Case VI.

George Barratt, Mt 43. Husbandman

In-Patient, December 23rd, 1805.

Was admitted as a case of Diabetes Mellitus, under the care of my late worthy colleague. Dr. Jackson, only a few days after William O'Brien (whose case follows) entered under mine. As Dr. Jackson was acquainted with the circumstance of my having enjoyed frequent opportunities of treating this disease, he consulted me on the plan to be pursued. We accordingly determined that this patient should live upon the ordinary diet of the house, without any particular restraint from vegetable food; and that his medical treatment should be confined to the exhibition of the nitric acid, to the amount of about two drachms in twenty-four hours. This quantity to be increased or diminished, according to its effects on the system. On examining the patient, I collected the following particulars :

He has been many years married, and for the most part enjoyed good health, but was liable to profuse sweating upon any ordinary exertion; and at such times, was accustomed to quench his thirst by drinking immoderately of cold whey, sour butter-milk, &c.

His diabetic symptoms commenced two years ago ; and he remarked, that since the great thirst, and flow of urine came on, his propensity to sweating had been diminished. He discovered, twelve months since, his urine to be sweet; from being persuaded, by a neighbour, to drink it, as a cure for his disorder.

The quantity of his water he estimates to be nearly twenty quarts every twenty-four hours, but he never exactly measured it. His appetite is extremely ravenous, and may be said to be omnivorous. He was accustomed to devour raw vegetables, when boiled ones were not in the way ; and he believes that he has consumed, in one day, five or six pounds of animal food.

He gets little sleep from the interruption every half hour, during the night, to make water; and he conjectures that the quantity far exceeds the amount of his drink. For six months past he has never experienced any venereal desires, and the semen is involuntarily discharged, but there is no phymosis : pulse 86, The emaciation is very great, and the debility proportionable. He is above the middle size, And was formerly a stout and muscular man ; but he is now so much reduced, that he only weighed nine stone, twelve pounds ; three days previous to his leaving home. He was capable, and very desirous, of keeping a register of the ingesta and egesta; and the better to secure the faithful discharge of this task, he was put into the same ward with my patient, O'Brien, (in whom I deservedly placed the greatest confidence) who was instructed to watch privately over his conduct. I shall select from this register, ( which I have every reason to believe correct) and my own notes, such particulars as are most deserving of notice.

On the 25th of December, the urine he passed within the last twenty-four hours, measured thirty-two pints, and his drink of nitric acid, diluted with water, twenty-five pints; exclusive of three pints of beer porridge.

January 6th — 16th

The patient threw up a large quantity of acid contents from his stomach, in consequence of the emetic.

Since the alteration in his diet an important and decisive improvement has taken place. His thirst is much abated. His mouth and tongue are moister and cleaner, and he sleeps longer and sounder. His strength is remarkably increased, and he feels every way more comfortable and alert.

His craving for food is entirely gone : and the sense of internal heat, especially in the palms of the hands, and soles of the feet, greatly moderated. His finger ends, which before felt benumbed, and looked almost livid, are now of a natural warmth and appearance; and the skin which was before hardened into scales, is become quite renewed, and feels soft and moist.

On the 9th, the solid ingesta were one pound and ten ounces, liquids eleven pints and a half, urine fourteen pints; and upon the average the egesta have exceeded the ingesta.

The urine is neither so sweet nor so whey colored and turbid, it has indeed a bitterish taste which resembles new small beer: one pint of this fluid yielded only nine drachms and a half of a dark coloured extract, which yet differed but little in its sensible and chemical properties from the last.

January 16th — February 1st.

There has been a considerable fluctuation in the quantity of the urine discharged within this period.

On the 19th, the solids were nineteen ounces, liquids twelve pints, and the urine sixteen pints ; while on the 23d the solids amounted to one pound and twelve ounces, and the liquids to Only six pints and a half, and the urine seven pints and a half.

It is, however, proper to notice, that on this day he had been troubled with a griping and purging, though not in a very considerable degree.

The urine is very slightly sweet, and has a more natural appearance ; indeed the general change for the better, is strongly marked in the patient's person and countenance.

February 1st — March 1st. There has been, upon the whole, a considerable amendment in the patient's disorder, within this period. He was allowed four ounces of toasted bread daily, and eggs and beef tea, occasionally.

This addition of vegetable food did not increase either the quantity, or saccharine quality of the urine ; but on the contrary, its quantity has been decreased, his appetite improved, and his strength recruited.

It appears, on the 13th, (four days after the use of bread) that he ate with great relish four ounces of this article, along with two pounds, three ounces of animal food; while his drink measured only five pints and a half, and the urine seven pints.

Whereas for seven days previously to the admixture of vegetable with the animal diet, the average daily quantity of his animal food did not exceed one pound six ounces ; yet the urine, during the same period averaged about nine pints, and the drink seven pints, and a half.

The urinary residuum on the 9th, weighed ten drachms, and was of the same colour and consistence as the last ; but its smell and taste were partly saccharine, and partly urinous. Indeed the urine, when tasted, seemed to partake of the same mixed properties.

In addition to these favorable changes, some other important ones were very conspicuous.

The patient had gained flesh, was more alert in his motions, and his countenance had become cheerful and animated. I saw him weighed on the 19th, and had the pleasure to find that he had gained not less than seventeen pounds and a half, since his entrance into the Infirmary.

The venereal appetite had returned, and the involuntary flow of the semen had entirely disappeared.

March 1st — April 1st

Nothing remarkable has occurred within this period. The highest quantity of urine has reached to nine pints, and the lowest has fallen to five pints ; but the average may be estimated at six pints, each twenty-four hours. There is still a slight excess of this discharge, when compared with the drink. One pint of urine left upon evaporation nearly eleven drachms of a thick extract, which differed, a little in its sensible properties from the last, as it was rather bitter, than either salt or sweet to the taste.

The patient is so far improved in general health and strength, as to be able to carry all the coals into the different wards upon the same floor, and to assist in various employments about the infirmary. He never feels thirsty but at meals. His appetite is regular and moderate, and he can sleep eight or nine hours without any interruption.

He was desirous of being discharged, as he fancied himself quite cured, and capable of undertaking his usual employments. As the urine, however, was not entirely free from saccharine impregnation, and consequently the assimilating powers of the system not completely restored ; it was thought advisable, both on the patient's account and for the sake of making a fair trial of the efficacy of the method of the cure, to detain him in the house for some time longer.

April 1st – 20th. He has remained nearly stationary during this interval. The average quantity of urine does not exceed six pints, it has no perceptible sweetness, but has very little of a urinous flavor. One pint of it on the 6th afforded ten drachms of a thick dark coloured extract, which certainly was both salt and sweet to the taste. The patient was weighed on the 15th, and was found to have gained four pounds since February the 29th. He observes that his old habit of sweating upon slight exertions has returned ; but he does not find himself weaker on this account.

Indeed, with the exception of the peculiarity of his urine, he may he said to enjoy his ordinary state of health ; and he is now so importunate to return to his family and usual occupations, that upon his promise to adhere as closely to his plan of diet as circumstances would permit, he was discharged on the 20th instant.

Remarks.

It appears from this well marked instance of diabetes mellitus that the nitric acid is productive of considerable advantage, in mitigating the thirst and heat, and thereby lessening the quantity of urine; but it is proved to be incompetent to destroy the saccharine impregnation of this fluids or to arrest the other characteristic symptoms of the disease

The efficacy of animal diet is strongly exemplified by the reduction of the quantity of urine from twenty pints to nine pints, in twenty four hours; and by the nearer approach to equality between this fluid and the liquids drank; but especially by the disappearance of great part of the saccharine properties of the urine ; all which events speedily followed the use of this regimen. Perhaps there could not have occurred a more favorable opportunity to ascertain the real effects of abstinence from vegetable diet than what the present case afiords. For the disease had existed two years ; its symptoms were unequivocal, and had attained their height of virulence; and the patient's constitution seemed free from any other malady. Nor were the opportunities for a trial of the remedy less auspicious. The patient was docile, steady, and capable of attending to the directions which were given him ; and he was under the vigilant care of the House Apothecary, and also of an intelligent and well principled patient, who was similarly afflicted ; and the whole arrangement was submitted to my daily inspection and superintendence.

If then the evidence contained in the reports on this case be admitted as correct and satisfactory, it will place beyond all doubt the existence of a fact which has lately been much disputed, viz: That in Idiopathic Diabetes Mellitus, the quantity of liquid egesta does sometimes exceed that of both the solid and liquid ingesta, and that the excess of the former cannot be accounted for solely on the supposition of its being derived from a general wasting and diminution of the solid and fluid parts of the system. For in Barratt's case we find, that during the period in which the register clearly pointed out almost a regular daily excess in the amount of the urine, compared with that of the liquids and solids taken; the patient, notwithstanding had gained an accession to his weight of seventeen pounds.

This singular phenomenon was likewise noticed, though not in so striking a degree, in the reports of the two last cases. Both Wild and Whitehead gained strength, and apparently flesh ; while at the same time the balance between the liquid and solid ingesta and egesta, was rather in favor of the latter.

To what law or process of the animal economy is the supply of this superabundant quantity of urine to be attributed ? Is it derived from cuticular or pulmonary absorption; or from a colliquation of the humours of the body? Each of these modes of supply have been insisted upon, by different writers.

I shall not, however, enter into the controversy, but content myself with remarking, that what happened in Barratt's case, seems to set aside the latter hypothesis ; for ( as before observed) he gained weight, during the time that the urinary discharge-exceeded the quantity of his drink; but it is proper to remark, that during his acquisition of strength and flesh, the sweetness of the urine, as well as other of the characteristic Diabetic symptoms were on the decline. This alteration of the qualities of the urine denoted the restoration of the assimilating powers, whereby the saccharine portion of the chyle was duly applied to the purposes of nutrition. Hence arose, I should imagine, the increase of the patient's vigor and bulk; notwithstanding the superiority of the quantity of urine to the liquids taken, remained. When the patient entered upon a mixture of vegetable with animal food, his strength and bulk were still more evidently increased, although the disproportion of the urine to the drink, remained stationary.

But as he was enabled by this plan to get down more solid food, and the powers of the system were capable of converting the same into nutriment, it is not surprising that his strength and flesh were so manifestly recruited.

The quantity of extractive matter in this patient's urine did not diminish in the degree that might have been expected; considering the amendment, not only of the specific complaint, but also in his general health. Nor could it be said, that the saccharine impregnation of the urine, was ever completely subdued, although the disease was' brought into that mild state, which led me to hope that it might be ultimately cured.

That the existence of sugar in the urinary residuum, obtained only a few days previous to the patient's departure, was proved by submitting it to the proper tests; but these chemical experiments will be adverted to, when the result of others of a similar kind are noticed.

There is one fact which I have omitted to mention, but as it serves, in some measure, to point out the Diabetic state of the urine, and was found to exist in this, as well as the other confirmed cases of Diabetes Mellitus, it may be proper to notice it. The urine not only stained the linen, but thickened it as if starch, or mucilage, had been applied. In proportion as the urine discovered less of saccharine and extractive matter, and the disease declined, it lost the properties both of stiffening and staining the linen. Barratt himself remarked with pleasure this change, which took place not long after he had entered upon animal diet.

Since writing the above, I received a letter from the patient's widow, in answer to some enquiries, informing me, that her husband died on the 12th of May, about three weeks from the date of his discharge. I then wrote to Mr. Wilson, Surgeon of Altrincham, who attended Barratt the day before his death, and he very obligingly communicated the following particulars ; and at the same time transmitted a register which the patient had very diligently attended to,, and preserved.

His diet had consisted of coffee, tea, and occasionally both, to breakfast; toasted oatcake and milk, to dinner and suppar; be made use of some opening pills when necessary; and lime water, to the amount of a pint daily.

He was capable of following his usual employment and his thirst was not more than natural to a person in health. From the register it appears, the average amount of his urine was nearly five pints and a half each twenty-four hours ; but it still exceeded the quantity of his drink. Its taste and colour remained nearly natural. His appetite and strength had not improved since he came home, and his bowels had been remarkably constipated.

On May 5th, at a public house, he ate very plentifully of bread and cheese, and drank two pints of porter. After this refreshment, he was seized on his return home, with an uneasy sensation in his bowels, which terminated in a violent fit of the colic. He continued in this state,  without any medical assistance, till the 11th, when Mr. Wilson first saw him. He found the patient evidently sinking under Enteritis. The bowels had never been emptied since his first seizure, and now resisted all attempts to procure an evacuation. On the same evening, the pain suddenly abating, the patient became faint, and soon after expired.

From the above narrative, it is highly probable, that the patient died of an inflammation df the intestines, which was brought on by over repletion, and suffered to terminate fatally, from the want of early medical assistance.