Type 1 Diabetes

SECT. III

Of the appropriate Treatment of the Diabetes Mellitus.

THE principles of the treatment, as established by our cases of the disease, by the view we have given of the proximate cause, and we may further add, by the general success, consist;

1. In the prevention of the formation or evolution of the saccharine matter in the stomach.

2. In the removal of the morbidly increased action of the stomach and in its restoration to a healthful condition. 

Whatever may be the cause of the formation of the saccharine matter, it is necessary to prevent it, as on its general stimulus in the system, and particularly on the kidneys, very general affections are maintained. Besides, the means employed to prevent such formation may tend to the removal of the morbid action of the stomach and lacteal absorbents, and the increased and altered state of the gastric fluid, on which its production probably depends. Animal food, and confinement, with an entire abstinence from every kind of vegetable matter, afford the general means ; but which may be facilitated by the daily use of alkalines, calcareous and testaceous substances. The quantity of animal food should be restricted, and given in as small quantities as possible to satisfy the stomach : see page 54. 

When the urine points out the absence of the saccharine matter, and at the same time its quantity continues more than natural, containing likewise more of the extractive matter in a viscid, or tenacious form, while the appetite remains keen, it may be presumed that the increased morbid action of the stomach is not removed. It becomes then necessary to exhibit the hepatifed ammonia, with an opiate and antimonial at night, and to continue them until the morbid condition of the stomach is removed; the marks of which are, a scarcity and high coloured state of the urine, with turbidness, furnishing on evaporation an offensively smelling and saltish tasted residuum, without tenacity, accompanied with a want of appetite and loathing of food. At this time the tongue and gums will be found to have lost their florid colour, and to have become pallid. 

When such a state occurs, exercise is to be enjoined, a gradual return to the use of bread, and those vegetables and drinks which are the least likely to furnish saccharine matter, or to become acid in the stomach, with the occasional use of bitters, &c. Should this period of the disease be overlooked, and the confinement and animal food rigidly persevered in, scurvy, or something akin to it, might be produced. That such might be the termination of Diabetes, the appearances which arose, more especially in Captain Meredith's case, render extremely probable. The gripings, and offensive stools; the oiliness on the surface, and the high colour of the urine; the foetid breath and saltish taste; the great latitude and heaviness, with indifference to either eating, drinking, or moving; were strong marks of a state approaching to scurvy.

When the disease has continued long, it may leave local effects, which may prevent the entire restoration of health ; the most ample form of which might be supposed to consist in mere dilatation, or enlarged capacity of vessels, as those of the kidneys; or in a habit acquired by long continued action. Our first case shows, that these, when the disease has not been of very long duration, may be soon removed. They may, however, prove one of the circumstances retarding recovery in such a length of disease as that of our second case ; but even in this, the kidneys very early partook of apparently their ordinary action. Dissection has shown some morbid condition or derangement of the mesenteric or lacteal absorbent glands, and some altered appearance of the kidneys. There may also arise some derangement of stomach structure, of pancreas, spleen, liver, and possibly of lungs. Such sequelae would probably be sooner and more certainly formed in scrofulous habits. Whenever they occur, recovery must be retarded, if not finally prevented. They, however, will not interfere with the actual removal of the diabetic disease. We suspected some affection of the mesenteric glands, and of the stomach, in our second case; but we are warranted in alleging, that want of steadiness in the patient solely prevented the complete removal of the complaint. The nature of its sequelae, or whether they will remain, so as to maintain a state of chronic disease depending on them for its cause, requires still to be determined. Of this determination we must now continue entirely ignorant, as the patient from unsteadiness died, and was not examined after death. 

These are the general means of treatment, and they will be found adequate to the most common circumstances of the disease. We think it, however, necessary to particularise certain cases and states of the complaint. The former, are those of short, or long continuance, acute or chronic in degree; the latter comprehend the progress and fleps of recovery. It is necessary to attend to these distinctions, as they must direct the remedies and regimen to be employed. 

When the disease has been of short duration, an entire use of the animal diet may be immediately pursued, with an abstraction of all vegetable food and fermented drink which may have been formerly taken. In this state of the disease it may be acute arid then the diet should be spare; blood-letting and blistering may be necessary, with the use of opening and diaphoretic medicines. But when the disease has been of long continuance, especially in persons advanced in years, and whose habits have been luxurious in point of living, it may be proper to regulate the plan of cure by gradually adopting the animal diet: see the case of the Gentleman of 77 Page 179 and Dr. Stoker's continuation, page 253. 

On the removal of the general symptoms, and the return of the urine to a natural condition, which may be ascertained by a comparative examination with the healthy standard of it, as described by Mr. Cruickshank, vegetable substances may be cautiously tried. In the selection of which, the preference should be given to those least likely to furnish sugar, or excite disturbance in the stomach. The urine should now be very frequently examined, and on any appearance of a return of the diabetic state of it, the animal diet must be again strictly renewed. In this way the diet must be varied, until we are certain not only of the removal of the disease, but of the disposition to it. In the prosecution of the plan much steadiness and perseverance are required. We have to lament, that our mode of cure is so contrary to the inclinations of the sick. Though perfectly aware of the efficacy of the regimen, and the impropriety of deviations, yet they commonly trespass, concealing what they feel as a transgression on themselves. They express a regret, that a medicine could not be discovered, however nauseous, or distasteful, which would superfede the necessity of any restriction in diet. 

The vegetable substances we have hitherto found the safest, in the change from the animal diet, are, broccoli, spinach, cauliflower, cabbage, and lettuce. These do not seem to furnish sugar when prudently used in the diabetic stomach, after a proper adoption of the animal diet ; but under certain circumstances they have been supposed to produce an acid urine : see the Cases of Mess. Houston and Thomas. When these vegetables have been safely taken, a return to a very small quantity of bread has reproduced the saccharine matter in the urine, and the general symptoms of distress, as thirst, &c. It becomes, therefore, a principal object in the treatment, to vary the articles of diet, so as to gratify the earned desire of the patient, without bringing on a return of the complaint.

W. Rhubarb was given, by Doctor Wittman, to a patient for four days; a portion of blood was then taken from the arm, and the serum was, as well as the urine, evidently tinged with its yellow

colour, staining linen.

(Rhubard is high in oxalates)

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 IV.

John Wild, age 33, Labourer.

Admitted an In-patient , April 12th, 1802;

Feels excessive thirst, an almost perpetual inclination to void sweet tasted urine, in profuse quantities, ( especially during the night) great clamminess in the mouth, and soreness of the gums; much pain and weakness in the loins, with an involuntary discharge of semen after voiding his urine.

His skin is dry, hard, and extremely rough ; pulse 125, weak and fluttering; and his countenance portrays the utmost anxiety and distress.

The emaciation is extreme, and his debility so great, that he was obliged to creep along the passages, leading to the physician's room, by laying hold of the walls for a support.

The excoriation, and swelling of the prepuce, are so considerable, as to have brought on a phymosis. He states his urine to be as sweet as honey, and to, amount to thirty pints in twenty-four hours. His appetite is so greedy, that his means are unable to gratify its longing; but after every indulgence of a full meal he feels loaded, and sick at his stomach, and often throws up its contents, which have a sour and unpleasant taste. He has lost several of his teeth, since the soreness of his gums came on, and many others are now loose in the sockets.

He describes his mode of life to have been very irregular; sometimes faring hardly, at other times indulging to excess, especially in the use of spirituous liquors.

About seven months ago, he had worked at the harvest, and getting intoxicated, he laid himself down to sleep near a pool of water, where he continued all the night.

From this period he dates the origin of his complaint; but has only noticed the increase in the quantity of his urine, and the peculiarity of its appearance and taste, five months from the present date.

He was ordered to be put upon a diet of animal food, without the least portion of bread, or any other vegetable matter; two blisters to be applied to the region of each kidney, and the ulcerated parts to be kept open, by irritating dressings: six drops of the hepatised ammonia, to be got down, mixed with mint water, three times a day, and also every night a bolus, containing one grain of opium, and five of rhubarb.

His thirst to be quenched with water, in which, at meals, toasted oat-cake was to be infused. The liquid ingesta and egesta to be accurately ascertained.

April 15th. (typo in text)

Urine 34 pints, Drink 27 pints

Has eaten, at least, from three to four pounds of cold beef, but has carefully abstained from every other kind of food; slept better, and feels easier.

The urine (which was kept in a bucket) appeared of a greenish straw colour, and was clear when first voided; but on standing some time in the vessel became turbid on agitation, and looked like thick small beer; it emitted a

faintish acid odour, although evidently sweet to the taste.

April 16th.

Urine 38 pints,  Drink 36 pints

He complained of tormenting thirst, and begged to have his drink changed. Ordered weak barley water, acidulated with the spirit : vitriol: ten: and, to support his strength, four ounces of wine in the course of the day. The dose of ammon: hepatisat: was increased to ten drops, four times a day; and the opiate with rhubarb repeated. The nitric was afterwards substituted for the vitriolic acid, and constituted, when mixed with water, the common beverage of the patient.

April 17th.

Urine 28 pints, Drink 26 pints

Has perspired copiously in ihe night ; pulse reduced to 108; appetite moderate, but he begins to loathe his animal food. The sensible qualities of the urine are not much changed; One pint of this fluid yielded, on evaporation, two ounces, within half a drachm, of an extract, resembling coarse brown sugar, both in colour and taste; at the same time one pint of healthy , urine, was exposed to evaporation under similar circumstances; and afforded a residuum amounting only to two drachms and twenty six grains. Medicines and diet to be continued, with the addition of broth at supper and breakfast

April 17th.—  April 27th.

The quantity of urine passed each twenty-four hours, within the last ten days, has greatly varied: on the 21st, thirty six pints were discharged, on the 27th only seventeen pints—- these being the maximum and minimum quantities within this period; but the average amount may be estimated at nineteen pints each twenty four hours.

The liquid ingesta were seldom equal to the egesta; and the relative proportions fluctuated considerably. On the 23d, the urine measured nineteen pints, and the drink only sixteen : On the 25th, urine twenty four pints, and drink twenty six ; yet these changes could not be attributed to any perceptible cause.

The patient has been almost daily improving in health and strength: his sleep is more refreshing, and prolonged (without the interruption of making water) to two hours at a time. The urine is become paler, and has lost some little of its faintish acid smell, and sweet taste. The pulse varies from eighty four to eighty eight. As he became disgusted with the hepatised ammonia, a solution of sulphurated kali, was administered as a substitute.

The bowels were to be kept open with castor oil, and his other medicines and diet to be repeated.

April 27th — May 8th.

During this period, and especially within these three or four days, a general amendment has taken place. The average quantity of urine has not exceeded fourteen pints in the twenty four hours, but has varied in quantity, at times, very considerably. On the first of May, it amounted to twenty two pints, and on the eighth, to no more than eight pints. The following extract from the register will point out the favorable changes which have taken place.

May 3rd: Urine 12 pounds, Drink 12 pounds

May 4th: Urine 11 pounds, Drink 9 pounds

May 5th: Urine 14 pounds, Drink 16 pounds

May 6th: Urine 12 pounds, Drink 16 pounds

May 7th: Urine 14 pounds, Drink 16 pounds

May 8th: Urine 8 pounds, Drink 12 pounds

The patient begins to feel his strength recruited, his countenance has lost its ghastly appearance, and he has evidently gained flesh, ai well as strength. He no longer complains of the offensive taste in his mouth, nor heat and tormenting pain in the bowels. His pulse is in general not more than eighty ; indeed his vigors arid spirits are such as to suffer him to be employed in assisting the patients, and performing several menial offices about the house; yet the urine has not lost its saccharine taste, although it has become, according to his own expression, "sharper and less pleasant."

The phymosis continues, but the swelling and excoriation are abated.

He still complains of occasional weakness in the loins, which is always aggravated by the involuntary seminal discharge.

The improvement has been so marked and rapid, within the last four days, that he feels assured of his speedy recovery, and begs to have an allowance of vegetable food, and is very desirous to be discharged in a short time.

May 8th — June 1st.

On the 9th, one pint of urine yielded, on evaporation, one ounce, two drachms, and forty grains of an extract of the consistence and colour of treacle; but with rather a saltish taste, and urinous smell.

Important changes for the worse have un- expectedly occurred within this period. For on the 9th, the patient injured his leg severely by a fall, in running up stairs; this accident occasioned the opening to a very considerable extent of the cicatrise of an old wound upon the shin bone. At this time he expressed a longing desire to be indulged with bread and vegetables, and from an apprehension, that a refusal might induce him to obtain them surreptitiously, he was allowed a small portion with his meat.

From this period, the diabetic symptoms increased, and the average daily quantity of urine amounted to twenty pints; but the ingesta were nearly upon a balance with the egesta. Bread and vegetables were again forbidden ; yet I have reason to believe that he contrived to purloin from the other patients, part of their vegetable diet.

The ulcer on the leg spread rapidly, and discharged a large quantity of ill conditioned pus.

He was now confined entirely to bed, and lost both his strength and flesh.

He was ordered to take wine, bark, and lime water, and to omit his other medicines. One of his legs becoming anasarcous, small doses of digitalis and calomel were prescribed, in conjunction with the bark. By this treatment the swelling was nearly subdued, but the diabetic symptoms remained stationary. He was again ordered rigidly to abstain from vegetable food, and to drink daily a quart of fresh lime-water, mixed with milk; and to make use of a bath every night, heated to ninety-five degrees : by these means, the progress of the disease seemed at least to be arrested; but no permanent change of the characteristic diabetic symptoms was effected.

June 29th.

One pint of urine, taken from twenty-four pints which had been discharged on this day, was again evaporated. The residuum resembled the last in colour, consistency, and smell ; and weighed one ounce, seven drachms and a half.

June 1st — July 1st.

During this month, the register points out little or no variation in the daily quantities of the liquid ingesta and egesta, when compared with the proceeding fortnight: twenty-six pints was the greatest, and eighteen the smallest quantity of urine discharged on any one day: the ulcer on the leg, so far from being healed, has assumed a phagedenic appearance, and ex- cites much pain and inconvenience — alum with galls, and opium, were prescribed at bedtime,

in addition to the bark and lime-water, during the day. He now complains of increased soreness in the gums, and an irregular voracious appetite, attended by frequent vomitings of food in an undigested state. Pulse 103. feeble and irregular. Finding there was little, or no chance of restraining him from the occasional use of vegetable food, and despairing of his recovery, he was permitted to combine bread and vegetables with his animal diet.

July 1st – July 19th.

The patient has been evidently sinkings although the quantity of urine, voided each day, does not exceed the former statement. The average being twenty two pints every twenty-four hours. The swelling of the lower extremities has much increased, and, he is troubled with a teazing dry cough: the hopelessness of his situation was strongly depicted in his countenance, and his dissolution seemed evidently approaching.

Notwithstanding his extreme debility, on the 18th, and 19th, he was able to walk about the ward, and expressed himself even with cheerfulness; but on the 19th, at 2 o'clock p. m he was suddenly attacked with a pain in the stomach, succeeded by violent convulsions, which shortly put a period to his existence.(he died)

Remarks.

This, at first view, seemed to be a hopeless case. The disease had been so rapid in it's progress, and had made such ravages in the patient's constitution, that little could be expected from any plan of cure. The quantity of urine (thirty-six pints) discharged in twenty-four hours, is equal to, if it does not exceed that of any other instance which has been recorded by authors of credit. The proportion of residuum ( nearly two ounces to one pint ) is also very extraordinary, especially when we take into the account that it only formed a twenty-eighth part of the solid matter, drained off from the body in twenty-four hours.

This immense and rapid waste was, however, nearly supplied by the patient's greedy appetite, for both solid and liquid nourishment. It is worthy of remark, that on some days, the register pointed out an excess in the liquid egesta considerably beyond that of the whole amount, both of the solid and liquid ingesta; now as this superiority of the egesta to the ingesta has been often insisted upon by some practitioners, and denied by others. I felt very anxious to ascertain the fact in the present instance: and, therefore, when the register denoted that such a circumstance had happened, I was very cautious and diligent in my enquiries concerning the accuracy of the report ; and in no instance was I able to detect any irregularity or imposition on the part of the patient or attendants.

In this case, as in the foregoing ones, much advantage was derived from the use of the nitric acid. It greatly assuaged the thirst, and was grateful to the palate, but its effects on the bowels often prevented a further trial. Opium, with rhubarb, was generally serviceable in allaying irritation, and probably the diminishing the morbidly increased action of the stomach. Perhaps success could not reasonably have been expected in the treatment of this deplorable instance of diabetes mellitus; and I must confess, that at first, my most sanguine hopes did not extend beyond a palliation of the more urgent symptoms; but from the unexpected, rapid, and important improvement, which the patient experienced soon after his admission, I am inclined to believe, that had he steadily persisted in the plan of cure, and no accident to his leg had occurred, his life might have been considerably prolonged ; and perhaps the diabetic symptoms eventually subdued.