' fatal, of all the complications of dia-
betes is that of Kussmaul's coma — sometimes, though I
think improperly, called acetonemia.

Dr. Ralfe, who has studied this subject closelj^,
advises, in the early stage, a vapor bath given in bed,
and the use of powerful stimulants, as ether, ammonia,
musk, valerian, and camphor. He records a case in
which he rescued a patient from a threatened attack by
the prompt administration of a hot bath. Temporary
improvement has followed the intra-venous injection of
sodium-carbonate solution in these cases. Thus, J.
Hesse has recently injected a 4-per-cent. solution of
sodium carbonate into the veins of a comatose diabetic,
with the result of a decided improvement for some
hours. The patient relapsed into coma, however, but
was again relieved by injection of 8 ounces more of the

Treatment 111

sodium solution. The patient, after twenty-four hours,
had a third attack, from which he died. Dickinson has
recently recorded a very similar case.

If the conclusions which I have reached as to the
causation of diabetic coma be correct, viz., as elsewhere
stated, that the condition is due to the toxic influence
of ptomaines, then the inlialation of oxygen gas would
seem to offer the best chances of relief in such cases.
I regret that, since I began the use of oxygen in the
treatment of diabetes, I have not had opportunities
for observing the effects of oxygen inhalations over
diabetic coma, for they seem to me altogether likely to
be capable of affording substantial relief in such cases.
I do not regard the temporary benefits derived from
intra-venous injections of alkalies in diabetic coma as
due to their neutralizing effects upon acetone in the blood,
but rather to their increasing the oxidizing powers of
that fluid, which alkalies are well known to do. In dia-
betic coma, therefore, I should employ the sodium-car-
bonate injections, as has been the practice heretofore,
but I should also re-inforce these by the most liberal
inhalations of pure oxygen gas.

Since the treatment of diabetic coma has thus far
proved so unsatisfactory, the ph3^sician should be con-
stantly on the alert for its early indications, in order
that every possible means may be employed to prevent
its appearance. In advanced cases, especially if emaci-
ation be marked and progressive, the patient may be
considered in constant danger. Constipation, mental
emotion, and fatigue should be avoided. Any unusual
illness, however slight, but especially in the way of
gastric disturbance, should be the signal for confine-
ment in bed, and appropriate treatment to prevent the
attack.

112 Diabetes Mellitus.

In conclusion, it seems desirable to emphasize the
immense importance of careful dieting, as greatly out-
weighing all our other resources against the disease
combined. This fact should be strongly impressed upon
the patient from the beginning. He should be taught
to rely but little upon medication, and the most effectual
means of accomplishing this is to teach him how much
can be achieved by careful dieting alone. When he has
once learned through experience that the amount of
sugar in his urine always bears a direct ratio to the
quantit}^ of prohibited foods indulged in, he is less
likely to overstep the proper limits imposed. Diabetic
patients are proverbially intelligent people, and with
their thirst, pol3'uria, and other discomforts relieved, a
sure sequence in most cases of careful conformance to
the diet rules, unless greatly lacking in gratitude they
will cheerfuUj^ submit to the restrictions imposed.

Hygienic Treatment. — In the hygienic management
of diabetes two points should be constantly kept in
view : the lowered bodily temperature, and the reduced
oxidizing powers of the economy. In order to com-
pensate for the first, these patients should be clad in
pure-wool under-garments (all wool) from head to foot,
thus economizing the body-heat as far as possible. To
meet the second indication, the respiratory apparatus
should have the widest possible scope, thus to facilitate
as perfect oxidation by the lungs as possible. The
patient should live as much as practicable in the open
air, and on no account should he live or sleep in small
rooms or confined atmosphere. His chambers should be
thoroughly ventilated by night as well as by day, with-
out, however, being permitted to become cold. Both
the indications above-named are more easily attained by
a residence in warm climates, near the sea-level, the par-

Treatment. 113

ticiiliir location of which will be seen by referring to
Section I, where this subject has been systematically
considered.

Warm-water baths are very beneficial to these
patients, and they may be rendered more efficient by
the addition of some alkali, such as sodium bicarbonate.
These baths should be repeated frequently, and they may
be followed by thorough rubbing of the skin by means
of brushes or coarse towels. On no account should cold
plunges or sea-baths be indulged in.

A moderate degree of exercise in the open air is
usually beneficial ; at the same time, care should be taken
to prevent great fatigue. The dangers of overexertion
are well known, and especially in elderly and debilitated
subjects it is unwise to permit overexercise. The cares
and anxieties of business, especially if exacting, should,
if practicable, be exchanged for more moderate and
cheerful employments, or, better still, thrown aside, and
a period of rest and relaxation indulged in.

Habits of regularity in eating, drinking, and sleep-
ing should be established. The question of sleep is of
special importance, for, as a rule, diabetic patients do
not sleep well. At least seven or eight hours' sleep
should be secured each night, as the tranquilizing influ-
ence of sleep upon tlie central nervous sj^stem secures a
more stable control of nerve-force in the vasomotor
tract. The noise and distractions of cit}^ life are un-
suitable because of the constant tension and waste of
nervous force. These should be substituted, when prac-
ticable, by the quiet of country life, more especially in
the summer months.

SECTION VII.

CLINICAL CONSIDERATIONS.

In order to better illustrate the clinical features of
saccharine diabetes, as well as to demonstrate the influ-
ence of treatment over the disease, the following cases
are subjoined from my records of private practice.

Cases of Severe Type in Young Subjects. — The first
3 cases may be taken as fair average tj^pes of the dis-
ease as usually found in young subjects, showing the
features of severity and intractability to treatment
almost universally characteristic of the disease in such
patients.

Case 108, J. L. — December 10^ 1885. Patient's age,
29 years. He states that his general health has always
been good ; that he never had any serious illness. He
has been very actively employed in business since he
was 18 years old. He first noticed weakness and debility
in September last. He has suffered from dyspepsia, more
or less, for a year. He has been rising at night to urin-
ate for the past three weeks, and he has noted very pro-
nounced thirst of late. Examination of his urine shows
a specific gravity of 1045, reaction sharply acid ; sugar
is present in quantit}^ between 5 and 6 per cent. The
urine is free from albumin. He was ordered nitro-
muriatic acid, dil., 10 drops, with strychnia, -^^ grain,
three times daily, for his d^^spepsia ; the diet to be
gradually restricted to meats, green vegetables, and a
small amount of bread.

(115)

116 Diabetes Mellitus.

December 18th. The quantit}'^ of urine is much re-
duced; its specific gravity is 1030, and the quantity of
sugar present is about 2 per cent. He no longer rises
at night to urinate, and his thirst has subsided.

January 11^ 1886. The patient passes, by measure,
118 to 134 ounces of urine daily. The specific-gravity
range is 1035 ; sugar, about 2 per cent.

Februar-y 5th. His condition seems somewhat im-
proved. The quantity of liis urine averages 80 ounces
daily ; the specific gravity, 1033, sharply acid in reac-
tion, and it contains no albumin, but sugar is present in
quantity of 6 grains to the ounce. His diet is restricted
to meats, green vegetables, fish, eggs, gelatin, and one
small slice of bread a day. He was now put upon
arsenite of iron, y^^ grain, three times a day, after food.
He is to leave for Florida, in a day or two, for a few
weeks' change.

February 16th. The patient reports marked improve-
ment since he arrived in Florida. His urine now averages
50 to 60 ounces daily, and he has gained 6 pounds in
weight.

May 2Jfth. The patient has just returned from
Florida, where he spent three and a half months. Ex-
amination of his urine to-day shows it to contain 2 per
cent, of sugar ; no albumin present ; quantity, 100 ounces.
He was ordered codeia at bed-time, in J-grain doses, to
be gradually increased, and to omit the arsenite of iron.

June 1st. No substantial improvement is apparent
in the condition of the patient ; in fact, he seems rather
to be losing ground. It was, therefore, deemed wise to
send him to the country to get him beyond reach of his
business, since while in the city he could not be kept
from dipping into commercial transactions, which made
him very nervous. He was sent to Minnetouka for a

Clinical Considerations. 117

few weeks, with directions to follow closely the diet
rules laid down, and to take no medicines.

September 1st. The patient has just returned to the
city much improved by his two months* stay in the
countr}''. He reports that his urine was free from sugar
a good deal of the time he was away. Examination
of his urine to-day shows the specific gravity to be
1025, reaction acid, and entirely free from sugar and
albumin.

September 20th. Sugar re-appeared in his urine in
moderate quantity, owing largely to relaxation of his
diet restrictions without orders.

November 11th. More or less sugar has been present
in his urine since September 20tli. The quantity of
urine ranges from 80 to 100 ounces daily.

The patient concluded, upon his own responsibility,
to go to California for the winter ,^ where he died from
diabetic coma almost immediately after his arrival.

The termination of the above case, under the circum-
stances, illustrates the dangers to diabetic patients of
undertaking long journeys ; the fatigues incident thereto
so often precipitate diabetic coma. The patient derived
much benefit from his residence in the country, but con-
cluded, without my knowledge, to make the trip to
California, — nearl}^ three thousand miles by rail, — when
he was not in condition to bear the fatigues of travel,
and the result was as reported in the records.

Case 212, A. K.—June 16, 1888. Patient's age, 21
3'ears ; unmarried ; apparently a very bright 3'oung
woman. No family history of diabetes or tuberculosis
is obtainable. She states that she was never seriously
ill, except with scarlatina two years ago, until her present
illness began. She states that about two years ago she

118 Diabetes Mellitus.

began to have unusual thirst, and to pass large quan-
tities of urine ; and she suffered much from weakness
and a muscular lassitude. These symptoms were first
noticed immediately after graduation from college, fol-
lowing a hard 3'^ ear's work in competing for a prize.

She consulted Dr. S., who found sugar in her urine,
the quantity of the urine measuring 8 pints. The
patient passed through the hands of several physicians,
her condition being sometimes better, and at others
worse, until the present date, when her symptoms were
noted as follows : The quantity of urine averages 2^ to
3 quarts daily ; she complains of much weakness ; con-
siderable thirst ; is easily chilled ; tlie throat and tongue
are dry and red ; she is rather nervous, and her menstrual
flow has appeared but once during the last year. Her
urine is pale, and rather green in color; its specific
gravity marks 1038 ; its reaction is sharply acid, and it
contains about 2J per cent, of sugar. The urine is free
from albumin.

The patient was directed to gradually restrict her
diet to animal foods and green vegetables. No medi-
cines ordered.

June 26th. The patient states that she feels less
tired ; that her thirst has sensibly diminished, and tliat
the quantity of urine averages about 5 pints daily.
Examination of the urine shows its specific gravity to
be 1028, and to contain about 8 grains of sugar to the
ounce. She was directed to draw the line very rigidly
in the matter of diet — only taking meats and green
vegetables, with eggs, and gelatin.

July loth. Patient reports that the quantity of
urine has measured from 3 to 6 pints daily since last
visit. She has suffered from diarrhoea and more or less
pain in her bowels during the last five days. The specific

Clinical Considerations. 119

gravity of the urine to-day is 1030, and it contains
6 grains of sugar to the ounce. She was directed to
relax the diet restrictions somewhat for a few days,
taking a small slice of bread twice daily, and she was
ordered deodorized tincture of opium, 10 drops, after
each loose movement of the bowels.

My absence abroad for three months necessitated
referring the case to my coUea^e until my return.

October 30th. The patient reports as follows : Diar-
rhoea was present, more or less, for two or three weeks
after last consultation. She has followed the diet rules
advised faithfully up to date, and the quantity of the
urine has not exceeded 4 pints daily. She now has no
unusual thirst, no chills, and is very little tired, and she
has gained a few pounds in weight. Her urine to-day,
before breakfast, marks a specific gravity of 1035, and
contains 7 grains of sugar to the ounce. After breakfast,
sample shows specific gravity 1035, sugar 8 grains to
the ounce. Patient's diet at present consists of meats,
eggs, green vegetables, some cream. Ordered the same
continued, excluding cream and adding almond-bread.

November 22d. Patient comes complaining of diar-
rhoea, distress in stomach, with flatulence, headache,
some thirst. The urine is clear, color light ; specific
gravity, 1034 ; reaction acid ; sugar present, 6 grains to
the ounce. The urine is free from albumin.

As the almond-bread disagrees, she is to be permitted
two or three small slices of common bread each da}^
To take 10 drops dilute nitromuriatic acid, with tea-
spoonful doses of pepsin-essence at meal-times.

February 8, 1889. The urine is clear ; specific gravity,
1028; sugar, 6 grains to the ounce. Her stomach has
been weak, more or less, since last visit, and some pain
and flatulence present, but no diarrhoea. The urine has

120 Diabetes Mellitus.

averaged 3J to 4 pints in quantity daily. Some days a
little thirst has been present. She is to be permitted
one apple a day, or one tomato, radishes, celery, green
peas, and string-beans.

March lJf.th. The urine to-day is acid in reaction,
clear, specific gravity 1029, and contains 5 grains of
sugar to the ounce. The patient feels better ; appetite
is good ; very little flatulence is now present. Treat-
ment to be continued unchanged.

April 7th. The urine two hours after breakfast marks
a specific gravity of 1029, and contains between 4 and
5 grains of sugar to the ounce. The daily volume of
urine averages from 4 to 5 pints. The patient rises at
night once to urinate. She was ordered to take 6 grains
of lithium bromide an hour before retiring, as she has
been somewhat sleepless of late.

May 17th. The urine has averaged from 3^ to 4 pints
in daily volume since last consultation. The urine ex-
amined to-day, after breakfast, marked a specific gravity
of 1023, and contained 3 grains of sugar to the ounce.

June 1st. Patient reports not having felt so well since
last visit. She complains of pain in the top of her head ;
her stomach is disordered, and she suffers distress after
food, with flatulence. Her bowels have been irregular,
her tongue is coated, and she has disrelish for food, but
she has no undue thirst. The daily volume of urine
ranges from 3^ to 4 pints. Urine examined two hours
after breakfast : specific gravity, 1021 ; sugar, about 1
grain to the ounce. The patient is following a closely
restricted diet, consisting of meats, fish, eggs, gelatin,
green vegetables, and occasionally a small slice of bread.
No medicines.

July 9th. The volume of urine has ranged from 3 to
3 J pints daily since last consultation. The patient sleeps

Clinical Considerations. 121

much better, — in fact, better than for years ; but her stom-
ach is still weak. The urine to-day is acid in reaction,
specific gravity 1026, and contains 2 grains of sugar to
the ounce. The patient was sent to "Waukesha for a few
weeks to drink the waters.

September 3d. The patient returned from the springs
about a week since, apparently improved. She states
tliat she sleeps well ; is not so easily tired ; her appetite
and digestion are much improved. The urine contains
a small amount of sugar.

October 30th. Patient says she has not been so well
since last visit, having had more or less trouble with her
stomach. The urine to-day is clear, sharply acid in re-
action, specific gravity 1028, and contains 8 grains of
sugar to the ounce. Her gums are swollen and tender,
and in places recede from the teeth. Yery marked and
typical xanthoma is present upon the lower and inner
margins of both upper eyelids, — a condition claimed by
some dermatologists to be associated very frequently
with diabetes. The diet is maintained as strictly as
possible according to the usual lines. No medicines
save iron-wash for the mouth.

November 25th. The patient reports improved diges-
tion, but the bowels have become rather costive. The
mouth and gums are much improved under the use of
iron-lotion. The urine marks a specific gravity of 1031,
and contains 7 grains of sugar to the ounce.

December 12th. Tiie patient states that she passes
less urine of late ; that she is very nervous and weak.
She looks thin, and is evidently emaciating rather
rapidly of late.

December 24th. Patient reports great disrelish for
food, and complains of long-continued restrictions of
diet. The urine is clear, acid in reaction, specific gravity

6 F

122 Diabetes Mellitus,

1026, and contains 5 grains of sugar to the ounce. The
restrictions as to diet were largely removed, and the
patient was put upon 10-grain doses of antipyrin, re-
peated three times daily.

December 28th. The urine marks a specific gravity
of 1032, and contains 12 grains of sugar to the ounce.
No change in diet was made, the patient to take what-
ever she chose except sugar and potatoes, and the anti-
pyrin was increased to 45 grains a day.

December 31st. The urine marks a specific gravity
of 1031, and contains 10 grains of sugar to tlie ounce,
the volume of urine being about 5 pints daily. She has
some thirst.

January 5, 1890. The urine marks a specific gravity
of 1035, its reaction is acid, and contains 10 grains of
sugar to the ounce. To continue antipyrin.

January 13th. The patient was suddenly seized dur-
ing the night of the 11th with intense dyspnoea, vomit-
ing, pain in her stomach, and collapse. Upon my visit
she presented all the typical symptoms of diabetic coma,
from which she died January 12th, at 10.50 p.m.

The above case well illustrates the worst t^^pe of the
disease, as well as the difficulties to be encountered in
the management of such cases. The patient was naturally
a delicate woman, of nervo-sanguine temperament, the
neurotic features being inherited from a pronouncedly
h3'Sterical mother. The chief obstacle in the way of
successful treatment was her very delicate stomach,
which could not be made to long tolerate the restrictions
of diet essential to completely control the disease. When
we consider that such cases usually run a rapid course,
we must conclude that the treatment was not without
influence in the above case, as the patient survived five
years under the disease.

Clinical Considerations. 123

The next case belongs to the same class and type.
The patient, however, possessed much better powers of
digestion, and the result illustrates how much can occa-
sionally be accomplished by treatment in the very worst
type of the disease.

Case 194, G. S.^February 10, 1888. The patient
comes from an adjoining State for advice about sugar
in his urine. He states that his age is 18 years and 3
months. He began to be thirsty over a year ago, and
about the same time he began to pass large quantities of
urine. He experienced muscular weakness, and he found
himself easily chilled. He relates that at one time he
passed from 120 to 160 ounces of urine daily, and the
specific gravity rose to 1050. His appetite became
voracious. At 4 years of age he had diphtheria severely,
but has suffered no serious illness since until the present
disease appeared. He has been strong and hearty as
a boy. No family history of diabetes could be traced.
He was put upon a restricted diet by his family phy-
sician, at home, which modified his S3^mptoms, al-
though it did not eliminate the sugar from his urine.
At present he seems well preserved, of healthy appear-
ance, and the tendon reflexes are present in both legs.
Examination of his urine showed it to be pale in color,
clear, of acid reaction, specific gravity 1040, and to con-
tain 15 grains of sugar to the ounce. The urine is free
from albumin. He was ordered to gradually restrict
his diet to meat, fish, eggs, gelatin, green vegetables,
and a limited amount of bread, well toasted. No
medicines were prescribed.

February 15th. The urine to-day marks a specific
gravity of 1029, and contains 10 grains of sugar to the
ounce. He has some constipation of the bowels and

124 Diabetes Mellitus.

lieadaclie ; otherwise he is doing well. He has much
less thirst, and does not rise at night to urinate.

March 1st. The urine marks a specific gravity of
1033, and contains about 7 grains of sugar to the ounce.
The patient was directed to confine himself exclusively
to animal food, not including milk.

March 15th. The patient has had considerable diffi-
culty in accustoming his stomach to the restricted diet,
as it has resulted in some pain and diarrhoea, although
he is better to-day. The volume of urine for the last
twenty-four hours was 64 ounces ; its specific gravity is
1028, and it only contained about 1 grain of sugar to
the ounce.

April 2d. The patient has suffered from pronounced
diarrhoea with gastric pains for some days past ; his
bowels moved ten times yesterday. His urine marks a
specific gravity of 1025, is free from sugar, and the
volume for twent3^-four hours past is 45 ounces. The
urine contains a trace of albumin. He was permitted
to relax slightly his diet restrictions, viz., to take one
small slice of bread dail}^ To take tincture of opium,
8 drops, after each loose movement of the bowels.

April 5th. Patient looks pale, but he states that he
feels better; his diarrhoea is much improved, — only one
moA^ement of the bowels ^^esterda}^ His urine averages
from 45 to 50 ounces in volume daily ; specific gravity,
1033 ; sugar, 3 grains to the ounce.

April 23d. Urine, to-day, specific gravity 1032 ;
sugar, 5 grains to the ounce. Since last report there
has been more or less diarrhoea, although he has been
improving in that respect during the last week, — about
two stools daily, unaccompanied b}'' pain. He has
suffered considerably from nausea, and he feels rather
weak. Diet to consist of string-beans, cresses, some

Clinical Considerations. 125

milk, meats, tea, eggs, and a little bread. Ordered im-
ported Carlsbad water to be taken three or four times
dail^^

May 8th. The urine has averaged from 44 to 46
ounces in volume daily. Patient says he feels " first-
rate;" no weakness; stomach and bowels in good con-
dition. The urine to-day is entirely free from sugar.

May 14th. Urine, 43 to 47 ounces daily; specific
gravity, 1026 ; free from sugar.

May 21st. Urine to-day, 46 ounces ; specific gravity,
1026 ; free from sugar. The patient's general condition
has been improving. No weakness complained of; his
digestion is good, but his bowels are slightly inclined
to looseness. His diet to be practically limited to
animal food.

June 2d. The urine averages from 40 to 52 ounces
in volume daily. To-day the specific gravity of the
urine is 1026, and sugar is absent. The patient continues
well ; no thirst, no diuresis, no weariness.

June 18th. Urine averages 43 to 45 ounces in
volume; specific gravity, 1023 to 1027 ; no sugar. The
urine has now been free from sugar, except occasional
traces, for a month, and the patient has gained 10
pounds in weight. He is to leave for home in a few
days, and is directed to continue strict diet, consisting
of animal food with some selected green vegetables ; no
bread to be used.

January 7, 1889. The patient has returned to the
city for treatment to-day. He relates that he is stronger
than when he departed, in June ; his stomach has given
him little or no trouble, his bowels are regular, and
there has been no essential change, so far as he is able
to judge, although he has not measured his urine since
June. His diet, while at home, has consisted chiefly of

126 Diabetes Mellitus,

animal food, with lettuce, string-beans, cabbage, eggs,
and nuts. His urine to-day is clear, of acid reaction,
specific gravity 1031, and contains about 1 grains of
sugar to the ounce. He was directed to restrict his
diet more closely to animal food.

January l^th. Urine, to-day, specific gravity 1028 ;
reaction, acid; sugar, 5 grains to the ounce.

Fehrury 2d. Urine, to-day, specific gravity 1028 ;
acid reaction ; 3 grains of sugar to the ounce. As the
quantity of sugar seems to fall no lower upon practically
an animal diet, he was given codeine, \ grain at bed-time,
to be slowly increased from day to day.

February 9th. The codeine causes some headache and
nervousness, especially at night. His stomach remains
in good condition. Urine, to-day, specific gravity 1026 ;
sugar, 3 grains to the ounce. To continue codeine at
bed-time, in doses of 1 grain and over.

February 16th. Patient states that his appetite has
fallen off, and his bowels have become constipated ;
some flatulence is present, and he does not feel as well
as usual. The quantity of urine has increased some-
what ; specific gravity, 1031 ; sugar present, about 3
grains to the ounce. Codeine was omitted, and strychnia
was ordered, in doses of -j-^ grain, after meals.

February 23d. Urine, to-day, specific gravity 1026 ;
reaction acid ; sugar present, 4 grains to the ounce.
No increase in volume of urine ; no thirst ; digestion
improved. Treatment continued unchanged.

March 16th. Urine, to-day, specific gravity 1028;
sugar, 2 grains to the ounce ; patient feels " very well."

March 30th. Urine, to-da}', specific gravity 1025 ;
sugar, 2 grains to the ounce. The patient feels well,
sleeps well, and has gained about 4 pounds in weight
during the last two weeks.

Clinical Considerations. 127

April Wtli. Urine specific gravity, 1026 ; sugar
present in mere traces.

May 4th. Urine to-day, after luncheon, specific
gravity 1026 ; sugar present in faint traces. Patient
feels exceptionally well. Treatment unchanged.

May nth. Urine, before breakfast, specific gravity
1022; entirely free from sugar. After breakfast,^ample,
specific gravity 1025 ; entirely free from sugar.

May 18th. Urine, to-day, specific gravity 1022 ;
entirely free from sugar. The patient feels very well;
his digestion is excellent ; he sleeps well. The patient
returns home with directions to live upon meats, fish,
eggs, and gelatin. He was instructed to test his urine
for sugar every week, and record the results.

December 1st. The patient reports that he has been
doing excellently since he left the city, in May last.
His urine has been free from sugar nearly all this time,
until very recently, when he fell through the ice while
skating, and became thoroughly chilled. Since then sugar
has re-appeared in his urine in small amounts. He reports
his general condition as better than for two years past,
and that he is quite contented with his diet, which
agrees with him admirably.

Cases of Mild Type. — The next 2 cases present pre-
cisely the opposite features from the preceding ones.
They belong to a class in which the disease is almost
invariably mild in character. For the most part these
patients are between 45 and 75 j^ears of age, usually well
nourished, and have been rather generous in their habits
of living, as well as active mentally and pliysicall}^ If
such patients can be induced to practice habits of mod-
erate restriction of diet, it is usuall}^ a matter of no diflfl-
culty to eliminate the sugar from their urine, and to

128 Diabetes Mellitus.

maintain an excellent degree of general health, in which
state they may continue almost indefinitely, without
abridgment of the usual duties or comforts of life.

Case 145, G. B..— January 26^ 1887. The patient
states that he is 61 j^ears of age, and has heen an active
business man all his life. He comes for advice in refer-
ence to thirst and diuresis, which be first noticed about
a year ago. No family history of diabetes obtainable.
He says that he has had great anxiety over his business
aflairs during the last two years. He rises at night to
urinate very frequently; is thirst^^and very susceptible
to cold. His appetite is very good ; but he complains
of being very nervous, and does not sleep well.

His urine examined to-day is light in color, clear,
reaction sharply acid, specific gravity 1035, and contains
25 grains of sugar to the ounce. The urine contains a
small percentage of albumin, and, upon microscopic
examination, a few hyaline casts were observed.

Diagnosis. — Diabetes, complicated by contracting
kidney (interstitial nephritis). He was directed to
avoid potatoes and farinaceous foods, as well as fruits,
and to take but little bread.

January 31st. The patient reports that he has less
thirst ; rises, at night, but once to urinate. Examina-
tion of his urine shows 12 grains of sugar to the ounce.

February 3d. The urine contains but 5 grains of
sugar to the ounce. He was directed to live upon
meats, green vegetables, and a small slice of bread twice
daily, well toasted.

February 6th. Urine specific gravity, 1024 ; free
from sugar.

February 15th. Urine, to-day, specific gravity 1021 ;
no sugar present.

Clinical Considerations. 129

February 21st. The urine to-day is free from sugar,
and the specific gravitj^ is 1018. A small amount of
albumin is still present in the urine.

March 3d. The urine to-day is free from sugar;
specific gravity, 1016 ; a trace of albumin is present, and
a few hyaline casts were observed upon microscopic
examination.

The patient complains of weakness, and says he is
very nervous. The drain upon his system, consequent
to the disease for the last year, has evidently reduced
him considerably. It was therefore deemed best to
order rest for a time, and he was accordingly sent South,
with directions to practice restrictions of diet to a
moderate degree while absent.

April 9th. The patient has just returned from the
South, greatly improved in general health. He states
that he feels stronger, sleeps well, is not so nervous, and
he looks much better. His urine is free from sugar;
specific gravit}^, 1018; contains a trace of albumin and
a few perfectly h^'aline casts. He was permitted some
relaxation in diet rules. In view of his interstitial
nephritis, it seemed desirable to reduce his meat diet as
much as possible, and to substitute therefor as much
carbohydrates as possible, without causing sugar to
re-appear in his urine. He was, therefore, allowed a
medium amount of toasted bread, apples and tomatoes
ad libitum^ and nearly all vegetables, except potatoes,
beets, and turnips. To substitute saccharin for sugar
in sweetening his food and drinks. No medicines.

May 5th. Patient states that he feels very well ;
has attended to his usual business duties for the past
month. His urine is free from sugar.

July 11th. Patient reports that he feels very well,
has no thirst, is not nervous, sleeps well, etc. Examina-

130 Diabetes Mellitus.

tion of urine shows specific gravity 1020; free from
sugar, but contains a small amount of albumin. He now
lives upon his usual diet, except sugar and potatoes.

August 25th. PaticHt reports that he has been very
well since last visit, and has gained considerably in
weight. His urine to-day is free from sugar, specific
gravity 1020, and a trace of albumin is present. He
was permitted to throw off all restrictions of diet.

October 31st. Patient comes complaining of weak-
ness in his limbs, tired feeling, and some nervousness.
The urine contains about 4 grains of sugar to the ounce ;
its specific gravity is 1026. The unrestricted diet upon
which he has lived for the last two months is evidently
the cause of return of some of his diabetic symptoms.
He was directed to avoid amylaceous and saccharine
foods for the present.

November 28th. Urine to-day contains about 2
grains of sugar to the ounce ; specific gravity, 1023.

January 31, 1888. The urine to-day is free from
sugar, specific gravity 1014, and a trace of albumin is
present.

March 13th. Urine is free from sugar ; specific
gravity, 1016. To continue moderate restrictions of
diet.

May 16th. Urine is free from sugar ; specific gravitj'',
1019. Patient states that he feels very well.

July 12th. The patient has been on rather a liberal
diet for a month, and his urine again contains sugar —
about 4 grains to the ounce. The specific gravitj'^ of his
urine to-day is 1025, and a trace of albumin is present
in his urine. He was directed to limit his diet more
closely.

November 2d. Examination of urine shows specific
gravity 1022 ; no sugar ; a trace of albumin present,

Clinical Considerations. 131

and a few hyaline casts. He has been very well since
last report, except for a week in August, when he suf-
fered from slight diarrhoea.

December' 20th. The urine contains a mere trace of
sugar; specific gravit}^, 1021 ; some albumin is present.

January 10^ 1889. The urine is free from sugar, and
the patient feels well. The patient has now observed
the effects of diet upon his urine so long and so closely
that he can, as a rule, tell that which best agrees with
him and that which will cause sugar to appear in his
urine. He is able to use bread rather liberall}', — 3 to
5 ounces daily, — to eat strawberries, apples, tomatoes,
and, in fact, nearly all table-vegetables except potatoes
and farinacese, without causing his urine to become
saccharine.

September 5th. Urine, to-daj^, specific gravity 1020,
free from sugar ; a trace of albumin present.

October 23d. Urine is free from sugar; specific
gravity 101 T ; patient feels very well.

January 10^ 1890. The urine is free from sugar, the
specific gravity is 1022, and a small amount of albumin
is present.

The above case illustrates how much can be accom-
plished by diet without medication in this class of cases.
Upon moderately restricted diet no sugar is ever present
in his urine. He is able to eat almost his usual amount
of bread, and most vegetables except potatoes, rice, and
farinaceae ; also to eat liberally such fruits as apples and
strawberries without sugar appearing in his nrine. He
has never, except in the beginning, been strictly dieted,
because, in view of his contracting kidneys, it was
deemed wise to permit as free use of vegetable foods as
possible, short of causing sugar to appear in his urine.
It will be noted that the specific gravity of his urine

132 Diabetes Mellitus.

frequently sank below 1020, and that on January 31,
1888, it even registered as low as 1014. It has already
been pointed out that when granular kidne}' complicates
diabetes, not only does the specific gravity of the urine
often range low, but sugar may be present when the
specific gravity is considerably below normal.

Case 153, L. L. — June i^, 1887. Patient's age is 55
years. He states that he has alwa3^s enjoyed good health,
although he has lived liberally, taking more or less wine
and spirits daily. He began to rise at night to urinate
about two months ago. He finds himself weak and
easily tired, is very sensitive to cold, and complains of
much thirst. He states that his urine measures from 8
to 10 pints in volume daily. The urine marks a specific
gravity of 1033, is acid in reaction, and contains 15
grains of sugar to the ounce. The urine is free from
albumin. Potatoes, sugar, and farinaceous vegetables
were prohibited, and bread was reduced to one-half the
normal daily use.

June 28th. Patient reports that he feels somewhat
better, though still weak. His urine contains 5 grains of
sugar to the ounce ; specific gravity, 1030 ; no albumin
present.

July 12th. Urine specific gravity, 1020 ; acid in reac-
tion ; free from sugar and albumin. The patient was
directed to live upon a moderately restricted diet, and
to practice habits of temperance. His urine was ex-
amined a number of times subsequentlj^ and found to be
free from sugar up to the end of the year.

I meet the patient frequently, and upon questioning
him find no indications that sugar is present in his urine
to date.

It would be easy to add numerous other cases from

Clinical Considerations. 133

my records here in which the disease proved mild and
amenable to treatment in patients between 45 and 10
years of age. Such cases are to be met with daily in
practice.

Case of Severe Type in Middle Age. — The following
case is the most marked exception to the general rule
laid down that I have CA^er encountered, and, since it is
likely to prove of interest, I herewith transcribe it from
my records in detail.

Case 185, Mrs. M..— November 28, 1887. Patient
states that she is 4t years of age, married, and has had
10 children. She has had no serious illness until the
present ; no family history of diabetes obtainable. She
states that her appetite and digestion have always been
exceptionally good. She has had no special grief or
worry or mental strain. No history of traumatism. Slie
is not especiall}^ nervous. Her normal weight is 1G3
pounds ; her present weight is 136 pounds. In January
last — ten months ago — she first noticed that she was un-
usually thirsty, and that she arose frequently at night
to urinate. She became much annoyed by a trouble-
some itching on the inner part of the thighs. These
symptoms continuing, she consulted a physician, who
discovered sugar in her urine, and ordered Giliford's
solution of bromide of arsenic, which she took in gradu-
ally increasing doses until the present. Her daily dose
now is 15 drops. Some restrictions in diet were also
advised by her attending physician.

Her urine to-day is clear, of light-greenish color ;
reaction acid, specific gravity 1031, and contains 30
grains of sugar to the ounce. A trace of albumin is
present, and tiie volume of urine is 10 pints in twenty-

134 Diabetes Mellitus.

four hours. She was directed to avoid potatoes, farina-
ceae, saccharine foods, and to reduce her usual quantity
of bread one-half. She was also ordered 6 grains of
powdered jumbul after meals.

December 19th. Urine specific gravitj', 1030 ; reac-
tion acid ; sugar, 20 grains to the ounce. The urine is
free from albumin. Diet restrictions were drawn more
closely, and jumbul continued as before.

January P, 1888. The urine to-day marks a specific
gravity of 1032, and contains 30 grains of sugar to the
ounce. The patient was ordered codeine, beginning with
J-grain doses after meals, to be increased daily. The
dietary rules were drawn somewhat more firmlj^

January 23d. Urine, to-day, specific gravity 1032 ;
sugar present, 20 grains to the ounce ; A^olume of urine
for twenty-four hours, 6 pints. Codeine was increased to
2 grains a day.

January 31st. Urine specific gravity, 1030 ; sugar, 8
grains to the ounce. Codeine increased to 3 grains a
day.

February 9th. Urine specific gravit}", 1029 ; sugar
present, 5 grains to the ounce. Codeine was ordered in-
creased to 4 grains daily.

March 3d. Urine, to-day, specific gravity 1028;
sugar present, 5 grains to the ounce. Diet to be limited
to animal food, and codeine to be taken to the extent
of 5 grains a day.

March 21st. Urine, to-da}^ specific gravity 1028;
sugar, 3 grains to the ounce. The urine is free from
albumin. The patient was obliged to discontinue the
codeine on account of nausea, A^omiting, constipation,
and headache. She is to take no medicine for the
present, bnt to live upon animal food.

AprHl 21st, Tlie urine, before breakfast to-day, has

Clinical Considerations. 135

a specific gravity of 1025, and contains 2 grains of
sugar to the ounce. Tiie patient has bad some nausea
during the last two weeks, otherwise she has felt better.
Directions were given to relax the diet rules slightly for
the present, as follows : To take some milk, oysters,
lettuce, radishes, and 2 ounces of bread dail3\

April 26th. Urine to-day marks a specific gravity
of 1031, and contains 8 grains of sugar to the ounce.
Volume of urine for twentj'-four hours is 5 pints.

May 3d. Urine, to-da}', specific gravity 1030 ; sugar,
6 grains to the ounce. Patient complains of weakness
in her muscles ; weary feeling ; she is sensitive to cold,
and has considerable thirst. She was ordered to dis-
continue the use of milk and bread, and confine her diet
to meats, eggs, gelatin, and a few green vegetables.

May 23d. The urine marks a specific gravity of 1024,
and contains 2^ grains of sugar to the ounce. Patient
states that she feels much stronger and better generally.

June 4th- The urine averages 5 pints daily in volume.
To-day the specific gravity is 1029, and the urine con-
tains 5 grains of sugar to the ounce. The urine is free
from albumin. The patient was ordered Clemens's solu-
tion of bromide of arsenic, to begin with 5-drop doses
after meals, which is to be slowly increased.

June 28th. The patient complains of some thirst, is
very tired much of the time. She states that her appe-
tite is good. She is now taking 6 drops of Clemens's
solution after her meals. Her urine to-day is as fol-
lows : Specific gravit}^ 1032 ; sugar, T grains to the
ounce ; no albumin present.

November. 10th. The patient states that she has lost
about 5 pounds in weight since last record. She now
passes about 6 pints of urine daily ; is thirsty at times,
at others not. She states that she feels tired a good

136 Diabetes Mellitus.

deal of the time, but is never nervous. Urine, to-day,
specific gravity 1028 ; reaction acid ; sugar, 6 grains to
the ounce; no albumin present. To eat fish, oysters,
tomatoes, green vegetables, eggs, gelatin, cheese, and
meats ; also to eat almond-bread. To take no medicine
for the present.

December 1st. The patient relishes the almond-bread
very much ; she is to continue diet as named unchanged.
The urine, to-day, specific gravity 1030 ; sugar, 6 grains
to the ounce.

December 17th. The urine has averaged 4 pints daily
since last consultation. To-day examination of urine
shows as follows : Specific gravity, 1026 ; sugar, 5 grains
to the ounce. To continue diet as before, and to take
ergotine (3 grains) after meals.

December 28th. The urine is about 5 pints in volume ;
specific gravity, 1029 ; sugar, 5 grains to the ounce.
Ergotine to be increased to 5 grains after meals. No
other change in treatment.

January 23^ 1889. Patient states that the daily vol-
ume of urine is about 3J pints. Urine, to-day, specific
gravity 1021 ; sugar, 4 grains to the ounce. To discon-
tinue ergotine, and to diet very strictly upon animal
foods, taking, in addition, almond-bread only.

February 15th. Tlie urine averages from 3 to 4 pints
in volume daily. The specific gravit}^ to-day is 1033,
and the urine contains 3 grains of sugar to the ounce.
The patient states that she lias had considerable nausea,
headache, and constipation of late. She was ordered
strychnia, ^^ grain, with 10-drop doses of nitromuriatic
acid, dil., after meals ; the diet continued unchanged.

March 1st. Volume of urine has averaged 4 to 5
pints daily. Her appetite is still poor, although no
nausea is present. The urine to-day is as follows : Spe-

Clinical Considerations. 131

cific gravity, 1030 ; sugar, 5 grains to the ounce. She
was ordered morphine, ^ grain at bed-time, to be slowly
increased.

April 3d. The patient was obliged to discontinue the
morphine on account of the nausea, headache, and con-
stipation it induced. She was ordered, in place of the
morphine, ^ grain of nux-vomica extract with gentian.
No essential changes in diet.

April 24th. Urine, to-day, specific gravity 1028;
sugar, 2^ grains to the ounce ; volume, 4 pints. The
patient was ordered strychnia, ^j^ g^'^i^^ after meals.

May 17th. The urine has averaged from 3J to 4 pints
daily. Examination to-day as follows : Specific gravity,
1030 ; sugar, 2 grains to the ounce. Ordered strychnia
increased to -j^ grain after meals. To diet strictly and
to discontinue almond-bread.

June 1st. The patient states that she has no unusual
thirst. She rises at night to urinate once each night.
Her appetite and digestion are good, and she feels very
well. The urine, to-day, specific gravity 1030 ; sugar,
3 grains to the ounce.

July 17th. Urine 4 pints in volume ; specific gravit}",
1028, acid reaction ; sugar, 2 grains to the ounce. The
patient" was sent to Waukesha to drink the waters for a
few weeks. She was permitted to use green vegetables
while there.

September 26th. Patient has just returned from the
Springs apparently improved in general condition. She
was ordered an exclusively animal diet.

November ^th- Patient has had a cold for some da3'^s.
She states that the urine has averaged from 5 to 6 pints
daily. Some thirst is present. Urine specific gravit3',
1027 ; sugar, 6 grains to the ounce. To take arsenite of
iron, ^Q grain, after meals.

138 Diabetes Mellitus.

December 17th. Urine to-day is clear ; acid in reac-
tion ; specific gravit}^, 1029 ; sugar, 6 grains to the
ounce ; no albumin ; volume ranges from 5 to 6 pints.
She was ordered nitro-glycerin, jj^ pill (McK. & E,.),to
be taken three times daily.

December 27th. Urine specific gravit}^ 1029 ; sugar,
8 grains to the ounce. Treatment to be continued, 5
pills of nitro-gl^^cerin to be taken daily. No changes in
diet.

January ^, 1890. Patient states that the volume of
urine has ranged from 5 to 6 pints daily. Specific grav-
ity of urine to-day is 1027 ; reaction acid ; sugar, 6
grains to the ounce. The patient has some thirst.

She was ordered 15-grain doses of antip3'rin three
times daily, and to take green vegetables and one or two
small slices of bread each day.

January 8th. Urine specific gravit}^, 1027 ; acid re-
action ; sugar, 4 grains to the ounce ; no albumin.
Patient complains of nausea, much of the time, since
beginning antipj^rin. To continue antipyrin, 46 grains
dail}^

January 16th. Urine specific gravity, 1028; sugar,
8 grains to tlie ounce. There has been no decrease in
the volume of urine. To discontinue antipyrin.

Januajy 25th. Urine specific gravity, 1026; acid
reaction ; sugar, 6 grains to the ounce ; volume, 6 pints.
Some thirst is present. The patient was again ordered
an absolutely animal diet, mostly meats, fish, eggs, and
gelatin.

February 12th. The patient notes no special changes.
She has plainly fallen away in flesh during the last six
months. Her skin looks wrinkled. She rises at night
twice, on an average, to urinate, and the dail}' volume of
urine is from 5 to 6 pints. Her gums are somewhat in-

Clinical Considerations. 1S9

flamed and tender. Urine specific gravity, 1029 ; sugar,
7J grains to the ounc

It will be seen, from a review of the above record, that
the patient, although over 50 years of age, suffers from the
disease in the most obstinate form. The very strictest
form of dieting has been enforced from time to time,
and nearl}'- every medicine resorted to of repute in such
cases, without eliminating the sugar from the urine.
The quantity of sugar has been greatly reduced, and
maintained at a comparatively low range (about 1 per
cent.), but it has never been entirely absent ; the lowest
point it ever reached was 2 grains to the ounce.

The patient has alwa3's had excellent digestive
powers, and no nervous complication has been present.
The disease has been very decidedly checked, and dur-
ing the first two 3'ears' treatment it miglit be said to
have been held fairly well under control. During the last
six months, however, it is very plain that she is losing
ground, and I have no doubt that a fatal termination of
the case is not far distant.

With reference to the drugs employed in this case,
codeine seemed to diminish to a slight degree the excre-
tion of sugar when given in full doses ; but ultimately
codeine, as well as the other preparations of opium, had
to be abandoned, because they induced nausea, headache,
constipation, or other unpleasant after-effects.

Ergot for a time seemingly lowered the percentage
of sugar in the urine to a slight degree, but ultimately
it also disturbed the digestive organs. Antipj^rin proved
worse than useless, and, like in most other cases in my
hands, it only did harm. On the whole, it will be per-
ceived, from a close study of the case, tliat the patient
did the best upon a restricted diet, with little or no
medication.

140 Diabetes Mellitus.

Mild Type in Hebrew Patients. — It is pleasant to turn
from such exceptionally intractable and unsatisfactory
cases to another class in which the disease is usually
mild and more amenable to treatment. It has already
been pointed out that diabetes in the Hebrew race is
nearly always mild and comparatively easily managed.
The following cases are submitted as illustrations of
that fact : —

Case 266, Mrs. A.— October 15, 1889. Patient's age
is 44 years ; inclined to stoutness ; her mother and
father were both diabetic. She states that in June last
sugar was discovered in her urine ; she also had much
thirst and polyuria. She has recently suffered much
from metrorrhagia, for which the uterus was curetted, but
without relief, as she still has recurring haemorrhages.
She has practiced some restrictions of diet prescribed
by her family physician. Examination of her urine
to-day gives the following results : Specific gravity, 1028 ;
reaction acid ; sugar, 8 grains to the ounce. The urine
is free from albumin. She has some thirst, and rises at
night several times to urinate ; she states that she feels
very weak and easily chilled.

She was ordered to gradually restrict her food to
meats, fish, green vegetables, eggs, gelatin, and to use
no bread. No medicines were prescribed.

October 18ih. Urine specific gravit}^, 1025 ; sharply
acid ; sugar, 4 grains to the ounce.

October 23d. Urine is clear; specific gravit}^, 1026 ;
reaction acid ; sugar, 2 J grains to the ounce ; no albumin
present. She was ordered to diet strictly upon meats
and green vegetables.

November 2d. Urine to-day is clear ; acid in reac-
tion ; specific gravity, 1021 ; entirely free from sugar and

Clinical Considerations 141

albumin. Some nric-acid cr3'^stals of large size are
present as urinary sediment.

November 12th. Urine to-day is clear ; acid in reac-
tion ; specific gravity', 1023 ; free from sugar and albumin.

December 6th. Urine to-day is clear; acid in reac-
tion ; specific gravity, 1020 ; free from sugar and albumin.
The patient states that she feels stronger and better in
every ^ay. Thirst has disappeared, and she no longer
rises at night to urinate. She is to take one small slice
of bread at her morning and evening meal, — 2 ounces
daily, — and more liberal use of vegetables is to be per-
mitted, excluding potatoes, farinaceae, and sugar.

December 28th. The urine to-day is clear; of acid
reaction; specific gravit}^, 1024; free from sugar and
albumin. To continue diet as before, unchanged.

January 20 , 1890. The urine continues to be nor-
mal, and the patient is in good general condition, upon
a moderately restricted diet. Her haemorrhages have
passed away, with the return of the urine to the normal
condition.

Case 221, Mrs. L. — February P, 1889. Patient's age,
54 years. She states that she has had sugar in her urine
for over a j-ear. At present thirst and diuresis is mod-
erate in degree, as she has been dieting to some extent.
Her back and shoulders are covered with small boils,
which have been extremely painful and irritating for
liearl}^ three months. The urine is clear, of acid reac-
tion, specific gravity 1027, and contains 10 grains of
sugar to the ounce. The urine is free from albumin.
She was directed to gradually restrict her diet to meats,
fish, green vegetables, eggs, and gelatin, and to take one
slice of bread morning and evening. She was ordered
10 grains of quinine daily in divided doses.

142 Diabetes Mellitus.

February 13th. Urine to-day clear ; reaction acid ;
specific gravity, 1020 ; free from sugar.

February 23d, Urine, to-day, specific gravity 1025 ;
a trace of sugar is present. The boils are rapidl}^ dis-
appearing. The patient was directed to discontinue the
use of bread : otherwise to continue diet as before.

3Iarch 9th. Urine, to-da}^ specific gravity 1021 ; no
sugar; no albumin. The boils have disappeared; but
the patient complains of nervousness, for which bromide
of lithium was ordered in 5-grain doses after meals.

March 19th. Urine to-day is clear ; acid in reaction ;
specific gravity, 1021 ; no trace of sugar or albumin is
to be found. The patient states that she feels excel-
lently well, and is perfectly contented with the diet
allowed. To discontinue lithium bromide and to con-
tinue diet as before.

June 21st. Urine to-day is clear ; acid in reaction ;
specific gravity, 1020 ; perfectly free from sugar. The
patient has continued perfectly well, her strength being
entirely restored. No thirst, polyuria, or nervousness
remain.

January^ 1890. Urine, to-day, specific gravity 1020,
acid in reaction, and absolutely free from sugar.

Case of Malarial Origin. — The next case is one of

special interest as illustrating the occasional origin of
diabetes in malaria, as the histor^^ of the case very
clearly indicates : —

Case 135, C. ^.—Jiine S, 1885. Patient's age, 54
years ; a robust, strong-looking man ; says that he has
alwa5^s lived regularly and temperately, but that he has
had a good deal of exacting mental labor. He states
that he has been under treatment for severe bronchitis

Clinical Considerations. 143

for a number of weeks past. He says that sugar wag
first discovered in his urine about two years ago. He
was advised to practice some restrictions of diet, and to
take arsenite of iron, which he thinks have done him
some good. He states that he has suffered much from
malarial attacks during the last twenty years. His ma-
larial complications doubtless originated in Michigan,
where much of his time has been spent in the forests as
lumber-merchant. Examination of to-day's urine shows
the following characters : Color light ; reaction acid ;
specific gravit}^ 1035 ; sugar, 15 grains to the ounce ; no
albumin. He was directed to restrict his diet to meats,
fish, green vegetables, eggs, gelatin, etc., and to take
arsenite of iron, ^^ gi'ain, after meals.

June 18th. The urine is free from sugar, and the
patient goes East for a few weeks' rest.

November 8th. Urine, to-day, specific gravity 1036 ;
sugar present, 10 grains to the ounce. The patient has
been living upon unrestricted diet for some weeks past.
He states that the use of quinine always benefits him.
He says that without change of diet quinine lowers the
specific gravity of his urine when it is unduly high.
The patient was again instructed to regulate his diet
and to take Giliford's solution of bromide of arsenic, in
10-drop doses, after his meals.

March ^, 1886. The patient has spent most of the
winter on the Pacific coast, but was not especially
benefited thereby. Had chills and fever while there and
while traveling. He thinks he has had some sugar in
his urine of late. Urine, to-day, specific gravity 1030 ;
sugar present, 5 grains to the ounce. He was instructed
to diet more closely, and to discontinue arsenic treat-
ment.

May 3d. Urine specific gravit}^, 1025 ; no sugar.

144 Diabetes Mellitus.

The patient states that he rarely rises at night now to
urinate, and that he feels very well.

June 13th. The urine is free from sugar, and the
patient says he feels very well, except that he has some
rheumatism. He was ordered to take sodium salicylate,
20 grains daily, for his rheumatism. No changes in diet.

July 6th. The urine is free from sugar. Rheuma-
tism not much improved. He was ordered to continue
lithium salicylate and warm baths. No change in diet.

July 12th. Urine specific gravity, 1025 ; no sugar
present. Patient states that he feels better ; his rheuma-
tism is passing away. He is to continue the lithium
salicylate,

July 19th. The patient states that the specific
gravity of his urine has ranged, since last visit, at about
1020. He feels better than for three months past.

July 26th. The patient reports that he is free from
rheumatism. His urine is free from sugar. He was
directed to practice moderate restrictions of diet, and,
for the present, to take no medicines.

August 20th. Urine, to-day, specific gravity 1023 ;
free from sugar ; contains no albumin.

October 25th. Urine, to-day, specific gravity 1018 ;
free from sugar and albumin.

November 9th. Patient states that his urine has
ranged, since last consultation, as follows: Specific
gravity, 1016 to 1026 ; no sugar present. He states
that he is feeling very well in all respects.

December 6th. Urine, to-day, specific gravity 1020 ;
no sugar present.

February 3, 1887. Urine, to-day, specific gravity
1022 ; free from sugar. The patient was permitted to
take a slice of white bread morning and evening, also
to eat tomatoes : otherwise diet to be restricted to

Clinical Considerations. 145

meats, fish, green vegetables, gelatin, and eggs. No
medicines prescribed.

March 22d, Urine, to-day, specific gravity 1024;
free from sugar.

April 18th. Urine, to-day, specific gravity 1022; a
faint trace of sugar is present. Patient complains of
some rheumatism, for which he was ordered lithium
salicylate, 5 grains three times daily.

May 5th. The specific gravity of the urine fluctuates
much between 1014 and 1026. A slight trace of sugar
is present in the urine to-day. Patient was ordered to
continue lithium salicylate.

May 18th. Urine, to-day, specific gravity 1028 ; free
from albumin, but contains 2 or 3 grains of sugar to the
ounce. He was ordered Giliford's solution of bromide
of arsenic, in 10-drop doses, after meals. The lithium
salicylate to be discontinued.

July 11th. The patient states that he has been very
well for the last month. Urine, to-da}", specific gravity
1023 ; entirely free from sugar.

September 26th. Urine to-day is clear ; acid in reac-
tion ; specific gravity, 1023 ; a trace of sugar is present.
The patient has been allowed to indulge in fruits —
peaches and apples — which he is now directed to dis-
continue. To continue Giliford's solution, as before.

November 5th. Urine to-day is clear ; acid reaction ;
specific gravit}^ 1024 ; free from sugar. To continue
treatment as before, unchanged.

March 20 j 1888. The patient has just returned from
New York, where he states he was not feeling well of
late. For the past two or three days he has had acute
cystitis, with some slight elevation of temperature.
Urine to-day is cloudy ; specific gravity, 1020 ; free from
sugar ; contains a large deposit of pus-corpuscles. He

7 G

146 Diabetes Mellitus.

was confined to his room, and put npon an infusion of
triticiim repens, with 10-grain doses of ammonium ben-
zoate for his cystitis.

March 21st. Cystitis is not improved ; patient urin-
ates every hour, with pain and vesical tenesmus ; some
blood in the urine to-day. His temperature is 99.5° F.
To take 12 grains of quinine daily, as malaria was sus-
pected to be the cause of the elevation of temperature ;
triticum repens and ammonium benzoate to be continued
as before.

March 2Jfth. C3'stitis continues more or less annoy-
ing ; at times there is much pain in urinating. Urine
to-day very cloudy ; specific gravity, 1009 ; free from
sugar ; a small amount of albumin and a large amount
of pus present. Treatment for cystitis continued un-
changed, and quinine to be continued in the same doses
as before. Diet restrictions to be somewhat relaxed.

March 30th. Urine very turbid still ; specific gravity,
1011; free from sugar; considerable sediment of pus
in urine still. There is much less distress from the
cystitis to-day.

April 2d. Urine, to-day, specific gravity 1012; free
from sugar, but very cloudy, and much sediment still.
The lowered specific gravity of the urine is doubtless
due to the large amount of demulcent drinks the patient
takes for his C3'stitis.

April 20th. The patient has been very ill for the
last three weeks. The cystitis was followed by remit-
tent fever of almost malignant type, which refused to
yield to quinine until the dose had been increased to
80 grains per day. Nothing short of 20-grain doses,
repeated three or four times daily, seemed to have any
modifying effect over his chills and elevated temperature.
The patient is now much better in all respects.

Clinical Considerations. 14t

May 5th. Urine, to-day, specific gravit}^ 1030 ; sugar
present, 7 grains to the ounce. The urine is increased
in volume, but is now clear, and contains little or
no pus.

As the re-appearance of sugar in the urine is doubt-
less due to relaxation of his diet rules, he is now directed
to diet again strictly.

May 10th. Urine, to-da}^, specific gravity 1023 ; a
trace of sugar is present — less than 1 grain to the
ounce. The patient's general condition is improving
very markedly. He was directed to take, once a week,
50 grains of quinine in divided doses during the day.

May 19th. Patient states that he is feeling stronger,
and has gained somewhat in weight. Urine, to-day,
specific gravity 1021 ; a trace of sugar is present.

May Slst. Urine, to-day, specific gravit^^ 1021 ; sugar
present, 2 grains to the ounce. The patient leaves for
Carlsbad in a few days, to spend the season at the
springs.

It should be stated that during the four years the
patient has been under observation, he has sufiered from
attacks of chills and fever (malarial) about twice each
year. Most of these attacks have occurred while he
was absent from home. If he undertook a railway
journey he was prett}'' sure to have an attack, an
occurrence I have frequently observed in those who
are saturated with malarial poison. His attacks have
been comparatively mild, except the last one described
in the records, complicated with c^^stitis.

Case Complicated by Amyloid Kidneys. — The next
case is cited as illustrating an interesting but rather
uncommon class of cases, in which diabetes becomes
complicated with amyloid disease of the kidneys.

148 Diabetes Mellitus

Perhaps, in the majority of such cases, as in the one
to be related, diabetes is the complicating disease, the
amyloid condition probably having existed for some
time previous. The case also illustrates the relation-
ship of tuberculosis to diabetes and amyloid conditions,
which is not uncommon.

Case 102, J. ^.—February 17, 1880.— "ThQ patient's
age is 41 years, merchant, married ; he states that
he has been ill for six weeks, during which time he has
lost 35 pounds in weight. He had a chronic cough
some years ago, which was pronounced to be of tuber-
cular origin by his physicians. He has not had syphilis.
His left humerus is in a condition of chronic necrosis,
discharging from several small openings, through which
numerous small spicula of bone have been extruded at
various times. At present only three openings are
present, and very little discharge issues therefrom. He
states that his necrosis is of about twenty years' stand-
ing. The three openings now discharging are situated
just below his shoulder-joint; those lower down the
shaft of the humerus have healed.

His present sj^mptoms are great thirst, ravenous
appetite, chills, much muscular weakness, dry skin, and
pronounced diuresis ; temperature, 9T.5° F. He passes,
by measure, from 16 to 18 pints of urine dail3% which,
upon examination, gives the following results : Specific
gravit}^, 1028; acid reaction; clear; sugar, 20 grains to
the ounce ; a small amount of albumin is present, and a
few large, clear casts were observed under the micro-
scope. The patient was put upon an exclusive milk diet
gradually enforced.

February 21st. Thirst is less urgent, and the urine
is diminished in quantity ; specific gravity, 1012.

Clinical Considerations. 149

March 3d. Urine specific gravit}^, 1012 ; some albu-
min present still.

March 10th. Patient has diarrhoea, and has vomited
several times during the past two days. Urine, 5 pints ;
specific gravity, 1015. He states that he feels very weak
and depressed, and that he does not sleep well. Slight
oedema of left foot appeared for the first to-day. Albu-
min present in considerable quantity. Removed patient
to hospital to-day for better care. Continued milk diet.

March l^th. The patient has had much nausea and
some vomiting during the past two days. Urine con-
tains about 6 grains of sugar to the ounce. To continue
milk treatment for the present.

March 20th. Urine, to-day, specific gravity 1019 ;
acid reaction ; sugar present, 3 grains to the ounce ;
albumin, 15 per cent., bulk measure. Some granular
and hyaline casts observed under the microscope.

March 31st. Urine, 4 pints in volume ; specific grav-
ity, 1014 ; a small amount of sugar present and con-
siderable albumin. The bowels continue to be loose
most of the time. The patient looks anaemic, and oedema
is extending to the limbs and upper extremities. Patient
was ordered to discontinue exclusive milk treatment,
and to begin eating green vegetables, meats, fish, eggs,
etc., still taking, however, a liberal quantity of milk with
his other food.

April 10th. Dropsy is becoming general. Urine, T
pints in volume; specific gravity, 1014; albumin, two-
thirds, bulk measure ; sugar, 4 grains to the ounce.

April 19th. Urine, 90 ounces ; specific gravity, 1012 ;
albumin, 45 per cent., bulk measure, upon standing
twentj^-four hours. Dropsy is becoming more marked
daily. Patient was ordered dry hot-air baths, of half
an hour's duration, each day.

150 Diabetes Mellitus.

April 25th. Urine, 160 ounces ; specific gravity, 1012 ;
albumin, 12 per cent., bulk.

April 30th. Urine, 192 ounces ; specific gravity, 1010 ;
albumin, 16 per cent., bulk measure; sugar present, 2
grains to the ounce. Dropsy is less marked. To con-
tinue diet and hot-air baths, unchanged.

May 4th. Urine, 224 ounces ; specific gravity, 1009.
Dropsy is subsiding rapidly under increased diuresis and
diaphoresis, induced by hot baths.

May 8th. Urine, 12 pints; specific gravity, 1010;
albumin, 20 per cent., bulk measure. The dropsy has
almost entirely disappeared except in the feet. Patient
feels very weak to-day. Hot bath was omitted.

May 17th. Urine, 6 pints ; specific gravity, 1010 ;
albumin, 36 per cent., bulk ; sugar present, 2 or 3 grains
to the ounce. A very obstinate diarrhoea has set in,
which greatly weakens the patient. The stools are fre-
quent and watery ; the pulse is weak, and the extremities
cold. Some sharp pain is complained of in region of the
liver, and extending to right lung. These symptoms were
followed by indications of collapse to-da3^ Deodorized
tincture of opium was ordered in 15-drop doses, per
rectum, after each loose stool. Restrictions of diet were
removed, except as to sugar, potatoes, and farinacese.

May 21st. Urine, 5 pints; specific gravity, 1010;
albumin, 30 per cent., bulk ; sugar present, 4 or 5 grains
to the ounce.

June 7th. Urine, 5 pints; specific gravity, 1009;
albumin, 35 per cent., bulk measure; sugar present, 6
grains to the ounce. Dropsy is again becoming promi-
nent, and diarrhoea is persistent. The liver and spleen
are both considerably enlarged. The specific gravity of
the urine descended to 1004 two days ago, but at this
low gravity it contained both albumin and sugar ^ the

Clinical Considerations. 151

latter in very small amount — less than 2 grains to the
ounce.

July 1st. The condition of the patient has fluctuated
much for the last three weeks, but dropsy has been
steadily increasing. The patient this morning passed
into uraemia, and died during the night in comatose
state without convulsions.

Cases Originating from Excessive Eating. — The next
2 cases are appended as types of that form of diabetes
brought about by overingestion of food. That diabetes
of severe grade is capable of being induced in certain
individuals by intemperance in eating has already been
pointed out in the section on Etiology. It only re-
mains to bring forward clinical illustrations of such
cases, as follow: —

Case 234, S. A.— -April 30, 1889. Patient's age is
44 years ; married ; is a stout, robust-looking man ;
weight, 194 pounds; occupation, traveling salesman.
He states that he was delicate as a child, but after 6
years of age he has had no illness. He has always had
a good appetite, — indeed, too good; for, to use his own
words, he " never knows when he has had enough to eat."
He states that he uses tobacco and spirits moderately.
He first noticed, a year or so ago, upon eating rapidly,
that he vomited his breakfast occasionally, and this has
become the rule of late. He began to be very thirsty
four weeks ago, and to urinate very freely. His tongue
became coated and dry, and he had headache much of
the time. After two weeks or so, during which his
symptoms grew more and more {pronounced, he consulted
a phj^sician, who found sugar in his urine, and ordered
^ diet of mutton, veal, chicken, brown bread, and milk.

152 Diabetes Mellitus.

He states that he has been a great bread-eater, and that
he has always taken a great deal of oatmeal with milk
at his breakfasts. A sample of his urine which he
brought for analysis contains a small percentage of sugar
— about 2 grains to the ounce. He was directed to eat
without restriction either as to quantity or quality of
food for twenty-four hours, and then bring his urine for
examination.

May 2d. Urine specific gravity, 1025 ; sugar, 4
grains to the ounce ; no albumin. He was now directed
to eat moderately ; to stop the use of oatmeal, and to
take little or no bread or farinacese ; but, above all, not
to overload his stomach.

May 6th. Urine of last evening, specific gravity,
1023 ; sugar present, but only a trace. He states that
he has little or no thirst, and diuresis has diminished
very decidedly ; he no longer rises at night to urinate.
He has not vomited for three days. He was ordered to
continue diet as before, unchanged, and take no medicine.

May ISth. Urine specific gravity, 1020; absolutely
free from sugar and albumin. The tongue has cleaned,
thirst has subsided, diuresis has passed away, and no
further nausea or vomiting has occurred.

June 1st. Tlie patient states that he feels very well ;
has no thirst or polyuria. Urine specific gravity, 1020;
free from sugar. He goes on the road for two months,
with instructions to exclude from his diet farinacese,
potatoes, and saccharine foods.

August 1st. Urine specific gravity, 1020 ; color
normal ; acid reaction ; free from sugar and albumin.
To continue treatment as before, unchanged.

October 2d. Urine, after breakfast of bread, eggs,
and steak, specific gravit}^, 1021 ; acid reaction; free from
sugar and albumin. He states that he never rises at

Clinical Considerations. 153

night to urinate now, has no thirst, is not weak, stomach
is in excellent condition, and he sleeps well. He was
permitted to eat apples and tomatoes, with bread, in
moderation ; in fact, diet to be very liberal in quality^
but strictly moderate in quantity.

October 9th. The patient has been eating, for a week
past, nine slices of white bread daily, and everything
except sweets, potatoes, and farinacese. He has no
thirst or diuresis.

Urine, to-da}", specific gravity 1020 ; no sugar. To
throw off all restrictions as to quality of diet except in
the matter of sugar. He was especially instructed to
eat moderately.

January 11^ 1890. The patient states that he has
been very well since last visit. He has no tliirst ; does
not rise at night to urinate. He eats everything ex-
cept sugar, "the same as before he took sick." Urine
specific gravity, 1023; no sugar; no albumin.

He was directed to practice habits of temperance in
eating, and to report if thirst or diuresis returns.
There can be no doubt that in the above case diabetes
was brought on by overloading the stomach. The
patient was an enormous eater, for, as he frankly con-
fessed, he "never knew when he had eaten enough."
For nearly a 5'ear before sugar appeared in his urine he
vomited his breakfast almost dail}', and when he first
came under observation he was suffering from the usual
symptoms of food poisoning.

Case 282, H. B.— December 7, 1889. Patient's age
38 3'ears ; weight, 230 pounds ; stout, plethoric man ;
comes for advice in reference to sugar in his urine,
which was discovered yesterday by medical examiner
for life-insurance company. His life was accepted three

154 Diabetes Mellitus.

years ago by another compaii3\ Preliminary examina-
tion of his urine shows it to contain 12 grains of sugar
to the ounce ; no albumin present. Patient states that
he noticed thirst of late ; he also says that he rises at
night to urinate, passing large quantities of urine by
night and by day. He has noticed considerable weak-
ness, especially for the last sixty days or so. He states
that he is a very large eater ; has taken oatmeal very
liberally for breakfast for the past fifteen or eighteen
years. He eats his oatmeal with much sugar. He states
that he is ver^^ fond of sweets. He does not eat much
meat, but is very fond of bread and potatoes. He does
not use spirits, but is a liberal tobacco-smoker. He
suffers much from flatulence and eructations after meals.
No history of diabetes is obtainable, either on his
father's or mother's side of the family. Urine, to-day,
specific gravity 1028; acid reaction; sugar present, 12
grains to the ounce. The urine contains no albumin.
He was directed to avoid oatmeal, farinacese, sweets,
etc., and to use bread in moderation. No medicines
were prescribed.

December 12th. Urine, to-day, color normal ; acid
reaction ; specific gravity, 1025 ; sugar, 3 grains to the
ounce ; no albumin.

December 19th. Urine, to-day, color normal ; acid
reaction ; specific gravitj^, 1021 ; free from sugar.
Patient feels greatly improved ; is no longer weak ;
does not rise at night to urinate ; is not thirsty. He
was directed to use but little farinaceous foods and
sweets, but especially to eat temperately, and to report
any return of thirst or diuresis, especially if he rises at
night to urinate.

March ^, 1890. Patient continues well, and his urine
is free from suorjir.

Clinical Considerations. 155

Case in Childhood. — The rarity of saccharine dia-
betes in childhood forms a sharp contrast with diabetes
insipidus, so frequent in the early ^^ears of life. The
following case, the 3^oungest patient with diabetes whom
I have treated, will illustrate both the severity and usu-
ally rapid course of the disease in subjects of tender age.

Case 223, B. Q— December 31, 1888. Patient's age,
4 years and 3 months. His mother first noticed in
August last that he was urinating very frequentlj^,
" wetting the bed " at night. About the same time he
became very thirst^'^. He has recently lost considerably
in weight. He complains of being weak and tired much
of the time. His mother states that he urinates about
every half hour. Careful inquiry fails to reveal any
history of diabetes in the family, but tuberculosis is
prominent. The patient has had no serious illness
before ; but he fell upon the floor of a car a short time
before his present illness begun, and sustained a severe
blow upon his head. His urine to-day is clear ; color
light greenish-3^ellow ; acid reaction ; specific gravity,
1083; and contains 20 grains of sugar to the ounce.
The urine is free from albumin. The patient was
ordered a diet of milk, meats, a little cracker, and some
green vegetables. No medicines were prescribed.

January S, 1889. Urine, to-day, specific gravity
1025 ; sugar, 12 grains to the ounce.

February 4th. Urine specific gravity, 1030; sugar,
10 grains to the ounce; no albumin. Diuresis and
thirst greatly diminished. He gives his nurse no more
trouble at night from calls to urinate. The family phy-
sician now volunteered to cure the patient, and, as my
prognosis was such as to afford the parents no hope of
recovery, the patient passed into the hands of the more
sanguine physician.

156 Diabetes Mellitus.

October I4, 1889. The parents of tlie child returned
and requested me to resume treatment of the case.
Examination of the patient disclosed extreme emaciation,
great thirst, and diuresis. The patient had been per-
mitted a mixed diet, including all fruits and farinaceae,
and, as a consequence, the disease had progressed at a
rapid pace. Examination of the urine resulted as fol-
lows: Color light; reaction acid ; specific gravit}^, 1038 ;
sugar present, 25 grains to the ounce ; urea, .013 gramme
to cubic centimetre of urine ; phosphates greatly in
excess ; the urine is free from albumin. The patient
seems tired, weak, restless, and has little or no appetite.
He was put upon milk, with a little bread ; and quinine
was ordered in 1-grain doses three times a da}'.

October 18th. The appetite has somewhat improved,
and the patient seems less weak. The urine to-daj^ is
clear, acid in reaction, specific gravity 1033, and con-
tains 25 grains of sugar to the ounce. Phosphates
greatly in excess ; no albumin present. Diet to be re-
stricted almost entirelj^ to milk. To continue quinine,
3 grains daily.

October 21st. Urine, 4 i)ints ; specific gravitj^, 1029 ;
sugar, 18 grains to the ounce. To continue treatment as
before.

October 28th, The patient seems very weak, has
little or no appetite. Urine, to-day, specific gravity
1033; sugar, 16 grains to the ounce; phosphates in
excess ; no albumin present.

November 4ih. Urine, to-da}^, specific gravity 1029 ;
clear; acid reaction; sugar present, 12 grains to the
ounce ; phosphates in excess. To continue milk diet,
with very little bread, and some green vegetables.

November 12th. Urine specific gravity, 1024 ; acid
reaction ; sugar, 10 grains to the ounce. The patient is

Clinical Considerations. 157

weak, has little relish for food, and is troubled with
slight cough.

November 24th, The cough is better, and, on the
whole, the patient seems somewhat stronger. Urine, 5
pints ; specific gravit}'', 1028 ; sugar, 10 grains to the
ounce ; no albumin.

December 6th. Urine is clear ; color light ; specific
gravity, 1033 ; sugar, 10 grains to the ounce.

December 18th. Patient began to complain of pains
in his stomach and bowels and to grow a little drowsy
to-day. His respirations were somewhat quickened.
He was given a hot bath, and hot bottles were applied to
liis extremities, and 10-grain doses of sodium bicarbonate
were ordered ever}^ hour.

December 19th. Patient is more stupid to-day;
sleeps much of the time. The respirations have in-
creased in frequency to 40 per minute ; the temperature
is 101° F. The abdominal pains have subsided. Toward
evening the patient became more stupid, and refused all
food.

December 20th. Patient died to-day in a comatose
state, without convulsions.

Cases Treated by Oxygen Inhalations. — The 2 fol-
lowing cases are herewith taken from my records of
practice, more especially with the view of illustrating
the oxygen treatment of the disease : —

Case 296, W.—July 5, 1890. Patient's age, 54
years; tall, dark, strong-looking man. States that he
ha3 had sugar in his urine, more or less, for four or five
years. Last j^ear he visited Carlsbad, and put himself
under the care of one of the local physicians there for
several weeks, with the result of considerable improve-

158 Diabetes Mellitus.

ment. Since his return home he has been dieting care-
fully, according to the instructions he received at Carls-
bad. The patient's face, neck, and shoulders are covered
with multiple boils, which he states have been gradually
growing worse for the last six weeks, to his great annoy-
ance. He rises at night to urinate, has slight thirst,
some weariness of the muscular S3^stem. The urine is
clear, specific gravity 1027, sharply acid, and contains
15 grains of sugar to the ounce; no albumin present.

Since his diet, as advised at Carlsbad, — which he is
observing strictly, — seems proper, no essential changes
were made in this respect, except to reduce his bread-
allowance to 3 ounces daily, instead of 5 ounces, which
has been his former allowance. Inhalations of pure
oxygen gas were administered daily to the extent of
12 litres.

July 7th. The urine is clear, specific gravity 1030,
reaction acid, and contains 12 grains of sugar to the
ounce. No special improvement in the boils.

July 8th. Urine clear ; acid in reaction ; specific
graA^ty, 1028; sugar, 8 grains to the ounce.

July 10th. Urine clear ; color normal ; reaction
acid ; specific gravity, 102Y ; sugar, 7 grains to the ounce.
He was given 10 grains of quinine daily and ox^^gen
inhalations continued as usual.

July 12th. Urine is clear ; color normal ; specific
gravity, 1024; sugar, less than 2 grains to the ounce.

July IJfth. Urine is clear ; color normal ; reaction
acid ; specific gravity, 1022 ; absolutely free from sugar.
The boils are rapidly improving, and the patient states
that he feels greatly improved.

July 20th. The urine to-day is clear ; color normal ;
reaction acid ; specific gravit}^, 1019 ; it is perfectly free
from sugar. The boils have practically disappeared,

Clinical Considerations. 159

the thirst is gone, and the patient no longer rises at night
to urinate. The oxygen inhalations were discontinued,
and the patient was ordered to take glycozone (Ch. Mar-
chand's) in teaspoonful doses before meals.

July 29th. The urine is clear ; color normal ; reac-
tion acid; specific gravity, 1019; and perfectly free from
sugar. The patient is, apparently, perfectly well, but
was directed to continue the glycozone for the present.

August 16th. The urine is clear; color normal;
specific gravity, 1022 ; reaction acid ; quite free from
sugar.

Case 298, H. B. F.—June 15, 1890. Patient's age,
47 ; weight, 210 pounds ; tall, robust-looliing ; rather
stout. He states that sugar was first discovered in
his urine about five years ago. For the last three
months he has had much thirst, and passes about 5 or 6
pints of urine daily. His digestion has been poor for
five 3'ears or more. Bowels inclined to constipation.
No hereditar}^ history of diabetes. He recently' returned
from Carlsbad, where he went for the cure, and thinks he
was much better while there. His urine to-day is clear ;
acid in reaction; specific gravity, 1027 ; it contains 24
grains of sugar to the ounce. No albumin present.

He was ordered inhalations of oxygen gas to the ex-
tent of 12 litres dail}^, and he was directed to limit his
bread -allowance to 3 ounces daily.

June 18th. The urine is clear ; color ratlier greenish;
reaction acid ; specific gravity, 1024 ; and contains 10
grains of sugar to the ounce. Patient states that his
thirst has disappeared, that he does not rise at night to
urinate, and that he passes but little more urine than
normal. Oxygen inlialations to be continued as before,
daily.

160 Diabetes Mellitus.

June 21st. The urine contains but 4 grains of sugar
to the ounce to-day. Treatment to be continued as be-
fore.

June 24th. Urine to-day is clear ; color normal ; re-
action acid ; specific gravity, 1022 ; and perfectly free
from sugar. Oxygen inhalations were ordered to be
reduced to 6 litres per day.

June 30th. Urine is clear ; color normal ; reaction
acid ; specific gravity, 1020 ; absolutely free from sugar.
Patient is to take 6 litres of oxygen every alternate day.

July 2d. Urine clear ; color normal ; reaction acid ;
specific gravity, 1020 ; no sugar.

July 11th. Urine to-day is clear ; color normal ; spe-
cific gravity, 1021 ; reaction acid ; free from sugar.

July 17th. Urine clear ; color normal ; reaction acid ;
specific gravity, 1019 ; no sugar. Patient states that he
feels perfectly well. He was ordered peroxide of hydro-
gen (Ch. Marchand's) in doses of 1 teaspoonful before
meals in water, and the oxygen inhalations were discon-
tinued.

The patient was directed to avoid saccharine and
starchy foods, but was permitted 2J ounces of common
bread daily.

July 25th. Urine to-day is clear ; color normal ;
specific gravity, 1020 ; free from sugar.

August 3d. Urine to-day clear; color normal ; reac-
tion acid ; specific gravity, 1019 ; free from sugar. The
patient goes to the sea-shore for a month with directions
to continue the diet as laid down above, and to discon-
tinue peroxide of hydrogen.

SECTION YIII.
Diabetes Insipidus

CLASSIFICATION.

Diabetes insipidus, polyuria, polydipsia, or hydruria,
as the disease has been severally called, is a morbid con-
dition of the system, the characteristic symptom of
which is an excessive flow of urine of low specific
gravity. As a rule, the urine contains neither albumin,
sugar, or other morbid chemical products. Willis was
the first to attempt a classification of the disease, and he
described it under three divisions, as follow : (1) cases
characterized by excessive excretion of aqueous urine,
the solid matters being deficient — hydruria; (2) cases
characterized by excessive flow of urine deficient in
urea — anazoturia ; (3) cases in which the flow of urine
is excessive, and characterized by an abnormal quantity
of urea — azoturia.

Parkes adopted a classification of the disease which
had reference to the degree of tissue changes involved.

It seems more convenient and practical, as Dr. Ralfe
has suggested, to adopt a classification which has refer-
ence, first, to the excessive excretion of water by the
kidneys, and, second, to the increase of solids in the
urine. Hydruria may be applied to cases characterized
by excessive flow of aqueous urine, and polyuria to
cases in which urea or other urinary solids are excreted
in excess.

Our knowledge of the physiology of diabetes insipi-
dus— meagre as it at present is — is largely due to the

G» (161)

162 Diabetes Insipidus.

investigations of Bernard. He has shown that the Taso-
motor centres for both the liver and kidne^^ are comprised
within the medulla oblongata. By experiments upon
animals Bernard has shown that when the floor of the
fourth ventricle of the brain in the central line is
wounded the urine becomes saccharine and excessive in
quantity. Wounded somewhat higher up, the urine
becomes excessive in quantity, but contains no sugar.
The higher area, therefore, comprises the vasomotor
centre which presides over the kidne}?", while the lower
area presides over the liver. Thus far, however, ph3^si-
ologists have failed to trace the path of the nervous
influence from the vasomotor centre to the kidne3'^, as
has been done in the case of the liver.

ETIOLOGY.

Diabetes insipidus, like diabetes mellitus, is over
twice more frequent in males that it is in females ; but
it differs from the saccharine disorder in its greater
frequency in early life — most of the cases occurring
under 30 years of age. It is quite common in childhood,
and even in infancy, but the disease is rare in advanced
life.

In a large proportion of the cases it seems impos-
sible to clearly trace the disease to any definite cau«^
In a considerable number of cases, however, a distinct
history of heredity is traceable. Lancereaux was able
to trace about 15 per cent, of the cases to this cause.
Diseases and traumatisms of the brain are, undoubtedly,
frequent causes of diabetes insipidus. Lancereaux
found about 16 per cent, of the cases to be due to this
cause, while Roberts found a still larger percentage of
cases originating from this source.

A considerable number of cases seem to owe their

Pathological Anatomy. 163

origin to intemperance, especially to habitual alcoholic

The remaining causes assigned for the disease are :
Exposure to cold, or sudden chills ; drinking cold fluids
when the body is overheated; hysterical and nervous
conditions ; mental emotion ; acute inflammatory and
febrile conditions. A cause which I do not remember
to have seen recorded, but which I have more than once
traced, is that of sexual excesses. The frequent mictu-
rition associated with irritable bladder, so common to
excessive sexual indulgence, is not to be mistaken for
polyuria. Finally, it is probable that nearly 40 per
cent, of the cases of diabetes insipidus cannot be traced
to any determinate cause.

PATHOLOGICAL ANATOMY.

The most frequent lesions found at the autopsy, in
cases of diabetes insipidus, are those of the brain,
although they are by no means uniform. From what
has already been said of the ph3'siology of polyuria, it
is evident that any disease involving the higher area of
the medulla oblongata is liable to give rise to this dis-
ease. Besides the various injuries to the head involving
the cerebellar substance, it is not uncommon to find, at
the autopsy, tubercular lesions implicating the upper
medullar tract. More rarely syphilitic deposits have
been found, as well as some of the hj^perplastic growths.
It is not absolutel}'- essential that the primary lesion of
the brain, which gives rise to diabetes insipidus, should
be situated in the vasomotor centre for the kidney.
Morbid growths or degenerative changes, elsewhere
situated, may, by involving the circulation of or ex-
erting pressure upon the renal A^asomotor centre, bring
about the disease secondarily. Miliary tuberculosis and

164 Diabetes Insipidus.

thickening have been found at the base of the brain in
these cases, and in other localities not directly involv^-
ing the fourth ventricle. "With regard to the kidneys,
the changes usually found are slight, and, for the most
part, such as we might expect to find as a result of ex-
cessive functional activity of these organs, the most
constant of these being hyperaemia and some enlarge-
ment. In those cases in which the disease has long
continued, evidences of inflammatory action are frequent,
and in some cases interstitial changes and atrophy are
to be found. Dilatation of the bladder, ureters, and of
the renal pelvis are common ; and certainly their almost
constant distention in these cases might be expected to
bring about such results.

SYMPTOMS AND COURSE.

The most prominent symptoms of diabetes insipidus
are diuresis and thirst. These are sometimes enormous,
and they usually correspond closely in degree. Cases
are commonly observed in which from 30 to 40 pints of
urine are voided daily. Perhaps the largest quantity
recorded was in a case related by Trousseau, in which
the patient passed, during twenty-four hours, 56 pints of
urine. Sir Wm. Roberts has recorded the case of a girl
who passed more than a third of her weight of urine daily
for several weeks. These, however, must be considered
exceptional cases, ordinarily the range being from 10
to 30 pints dail3\ The urine is pale in color, almost
watery in appearance, and usually of very low specific
gravity, ranging from 1008 to 1002, and it may even
descend lower. Notwithstanding this low specific gravity
of the urine, and consequent disproportion of solids,
the gross quantity of the latter eliminated by the kid-
ne^^s may suffer no reduction whatever j indeed, the

Symptoms and Course. Ifr5

quantity of urea aud phosphates is often increased.
The urine often contains inosite, but since this substance
is often present during diuresis, however induced, it can
scarcely be considered a morbid product, or at least one
characteristic of this disease. In exceptional cases
albumin or sugar may appear in the urine, especially in
chronic and inveterate cases, but this is unusual.

Thirst is quite as prominent a symptom in diabetes
insipidus as is diuresis; in fact, as already indicated,
tUey usually go hand in hand together, the volume of
fluid ingested corresponding closely with that eliminated.
Some observers have claimed that the volume of urine
exceeds the quantity of fluids imbibed in some of these
cases ; but more recent and accurate observations show
that when the patient is unrestricted in the matter of
drinks, the amount of fluid eliminated by the kidnej'S
corresponds closely to that ingested. When the quantity
of imbibed fluid is restricted, however, there seems to
be some excess eliminated for a time, at the expense of
dehydration of the tissues.

The thirst in diabetes insipidus is even more urgent
than it is in diabetes mellitus, and, moreover, the
capacity for fluids seems to be greater. There is this
difference, however: in diabetes insipidus a copious
draught usually satisfies the craving for water for a
time, while in saccharine diabetes the thirst seems
unquenchable.

In many of these cases the general health seems to
be little, if any, impaired ; more especially is this the
case in that form of the disease termed hydruria^
in which the elimination of solids is not excessive.
Numerous cases are on record in which the disease
has existed from childhood to middle and even ad-
vanced age, during all of which time the patients have

166 Diabetes Insipidus.

enjoyed a very fair degree of health and vigor, bodily and
mentally. Indeed, it is recorded that some of the sub-
jects of this disease have become fathers and mothers
of large families, apparently suffering no discomforts or
physical disadvantages except the frequent demands
made by the system to ingest or void fluids. In other
cases li3'druric patients exhibit symptoms which corre-
spond in a measure to a mild tj'pe of saccharine diabetes.
Thus, more or less gastric discomfort may be expe-
rienced, often amounting to pain; the appetite may be
morbidly increased, or again it may be impaired or abol-
ished. The patient may become nervous, fretful, or
querulous; and emaciation and general enfeeblement are
sometimes the sequel in the more chronic cases. The
abstraction of heat, caused by large quantities of fluids
passing through the bod}^, renders the patient suscepti-
ble to disagreeable sensations of cold, or to actual chills.
The bowels are usually constipated, and sometimes this
state alternates with attacks of diarrhoea.

In the poly uric form the general symptoms are apt to
be most pronounced. The increased elimination of urea
and phosphates point to retrograde tissue metamorpho-
sis in progress, which sooner or later must tell upon
both the vital and muscular forces. The quantity
of urine, though greatly increased in this form of the
disease, never reaches the enormous range common to
hydruria. The specific gravity of the urine ranges
usually from 1010 to 1025, and the reaction is distinctly
acid.

Tessier has described certain of these cases, charac-
terized by excessive quantities of phosphoric acid in the
urine, under the name of "phosphatic diabetes." The
essential features of these cases are slight, if any, in-
crease in the volume of urine ; but very decided increase

Diagnosis. 167

in the solids, especially of the phosphates. There is
usually great debility, neuralgic pains, but moderate
thirst, and the urine is of high specific gravity. Dr.
Ralfe has confirmed Tessier's observations and recorded
a number of similar cases.

The course of diabetes insipidus is exceedingly va-
riable, depending much upon its cause. Thus, when
brought about by diseases and traumatisms of the brain,
its course is largely influenced by the extent and con-
sequences thereof in each individual case.

As a rule, the disease is not directly fatal through its
own effects. The loss of sleep consequent upon the
frequent disturbance to urinate, or to quench thirst,
coupled with mental worry and depression in delicate
subjects, may at length bring about an enfeebled state
of health, which often precipitates some secondary dis-
ease, from which the patient may succumb.

In the late stages of the disease oedema of the feet is
common, and this is doubtless due to anaemia. Furun-
culae (multiple boils) sometimes complicate this stage,
although this is not so common as in diabetes mellitus.

The duration of the disease, as shown by the records,
varies from a few months to fifty-nine years. The cases
that recover usually do so within one or two years,
although recoveries are recorded after the disease had
lasted twenty years. In fatal cases death is most
common within the first two years.

DIAGNOSIS.

Diabetes insipidus may be confounded with irritable
bladder unless the symptoms are carefully distinguished.
In irritable bladder the urine may be voided as fre-
quently as in diabetes insipidus. Careful inquiry, how-
ever, will elicit the fact that the quantity of urine voided

168 Diabetes Insipidus.

is only an ounce or two at a time. Measurement of
the twenty-four hours' urine will at once determine the
point in question.

In granular atrophy of the kidneys (interstitial ne-
phritis) the patient often rises at night and passes con-
siderable quantities of urine of low specific gravity, with
or without albumin. The quantity of urine, however, in
these cases, if measured for the whole twentj^-four hours,
will usually be found only slightly to exceed the normal
standard, and, moreover, the specific gravity rarely
sinks so low as in diabetes insipidus. In granular
kidney the polyuria occurs onl}^ — or chiefly — at night.
Cardiovascular changes are usually present, and thirst
is absent.

The absence of sugar from the urine distinguishes
the disease from diabetes mellitus.

PROGNOSIS.

Diabetes insipidus may be regarded in general as a
less serious disease than is diabetes mellitus ; at the same
time, it often resists all treatment, and runs a fatal
course. In the hydruric form the disease is less fatal,
though long continued, and absolute cure is the excep-
tion rather than the rule.

Cases arising in the wake of inflammatory diseases,
or those beginning in youth without assignable cause,
may be regarded as most favorable in a prognostic point
of view.

In the polyuric form, which is attended by the loss
of much solids by the urine, the prognosis must be
looked upon as serious. Such cases are more apt to lay
the foundation for some intercurrent disease, such as
phthisis, or organic disease of the central nervous
system, which precludes a favorable prognosis.

Treatment. 169

TREATMENT.

Experience has demonstrated that restrictions of
food serve no useful purpose in tliis disease, and that
restriction of drinks only do harm. It was thought, at
one time, that the diuresis might be brought under con-
trol by limiting the amount of fluids ingested. This
course not only greatly increased the suffering of the
patient, but also, in at least one case, brought about a
fatal termination through ursemia. The more advisable
course is to permit the patient the use of water without
restriction. In cases attended by excessive tissue meta-
morphosis— and they are the most numerous — the free
ingestion of fluid .serves to absorb and wash out the
effete products, which must otherwise accumulate in
the system, without doubt to the detriment of the latter.
In addition to this the free use of fluids relieves the
chief discomfort of the patient — his thirst ; and we
have no right to deny him this relief tlirough measures
that are, in themselves, harmless. The patient may,
therefore, indulge in aqueous beverages ad libitum^ and
he will find lemonade, especially if made with soda-
water, very grateful to the palate. Alcoholic drinks
increase both the thirst and diuresis, by abstracting
water from the tissues, and, therefore, they should be
avoided. The patient should not take his beverages
too cold (iced), — an injunction not to be overlooked,
as he is sure to select iced drinks, if not otherwise
instructed.

The patient should be warmly clad ; pure-wool gar-
ments should be worn next tlie skin at all times. "With
a view to relieve the tension of the visceral circulation,
which favors diuresis, warm baths should be employed,
as they invite the blood to the surface and prove very
serviceable. The good effects of warm baths are ren-

8 H

170 Diabetes Insipidus.

dered more durable by following them with thorough
frictions of the skin by means of coarse towels.

Of the medicinal agents employed for the relief of
diabetes insipidus, ef^got seems to have enjoyed the
highest as well as the longest popularity in point of
time. On theoretical grounds, the indications for the
use of ergot are clear. Its contractile power over the
email vessels should lessen the blood-tension in the renal
circulation, and thus lessen the excessive diuresis. In
some cases the drug undoubtedly exercises a favorable
influence over the disease, as a number of unquestion-
able cures have been effected by it. It is somewhat
uncertain, however, in its effects, many cases failing to
improve under its use. It should be employed in full
doses in order to be effective — 5i to 5ii of the fluid ex-
traxjt (preferabl}^ Squibb's).

Valerian was long ago recommended by Trousseau
for diabetes insipidus. Both he and Rayer claimed the
very highest merit for large doses of this drug; but
these claims have scarcely been realized by its subsequent
use.

Opium seems to diminish the diuresis in some cases,
but in others it only aggravates the symptoms, and, on
the whole, the evidence does not favor its employment
in these cases. The same may be said of belladonna.

Yarious other drugs have been recommended for
diabetes insipidus, among which are acetate of lead, ar-
senic, the bromides, camphor, jaborandi, etc. The only
one of» these that I have derived good results from has
been the bromide compounds, especiall}^ the bromide of
sodium. In at least two cases of recent origin I believe
the disease was arrested by full doses of sodium bro-
mide. To be effective the dose should be rather large.
The patient should be rapidly brought under its influ-

Treatment. 171

ence by the administration of from 2 to 4 drachms dur-
ing the first twenty-four hours ; after that, 20 to 30
grains should be given everj- four to six hours, until
some muscular relaxation in the legs is notfed, or slight
unsteadiness in walking. After the above effects are
obtained, the dose should be decreased to a point just
short of affecting the locomotion. The constant gal-
vanic current has been found beneficial in some cases.
Tiie best results are said to follow the application of the
positive pole to the cervical region over the vertebra
and the negative pole to the lumbar region and pit of
the stomach, alternatel3\

Antipyrin has recently been brought forward as a
remedy for diabetes insipidus, and several cures are re-
corded from its use. The dose recommended is from 2
to 5 grammes daily. In the poly uric form of the disease,
where the loss of solids by the urine is excessive, an
effort should be made to conserve the tissue waste by
tonic medication. Among the most useful agents of
this class will be found strychnia^ iron, quinine^ and
arsenic. In cases in which tlie disease is traceable to
traumatic lesions of the brain, intra-cranial growths,
constitutional taints, etc., the treatment should include
appropriate measures for the relief of the primary
disease.

BIBLIOGRAPHY.

It has been found absolutely necessary to limit the
following list to treatises on the subject. The large mass
of current literature on diabetes, if included, would
occupy altogether too much space in a volume of this
size.

Aenstools, F. Zur Etiologie und Symptomatologie des Diabetes Mel-

litus. 8vo. Griefswald, 1869,
Audrey. Du Diabete et de son Traitement. 4to. Paris, 1869.
Audi, F. G. De Diabete. 8vo. Berlin, 1835.

Auttan, A. Du Diabete Sucre ou de la Glucosurie. 4to. Strasbourg, 1858.
Bandelow, E. De Diabete Mellito. 8vo. Berlin, 1838.
Baruaud, A. Du Diabete Sucre. 8vo. Berne, 1862.
Barow, F. De la Glucosurie ou Diabete Sucre. 4to. Paris, 1853.
Bell, H. An Essay on Diabetes. 8vo. Transl. London, 1842.
Burnett, J. B. Diabetes Mellitus. 8vo. Edinburgh, 1801.
Bennighof, J. P. Ueber Meliturie. 8vo. Munich, 1843.
Bernard, C. Lemons sur le Diabfete et la Glycogen^se Animale. 8vo.

Paris, 1877.
Bertail, E. fitude sur la Pthisie Diabfetique. 4to. Paris, 1873.
Biaille-L<alongeay, J. B. A. A. Du Diabete Sucre, et specialement de

ses rapports avec les differents modes d' alimentations. 4to. Paris,

1848.
BibergeU, H. On Diabetes Mellitus. 8vo. Berlin, 1835.
Biggs, B. E. Diabetes Mellitus. 8vo. Edinburgh, 1803.
Bos, J. J. Bijdrage tot de kennis der Glycogenese bij den Diabetes

Mellitus. 8vo. Amsterdam, 1867.
Brandao, A. B. de S. Glycosuria. 4to. Bahia, 1871.
Brlgham, C. B. Diabetes Mellitus. 8vo. Boston, 1868.
Brouwer, N. Akademisch procfachrif t over den Diabetes Mellitus. 8vo.

Groningen, 1862.
Badde, T. De Diabete Mellito. 8vo. Gryphie, 1835.
Champlin, J. M. On Diabetes and its Successful Treatment. 8vo. From

second London edition. New York, 1861,
Capezzaoli, S. Sul Diabete. 8vo. Florence, 1851.
Carter, C. De Diabete Mellito. 4to, Paris, 1811.
Cazalas, L. Du Diabete. 4to, Montpellier, 1875,
Chaloin, L. E. Du Diabete Sucre'. 4to. Paris, 1853.
Clndius, O. C De Diabete qui dicetur Mellitus quaedam. 8vo. Regi-

monte, 1843.
Contour, L.. A. Du Diabete Sucre. 4to. Paris, 1844.
Currie, F. On Diabetes. 8vo. Edinburgh, 1798.

(173)

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Cyr, J. Etiologie et Pronostic de la Glycosurie et du Diabete. 8vo.

Paris, l«79.
Dantagnan, E. M. fitudie Physiologique sur la Glycosurie. 4to. Paris,

1866.
Dedebaat, J. P. L.. Du Diabfete Sucre. 4to. Paris, 1856.
Destouches, A. A. Du Diabete Sucre. 4to. Paris, 1817.
JDickinson, W. H. Diseases of the Kidneys and Urinary Derangements.

Part I, Diabetes. Svo. London, 1875.
DieM, G. Butrage zur Pathologie und Tlierapie des Diabetes Mellitus.

Svo. Erlangen, 1875.
I>onkin, A. S. The Skim-Milk Treatment of Diabetes and Bright's

Disease. 12mo. London, 1871.
Vrlessen, J. C. De Phosphuria et Diabete Mellito. Svo. Groningen, 1818.
During, A. von. Ursache und Heilung des Diabetes Mellitus. Svo.

Hannover, 1868.
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Diabete. Svo. Lousle-Saulnier, 1877.
Dapla, A. Du Diabete Sucre. 4to. Paris, 1864.

Duport, S. F. E. De la Glucosurie ou Diabete Sucre. 4to. Paris, 1853.
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Dyett, K. H. Diabetes Mellitus. Svo. Edinburgh, 1808.
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Saxony, 1830.
Eckholt, D. DeDiabfete. 4to. Argentorati, 1863.
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INDEX.

PAGE

Acetone in the urine in diabetes mellitus 56

Age as a cause of diabetes mellitus 34

in prognosis of diabetes mellitus 78

Albumin in the urine in diabetes mellitus 56

Albuminuria complicating diabetes mellitus 63

Alcoholic beverages in diabetes mellitus 91

in diabetes insipidus 169

Ales, quantity of sugar in 94

Alkalies in treatment of diabetes mellitus 108

American wines, sugar contents of 91

Amyloid disease with diabetes mellitus 65

Anaemia in diabetes mellitus 50

Antipyrin in treatment of diabetes mellitus 102

in treatment of diabetes insipidus 171

Appetite in diabetes mellitus 48

Approximate test for sugar, the author's 76

Arsenic in treatment of diabetes mellitus 104

in treatment of diabetes insipidus 170

Artificial glycosuria 26

Belladonna in treatment of diabetes mellitus 108

Beverages in diabetes mellitus 90

permitted in diabetes mellitus 96

prohibited in diabetes mellitus 96

Bibliography of diabetes 173

Blood, changes of, in diabetes mellitus 46

Brain-lesions as causes of diabetes mellitus 88

Brain, anatomical changes of, in diabetes mellitus .... 44

Bread, use of, in diabetes mellitus 84

Bromides in treatment of diabetes mellitus 103

in treatment of diabetes insipidus 170

Burgundy wines, analysis of, for sugar 93

Calabar bean in treatment of diabetes 108

Cases of diabetes treated by oxygen 157

of mild type of diabetes mellitus in aged subjects . . 127

of severe type of diabetes mellitus .115

showing mild type in Hebrew race . 140

(179)

180 Index.

PAGE

Cases of diabetes in childhood 155

of diabetes of probable malarial origin 143

of diabetes complicated by amyloid disease 147

of diabetes caused by overeating 151

of severe type of diabetes mellitus in aged subjects . 133

Camphor in treatment of diabetes insipidus 170

Cataract in diabetes mellitus 61

Central Appalachian region, diabetes mellitus in 9

Champagnes, quantity of sugar in 93

Chinese race, absence of diabetes in 17

Circulatory symptoms of diabetes mellitus 49

Civil war, American, influence of, over diabetes 18

Classification of diabetes mellitus 47

of diabetes insipidus 161

Climatic influences over diabetes mellitus 34

Climatology of diabetes mellitus 3

Clinical considerations of diabetes mellitus 115

Cold, influence of, over diabetes mellitus 7

as a cause of diabetes insipidus 163

Coma, diabetic 57

treatment of 110

Complications of diabetes mellitus 57

treatment of 109

Constipation in diabetes mellitus 48

treatment of 109

Course and duration of diabetes mellitus 65

of diabetes insipidus 167

Curare as a cause of glycosuria 26

Cutaneous symptoms of diabetes mellitus 51

Diabetes mellitus 1

clinical illustrations of 115

diagnosis of 69

duration of 65

etiology of 31

morbid anatomy of 41

physiology and pathology of 19

prognosis of 78

symptomatology of 47

treatment of 81

Diabetifi insipidus 161

course of 167

diagnosis of i 167

duration of 167

etiology of 163

pathological anatomy of .... , 163

prognosis of 168

symptoms of. .... 164

treatment of . . • 169

Diabetic coma . . : : 57

Index. 181

PAGE

Diabetic coma, treatment of 110

Diagnosis of diabetes mellitus 69

of diabetes insipidus 167

Dieting for diabetes mellitus 97

Digestive symptoms of diabetes mellitus 48

of diabetes insipidus 166

Duration of diabetes mellitus 65

of diabetes insipidus 167

Emaciation in diabetes mellitus 52

Ergot in treatment of diabetes mellitus 104

in treatment of diabetes insipidus 170

Etiology of diabetes mellitus . 31

of diabetes insipidus 162

Examination of urine for sugar 69

Exercise in diabetes mellitus 113

Exciting causes of diabetes mellitus 36

Exclusive meat diet in diabetes 83

Farinaceous foods in diabetes mellitus 86

Fatality of diabetes mellitus in young people 66

Feliling's test for sugar 70

Foods permissible in diabetes mellitus 96

prohibited in diabetes mellitus 96

Fruits, use of, in diabetes mellitus 87

Furuncles in diabetes mellitus 110

General principles of diet for diabetes mellitus 81

Geographical distribution of diabetes mellitus 2

Glycogenic function of the liver 19

Glycosuria from puncture of medulla 22

Green vegetables, use of, in diabetes mellitus 86

Gulf Coast, topography of 9

low mortality from diabetes in 12

Habits of Americans as influencing diabetes 18

Haines's test for sugar in urine 71

Heart-lesions in diabetes mellitus 44

Hebrew race, frequency of diabetes in 32

mild character of diabetes in 33

Heredity as a cause of diabetes mellitus 31

History of diabetes 1

Humidity of atmosphere, influence of, over diabetes mellitus 13

Hygienic treatment of diabetes mellitus 112

Hypertrophy of heart in diabetes mellitus 50

Imported wines, sugar contents of ... 92

Indian race, exemption from diabetes in 17

182 Index.

PAGE

Intellectual faculties in diabetes mellitus 50

Interior Plateau, topography of 10

Interstitial nephritis with diabetes mellitus 64

Iodine tincture in treatment of diabetes mellitus 108

Iodoform in treatment of diabetes mellitus 105

Jaborandi in treatment of diabetes insipidus 170

Jambul in treatment of diabetes mellitus 106

Liver, morbid anatomy of, in diabetes mellitus 41

Lung-lesions in diabetes mellitus 41

Maine, high mortality from diabetes mellitus in 6

Medicinal treatment of diabetes mellitus 101

Mental emotion as a cause of diabetes mellitus 86

as a cause of diabetes insipidus 163

Middle Atlantic Coast, topography of 9

Mineral waters for diabetes mellitus 95

Morbid anatomy of diabetes mellitus 41

Mortality from diabetes, rural and urban 14

Muscular symptoms in diabetes mellitus 53

Nervous system in diabetes mellitus 24

symptoms in diabetes mellitus 50

Nitrate of uranium in treatment of diabetes mellitus . . . 108

North Atlantic Coast, topography of 9

Northeastern Hills and Plateaus, topography of 9

high mortality from diabetes in 11

Northern Mississippi River Belt, topography of 10

Northwestern Region, typography of 11

high mortality from diabetes in 12

Ocular complications of diabetes mellitus 61

Ohio River Belt, typography of 10

Opium in treatment of diabetes mellitus 101

in treatment of diabetes insipidus 170

Oxygen gas in treatment of diabetes mellitus 106

Pacific Coast, topography of 11

mortality from diabetes mellitus in 11

Pancreas, lesions of, in diabetes mellitus 42

Pancreatic diabetes 27

Patellar reflexes, prognosis of, in diabetes 79

Pathological anatomy of diabetes insipidus 163

considerations of diabetes mellitus 19

Phenylhydrazin test for sugar in urine 72

Phlegmon in diabetes mellitus 63^

Phosphatic form of diabetes insipidus 166

Index. 188

PAGB

Phosphorus in treatment of diabetes mellitus 108

Physiological features of diabetes mellitus 19

Picric acid in treatment of diabetes mellitus 108

Potassium iodide in treatment of diabetes mellitus .... 108

Prairie Region, topography of 11

Prognosis of diabetes mellitus 78

of diabetes insipidus 168

Pulmonary complications in diabetes mellitus 60

Quantitative determination of sugar in urine, the author's

method 74

Quinine in treatment of diabetes insipidus 171

Rhine wines, sugar contents of 93

Rural mortality from diabetes mellitus 16

Salicylic acid in treatment of diabetes mellitus 108

Sauterne wines, sugar contents of 92

Sex as a cause of diabetes mellitus 33

Sexual symptoms of diabetes mellitus 51

excesses as a cause of diabetes insipidus 163

Sodium phosphate in treatment of diabetes mellitus . . . 108

Soj a as a food in diabetes mellitus 87

South Atlantic Coast Region, topography of 9

Southern Central Appalachian Region, topography of . . 10

Interior Plateau, topography of 10

Southwest Central Region, topography of 10

Spinal cord, alleged changes in diabetes mellitus 45

Spirits, analysis of, for sugar 93

Starch, relation of, to glycogen 20

Strychnia in treatment of diabetes insipidus 171

large doses of as a cause of glycosuria 26

Sugar, source of, in the economy 24

percentage in urine in diabetes mellitus 55

in urine, tests for . 70

Symptoms of diabetes mellitus 47

of diabetes insipidus 164

Sweet taste in diabetes mellitus 49

Table showing distribution of diabetes in Europe .... 3

showing mortality ratio of diabetes in United States . 5

showing mortality ratio of diabetes by State groups . 8

showing rural and urban mortalities from diabetes . . 15
showing increase of diabetes in United States for forty

years 18

Temperature in diabetes mellitus 49

atmospheric, influence of, over diabetes 7

Thirst in diabetes mellitus 48

184 Index.

PAGE

Thirst in diabetes insipidus , 165

Treatment of diabetes mellitus > . . . 81

of complication of diabetes mellitus 109

of diabetes insipidus 169

Urban mortality from diabetes mellitus 16

Urea in urine in diabetes mellitus 55

Urine in diabetes mellitus 53

in diabetes insipidus 164

Valerian in treatment of diabetes mellitus 108

in treatment of diabetes insipidus 170

Vermont, high, mortality in, from diabetes 6

"Warm baths in treatment of diabetes mellitus 113

in treatment of diabetes insipidus 169

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DAVIS — ^Diseases of the Heart, Lungs, and BZidneys.

By N. S. Davis, Jr., A.M., M.D., Professor of Principles and
Practice of Medicine in the Chicago Medical College, Chicago, 111.,
etc. In one neat 12mo volume. No. 9 in the Phy{>iciam^ and SticdeTits*
Eeady-Hefet-ence Series. In Preparation.

EDINGBR — Twelve Lectures on the Structure of the
Central Nervous System. For Physicians and Stu-
dents.
By Dr. Ludwig Edinger, Frankfort-on-the-Main. Second Re-
vised Edition, with 133 illustrations. Translated by "Willis Hall
ViTTUM, M.D., St. Paul, Minn. Edited by C. Eugene Riggs, A.M.,
M.D., Professor of Mental and Nervous Diseases, University of Minne-
sota ; Member of the American Neurological Association. In one
Octavo volume, handsomely bound in Cloth. Just Published.

Net Price, in United States and Canada, SI. 75, post-paid;
Great Britain, 7s. 3d. ; France, 12 fr. 30.

EISENBERG — Bacteriological Diagnosis — Tabular
Aids for Use in Practical "Work.

By James Eisenberg, Ph.D., M.D., Vienna. Translated and
augmented, with the permission of the author, from the Second Ger-
man Edition, by Norval H. Pierce, M.D., Surgeon to the Out-Door
Department of Michael Reese Hospital ; As^stant to Surgical Clinic
College of Physicians and Surgeons, Chicago, 111. In one Octavo
volume, handsomely bound in Cloth. Ready in Autumn, 1890.

Net Price, in United States and Canada, 8S1.50, post-paid ;
Great Britain, 6s. 6d. ; France, 9 fr. 35.

GOODELL — Lessons in Gynecology.

By William Goodell, A.M., M.D., etc., Prolessor of Clinical
Gynecology in the University of Pennsylvania. With 112 Illustra-
tions. Third Edition, thoroughly revised and greatly enlarged. One
volume, large Octavo, 578 pages. This exceedingly valuable work,
from one of the most eminent specialists and teachers in gynecology ia

Catalogue of Medical Publications.

the United States, is now offered to the profession in a much more com-
plete condition than either of the previous editions. It embraces all
the more important diseases and the principal operations in the field
of gynecology, and brings to bear upon them all the extensive practical
experience and wide reading of the author. It is an indisp<?nsable
guide to every practitioner who has to do with the diseases peculiar to
women.

Price, in United States and Canada, Cloth, $5.00 ; Full Sheep,
S6.00. Discount, 30 per cent., mailing it, net. Cloth, $4.00 ;
Sheep, $4.80. Postage, 3T Cents extra. Great Britain,
Cloth, 17s. ; Sheep, 81s., post-paid, net. France, 30 fr. 80.

GUERNSEY— Plain Talks on Avoided Subjects.

By Henry N, Guernsey, M.D., formerly Professor of Materia
Medica and Institutes in the Hahnemann Medical College of Philadel-
phia ; Author of Guernsey's " Obstetrics," including the Disorders
Peculiar to Women and Young Children ; Lectures on Materia Med-
ica, etc.

The following Table of Contents shows the scope of the book : —
Contents. Chapter I. — Introductory, II. — The Infant, III. —
Childhood. IV. — Adolescence of the Male. V, — Adolescence of the
Female, VI,— Marriage : The Husband. VII.— The Wife. VIII.—
Husband and Wife. IX. — To the Unfortunate. X. — Origin of the
Sex, In one neat 16mo volume, bound in Extra Cloth.

Price, post-paid, in United States and Canada, 91.00 ; Great
Britain, 4s. 6d. ; France, 6 fr. 30.

HARE— Epilepsy : its Pathology and Treatment.

By HoBART Amory Hare, M.D, (University of Pennsylvania),
B.Sc; Clinical Professor of the Diseases of Children and Demon-
strator of Therapeutics in the University of Pennsylvania ; Physician
to St. Agnes' Hospital and to the Children's Dispensary of the Chil-
dren's Hospital ; Laureate of the Royal Academy of Medicine in Bel-
fium, of the Medical Society of London, of the Rhode Island Medical
ociety, the Massachusetts General Hospital, and the College of Phy-
sicians and Surgeons of New York ; Member of the Association of
American Physicians, of the American Neurological Association, and
Fellow of the College of Physicians of Philadelphia and the Medical
Society of London, etc., etc. In one neat 12mo volume. No. 7 in the
Physicians' and Students' Ready-Referetice Series. Handsomely bound
in Dark-Blue Cloth, Just Published,

Net Price, in United States and Canada, $1.35 ; Great Britain,
5s. 3d. ; France, 7 fr. T5.

JAMBS — American Resorts, -witli Notes upon Tlieir
Climate.
By BusHROD W, James, A.M., M.D., Member of the American
Association for the Advancement of Science, the American Public
Health Association, the Pennsylvania Historical Society, the Franklin
Institute, and the Academy of Natjiral Sciences, Philadelphia ; the
Society of Alaskan Natural History and Ethnology, Sitka^ Alaska,

F. A. Davis, Philadelphia , Fa.

etc. With a translation from the German, by Mr. S. Kauffmann, of
those chapters of "Die Klimate der Erde/' written by Dr. A. Woei-
KOF, of St. Petersburg, Russia, that relate to North and South America
and the islands and oceans contiguous thereto. In one Octavo volume,
handsomely bound in Cloth. Nearly 300 pages .

Net Price, post-paid, in United States and Canada, 92.00 •
Great Britain, 8s. 6d. ; France, IS fr. 40.

KEATING— Record-Book of Medical Examinations for
Life-insurance.
Designed by John M. Keating, M.D, This record-book is small,
neat, and complete, and embraces all the principal points that are re-
quired by the different companies. It is made in two sizes, viz. : No. 1,
covering one hundred (100) examinations, and No. 2, covering two
hundred (200) examinations. The size of the book is 7x3% inches,
and can be conveniently carried in the pocket.

Net Price, post-paid : No. 1, for lOO Examinations, in Cloth,
United States and Canada, 50 Cents; Great Britain, 2s.
6d. ; France, 3 fr. 60. No. 2, for 200 Examinations, in Full
l,eather, witli Side-Flap, United States and Canada, $1.00 ;
Oreat Britain, 4s. 6d. ; France, 6 fr. 20.

KEATING AND ED'WARDS— Diseases of the Heart
and Circulation in Infancy and Adolescence:

WITH AIT Appendix Entitled " Clinical Studies on the
Pulse in Childhood."
By John M. Keating, M.D., Obstetriciain to the Philadelphia
Hospital and Lecturer on Diseases of Women and Children; Surgeon
to the Maternity Hospital ; Physician to St. Joseph's Hospital ; Fellow
of the College of Physicians of Philadelphia, etc.; and William A.
Edwards, M.D., Instructor in Clinical Medicine and Physician to the
Medical Dispensary in the University of Pennsylvania; Physician to
St. Joseph's Hospital ; Fellow of the College of Physicians; formerly
Assistant Pathologist to the Philadelphia Hospital, etc. Illustrated
by Photographs and Wood-Engravings. About 225 pages. 8vo. Bound
in Cloth.

Price, post-paid, in United States and Canada, $1.50, net ;
Great Britain, 6s. 6d. ; France, 9 fr. 35.

KELLER — ^Perpetual Clinical Index to Materia Med-
ica, Chemistry, and Pharroacy Charts.
By A. H. Keller, Ph.G., M.D., consisting of (1) the "Perpetual
Clinical Index," an oblong volume, 9x6 inches, neatly bound in Extra
Cloth ; (3) a Chart of " Materia Medica," 32x44 inches, mounted on
muslin, with rollers ; (3) a Chart of " Chemistry and Pharmacy,"
32x44 inches, mounted on muslin, with rollers.

Net Price for tlie Complete Work, United States, 95.00;
Canada (duty paid),S5.50 ; Great Britain, «1 Is. ; France,
30 fr. 30.

Catalogue of Medical Publications.

LIEBIG and ROHE — ^Practical Electricity in Medicine

and Surgery.

By G. A. LiBBiG, Jr., Ph.D., Assistant in Electricity, Johns Hop-
kins University; Lecturer on Medical Electricity, College of Phy-
eicians and Surgeons, Baltimore ; Member of the American Institute
of Electrical Engineers, etc. ; and George H. Rohe, M.D., Professor
of Obstetrics and Hygiene, College of Physicians and Surgeons, Balti-
more; Visiting Physician to Bay View and City Hospitals; Director
of the Maryland Maternite; Associate Editor " Annual of the Uni-
versal Medical Sciences," etc. Profusely Illustrated by Wood-Engrav-
ings and Original Diagrams, and published in one handsome Royal
Octavo volume of 383 pages, bound in Extra Cloth.

Net Price, post-paid, in United States and Canada, $3.00;
Great Britain, 8s. 6d. ; France, 13 fr. 40.

The constantly increasing demand for this work attests its thor-
ough reliability audits popularity with the profession, and points to
the fact that it is already the standard work on this very important
subject. The part on Physical Electricity, written by Dr. Liebig, one
of the recognized authorities on the science in the United States, treats
fully such topics of interest as Storage Batteries, Dynamos, the Elec-
tric Light, and the Principles and Practice of Electrical Measurement
in their Relations to Medical Practice. Professor Roh6, who writes on
Electro- Therapeutics, discusses at length the recent developments of
Electricity in the treatment of stricture, enlarged prostate, uterine
fibroids, pelvic cellulitis, and other diseases of the male and female
geni to-urinary organs.

MANTON — Childbed ; its Management ; Diseases and
their Treatment.

By Walter P. Manton, M.D., Visiting Physician to the Detroit
Woman's Hospital ; Consulting Gynaecologist to the Eastern Michigan
Asylum ; President of the Detroit Gynaecological Society ; Fellow of
the American Society of Obstetricians and Gynaecologists, and of the
British Gynaecological Society ; Member of Michigan State Medical
Society, etc. In one neat 12mo volume. No. 10 in the Physicians' and
Students' Beady-Beference Seines. In Preparation.

MASSBY— Electricity in the Diseases of "Women : with
Special Reference to the Application of Strong Currents.

By G. Betton Masset, M.D., Physician to the Gynaecological
Department of Howard Hospital ; late Electro-Tlierax)eutist to the
Philadelphia Orthopaedic Hospital and Infirmary for Nervous Diseases;
Member of the American Neurological Association,of the Philadelphia
Neurological Society, of the Franklin Institute, etc. No. 5 iii the Phy-
sicians' and Students' Beady-Beference Series. Second Edition, Re-
vised and Enlarged. With New and Original Wood-Engravings.
Handsomely bound in Dark-Blue Cloth. 240 pages, 12mo.

Price, post-paid, in United States and Canada, 81.50, net ;
Great Britain. 6s. 6d. ; France, 9 £r. 35.

F. A. Davis, Philadelphia, Pa.

MEARS — Practical Surgery.

By J. EwiNG Mears, M.D., Lecturer on Practical Surgery and
Demonstrator of Surgery in Jefferson Medical College ; Professor of
Anatomy and Clinical Surgery in the Pennsylvania College of Dental
Surgery, etc. With 490 Illustrations. Second Edition, Revised and
Enlarged. 794 pages. 12mo. Cloth.

Price, in United States and Canada, Cloth, $3.00. Discount,
20 per cent,, making it, net, $2.40 ; Postage, 20 Cents £xtra.
Great Britain, 13s. France, 18 fr. 75.

Medical Bulletin Visiting List, or Physicians' Call
Record. Arranged upon an Original and Convenient
Monthly and Weekly Plan for the Daily Recording
OF Professional Visits.
This is, beyond question, the best and most convenient time- and
labor- saving physicians' pocket record-book ever published. Phy-
sicians of many years' standing and with large practices pronounce
this the best list they have ever seen. It is handsomely bound in fine,
strong leather, with flap, including a pocket for loose memoranda, etc.,
and is furnished with a Dixon lead-pencil of excellent quality and
finish. It is compact and convenient for carrying in the pocket. Size,
4 X 6J^ inches. In three styles.

Net Price, post-paid: No. 1, Regular Size, for 70 patients
daily eacli month for one year. United States and Canada,
^1.25 ; Great Britain, 5s. 3d. ; France, 7 fr. 75. No. 2, Large
Size, for 105 patients daily each month for one year, United
States and Canada, S^l.oO ; Great Britain, 6s. 6d. ; France,
9 fr. 35. No. 3, in which "The Blanks for Recording Visits
in " are in removable sections, United States and Canada,
»1.75 ; Great Britain, 78. 3d. ; France, 12 fr. 20.

MIOHENER — Hand-Book of Eclampsia; or, Notes and
Cases of Puerperal Convulsions.

By E. MiCHENER, M.D.; J. H. Stubbs, M.D. ; R. B. Ewing,
M.D. ; B. Thompson, M.D. ; S. Stebbins, M.D. 16mo. Cloth.

Net Price, 75 Cents ; Great Britain, 3s. ; France, 4 fr. 20.

NISSEN— A Manual of Instruction for Giving Swedish
Movement and Massage Treatment.

By Prof. Hartvig Nissex, Director of the Swedish Health Insti-
tute, Washington, D.C. ; late Instructor in Physical Cultureand Gym-
nastics at the Johns Hopkins University, Baltimore, Md. ; Author of
'•Health by Exercise without Apparatus." Illustrated with 29 Original
Wood-Engravings. In one 12mo volume of 128 pages. Neatly bound
in Cloth.

Price, post-paid, in United States and Canada, Sl.OO, net;
Great Britain, 4s. 6d. ; France, 6 fr. 20.

8 Catalogue of Medical Publications.

Physicians' All-Bequisite Time- and Labor- Saving
Account-Book. Being a Ledger and Account-Book
FOR Physicians' Use, Meeting All the Requirements of
THE Law and Courts.

Designed by William A. Seibert, M.D., of Easton, Pa. There
is no exaggeration in stating that this Account-Book and Ledger re-
duces the labor of keeping your accounts more than one-half, and at
the same time secures the greatest degree of accuracy.

To all physicians desiring a quick, accurate, and comprehensive
method of keeping their accounts, we can safely say that no book as
suitable as this one has ever been devised.

Net Price, Shipping Expenses Prepaid: No. 1, 300 Pages,
for 900 Accounts per Year, Size 10 x 13, Bound in 3^-Kussia,
Kaised Back-Bands, Clotli Sides, in United States, 855.00 ;
Canada (duty paid), 95.50; Great Britain, 21s.; France,
30 fr. 30. No. 3, 600 Pages, for 1800 Accounts per Year,
Size 10 X 13, Bound in 3^-Kussia, Kaised Back-Bands, ClotU
Sides, in United States, »8.00 ; Canada (duty paid), J$8.80 :
Great Britain, 1.13s. ; France, 49 fr. 40.

A circular showing the plan of the book will be sent free to any
address on application.

Physicians' Interpreter: In Four Languages (English,
French, German, and Italian).

Specially arranged for diagnosis by M. von V. The object of this
little work is to meet a need often keenly felt by the busy physician,
namely, the need of some quick and reliable method of communicat-
ing intelligibly with patients of those nationalities and languages un-
familiar to the practitioner. The plan of the book is a systematic
arrangement of questions upon the various branches of Practical
Medicine, and each question is so worded that the only answer re-
quired of the patient is merely Yes or No. The questions are all
numbered, and a complete Index renders them always available for
quick reference. The book is written by one who is well versed in
English, French, German, and Italian, being an excellent teacher in
those languages, and who has also had considerable hospital experi-
ence. Bound in full Russia Leather, for carrying in the pocket. Size,
5x2^ inches. 206 pages.

Price, post-paid, in United States and Canada, $1.00, net;
Great Britain, 4s. 6d. ; France, 6 fr. 30.

PURDY— Diabetes : its Cause, Symptoms, and Treat-
ment.

By CiiAS. W. Purdy, M.D. (Queen's University), Honorary
Fellow of the Ro3'^al College of Physicians and Surgeons of King-
ston ; Member of tlie College of Physicians and Surgeons of Ontario ;
Author of '' Bright's Disease and Allied Atfections of the Kidneys ;"

F. A. Davis, Philadelphia, Pa.

Member of the Association of American Physicians ; Member of the
American Medical Association ; Member of the Chicago Academy of
Sciences, etc., etc. With Clinical Illustrations. In one neat 12mo
volume. No. 8 in the Physidans' and Students' Heady-Reference Series.
Handsomely bound in Dark-Blue Cloth. Ready October, 1890.

Net Price, United States and Canada, 81.35 ; Great Britain
OS. 3d. ; France, 7 fr. 75 ; post-paid.

PRICE AND BAGLETON— Three Charts of the Nervo-
Vascular System. Pakt I. — The Nerves. Paet II. —
The Arteries. Part III. — The Veins.

Arranged by W. Henry Price, A.M., M.D., and S. Potts
Eagleton, M.D. Endorsed by leading anatomists. " The Nervo-
Vascular System of Charts " far excels every other system in their
completeness, compactness, and accuracy.

Price, United States and Canada, 50 cents, net, complete ;
Great Britain, 2s. 6d. ; France, 3 fr. 60.

ROHE— Text-bcx)k of Hygiene: A Comprehensive Trea-
tise ON the Principles and Practice of Preventive Medi-
cine from an American Stand-point.

By George H. Rohe, M.D., Professor of Obstetrics and Hygiene
in the College of Physicians and Surgeons, Baltimore; Director of the
Maryland Maternity ; Member of the American Public Health Asso-
ciation ; Foreign Associate of the Soci6t6 Francaise d'Hygiene, of the
Soci6t6 des Chevaliers-Sauveteurs des Alpes Maritimes, etc. Second
Edition, thoroughly Revised and Largely Rewritten, with many Illus-
trations and valuable Tables. Roh6's Hygiene is the Standard Text-
book in many Medical Colleges in the United States and Canada.
It is a sound guide to the most modern and approved practice in Ap-
plied Hygiene. In one handsome Octavo volume of about 400 pages,
bound in Extra Cloth.

Net Price, United States and Canada, SS.50 ; Great Britain,
lis. 6d. ; France, 16 fr. 30.

SAJOUS— Hay Fever and its Successful Treatment by
Superficial Organic Alteration of the Nasal
Mucous Membrane.

By Charles E. Sajous, M.D., Lecturer on Rhinology and Laryn-
gology in Jeflerson Medical College ; Vice-President of "the American
Laryngological Association ; Officer of the Academy of France and
of Public Instruction of Venezuela ; Corresponding Member of the
Royal Society of Belgium, of the Medical Society of Warsaw (Poland),
and of the Society of Hygiene of France ; Member of the American
Pliilosophical Society, etc., etc. With 13 Engravings on Wood. 12mo.
Bound in Cloth. Beveled edges.

Price, United States and Canada, Net, Sil.OO ; Great Britain,
4s. 6d. : France, 6 fr. 20.

10 Catalogue of Medical Publications.

SANNE— Diphtheria, Croup : Tracheotomy and Intu-
bation.

From the French of A. Sanne. Translated and Enlarged by
Henry Z. Gill,, M.D., LL.D. Diphtheria having become such a
prevalent, wide-spread, and fatal disease, no general practitioner can
afford to be without this work. It will aid in preventive measures,
stimulate promptness in the application of and efficiency in treatment,
and moderate the extravagant views which have been entertained re-
garding certain specifics in the disease Diphtheria.

A full Index accompanies the enlarged volume, also a list of
authors, making, altogether, a very handsome illustrated volume of
over 680 pages.

Net Price, post-paid, United States, Cloth, $4.00; Leather,
S5.00. Canada (duty paid). Cloth, $4.40; L-eather, $5.50.
Great Britain, Cloth, 17s. ; L.eather, £1 Is. France, Cloth,
24 fr. 60 ; Leather, 30 Ir. 30.

SBNN— Principles of Surgery.

By N. Sexn, M.D., Ph.D., Milwaukee, Wis. ; Professor Principles
of Surgery and Surgical Pathology in Rush Medical College, Chicago,
111. ; Professor of Surgery in the Chicago Polyclinic ; Attending Sur-
geon to the Milwaukee Hospital ; Consulting Surgeon to the Mil-
waukee County Hospital and to the Milwaukee County Insane Asylum ;
Honorary Fellow College of Physicians in Philadelphia, Pa. ; Perma-
nent Member of the German Congress of Surgeons ; Member of La
Academic de Medicina de Mexico, of the D. Hayes Agnew Surgical So-
ciety in Philadelphia, Pa., of the Ohio State Medical Society, and of the
Minnesota State Medical Society ; Member of the American Surgical As-
sociation, of the American Medical Association, of the British Medical
Association, of the Wisconsin State Medical Society, and of the
Brainard Medical Society, etc. In one handsome Royal Octavo volume,
with over 100 Illustrations. In Press. Will be issued in October,
1890.

SHOEMAKER — Ointments and Oleates, Especially in
Diseases of the Skin.

By John V. Shoemaker, A.M., M.D., Professor of Materia
Medica, Pharmacology, Therapeutics, and Clinical Medicine, and
Clinical Professor of Diseases of the Skin in the Medico-Chirurgieal
College of Philadelphia ; Physician to the Medico-Chirurgical Hos-
pital ; Member of the American Medical Association, of the Pennsyl-
vania and Minnesota State Medical Societies, the American Academy
of Medicine, the British Medical Association ; Fellow of the Medical
Society of London, etc. Second Edition, Revised and Enlarged.
No. 6 in file Fhyfticians' and Students' Heady- Reference So'ies. 12mo.
Neatly bound in Cloth.

Price, in United States and Canada, net, $1.50, post-paid;
Great Britain, 6s. 6d. ; France, 9 fr. 35.

F. A. Davis, Philadelphia, Fa. 11

The accompanying Table of Contents will give a general idea of
the work : —

Contexts.— Part I. History and Origin. Part II. Process of
Manufacture. Part III. Physiological Action of the Oleates. Part
IV. Therapeutic Effect of the Oleates. Part V. Ointments: Local
Medication of Skin Diseases. Antiquity of Ointments. Different
Indications for Ointments, Powders, Lotions, etc. Information about
Ointments : Scanty, Scattered, and Insufficient. Fats and Oils : Ani-
mal and Vegetable. Their Chemical Composition, Comparative
Permeability of Oils into the Skin ; of Animal, of Vegetable. Incor-
poration of Medicinal Substances into Fats : (1) Mode of Prepara-
tion, (2) Vegetable Powders and Extracts, (3) Alkaloids, (4) Mineral
Substances, (5) Petroleum Fats : Chemical Composition : Uses and
Disadvantages. List of Officinal Ointments. Indications. Substances
often Prescribed Extemporaneously in Ointment Form. Indications.
A full index rendei-s the book convenient for quick reference.

SHOEMAKER AND AULDE— Materia Medica, Phar-
macology, and Therapeutics.

By John V. Shoemaker, A.M., M.D., Professor of Materia
Medica, Pharmacology, and Therapeutics in the Medico-Chinirgical
College of Philadelphia, and Member American Medical Association,
and John Aulde, M.D., Demonstrator of Clinical Medicine and of
Physical Diagnosis in the Medico-Chirurgical College of Philadelphia,
and Member American Medical Association. Royal Octavo. Vol. I
Now Ready.

Net Price, per volame, in United States and Canada, Cloth»
»2.50 ; Slieep, «3.S5. Great Britain, Cloth, 10s. 6d. ; Sheep,
14s. 6d. France, Cloth, 16 fr. 30 ; Sheep, 20 fr. 20.

Several blank sheets of closely-ruled letter-paper are inserted at
convenient places li the work, thus rendering it available for the stu-
dent and physician to add valuable notes concerning new remedies
and other important natters. Part I embraces three subdivisions, as
follows : —

First. A brief synopsis upon the subject of Pharmacy. Second.
A Classification of Medi.-ines is presented under the head of General
Pharmacology and Therapeutics, with a view to indicate more espe-
cially the methods by which the economy is affected. Third. A sum-
mary has been prepared upon Therapeutics, covering methods of
Administration, Absorption and Elimination, Incompatibility, Pre-
scription-Writing, and Dietary for the Sick. This section of the work
embraces nearly one hundred and fifty pages.

Part II is devoted to Remedies and Remedial Agents not Properly
Classed with Drugs, and includes elaborate articles upon Electro-
Therapy, Hydro-Therapy, Masso-Therapy, Heat and Cold, Oxygen,
Mineral- Waters, and other subjects, such as Climatology, Hypnotism
and Suggestion, Metallo- Therapy, Transfusion, and Baunscheidtismus,
have received a due share of attention.

12 Catalogue of Medical Publications.

SHOEMAKER— Heredity, Health, and Personal

Beauty.

By John V. Shoemaker, A.M., M.D., Professor of Materia
Medica, Pharmacology, Therapeutics and Clinical Medicine, and
Clinical Professor of Diseases of the Skin in the Medico-Chirurgical
College of Philadelphia, etc. In one Royal Octavo volume. In
Pkess. Ready in Autumn, 1890.

SMITH — The Physiology of the Domestic Animals : A

Text-Book for Veterinary and Medical Students and
Practitioners.

By Robert Meade Smith, A.M., M.D., Professor of Compara-
tive Physiology in University of Pennsylvania; Fellow of the College
of Physicians and Academy of the Natural Sciences, Philadelphia ; of
the American Physiological Society ; of the American Society of
Naturalists; Associe Etranger de la Soci6t6 Francaise d'Hygiene, etc.
In one handsome Royal Octavo volume of over 9.50 pages. "Profusely
Illustrated with more than 400 fine Wood-Engravings and many
Colored Plates.

Net Price, in United States, Cloth, $5.00; Sheep, S^G.OO.
Canada (duty paid), Cloth, $5.50; Sheep, $6.60. Great
Britain, Cloth, 3l8. ; Sheep, 24s. France, Cloth, 30 fr. 30;
Sheep, 36 fr. 20.

This new and important work, the most thoroughly complete in
the English language on this subject, has just been issued. In it the
physiology of the domestic animals is treated in a most comprehensive
manner, especial prominence being given to the subject of foods and
fodders, and the character of the diet for the herbivora under different
conditions, with a full consideration of their digestive peculiarities.
Without being overburdened with details, it forms a complete text-
book of physiology, adapted to the use of students and practitioners
of both veterinary and human medicine. This work has already been
adopted as the Text-Book on Physiology in the Veterinary Colleges of
the United States, Great Britain, and Canada.

STEWART— Obstetric Synopsis.

By John S. Stewart, M.D., Demonstrator of Obstetrics and
Chief Assistant in the Gynaecological Clinic of the Medico-Chirurgical
College of Philadelphia. With an Introductory Note by William S.
Stewart, A.M., M.D., Professor of Obstetrics and Gynaecology in the
Medico-Chirurgical College of Philadelphia. Forty-two Illustrations ;
202 pages. 12mo. Handsomely bound in Dark-Blue Cloth. No. 1 in
the Physicians' and Shtdents' Ready-Reference Senes.

Price, post-paid, in United States and Canada, net, $1.00 ;
Great Britain, 4s. 6d. ; France, 6 fr. 80.

F. A. Davis, Philadelphia, Pa. 13

ULTZMANN— The Neuroses of the Genitourinary
System in the Male: "with Sterility and Impo-
tence.
By Db. R. Ultzmann, Professor of Gen i to-Urinary Diseases in
the University of Vienna. Translated, with the author's permission,
by Gardner W. Allen, M.D., Surgeon in the Genito-Urinary De-
partment Boston Dispensary. Just Issued. N^o. 4 i^ ihe Physiciann'
and Shuienfs' Ready -Reference Series. Illustrated. 12mo. Handsomely
bound in Dark-blue Cloth.

Net Price, in United States and Canada, 81.00, post-paid ;
Great Britain, 4s. 6d. ; France, 6 fr. 30.

Synopsis of Contents. — First Part. — I. Chemical Changes In
the Urine in Cases of Neuroses. II. The Neuroses of the Urinary and
of the Sexual Organs, classified as : 1, Sensory Neuroses ; 2, Motor
Neuroses ; 3, Secretory Neuroses. Second Part. — Sterility and Impo-
tence.

The Treatment in all Cases is described Clearly and Minutely.

"WITHERSTINE— International Pocket Medical For^
mulary. Arranged Therapeutically.

By C. Sumner Witherstine, M.S., M.D., Associate Editor of
the " Annual of the Universal Medical Sciences ;" Visiting Physician
of the Home for the Aged, Germantown, Philadelphia; late House<
Surgeon Charity Hospital, New York. More than 1800 fomiuloe from
eeveral hundred well-known authorities. With an Appendix contain-
ing a Posological Table, the newer remedies included ; Important In-
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14 Catalogue of Medical Publications.

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16 Catalogue of Medical Publications.

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