Ketogenic Diet

EXCLUSIVE of the cases of the Diabetes Mellitus, which have been published in this Work, we have heard of several others, particularly of one in Guy's Hospital, but we remain unacquainted with all the circumstances. Doctor Odier, of Geneva, mentions a cafe in the Bibliotheque Britannique, vol. vii. p. 321, and vol. viii. -p. 168. Doctor Wilmot, at Hawkehurft, in Kent, has also had a case under his charge ; and Doctor Yeats, at Bedford, informs us of a patient he has successfully treated by the animal food; but as he intends to communicate an account of it, we defer any detail. Doctor Beddoes has very lately mentioned to us four cases of the disease, one of which has been cured by the diet alone. He observes, “that in one case, he endeavoured to please the palate by recommending occasionally articles of food, as nearly resembling dishes made of the farinacea as possible. Tripe, fried in a certain way resembles pancake. Buttered eggs offered an agreeable variety. He also advised a method of trying to reduce dried fish and flesh into a kind of flour. These culinary considerations are extremely important; and he has no doubt a diet might be contrived under which patients would feel little privation." We have likewise received indistinct accounts of four cases of the disease in London and its neighbourhood. There is, besides, one which Doctor Marcet has visited. In order, therefore, to show the necessity of attending to this peculiar disease, which has been hitherto deemed uniformly fatal, we shall recapitulate the number of cases we have either seen or heard of since the dispersion of the notes of Captain Meredith's cafe in January 1797-

• Captain Meredith's Cafe — Page 17:    1

• General Officer's do. — Page 63:           1

• Cafes in Chap. II. Sect. I. — Page 142: 10 and upwards

• Cases in Chap. II. Sect. II. Page 237:     23

• this Appendix:                                                 13

• Total:                                                                    48 and upwards

Along with this number may be examined the account of cases given in the third Chapter, p. 356, being those described previous to that of Captain Meredith. From the whole it will appear, that the disease occurs more frequently than has been generally supposed; and of course, its discussion claims the attention of the medical enquirer. It also is entitled to it in another point of view, as tending to illustrate many other complaints depending on a morbid affection of the stomach, and constituting the most troublesome of our chronic diseases.

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.

Case V.

Thomas Whitehead, age 50.

Admitted an In-Patient April 22d, 1805.

Complains of a preternatural flow of sweet tasted urine, (which on some occasions has amounted to twelve pints in twenty-four hours ) of thirst, and dryness in the mouth, and great pains extending over the loins and pubes. The appetite is irregular and sometimes craving. He has served nine years as a soldier in the East Indies, where he was much exposed to all the hardships incidental to the climate. Since his discharge from the army, he has acted for some years as a watchman in Manchester, and during this employment, he indulged freely in the use of spirits, and often suffered from cold, wet, and fatigue.

About four months since he was first attacked with the pain in his loins, unusual thirst, heat, and a slight increase in the quantity of urine. The pains were not stationary, but would suddenly leave him for the space of a week, and then return upon the least fatigue, or increased exertion, with an augmentation in the quantity of his urine.

He was never fond of vegetables, and since his illness has confined himself to a milk diet:

pulse 86

April 23d, 1805

He was ordered to live on cold beef and mutton, and occasionally fat pork. For common beverage, one drachm and a half of nitric acid to three pints of water ; two blisters were applied to the region of the kidneys, and an opiate with rhubarb, at bedtime.

April 24th,

Drink three pints, solid ingesta one pound. Urine four pints : one pint of the urine when evaporated, left a residuum weighing four drachms and five grains, which exhibited aii urinary smell and taste, but its consistence was tenacious, and unlike that obtained from healthy urine. Has passed a more comfortable night; his thirst, and inclination to make water being much abated.

April 25th.

Solids Liquids Urine

14oz. 2 pints 3.5 pints

His bowels are open, and thirst moderate. He complains of great faintness in the morning;

pain in the loins and pubes relieved; his urine is still sweet to the taste.

Solids Liquids Urine

9oz. 3 pints 3 pints

April 27th.

Solids Liquids Urine

1 lb   3 pints 3 pints

Says his acid mixture rather gripes him, but is ordered to continue its use.

April 28th, Solids Liquids Urine

15oz. 3 pints. Less than 3 pints

Thirst almost gone.

29th. Solids Liquids Urine

1 lb 3 pints 2.5 pints

The urine now appears of a natural colour, and possesses nearly its usual smell and taste. The patient feels much disinclination to his animal food, and complains of loss of appetite and general debility. He was allowed two ounces of toasted oat-cake daily.

30th. Solids Liquids Urine

19oz. 3 pints 3.5 pints

( Bread two ounces, animal food seventeen) The urine has acquired a sweet taste, and the patient's thirst has rather increased; but he feels stronger, and looks more cheerful.

May 1st. — June 10th,

During this interval, a very favorable alteration has taken place ; the allowance of bread has been gradually increased to six ounces daily, without any unfavourable change in the qualities of the urine, which on the 3d, amounted only to two pints, while the drink was nearly three pints, and the solids one pound. The colour of the urine is quite natural, and it has lost nearly all its saccharine taste and smell.

On evaporation, one pint yielded four drachms, and twelve grains, of a dry, friable, and urinous residuum ; differing little in bulk or appearance, from that which is commonly the product of the same quantity of healthy urine.

The liquid egesta has been, on the average, considerably inferior in quantity, to the ingesta. On some days, the former exceeded the latter, more than one third.

The patient's stomach was not able to digest some broccoli, that was allowed for dinner : it occasioned acidity and griping, and was therefore discontinued.

May 10th – 18th

On the 13th his bread was increased to seven ounces, and a pint of milk allowed for supper; in consequence of which alteration, he passed a restless night; and his urine exceeded more than one-third the liquids he had drank for the last twenty-four hours. On the 13th, he complained of slight febrile symptoms, with nausea, and a sour taste in the mouth.

He was ordered an emetic, and a gentle purgative; on the 18th, the febrile symptoms had totally vanished, and believing himself to be nearly cured, he was urgent to be made an out-patient; at the same time, promising a faithful adherence to the plan of diet, and mode of keeping the register ; which he had so strictly followed, while in the Infirmary. He was discharged accordingly.

May 24th.

The patient was re-admitted into the house, as he experienced a return of his complaint. His urine had augmented in quantity, and become sweet to the taste; his pains in the loins and pubes were troublesome; and his flesh and strength both diminished. His circumstances had not permitted him to adhere steadily to his late plan of diet, and he had also returned to his occupation in a cotton-mill.

To these causes, the relapse of his disorder may be attributed. He was again put upon animal diet, without milk or vegetables; and the acid mixture, and beef tea. were ordered for common drink; an opiate at night, and the blisters on the loins, were also renewed.

July 3rd

By persisting in this plan, the diabetic symptoms have been again subdued. The solid ingesta amounted to eighteen ounces, and the liquid to four pints ; urine to three pints and a half, which had lost all its sweetness, and was of a natural appearance; still the patient remained feeble, and did not gain flesh ; he was therefore ordered the bark with alum, and occasionally, when griped, a carminative mixture with opium; and likewise toasted bread to be added to his diet.

June 6th,

The patient has taken four ounces of toasted bread each day ; not only with impunity, but evident advantage to his appetite and strength.

The liquid ingesta and egesta, have been nearly balanced, and never exceeded three pints each in twenty-four hours.

In order to confirm the cure, and restore the patient to general health, he was continued under a similar treatment, with the addition of a more liberal use of vegetable food, and a small portion of wine, until the 20th ; when be was discharged, not only free from every diabetic symptom, but quite restored to his wonted health and vigor.

Remarks. 

This case is important, not only on account of its successful termination, but also from the entire dependence to be placed on the facts, as stated in the reports of the register. It is an evil which has often been lamented, that the negligence of nurses, and the gross ignorance, and irregular habits of the generality of patients, belonging to public Hospitals ; render it difficult, if not almost impossible, for the practitioner to be assured, that his orders are implicitly obeyed, whenever they enjoin great restraints and privations on the part of the sick.

But in the present instance, no suspicion could be attached to the patient, for his conduct was uniformly regular, and he sustained, with credit, the most minute and scrupulous inspection. Finding him to be a very intelligent man, capable of keeping a Journal, and duly impressed with the necessity of a strict adherence to his plan of written instructions, I was induced to furnish him with accurate weights and scales, and proper vessels, that he might keep an exact register of both the liquid and solid ingesta and the liquid egesta. This was strictly complied with, and the register was submitted to my daily inspection, and to the more frequent superintendance of Mr. Heartley, House-Apothecary, and Mr. Le Sassier, Physician's Pupil. Most, if not all of the characteristic symptoms of diabetes mellitus, were to be discovered in this case. The sweetness of the urine was first noticed by the patient, who was led to taste it from its peculiar odour. The emaciation was certainly much greater than might have been expected, from the short duration of the complaint, and the comparatively moderate discharge of urine. Yet the increased bulk of the urinary residuum, and its altered consistence, sufficiently prove, that much animal extractive matter was carried off by the kidneys; but it does not appear, from its sensible qualities, that the extract contained any portion of saccharine matter, although it is very probable, that the predominant flavor of the urinous salts might prevent its detection.

In other instances (one of which will be noticed hereafter) where the urine was sweet to the taste, and yet the residuum devoid of that quality; oxalic acid was obtained by treating the latter in the usual way with nitric, acid.

The efficacy of animal food, in subduing the diabetic symptoms in this case, is placed beyond all controversy. Its effects were rapid, manifest, and decisive. For, when the patient could not confine himself to this part of the plan, although he steadily persisted in all the rest, a relapse speedily ensued.

He likewise found great and evident relief from the application of perpetual blisters to the loins ; and the nitric acid proved useful in abating thirst and heat.

It is, worthy of observation, that in this case, as well as in some of the others, there seemed to be a certain period, at which it was necessary to join vegetable with animal food. For when the more urgent and characteristic symptoms were subdued, but at the same time the strength and bulk rather diminished than increased, and the appetite also feeble and fastidious ; it was then found necessary to administer with caution, a small proportion of vegetable food. The salutary effects of this addition were soon visible in the patient's improved appetite, and increase of flesh, strength, and spirits. Moreover, whenever a return to vegetable diet was suffered, not only with impunity but advantage ; it formed the surest criterion of the restoration of the assimilating powers of the system, and consequently of the removal of the disease.

I have the satisfaction to add, that I have since frequently conversed with this patient, and found him free from any return of his complaint; and that he is now (September 9th,1806. ) in the enjoyment of better health than he has experienced for many years past.

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.

It is only of late that any consistent and rational attempts have been made to explain the phenomena of this singular and obstinate disease and to establish a proper mode of cure. To the ancients we are indebted for little more than a history of the disorder by Aretaeus; which has been faithfully transcribed by all subsequent systematic writers, without addition or improvement, till the time of Dr. Willis. This writer first pointed out the remarkable properties of sweetness to the taste, and honey-like smell, in diabetic urine; and thus, by establishing a more decided and specific character of the disease, subsequent practitioners were enabled to distinguish it from many others, with which it had formerly been confounded. Hence, since Dr. Willis's discovery, diabetes has been more frequently noticed; and this, I imagine, has given rise to the erroneous hypothesis, of its being a more common disease in modern, than in ancient times. No further improvement in its history or theory seems to have taken place until Dr. Dobson discovered, by chemical analysis;, the existence of sugar in diabetic urine; and also pointed out the sweet taste and wheyish appearance in the serum of the blood. From hints which he derived from Dr. Cullen and his own experiments, he was led to consider diabetes as a species of imperfect digestion and assimilation. This idea of the nature of the disease was adopted confirmed, and further extended by Dr. Home. He may be said to have first opened the mine which Dr. Rollo and Mr. Cruickshank have so successfully explored. Dr. Home seems indeed to have erred in not steadily adapting his practice to his theory and in too hastily considering both the one and the other as defective, if not nugatory, merely from his want of success in two cases of very long standing.

To the ingenuity and industry of Dr. Rollo and his coadjutor, Mr. Cruickshank, in the treatment of diabetes, every praise is certainly due. For Dr. Home had abandoned the field of enquiry to future practitioners ; but Dr. Rollo  judiciously pursued the tract of his predecessor which in the end led him to success* This success; may be attributed to the revival of the practice which Dr. Home justly takes credit to himself for having first adopted; viz. The employment of animal diet> and air kalies with a view to their specific operation as septics. Indeed this idea of preventing the formation of sugar by the abstraction of vegetable food and of establishing a more perfect assimilation throughout the whole system by the rigid use of animal diet and medicinal septics forms the principal part, if not the entire basis of Dr. Rollo's plan. To this author then, we owe the revival of a practice, which had fallen into disuse, and would probably have sunk into entire oblivion bad not he, by the publication, and extended circulation of Captain Meredith's case, (in which -Dr. Home's principles and practice are judiciously applied and improved) roused the attention of practitioners to the subject ; and enabled them to form more correct notions of the nature and treatment of diabetes.

This is by no means a common disease for I believe there are many practitioners who have the care of extensive public Hospitals, to whom cases of diabetes have never occurred *. It has been my lot to see several instances of the kind ; and I have endeavored to avail myself of the principles and practice laid down by Dr. Rollo and other writers on the treatment of this stubborn and too often fatal disease ; with what success will be seen in the sequel.

I shall now proceed to give an abstract from my Infirmary register and private notep, of the several diabetic cases which have fallen under my care. Two of them, which were lately admitted, at the same time, into the Infirmary have afforded me a favorable opportunity of comparing the result of different modes of practice, and establishing, very satisfactorily, some important conclusions. With these patients I took much pains and I feel myself justified in reporting their cases more at large.