Type 2 Diabetes

https://wellcomecollection.org/works/hhqkczzb

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

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

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

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

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

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

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

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

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

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

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.

The medical practitioner cannot be said to have entirely performed his duty by treating successfully a disease which, withstands in general the efforts of others, unless he also makes it known the means to which such success may be attributed. Was this idea more strongly impressed, than it appears to be on the minds of professional men, the page of medical history could not fail of having been enriched even beyond its present state. Many a valuable fact, I am persuaded, has gone down with its possessor to the grave, which, if communicated to the world, would at once have benefited the community, and rescued from oblivion the name of its observer. Nor is the communication of successful practice alone attended with advantage. The correct and impartial detail of those cases, which baffle our exertions, has also its utility; for, from the failure of the remedies employed, we receive a lesson which should be carefully remembered. We are taught thereby fairly to appreciate the value of the means recommended, and, from a perception of the insufficiency of our knowledge, are led to the extension of our inquiries. Induced by a belief that the history of the following case may be attended with beneficial consequences, I take the liberty to request its insertion, with remarks, in your valuable Journal. 

John Cronin, a countryman employed in the Ordnance Department at Spike Island, Cork harbour, applied to me for relief of what he considered mere debility, on the 14th November 1806. He was greatly emaciated, had a constant hectic flush, and his under eyelids were red and inflamed; his skin was dry and scurfy; he had continual and excessive thirst, and a ravenous craving for food. The pulse was 90 in the minute, and was somewhat hurried; his breathing, however, did not appear affected. His belly was natural, but the secretion of urine, which was the oniy circumstance he omitted in his account of his complaint, I discovered to be very considerable. 

On the 16th he was admitted into the Ordnance Hospital at Spike Island ; on that day he made 16 pints, by measurement, of a clear and almost colourless water, without odour, and perfectly sweet to the taste. On examination into the previous history of the disease, I learned, that he had always been very temperate, and extremely healthy, till about thirteen months before this period, when, after being much heated, he drank cold water, and lay a short time on the grass. This imprudence was very soon followed by a copious discharge of urine, by no means, however, so great as at the time he made application to me for relief. The increase of the urinary discharge was succeeded by the other symptoms before enumerated, which, by degrees, arrived at the height already described. One circumstance particularly deserving of notice, was the tendency which milk at all times had to augment the flow of urine. 

He was ordered to be confined to a strict animal diet, consisting of one pound of boiled beef without bone, and two quarts of strong soup, without any vegetable ingredient, in the course of the day; he was also ordered to take a drachm of the pulv. cinchon. three times a day, each dose to be taken about an hour before he made use of solid food. On the 17th, the urine, though diminished little more than a pint, was somewhat less sweet to the taste, and emitted a more heavy odour, a circumstance which gave me some little hope of success. The bark was continued ; and as he complained of great thirst, and a very painful gnawing sensation of the stomach, whenever it was empty, his allowance of meat was doubled, and another quart of broth was added to his drink. 

On the 18th, the urine was surprisingly diminished, hardly exceeding seven pints. It had assumed, besides, a much deeper colour and, both in smell and taste, differed little from the natural state. His thirst was considerably diminished, but his appetite still continued voracious. Ordered to go on as before. 

On the 19th, he made but five pints of urine, which bore all the characteristic marks of a natural secretion ; the thirst was nearly gone ; the appetite, though less, was still, considerable. He was directed to proceed.

 On the 20th, his urine did not exceed four pints; the appetite was much diminished, and the thirst entirely gone. As he wished to go home to his family, who resided a few miles distant, and as no provision is made by the Board of Ordnance, excepting for those actually hurt upon their works, (and even their patients of the civil branch cannot be detained against their consent), he was dismissed from hospital. Before his departure, I explained to him very particularly the nature of the disease, from which he had so fair a prospect of being perfectly relieved, by a steady perseverance in the plan I had adopted. I also pointed out to him the certain fatality of the complaint, unless treated after this manner; and expressed my decided opinion, that his disorder would return should he deviate, in the smallest degree, from my instructions. He seemed perfectly aware of his own danger; and, in order to enable him to follow my advice, I gave him a letter to a friend of mine, on whose estate he resided, who kindly and humanely supplied him with the necessary food, and who, being interested by the peculiarity of the case, and method of treatment, in a great measure, inspected the matter himself. 

My patient called upon me once a week for bark, and at the end of the sixth week, (December 25th), he was allowed half a pound of bread at dinner. From that day he continued to use vegetable food without restraint, and has experienced no return of the disease. He has since regained his strength, and his former healthy appearance. 

Remarks. The success of this case must be attributed entirely to the use of the animal diet, as bark, when given without prohibition from vegetable food, has but little effect in the cure of this truly formidable disease. The cinchona was prescribed with a view to its invigorating principle, which enables the chylopoetic viscera to perform their functions. This I think it necessary to mention, lest it should be supposed to be my wish to recommend the use of that medicine with any other view, but as an auxiliary to the only plan which has yet been generally adopted with success. As an auxiliary, I must, however, consider it preferable to anyother, for the reason already assigned. At the same time, I will not deny, that other remedies may also have their uses in the same way. The use of septics, which Dr Rollo strongly recommends, in his valuable publication on this subject, was first tried by Dr Francis Home, in two cases, which occurred at the Royal Infirmary of Edinburgh. Dr H. was induced, he says, to try the use of septics, in order to promote the animal process, as the urine appeared too little animalized ; " and," he observes, " it is the first time that I, or perhaps any other, ever pursued that idea." It is indeed not a little singular, that Dr H. did not follow up this idea, or that of reducing the quantity of urine by incrassants. By the latter plan, the urine of one of his patients was diminished from 12 to nine pints in the 24 hours; and it should be remarked, that this patient got 30 oysters in the course of the day. This, however, was reserved for the sagacity of the learned Dr Rollo, to whom, whatever may be the theory entertained by that enlightened physician, the medical world is certainly indebted for the suggestion of the plan of animal diet alone, and which cannot fail of transmitting his name with honour to posterity. The rapid change in the state of the urinary discharge from the use of animal food, is a circumstance, which, though noticed by Dr R., must excite considerable surprise. It was one, which, whatever hopes I might have entertained from a steady perseverance in the method of treatment adopted, I was by no means prepared to expect. Our astonishment, however, must, no doubt, suffer some diminution, from a consideration of Dr R.'s experiments, which very clearly demonstrate, that the urinary, or rather saccharine, secretion in diabetes, depends on the imperfect animalization of the blood, and that such imperfect animalization is the consequence of defective assimilation of the aliment. This is very clearly deducible from those experiments, though Dr R., as I apprehend, considers the saccharine secretion as formed in the stomach. No dissection, as far as I know, has yet discovered the presence of a saccharine matter in the stomach, nor is it easy to conceive, that, if that viscus did secrete that matter, it could pass from the stomach unchanged to the bladder, unless we also acknowledge the existence of the vasa brevia, a, position denied by the most celebrated anatomists. Dr R. mentions, (in the case of Captain Meredith), that the patient was bled, and the blood was kept for several months, without undergoing any putrefactive process ; while a portion of healthy blood, taken at the same time, and placed in the same room, exhibited evident marks of great putrefaction in four days, and was obliged to be thrown away on the seventh. This circumstance leads me to adopt, in preference, the theory of the saccharine secretion being performed by the kidneys, and which is well expressed by Dr Baillie. ( From the state of the kidneys," says this celebrated morbid anatomist, " upon examination, it seemed to me probable, that diabetes depends, in a considerable degree, Upon a deranged action of the secretory structure of the kidneys, by which the blood there is disposed to new combinations. The effect of these combinations is the production of a saccharine matter. I think it probable, at the same time, that the chyle may be so imperfectly formed, as to make the blood be more readily changed into a saccharine substance by the action of the Icidneys The cause of the imperfect animalization of the blood will necessarily appear to be imperfect digestion, or defective assimilation of the aliment. This by some has been supposed to depend on disease, either in the structure or functions of the liver. This was the opinion of Actuarius among the ancient, and of Mead amongst the modern medical writers ; but later observations have not confirmed this idea. Dr Home examined very Carefully one of the cases before mentioned, which terminated fatally, and reports the liver "natural." Dr Baillie's history of the dissection of a case, which occurred to him, at St George's Hospital, London, is very satisfactory : He remarks, "the liver, at the same time, I examined with care, because it has been thought by some to be the chief source of disease in diabetic patients; but it was perfectly sound." Even allowing the liver to be sometimes engaged, it is a circumstance which, as Cullen observes, does not often take place, and therefore the disease must acknowledge a different cause. The mesenteric and pancreatic glands have likewise been said, in some instances, to have been enlarged and diseased ; and the latter, especially, have been found, in two cases, to have been much altered in their structure, by an eminent professional friend of mine, in Cork, whose name I am not at liberty to mention ; but this is only casual, and cannot be set down as the general cause of diabetes ; yet one idea strikes me, from a consideration of the histories of the chylopoetic viscera being sometimes found diseased in this complaint, and which I submit with much diffidence: It is, that where diabetes resists the plan of animal diet, it may be fair to conclude, that diseased structure may be the cause, and thence, that a mercurial course might be, at the same time, attended with advantage. The utility of this plan will perhaps be more apparent from a consideration of the declaration of the very accurate and learned Dr Willan, in his reports on the diseases in London, " that this disease has been relieved, and the saccharine quality of the urine removed by animal diet, and the general plan recommended in Dr Rollo's treatise on this subject; but I never yet," he continues, " met with a confirmed case, wherein there was not some considerable disorder of the constitution, or a defect in some organ essential to life I do not see that any advantage is to be expected from local applications to the region of the kidneys : That the affection of those organs is but secondary, or, in other words, is dependant on the defective assimilation of the aliment, and the consequent imperfect animalization of the blood, will hardly be denied ; and the admission of this fact is necessarily followed by that of another, that the cure does not lie in any medicine or application, acting directly on the urinary organs, but in altering and correcting depraved digestion. This is most effectually done by the administration of those remedies which impart tone to the organs concerned, and by affording that kind of aliment onlyy whose direct tendency is to promote the animal process. I shall conclude this corrununication, by adverting to the place which this disease should have in systems of nosology. Dr Cullen has placed it under the order of spasmi. This improper arrangement has been wisely accounted for by Dr Willan, when he says, " most of the plans of nosology are exceptionable, as being founded on hypothetical principles, rather than a strict analogy between the diseases put in the same order if we attentively consider the circumstances attendant on diabetes, the emaciation, debility, oedematous swellings of the legs and feet, and, in some cases, (particularly towards the close of the disease), the quick pulse, and hectic flush, we shall be inclined to take the disease from the order in which Cullen has placed it, and rank it under the class of cachexiay and amongst the marcores. The tabes sudatoria resembles much, in its nature, diabetes; the former is attended with a diseased state of the primse viae, and cutaneous vessels, the latter with a diseased state of the primae viae and kidneys : In the former, the skin is evidently relaxed, and the histories of the dissections of diabetic patients shew a similar laxity and softness of the kidneys. The perspiratory discharge in the former, when collected on a sponge, speedily acquires a sour odour; the urine in diabetes soon undergoes the same change. To these may be added, that in the tabes sudatoria the urine is very scanty, while in diabetes the perspiratory discharge is, in a great measure, suppressed. The other symptoms are nearly the same; emaciation, debility, and hectic, equally mark both diseases. The analogy then, which subsists between diabetes and diseases usually ranked under the head of cachexia;, would, as before mentioned, strongly incline me to place it in that order. 

Cove, Cork.