Meatritionist

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.

My other Patient, Elizabeth Francis, aged 36, is a married woman. She miscarried near 12 years ago, but never had a live child. Eighteen months after that, she became dropfical, and had 17 quarts of water drawn off by the operation of paracentesis. She recovered of this, and enjoyed tolerable good health for near five years ; but she has been complaining these four years past, and became diabetic about June 1797.

 She was admitted into the Infirmary on the 28th of September following, at which time Mary Jackfon was using the carbonated ammonia, and apparently with advantage. Francis was therefore ordered to take it in the same manner, and to pursue the animal diet; I believe she did so rigidly, and with so good an effect, that on the 12th of November she was discharged at her own request, in consequence of feeling herself better than she had been for four years before, and indeed, to her own thinking, well; her strength being much improved, her thirst and appetite very moderate, and her water reduced to four, and sometimes to three pints in the- 24 hours, and free from sweetness, though for a week before she left us, she had been allowed two ounces of bread per day, and for the week preceding that, one ounce per day. On her going home, however, she increased it to a penny loaf per day, and at the same time took less animal food, owing to her inability to procure it ; the consequence was, that in a few weeks she became somewhat weaker, her urine increased a little, and she was frightened. She was therefore re-admitted on the 1 3th of February, and put again upon the animal diet, which she adhered to strictly till the 29th of March, when she was discharged again, to all appearance cured of the disease, though not restored to the strength and vigour of full health. 

She still keeps to the plan of eating animal food, and avoiding all vegetable matter, but lives a good deal upon milk; and when I called upon her yesterday, she said she had certainly gained strength lately. I then learned, for the first time, that she had also been affected two different times with an itching about the meatus urinarius, which was exceedingly troublesome to her; the water was increased in quantity each time, and was hot and acrimonious ; but she has had no return of it since she left the Infirmary. 

I shall now conclude this account with remarking, that the effects of the animal diet have been so obvious in all the three cases under my care, notwithstanding two of them occasionally deviated very largely, that I perfectly agree with you, in suspecting a deviation from the plan, wherever they are wanting, though the patient should strenuously deny it; for I have experienced the same propensity to deviate, and the same reluctance to acknowledge it, that you have done; and so averse are the other patients to betray the secret, that I believe the truth will seldom be obtained in an Hospital, while the patient remains there.

From Dr Cleghorn

I am just now treating a Gentleman in private practice with equal success. 

I examined John Rogers, (p. 168) today, and found that he had lived very irregularly. He keeps the tap in our prison, where he is much exposed to temptation; and his urine has from time to time become sweet, generally in proportion to his deviation from your rules; he is, however, much stronger, and has continued to be able to attend to his business.

John M'Lean, (p. 158) died last year, in the beginning of August. A month before he had been confined to bed by a violent pain darting from his breast-to-his back, accompanied with difficult breathing, and very severe cough. Having repeatedly recovered from similar attacks without medical aid, he waited till the 10th day, though I had requested him to let me know whenever he began to complain. On the 10th day of his disease I found him extremely hot and oppressed; his breathing hot and laborious, constrained by dreadful pains through the chest, and frequently interrupted by a most severe cough; by which, after violent straining, he brought up a quantity of pus or blood. His pulse was quick, and feeble, but sharp. His features were ghastly and expressive of great agony. His present were so different from his former feelings, that he gave up all hope of recovery, and in despair, not only refused to go again to the Infirmary, but was unwilling to try any remedies. Some of the ordinary ones, however, were used, to no purpose; and in the fifth week of his disease, after voiding a quantity of blood by stool, he expired. In the thorax were numerous adhesions, especjally on the lower part of the sternum, from which the lungs could scarcely be separated, and the separated surfaces were covered with a gelatinous mass; there were familiar adhesions in the posterior part of the right cavity, nearly opposite, in which direction, chiefly, the pain had darted; and also over a great part of the left cavity. Around the adhesions the structure of the lungs was much altered. There were many ulcers, some nearly empty, others full of pus and several parts apparently ruptured, were surrounded with masses of grumous blood. The bowels were very pale, but there was no hardness in any mesenteric gland. The kidneys appeared sound, only more flaccid than usual. That the pneumonia which destroyed this Patient was not connected with Diabetes, is abundantly certain, but it may perhaps be thought, that the animal food necessary for curing the one, tended to produce the other. This is true, though I imagine the great fatigue, and the frequent alternations of heat and cold to which he was exposed, might have produced pneumonia under any regimen. Indeed, it seems probable that he had partial adhesions in the chest before he came to the Infirmary, because every slight causes excited cough and pain in the breast; but the last attack was most violent from the beginning, and the time when evacuations might have checked its progress was unfortunately allowed to go by. I had the curiosity to taste his urine twice or thrice, but it was not sweet. 

From some friends, to whom I have sent or recommended your work, (which is now known over all the west of Scotland). I have learned other instances of success; but, as I do not know the particulars, I think it unnecessary to mention them. Last winter we had a complaint among horses, called by our Sarriers Jaw-pish marked by a great flow of clear urine, emaciation and weakness-— lately I obtained a portion of the urine of a horse labouring under this disease, and found it four; but I had not lesfure to examine it farther.

From Doctor Cleghorn. Glasgow, June 12, 1798. 

TOGETHER with the conclusion of John M'Lean's Case, I have sent a short account of four other Patients, cured according to your plan in our Infirmary. As they were chiefly under the care of my learned Colleague, Dr. Freer, (for I attended them only during a few weeks in his absence) I requested him to write out their cases; but after considering them, he found them so exactly like those already published, that he thought a full detail of the symptoms or practice would lead to unprofitable repetitions. With his concurrence I have extracted the following particulars from the Infirmary Registers. 

One of the Patients was a Weaver, age. 35, of a dark complexion and stout make. The disease had continued 18 months, and arose, as he thought, from cold, to which he was exposed while under salivation from mercury. When admitted on the 9th of February, 1798, his urine, which was very sweet, amounted to 20 lb. daily; when dismissed, in the beginning of May, it varied from 4 to 5 lb. and had no sweetness. 

This Patient got no hepatifed ammonia. He was restricted to animal food, using water, lime water, or alum whey, for drink; he got occasionally laxatives, emetics, and pills containing extract of bark and steel. While he got eggs for supper, his appetite and thirst began to increase, for which reason they were omitted; but the chief peculiarity of his case consisted in the trifling effect of emetics upon him. Ten grains of tartarifed antimony excited no sickness, nor vomiting or purging ; seven grains of vitrified copper with the same quantity of ipecacuan, were equally ineffectual, as was also vitrioiated zinc given to the extent first of 30, afterwards of 35 grains. 

I do not ascribe this insensibility of the stomach to Diabetes, because I never met with it in other cases ; it certainly arose from a constitutional peculiarity as the Patient told me it had always been very difficult to make him vomit. In other respects his progress was quite similar to that already often described. His skin, formerly arid, became soft and moist; in proportion to the abatement of his appetite and thirst, he gained flesh and strength; and his urine, acquiring daily more and more of the natural appearance, during the last month of his fray in the Infirmary, most frequently amounted to 4, but never exceeded 5 lb. Nothing has been heard of this Patient since he left Glasgow, from which, as he lives in the neighbourhood, we conclude that he continues well, because he promised either to return or to write, if he should relapse.

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.