Carbotoxicity

From Mr. Houston, Brewer Street, London. 

L........... , aged about 30, fair complexion, light hair, and naturally of an extremely irritable constitution, in the month of February, 1793, received a violent shock by the death of one of her parents. On this melancholy occasion her grief was so very poignant, and at times so frantic, that serious apprehensions were entertained of a total derangement of intellect, and in this state she continued several weeks.

(several pages discussing the deterioration of her health leading to diabetes)

On their quitting the Wells, they, on their way home, stopped at Bath; and as her parent received benefit from the use of the waters of that place, they remained there eight weeks ; but before the expiration of the first fortnight, she found her stomach again disordered with heat and acidity, which in a short time increased to a height almost intolerable; the fauces were so sore, that it was a pain to swallow anything; and her tongue was equally so, being covered with a emit, or hardened slough on the top, and blisters round the edge. Her thirst was insatiable; to quench which, she ate a great quantity of fruit, and drank profusely of Seltzer Seltzer water and hock, but to no purpose.

Her skin was so parched, that the pores did not seem to emit the least moisture. To remedy this evil, some doses ofJames's powders were given, but to no effect ; towards the close of her time at Bath, she drank the waters for about a fortnight, they were supposed, however, to do more harm than good ; and growing daily worse there, she set out for London, where she arrived the 4th December, 1796. She immediately sent for her apothecary, who was greatly shocked ; as to all outward appearance, she seemed to be in the last stage of a consumption. Her pulse was exceedingly quick, but so feeble, that he could scarcely feel it, and so tremulous, that he could not with any certainty count or distinguish the strokes. For two days, he gave her every six hours a draught with kali ppt. magnef. alb. aa ^i, taken with half an ounce of lemon juice in the state of effervescence ; they agreed with her, and, as (he thought, cooled her; (he had no cough, but for some time back had loft her appetite, the stomach rejecting almost all solids; and when it did receive any, they generally laid heavy on it, or disagreed ; as some nourishment, however, was necessary, she was advised to eat eggs raw, or done very soft ; as also oysters and other shell-fish, as having a tendency to correct acidity. On the 3d day after her arrival in town (Dec. 6th) an eminent physician was sent for, who ordered a blister to be applied to her breast ; magnef. alb. qr. xv. in a draught every eight hours. These she took till the 15th, when she was ordered a draught with myrrh pulv. gr. xij. ferr. vitriol gr. iij. kali ppt. gr. viij. three times a day. This course she continued, with some trifling variations, but little interruption, till about the 19th February, 1797. By this time those medicines had the effect: of greatly recovering her appetite, and she had been allowed to eat such light animal food as she fancied ; but from this indulgence, of which she availed herself, with the return of her night's rest, which by this time she began to enjoy, she derived no other advantage than a small acquisition of strength ; for there was not the least appearance of bodily nurture, or any abatement of heat and acidity. 

The physician having compared the tardy, if any progress in amendment, with the quantity of food she was able to take, (for her appetite was greater than before her illness) began to discover symptoms of diabetes, and therefore gave orders to measure the quantity of fluids drank, and the quantity of urine she made and finding the latter exceed the former, he had some of it evaporated, and found it to contain a considerable portion of saccharine matter ; upon which she was advised to eat less vegetables and more animal food.

On the 18th, a gentle opening draught was given, though she usually took magnefia when any thing of the kind was necessary. On the 20th March, Dr. R. was consulted with her former physician ; and as he is already so well acquainted with all that has since been done, or happened, it is unnecessary for the writer of this to carry it any further.

Continuation by the Author.

On the 20th March, 1797, I visited the patient, with her physician and apothecary; she complained of a burning sensation at her stomach, which she faid was intolerable, with the sense of a sharp and hot acid rising into her throat ; her teeth were on edge, tongue red, and gums full ; she had little thirst, and was occasionally sensible of a moisture on the palms of her hands, and on other parts of her body ; her appetite was keen, and she never felt satisfied, but said that this degree of appetite had only been lately remarkable ; and she complained much of a burning sensation in her stomach, and of great acidity ; she was extremely emaciated, feeble, and inactive ; her skin dry, and rather warm ; pulse about 88 ; her urine of a pale colour, but to the taste scarcely sweet ; the quantity could not be distinctly ascertained ; it did not seem, however, to have been so increased as to engage any particular notice ; a little of the urine was evaporated; the residuum resembled treacle, but was salty to the taste, and the extractive matter did not seem much to exceed the quantity in healthy urine. On the whole, the adoption of light animal food, with less vegetable matter, and the medicines, had mitigated the disease. The physician who attended had a copy of the notes of Captain Meredith's case the preceding January, and he now very readily agreed to the animal diet entirely.

On the 14th April I saw the patient, with the physician and apothecary ; her looks had more the appearance of returning health ; she moved about with more agility and strength, though she complained of not gaining flesh ; her appetite is now good ; the tongue is clean, but not so florid ; she has no thirst ; the urine does not exceed a quart, a small portion of which being evaporated, the residuum was quite saline, and urinous in smell, but it was not evaporated so much as to determine the tenacity. The burning sensation in her stomach is diminished, and there is less acidity ; however, another emetic is prescribed, and the matter thrown up is to be examined, in order to ascertain whether it possesses acid properties. The patient informed me to-day, that for several years she has indulged in fruit, pickles, and sweetmeats.

April 25th. The emetic ordered on the 14th brought up very acid matter, which was found by the apothecary to effervesce with an alkali ; the urine deposits a reddish sediment ; she has less uneasiness at the fiomach, has more strength, and a more natural appetite ; her skin is moister.

May 10th. Very little change. Asafoetida is added to the pills, with calcined soda, and the quantity of the hepatized ammonia increased. From the delicacy of circumstances, an accurate enquiry cannot be made ; deviation of diet may happen ; in this cafe, we can only hope for a certain compliance with regimen, and a certain information with regard to appearances, and ultimately a recovery with tardy and irregular advances ; it merits much attention however, even with the view of discovering points of importance in the treatment, under the most unfavourable progress.

June 8th. Very sensible of an increase of strength, and that health is returning, the urine continues in a natural state, at least there is no saccharine matter. The heat of the stomach is much diminished ; the appetite feels natural ; no thirst or hectic symptoms ; she has discontinued our medicines, and only takes Schweppe's acidulous soda water, which she likes, and says it has been of much service in relieving the uneasiness of her stomach. To be allowed about four ounces of bread in the day.

June 16th. Since the use of the bread, the disease has been reproduced ; the urine is clear, and of a sensibly sweetish taste ; 18 ounces yielded a saccharine residuum of 1 ounce and 5 drachms ; her skin is again hot and dry ; the pulse quicker, thirst: intenfe, appetite keen, tongue florid and red ; alfo the heat of the stomach extremely unpleasant. She promises to return to the entire use of animal food ; her antimonial opiate to be taken at night; Schweppe's water for drink ; and a blister to be applied to the region of the stomach.

lid. The urine, in smell and taste urinous, having become so in twenty-four hours after leaving off the bread; her appetite is not so keen ; the tongue is not more florid than common, and the uneasy hot fenfation of the stomach is much less, though occasionally troublesome ; the thirst is gone ; the blister relieved the stomach ; the regimen, with Schweppe's water, to be continued.

July 14th. In a state of apparent recovery ; me occasionally takes a biscuit or two, but perseveres in the diet generally, and Schweppe's soda water. Next week she goes to Bristol, where she is to observe the fame conduct, being fully sensible of the influence of a change of diet, and equally so, that everything depends on her own steadiness. No accurate account could be obtained with regard to the quantity of urine ; in general terms it was said that it corresponded with the quantity of drink.

February 5th, 1798. Returned a few days ago from Bristol and Bath ; at the latter place she bathed in the warm bath, and was relieved, by its being followed by a moist skin. The Bristol water was very grateful to her stomach, and generally superfeded the use of Schweppe's soda water. She appears much in the same state as when I saw her in July ; the disposition to the disease still remains, and the feels better or worse according to her diet ; she eats daily some biscuit, and has done fo generally all the time the has been away ; the acidity of her stomach still continues a distressing symptom ; the urine yields a saccharine extract. 

March 6th. Since the first, has been strictly on animal diet ; the several symptoms are removed, and she appears altogether better than I have yet seen her.

March 21st. Continues better, perseveres in the diet. On the l7th she ate a sweet cake which was soon vomited in a sour state.

April 2nd. She assures me no change in the diet has yet been made ; she begins to loath food, but believes it is only animal food, as she feels a strong desire for vegetables ; and alleges that, even under the animal food, she has had the acid state of her stomach, especially at times when her mind has been uneasy ; tongue less red, indeed it is rather pallid ; the urine smells strongly, and has a greasy scum ; on evaporation, it yielded a saline and bitterish tailed residuum, without tenacity ; and when treated with nitrous acid, furnished scales. She was allowed a small quantity of broccoli, spinach, or salad, without sauce.

April 16th. In all respects better, and for these eight days has been eating broccoli and salad occasionally, without any reproduction of the disease.

April 18th. A portion of urine was examined, which was found clear, but of a urinous taste and smell ; its residuum, however, yielded oxalic acid when treated with the nitrous acid.

May 5 th. It was ascertained that she had eaten some biscuit between the l6th and 24th April.] Her skin is moist ; pulse 72, and regular; her appetite less keen, and she feels more uneasiness after eating, or rather has a sense of indigestion ; tongue clear, but not florid; she has gained flesh. She promises to leave off bread, and to take only cauliflower and spinach. The salad does not agree with her; she assures me, and so does her maid, that the other day, after eating more vegetables than usual, the urine smelt and tasted sour immediately after it was voided.

May 10th. Is again to visit Bath and Bristol ; she promises an adherence to the plan, though she acknowledges that her resolution is often likely to fail her; she will, however, be as steady as she can, being perfectly persuaded she has no other prospect of recovery but by so doing. She has again been sensible of the acid smell and taste in the urine, after vegetables. I examined her urine today, but it did not smell or taste of anything, except the urinous flavour and impression.

This Case, though not as yet completely terminated, appears to me of so much importance, that I have inserted it in its present progress. There can be little doubt, that the adherence which has been bestowed on the animal diet since the 20th March, 1797, has not only prolonged life, but given strong hopes of the re-establishment of as great a degree of health, as can possibly be expected, under a long continued stomach complaint. The exact period when Diabetes Mellitus was actually formed cannot be determined : it was probably when the keenness of the appetite took place, but when that happened cannot be accurately ascertained. She had been long subject to stomach complaints, and the keenness of the appetite is only noticed in the account about the lft March, 1797 whereas the cardialgia is mentioned as long before as May, 1796 ; and before these periods the health was much impaired. These complaints had been partly brought on by the circumstances so well related by Mr. Houfton, and partly by the frequent use of fruit, pickles, &c. The animal diet, though not unremittingly perilled in, yet by a more steady use of it in March and the beginning of April, the disease was so far overcome, that the urine became as near as possible to the standard of health. It is to be regretted that a further perseverance did not at that time follow ; however, the progress shows, that certain vegetables, such as broccoli, spinach, salad, &c. may be eaten at a proper time of the treatment, without reproducing the disease, while bread could not be eaten with impunity. This fact we consider of much advantage, as it enables us to guard against the effects of a long continued use of animal diet, and at the same time gratify, in some measure, our longing patient ; we say in some measure, because even these vegetables do not long check the ardent desire for bread ; indeed, the stomach appears very whimsical, for when it obtains its desires, other things are soon solicited. The circumstance of the urine having become acid after the use of more than the usual quantity of vegetables, is a curious fact, but as it merely rests on the testimony of taste and smell, we do not hold it, in this case, as satisfactorily ascertained; it deserves, however, to be kept in view.

From Doctor Gerard. Liverpool, 15 th May, 1798. IN compliance with your request, I shall give you a short account of two cafes of Diabetes Mellitus, which have fallen under my care at our Infirmary since that of Clarke, who, by the way, I must tell you, has never been heard of since he was discharged. They were both females. Mary Jackson, aged 57, was very much reduced indeed, when she was admitted in July last..

She had had 13 children ; the last 7 years of age. The disease commenced about July 1796, but was not attended with any particular circumstance, except an uncommon itching about the meatus urinarius, which returned at intervals, and was always attended with an increased flow of urine. She remarked, that upon the occurrence of a spontaneous vomiting, which continued several days, her water was reduced in quantity one half, but when the vomiting fubfided, the quantity became as great as before. 

She was put upon the animal diet, and in the course of eight or ten days was better, to her feeling, though the urine was little altered; her appetite and thirst were more moderate, her spirits and complexion improved and the skin, which had been very harm and dry, had yielded to moderate perforation, and was become much softer.

 She frequently took an opiate, and occasionally an emetic; and upon the disease proving obstinate, I ordered her five drops of hepatifed ammonia three times a day; the dose was gradually increased to 20 drops, which was repeated five times in the 24 hours, without producing any lasting amendment. Not meeting with the same success in this case as I had experienced in Clarke's, I determined to give her the carbonated ammonia in very full doses, which I was led to make trial of, both from the late discovery of its component parts, and also from the consideration of its being of copiously afforded by healthy urine, and animal matter in general, and therefore corresponding with the plan of animal diet. I also found a further inducement to persevere in this plan, upon hearing that Dr. Currie, of Chester, had succeeded in a case where he had made use of it. It was continued from August to December, and for a great part of the time, to the quantity of giv daily, one half in the form of pills, and the other in solution, saturated with carbonic acid air. It failed, however, in this instance, for she died on the 13th of December; but it must be remarked, that she was continually deviating from the plan, in eating different vegetable matters, and particularly sweets; but this did not come to my knowledge till it was too late; the fact, however, was proved beyond a doubt. The want of success in this instance, cannot, therefore, with any propriety, be attributed to the insufficiency of the plan.

From Doctor Pearson, Physiclan to St. George s Hospital, Lecturer on the Practice of Physic and Chemistry, &c. London.

CASE III. 

July, 1798. 

A Gentleman, aged about 56 years, who had lived rather in a fedentarv manner, was troubled for five succeffive winters with a cough, attended by a copious spitting. In the Summer he was almost free from these ailments. During the two last of these winters symptoms appeared, which, it was apprehended were those produced by pulmonary tubercles and vomicae. In the early part of the Summer succeeding the fifth Winter, namely, in May 1797, when the patient was considered as labouring under the chronic kind of pulmonary phthisis, besides taking the usual medicines in such disorders, he began to breathe hydrocarbonate gas; which was administered to him by Dr. Thornton. Soon after the use of this medicine, he experienced a very decisive amendment of his pulmonary disorder ; and continued almost entirely free from cough, spitting, and difficulty of breathing the whole of the Summer ; nor did these complaints return in October following, as they had constantly done for several preceding years. In October last it was observed that, notwithstanding the amendment of the disorder of the chest, a gradual wasting of the flesh had taken place ; so that instead of being, as in health, muscular, and rather corpulent, his body was become thin, and his limbs were emaciated. The appetite continued to be as great, and was frequently greater than in health. The pulse at the wrifl was most commonly about 80 in a minute, and never exceeded that number. The tongue had a healthy appearance, and there was pretty constant thirst. The patient had sweat profusely for the whole preceding year. 

I now learnt that he had been accustomed, for five or six years past, to drink to the amount of from five to eight pints of liquids, such as tea, capillaire, fmall beer, wine, water, coffee, &c. in the space of every twenty-four hours. A proportional quantity of urine was discharged ; that is, as much urine, or thereabouts, as he had taken of drink. As will be expected, the nightrest was difturbed by riling to pass urine. The quantity of urine being at first attended to without reckoning the quantity of drink ; and being perceived by the attendants to be sometimes sweet to the taste, the patient was pronounced to labour under the Diabetes. 

The urine also having been tasted by a person of unquestionable accuracy, it was discovered to be saccharine. A parcel which I examined was not decisively sweet, but I was struck with a smell which I had never perceived on any former occafton, namely, that of stale beer. Half a pint of this urine, on evaporation, yielded 400 grains of extract-like matter, which contained no sugar perceivable by the taste. Another parcel of the same urine, on standing ten days in a warm room, in a three pint bottle, which was half full, and closed with a glass stopper, became covered with a white scum, and a deposit took place of seemingly the same fort of matter ; but the urine itself, which was quite clear, smelled strongly of vinegar, and tasted sourish. On distillation, this sour urine afforded three-fourths of an ounce of liquid acetous acid, of nearly the strength of weak distilled vinegar. It may be useful to notice that the patient had lived principally on animal food for several months, and had drunk a pint of wine daily, instead of a larger quantity, as was his custom before his illness. During my attendance occasionally for three months, the urine generally had the beer smell, and on standing became sour. Two or three different times it had however, undoubtedly, the saccharine taste. Some parcels of this patient's urine, which had a fleshy and beerish smell, happening to stand in a closed vessel, in a warm room, from November, 1797, to May following, not one of them had the usual smell of urine of persons in health, nor of putrid urine ; but either smelled sourish, or musty ; and they deposited less, and were covered with white scum. The urine of the patient, however, sometimes smelt like ordinary urine ; but on keeping it did not grow ascetic, nor acquire an animal odour ; nor did it ferment, and became four. It was also found that this last mentioned sort of urine retained the usual acescency of urine of healthy persons, as betrayed by the test of turnsole, even after keeping in a warm room fix months.

The patient was directed to live four days entirely on vegetable food. The urine during this time proved fo irritating to the urethra and glans penis, as to inflame them, and a little of it was even paffed involuntarily. It was observed that the urine excreted during the ufe of this kind of food, contained none of the uric oxide, which is the usual basis of urinary concretions. According to my observation the urine voided, when the food was entirely animal matter, was equally acescent, and fermentable into vinegar, as when it was entirely vegetable matter.

The quantity of urine, in October and November last, never exceeded, according to eflimation, the quantity of drink ; and the quantity of urine seemed to vary proportionally, or nearly so, as the quantity of liquor varied. Except for some slight incidental colds, the patient was quite free from pulmonic complaints the whole of the last Winter, as well as during the prefent Summer. The thirst has abated a little ; the appetite for food has been of late about the fame as it was in health, instead of being greater than formerly. The pulse at the wrift has varied between 70 and 80 in a minute. The wasting of the flesh has scarce continued to go on of late, and the strength has decreased very little for several months past. The urine, however, does not appear to have diminished in quantity; nor to have been altered in its properties, in proportion to the general amendment. The amount of this excretion has been for fome months, at least, five to six pints in the face of twenty-four hours. It flill commonly has a beerifh fmell, and on Handing in a warm room does not ordinarily fmell urinous, and putrefy like common urine, but becomes acefcent, and deposits lees, and throws up fcum as malt liquor does, on growing four. There is no room to suppofe that the quantity of urine exceeds the quantity of drink.

The patient has continued to live almost entirely on animal food, even breakfasting usually on what is called beef-tea, in place of the vegetable matter commonly taken at this meal. When vegetable substances were occasionally taken as food, the urine was increased in quantity, but no effects were otherwise experienced different from those during the ufe of animal food. It was thought advisable to continue, however, the animal food, as it agreed very well with the patient, and as the urine was less in quantity than when vegetable food was taken.

Remarks.

Saccharine matter is not the immediate cause of Diabetes, but the effect of this disease ; and if animal food is beneficial, and vegetable food is detrimental, it cannot, I think, be shown, that it is because the former does not afford sugar and the latter does. In support of your theory, that the Diabetes is not seated in the kidneys, it may be asserted that the kidneys do not appear to be secretory organs, or organs which compound matters of a different kind from those which enter into them from the blood ; for excepting, perhaps, the secreted mucus from the urinary passages, there is nothing in urine that does not exist in the same state of composition in the blood itself.

It has been attested by persons whose abatements cannot be doubted, that the blood has, in some instances of Diabetes, tasted sweet, and that it had other properties denoting sugar. A single positive evidence of this sort ought not to rejected by any number of negative ones. But, in short, blood and urine to most persons taste is commonly somewhat sweet ; and therefore, it seems not improbable, that there is in general, sugar both in the blood and urine of all animals at certain times. It is not doubted that the sweetness of chyle, and of milk, is from sugar. It seems also that the digestive and assimilating organs of animals compound sugar from merely animal, as well as vegetable aliment ; as appears on examining the chyle and milk of animals which live entirely on animal food ; namely, either those which are purposely fed or which are naturally carnivorous. It does not seem that the fluids of animals which feed on saccharine matters, contain more sugar than those which feed on animal substances. Vegetables manured with merely animal matter contain as much sugar in their fluids as when manured with vegetable matter, or probably with sugar itself. But fugar can also be compounded by fermentation, without the aid of live powers, from dead animal matter and tasteless farina. These facts, it may be proper to notice, seem to justify the observation above made, that, on a theoretical ground, we might conclude that animal food was not likely to be either more beneficial, or less hurtful, than vegetable. In this place it will be proper to point out that fermentation is a more delicate criterion of the preference of sugar in urine than the taste ; for the urine of the above patient did not taste sweet, but it fermented into acetous acid.

5. If the Diabetes be essentially an organic disease of the kidneys, one might expect to see air-ways such a diseased state on dissection ; which, however, could not be perceived in Laurie's cafe above related. There are also deflections published by various persons, in a few of which only was any disease {etn in the kidneys ; nor are there, in general, any complaints of the loins, urinary passages, hips, &c. in diabetic cases. Wherefore if organic affection takes place, it should be considered as an accidental attendant, or consequence ; and in this light mould be regarded the diseased state of the liver, spleen, lungs, &c. observed in some instances. At the most, such organic disease can only be confidered as productive of one species of Diabetes, in which, on examination, it is probable the urine will be found to be very different from that in the other species of this disease. The state of the mesentery should be more accurately attended to on diffection of diabetic patients. In Laurie's cafe above described, it was observed to be diseased, but I was not prepared at that time for examination of this part with a view to any theory. The urine ought also to be examined after the death of the patient, as well as while alive. In fome cafes, as the appetite fails the urine diminishes in quantity, and loses its sweetness a short time before death. The theory that Diabetes is a diseased state of the assimilatory organs, accounts for fome of its molt characteristic symptoms ; namely, for the urine containing fugar and other nutritious matters, the walling of the flesh, frequent discharges of urine, thirst, hunger, weakness of the organs of voluntary action, &c* but it does not account for the quantity of urine much exceeding the quantity of drink.

Case III. Thomas Kay, age 24

Admitted an In-Patient, September 29, 1800.

Complains of great thirst, weakness in his loins, and an incessant inclination to make water, which is of a light colour, and very sweet taste. He first discovered the latter quality about four months ago, when being urged by extreme thirst in the night, he drank copiously of his urine, which practice he has since occasionally repeated.

His appetite is generally very voracious, and when he can indulge his inclination, he eats until the stomach is often obliged to disgorge its contents. What he throws up varies in taste and smell ; being sometimes sweet, but more frequently of a pungent acid taste, and odor. The saliva is white and frothy; the mouth peculiarly clammy ; he has a sour taste, and the corners of his lips are covered with fur. The heat in his bowels is frequently distressing, and to use his own expression, "they seem at times burned up." His skin is dry and shriveled, and he seldom perspires.

Pulse 80 ; his figure is lean and gaunt, his complexion sallow, and he has a dejected air. He enjoyed a tolerable state of health till within the last twelve months ; and attributes his present malady to a frequent exposure to wet and cold, and a habit of drinking spirits. He has frequently, when intoxicated, laid out all night in the open fields. His occupations have been various, but of late he has been employed as a laborer to bricklayers. Upon examination, he was found to be afflicted with a painful phimosis. He had never measured the quantity of his urine for any given time, but thinks it must amount to some gallons in 24 hours. This being considered as an undoubted instance of Diabetes Mellitus, under its most aggravated form, an accurate register of the liquid ingesta and egesta, was ordered to be kept, and every material circumstance, connected with the progress, and treatment of the malady, to be carefully noted down. From these documents, the following abridged statement is copied.

September 30th. One pint of urine yielded by evaporation, two ounces and one drachm of a thick sweet syrup, of the colour and consistency of treacle.

In the last twenty-four hours, he has passed thirteen pints of urine, and drank twelve of liquids. The urine is of a whitish colour, sweet to the taste, smells like wort, and exhibits air bubbles on the surface. This decrease in the quantity of urine, compared with what he had usually passed in the same time, he attributed to his being abridged by the nurse(from mistake) in the indulgence of his appetite for liquids.

He was directed to pursue a strict plan of animal diet, consisting of cold fat meat, with beef-tea; and to use daily, one drachm of the nitric acid, diluted with a sufficient quantity of water, as a part of his common beverage. To take five grains of rhubarb, and one of opium, each night.

A remarkable increase in the quantity of urine, and an aggravation of some of the most distressing symptoms, led to an inquiry as to the patient's strict adherence to the plan of animal diet; when it was found, that for three evenings past, he had, by a mistake of the nurse, been indulged in a liberal allowance of bread and cheese for supper, instead of cold meat.

This error was ordered to be rectified, and the greatest attention enjoined, to confine the patient in the future, solely to animal food; medicines and acid drink to be repeated.

October 8-13th.

October 10th - Urine 13 pints, Drink: 12 pints

October 11th - Urine 8 pints, Drink: 9 pints

October 12th - Urine 8 pints, Drink: 9 pints

October 13th - Urine 8 pints, Drink: 9 pints

This diminution in the quantity of urine (as appears from the register) was accompanied with a mitigation of the thirst, internal sense of heat, and stricture of the skin.

He has suffered little disturbance in the night, and finds his strength recruiting, but his urine has not quite acquired its natural smell and taste. Pulse 80, one pound of urine, yielded, by evaporation, one ounce and seven drachms of a thick tenacious extract, not quite so sweet nor so fluid as the last, and less in quantity by one drachm and a half.

As he complained of griping, and soreness of the mouth and gums, from the use of the acid ; he was ordered to be laid aside, and the rest of the plan to be continued.

October 12-20th 

In this interval no material change has occurred; except that on the average, the daily quantity of liquid egesta, rather exceeds that of the liquid ingesta. He has never passed more than eleven pints of urine, nor less than eight in twenty-four hours. On one day, this discharge exceeded, by two pints, the liquids taken in. He complains of a tickling cough, and flight pains in the chest; to appease which, he was ordered an oily linctus, and a warm stimulating plaster.

Pulse 68, urine more natural. Prescribed for daily consumption, one drachm of Kali-sulphuratum, in two pints of soft water. Regimen and opiate to be continued.

October 23rd. 

He was attacked with a violent colic, attended with rigor, which was succeeded by a hot fit. After clearing the stomach, he took a carminative opening mixture, which was ordered to be repeated, with or without an opiate, according to circumstances.

He soon obtained relief, but has suffered, every other, or third day, in a slight degree, from griping pains in his bowels, which have been always mitigated by the carminative mixture. The disorder in his bowels has generally come on after a full meal.

The quantities of urine and drink, have born nearly a relative proportion to each other-; nine pints and a half form the highest, and seven pints and a half, the lowest amount of urine in twenty-four hours.

October 27th

An augmentation was noticed of nearly two pints in the quantity of urine, compared with that of the preceding twenty-four hours. On being interrogated by the House-Surgeon, who suspected some irregularity on account of the change which had taken place, both in the quantity, and sensible qualities of the urine, the patient freely confessed, that he had seized an opportunity to indulge privately in bread and cheese for supper. He has been admonished of his faults and seems determined to act with more discretion) in future.

October 31st — November 12th,

November 9th.

Pulse 76. Obtained, by evaporating one pound of urine, an ounce and five drachms of a thick residuum, of a mixed saccharine and urinary taste and smell; but the latter rather predominated.

The register affords nearly the same result as the last report, except that within the last four days the urine and drink have diminished to seven pints and a half; but the latter is still rather sweet. He gains but little strength and flesh, and complains of weariness and general debility. On the 2d. he began to take a bolus, composed of half a drachm of Kali sulphuratum, and ginger, thrice in the day ; and as he suffered from pain in the lumbar region, blisters were applied over each kidney, and the blistered parts ordered to be kept open. This plan was continued till the 10th. when, on account of the nausea excited by the Kali sulphuratum, and the stationary point of debility, at which the patient remained, notwithstanding the removal of the most formidable of the diabetic symptoms, an infusion of bark in lime water was substituted for the solution, and alum and gum kino were added to his opiate at bed time.

November 12th —20th.

 The urine is scarcely, if at all, sweet; and has varied little since the I2th, either in quality, or quantity. The average amount may be reckoned at eight pints each twenty-four hours. His appetite is fickle, and for the most part puny; the clamminess and sour taste in the mouth have disappeared; the patient has been allowed a small portion of toasted bread at his dinner, without any increase of the diabetic symptoms. He has for two or three days past complained of a fixed dull pain in the back, underneath the right shoulder-blade, to which a warm plaster was applied.

November 20th – December 10th.

Continued the medicines, and the regimen. The pain under the shoulder, having gradually increased, and a tumor appearing; surgical aid was requested. The Surgeon gave it as his opinion, that an abscess was forming, and treated the patient accordingly. The urine has remained stationary in quantity and quality. He has been troubled with flying pains in his knees and ankles ; for the relief of which, a stimulant liniment was ordered. On the 9th, he had transient chills and flushings, with a regular febrile paroxysm in the evening, which, together with the increased size of the tumor, sufficiently indicated the formation of matter. Under these circumstances, it was thought necessary to change his diet; milk was allowed for breakfast, and supper, and the common broths of the house, with animal food at dinner. The bark, and anodyne to be continued.

December 12th — January 1st. 1801

The symptoms have been nearly stationary within this period. The discharge of urine has been reduced, at times, to five pints within twenty four hours, but the average quantity may be reckoned at seven pints. It is improved, both in natural colour, and smell; but the patient says it has acquired a sweeter taste, since vegetable diet was entered upon. The tumor, having pointed outwards, was opened by the Surgeon, and discharged a considerable quantity of laudable pus. The bark, with Vitriolic acid, and a mixture of vegetable, with animal food were continued.

Pulse 80, soft and regular. His countenance, and general appearance, rather improved; notwithstanding the discharge from the abscess was considerable. The excoriation, and swelling of the prepuce, are nearly gone, and the pain in his loins, and sense of internal heat, are very little troublesome. He does not appear to have gained flesh ; but his spirits are good, and he expresses a full confidence of his recovery.

January 1st — February 1st. 1801

The report of this month has varied more than the last. The register points out as much as eleven pints of urine, in twenty four hours; and the average quantity may be estimated at eight pints.

The abscess is not yet healed, but the discharge daily decreases. The bowels are with difficulty kept open, and his evening feverish paroxysms, attended with a short dry cough, have been constant and troublesome. Ordered to wear a flannel waistcoat, and to take opiates, with mucilaginous pectorals. The other medicines to be continued. On the 18th, one pint of urine afforded one ounce and six drachms of an extract, nearly resembling the last; except that there was rather more sweetness, both to the smell and taste. His diet was again ordered to be restricted to animal food; but this was found difficult to accomplish, not only on account of the patient haying been for some time past indulged in the agreeable article of vegetable diet, but also from the persuasion he entertained of his being already cured of his ordinal disorder.

February 1st. — 16th. The patient has remained nearly stationary. His urine is natural, in appearance and smell, though (in his own opinion) rather sweet: The average quantity amounts to nine pints in a day/ yet his thirst, heat, and dyspepsia are all abated. His strength is certainly increasing, the skin feels more soft and natural, and his visage is less sallow and dejected. The cough is troublesome occasionally, but without any fixed pain in the side, or purulent expectoration; yet, notwithstanding these favorable changes, his bulk is little, if any increased. His impatience to quit the infirmary, in order to complete (what he considers to be) his cure, among his friends in the country: and his increasing aversion to any restriction of diet, have led to a compliance with his wishes; and he was accordingly discharged, relieved, on February the 16th.

Remarks.

This appears to be a decisive and aggravated instance of diabetes mellitus. The sweet taste and smell, and profuse discharge of the urine, thirst, dry skin, voracious appetite, and wasting of the body, with hectic fever, (all which symptoms were apparent in this patient's case) are sufficient indications of the nature of the disease. An indulgence in spirituous liquors, and exposure to hard fare, cold and moisture, seem to have operated as remote causes in the production both of Piggin's and Kay's disorder. The efficacy of animal diet, in mitigating the patient's diabetic symptoms, is sufficiently evident; and it is probable, if this case had not been complicated with a pulmonic affection, and the formation of a large abscess under the shoulder, that its termination would have been successful. For the hectic fever arising from these latter causes, contributed greatly to the patient's extreme emaciation and exhausted strength. It may therefore be presumed that the slight remains of the diabetic affection would have given way ; provided the patient had strictly persisted in his regimen and diet. Indeed the changes which so remarkably followed every irregularity in the plan of abstinence from vegetable food ( especially in the first stages of the treatment of the disorder) sufficiently point out the necessity of a strict adherence to this essential part of the method of cure. The quantity of solid matter carried off by this patient's urine is very extraordinary. It amounted, in the first experiment, to two ounces and thirty grains, troy weight, from one pint (wine measure) of the fluid. This is nearly the largest quantity ever before collected by a similar experiment on diabetic urine; at least in all the cases hitherto published, which have come to my knowledge, there is but one instance of more than two ounces of extractive matter having been obtained from one pint of urine ; but the medium quantity in even very aggravated cases of diabetes mellitus, may be fairly estimated at not more than ten drachms of solid extract. The gross ignorance of this patient, joined to his habit of self indulgence, rendered it highly necessary to keep a constant watch upon his conduct; but in spite of every precaution, I believe he succeeded too often latterly, in eluding the vigilance of the man-nurse, and house apothecary. He was strongly urged, and he promised a compliance with the request, to send occasional information of the state of his health; but since he left the infirmary, and went into a distant county, no account from him has been received ; and consequently the termination of his complaint, although most likely to be unfavorable, cannot be ascertained.

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Page 153:

As I wish only in this part of the work to enumerate facts, with the intention of applying them in support of any arguments which I may in the conclusion employ for maintaining any particular opinions, I will not here anticipate any thing that I may then judge right to advance concerning the method of cure; let me however just observe , that during the former period of this gentleman's disease, I enjoined him a strict animal diet, with as much milk as he chose; but in the latter part of it he eat and drank almost as his fancy directed him, since it was found that none of the vegetable decoctions had for several weeks affected his urine, nor any sweetness again arisen from the use of vegetable matters, or from fermented or vinous liquors.

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The next was the case of a gentleman with whom I was afterwards upon terms of very friendly intercourse, and whose urine yielded sugar upon evaporation, in the pro portion of one ounce in sixteen or twenty. A common attack of fever first made me acquainted with him , and which, with some difficulty, gave way to the usual methods of cure : his recovery I found retarded by a frequency of micturition, which interrupted his sleep, and which had very long distressed him : he attributed it, however, to some disease either of the bladder or of the prostate gland, which he said he knew to exist, for that his water was often loaded with large quantities of mucus, and that he had been in the habit of introducing bougies for several years, to overcome a stricture which he always found seated very high in the urethra. As he recovered his strength, and was again able to pursue his professional concerns, I did not then at all suspect that there might be any additional cause of his frequent calls to void his urine: nor in truth did I ever suppose, during two or three attendances which I had afterwards upon this gentleman, that any thing more than irritation at the neck of the bladder, increased by a little occasional intemperance, was the cause of the hectic which usually attacked him, accompanied by its common symptoms of thirst, and heat of body, and costiveness. It was nearly two years afterwards, when, from a continuance of these symptoms beyond their usual period; I first suspected that something Diabetic might be connected with them; and on examining the urine I found it sweet. As he was a man of a sound understanding, I explained to him such circumstances as might best induce him to persevere strictly in a proper plan of diet and of medicine; and although he had been accustomed, from a public situation which he held , to live well, I found no difficulty in shewing him the necessity of avoiding all vinous and spirituous liquors, and of entering upon a plan of complete abstinence from all vegetable matters. He took freely and largely of milk, both night and day, to which he latterly added mutton-suet; and his more substantial meals consisted of animal food, with a very small quantity of bread. He took the sulphurated hydrogenous medicines, in very large doses, without any manifest advantage: and afterwards, for many weeks, persevered in the common green mixture of sulphat of iron, with myrrh and tartrat of potash, in the quantity of half a pint in every twenty four hours, which I was induced to press upon him from the benefit I supposed to have arisen from its use in a case above related : this gentleman's strength very much increased under this plan, which, from the relief obtained, he pursued with astonishing perseverance: his urine became much less troublesome, having sometimes but very little sugar, and occasionally none at all: the organic mischief at the neck of the bladder, of course, still continued, and his nights were still disturbed, by his being frequently obliged to make water, but he recovered his usual countenance and his strength again. He did not afterwards indulge to any immoderate extent in company, but as to food, took his milk and suet during some years, pursuing to the time of his death, in 1803, a very active employment, and undergoing great exercise, both of body and mind.

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Hitherto I have detailed the cases that have occurred to me, more at length, per haps, than might be necessary; but if any apology may be required for it, I have only to observe, that what I have stated is almost literally written from notes which were taken when the cases were pässing under my observation : and the same apology must be offered for any imperfect statement, if such it should appear, in those which follow ; for having made up my mind with re spect to the method of treatment, from finding it in several instances successful, I was not so studious about noting all the particulars of any individual case, as I had been accustomed to be : but the truth of the matter is, that besides those which have been already, and those which are about to be mentioned, many others did occur, of which I took no note whatever, either be cause they yielded (although the symptoms were really Diabetic) in so short a time, that I had not a convenient opportunity of ascertaining the sweetness of the urine ; or because, from the very common versatility of mind attending this disease, the patients did not return to me after the first inter view : of these, therefore, as cases merely of conjecture or suspicion, I have not made any record ; considering those only as truly legitimate, whose names, with other circum stances, impossible from their notoriety to be misunderstood, I could fairly and honestly register.

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"I have had no experience myself of the Hepatised Ammonia, nor did I know whether it could be procured here or not ; and as the gentleman's stay was likely to be so short in Oxfordshire, I was not very anxious about it : but as I have seen the best effects by limiting the use of vegetables, and if possible preventing it entirely, I urged this point as much as I could, but I am afraid I was but imperfectly obeyed. Indeed, I fear we shall have but very few patients who will so perfectly comply with that part of Dr. Rollo's plan, as the patient he has described.

The three next cases may be said to be still my patients, as they continue under the regimen prescribed for them ; or if they are deviating from it, they remain as examples not merely of the efficacy of the plan, but of the durability of the cure: The first was a gentleman from Kent, who consulted me more than a year ago, for indigestion and a bilious irregularity. In March, 1809, he called upon me with every symptom of Diabetes ; and in addition to the large quantity of water, and the usual thirst and voracious appetite, he complained of a wasting of his pudenda, and of absolute impotency; circumstances which I believe to happen not unfrequently in Diabetes, notwithstanding I have not hitherto made such the subject of particular enquiry: I ordered him upon the chalybeate plan, and enjoined him the usual strict regimen with respect to diet: I was to see him again, or hear from him in case of necessity : but not hearing from him I wrote to him, expressing my anxiety about him, which brought him to London : -He then candidly acknowledged, that he had not tried the plan, for that he had taken it into his head that nothing could be of any service to him. I remonstrated with him most strongly, and shewed him his danger ; and on his return to Rochester, he commenced his plan, for his apothecary some time afterwards informed me, in a letter dated Oct. 27, 1809— “Our patient, Mr. S—, is perfectly recovered, from the plan you recommended.” 

A gentleman who resides in Surrey, up wards of sixty years of age, was also, a year ago, relieved by a similar plan; for, in about three weeks, his urine, and thirst and appetite, became natural, and his emaciation was succeeded by flesh and strength : In the following year, 1809, the symptoms returned , and the same treatment was pursued with the same fortunate result ; for his urine, which had again become sweet, soon was found, upon evaporation, to .contain not a particle of sugar, and his health, in proportion, improved. It may not be improper to mention, that I found it necessary to secure rest at night by means of ten grains of the compound powder of ipecacuanha. 

The next case is that of a gentleman's housekeeper in Portland Place, who states her complaint to have arisen six years ago. About ten years since, one of her breasts was removed, from an apprehension of cancer. Her age is above sixty. Her urine was very sweet, and in large quantity, and very frothy, and when spilled upon the ground, left an incrustation like chalk, in appearance, but which was, in reality, a saccharine crystallization. —The peculiar odour from her body and her lungs was here remarkably, characteristic of her complaint : but this, as well as the other symptoms of the disorder, admitted of a change in less than two days : She had complained of an uneasiness and weight at the stomach, which was removed by a bolus of the hydragyrus cum cretà , given for a few successive nights, and then the strict animal diet, with forbearance from all sorts of vegetables, and from fermented liquors, together with the common steel ' draught, with myrrh, three times a day, was perse vered in most accurately ; the change al most immediately took place for the better, and her health, more than could have been expected at her time of life, is manifestly improving: 

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--After persevering about three weeks, rigidly, in the plan prescribed, I indulged her with beer at her meals, and with potatoes, and had the satisfaction of finding no sugar reproduced in her urine : In a few days she used stale bread, (for she had fancied that new bread had a tendency to bring back the disease) with the same happy result : and was then directed to eat any sort of vegetables she pleased, adapting the quantity to her usual portion of animal food ; and, after a trial of ten days, she experienced no renewal of her disorder. After the expiration of two months, I saw her again, without any symptom of the complaint whatever; and again, after an absence of several more months, still continuing in a perfect state of health.

Whilst these pages were preparing for the press, I was consulted for a young lady in the neighbourhood of Liverpool, who was labouring under the worst description of saccharine Diabetes :-She certainly experienced considerable relief during several weeks from the full plan of animal diet, chalybeates, and the phosphoric acid, but: ultimately she fell a victim to her disorder: In the last stage of the disease I visited her at her father's house, and I think I never saw emaciation so extreme, nor patience so constant, nor attention to the plan of regimen so scrupulously exact; as in this amiable, and exemplary young lady. 

I was ałşo, about the same time, consulted by a gentleman near Somerset House, in the Strand : He was about sixty years of age : His skin was cold and harsh ; and his pulse small and freqüent: He made · water very often , but it was not at all sweet; and on evaporation it yielded plenty of crystallized salts , leaving a bitter and offensive residuum . His appetite was moderate, and so was his thirst, but his debility and emaciation were excessive ; and his nervous irritability, which seldom suffered him to sleep, had terminated in a slight paralysis, affecting the organs of speech, and the whole of his right side. His case seemed to me to want nothing .but the saccharine Characteristic to constitute it a true Diabetes, and I accordingly ordered him eggs instead of bread, milk and broth instead of tea, and animal food under any form he pleased, and the exclusion of all vegetable and fermented matters; and his medicine was the myrrh draught, with the sulphat of iron. Although I had not much expectation of doing him good, I had the satisfaction of finding him better in a few days; and, after visiting him, perhaps twice a week, for about a month, I requested him to remove to Hampstead, --for the benefit of the chalybeate water, and where he might have the opportunity of exercise in a fine air. This, however, he neglected to do ; and, during my absence from London at my house in the country, I found that he had deviated altogether from the plan advised for him, and that a fresh attack of palsy had terminated his existence.: A clergyman, also , from the neighbour hood of Harrow , consulted me for a dropsy. He was advancing in years, his debility was great, and his legs were much swollen : I found, however, that his appetite was very good, and his complexion clear; and that, independent of his extreme weakness. and the tumefied legs, he was apparently in health: On examination, too, it was discovered that his urine was in greater quantity than is usual, but that it neither to the taste, nor on evaporation, yielded any sugar: Still I was not convinced that his dropsy could arise from any other cause.